Drugs and alcohol in the Emergency Department

Emergency physician Dr Graeme Maw has pretty much seen it all in more than 20 years working in hospitals in Australia, the UK, and New Zealand and the one constant in that time has been the ongoing conundrum of drugs and alcohol in emergency patient presentations. 

The Australasian College for Emergency Medicine reports that 16 per cent, or around one in six, of all emergency presentations nationally relate to drug or alcohol use, a figure that does not surprise Dr Maw one bit.

“Alcohol is easily the most abused drug in terms of volume, but methamphetamine presentations are on the rise in Townsville,” he said.

“Ice use has increased significantly over the past five years and there is anecdotal evidence of more intravenous use of ice which brings a whole new set of problems including communicable diseases like HIV and hepatitis C, endocarditis (infection of the valves and membrane of the heart) and bacteraemia (bacteria in the bloodstream).

“These are very serious medical problems that can have life-long consequences.”

Dr Maw said medical issues for alcohol-affected patients in emergency related both to acute alcohol intoxication and chronic alcoholism.

“Both of these go hand in hand with the serious social and medical issues associated with drug and alcohol misuse,” he said.

“Alcohol is a depressant so presentations can relate to altered levels of consciousness, aspiration, and disinhibition which leads to injuries caused by falling over and getting into fights.

“Alcohol affects pretty much every system in the body including the brain, heart, gut, liver, endocrine and nervous systems while chronic alcoholism causes heart issues like cardiomyopathy (disease of the heart muscle) and arrythmia (fault in the heart’s electrical system) and is a big factor in incurable liver disease.

“There is no question that the burden of disease from alcohol and the cost to the community, and to the health system as a whole, is huge,” he said.

Dr Maw said chronic alcoholism also led to devastating social consequences like family and marriage breakdown, social isolation, and suicidal ideation, an observation echoed by emergency department allied health team leader Jenni Meehan.

Ms Meehan’s role is to coordinate the day-to-day input of the allied health team, including social work and drug and alcohol services, into emergency care.

“We are in the ED for extended hours seven days a week where part of our role is to help patients connect with services that can support their rehabilitation and connection back to home and family.

“The doctors and nurses are focussed on the medical and nursing response to the patient; our role is to look at the whole picture and see how and where we can support the patient,” she said.

“One of our biggest barriers, though, is that many people are not ready, or prepared, to engage in their own recovery.”

Ms Meehan said it was for this reason, she really wanted the problem with alcohol and drugs to stop before it started.

“There are many reasons that people misuse drugs and alcohol, including an inability to cope with the stresses of life, but the community needs to understand that this misuse can have disastrous consequences including mental health decline, traumatic injury, domestic and family violence.

“I really want to shine a light on that single fact; understand the damage drugs and alcohol can do and choose a different path because you will have a happier, healthier life.”

Dr Maw said serial presenters with alcohol and drug issues were a serious issue.

“There are a significant number of patients who came into the emergency department intoxicated, drug-affected, or both, very regularly,” he said.

“We have one or two patients who come in most days with presentations related to alcohol and drugs. 

“We had one patient who came in one or twice every day for three months intoxicated, with altered levels of consciousness bordering on intubation.

“He would tend to wake up quite aggressive so in addition to the high level of medical and nursing care he needed, we also needed a security presence to keep the environment around him safe.

“This patient took up a huge amount of resources and time every day and that’s the problem we have with patients who come in very intoxicated.

“There’s assessment, sometimes sedation, imaging, blood work, security is involved, and someone who is short of breath, for example, is waiting for me while I’m treating a patient whose presenting complaint was self-inflicted.

“The costs are enormous.”

Dr Maw said while he was often frustrated by alcohol and drug-affected patients, he never judged.

“It’s not my job to judge. As a doctor, it’s my job to help and heal,” he said.

“It doesn’t achieve anything to approach a patient with anything other than a plan to get them well.”

Dr Maw said he had worked many shifts in emergency where his only patients were those affected by drugs and alcohol.

As a senior emergency physician, he can be called on intubate a patient or manage a polytrauma caused by intoxication, overdose, or both.

“The frustration in this, is that it is so avoidable,” he said.

Dr Maw said alcohol and drug-affected patients were an issue everywhere he’s ever worked.

“In north-east England, where I come from, it’s far, far worse,” he said.

“I don’t have the solution, I don’t think anyone does, but my strong advice to the community is look after yourself and look after each other,” he said.

“We will always quite literally roll with the punches, but I ask people to reconsider the decision to drink to excess or inject ice.

“The consequences can be staggering for you, your community, and for hospitals like ours where we need and want to look after sick people.

“We will always look after you, CT your head, and stitch you up but we’d really rather that you were smart enough to understand the risks of drugs and alcohol and avoid them for both your own sake and for ours."