Risks associated with alcohol-positive status among adolescents in the emergency department: a matched case-control study

Marijuana and other substance use among male and female underage drinkers who drive after drinking and ride with those who drive after drinking

The study sought to describe the occurrence of adolescent driving after drinking (DD) and riding with a driver who had been drinking (RWDD) and associations with substance use for both males and females. As part of screening for a randomized controlled trial, we surveyed 16-20year olds (N=3418) recruited from an emergency department (ED) and analyzed data from those reporting past-year alcohol consumption (n=2150, 58% females). DD was reported by 22% of females and 28% of males and RWDD was reported by 39% of females and 38% of males, also in the past year. In regression models, risky alcohol use and past-year marijuana use were associated with increased odds of DD and RWDD for females and males. Marijuana use was a strong predictor, with odds increased by 2.3 and 1.7 times for DD among females and males respectively and 1.4 times for RWDD for females and males. Prescription drug misuse was also associated with RWDD for females and for both males' and females' reported DD. The findings highlight the alarming rate of DD and RWDD among both males and females and suggest ED-based injury prevention efforts consider such risky road behavior as well as consider their substance use. Future research might also further examine the effects of driving under influence of substances, particularly marijuana, and the negative synergistic effects of co-ingestion prior to driving.

Developmental Hazards Among Young Alcohol Intoxicated Patients

PURPOSE

The rising numbers of alcohol intoxicated adolescents (AIA) treated in emergency care units in several European countries have drawn attention to this target group for prevention. To our knowledge, this is the first study to assess a broad array of developmental hazards and their stability in AIA and to compare their distribution with representative samples (RS).

METHODS

A multisite cohort study of AIA aged 13-17 years assessed, in the hospital (t0) and 6 months later (t1), (family) violence, cannabis and alcohol use, school problems, delinquency, homelessness, depression, and suicidality, using items from representative German surveys: Children and Adolescent Health Survey (KiGGS), Childhood Trauma Questionnaire and Communities That Care Youth Survey. We calculated the differences between AIA and RS and corresponding 95% confidence intervals. For AIA respondents who completed t0 and t1 information, we calculated prevalence/persistence/incidence of developmental hazards and corresponding 95% confidence interval.

RESULTS

A total of 342 AIA participated at t0, 228 at t1 (67%). AIA had a significantly higher burden of concomitant risks regarding physical and emotional family abuse, (sexual) victimization, cannabis use, binge drinking, school expulsion, police arrest, gang membership, and being violent. Six months after hospitalization, emotional family abuse (34.1%), cannabis use (23.5%), depression (14.8%), and being violent (13.2%) were especially prevalent.

CONCLUSIONS

Developmental hazards are up to six times more prevalent in AIA than in RS. Therefore, when assessing the risk profile of AIA, it is important to consider developmental hazards as well as detrimental alcohol use.

Long-term outcomes after adolescent in-patient treatment due to alcohol intoxication: A control group study

BACKGROUND

The long-term psychosocial development of adolescents admitted to in-patient treatment with alcohol intoxication (AIA) is largely unknown.

METHODS

We invited all 1603 AIAs and 641 age- and sex-matched controls, who had been hospitalized in one of five pediatric departments between 2000 and 2007, to participate in a telephone interview. 277 cases of AIA and 116 controls (mean age 24.2 years (SD 2.2); 46% female) could be studied 5-13 years (mean 8.3, SD 2.3) after the event. The control group consisted of subjects who were admitted due to conditions other than alcohol intoxication. Blood alcohol concentration on admission was systematically measured in the AIA but, owing to the retrospective study design, not in the control group. Subtle alcohol intoxication could therefore not be entirely ruled out in the control group. Long-term outcome measures included current DSM-5 alcohol use disorders (AUD), drinking patterns, illicit substance use, regular smoking, general life satisfaction, use of mental health treatment, and delinquency.

RESULTS

AIA had a significantly elevated risk to engage in problematic habitual alcohol use, to exhibit delinquent behaviors, and to use illicit substances in young adulthood compared to the control group. Severe AUD also occurred considerably more often in the AIA than the control group.

CONCLUSIONS

In the majority of AIAs, further development until their mid-twenties appears to be unremarkable. However, their risk to develop severe AUD and other problematic outcomes is significantly increased. This finding calls for a diagnostic instrument distinguishing between high- and low-risk AIAs already in the emergency room.

Familial risk and protective factors in alcohol intoxicated adolescents: psychometric evaluation of the family domain of the Communities That Care Youth Survey (CTC) and a new short version of the Childhood Trauma Questionnaire (CTQ)

BACKGROUND

Alcohol intoxicated adolescents (AIA) in emergency department are an important target group for prevention and valid information on their familial risk and protective factors (RPF) is crucial for implementing customized family-based counseling in hospitals. We therefore, examined the psychometric characteristics of scales which assess familial RPF.

METHODS

We used seven family scales from the Communities That Care Youth Survey Instrument (CTC-F7); four assess risk factors: family conflicts, poor family management, parental attitudes favorable towards drug use/antisocial behavior; three assess protective factors: family attachment, opportunities and rewards for prosocial involvement. To assess physical and emotional abuse and emotional neglect, we created a new scale composed of six items from the Childhood Trauma Questionnaire (CTQ-6). We tested these eight scales on 342 AIA aged 13-17. Based on the classical test theory we calculated descriptive item and scale statistics and internal consistency. We assessed construct validity by confirmatory factor analysis with Maximum Likelihood (ML) estimation in a sample with imputed missing values (EM-Algorithm). To check robustness, we repeated the analyses with complete cases, with multiple imputed data, and with methods suitable for categorical data. We used SPSS 21, AMOS 21 and R (randomForrest and lavaan package).

RESULTS

Three of seven CTC-F scales showed poor psychometric properties in the descriptive analysis. A ML-confirmatory model with five latent factors fitted the remaining CTC-F scales best (CTC-F5). The latent structure of the CTQ-6 is characterized by three first-order factors (physical abuse, emotional abuse, emotional neglect) and one second-order factor. The global goodness-of-fit indices for the CTC-F5 and the CTQ-6 demonstrated acceptable fit (for both models: TLI and CFI>0.97, RMSEA<0.05). The confirmatory evaluation based on complete cases (n=266), on multiple imputed data, and with alternative estimation methods produces global and local model-fit indices that are comparable to those from the main analysis. The final subscales CTC-F5 and CTQ-6 show acceptable to good internal consistency (α>0.7).

CONCLUSIONS

The final CTC-F5 and the newly developed CTQ-6 demonstrate acceptable to good psychometric properties for the AIA sample. The CTC-F5 and the CTQ-6 facilitate a psychometrically sound assessment of familial RPF for this vulnerable and important target group for prevention.

Emergency department alcohol and drug screening for Illinois pediatric trauma patients, 1999 to 2009

BACKGROUND

Recent guidelines recommend universal substance abuse screening for all trauma patients aged 12 years and older because brief interventions can help prevent future trauma. However, little is known about actual rates of screening in this setting.

METHODS

The Illinois State Trauma Registry was queried for severely injured patients from 1999 to 2009. Multivariate logistic regression was used to characterize, according to demographic and physiologic parameters, which patients were screened with blood alcohol and urine toxicology and which screened positive.

RESULTS

Of the 12,264 pediatric patients, 40% were tested for alcohol and 37% for drugs. Nine percent of patients screened positive for alcohol and 8% for drugs. Age strongly predicted positive tests, as did male sex. Black and Hispanic patients were screened for alcohol most frequently, but only Hispanics were more likely to test positive.

CONCLUSION

Although current guidelines recommend screening all trauma patients 12 years and older, current practice falls far short of this goal.

Adolescence and Alcohol: a review of the literature

Up to two thirds of adolescents consume alcohol and about a quarter engage in abusive behavior at some point. Many users begin alcohol use at young ages, and binge drinking is a dominant pattern for a proportion of youth. Because neurogenesis is inhibited by ethanol, consequences of adolescent alcohol abuse include changes in brain development and impairment of neurocognitive performance. A variety of mental and psychosocial problems are also often witnessed in alcohol abusing youth. Apart from the influence exerted by genetic and psychosocial factors, the chance of developing problematic alcohol consumption is increased by consumption in a binge drinking manner and by first contact with alcohol at a young age. Discrimination of alcohol consumption within the frames of normal adolescent behavior from problematic use is still a challenging issue. Different prevention programs provide treatment either directly to the adolescent, in the context of the school, or within the frame of the adolescent's family. Although some of these efforts have been shown to be effective in reducing alcohol misuse in youth, hardly any intervention reveals satisfactory outcomes in a long-term prospect. Successful prevention strategies would need to comprise treatment of current neuropsychological impairment as well as of comorbid mental health problems and concurrent other substance misuse.

Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors

PURPOSE

The United States Centers for Disease Control and Prevention monitors health-risk behaviors of adolescents in United States, which include (1) violence; (2) tobacco use; (3) alcohol and other drug use; (4) sexual behaviors contributing to unintended pregnancy and sexually transmitted diseases; (5) inadequate physical activity; and (6) unhealthy dietary behaviors. We reviewed original research published in peer-reviewed journals between 1985 and 2010 to synthesize evidence about the association of adolescent health-risk behaviors and academic achievement.

METHODS

Using predetermined selection criteria, 122 articles were included that used at least one variable for health-risk behaviors and also for academic achievement.

RESULTS

For all six health-risk behaviors, 96.6% of the studies reported statistically significant inverse relationships between health-risk behaviors and academic achievement.

CONCLUSIONS

With this persuasive evidence about the interrelationship of health-risk behaviors and academic achievement, it is imperative that leaders in education and health act together to make wise investments in our nation's school-age youth that will benefit the entire population. A unified system that addresses both health behavior and academic achievement would have reciprocal and synergistic effects on the health and academic achievement not only of children and adolescents, but also of adults in the United States.

Guidelines for alcohol screening in adolescent trauma patients: a report from the Pediatric Trauma Society Guidelines Committee

BACKGROUND

Alcohol misuse is an important source of preventable injuries in the adolescent population. While alcohol screening and brief interventions are required at American College of Surgeons-accredited trauma centers, there is no standard screening method. To develop guidelines for testing, we reviewed available evidence regarding adolescent alcohol screening after injury, focusing on the questions of which populations require screening, which screening tools are most effective, and at which time point screening should be performed.

METHODS

A comprehensive PubMed search for articles related to alcoholism, trauma, and screening resulted in 1,013 article abstracts for review. Eighty-five full-length articles were considered for inclusion. Articles were excluded based on study type, location (non-US), year of publication, and nonapplicability to the study questions.

RESULTS

Twenty-six articles met full inclusion criteria. Results support universal screening for alcohol misuse in the adolescent trauma population. Although adolescents 14 years and older are more likely to test positive for alcohol misuse, studies suggest screening may need to start at 12 years or younger. Both survey and biochemical screens can identify at-risk adolescents, with the Alcohol Use Disorders Identification Test and the two-question survey based on the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition criteria for alcohol-use disorders being the most sensitive surveys available.

CONCLUSION

Injured adolescent trauma patients should be universally screened for alcohol misuse during their hospital visit. To maximize the number of at-risk adolescents targeted for interventions, screening should begin at minimum at 12 years. As no screen identifies all at-risk adolescents, a serial screening method using both biochemical tests and standardized questionnaires may increase screening efficacy.

Trajectories of adolescent alcohol use after brief treatment in an Emergency Department

OBJECTIVE

The primary aim of this study was to identify distinct classes of trajectories of adolescent substance use following a brief motivational interviewing (MI) intervention in an Emergency Department (ED). The secondary aim was to identify predictors of class membership.

METHODS

Latent growth mixture modeling was used with 177 adolescents who participated in two randomized clinical trials evaluating MI for an alcohol-related event.

RESULTS

Three classes were identified: (1) moderate use, decreasers consisting of 56.8% of participants; (2) heavy use, decreasers, consisting of 10.5% of participants, and (3) heavy use sustainers, consisting of 32.7% of participants. Hispanic ethnicity, parental monitoring, and days of high-volume drinking were significant predictors of class membership. Hispanic ethnic status and high levels of parental monitoring were associated with decreased likelihood of belonging to either of the two heavy use classes. More frequent high-volume drinking at baseline was associated with increased likelihood of belonging to the heavy use, sustainer class, and decreased likelihood of belonging to the heavy use, decreaser class. Across all three classes, being female and having frequent high-volume drinking at baseline were associated with worse response to the intervention.

CONCLUSIONS

These findings have important implications for identifying adolescents who may benefit from different or additional intervention, and for anticipating and informing families of adolescents' potential drinking course following treatment.

Screening, brief intervention, and referral for alcohol use in adolescents: a systematic review

BACKGROUND AND OBJECTIVE

Alcohol use by adolescents is widespread and is connected to a number of negative health and social outcomes. Adolescents receiving emergent care for injuries are often linked with risky use of alcohol. The trauma system has widely adopted the use of screening, brief intervention, and referral to treatment (SBIRT) for preventing alcohol-related injury recidivism and other negative outcomes. The purpose of this article is to review the evidence around SBIRT with adolescent patients in acute care settings.

METHODS

This article reviews 7 randomized controlled trials evaluating risky drinking interventions among adolescent patients in acute care settings. All studies took place in the emergency departments of level I trauma centers.

RESULTS

Four of the 7 studies reviewed demonstrated a significant intervention effect; however, no one intervention reduced both alcohol consumption and alcohol-related consequences. Two of these 4 studies only included patients ages 18 and older. Subgroup analyses with adolescents engaged in risky alcohol-related behaviors, conducted in 2 of the studies, showed significant intervention effects. Five studies showed positive consumption and/or consequences for all study participants regardless of condition, suggesting that an emergent injury and/or the screening process may have a protective effect.

CONCLUSIONS

Based on existing evidence, it is not clear whether SBIRT is an effective approach to risky alcohol use among adolescent patients in acute care. Additional research is needed around interventions and implementation.

A public health enforcement initiative to combat underage drinking using Emergency Medical Services call data

OBJECTIVE

The objective of this study was to determine whether Emergency Medical Services (EMS) records can identify bars that serve a disproportionate number of minors, and if government officials will use this data to direct underage drinker enforcement efforts.

METHODS

Emergency Medical Services call logs to all bars in the study area were cross-referenced with a local hospital's records. The records of patients with alcohol-related complaints were analyzed. Outlier bars were identified, and presented to government officials who completed a survey to assess if this information would prompt new enforcement efforts.

RESULTS

Emergency Medical Services responded to 149 establishments during the study period. Eighty-four responses were distributed across six bars, and 78 were matched with the hospital's records. Fifty-one patients, 18 (35%) of whom were underage, were treated for alcohol intoxication, with 46% of the cases originating from four bars. Government officials found the information useful, and planned to initiate new operations based on the information.

CONCLUSIONS

Alcohol consumption by minors can lead to life-long abuse, with high personal, financial, and societal costs. Emergency Medical Services response data and hospital records can be used to identify bars that allow underage drinking, which is useful in directing law enforcement efforts.

Clinical prevalence and correlates of substance use in adolescent psychiatric emergency patients

OBJECTIVES

This study used clinical and administrative data to describe the clinical prevalence and correlates of substance use disorders (SUDs) in 622 adolescents aged 12 to 17 years who were evaluated with 1 or more psychiatric diagnoses after presenting to an urban psychiatric emergency service.

METHODS

Clinical and administrative data including demographics, diagnosis, psychiatric severity, suicidality, treatment history, treatment disposition, social support, and overall functioning were retrospectively obtained from patient records. These data were used to describe the prevalence and correlates of SUDs in this sample of adolescents with psychiatric disorders.

RESULTS

Twenty-eight percent of youth had an SUD. Marijuana and alcohol use disorders were the most common. The diagnosis of SUD was not associated with specific psychiatric diagnostic categories (mood, anxiety, and psychotic), psychiatric symptom severity, or suicidality, in the overall sample. There was limited evidence for a mediating/moderating effect of sex on the correlation between psychiatric measures and SUD diagnosis. Older age, SUD treatment history, and role dysfunction (ie, poor school functioning) were independently associated with any SUD diagnosis or a drug use disorder when accounting for sex. Older age and history of SUD treatment were independently correlated with alcohol use disorders. Twenty-three percent of youth with SUDs were referred for SUD treatment.

CONCLUSIONS

Substance use disorders were prevalent in this population, and the rate of SUD treatment disposition was lower than anticipated. Substance use disorders were associated with lower functioning but not independently correlated with psychiatric diagnostic categories or symptom severity. This study supports the need for improved screening, intervention, and referral options for SUDs in this setting.

Strategy for increasing detection rates of drug and alcohol abuse in paediatric emergency departments

AIM

To determine whether implementation of criteria for performing a toxicology screen and increasing staff awareness improve detection of substance abuse among adolescents presenting to the emergency department.

METHODS

Patients 12 to 18 years of age presenting to one of three emergency departments in Israel were included in a prospective cohort study. In the 'study' hospital, a set of criteria for urine toxicology screen and measurements of ethanol serum level were implemented. No specific interventions were implemented in the two other hospitals. The main outcome measure was the rate of substance abuse detection.

RESULTS

The number of adolescents seen in the participating centres was 3200 at the study hospital, and 3493 and 2792 at the two other hospitals. High blood ethanol concentrations were found in 49 patients at the study hospital compared with 30 and 19 patients at the two other hospitals (p < 0.001). Illicit drugs were detected in 13, 4 and 1 patients, respectively (p = 0.002).

CONCLUSIONS

Introducing structured guidelines for ordering toxicological screening increases the detection of alcohol and drug of abuse among adolescents presenting to paediatric emergency departments.

Parental factors influence teen alcohol use after an emergency department visit

OBJECTIVES

To determine if parental factors are significant predictors of short-term adolescent drinking after an alcohol-related emergency department (ED) visit.

METHODS

Adolescents, 13 to 17 years, who either had evidence or reported usage of alcohol in the 6 hours before an ED visit, were eligible for this study. Alcohol use was assessed at baseline and at 3-month follow-up. Data on parental variables and parenting practices were collected at baseline. Linear regression models were created to determine the relationship between parental factors and follow-up drinking.

RESULTS

Parental alcohol use, socioeconomic status, and monitoring practices were significant predictors of adolescent alcohol use at 3-month follow-up.

CONCLUSIONS

Parental factors may significantly influence subsequent adolescent drinking after an ED visit. These factors should be assessed when treating alcohol-positive teens, and parents should be advised to closely monitor their teens.

Emergency department detection of adolescents with a history of alcohol abuse and alcohol problems

OBJECTIVE

To compare the characteristics of adolescents with and without a history of problematic alcohol use, who are treated in the emergency department (ED) for an alcohol-related problem.

METHODS

Three hundred seventeen adolescents presenting to the ED after an alcohol-related incident were divided into 2 groups based on whether their score on the Adolescent Drinking Inventory reached the clinical cutoff on problematic drinking, and compared regarding current drinking, depression, and risk-taking behaviors.

RESULTS

Adolescents who reached the clinical cutoff on the Adolescent Drinking Inventory were older and reported more frequent drinking, greater depressed mood, and more risk-taking behaviors.

CONCLUSIONS

Of the adolescents presenting to the ED with an alcohol-related incident, those with a positive history of problematic drinking represent a particularly high-risk subgroup.

Substance misuse, anxiety and depression and urgency of presentation to a public emergency department in Australia

OBJECTIVES

To establish the prevalence and comorbidity of substance-related problems and anxiety and depression, among ED presentations, and to compare the prevalence of these conditions among more and less urgent presentations.

DESIGN AND SETTING

Cross-sectional survey of ED presentations over a 14 day period (24 h/day) at the Gold Coast Hospital Emergency Department in south-east Queensland, Australia, in October 2002.

MEASURES

Usual level of alcohol consumption (Alcohol Use Disorders Identification Test), acute alcohol and illicit drug use (during 24 h prior to interview), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and triage category (Australasian Triage Scale).

RESULTS

Thirty-one per cent of the sample reported usually consuming alcohol at a hazardous or harmful level. Twenty per cent of participants reported clinically significant levels of anxiety and/or depression, which were in turn significantly associated with hazardous and harmful levels of alcohol use. Hazardous/harmful alcohol consumption was over-represented among less urgent ED presentations, whereas anxiety and depression were more prevalent among more urgent ED presentations.

CONCLUSIONS

Emergency departments in Australia are appropriate settings for the detection of both substance use and mental health problems in the wider community. The prevalence of these problems in ED settings is high and there is a need for the development of systematic screening and referral processes. The evidence of a link between urgency of presentation and these problems needs to be further explored.

Posttraumatic Stress and Depressive Symptoms, Alcohol Use, and Recurrent Traumatic Life Events in a Representative Sample of Hospitalized Injured Adolescents and Their Parents

OBJECTIVE

Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings.

METHODS

Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms.

RESULTS

Fifty-seven percent [corrected] of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms.

CONCLUSIONS

The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.

A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department

We tested whether a brief motivational interview (MI) would reduce alcohol-related consequences and use among adolescents treated in an emergency department (ED) after an alcohol-related event. Patients aged 13 to 17 years (N = 152) with a positive blood alcohol concentration (BAC) by lab test or self-report were recruited in the ED and randomly assigned to receive either MI or standard care (SC). Both conditions resulted in reduced quantity of drinking during the 12-month follow-up, whereas alcohol-related negative consequences were relatively low and stayed low at follow-up. Adolescents who screened positive for problematic alcohol use at baseline reported significantly more improvement on 2 of 3 alcohol use outcomes (average number of drinking days per month and frequency of high-volume drinking) if they received MI compared with SC. We conclude that brief interventions are recommended for adolescents who present to an ED with an alcohol-related event and report preexisting problematic alcohol use.

Gender differences in the relationships between alcohol, tobacco and mental health in patients attending an emergency department

AIMS

There is evidence of a non-linear relationship between alcohol consumption and mental health status, and of an association between tobacco use and poor mental health. This paper examines the nature of the association between usual alcohol consumption, tobacco use and symptoms of anxiety and depression in Emergency Department patients in Queensland, Australia.

METHODS

A cross sectional survey of patients aged 16-84 presenting for treatment over a 14 day period to Gold Coast Hospital Emergency Department using socio-demographic items, the Alcohol Use Disorders Identification Test (AUDIT) to measure moderate, hazardous and harmful alcohol consumption, and the Hospital Anxiety and Depression Scale (HADS) to measure state anxiety and depression.

RESULTS

812 patients were interviewed. Gender differences in results were evident. For men, there was a U-shaped relationship between alcohol consumption and anxiety/depression, and a linear association between smoking and anxiety. For women, alcohol consumption and anxiety/depression showed a more linear relationship, but there was no significant relationship between tobacco use and anxiety/depression.

CONCLUSIONS

There may be important gender differences in the relationships between alcohol consumption, tobacco use and mental health status. This study supports previous evidence that mental health status of non-drinkers is worse than that of moderate drinkers, but only among males.

United States male students who heavily consume alcohol in Mexico are at greater risk of travelers' diarrhea than their female counterparts

BACKGROUND

The relationship between alcohol consumption and travelers' diarrhea has not been well studied.

METHODS

A cohort of US college students (n=171), who attended 2001 or 2002 summer educational sessions in Guadalajara, Mexico, were followed prospectively to examine the frequency of alcohol consumption and the development of travelers' diarrhea.

RESULTS

More male students reported consuming >5 drinks/day of drinking while in Mexico compared to female students (p <.001). Males who consumed >5 drinks/day of drinking while in Mexico were more likely to develop diarrhea than their female counterparts who drank the same amount (79% vs. 46%; p=.035). No association was found between the development of travelers' diarrhea and the consumption of fewer than 5 drinks per day in Mexico. Non-drinkers accounted for only 8% of the population and had a relatively high attack rate of diarrhea (69%).

CONCLUSIONS

This study suggests that males who drink heavily are at high risk for developing travelers' diarrhea and may be a group of people to target for education about the moderation of use of alcohol while traveling. Nondrinkers also deserve further study in larger numbers to confirm an apparently high attack rate of diarrhea and to explore what risk factors might be involved.

Identification and brief treatment of alcohol problems with medical patients: an international perspective

This article summarizes the proceedings of a symposium at the 2002 RSA meeting in San Francisco, California. The chair was Peter Monti and co-chair was Nancy Barnett. The aim of the symposium was to bring together researchers from the United States, Sweden, and Mexico to present current findings on the development and implementation of screening and intervention research in Emergency Departments (ED). Cheryl Cherpitel presented findings on the performance of the Rapid Alcohol Problems Screen (RAPS4), a 4-item instrument used for screening for alcohol dependence and harmful drinking in the ED. Dr. Cherpitel also presented for her collaborator, Guilherme Borges, their research on the performance of a number of screening measures including the RAPS among Mexicans and Mexican-Americans with alcohol-related disorders in the ED. Preben Bendtsen described the implementation of an alcohol screening and intervention procedure delivered by ordinary ED staff in Sweden. Nancy Barnett presented data on characteristics related to readiness to change alcohol use in a sample of young adults who were treated in an ED for injury or intoxication.