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Published on July 31, 2017

This problem is worse on Cape Cod than opiate dependencyThis problem is worse on Cape Cod than opiate dependency

While the opioid crisis on Cape Cod is an epidemic in need of addressing, another type of substance use is more prevalent in the region.

“The burden of alcoholism on Cape Cod is much larger than the burden of opiate use,” said Daria Hanson, MD, chief of behavioral health at Cape Cod Healthcare.

The numbers back up the anecdotal evidence. In 2015, the Barnstable County Department of Human Services issued a report, “Analysis of Substance Abuse on Cape Cod.” [pdf] The report estimated that 17,063 or 7.9 percent of the population on Cape Cod is dependent on alcohol. That is higher than all the other addictions combined.

Because of the serious nature of the problem, Cape Cod Healthcare instituted a policy last year at both Cape Cod Hospital and Falmouth Hospital whereby all patients who are admitted are screened by a trained nurse for alcohol dependence.

“We try to let people know that our questions about their alcohol use are not meant to accuse them of anything,” Dr. Hanson said. “We’re screening everyone because you never know who is going to go into alcohol withdrawal unless you ask the questions. Our goal is to provide a safety net underneath the patient.”

The protocol was developed because in the past so many patients would be admitted to the hospital for health conditions and the staff wouldn’t discover that the patient was in alcohol withdrawal until it was well underway. That meant that treatment for it wasn’t as accurate as it would be if the medical personnel had that information upfront.

“Alcohol withdrawal is a very serious condition,” Dr. Hanson said. “The patient will have changes in their heart rate, their blood pressure and their mental status. Oftentimes they become confused and agitated. They are at risk of progressing into a dangerous and potentially fatal condition called delirium tremens.”

How It’s Treated

The treatment of choice for alcohol withdrawal is a group of medications called benzodiazepines. In the past the hospital staff had to play “catch up” after the symptoms of alcohol withdrawal were detected. This led to over or under prescribing of the medicines that can help.

If a patient is overprescribed one of the medications, their gag reflex could be reduced and lead to aspiration and a stay in the intensive care unit for aspiration pneumonia. If a patient is under-medicated and the condition isn’t caught in time, no amount of benzodiazepines will be able to prevent the slide into serious alcohol withdrawal, seizures and delirium tremors. That patient would also end up in the ICU. Both problems dramatically increase the amount of time in the hospital.

“It’s a fine balance,” Dr. Hanson said. “You want to find the right dosing that matches up to their withdrawal symptoms.”

To do so, there are a series of screening tools. The first one is called an AUDIT-C Questionnaire [pdf] (Alcohol Use Disorders Identification Test). The admitting nurse asks all patients three simple questions:

  • How often do you have a drink containing alcohol?
  • How many standard drinks containing alcohol do you have on a typical day?
  • How often do you have six or more drinks on one occasion?

The answers to each question are scored given points from zero to four. If a person scores a total of four or higher total for all three questions, they progress onto another brief tool called the Prediction of Alcohol Withdrawal Severity Score (PAWSS). PAWSS is a 10-question assessment that predicts someone’s likelihood to go into dangerous alcohol withdrawal. If a patient scores four or higher on this series of questions, the doctor is informed and the nurse uses an assessment called CIWA-Ar [pdf] (Clinical Institute Withdrawal Assessment for Alcohol).

“The CIWA-Ar spells out how frequently the patient should be reassessed and how much medication should be administered,” Dr. Hanson said. “So if you don’t need the medication, you don’t get it. That avoids overmedicating people. But if you do need the medication and you need quite a bit of it, you’ll get it.”

Those whose assessment scores determine they might drink too much but that no medication is necessary will be monitored more closely to assure they aren’t going into alcohol withdrawal. If they have no symptoms after 24 hours, the protocol goes away.

While no one will be forced into treatment, the second part of the protocol is to offer referrals and tools to help patients who want help overcoming alcohol addiction. Cape Cod Healthcare hired Thomas Penders, MD, a certified addiction specialist, to address this issue. Dr. Penders helped design and implement the program and works in consultation with the psychiatry service.

“It appears that the new approach has been helpful for patients and staff,” Dr. Hanson said. “Anecdotally we are hearing from the nurses and physicians that our new approach has been a helpful tool in assessing and treating alcohol withdrawal. The hope is that by properly screening, continually assessing, and treating patients at risk for alcohol withdrawal we will improve the outcomes for these patients.

“We hope to decrease the length of stay in the hospital and the ICU. Another goal is to keep patients and staff safe while the patient progresses through alcohol withdrawal. Often those going through alcohol withdrawal can become delirious and then assaultive. If a patient is not thinking clearly they can get up out of bed and fall. We often must order sitters to stay with patients to keep them safe at all times.

“It’s best to just try to prevent the progression of alcohol withdrawal to avoid all of these negative outcomes. There are some patients who will not respond to intensive treatment no matter how much medication they receive. For these patients we hope to intervene early and intensively. The increased awareness and assessments can assist with this as well.”

The team of physicians and nurses also works closely with hospital social workers to help patients connect to ongoing substance abuse treatment services in the community.

“We aim to use a team approach to help our patients safely progress through alcohol withdrawal and to help them continue the treatment outside of the hospital,” Dr. Hanson said. “We work to involve family and outpatient providers so the safety net continues long after they leave our care.”

The answers to each question are scored given points from zero to four. If a person scores a total of four or higher total for all three questions, they progress onto another brief tool called the Prediction of Alcohol Withdrawal Severity Score (PAWSS). PAWSS is a 10-question assessment that predicts someone’s likelihood to go into dangerous alcohol withdrawal. If a patient scores four or higher on this series of questions, the doctor is informed and the nurse uses an assessment called CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol).

“The CIWA-Ar spells out how frequently the patient should be reassessed and how much medication should be administered,” Dr. Hanson said. “So if you don’t need the medication, you don’t get it. That avoids overmedicating people. But if you do need the medication and you need quite a bit of it, you’ll get it.”

Those whose assessment scores determine they might drink too much but that no medication is necessary will be monitored more closely to assure they aren’t going into alcohol withdrawal. If they have no symptoms after 24 hours, the protocol goes away.

While no one will be forced into treatment, the second part of the protocol is to offer referrals and tools to help patients who want help overcoming alcohol addiction. Cape Cod Healthcare hired Thomas Penders, MD, a certified addiction specialist, to address this issue. Dr. Penders helped design and implement the program and works in consultation with the psychiatry service.

“It appears that the new approach has been helpful for patients and staff,” Dr. Hanson said. “Anecdotally we are hearing from the nurses and physicians that our new approach has been a helpful tool in assessing and treating alcohol withdrawal. The hope is that by properly screening, continually assessing, and treating patients at risk for alcohol withdrawal we will improve the outcomes for these patients.

“We hope to decrease the length of stay in the hospital and the ICU. Another goal is to keep patients and staff safe while the patient progresses through alcohol withdrawal. Often those going through alcohol withdrawal can become delirious and then assaultive. If a patient is not thinking clearly they can get up out of bed and fall. We often must order sitters to stay with patients to keep them safe at all times.

“It’s best to just try to prevent the progression of alcohol withdrawal to avoid all of these negative outcomes. There are some patients who will not respond to intensive treatment no matter how much medication they receive. For these patients we hope to intervene early and intensively. The increased awareness and assessments can assist with this as well.”

The team of physicians and nurses also works closely with hospital social workers to help patients connect to ongoing substance abuse treatment services in the community.

“We aim to use a team approach to help our patients safely progress through alcohol withdrawal and to help them continue the treatment outside of the hospital,” Dr. Hanson said. “We work to involve family and outpatient providers so the safety net continues long after they leave our care.”