Managing substance abuse in the acute setting

Introduction: Substance abuse emergencies represent a unique set of challenges for physicians working in acute care settings. Patients presenting acutely with substance abuse issues often suffer from other psychiatric disorders, medical disorders, or frequently a combination of both. Furthermore, many patients who abuse alcohol, prescription drugs, or illicit drugs will present without revealing this fact at all. The prevalence of serious mental health disorders in patients with a history of substance abuse has been estimated to be over 25%. Medical emergencies associated with substance abuse have been estimated to be 2 million visits per year according the Drug Abuse Warning Network (DAWN). Another challenge with substance abuse patients is the presence of “altered mental status” (delirium or stupor) associated with acute and subacute ingestions, which frequently confounds a provider’s ability to obtain an accurate medical and psychiatric history and can obscure aspects of the examination. Furthermore, clinical presentations from different substance exposures and withdrawal states share common signs, potentially causing delays in definitive diagnoses. Finally, screening and detection through the utilization of toxicological analysis remains an imperfect and still developing technology. All of these challenges associated with substance abuse, in combination with potentially obscured medical and psychiatric comorbidities, often compel the clinician to make critical diagnostic and therapeutic decisions with incomplete information.