Substance Use and Alcohol Abuse in Emergency Medicine Training Programs, by Resident Report

ABSTRACT
Objective : To determine the prevalence of substance use and alcohol abuse among emergency medicine residents.
Method : The study instrument was an anonymous, self-report survey that assessed the use of 13 substances and included the CAGE questions for measuring alcohol abuse. The survey was administered to emergency medicine residents at the time of the American Board of Emergency Medicine's annual In-Service Examination.
Results : Alcohol was the substance most commonly used by emergency medicine residents for nonmedical reasons. Using the CAGE score, 4.9% of residents were classified as alcoholic and another 7.6% as suspect for alcoholism, rates similar to those for housestaff of all specialties as reported in earlier studies. Instruction related to physician impairment during training in their emergency medicine residency was reported by only 36% of the respondents.
Conclusions : Emergency medicine residents report a low rate of illicit substance use and do not appear to misuse alcohol differently than other housestaff. Interpretation of these results must be tempered with the potential for underreporting that may occur with a voluntary self-report survey of a sensitive nature.
Acad. Emerg. Med. 1994; 1:47–53.     

Alcohol consumption,dependence and foraging

Background: Smartphone technology enables treatment providers to deliver targeted outpatient support “on site” in “real time,” but this will require a better understanding of peer networks and substance users’ acquisition of drugs. Objectives: This study sought to understand contextual factors associated with risky levels of alcohol consumption. Methods: A total of 280 participants answered an online survey, completed the AUDIT and indicated their numbers of regular drinking partners, and the number of times and places alcohol was normally consumed. Results: Hazardous drinkers had a greater number of drinking partners and drank alcohol at a greater number of times and locations. Alcohol dependence was associated with alcohol use in more times and places, but was not linked to the numbers of drinking partners. Models drawn from foraging literature were used to describe the data. Conclusions/Importance: Patterns of alcohol foraging could be described by power laws, and such power laws could be used to compare foraging for a range of substances. A consideration of foraging behavior may inform location-aware services targeting risky substance use.     

Religiousness, Current Substance Use, and Early Risk Indicators for Substance Abuse in Nursing Students

Nursing students have been targeted by the American Nurses' Association (ANA) for efforts focused on the prevention of substance abuse. This study surveyed 241 nursing students enrolled in their first year of nursing courses at seven faith-based colleges and universities. The purposes were to investigate the prevalence of current substance use and the number of early risk indicators for substance abuse and dependence among nursing students, and to examine the relationships among religiousness, current substance use, and early risk indicators for substance abuse. Efinger's Alcohol Risk Survey, the CAGE Questionnaire, and the Intrinsic/Extrinsic-Revised Scale were used to collect data. Twenty-four percent of respondents reported current substance use, 15% scored in the probable abuse/dependence category: those who were more religious tended to have lower prevalence rates of substance use as well as fewer numbers of early risk indicators.     

Hazardous and harmful drinking: a comparison of the AUDIT and CAGE screening questionnaires

BACKGROUND: Hazardous and harmful use of alcohol remains a public health concern, and many general hospital admissions are alcohol-related. AIM: To compare the CAGE and Alcohol Use Disorders Identification Test (AUDIT) questionnaires in screening general medical admissions for harmful or hazardous drinking. DESIGN: Prospective questionnaire-based study. METHODS: Both questionnaires were administered, and demographic data collected. RESULTS: One hundred and three patients were included. Of these, 36% were identified by the AUDIT to be drinking hazardously or harmfully, and 22% were identified as CAGE cases. All CAGE cases were also AUDIT cases. DISCUSSION: As the CAGE and the AUDIT are designed to identify different populations, it is not surprising that significantly fewer cases were identified using the CAGE. The AUDIT identifies not just the harmful drinkers detected by the CAGE, but also hazardous drinkers, who have not yet reached that level of harm. As drinkers at an earlier stage may respond better to interventions aimed at reducing their consumption, the AUDIT is preferable in clinical practice.     

Violence and Substance Use among an Injured Emergency Department Population

OBJECTIVES: This study evaluated a sample of emergency department (ED) patients for history of violence and substance abuse. METHODS: Injured patients (n = 320) completed questionnaires (14% refusal rate) during a visit to a Level 1 urban ED after an acute injury. Specific questions were asked regarding whether the injury was related to acute violence (AV), whether there was past-year violence history (VH), including violence victimization and perpetration in both partner and nonpartner relationships, as well as any substance use in the past month and any substance-related consequences in the past year. RESULTS: Fourteen percent of the participants presented with an AV-related injury, and 53% reported VH. Most AV patients (89%) reported VH. No significant differences were found between the participants with AV and VH in demographic, substance use, or substance-related consequences. The AV and VH groups were combined (V), with analyses comparing these participants with those without AV and VH. Men were significantly more likely than women to report V (odds ratio = 2.0). V was significantly related to substance use and substance-related consequences. For example, in comparison with the participants reporting no alcohol or drug use, those reporting illicit drug use were 6.2 times as likely to report V, and those drinking any alcohol only were 2.0 times as likely to report V. CONCLUSIONS: A large percentage of injured patients in this urban ED experienced violence in the past year. Alcohol and illicit drugs appear to be concomitant with violence.     

Laboratory measures of alcohol (ethanol) consumption: strategies to assess drinking patterns with biochemical measures

Alcohol (ethanol) use is a global, health-related problem that spans a continuum ranging from low-risk, at-risk, and problem drinking to alcohol dependence and chronic abuse. Clinicians and researchers alike have the need to quantify drinking patterns to determine the risk for adverse, health-related events such as injury, liver damage, and cancer Biochemical measures of ethanol consumption are affected by temporal patterns of drinking as well as individual characteristics such as gender and age. The choice of a laboratory analysis to determine ethanol consumption is complex; no single laboratory test will predict drinking accurately across all drinking patterns, across the life span, and across gender. In conjunction with interviews and physical assessment, however, biochemical laboratory tests are sensitive tools used to measure both recent and long-term patterns of alcohol consumption.     

Injury severity: role of alcohol, substance use and risk-taking

Objective: The objective of the present study was to quantify the relationship between acute alcohol consumption and injury severity. Methods: A cross‐sectional study was conducted at the Gold Coast Hospital, Gold Coast, Queensland, Australia between October 2000 and October 2001. Data were collected from a systematic sample of patients greater than 15 years of age who presented to the ED for treatment of an injury sustained less than 24 h prior to presentation. Study participants were interviewed face to face on‐site. Information obtained included: demographics details; situational variables relative to time of injury (i.e. location, activity and companions at time of injury); self‐reported alcohol consumption in the 6 and 24 h prior to time of injury; usual alcohol consumption patterns; self‐reported substance use in the 6 and 24 h prior to time of injury; and risk‐taking behaviour. Injury severity was coded from patient medical records using the New Injury Severity Score. Results: Of 789 eligible patients presenting during the study periods, 593 were interviewed (75.2%). Patients who reported drinking above low‐risk levels (odds ratio [OR] = 3.35; 95% confidence interval [CI] 1.2–9.6) or who drank beer (OR = 3.54; 95% CI 1.1–11.1) in 6 h prior to injury were significantly more likely to sustain serious than minor injury. Drinking setting and usual drinking patterns were not significantly associated with injury severity, either in crude analyses, or after adjusting for relevant variables. Conclusion: The results of the present study support the conclusion that among injured patients who presented for treatment at a large metropolitan ED, although acute alcohol consumption does not appear to be associated with minor or moderate injury, there is some evidence to suggest that acute alcohol consumption is associated with serious injury.     

Health outcomes among American Indians with spinal cord injury

OBJECTIVE: To identify factors related to risk for poor health outcomes and secondary conditions in a sample of American Indians with spinal cord injury (SCI). DESIGN: Interviews were conducted by telephone with most participants; those who did not have telephones returned materials by mail. SETTING: A large rehabilitation hospital in the Western/ Mountain region of the United States. PARTICIPANTS: Ninety-seven American Indians with SCI completed a comprehensive health interview. All participants were adults with traumatic SCI and were at least 1 year postinjury. MAIN OUTCOME MEASURES: Selected items from the Behavioral Risk Factor Surveillance System were used to assess health behaviors and general health outcomes. Two secondary conditions were also investigated as outcome measures: pressure sores and post-SCI injuries. RESULTS: Multiple linear regression was used to predict seven health-related outcomes. Depressive symptomatology and post-SCI injuries were the primary predictors of the majority of health outcomes. Alcohol consumption was associated with a greater risk for post-SCI injuries, and being older at injury was associated with poorer health outcomes. CONCLUSIONS: Interventions to reduce depression, injuries, and alcohol misuse have potential for improving health among American Indians with SCI.     

The magnitude and correlates of alcohol and drug use before traumatic brain injury

OBJECTIVE: To describe preinjury alcohol and drug use and opportunities for secondary prevention among persons with recent traumatic brain injury (TBI). DESIGN: Survey. SETTING: Acute inpatient rehabilitation program. PARTICIPANTS: A total of 142 (91%) of 156 consecutive admissions who met inclusion criteria and were screened. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Alcohol and drug use questionnaires, alcohol problem questions, toxicology results, readiness to change, and treatment preference questions. RESULTS: Subjects were on average 37 years old, 80% were men, and 80% were white. Fifty-nine percent of the sample was considered "at-risk" drinkers and, as a group, subjects reported a high degree of preinjury alcohol-related problems. Thirty-four percent reported recent illicit drug use, and 42 (37%) of 114 cases with toxicology results were positive for illicit drugs. Motivation to change alcohol use correlated positively with greater self-reported alcohol consumption and problem severity. Most at-risk drinkers wanted to change on their own, whereas a minority were interested in treatment or Alcoholics Anonymous. CONCLUSION: Both alcohol abuse and drug use are common before TBI. Inpatient brain injury rehabilitation represents an important opportunity to identify and intervene in substance abuse problems.     

Adolescents’ reflections on school-based alcohol education in the United Kingdom: education as usual compared with a structured harm reduction intervention

Alcohol consumption by adolescents in the United Kingdom (UK) remains high. School-based interventions are expected to play a key role in preventing adolescent alcohol consumption. A series of focus groups were conducted with pupils who received alcohol education as usual and pupils who received a Northern Ireland adaptation of the School Health and Alcohol Harm Reduction Project (SHAHRP), a universal alcohol education program designed to reduce the harms experienced by young drinkers. This study sought to compare and contrast the participants’ engagement with and enjoyment of the different alcohol education that they had received. Focus groups were completed with 129 pupils in 16 schools in Northern Ireland and Scotland. Alcohol education as usual was viewed negatively and was regarded as unstructured, boring, repetitive, and unrealistic. In contrast, the adaptation of SHAHRP was viewed positively and was regarded as enjoyable and worthwhile, and engaging and relevant to the participants’ experiences of alcohol use. These findings suggest that one reason why alcohol education as usual may not be successful in preventing adolescent drinking and protecting adolescents from negative outcomes may be due to its failure to engage participants. Higher acceptability by pupils means that the adaptation of SHAHRP may be one viable alternative.     

Patterns of alcohol consumption and factors influencing problematic drinking among Angolan soldiers

Alcohol prevention strategies for soldiers in sub-Saharan African countries suffer from limited knowledge about soldiers' alcohol consumption patterns. The present study was conducted to understand such patterns in Angolan soldiers, including associated risk and protective factors. From 12 military bases, 568 soldiers completed structured interviews that assessed demographic information, level of alcohol consumption, mental health, social support and religious activity. Logistic regressions were used to determine factors associated with any alcohol intake, problematic drinking, binge drinking and alcohol consumption prior to sexual activity. Nearly 35%% of participants exhibited problematic drinking behaviour on the Alcohol Use Disorders Identification Test. Approximately 26%% reported at least one incidence of binge drinking during the past year; 16%% described having recently consumed alcohol before sexual activity. Risk factors included being older, being unmarried, having poorer mental health or increased number of traumatic events and socialising with family and friends two to four times a month. Attending religious services more than once a week appeared to protect against problematic drinking. Results emphasise the need for effective alcohol prevention campaigns in Angola and for targeting efforts towards individuals exhibiting the observed high-risk characteristics.     

Q.E.D. Alcohol Test: a simple and quick method to detect ethanol in saliva of patients in emergency departments

Objective: The aim of this pilot study was to assess whether ethanol concentrations in saliva are comparable to those in blood and to evaluate whether this new non-invasive saliva alcohol test is suitable for use in emergency departments. Design: Prospective, open, non-randomised study. Setting: University hospital emergency department. Patients and methods: 100 consecutive patients who were admitted to the emergency department whose smell and/or behaviour indicated alcohol abuse. Fifteen patients participated as a control group after they were asked to abstain from alcohol consumption for 24 h before the study. Interventions: Blood and saliva samples were obtained at the same time for ethanol measurement. The Q.E.D. Alcohol Test A 350 was used in order to measure the concentration of ethanol in saliva. Blood samples were analysed by the alcohol dehydrogenase method. Results: The mean difference between the ethanol levels in blood and saliva was − 0.1 mg/dl, whereas the values measured in saliva were on average 0.1 mg/dl higher than those measured in blood (p = 0.002). Conclusion: The Q.E.D. Alcohol Test A 350, which uses saliva, is well suited for quantitative determination of alcohol levels. The levels measured in saliva correlate well with those measured in blood at both the lower and the upper end of the scale. Because this test is quick and easy to perform by emergency room personnel and the results are accurate enough for clinical purposes, it should prove valuable to determine whether impaired consciousness is related to alcohol intoxication or to other likely causes. Received: 26 June 1998 Accepted: 25 February 1999     

Epidemiology of Alcohol-related Emergency Department Visits

Abstract. Objective : To examine the population and geographic patterns, patient characteristics, and clinical presentations and outcomes of alcohol-related ED visits at a national level. Methods : Cross-sectional data on a probability sample of 21,886 ED visits from the 1995 National Hospital Ambulatory Medical Care Survey were analyzed with consideration of the individual patient visit weight. The annual number and rates of alcohol-related ED visits were computed based on weighted analysis in relation to demographic characteristics and geographic region. Specific variables of alcohol-related ED visits examined included demographic and medical characteristics, patient-reported reasons for visit, and physicians' principal diagnoses. Results : Of the 96.5 million ED visits in 1995, an estimated 2.6 million (2.7%) were related to alcohol abuse. The overall annual rate of alcohol-related ED visits was 10.0 visits per 1,000 population [95% confidence interval (CI) 8.7–11.3]. Higher rates were found for men (14.7 per 1,000, 95% CI 12.5–16.9), adults aged 25 to 44 years (17.8 per 1,000, 95% CI 15.0–20.6), blacks (18.1 per 1,000, 95% CI 14.0–22.1), and residents living in the northeast region (15.2 per 1,000, 95% CI 12.1–18.2). Patients whose visits were alcohol-related were more likely than other patients to be uninsured, smokers, or depressive. Alcohol-related ED visits were 1.6 times as likely as other visits to be injury-related, and 1.8 times as likely to be rated as "urgent" or "emergent." The leading principal reasons for alcohol-related ED visits were complaints of pain, injury, and drinking problems. Alcohol abuse/dependence was the principal diagnosis for 20% of the alcohol-related visits. Conclusion : Alcohol abuse poses a major burden on the emergency medical care system. The age, gender, and geographic characteristics of alcohol-related ED visits are consistent with drinking patterns in the general population.     

Proportion as a metric of problematic alcohol-energy drink consumption in college students

Background: Alcohol mixed with energy drinks (AmED) is linked to deleterious drinking, particularly within college students. However, measurement and methodological concerns complicate a more thorough understanding of how AmED contributes to problematic alcohol consumption. This study examined AmED proportion (i.e., percentage of overall drinking events involving AmED consumption) as a metric for differentiating problematic alcohol use and tested the utility for explaining additional risk of alcohol-related problems beyond overall alcohol involvement. Methods: Self-report data were collected from a diverse sample of AmED consumers from two west-coast U.S. universities (N = 458; 60.1% female; 31.4% White). Participants were divided into three AmED proportion groups: low (25% or less of all drinking events), moderate (about 50%), or high (75% or more), and assessed for overall alcohol use and related consequences. Results: The groups did not differ on demographics or recent alcohol use. However, high proportion users reported significantly more alcohol-related problems than the low and moderate groups, even after controlling for overall alcohol involvement. However, proportion did not differentiate at-risk drinking as measured by cut-scores of the AUDIT. Conclusions: Findings provide support for proportion as metric for differentiating alcohol-related problems within AmED consumers. Implications for future research and interventions were discussed.     

Effects of an intervention brochure on emergency department patients' safe alcohol use and knowledge

Alcohol abuse is a leading cause of morbidity and mortality in the United States, contributing to over 100,000 deaths and costing society over 185 billion dollars each year. The objective of this study was to evaluate the effects of the American College of Emergency Physician's brief alcohol use intervention brochure on patients' hazardous drinking behavior and knowledge of safe alcohol use. We conducted a controlled trial comparing Emergency Department (ED) subjects receiving the alcohol use intervention brochure vs. receiving no brochure. One-month outcome measures included the following: 1) change in days of hazardous drinking; 2) change in knowledge of safe alcohol use; and 3) movement along a readiness-to-change continuum for excessive alcohol use. Of 277 subjects, 252 (91.0%) agreed to participate, and 188 of these (74.6%) were successfully contacted for 1-month follow-up assessment. We did not find any significant decreases in days of hazardous drinking or increases in knowledge of safe drinking limits for either the intervention or comparison groups. However, among the subgroup of excessive alcohol users (n = 100), we found that significantly more intervention subjects had advanced along the readiness-to-change continuum than comparison subjects (p < 0.01). This effect was even greater among the intervention group subjects who stated that they read the brochure (p < 0.001). A brief alcohol use intervention brochure does not affect ED patients' hazardous drinking behavior or knowledge of safe alcohol use. The brochure, however, may affect certain patients' motivation to change their drinking behavior. Changing drinking behavior requires more than simply handing out a brochure in the ED; referral to community resources for those motivated to change is likely an important component to successful management of this problem.     

Do women change their drinking behaviors while trying to conceive? An opportunity for preconception counseling

BACKGROUND: Prenatal alcohol exposure is a leading cause of preventable mental retardation and developmental disabilities, including fetal alcohol syndrome. Current medical guidelines recommend that no alcohol should be consumed over the period of conception and throughout pregnancy. Although the majority of women reduce alcohol consumption when they realize they are pregnant, this recognition may not occur until well into the first trimester, potentially impacting embryonic development. OBJECTIVES: To describe and assess changes in patterns of women's alcohol use between the preconception, pre-pregnancy recognition and post-pregnancy recognition time periods. Secondly, to describe characteristics of women consuming any alcohol and those binge drinking during pre- and post-pregnancy recognition periods. METHODS: Computer assisted telephone interviews were conducted with 1042 women who had recently delivered a baby in urban Alberta, Canada. Differences in consumption patterns between time periods were analyzed using analysis of variance and Chi-square tests. Characteristics of those drinking both before and after pregnancy recognition were analyzed using logistic regression. RESULTS: Eighty percent of women reported alcohol consumption pre-conceptually, 50% pre-pregnancy recognition and 18% post-pregnancy recognition. Binge drinking was reported by 32%, 11% and 0% for preconception, pre-pregnancy recognition and post-pregnancy recognition periods, respectively. Alcohol consumption patterns (i.e., the mean number of drinks per drinking day and week) did not differ significantly between preconception and pre-pregnancy recognition periods but did significantly drop after pregnancy recognition (p<0.001). Alcohol use during the period of pre-pregnancy recognition was higher among those not planning a pregnancy, not using assisted reproductive technology, of higher income, without a history of miscarriage, who were Caucasian, and who used tobacco. Binge drinking was higher among women not planning a pregnancy, those who used tobacco, and those with low self-esteem. Women continuing to drink small amounts of alcohol after pregnancy recognition were more likely to be between the ages of 30-39 years, be Caucasian and use tobacco. CONCLUSION: Preconception and "well-women" counseling strategies would be improved by increasing the emphasis on the risks of alcohol use during periods when pregnancy can occur.     

Reproductive Risks of Alcohol and Illicit Drugs: An Overview

Some studies suggest that alcohol and illicit substance abuse has an adverse effect on behavior, sexual performance, and reproduction. The aim of the paper is to present an overview of the effects of substance abuse and its risks for reproduction. Alcohol abuse is associated with high-risk behaviors and individuals who abuse alcohol are at risk for sexually transmitted infections and unwanted pregnancy. The primary concern of alcohol misuse in pregnancy is its teratogenic potential result that can in fetal alcohol syndrome and potential miscarriage. Cocaine is associated with perinatal complications and spontaneous abortion following maternal abuse during pregnancy and other risky behaviors. Cannabis also is associated with perinatal complications such as miscarriage, intrauterine growth restrictions, abruptio placentae, pre-term delivery, and neurobehavioral abnormalities. A preventative approach needs to be implemented in order to reduce the risks associated with substance abuse and to provide minimal interventions at primary and community care settings.