Evidence-Based Reviews

Teachable moments: Turning alcohol and drug emergencies into catalysts for change

Current Psychiatry. 2002 December;1(12):50-57

References

1. John F. Kennedy (speech). Indianapolis: April 12, 1959.

2. Office of Applied Studies Emergency department trends from the Drug Abuse Warning Network. Preliminary estimates, January-June 2001, with revised estimates, 1994-2000. Rockville, MD: Department of Health and Human Services, February 2002:40.

3. Office of Applied Studies. Mortality data from the Drug Abuse Warning Network, 2000. Rockville, MD: Department of Health and Human Services. January 2002:56-68.

4. Rosenthal RN, Westreich L. Treatment of persons with dual diagnoses of substance use disorder and other psychological problems. In: McCrady BS, Epstein EE (eds). Addictions: a comprehensive textbook. New York: Oxford University Press, 1999;439-76.

5. Sexia FA. Criteria for the diagnosis of alcoholism. In: Estes NJ, Heinemann ME (eds). Alcoholism: development, consequences and intervention. St. Louis: CV Mosby, 1982;49-66.

6. Menninger K. Man against himself. New York: Harcourt, Brace and World, 1938:147.

7. Hirschfeld RM. When to hospitalize the addict at risk for suicide. Ann NY Acad Sci 2001;932:188-96.

8. Malone KM, Oquendo MA, Haas GL, et al. Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry 2000;157:1084-8.

9. Sixth Special Report to the United States Congress on Alcohol and Health Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1987.

10. Erwin WE, Williams DB, Speir WA. Delirium tremens. South Med J 1998;91(5):425-32.

11. Mee-Lee D, Shulman GD, Fishman M, et al. ASAM patient placement criteria for the treatment of substance-related disorders (2nd ed, rev). Chevy Chase, MD: American Society of Addiction Medicine, 2001;27-33.

12. Weiss RD, Mirin SM, Bartell RL. Cocaine (2nd ed). Washington, DC: American Psychiatric Press, 1994;31-3.

13. Catravas JD, Waters IW, Walz MA, et al. Antidotes for cocaine poisoning. N Engl J Med 1977;301:1238.-

14. Stimmel B. Alcoholism, drug addiction, and the road to recovery. New York: Haworth Medical Press, 2002;142.-

15. Henry JA, Jeffreys KJ, Dawling S. Toxicity and deaths from 3,4 methylenedioxymethamphetamine (“ecstasy”). Lancet 1992;340:384-7.

16. Cohen RS. The love drug: marching to the beat of ecstasy. Binghamton, NY: Haworth Medical Press, 1998.

17. Baldridge EB, Bessen HA. Phencyclidine. Emerg Med Clin North Am 1990;8(3):541-50.

18. Silberstein SD. Drug-induced headache. Neurol Clin North Am 1998;16(1):114.-

19. Arana G, Rosenbaum JF. Handbook of psychiatric drug therapy (4th ed). New York: Lippincott Williams & Wilkins; 2000;179.-

20. Roche Laboratories Romazicon (package insert).

Withdrawal is treated by tapering the benzodiazepine dosage or substituting another benzodiazepine such as clonazepam. Benzodiazepine intoxication usually occurs only with large overdoses, although intoxication can last for days in a patient with hepatic disease. Lorazepam and oxazepam are not metabolized by the liver and can be prescribed to the patient in liver failure without causing an overdose.

Intoxication is usually treated with supportive measures and close observation for signs of withdrawal. Parenteral flumazenil immediately reverses benzodiazepine intoxication—which may assist both diagnosis and treatment—but its potential to cause seizures²⁰ decreases this antagonist’s clinical usefulness.

Because benzodiazepine addiction often begins with prescribed medication, emergency department personnel can educate both patients and prescribers. Medications such as diazepam, lorazepam, and alprazolam are relatively safe short-term soporific agents, but use for more than a few weeks often leads to physical dependence and/or addiction. Emergency personnel can help the patient and prescriber switch to a treatment with fewer side effects and less danger of addiction.

Summary

Addicts do often change their destructive behavior when faced with increasing consequences such as job loss, relationship problems, financial difficulties, and physical deterioration. Emergencies related to drug and alcohol abuse can serve as learning experiences. Emergency department psychiatrists and other clinicians can use these crises as opportunities to help the addict:

examine the consequences of substance use
and change the destructive behaviors that lead to medical and social consequences.

Related resources

American Academy of Addiction Psychiatry. www.aaap.org
Galanter M, Kleber HD (eds). Textbook of substance abuse treatment (2nd ed). Washington, DC: American Psychiatric Press, 1999.
Graham AW, Schultz TK (eds). Principles of addiction medicine (2nd ed). Chevy Chase, MD: American Society of Addiction Medicine, Inc., 1998.
National Clearinghouse on Alcohol and Drug Issues. www.ncadi.org

Drug brand names

Alprazolam • Xanax
Diazepam • Valium
Disulfiram • Antabuse
Flumazenil • Romazicon
Lorazepan • Ativan
Oxazepam • Serax
Secobarbital • Seconal

Disclosure

Dr. Westreich reports that he serves on the speakers’ bureaus of Pfizer Inc. and Bristol-Myers Squibb Company.