Chapter 13 Alcohol Abuse

An estimated 7.6 million of the 116.8 million (e.g. 6.5%) emergency department (ED) visits reported in 2010 were related to alcohol use.^1,²

• Three out of 10 American adults engage in alcohol consumption at a level that puts them at risk for medical or social problems.

• Eighteen percent of those hospitalized after a motor vehicle crash meet the criteria for alcohol dependence.

• Up to 31% of patients treated in EDs and 50% of severely injured trauma patients (i.e., those requiring hospital admission, usually to an intensive care unit) screen positive for alcohol abuse.³

Alcohol Screening

Screening patients in the ED for alcohol use uses the window of opportunity to motivate patients to alter their drinking behavior. Patients treated in EDs are 1.5 to 3 times more likely than those treated in primary care clinics to report heavy drinking, to experience the adverse effects of drinking (e.g., alcohol-related injuries, illnesses, and legal or social problems), and to have been treated previously for an alcohol problem.⁴ Of surveyed adults, 15% reported binge drinking and 5% reported heavy drinking, defined as “more than two drinks per day on average for men or more than one drink per day on average for women.”⁵

The U.S. Preventive Services Task Force recommends routine screening for alcohol abuse in the outpatient setting.⁶ The Emergency Nurses Association (ENA) supports this obligation to screen and provide a brief intervention for underlying alcohol use problems.⁷ Screening is cost effective; it is estimated to save $254 per screened person in saving quality life-years and preventing consequences.⁸

Screening, Brief Intervention, and Referral to Treatment

Screening, brief intervention, and referral to treatment (SBIRT) is a framework aimed at providing services for not only those with substance use disorders but also those at risk of developing difficulties with substances.

Implementation involves:

• Screening for severity of use and treatment necessary

• Brief intervention to raise awareness regarding use and enhance motivation for change

• Referral to treatment for specialized care

Screening Tools

• The Alcohol Use Disorders Identification Test (AUDIT) is typically used for inpatients because of its longer length and complexity.⁹

• The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) screens for all substances but was designed by the World Health Organization mainly for primary care use.¹⁰

• CAGE (Table 13-1)¹¹ and CAGEAID (adapted to include drugs and included the addition of the phrase “or drug use” to each question) is well suited for the ED. However, it does not detect low but risky drinking and does not perform as well among women and minorities.

• T-ACE, based on CAGE, is valuable for identifying a range of use, including lifetime and prenatal use, based on the Diagnostic and Statistical Manual of Mental Disorders-III-R criteria (Table 13-2).¹¹

• TWEAK was originally designed to screen harmful drinking behavior in pregnant women.

• The Michigan Alcohol Screening Test (MAST) is a 22-question, self-administered test and does not include screening for other drugs.

• HALT

• “Do you usually drink to get High?”

• “Do you drink Alone?”

• “Do you ever find yourself Looking forward to drinking?”

• “Have you noticed whether you seem to be becoming Tolerant of alcohol?”

• BUMP

• “Have you ever had Blackouts?”

• “Have you ever used alcohol in an Unplanned way?”

• “Do you ever drink alcohol for Medicinal reasons?”

• “Do you find yourself Protecting your supply of alcohol?”

• FATAL DT

• “Is there a Family history of alcoholic problems?”

• “Have you ever been a member of Alcoholics Anonymous?”

• “Do you Think you are an alcoholic?”³

• “Have you ever Attempted or had thoughts of suicide?”

• “Have you ever had any Legal problems related to alcohol consumption?”

• “Do you ever Drive while intoxicated?”

• “Do you ever use Tranquilizers to steady your nerves?”

• General questions about quantity and frequency (Table 13-3): One study found that the single question “When was the last time you had more than X drinks in one day?” (where X is 5 for men and 4 for women) was effective. With a threshold value at the past 3 months, this method had a sensitivity and specificity of 85% and 70% in men and 82% and 77% in women. The screening was similar whether screening was conducted in person or by telephone.¹²

TABLE 13-1 CAGE ALCOHOL SCREENING TOOL

CAGE

Have you ever felt you should CUT DOWN on your drinking?

Have people ANNOYED you about your drinking?

Have you ever felt bad or GUILTY about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE-OPENER)?

CAGE can identify alcohol problems over the lifetime. Two positive responses are considered a positive test and indicate that further assessment is warranted.

National Institute on Alcohol Abuse and Alcoholism. (2005, April). Screening for alcohol use and alcohol related problems. Retrieved from http://pubs.niaaa.nih.gov/publications/aa65/aa65.htm

TABLE 13-2 T-ACE ALCOHOL SCREENING TEST

T Tolerance: How many drinks does it take to make you feel high?

A Have people annoyed you by criticizing your drinking?

C Have you ever felt you ought to cut down on your drinking?

E Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

A score of 2 or more is considered positive. Affirmative answers to questions A, C, or E = 1 point each. Reporting tolerance to more than two drinks (the T question) = 2 points.

National Institute on Alcohol Abuse and Alcoholism. (2005, April). Screening for alcohol use and alcohol related problems. Retrieved from http://pubs.niaaa.nih.gov/publications/aa65/aa65.htm

TABLE 13-3 SAMPLE QUANTITY AND FREQUENCY ALCOHOL SCREENING QUESTIONS

In the, past 30 days:

• On average, how many days per week do you drink alcohol?

• On a typical day when you drink, how many drinks do you have?

• What is the maximum number of drinks you had on any given occasion during the past month?

Standard Quantities

When discussing quantities, note that a standard drink contains about 0.6 fluid ounces of pure alcohol. Often a mixed drink or full glass of wine is equivalent to more than one drink (Table 13-4). Guidelines from the National Institute on Alcohol Abuse and Alcoholism (NIAAA)¹³ make a distinction between low-risk and moderate drinking. Most people do not have a consistent, low-level consumption but drink more heavily on weekends. The weekly total cannot be consumed in 1 or 2 days without consequences.

• Low-risk drinking for healthy men under age 65 years is defined as no more than 4 drinks on any day and 14 per week and for healthy women (and men over 65 years old) is defined as no more than 3 drinks on any day and 7 per week.

TABLE 13-4 STANDARD DRINK EQUIVALENTS

• 12 oz of beer or cooler

• 8–9 oz of malt liquor

• 5 oz of table wine

• 3–4 oz of fortified wine

• 2–3 oz of cordial or liqueur

• 1.5 oz of brandy or spirits

National Institute on Alcohol Abuse and Alcoholism. (n.d.). What is a standard drink? Retrieved from http://pubs.niaaa.nih.gov/publications/practitioner/pocketguide/pocket_guide2.htm

General Assessment ²

History

As much as possible, obtain an accurate history of recent alcohol use. History questions can include:

• Time of last drink

• What type of alcohol and amount usually ingested

• Frequency of drinking

• Years of drinking

• History of alcohol-related seizures or delirium tremens

• Prior detoxifications

• Other substance use

• Prescription drug use

• Other medical or psychiatric conditions

• Toxic alcohols

If the patient’s answers about consumption seem doubtful, try the following methods in a “matter of fact” manner to get a more forthright answer ¹⁴:

• Start the interview with questions about other nonthreatening health behaviors (i.e., whether the individual wears a seat belt or smokes cigarettes) and move to the more sensitive subject of alcohol consumption.

• Frame the questions to take into account a positive response. For example, instead of asking “Do you drink alcohol?” ask “When you drink, how many times a month do you drink four drinks or more?”

• Overestimate and let the individual correct you.

• Feign surprise at a negative or low answer.

• Ask, unexpectedly, a second time later in the interview.

Other assessment and history signs that a patient may have a (denied) problem with excess alcohol include ¹⁴:

There is no correlation between the strength of alcohol odor on the patient’s breath and the level of intoxication.

Consider Other Etiologies and Comorbidities

A coexisting medical condition that is causing the “intoxicated” patient’s symptoms must be considered. Intoxicated patients with blood alcohol levels less than 200 to 240 mg/dL and a Glasgow Coma Scale (GCS) of 13 or less should be evaluated for additional causes of altered mental status.¹⁵ Other etiologies and comorbidities can include head trauma, glucose imbalance, sepsis, dehydration, hepatic encephalopathy, or ingestion of other substances that complicate clinical course.

The mental status of most patients who are intoxicated without complications normalizes 3 to 5 hours from emergency department admission.³¹

Signs and Symptoms

An intoxicated patient should always (Table 13-5):

• Have a physical examination, including inspecting for injury.

• Have a neurologic examination.

• Have glucose measured.

• Have temperature checked. (There is a risk for hypothermia from depleted glycogen stores and malnutrition.)

TABLE 13-5 BLOOD ALCOHOL LEVELS AND ASSOCIATED SIGNS AND SYMPTOMS

Blood Alcohol Level	ALCOHOL INTAKE	SIGNS AND SYMPTOMS
25–50 mg/dL (0.02–0.05%)	1–2 drinks	Relaxation
80 mg/dL (0.08%)	2–5 drinks	Considered legal intoxication in most states.
150 mg/dL (0.15%)	7–9 drinks	Staggering
250 mg/dL (0.25%)	13–14 drinks	Ataxia, nausea or vomiting
300 mg/dL (0.30%)	15–18 drinks	Stuperous
400 mg/dL (0.40%)	20–24 drinks	Anesthesia
500 mg/dL (0.50%)	25–30 drinks	Lethal in 50%