Transcript Presentation on alcohol use disorders for

ED Management of
Alcohol Use Disorders
Education Rounds for ED Nurses
META:PHI 2015
About META:PHI
Mentoring, Education, and Clinical Tools for Addiction:
Primary Care–Hospital Integration
•
Goals:
– Promote evidence-based addiction medicine treatment
– Implement care pathways between the ED, hospital, WMS, primary care, and
rapid access addiction medicine clinics
•
Seven sites in Ontario are currently involved, with plans to expand the spread of
the project in the future
•
Funding and support provided by the Adopting Research to Improve Care (ARTIC)
program (Council of Academic Hospitals of Ontario & Health Quality Ontario)
https://www.porticonetwork.ca/web/meta-phi
META:PHI 2015
Baseline Survey
The baseline survey is anonymous and entirely optional. You may skip any question
that you do not wish to answer. We will not ask you for any personal information.
Please tear off and keep the front page with contact information, should you have
any questions about the survey or the META:PHI project.
Please return the completed or incomplete survey face down to the facilitator when
you leave the presentation.
OVERVIEW
META:PHI 2015
Role of the Nurse
• In managing alcohol use disorders in the ED,
nurses play a key role:
– Nurses spend more time with patients
– Patients are more likely to confide in nurses than in
other medical staff
– Nurses are more likely to
provide discharge advice
– Nurses can send patients
to the RAAM clinic without
a formal MD referral
META:PHI 2015
Beyond Clinical Knowledge
• Nurses play a significant role in a patient’s early recovery
– Patients coming to the ED with an alcohol problem are often:
• Fearful
• Ashamed
• Wanting to change but unsure how
– Nurses can play an important role in helping them change by
offering:
• Empathy
• Optimism that things can improve with treatment
• Practical advice and suggestions (e.g. to attend the RAAM clinic)
– It is important to remember that nurses can, and often do, make
a big difference to patient outcomes
META:PHI 2015
Beyond Clinical Knowledge (2)
– Patients often attend the emergency department
when in crisis, e.g.:
•
•
•
•
Partner threatening to leave
Children taken by CAS
DUI
Job loss
– Nurse attitude toward a patient with AUD during
their first treatment encounter can influence their
future participation in treatment
META:PHI 2015
Nursing Goals for
AUD Patients in the ED
1. Treat presenting problem (intoxication,
overdose, withdrawal, alcohol-related injury
etc.)
2. Screen for possible alcohol use disorder
3. Give advice on avoiding alcohol-related
harms
4. Provide referral to rapid access addiction
medicine clinic for long term medicationassisted treatment
META:PHI 2015
IDENTIFYING AN ALCOHOL USE
DISORDER
META:PHI 2015
Identifying an AUD
• Common alcohol-related presentations in the
ED:
– Intoxication
– Withdrawal
– Trauma
– GI (gastritis, alcoholic hepatitis, cirrhosis)
– Depression and suicidal ideation
– Failure to thrive (elderly)
META:PHI 2015
Screening for AUD
• In all patients with a possible alcohol-related problem, ask this
screening question:
– “How many times in the past year have you had 5 or
more drinks on one occasion (men) or 4 or more drinks
on one occasion (women)?”
• If they answer 2 or more times ask:
– “How many days per week do you drink? How many
drinks do you usually have per day?”
• Note: One drink = 5 oz. wine, 1 bottle of beer, 1 ½ oz.
liquor
– One bottle of wine = 5 drinks
– One “mickey” of liquor (13 oz) = 9 drinks
– One 26 oz bottle of liquor = 18 drinks
META:PHI 2015
Standard Drink Size
Image from Canadian Centre on Substance Abuse
META:PHI 2015
Low-Risk Drinking
• Canada’s low-risk drinking guidelines suggest that:
– Women not exceed 10 drinks a week
• Consume no more than 2 drinks a day most days
– Men not exceed 15 drinks a week
• Consume no more than 3 drinks a day most days
• If the patient drinks in excess of these guidelines, it may
indicate problematic alcohol use, and patient should be
referred to Rapid Access Addiction Medicine (RAAM) Clinic
META:PHI 2015
Other Indicators of AUD in the ED
• Signs of intoxication
• High blood alcohol level
– 17 mmol/l = legal limit
• Men would need to have 4 drinks in preceding hour or
5 in preceding 2 hours etc. to have a BAL of 17 mmol/l
• Women would need 3 drinks in preceding hour
• Other labs: Elevated GGT, MCV; AST > ALT
META:PHI 2015
GENERAL APPROACH TO
MANAGING AUDS IN THE ED
META:PHI 2015
Advice and Referral
• ED nurses should provide advice and referral
to all patients with an alcohol-related problem
– These discussions are more effective if family
members are present
META:PHI 2015
Advice on Treatment
• Explain the link between patient's alcohol use
and their presenting condition
• Tell patients that treatment works for many
people, and they are unlikely to recover
without treatment
• Inform them that their alcohol-related
condition will improve or resolve with
abstinence
META:PHI 2015
Referral to WMS
• Refer patients to withdrawal management,
particularly if:
– They may go into withdrawal
– They do not have positive social supports
– They are in crisis (e.g., their partner has
threatened to leave them) and they want to start
treatment right away
META:PHI 2015
Refer All Patients to the RAAM Clinic
• Advantages of RAAM clinic:
– Located near the ED
– Patient can be seen within a few days without an
appointment
– RAAM clinic provides both counselling and anticraving medication
– Addiction specialist provides shared care with the
patient’s family physician
• Refer patients to withdrawal management until
next RAAM clinic day if support would be helpful
META:PHI 2015
Anti-Craving Medications
• The RAAM clinic will prescribe medications
that have been shown to reduce cravings and
binges
– None of the medications on the following slide
have psychoactive effects
– None of the following medications are addicting
META:PHI 2015
Medication
What it Does
Is it
Addictive?
Does it cause
nausea if you
drink?
Naltrexone
*Frontline treatment
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Acamprosate
*Frontline treatment
Reduces alcohol cravings
No
No
Topiramate
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Gabapentin
Reduces alcohol cravings
Improves mood
Improves sleep
No
No
Baclofen
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Disulfiram
Makes you sick if you drink
Most effective if dispensed
daily by spouse or friend
No
Yes
META:PHI 2015
MANAGING ALCOHOL WITHDRAWAL
IN THE ED
META:PHI 2015
Clinical Features of Alcohol
Withdrawal
• Signs of withdrawal begin 6-12 hours after the
last drink
• Withdrawal symptoms usually resolve in 2-3
days, but can last up to 7 days
• Most reliable signs: sweating and tremor
– Other signs: tachycardia, hyper-reflexia, ataxia
• Symptoms: anxiety, nausea
META:PHI 2015
Risk Factors
• Risk and severity increase with amount
consumed; uncommon with < 6 drinks per day
• Large inter-individual variation in risk and
severity
• Predictable pattern: patients with previous
withdrawal seizures at high risk for recurrence
META:PHI 2015
Tremor
• With true tremor, patient does not fatigue
• Patients trying to mimic tremor will likely fatigue
• Best assessed with patient seated, arms fully
extended
• Not a resting tremor
• Sometimes a whole body
tremor (head, legs)
META:PHI 2015
Withdrawal Severity Scales
Clinical Institute Withdrawal
Assessment for Alcohol (CIWA-A)
• Validated, reliable
• Administered by nurse every
1-2 hours; takes 3-5 minutes
• 10 questions, each rated on
scale from 1 to 7
• Questions include symptoms
(anxiety, nausea, headache)
and signs (tremor, sweating)
• False positives: Other causes
of vomiting, headache,
anxiety, etc.
• False negatives: Language
barrier
Sweating, Hallucinations,
Orientation, Tremor (SHOT)
• 4 items scored on a scale from
2-4
• Administered by nurse every
1-2 hours; takes 1-2 minutes
• Takes less time to administer
• Less likely to give false positive
• Less evidence on validity and
reliability
META:PHI 2015
How to assess and treat
patients in alcohol withdrawal
using the CIWA Protocol and
SHOT Scale
META:PHI 2015
CIWA-Ar scale
Nausea/vomiting: “Do you feel sick to your stomach? Have you vomited?”
0 No nausea or vomiting
1
2
3
4 Intermittent nausea with dry heaves
5
6
7 constant nausea, frequent dry heaves and
vomiting
Tremor: Arms extended and fingers spread apart
0 No tremor
1 Tremor not visible but can be felt fingertip
to fingertip
2
3
4 Moderate with patient’s arms extended
5
6
7 Severe, even with arms not extended
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats
2
3
4 Moderately anxious, or guarded, so
anxiety is inferred
5
6
7 Equivalent to acute panic states as seen in
severe delirium or acute schizophrenic
reactions
Paroxysmal sweats
0 No sweat visible
1 Barely perceptible sweating, palms moist
Anxiety: “Do you feel nervous?”
0 No anxiety, at ease
1 Mildly anxious
Headache, fullness in head: “Does your head feel different? Does it feel like there is a band around your head?” Do not
rate for dizziness or light-headedness. Otherwise, rate severity.
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
META:PHI 2015
5 Severe
6 Very severe
7 Extremely severe
Agitation
0 Normal activity
1 Somewhat more than normal activity
META:PHI 2015
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the
interview, or constantly thrashes about
Tactile disturbances: “Have you had any itching, pins and needles sensations, any burning or numbness, or do you feel
bugs crawling on your skin?”
0 None
1 Very mild itching, pins and needles,
burning, or numbness
2 Mild itching, pins and needles, burning, or
numbness
3 Moderate itching, pins and needles,
burning, or numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Auditory disturbances: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you
hearing anything that is disturbing to you? Are you hearing things you know are not there?”
0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Visual disturbances: “Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you
seeing anything that is disturbing to you? Are you seeing things you know are not there?”
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe sensitivity
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Orientation and clouding of sensorium: “What day is this? Where are you? Who am I?”
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain
about date
2 Disoriented for date by no more than 2
calendar days
3 Disoriented for place by more than 2
calendar days
4 Disoriented for place and/or person
• Score of 10+ indicates need for benzodiazepines
• Discontinue treatment when score < 8 on two consecutive occasions
Application of the CIWA
• In general, record your interpretation of what
the patient says and what you observe
– E.g. Patient says they feel very nauseated, yet they
are eating and drinking normally – Should be rated
as a 1 or 2
• Record discrepancies between answers and
observations in the nursing note
META:PHI 2015
NAUSEA & VOMITING: Ask “do you feel sick? Have you
vomited?”
0 No nausea/vomiting
1
2
3
4 Intermittent nausea with dry heaves
5
6
7 Constant nausea, frequency dry heaves & vomiting
Ask: “Are you nauseous? On a scale of 0-7, how nauseated do you feel?”
Observe: Look for any evidence of vomiting (k-basin etc. at bedside).
•
Is patient asking for something specifically for nausea?
META:PHI 2015
TREMOR: Arms extended and fingers spread apart
0 No tremor
1 Not visible, but can be felt fingertip to fingertip
2
3
4 Moderate, with patient’s arms extended
5
6
7 Severe, even with arms not extended
Ask: “Can you reach for this coffee cup/pen?”
Ask: “Can you please extend your arms in front of you, with your palms at a ninety degree angle?”
Observe: Look out for any evidence of tremor.
•
How severe is the tremor?
•
Is the tremor typical (high frequency, visible with movement/action, does not fatigue)?
•
If you cannot see a tremor, you can consider putting your fingertips in contact with the patient.
If you can feel a tremor that you cannot see, it is a 1/7.
META:PHI 2015
PAROXYSMAL SWEATS:
0 No sweat visible
1 Barely perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats
Observe: Observe patients for sweat, and feel their palms.
META:PHI 2015
ANXIETY: Ask “Do you feel nervous”
0 No anxiety, at ease.
1 Mildly anxious
2
3
4 Moderately anxious, or guarded, so anxiety is inferred
5
6
7 Acute panic as seen in severe delirium or acute schizophrenic
reactions
Ask: “How anxious are you feeling right now on a scale of 0-7, with 0 being at ease, and 7
being the most anxious you have ever been?”
• If a patient answers with “7” (acute panic), but they are clearly able to concentrate and are
not fidgety, they are probably not a true 7.
META:PHI 2015
AGITATION: Observation
0 Normal activity
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of interview, or constantly
thrashes about
Observe: Observe the patient to look for signs of agitation.
• Signs may be obvious, or subtle.
• E.g. patients may not want to sit down, may continuously readjust the way they are sitting,
may play with hospital bands or pace constantly etc.
• Agitation is more accurately rated through observation rather than by asking.
META:PHI 2015
TACTILE DISTURBANCES: Ask “Have you had any itching, pins
and needle sensations, any burning, any numbness or do you
feel bugs crawling on or under your skin?”
0 None
1 Very mild itching, pins and needles, burning or numbness
2 Mild itching, pins and needs, burning or numbness
3 Moderate pins and needles, burning or numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Ask: “Sometimes people in alcohol withdrawal feel weird sensations in their skin – have you had any
feelings like that?”
• Let the patient explain what they are feeling.
META:PHI 2015
AUDITORY DISTURBANCES: Ask “Are you more aware of sounds
around you? Are they harsh? Do they frighten you? Are you
hearing anything that is disturbing you? Are you hearing things
you know are not there”
0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate mild harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Ask: “Do you feel that you are more aware of sounds around you?”
Ask: “Do you ever think that you are hearing things that maybe not everyone else hears?”
META:PHI 2015
VISUAL DISTURBANCES: Ask “Does the light appear to be too
bright? Is its colour different? Does it hurt your eyes? Are you
seeing anything that is disturbing to you? Are you seeing things
you know are not there?”
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Ask: “Does the light appear to be too bright?”
• Sometimes people in withdrawal are much more sensitive to light.
• In general, patients who have light sensitivity but no hallucinations could rate up to a 3 on the scale,
so if patient responds that they are sensitive to light, ask them to rate it on a scale of 0-3.
Ask: “Are you seeing anything that you think other people might not see?”
• Sometimes people in alcohol withdrawal see things that other people do not seem to see or feel.
• In general, people who are having visual hallucinations would rate 4 or more.
• If patient has hallucinations, score rate as 4 for occasional hallucinations and up to 7 for continuous
hallucinations.
META:PHI 2015
HEADACHE, FULLNESS IN HEAD: Ask “Does your head feel
different? Does it feel like there is a band around your head?”
Do not rate for dizziness or lightheadedness.
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe
Ask: “Do you have a headache?”
• If patient reports that they do, ask them to rate it on a scale of 0-7.
• Make sure to only rate for pain, and not dizziness or lightheadedness.
META:PHI 2015
ORIENTATION & CLOUDING OF SENSORIUM: Ask “What day is
this? Where are you? Who am I?”
0 Orientation and can do serial additions
1 Cannot do serial additions or is uncertain about the date
2 Disorientated for date by no more than 2 calendar days
3 Disoriented for date by more than 2 calendar days
4 Disoriented to place and/or person
Ask: “What is today’s date (day of the week, month, year)?”
Ask: “Where are you right now?”
•
•
Orientation is critical to assess.
• If a patient is disoriented, it may indicate that they are suffering from delirium, which may be
related to alcohol withdrawal.
• All patients with delirium should be admitted to hospital until the cause is determined and
appropriately managed.
Remember that responses are contextual.
• E.g. if a business person has come from place of employment, you would expect them to
know the exact date. A homeless person, might be expected to know place and season.
META:PHI 2015
Application of the SHOT
• In general, record your interpretation of what the patient says
and what you observe
– Be careful of false positives:
• Interpret SHOT with caution if patient has a febrile
illness, cerebellar disease or benign essential tremor,
psychosis, dementia, impaired consciousness, or
delirium not related to alcohol
– Positive H or O: If either H or O is greater than zero, assess
and treat for delirium, encephalopathy, and/or psychosis
META:PHI 2015
SHOT Scale
Sweating
0 – No visible sweating
1 – Palms moderately moist
2 – Visible beads of sweat on forehead
Hallucinations
“Are you feeling, seeing, or hearing anything that
is disturbing to you? Are you seeing or hearing
things you know are not there?”
0 – No hallucinations
1 – Tactile hallucinations only
2 – Visual and/or auditory hallucinations
Orientation
“What is the date, month, and year?
Where are you? Who am I?”
0 – Oriented
1 – Disoriented to date by one month or more
2 – Disoriented to place or person
Tremor
Extend arms and reach for object.
Walk across hall (optional).
0 – No tremor
1 – Minimally visible tremor
2 – Mild tremor
3 – Moderate tremor
4 – Severe tremor
• Score of 2+ indicates need for benzodiazepines
• Discontinue treatment when score < 2 on two consecutive occasions
META:PHI 2015
Treatment of Alcohol Withdrawal
• Benzodiazepines treat alcohol withdrawal
• Mimic ethanol’s effect on GABA receptors
• Diazepam is the preferred benzodiazepine unless
there is liver failure (cirrhosis, jaundice, ascites)
• Then Lorazepam should be used
• Not unusual to give large total amounts (over 100
mg diazepam) as heavy drinkers will be very
tolerant
• Once fully treated, patients can be safely
discharged to home/detox
META:PHI 2015
Protocol: Symptom-Triggered
Treatment of Alcohol Withdrawal (1)
1. Diazepam treatment
• 10-20 mg PO q 1-2 H when CIWA ≥10 or SHOT
≥2
• If cannot take diazepam orally, lorazepam is
best alternative, or IV diazepam at a rate of no
more than 2-5 mg/min
META:PHI 2015
Diazepam: Precautions
• Can cause sedation if:
–
–
–
–
–
Patient intoxicated (estimated BAL > 30-40 mmol/l)
Liver dysfunction
Patient is elderly
Low serum albumin
On methadone or high doses of opioids
• Can trigger encephalopathy in patients with
decompensated cirrhosis
• Can cause respiratory depression in patients with
severe COPD, asthma or pneumonia
META:PHI 2015
Symptom-Triggered Treatment of
Alcohol Withdrawal (2)
2. Lorazepam
• 2-4 mg PO, SL, IM, IV q 1-2 H
• Shorter duration of action than diazepam
• Safer in patients at high risk for diazepam
toxicity:
– Liver dysfunction, elderly, low serum albumin, on
methadone or high dose opioids, decompensated
cirrhosis, respiratory impairment
META:PHI 2015
Diazepam Vs. Lorazepam
Diazepam
Lorazepam
Dosing Equivalents
5 mg
1 mg
Dispensing for
withdrawal
10-20 mg PO q 1-2 H
2-4 mg PO, SL, IM, IV q 12H
Duration of action
Up to 5 days
12 hours
• Diazepam’s long half life reduces the number of additional doses required
META:PHI 2015
Discharge Home
• Ideally, patients who have had withdrawal
treated DO NOT require a prescription but
there may be times when this is necessary
• If prescription required:
– Coach patient’s partner/support person on
dispensing medication at home if present
– Coach patient not to drink
– Direct patient to follow up with family physician in
1-2 days
META:PHI 2015
Case Scenario - Gary
• Gary is a 46-year-old street-involved man with
a short but severe history of alcohol use. Gary
frequently presents to the ED, usually
intoxicated, occasionally in withdrawal. Gary
arrived at the ED last night severely
intoxicated and was given an IV and kept
overnight. He is now in mild withdrawal and
wants to leave.
META:PHI 2013
Question
• How would you manage Gary and his request
to leave the ED?
META:PHI 2013
Managing Gary
• Ensure that Gary’s CIWA score is less than 8 on
two consecutive occasions and he has minimal or
no tremor before being discharged from the ED
• Refer Gary to RAAM clinic and emphasize that
alcohol use disorder is treatable and that
effective medications exist
• Refer Gary to WMS until next open RAAM clinic,
for psychosocial support and safe shelter
META:PHI 2013
MANAGEMENT OF CO-OCCURRING
CONDITIONS AND COMPLICATIONS OF
ALCOHOL USE
META:PHI 2015
Anxiety, Depression, and Suicidal
Ideation
• If patient is intoxicated and suicidal, observe
patient in ED until intoxication resolves
• Even if suicidal ideation resolves when sober,
patient should be seen by psychiatrist if:
– Has recently attempted suicide
– Remains severely depressed
– Has frequent binges
– Has other major risk factors for suicide
META:PHI 2015
Discharging the Patient with AlcoholInduced Depression
• Upon discharge, explain that:
– Alcohol causes short-lived relief of
depression/anxiety but overall it can cause or
dramatically worsen mood or anxiety
– Abstinence/reduced drinking improves mood
within days or weeks
– Patient needs treatment urgently
• Refer to RAAM clinic and other community
treatment
META:PHI 2015
Alcohol and Trauma
• Risk of trauma dramatically increases with each drink
• Even if you suspect patient is just young, reckless weekend
binge drinker without AUD, they are still at high risk of trauma
and need treatment
– Refer to RAAM clinic
META:PHI 2015
Harm Reduction Strategies to
Avoid Intoxication
• Strategies:
– No more than one drink per hour
– Sip rather than gulp
– Switch to non-favourite drink
– Avoid unmeasured drinks (especially vodka)
– Alternate alcoholic drinks with non-alcoholic drinks
– Eat before and while drinking
• If patient has serious AUD (e.g., recurrent visits to ED for
intoxication and withdrawal) harm reduction advice is unlikely to
work
– Patient must remain abstinent
– Refer them to RAAM clinic
META:PHI 2015
Ways to Avoid Trauma if Drinking
• Strategies:
– Do not drive a car or boat after drinking
– Do not get in a car or boat with people who have been
drinking
– Do not engage in arguments with intoxicated people
– Leave a party if lots of strangers begin to arrive, or if it
starts to get chaotic
– Have a non-drinking friend accompany you and take you
home
META:PHI 2015
Case Scenario - Steve
Steve is a 21-year-old man who fell in a bar
parking lot. He sustained a Colles’ fracture of the
wrist. On presentation to the emergency
department the nurses noted a strong odor of
alcohol. The patient was somewhat boisterous
but cooperative. Several hours later his fracture
has been casted and he is ready for discharge.
META:PHI 2013
Question
• What are 3 pieces of advice that you would
want to give Steve?
META:PHI 2013
Three Pieces of Discharge Advice
1) Avoid severe intoxication using the harm
reduction strategies above
2) If drinking, avoid risky situations and
activities (e.g., driving, boating)
3) If your drinking is interfering with your life
(e.g., you’re getting injured) you should
consider attending treatment (e.g. RAAM
Clinic)
META:PHI 2013
Other Conditions
• Decompensated cirrhosis, GI conditions,
cardiac, elderly (e.g. failure to thrive)
• In any condition where AUD suspected:
– Ask patient about alcohol consumption
– Talk to patient’s family
– Advise patients that alcohol cessation or reduction
is essential for successful treatment
– Advise patient to attend treatment and RAAM
META:PHI 2015