Emergency Medicine and Addiction Medicine: Much in Common
Daniel P. Logan, M.D., F.A.C.E.P.
Assistant Professor, Department of Psychiatry, Division of Addiction Medicine, University of Florida, College of Medicine

Abstract
Addiction Medicine and Emergency Medicine have much in common. Their greatest similarity is in the overlap of the patient population that they each serve. The substance abusing population is over-represented in the emergency room (ER), placing increasing demands upon financial and staff resources. Identification and proper intervention in the ER has been a focus of most joint research in the past, but other areas of investigation are open. Additionally, emergency medicine as a relatively new specialty has much in its history to share with addiction medicine as it strives for recognition. Emergency physicians are also finding themselves to be over-represented among the patients of the addiction medicine specialist.

Keywords: Addiction Medicine; Emergency Medicine

The association between emergency medicine and addiction medicine is apparent to the casual observer who walks through almost any emergency room (ER) on a Saturday night. The patients in the ER are often those who have previously been seen by the addictionologist or should be. Patients with alcohol and substance abuse related problems are disproportionately represented in the ER (1). 18% of patients seen in a typical ER shift were reported in one study to have alcohol related problems (2). Drugs and alcohol may be the direct cause of the visit as with the patient with cocaine induced chest pain or injuries sustained while driving an ATV while intoxicated. For others the connection to substance use may be less apparent, like the elderly woman who is brought into the ER by concerned family because of her recurrent falls and increasing confusion who has been secretly taking extra benzodiazepines to help her sleep.

A study published in the Annals of Emergency Medicine in 2004, however, demonstrated the need for a closer relationship between the emergency physician and the addictionologist. In a study of Tennessee hospitals, it was estimated that 27% of adult patients had unmet substance treatment needs (3). These patients were 81% more likely to require hospitalization during their ER visit and 46% more likely to have had another ER visit in the previous year. It was estimated that the cost in extra hospital charges for these patients was $777.2 million. The article describes the ER visit as “a teachable moment.” It clearly illustrates the possible cost for a failure to take advantage of that moment.

As has been mentioned, patients with substance problems make up a disproportionate number of ER patients compared to the general population. The Drug Awareness Warning Network (DAWN) report shows a significant trend, however, in the types of drugs and the numbers of ER visits.There was a 21% increase in 2005 of visits related to the nonmedical use of pharmaceuticals - both prescription and over the counter (4). This would coincide with figures in Addiction Medicine showing that prescription drug addiction is the fastest growing segment of the treatment population (5). Benzodiazepines were up 19%, opiates other than methadone were up 24%, and methadone alone was up 29%. The combination of prescription and illicit drugs with alcohol accounted for 36% of ER visits. This combination of substances leads to effects and interactions that no drug company ever imagined. Dealing with the toxic side effects of this combination falls to the emergency physician.

Among patients presenting to the ER who require admission for causes unrelated to substances, it remains incumbent upon the emergency physician to recognize substance use issues. The American College of Surgeons has made documentation and screening for alcohol and substance problems a part of the requirements for Trauma Center Level I and II certification. The emergency physician must identify patients at risk for substance problems during their hospitalization. Failure to recognize alcohol dependence in a patient admitted for COPD or chest pain may lead to significant worsening of the patient’s underlying problem as withdrawal progresses. That this patient in many community hospitals may not see another doctor until morning risks the development of withdrawal seizures or delirium tremens as well as deterioration of his primary medical condition. The problem with benzodiazepines is even more problematic in that a seizure may be the presenting symptom of sedative withdrawal without the preceding autonomic instability seen with alcohol (6). Awareness of the problem of substance dependence on the part of the emergency physician is the only preventive. While trained to deal with withdrawal, failure to identify dependence may put the emergency physician at a disadvantage. Part of the core competency in emergency medicine now required for board certification includes training and testing in dealing with these issues.

Emergency Medicine Research in Addiction Medicine
Most of the published research about emergency medicine and addiction has focused on brief intervention with patients identified as problem alcohol drinkers. They make up, as previously noted, a significant ER patient population. In addition, studies have shown that self reporting of alcohol use among ER patients can be reliable as an indicator of actual alcohol consumption, making alcohol abusers a relatively easy population to study not requiring the use of drug screens or breath tests to confirm data (7). To date, little has been published about ER interventions with drug use. The research in alcohol has been based upon the recognition that, in the primary care setting, brief intervention with patients identified as drinking more than 14 drinks per week or 4 per occasion for men or 7 per week or 3 drinks per occasion for women (i.e. above the “low risk” guidelines from the National Institute of Alcohol Abuse and Alcoholism) changed their behavior, resulting in less drinking. It was reasoned that a similar approach should be tested in the ER setting. The SBIRT (screening, brief intervention, referral to treatment) Project was an academic collaborative emergency department (ED) study that attempted to use similar tools in an ER setting (8). At 3 months follow up there was about a halving of the total number of patients who still exceeded the low risk guidelines who received the intervention compared to controls. Another study published from Yale in June 2008, however, disputed this conclusion, showing essentially no benefit at 6 and 12 months for a similar ED based intervention protocol. In an editorial accompanying the paper, it was noted that “5 of 12 studies failed to show an intervention effect” (9). This stands in contrast to studies from primary care and trauma where interventions have been shown to be effective to the point that they are now the standard of care. Rather than suggesting that intervention is not worthwhile in the ER, however, it is possible that the ER represents a setting significantly different than either the inpatient trauma service or family doctor’s office. The appropriate intervention technique has yet to be developed.

A criticism can be made from the addiction medicine standpoint concerning the standards by which these interventions are judged. They primarily use a public health standard of reduced drinking days or quantity consumed. This may be a helpful public health and large population measure but from the perspective of addiction medicine lacks usefulness in demonstrating that the interventions provide individuals with meaningful help. The diagnostic criteria used for alcohol abuse and dependence specifically do NOT include any mention of quantity of alcohol consumed. To suggest that an intervention that simply leads to less consumption is a success is a misunderstanding of the disease of addiction. It is not just a continuous spectrum disease where the more consumed the more severe the disease. Ultimately finding measures that focus on behaviors associated with drinking will prove most useful in that they will match more closely our understanding of the neurobiology of addiction. In that way interventions that result in meaningful change can be confirmed.

Addiction Screening in the Emergency Room
The ED is the perfect setting for the use of these screens since many of the patients are there as a direct or indirect result of their alcohol or drug use. Screening tests like the CAGE or AUDIThave been useful in both the primary care and ER setting (9). The interventions used have varied from scripted instructions (11) to training given to physicians who then do directed interviews (12). What follows these brief interventions has been perhaps the part that is most left to individual practice variation depending upon the ER setting. In one large city a special Alcohol Emergency Room was tried (13). At one time they were seeing 400 patients monthly and answering 270 calls for alcohol treatment referral, suggesting a possibility of funneling services through one provider. In the university hospital setting an addiction or psychiatric consultation may be available. In some large community hospitals social workers are in the ER helping with appropriate referral and placement once the patient is identified as needing addiction services. In some smaller hospitals referral to a community health center or tertiary center may be the only options. Addiction services are not always readily available to every ER patient. ER doctors may at times find dealing with substance patients time consuming and frustrating. To say the least, they can be resistant, belligerent and at times openly combative. Rarely are they the bright spot in the emergency physician’s night. Developing a plan for intervention and management with the help of addiction services can make the encounter less traumatic for everyone.

Emergency Physicians as Patients
Emergency physicians are finding themselves interacting with addiction medicine on a more personal level as well. Data from physician health programs show that emergency physicians, along with anesthesiologists and family practitioners, make up the largest numbers of physicians dealing with substance problems (14). In Florida 18% of participants in 2007 were ER doctors compared to anesthesiologists at 21% and family medicine at only 6% (14). The reasons for this disproportionate representation are mostly a matter of speculation. More emergency medicine residents report having used illicit substances in the last year than any other specialty (15). Similar findings were made about practicing emergency physicians as well (16). In spite of this, the majority of emergency physicians have a drug of choice of opiates, as do surgeons and anesthesiologists. To date no studies have specifically addressed the ability of emergency physicians to return to the ER to practice following addiction treatment versus a need to practice in another setting or re-training. Generally, the decisions are made on an individual basis depending on history and comorbidities.

The Newest Specialties
Finally, addiction medicine is going through the process that emergency medicine endured only a short time ago in being recognized as a legitimate medical specialty. The American College of Emergency Physicians was founded only 40 years ago by physicians who, while trained in other fields, practiced primarily in the ER setting and saw a need for recognition as a separate type of practice with a need for specific professional standards and training. This is similar to the current path of addiction medicine acting through the American Society of Addiction Medicine (ASAM). ASAM is working to develop certification and training standards that will meet approval from the American Board of Medical Specialties. The path from practitioners trained in other fields to academic departments of emergency medicine has been a rapid but at times difficult and controversial process. The specialty of addiction medicine as distinct from psychiatry, for whom it has always been a redheaded stepchild, has as difficult a task in carving its niche as a specialty.

Author Information
Dr Logan was raised in Kansas and graduated from the University of Kansas with honors in Political Science. He was a Summerfield Scholar (KU top academic scholarship for men) and received the Veta Lear Award (highest academic award for freshmen). He was in the political science honor society Phi Sigma Alpha and a member of Phi Beta Kappa. Dr Logan went to medical school at Baylor College of Medicine in Houston, graduating after three years. He was awarded a Texas Medical Association Scholarship. After initial training in Obstetrics and Gynecology at University of Kansas-Wichita and the Mayo Clinic in Rochester, MN Dr Logan started a career in Emergency Medicine. He practiced Emergency Medicine for 25 years and in 2007 was recertified by the American Board of Emergency Medicine. He has worked in small to very large community hospitals and large academic institutions as a staff physician, assistant director and department chairman. He has previously been medical director for the Franklin County (KS) EMS service. A mid-life career change started with work in the Addiction treatment field in Kansas and training at the University of Florida College of Medicine. He completed his fellowship in Addiction Medicine in February 2008 after working at the Florida Recovery Center under mentors Dr. Scott Teitelbaum and Dr. Kenneth Thompson. During his fellowship he worked with Dr. Mark Gold writing and editing educational programs for nurses and physicians on tobacco abuse and alcohol use in adolescents. He predicated in a study on a potential new surgical management of obesity. He also was a regular participant in the Department of Psychiatry Pain Management Clinic. As an Assistant Professor in the Addiction Medicine Division, College of Medicine, Dr Logan lectures to residents, physician assistant and medical students on topics of addiction related emergencies and smoking cessation. He has continued interest in the interface between addiction and emergency medicine and will holds appointments in both the Department of Psychiatry Division of Addiction Medicine as well as in Emergency Medicine as clinical faculty working on joint research and education projects. A rabid fan of Jayhawk basketball and football he is a member of the Kansas University Alumni Association. He is eligible to take the board exam in Addiction Medicine and is a member of the American Society of Addiction Medicine and the Florida Society of Addiction Medicine. He is a Fellow of the American College of Emergency Physicians and a Diplomate of the American Board of Emergency Medicine.

References
1. D’Onofrio G, Becker B, Woolard RH. The impact of alcohol, tobacco, and other drug use and abuse in the emergency department. Emerg Med Clin North Am. 2006 Nov 24(4):925-67

2. O’Rourke M, Richardson LD, Wilets I, D’Onofrio G. Alcohol-related problems: emergency physicians’ current practice and attitudes. J Emerg Med. 2006 Apr;30(3):263-8

3. Rockett IR, Putnam SL, Jia H, Chang CF, Smith GS.Unmet substance abuse treatment need, health services utilization, and cost: a population-based emergency department study. Ann Emerg Med.2005 Feb;45(2):118-27

4. Dawninfo.samhsa.gov [homepage on the Internet]. Drug Abuse Warning Network. Available from http://dawninfo.samhsa.gov

5. McCabe SE, Cranford JA, West BT. Trends in prescription drug abuse and dependence, co-occurrence with other substance use disorders, and treatment utilization: Results from two national surveys. Addict Behav.2008 Oct;33(10):1297-305.Epub 2008 Jun 12

6. Brunton, Parker, Lazo. Goodman and Gillman’s The pharmacological basis of therapeutics. 11th ed.New York: McGraw Hill; 2005

7. Vitale SG, Van De Mheen D, Van De Wiel A, Garretsen HF. Alcohol and illicit drug use among emergency room patients in the Netherlands. Alcohol Alcohol 2006 Sep-Oct;41(5):553-9.Epub 2006 Jun2

8. Bernstein E, Berstein J, Feldman J, Fernandez W, Hagan M, Mitchell P, et al. An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skill and utilization. Subst Abus.2007;28(4):79-92

9. CAGE meaning “Do you ever want to CUT down on your drinking,” and AUDIT meaning “Do you get ANGRY when someone comments on your drinking?”

10. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, Busch SH, Chawarski MC, et al. Brief intervention for hazardous and harmful drinkers in the emergency department. Ann Emerg Med.2008 Jun;51(6):742-750,e2.Epub 2008 Apr 23

11. Academic ED SBIRT Research Collaborative. The impact of screening, brief intervention, and referral for treatment on emergency department patients’ alcohol use. Ann Emerg Med. 2007 Dec;50(6):699-710, 710.el-6.Epub 2007 Sep 17

12. D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’Connor PG. Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med.2005 Mar;12(3):249-56

13. Dilts SL, Berns BR, Casper E. The alcohol emergency room in a general hospital: a model for crisis intervention. Hosp Community Psychiatry. 1978 Dec;29(12):795-6

14. Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders; Journal of Global Drug Policy and Practice. 2008 Vol 1 Issue 2. Available from: http://www.globaldrugpolicy.org/2/2/3.php

15. Hughes PH, Baldwin DC Jr, Sheehan DV, Conard S, Storr CL. Resident physician substance use, by specialty. Am J Psychiatry. 1992 Oct;149(10):1348-54