Alcohol and Substance Abuse Evaluation
- Author: Richard S Krause, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Physicians in the emergency department (ED) regularly encounter patients seeking treatment for alcohol or substance abuse problems. Data supports the notion that the ED serves an important role in identifying and helping patients with alcohol and substance abuse issues. The initial evaluation may seem routine, yet these patients have multiple physical and emotional issues that should be addressed whenever possible. The emergency physician (EP) should strive to identify patients who might benefit from appropriate referrals for drug and alcohol problems. The ED may be the initial or only point of contact with the health care system for these patients.
There are studies that have shown that a brief intervention in the emergency department may be effective for alcohol users. This concept is sometimes called the "teachable moment". In one study, injured alcohol-using ED patients (n = 494) were randomly assigned to receive either brief advice or no advice regarding alcohol abuse and completed a 12-month follow-up interview. The group receiving the brief advice tended to report lower alcohol consumption at 12-month follow-up compared to those who did not receive advice. However, a Cochrane Database of Systematic Reviews article including 11 studies and 2441 patients concluded that evidence of benefit of brief intervention on heavy alcohol users is inconclusive; data from 2 of the studies noted that alcohol consumption could be reduced at one-year follow-up, but further studies are needed.
Similarly, among urban adolescents identified in the ED with self-reported alcohol use and aggression, a brief intervention resulted in a decrease in both behaviors. Walton et al found that about a quarter of adolescent ED patients surveyed reported both alcohol (alcohol use, binge drinking, and/or alcohol consequences) and violence (peer aggression and violence and/or violence consequences). Patients who received a 35-minute intervention in the ED delivered by a therapist (n = 254) demonstrated a 34.3% reduction in peer aggression at 3 months and a 32.2% reduction in alcohol consequences at 6 months. Control patients, who received a brochure (n=235), showed 16.4% and 17.7% reductions, respectively. Patients who received an intervention delivered by a computer (n=237) had a 29.1% reduction in alcohol consequences at 6 months.
An excellent literature review on screening and brief intervention for patients with an alcohol use disorder (AUD) in the ED is available online. Based on their research, the authors suggest that screening and brief interventions are feasible and effective in the ED setting. ED visits offer practitioners an important opportunity to screen patients for alcohol problems and initiate brief intervention.
The American College of Emergency Physicians (ACEP) has produced a resource kit titled Alcohol Screening and Brief Intervention in the ED. It provides a framework for screening and intervention taking into account the time and resource limitations of the ED. It lists recommendations from the National Institute of Alcohol Abuse and Alcoholism (NIAAA), which advocates the use of Quantity and Frequency (Q&F) questions as well as the CAGE questionnaire for screening for alcohol problems. The Q&F questions can elicit whether the patient is over the recommended levels for moderate drinking and therefore “at risk” for illness and injury. The CAGE questionnaire is better for identifying dependence with 90% specificity and 76% sensitivity when used in the ED. Since the CAGE was originally designed for lifetime prevalence, it may be helpful to specify “during the past 12 months.” Asking Q&F questions, then adding the CAGE questions if the responses exceed moderate levels is one way to use the screens. Another approach is to jump to the CAGE questions for patients who present intoxicated with very high ethanol levels, or when dependence is suspected. This eliminates the negative connotations and resistance that can occur when the patient is asked to quantify their drinking.
Substances of abuse include alcohol, cocaine, opiates, amphetamines, and hallucinogens. This article provides a brief review of the physiologic effects of these substances as well as the signs and physiologic effects of withdrawal with which the caregiver should be familiar. More detailed information can be obtained from the specific articles on each substance (see Toxicity, Alcohols; Toxicity, Cocaine; Toxicity, Amphetamine; Toxicity, Hallucinogen; Toxicity, Narcotics).
Alcohol is a CNS depressant. In low doses, alcohol acts primarily to depress inhibitory centers. Resultant disinhibition may lead to out-of-character activities (eg, dancing with a lampshade on the head, blurting out a long-held confidence). At higher doses, alcohol inhibits excitatory centers. People may show effects ranging from impairment of rational thinking to absence of motor coordination. Physiologic effects of chronic alcohol use include the following:
Gastrointestinal - Cirrhosis of the liver, peptic ulcer disease, gastritis, pancreatitis, and carcinoma
Cardiovascular - Hypertension, cardiomyopathy, atrial fibrillation (" holiday heart syndrome ")
Immunologic - Suppression of neutrophil function and cell-mediated immunity
Endocrine - In males, increase in estrogen and decrease in testosterone, leading to impotence, testicular atrophy, and gynecomastia
Psychiatric - Depression or anxiety disorders
Heroin is by far the most commonly abused opiate. Other drugs of abuse in this category include methadone, morphine, codeine, oxycodone, fentanyl (China white), and black tar (a potent form of heroin). Signs of intoxication are decreased respiratory rate and pinpoint pupils. Acute complications include noncardiogenic pulmonary edema and respiratory failure. Complications of chronic use are primarily infectious and include skin abscess at an injection site, cellulitis, mycotic aneurysms, endocarditis, talcosis, HIV, and hepatitis. Snorting of heroin is a recent trend that has expanded its user base in many areas.
Cocaine may be smoked, inhaled, used topically, or injected. Acute cocaine intoxication may present with agitation, paranoia, tachycardia, tachypnea, hypertension, and diaphoresis. Complications of acute and chronic use can include myocardial ischemia or infarction, stroke, pulmonary edema, and rhabdomyolysis.
Acute intoxication with amphetamines presents with signs of sympathetic nervous system stimulation, tachycardia, hypertension, anorexia, insomnia, and occasionally seizures.
Different hallucinogens present with a variety of organ system effects. Phencyclidine (PCP) has been known to cause muscle rigidity, seizures, rhabdomyolysis, and coma. Anticholinergics have been associated with delirium, supraventricular tachycardia, hypertension, and seizures. Other hallucinogens (eg, lysergic acid diethylamide [LSD], peyote, marijuana, nutmeg) rarely cause significant physical complications.
Prescription and over-the-counter drug abuse
Prescription drug abuse is considered to be a serious and growing problem. Narcotics, stimulants, and sedatives are the common prescription drugs of abuse. Patients may present to the ED with deliberate or accidental overdose. Rapid increases in the amount of a medication needed, frequent requests for refills before the quantity prescribed should have been finished, and visits to multiple providers may be indicators of abuse.
Similarly, some over-the-counter (OTC) medications, such as cough and cold medicines containing dextromethorphan, can also be abused and lead to significant CNS effects including a dissociative state. This is a special problem among teenagers. Parents should be aware of the potential for abuse of these medications, especially when consumed in large quantities, which should signal concern and the possible need for intervention.
Quantitative information on the prevalence of substance abuse is difficult to obtain because of the unwillingness of abusers to accurately disclose consumption. Surveys are taken routinely in high schools and door-to-door in communities, but complete figures are not available.
According to the National Institute on Alcoholism and Alcohol Abuse (NIAAA) in the United States:
Prevalence of Drinking: In 2013, 86.8% of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.7% reported that they drank in the past year; 56.4% reported that they drank in the past month.
Prevalence of Binge Drinking and Heavy Drinking: In 2013, 24.6% of people ages 18 or older reported that they engaged in binge drinking in the past month; 6.8% reported that they engaged in heavy drinking in the past month.
In addion, the NIAAA reports that 16.6 million adults ages 18 and older (7.0% of this age group) had an alcohol use disorder (AUD) in 2013. This includes 10.8 million men (9.4% of men in this age group) and 5.8 million women (4.7% of women in this age group). About 1.3 million adults received treatment for an AUD at a specialized facility in 2013 (7.8% of adults who needed treatment). This included 904,000 men (8.0% of men in need) and 444,000 women (7.3% of women who needed treatment). For those aged 12-17 an estimated 697,000 adolescents (2.8% of this age group) had an AUD. This number includes 385,000 females (3.2% of females in this age group) and 311,000 males (2.5% of males in this age group).
Reports indicate that roughly two thirds of all adults drink alcohol occasionally. Studies performed in urban EDs indicate that up to 20% of patients may have problems with alcohol, with the highest rate in patients who present late at night.
Alcohol use reportedly has been on the decline in recent years. In contrast to alcohol use, heroin use is rising. Estimates place the number of heroin users in the United States at 750,000.
Heavy cocaine use has remained fairly steady since its peak in the late 1980s and early 1990s, with an estimated 600,000-700,000 regular users.
On the rise in rural communities is use of methamphetamine, also known as crystal meth. It is easily manufactured as the base ingredient is over-the-counter cold medication. It is found to be abused most often in the 15- to 25-year-old age bracket.
Abuse of prescription and over-the-counter drugs is rapidly increasing, especially in teenagers.
There are a number of studies that identify various groups of patients presenting to EDs who are at high risk for substance abuse. Practically, almost every patient is at risk. Even with the time/resource pressures in the ED, it is reasonable and appropriate to ask every patient about use/abuse of tobacco, alcohol, or other drugs. If the patient admits to alcohol use, a pattern of abuse may often be easily elicited with simple questioning, but unless there is obvious abuse a simple screening tool should be used. These are further described below.
There are also many patients who present to the ED requesting help for their drinking or substance abuse. Response to this request will be very dependent on local resources, which emergency physicians should be familiar with. There are 3 components of ED evaluation for persons seeking treatment for a substance abuse problem or those confirmed to have such a problem while in the ED. They are (1) assessment of the need for treatment, (2) placement or referral into appropriate treatment, and (3) determination of physical suitability for treatment.
In assessing need for treatment, keep in mind that patients frequently underestimate their consumption. This underestimation may be attributed to denial, one of the hallmarks of the disease process of substance abuse. Question patients about their drug or drugs of choice and the frequency, amount, and method of use. Obtain information on prior detoxifications, concomitant use of other substances, date of first use, and time interval from last use. Most physicians know and employ the CAGE questioning technique as follows:
C - Has anyone ever felt you should Cut down on your drinking?
A - Have people Annoyed you by criticizing your drinking?
G - Have you ever felt Guilty about your drinking?
E - Have you ever had a drink first thing in the morning ( Eye-opener) to steady your nerves or to get rid of a hangover?
A single positive response to the CAGE questions is considered suggestive of an alcohol problem, and 2 or more positive responses indicate the presence of such a problem with a sensitivity and specificity approximately 90% in most studies. One report indicated that the CAGE questions are best applied if not preceded by questions attempting to quantify alcohol intake. However, the Quantity and Frequency (Q&F) questions are recommended by ACEP to identify at-risk patients who may not yet have a dependence problem. The Q&F questions are:
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 last month?
A positive response is when drinking reaches these levels:
Men > 14 drinks/week or > 4 drinks/occasion
Women > 7 drinks/week or > 3 drinks/occasion
Over 65 years old > 7 drinks/week or > 3 drinks/occasion
These questions may not accurately indicate abuse problems when universally applied across gender and cultural lines. For example, the CAGE score has been shown to be less accurate in white females; therefore, attempt to gather a complete picture of the patient rather than relying solely on this questioning technique. Several other screening methods exist, with the Brief Michigan Alcohol Screening Test (MAST) the most widely used screen suitable for ED use.
One very brief modification of the MAST, which has a reported sensitivity of 91%, requires a positive response to 1 of the following 2 questions:
Have you ever had a drinking problem?
When was your last drink? (< 24 h = positive response)
The TWEAK screen has been recommended for white females, and a score of 3 or higher indicates an alcohol problem. The TWEAK involves the following questions:
Tolerance (2 points): How many drinks can you hold? (Six or more indicates tolerance.)
Worried (2 points): Have close friends or relatives worried or complained about your drinking in the past year?
Eye openers (1 point): Do you sometimes take a drink in the morning when you first get up?
Amnesia (1 point): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
[ K] Cut down (1 point): Do you sometimes feel the need to cut down on your drinking?
Frequent injury and injury while drinking also should prompt screening for alcohol abuse.
Screening and counseling recommendations for reducing alcohol misuse are available from the US Preventive Task Force.
Placement into the appropriate treatment program ultimately is the responsibility of the detoxification specialist who follows the patient during rehabilitation. The specialist's initial decisions may be based in large measure on the information gathered by the EP's assessments.
The physical examination should take into account that this population is much less likely to have regular medical care than the general population. The emergeny physician must also be aware of the specific symptoms of withdrawal from various substances.
Many alcoholics experience "the shakes" approximately 12-24 hours after their last drink. The shakes are tremors caused by overexcitation of the CNS.
Tremor may be accompanied by tachycardia, diaphoresis, anorexia, and insomnia.
After 24-72 hours, the alcoholic may have rum fits (ie, generalized seizures).
Delirium tremens (DT) begins 3-5 days after the last drink. DT is characterized by disorientation, fever, and visual hallucinations.
DT or significantly symptomatic alcohol withdrawal is a medical emergency and should be treated on an inpatient basis.
Withdrawal symptoms from opioids may begin just a few hours after last use.
The onset of withdrawal may be delayed in patients abusing long-acting opioids.
Along with a strong craving for the drug, opioid withdrawal produces yawning, tears, diarrhea, abdominal cramping, piloerection, and rhinorrhea.
Symptoms of withdrawal usually peak around 48 hours and again at 72 hours.
Withdrawal usually subsides after 1 week, but some heavily dependent users may have mild symptoms for up to 6 months.
Although physically uncomfortable, opioid withdrawal is not life threatening.
Withdrawal is fairly mild.
Patients may complain of depression, increased appetite, abdominal cramping, diarrhea, and headache.
Cocaine and hallucinogen withdrawal
Cocaine and hallucinogens do not have a typical withdrawal pattern.
These drugs are considered psychologically addicting rather than physically addicting.
Benzodiazepine and other CNS depressant withdrawal
Discontinuing prolonged use or abuse of high doses of CNS depressants can lead to serious withdrawal symptoms. This can result in CNS stimulation to the point of grand mal seizures.
Benzodiazepines are the drug of choice for withdrawal seizures.
Milder symptoms such as agitation, restlessness, and insomnia are more common.
Other Problems to be Considered
No specific laboratory studies are indicated for the patient seeking detoxification or who presents in an intoxicated state, unless history or examination suggests the need. In the patient with acute intoxication, a screen for substances of abuse and a blood or breath alcohol level may be considered, but these generally do not alter management. Consider electrolytes, glucose, BUN, and creatinine because of the dehydration and poor nutrition observed in this population. A CBC may be sent if GI bleeding, anemia, bone marrow suppression, or infections are concerns. Complications of cocaine intoxication may require a cardiac or CNS evaluation that may include an ECG and brain CT scan.
Dependence on laboratory abnormalities (eg, elevated mean corpuscular volume of red blood cells, abnormal liver enzymes) to confirm the diagnosis of alcoholism causes the physician to miss the majority of patients with the disease; therefore, the physician should query patients with such abnormalities to determine if substance abuse is an issue.
A patient with an alcohol addiction may require vitamin supplementation with thiamine (200 mg), folic acid (1 mg), and a multivitamin. If the patient develops agitation or tremulousness, benzodiazepines may be needed.
Treatment and Rehabilitation
Personnel in a detoxification center perform definitive treatment. Substance abuse is a life-long disease that only can be controlled, not cured. In the detoxification center, treatment initially consists of managing the varied symptoms of withdrawal, which can range from a longing to reuse to hallucinations and seizures. Once physical withdrawal is complete, group and individual counseling begins and continues on an inpatient, outpatient, and group support basis (eg, Alcoholics Anonymous, Narcotics Anonymous).
At times, patients may refuse offered inpatient detoxication or structured outpatient care or it may not be available. In this circumstance, a physician may choose to offer unstructured outpatient detoxication. Drugs may be prescribed for symptomatic relief of the observed or expected symptoms. Caution should be used in this population due to the obvious potential for misuse or diversion of any medications. Regimens for this type of care are supported primarily by anecdotal evidence, which is another reason for caution. For example, various medications may be used to ameliorate narcotic withdrawal symptoms in outpatients. These should be targeted to the prominent symptoms and quantities of prescription medication strictly limited to minimize possibilities for abuse or diversion.
Suggestions by the authors for symptomatic outpatient treatment of opiate withdrawal are as follows.
Pain: OTC analgesics or prescribed NSAIDS.
Diarrhea: Immodium AD or diphenoxylate/atropine (Lomotil).
Sneezing/tearing/runny nose: H1 blocking antihistamines
Tachycardia/hypertension: clonidine (also may help many of the other symptoms).
Anxiety/insomnia: H1 blocking antihistamines or benzodiazepines.
For excellent patient education resources, visit eMedicineHealth's Mental Health Center. Also, see eMedicineHealth's patient education articles Alcoholism, Alcohol Intoxication, Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.
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