Follow-up of young patients after acute poisoning by substances of abuse: a comparative cohort study at an emergency outpatient clinic

Clinical impact of chronic substance abuse in a Norwegian ICU-population

BACKGROUND

The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD).

RESULTS

Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)).

CONCLUSION

One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.

Substance Use in Adolescents Presenting to the Emergency Department

Background:

Adolescent substance use is a dynamic public health problem. Adolescence is a unique developmental period involving overlapping biological, psychological, and social factors which increase the rates of initiation of substance use. The developing adolescent brain is particularly susceptible to the effects of substances and most adults with substance use disorders began to have symptoms and problems in their adolescent years. Yet, for various reasons, most adolescents who use, misuse, abuse, or are addicted to substances do not perceive the need for treatment.

Objective:

Drug and alcohol use among adolescents is a common presentation in hospital Emergency Departments (EDs) and presents in different forms including in association with intoxication, withdrawal states, or trauma associated with drug-related events. For many adolescents with substance use, the Emergency Department (ED) is the first point of contact with medical personnel and thus also serves as a potential entry point into treatment.

Methods:

This article reviews the common ways drug and alcohol problems present in the ED, clinical assessment of the patient and family, screening, laboratory testing, brief interventions in the ED, and referral to treatment beyond the ED.

Conclusion:

Guidelines on how to manage the shifting terrain of adolescent substance use presenting in EDs across the nation continue to evolve. We highlight that considerable further research is needed to inform effective ED protocols to address this important individual and public health safety concern. Systems of care models which include collaborative teams of diverse stake holders are needed to effectively manage adolescents with substance use disorders.

Characteristics and costs in adults with acute poisoning admitted to the emergency department of a university hospital in Belgium

Objective

The aims of this study were to assess the characteristics of all acute poisoning admissions among adult emergency department (ED) patients, to identify factors associated with admission and to calculate direct medical cost.

Methods

Data of 2017 (1^st January to 31^st December) were collected and analyzed retrospectively using patients’ medical records and hospital invoices. Factors associated with type of hospitalization were identified using appropriate statistics.

Results

A total of 1,214 hospital admissions were included, accounting for 3.6% of all ED admissions. Men (62.2%) and the age group 21–40 years (43.0%) accounted for the largest proportion. Substances most commonly involved were ethanol (52.9%), benzodiazepines (9.7%), cocaine (4.9%), cannabis (4.6%), antidepressants (4.6%) and psychostimulants (4.6%). A total of 4,561 treatment acts were recorded, most commonly monitoring of vital signs (63.6%) and medication and/or intravenous drip administration (62.9%). Patients were discharged home after having received care in the emergency department (ED-amb) in 54.5% of admissions, were admitted to the emergency-department-24-hours-observation unit (ED-24h) or were hospitalized (Hosp) in 24.6% and 20.9% of admissions, respectively. Factors found to be associated with hospitalization type were age, hour of admission, victim location, degree of severity, use of antidotes, involvement of antidepressants, antipsychotics, psychostimulants, benzodiazepines and ethanol. Total cost was €1,512,346 with an average of €1,287 per admission.

Conclusion

Poisonings entail a considerable percentage of patients admitted to an ED and financial burden. In particular, ethanol poisonings account for the largest proportion of all ED admissions. Comparison of our figures with other data is hampered by the heterogeneity in inclusion criteria. Availability of a uniform template would facilitate comparison and allow better monitoring policies for prevention and cost reduction.

Mortality and repeated poisoning after self-discharge during treatment for acute poisoning by substances of abuse: a prospective observational cohort study

Background

Though substance use is a known risk factor for self-discharge, patients self-discharging during treatment for acute poisoning have not previously been described. We charted characteristics of patients self-discharging during treatment for acute poisoning by substances of abuse looking for associations between self-discharge, repeated poisoning, and death.

Methods

All patients 12 years and older treated for acute poisoning by substances of abuse at an emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We collected data on gender, age, main toxic agent, suicidal intention, homelessness, history of severe mental illness, and self-discharge. Information on deaths was retrieved from the National Cause of Death Register. We did a multiple logistic regression analysis to look for associations between self-discharge and repeated poisoning and a Cox regression analysis for associations between self-discharge and death.

Results

During one year, 1731 patients were treated for 2343 episodes of acute poisoning by substances of abuse. Two-hundred-and-sixty-six (15%) patients self-discharged during at least one poisoning episode. Self-discharging patients were older, median age 39 years vs 32 years (p <  0.001), more frequently homeless, 20/266 (8%) vs 63/1465 (4%) (p = 0.035), and the main toxic agent more frequently was an opioid, 82/266 (31%) vs 282/1465 (19%) (p <  0.001). Self-discharge was an independent risk factor for repeated poisoning. The adjusted odds ratio for two or more poisoning episodes during one year among self-dischargers was 3.0 (95% CI 2.2–4.1). The association was even stronger for three or more poisoning episodes, adjusted odds ratio 5.0 (3.3–7.5). In total, there were 34 deaths, 9/266 (3.4%) among self-discharging patients and 25/1465 (1.7%) among patients not self-discharging (p = 0.12). The adjusted hazard ratio for death among self-discharging patients was 1.6 (0.75–3.6).

Conclusions

Self-discharge was associated with frequent poisonings by substances of abuse. Short-term mortality was doubled among self-discharging patients, though this increase was not statistically significant. Still, the increased risk of repeated poisoning marks self-discharging patients as a vulnerable group who might benefit from targeted post-discharge follow-up measures.