Waking up in the A&E clinic can be an eye-opener.
It’s just drunkenness. We have often tended to think this when teenagers and young adults are brought to the A&E clinic in a state of extreme intoxication, completely legless and unable to account for themselves. We have taken care of them until they have recovered and then sent them home.
Ulseth and colleagues have undertaken a study of young people admitted to Sørlandet Hospital with acute poisoning, and it is now published in the Journal of the Norwegian Medical Association (1). Half of these poisonings were related to substance use, and the majority were caused by alcohol. In contrast to patients who declared self-harm as their intention, few of them were referred for further follow-up after poisonings related to recreational substance use. Previously, this was also the case in Oslo (2).
At the Oslo Accident and Emergency Outpatient Clinic (OAEOC), we share the concerns of Ulseth and colleagues that poisonings associated with substance use are not recognised as hazardous behaviour. Alcohol poisoning is only seldom acutely lethal, but the young people who are brought to A&E clinics and emergency wards have been in a very vulnerable situation. They are often brought in from the city’s streets, where they have been unable to take care of themselves, but were found by someone who did the good deed of ensuring that they received help. Being found by someone with good intentions cannot be taken for granted, however.
Patients treated for poisoning related to substance use are at an increased risk of repeated poisonings, disease, poverty and early death (3–5). Although fortuitous accidents undoubtedly occur, those young people who end up in observation at the A&E clinic are unlikely to constitute a random sample of those who have gone out for a drink.
We use motivational interviews and undertake a screening to identify young people who are at an especially high risk of problems
About ten years ago, when we became aware of the disparity between the increased risk and the lack of follow-up, we felt that we had to take action. We decided to start with young people and established a follow-up intervention that targeted patients who were younger than 23 years and had problems related to substance use (6). The vast majority of these are brought in with acute alcohol poisoning. When the poisoning has been treated and the patient has woken up, we offer the opportunity for an appointment with a social worker or a nurse. We regard this as an opportune moment for an intervention. Nobody plans to wake up in the A&E clinic when they are taking the first drink of the evening, and such an event may be an eye-opener for many (7). The patient is also contacted by telephone for a new appointment within a couple of weeks. If the patient is younger than 18 years, his/her parents/guardians are alerted and included in parts of the interview. We use motivational interviews and undertake a screening to identify young people who are at an especially high risk of problems, in order to implement suitable follow-up.
Does this work? The idea is that these conversations by themselves help reduce the hazardous substance use-related behaviour, as some research on brief interventions indicates (8). When we were trying to answer this question at the OAEOC we found that we were referring more people to follow-up than previously, but we found no decline in the number of people who returned with a repeated poisoning (6). However, our study had some methodological weaknesses. Based on available research (8) and our own experience, we nevertheless believe that the follow-up project is a good idea. It has now been integrated as standard practice at the OAEOC, and a total of 790 such interviews were held after acute incidents in 2018 (9). The follow-up often reveals problems that extend beyond mere drunkenness, which indicates that this type of intervention should be integrated into the emergency treatment of substance use-related poisonings in A&E clinics and emergency wards. In the planning of similar measures, we also hope that others will seize the opportunity to undertake a randomised controlled trial, to be better able than us to answer the question of whether this works or not.