What should you do next?
a. Send Mr. Hake to the hospital emergency department for immediate evaluation
This is the safest choice since Mr. Hake appears to be experiencing alcohol withdrawal again. Since he is at risk of delirium tremens which cares with it significant mortality risk. He should be watched closely and given medications to prevent serious complications such as seizures.
b. Call a substance use counselor for immediate consultation
If Mr. Hake were medically stable, this would be the best choice. When a patient comes to you and is ready for change, one of the best things you can do is get them the care they need right away. Strike while the iron is hot!
c. Give Mr. Hake the number to a substance use center and urge him to call himself
If Mr. Hake were medically stable, this would be one choice. However, if you have access to an on-site counselor or social worker, it is preferable to have the patient talk to someone knowledgeable who can help them get the next level of care. A phone number is OK, but a person who can answer questions, help find out more information such as insurance coverage, treatment options and other details is far superior.
d. Begin chlordiazepoxide 10 mg and have Mr. Hake return for re-assessment tomorrow
In oversimplified terms, this is what patients do when they are going through alcohol detox as an outpatient. Additionally, a patient will attend educational and counseling sessions as part of a comprehensive treatment plan. However, a patient must meet many criteria to be considered good, safe candidates for this type of treatment. First and foremost, they must be medically stable, which Mr. Hake is NOT!
Mr. Hake returns to your office for a follow up from his hospital visit. He looks disheveled and unwell. His vital signs again revealed marked hypertension and a pulse of 102. He is afebrile. His exam reveals bilateral upper extremity intention tremor and some inattentiveness on his mental status testing but is otherwise unremarkable. When you ask him when his last drink of alcohol was, he states he went on “a bender” drinking “more than I can remember” after he was released from the hospital. But he notes that he decided 3 days ago he “just can’t go on this way” so he stopped drinking altogether.