UBC Objectives: Addiction Medicine

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• ​Manage – including referral when appropriate – the most common acute intoxication and/or withdrawal syndromes

Based on my experience training in Canadian emergency departments in Alberta and British Columbia, in urban and rural centres, patients most commonly present with intoxication from alcohol, opioids, and methamphetamine. The most common withdrawal syndromes would likely be alcohol and opioids as well based on my experience. I also just asked some of my girlfriends who are also Family Medicine residents traveling in a car road-tripping with me this weekend, and they thought the same thing, in case you were wondering! 

Intoxication

1. In the intoxicated patient, you always want to start with the ABCs, providing supportive care as the ultimate priority while assessing the patient and collecting clues about the nature of the intoxication.
2. Decontamination to prevent further absorption of substances, if applicable. Being applicable is, however, usually the exception rather than the norm. If it is applicable, options include irrigation for topical exposures and gastric lavage and/or activated charcoal for ingestions, among other possible decontamination methods. The evidence is fairly limited that such interventions make a difference, and activated charcoal is not useful in the setting of alcohol intoxication as ethanol doesn’t bind to charcoal.
3. Administration of an antidote, if available. Naloxone is the antidote for an opioid overdose and would hopefully have already been given when the clinician is performing their rapid primary survey (aka ABCs). It’s important to remember that the half life of naloxone can be shorter than the opioids in the patient’s system, so repeated dosing of naloxone may be indicated.
4. Further elimination of the poison that is already floating around in the patient’s blood, when applicable. Dialysis may be used for life-threatening alcohol intoxication. Consult a Nephrologist if you think this may be needed.
5. Contact the nearest poison control centre for advice, if indicated. This would be useful if there is any uncertainty about poisonings and for advice on management. The World Health Organization has a list of all of the poison control centres worldwide. (WHO list of poison centres worldwide)
6. Refer for psychiatric consultation, if indicated, for ongoing care. The patient may also benefit from being linked to various support services in the community.

Withdrawal

1. Again, you always want to start with the ABCs, providing supportive care as the ultimate priority while assessing the patient and collecting clues about the nature of the withdrawal syndrome.
2. You want to be sure the patient is in or transferred to an environment where they can hopefully feel as safe as possible. Alcohol can be one of the most dangerous substances to withdraw from in a patient who is very physiologically dependent on it because of the risk for life-threatening seizures. Patients in alcohol withdrawal may be able to be managed in the outpatient setting if they have never had a history of alcohol withdrawal seizures and score sufficiently low on the Clinical Institute Withdrawal Assessment (CIWA) scale. 
3. Pharmacological interventions, if applicable. In the setting of alcohol withdrawal, benzodiazepines are the go to in preventing seizures. Consider that a patient may benefit from vitamin supplementation if they are severely malnourished, although this is usually not an urgent priority unless you think the patient may have Wernicke’s encephalopathy, an acute encephalopathy caused by a lack of folate that can happen in patient’s who have severely abused alcohol over a period of time.
4. Psychological interventions, as may be applicable via a referral to a Psychiatrist or community programs/services for ongoing support.