ED Visits for Alcohol and Substance Use Disorders Surging Nationally
One in 11 ED visits were made by adults with alcohol use disorder (AUD) or substance use disorder (SUD), according to the results of a recent study.1 “As clinicians, we had been experiencing a rising number of ED visits and hospitalizations among individuals with alcohol and other substance use disorders in recent years,” reports Leslie Suen, MD, MAS, the study’s lead author.
Suen and colleagues wanted to learn whether what they were seeing reflected national trends. They analyzed ED visits recorded from 2014 to 2018 using the National Hospital Ambulatory Medical Care Survey. They found that on average, 9.4% of ED visits annually involved AUD or SUD. The percentage of visits increased steadily over time. “When we examined visits by individuals with alcohol and other substance use disorders visiting safety net vs. non-safety net hospitals, we found populations were similar,” says Suen, a fellow in the National Clinician Scholars Program at the University of California, San Francisco Philip R. Lee Institute for Health Policy.
Suen and colleagues expected patients who visited safety net hospitals would be sicker, but this was not the case. “This fact only highlights for us how this issue affects all hospitals, not only those seeing predominantly disadvantaged populations,” Suen says.
ED patients with AUD or SUD were more likely to present with Medicaid coverage, to be experiencing homelessness, to have undergone mental health treatment previously, and to present with trauma and injury. The paper suggests systematically screening people who present with trauma for AUD/SUD.
In another analysis, the authors reported SUDs are just as deadly as heart attacks.2 “Yet so many EDs are still not offering any form of standard of care substance use treatment, potentially making them vulnerable to facing liability and lawsuits due to violation of EMTALA,” Suen says.
According to a recent report, EDs could be liable for disparate treatment and/or disparate impact discrimination if the EDs do not use evidence-based practices for substance use-related emergencies.3 “There is a moral and ethical obligation to offer standard of care for these conditions,” Suen concludes.
Patients with AUD and SUD “are among the most vexing and risky subcategory of patients who present to the emergency department,” according to Andrew P. Garlisi, MD, MPH, MBA, VAQSF, EMS medical director at Cleveland-based University Hospitals EMS Training & Disaster Preparedness Institute.
Presentations often are “bundled” with a host of comorbid conditions and chronic or acute traumatic events. “They range from the acutely intoxicated to patients suffering from potentially life-threatening withdrawal syndromes,” Garlisi says.
The group includes preteens experimenting with alcohol or recreational drugs and elderly patients who overdose on anxiolytic or narcotic prescription medications.
Garlisi says ED providers must consider many possibilities, including methamphetamine or cocaine abusers who present with uncontrolled hypertension and chest pain, chronic alcoholics in withdrawal experiencing seizures or arrhythmias, and auto-anticoagulated chronic alcoholics who collapse due to serious anemia from GI bleeding.
Providers also should consider intoxicated patients with multiple trauma, geriatric patients on chronic narcotics with subdural hematoma caused by frequent falls, intoxicated patients who intentionally overdose, and heroin overdose patients who were unresponsive at the scene but were revived with multiple doses of naloxone.
Providers should “suspect and expect an underlying potentially serious coexisting medical complication in each patient encountered until proven otherwise,” Garlisi stresses.
For example, chronic alcoholism is associated with a plethora of medical complications: liver disease, coagulopathy with bleeding complications, electrolyte imbalance, cardiac complications, hypoglycemia, and malnourishment.
“Traumatic injuries are common among this patient population and are often subtle,” Garlisi warns. “Added to the high risk is the stigma of the abuse disorder.”
This could negatively affect the judgment of ED staff who dismiss the patient as a “druggie” or a “frequent flyer.”
“Disparaging comments and judgmental statements should never be entered into the medical record,” Garlisi cautions.
The plaintiff attorney could argue the provider’s medical judgment was affected by bias or prejudice against the plaintiff. Unkind comments could be highlighted and magnified on a large screen for the jury to view. “Several of the jurors might have family members or close acquaintances who suffer from addiction, and the verdict [could be] impacted accordingly,” Garlisi says.
AUDs and SUDs can cloud the evaluation of other issues, such as trauma. “Primary emergent toxic effects of alcohol can present as bleeding from the GI tract, pancreatitis, alcoholic ketoacidosis, obtundation, arrhythmias, cardiomyopathy, and liver damage,” says Kenneth Alan Totz, DO, JD, FACEP, a Houston-based attorney and practicing EP.
Totz says the ED evaluation of an acutely intoxicated patient should include analysis of airway, breathing, and circulation; decision-making capacity; and serious consideration to ruling out coexistent trauma accounting for any pain or altered mental status. “The malpractice literature is littered with cases of missed subdural hematomas and [cervical] spine injuries that were blamed on alcohol intoxication,” Totz warns.
ED providers also should document the placement of a cervical collar until a cervical spine injury is eliminated from the differential diagnosis. If the provider elects not to place a cervical collar, documenting a reasonable rationale is important. “Your documentation will be helpful in case a patient removes their own collar and injures themselves or elopes from the ED,” Totz says.
The chart should reflect that cervical spine or head injury was considered, but ruled out using clinical decision rules, history, or physical exam.
“The medical record should be crystal clear that we considered the injuries, but that the patient was not injured at the time and place we evaluated them,” Totz says.
REFERENCES
- Suen LW, Makam AN, Snyder HR, et al. National prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014-2018. J Gen Intern Med 2021;Sep 13:1-9.
- King C, Cook R, Korthuis PT, et al. Causes of death in the 12 months after hospital discharge among patients with opioid use disorder. J Addict Med 2021; Sep 10. doi: 10.1097/ADM.0000000000000915. [Online ahead of print].
- Yeboah-Sampong S, Weber E, Friedman S. Emergency: Hospitals are Violating Federal Law by Denying Required Care for Substance Use Disorders in Emergency Departments. Legal Action Center, 2021.
Presentations often are bundled with a host of comorbid conditions and chronic or acute traumatic events. Providers should suspect and expect an underlying potentially serious coexisting medical complication in each patient encountered until proven otherwise.
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