Marijuana Use and Prior Injury among Injured Problem Drinkers

OBJECTIVES: The purpose of this paper is to better understand marijuana use among injured problem drinkers in the emergency department (ED). The specific objectives are: 1) to assess the prevalence of marijuana use; 2) to identify factors associated with marijuana use; 3) to determine whether prior injury is associated with marijuana use; and 4) to determine whether marijuana-using problem drinkers want to change behaviors. METHODS: The authors conducted a post-hoc analysis on data obtained prospectively. Subjects had injury and problem drinking: either measurable alcohol level (blood alcohol concentration, BAC), report of drinking, or an Alcohol Use Disorders Identification Test (AUDIT) score of > or =8. The study was conducted on weekend nights; 3,776 injured ED patients were screened, 383 refused, 578 were enrolled, and 433 had complete data. RESULTS: Of the 433 subjects, 48.3% reported using marijuana in the three months prior. Marijuana-using problem drinkers had more hazardous drinking, higher AUDIT scores (14.0 vs. 11.4, p < 0.001), and higher risk-taking scores (12.4 vs. 10.1, p < 0.001). More used other drugs (69.7% vs. 30.3%, p < 0.001). In regression analyses, marijuana use remained an independent predictor of prior injury (OR = 2.16, 95% CI = 1.25 to 3.75), particularly prior alcohol-related (OR = 2.26, 95% CI = 1.45 to 3.53) and motor-vehicle-related (OR = 1.69, 95% CI = 1.03 to 2.79) injury. Readiness-to-change scores were similar (4.14 vs. 4.22, p = 0.21) between users and nonusers. CONCLUSIONS: Marijuana use among injured problem drinkers is prevalent. Their risk of prior injury is increased. Counseling for alcohol and injury should address marijuana use.     

Psychometric properties of a single-item assessing drunkenness to identify hazardous drinking: a replication study

Background: The Alcohol Use Disorders Identification Test (AUDIT-C) is a commonly used scale to screen for hazardous alcohol use in various settings, including primary and emergency care settings. In such settings, brevity of effective screening tools is needed; therefore, single items have been developed and tested for detecting at-risk alcohol use behaviors.

Purpose: This study replicates previous work validating the ability of a non-quantity-based single item assessing drunkenness to effectively identify signs of hazardous alcohol use.

Methods: During fall 2013, alcohol use data were collected from 781 self-reported current drinkers. Concurrent validity of a drunkenness item to detect hazardous drinking behaviors was assessed against gender-based AUDIT-C thresholds. Convergent validity of the drunkenness item was assessed against biologic BrAC samples.

Results: The single drunkenness item accounted for 0.856 of the area-under-the-received operating characteristics (ROC) curve for hazardous alcohol use (p?<?0.001). Using a specific cut-off of 1, the drunkenness item was 99.8% sensitive in detecting hazardous drinking behavior and was 93.5% specific in identifying non-hazardous drinking behaviors.

Conclusion: In a new sample, initial psychometric findings of the single drunkenness item to accurately detect hazardous alcohol use were replicated, providing additional support for the utility of this item.     

Motivational interviewing with hazardous drinkers

PURPOSES: To test the effectiveness of motivational interviewing in a population of hazardous drinkers utilizing community health care centers in rural southeastern Idaho. DATA SOURCES: This study targeted rural people at risk for alcohol dependence utilizing low-income community health care centers in rural southeastern Idaho. The Alcohol Use Disorders Identification Test (AUDIT) was used to screen interested clients' alcohol use. Clients achieving an AUDIT score indicating hazardous alcohol use were recruited into the study and randomized into a control or treatment group. Twenty-six hazardous drinkers attending five low-income community health centers participated in the study. The experimental group participated in one motivational interviewing session with the investigator, a family nurse practitioner (NP). The comparison group received no treatment. Alcohol use was tracked for 6 weeks after successful recruitment into the program. CONCLUSIONS: Participants in the study significantly decreased their average number of drinks per day. At time 1 (pretreatment), the control group drank 4.37 drinks per day and the treatment group drank 4.65 drinks per day. At time 2 (posttest), the control group drank 3.77 drinks per day and the treatment group drank 1.95 drinks per day. The effects of the motivational interviewing treatment on hazardous drinking also were measured by serum gamma-glutamyltransferase (GGT), a liver function test. There was also a significant decrease in the GGT from pretest to posttest in the treatment group. IMPLICATIONS FOR PRACTICE: The results of this investigation found that motivational interviewing shows promise as an effective intervention for hazardous drinkers attending low-income community clinics. Although other possible explanations could be postulated for the positive changes in sample participants, the data indicate that the motivational interviewing approach was responsible for a significant portion of the positive changes within the current sample. The information collected from the study adds to the literature on hazardous drinking, research, and treatment of this significant problem. Negotiating change in behavior is part of the practice of NPs. People struggling with alcohol use are more likely to encounter NPs, family doctors, or social workers than counselors specializing in alcohol treatment. Motivational interviewing is specifically designed for preparing people for change. Because most people resist being told what to do, that is, "you have to stop drinking," use of motivational interviewing principles can decrease resistance and optimize change. Additionally, identifying and intervening with hazardous drinking in a primary care setting can reduce healthcare costs and reduce the stigma of specialist care. Adding this valuable communication skill to the competencies of NPs is important to both clients and NPs.     

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.     

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.     

Alcohol consumption and suicide

About 90% of people in Western countries use alcohol at some time in their lives, and 40% experience temporary or permanent alcohol-related impairment in some area of life as a result of drinking. Multiple sociocultural and environmental factors influence suicide rates, and thus studies conducted in one nation are not always applicable to other nations. Impulsivity and aggression are strongly implicated in suicidal behaviour. Constructs related to aggression and impulsivity confer additional risk for suicidal behaviour in people with alcohol dependence. Lower serotonin activity is tied to increased aggression/impulsivity, which in turn may enhance the probability of suicidal behaviour. Acute alcohol use is associated with suicide. Suicide completers have high rates of positive blood alcohol. Intoxicated people are more likely to attempt suicide using more lethal methods. Alcohol may be important in suicides among individuals with no previous psychiatric history. Alcohol dependence is an important risk factor for suicidal behaviour. Mood disorder is a more powerful risk factor for suicide among problem drinkers as age increases. All individuals with alcohol use disorders should be assessed for suicide, especially at the end of a binge or in the very early phase of withdrawal. Middle-age and older men with alcohol dependence and mood disorders are at particularly high risk.     

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.     

The association of long-term alcohol biomarkers with risk for alcohol-related injury: Implications for screening

Alcohol misuse is a leading risk factor for serious injury and death. For those experiencing trauma in emergency care settings, recent alcohol misuse history is typically assessed via self-report measures. Since underreporting may be a problem in these settings, objective indicators like long-term biomarkers may be useful for identifying hazardous drinkers who may need intervention. Recognizing this, we investigated (1) whether hazardous drinking was linked to reports of alcohol-related injury in a probability sample of over 600 college students from a large, Midwestern, urban university; (2) whether elevated long-term biomarkers showed similar associations in the same sample. Associations derived from responses to the Alcohol Use Disorder Identification Test-C (AUDIT-C) as well as from hair and fingernails tested for ethyl glucuronide, a direct alcohol biomarker, suggested that hazardous drinking is significantly associated with elevated risk for alcohol-related injury. Implications for screening and intervention in health care settings are discussed.     

Alcohol use among young adults presenting to the emergency department

Objectives: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high‐risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. Methods: We undertook a cross‐sectional survey of 336 ED patients aged 18–30 years, inclusive. All were breathalysed prior to self‐administering the AUDIT. A ‘positive’ AUDIT score (≥8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. Results: One hundred and thirty‐one (39.0%, 95% confidence interval [CI] 33.8–44.5) patients were classified as AUDIT‐positive. Men were significantly more likely to be AUDIT‐positive (49%vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT‐positive (P < 0.001) and had significantly higher AUDIT scores than non‐trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT‐positive. One hundred (76.3%, 95% CI 68.0–83.1) AUDIT‐positive patients did not report others being concerned about their drinking or had not been given advice to cut down. Conclusion: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.     

Alcohol and substance use in civilian chronic PTSD patients seeking psychological treatment

Alcohol and substance use in patients suffering from chronic posttraumatic stress disorder (PTSD) were investigated. Those with alcohol‐ or substance‐abuse disorders that pre‐dated their trauma were excluded from the study. Participants were assessed by interview and with questionnaires. Information on 120 participants was obtained. The mean number of units of alcohol consumed per week was 11.96 with a median of 6. Twenty‐eight per cent of the sample claimed to be abstinent, whereas 23 (19%) consumed units in excess of the recommended limit and eight (7%) suffered from alcohol‐abuse disorder. Twenty‐three (19%) participants also admitted to substance use, the majority cannabis. Of these, 10 were also hazardous drinkers. Two participants suffered from substance‐abuse disorder. Comorbidity of anxiety and mood disorders was high, with depression (48.7%), generalized anxiety disorder (36.5%), panic attack disorder (13.2%) and specific phobias (6.1%) being the most common. Other than a significant association between depression and substance use, comorbid disorders were not associated with alcohol consumption or substance use. Gender, the severity of threat to life during the trauma, age and arousal symptoms were significantly associated with the units of alcohol consumed. Age, life impairment and depression were significantly associated with substance use. The use of alcohol in this PTSD sample overall did not appear to differ from the general population. In a relatively small proportion of chronic civilian PTSD patients, alcohol and substance use may be problematic; however, the extent of this problem appears limited.     

Prevalence and characteristics of patients with risky alcohol consumption presenting to emergency departments in rural Australia

Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short‐term harm (26% vs 18%) and alcohol consumption posing a high risk of long‐term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.     

Conjoint Smoking and Drinking: A Case for Dual-substance Intervention among Young Emergency Department Patients

OBJECTIVES: To better understand conjoint smoking and drinking among young adult emergency department (ED) patients, the purposes of this investigation were: 1) to assess the prevalence of conjoint use; 2) to determine the factors associated with conjoint alcohol use and smoking; and 3) to address the implications for future ED-based investigation of dual-substance intervention. METHODS: Data for this investigation were obtained from a battery of questionnaires administered to the routine-care patients during an alcohol screening in the ED, which was part of a larger alcohol intervention study. RESULTS: Study findings revealed that a majority of patients with self-reported alcohol-related problems were smokers. In fact, drinkers who smoked were likely to be pack-a-day smokers. Among the study sample, being female, having low education levels (e.g., high school education or less), having some emotional problems, and currently using marijuana were risk factors for conjoint smoking and drinking. CONCLUSIONS: Conjoint users were identifiable through brief screening. Given the prevalence of conjoint smoking and alcohol use among the ED sample and a specific set of risk factors, tailored intervention for alcohol and nicotine dependence may be an important and opportunistic clinical ED service.     

Alcohol misuse and report of recent depressive symptoms among ED patients

Objective

This study examined the magnitude of association between alcohol misuse and recent depressive symptoms.

Methods

We conducted a cross-sectional study of 412 randomly selected patients at least 18 years old and seeking emergency department (ED) care.

Results

Of the patients, 51.0% reported depressive symptoms. At-risk drinking was reported by 26.0%, and 28.2% scored positive on the Rapid Alcohol Problems Screen 4. Alcohol abuse and binge drinking were reported by 25.1% and 28%, respectively, of the patients. According to our results, at-risk drinking (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.47-4.20, P ≤ .001), problem drinking (OR = 2.11, 95% CI = 1.27-3.51, P ≤ .004), drinking abuse (OR = 2.58, 95% CI = 1.51-4.40, P < .001), and binge drinking (OR = 1.89, 95% CI = 1.13-3.15, P < .001) were all related to the manifestation of depressive symptoms.

Conclusions

The findings of this study yield information that could be used by ED health care practitioners and health educators to educate ED patients at risk for alcohol misuse and depression.     

Do alcohol use disorders impact on long term outcomes from intensive care?

IntroductionThere is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge.MethodThis was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency.Results34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001).ConclusionAlcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0909-6) contains supplementary material, which is available to authorized users.     

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.     

Increased Detection of Alcohol Consumption and At-risk Drinking with Computerized Alcohol Screening

Background

The impact of alcohol use has been widely studied and is considered a public health issue. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends Screening and Brief Intervention and Referral Treatment (SBIRT), but the actual practice in the Emergency Department (ED) is constrained due to limited provider time and financial resources.

Objectives

To assess the effectiveness of alcohol screening using Computerized Alcohol Screening and brief Intervention (CASI) compared to alcohol screening by triage nurse during Medical Screening Examination (MSE) in the ED.

Methods

Retrospective review of CASI/MSE database from January 2008 through December 2009, collected in the tertiary, Level I Trauma ED was performed. Inclusion criteria included age ≥18 years, and completion of both the MSE and CASI. We analyzed the database by comparing age, gender, primary language (English, Spanish), and Alcohol Use Disorders Identification Test scores using McNemar's test.

Results

Data were available for 5835 patients. CASI showed a significant increase in detection of at-risk drinking over MSE across all ages, gender, and primary language (p < 0.05). MSE found 2.5% at-risk drinkers and CASI found 11.5% at-risk drinkers (odds ratio [OR] 8.88, 95% confidence interval [CI] 6.89–11.61). Similar results were found in 18- to 20-year-old patients. MSE identified 1.8% at-risk drinkers and CASI reported 15.94% (OR 19.33, 95% CI 6.30–96.47).

Conclusion

CASI increased detection of at-risk alcohol drinkers compared with MSE across all ages, gender, and primary language. CASI is a promising innovative method for alcohol screening in the ED for the adult population, including under-aged drinkers.     

Genetic predisposition for alcoholism

A number of socio-economic, cultural, biobehavioral factors and ethnic/gender differences are among the strongest determinants of drinking patterns in a society. Both epidemiological and clinical studies have implicated the excessive use of alcohol in the risk of developing a variety of organ, neuronal and metabolic disorders. Alcohol abuse related metabolic derangements affect almost all body organs and their functions. Race and gender differences in drinking patterns may play an important role in the development of medical conditions associated with alcohol abuse. The incidence of alcoholism in a community is influenced by per capita alcohol consumption and covariates with the relative price and availability of alcoholic drinks. The majority of the family, twin and adoption studies suggest that alcoholism is familial, a significant proportion of which can be attributed to genetic factors. The question is how much of the variance is explained by genetic factors and to what degree is this genetically mediated disorder moderated by personal characteristics. Among the most salient personal characteristics moderating, the genetic vulnerability may be factors such as age, ethnicity, and presence of psychiatric co morbidity. Cultural factors and familial environmental factors are most likely predictors as well.     

Negative Repetitive Thought and College Drinking: Angry Rumination,Depressive Rumination,Co-Rumination,and Worry

Alcohol abuse among college students continues to be a large societal problem in need of further study. This project investigated the influence of different types of negative repetitive thought (NRT) on alcohol use and binging behavior among undergraduates. Specifically, angry rumination, depressive rumination, co-rumination, and worry were examined. An initial exploratory factor analysis supported the distinctiveness of these four forms of NRT. With respect to quantity of weekly drinking, worry was significantly associated with less alcohol use among drinkers whereas angry rumination was associated with greater weekly usage. The effect of co-rumination was moderated by sex such that higher levels of co-rumination was associated with less weekly drinking in men but more weekly drinking in women. The tendency to co-ruminate was also significantly associated with of being a binge drinker, and demonstrated similar gender moderation. Higher levels of worry were associated with less binge drinking among women, but no association between worry and binging was present among men. The implications for these findings in the study of NRT and alcohol use are discussed.