Patients admitted to emergency services for drunkenness: moderate alcohol users or harmful drinkers?

Understanding the Mechanisms of Action and Effects of Drugs of Abuse

AIM

Drug abuse and addiction are major public health concerns, with millions of people worldwide affected by the negative consequences of drug use. To better understand this complex issue, a review was conducted to examine the mechanisms of action and effects of drugs of abuse, including their acute and chronic effects, the symptoms of abstinence syndrome, as well as their cardiovascular impacts.

METHODS

The analyzed data were obtained after surveying an electronic database, namely PubMed, with no time limit, grey literature sources, and reference lists of relevant articles.

RESULTS

The review highlights the different categories of drugs of abuse, such as opioids, stimulants, depressants, hallucinogens, and cannabis, and discusses the specific ways that each drug affects the brain and body. Additionally, the review explores the short-term and long-term effects of drug abuse on the body and mind, including changes in brain structure and function, physical health problems, and mental health issues, such as depression and anxiety. In addition, the review explores the effects of drug abuse on cardiovascular health, focusing on electrocardiogram changes. Moreover, the analysis of relevant literature also highlighted possible genetic susceptibility in various addictions. Furthermore, the review delves into the withdrawal symptoms that occur when someone stops using drugs of abuse after a period of chronic use.

CONCLUSION

Overall, this review provides a comprehensive overview of the current state of knowledge on drug abuse and addiction. The findings of this review can inform the development of evidence-based prevention and intervention strategies to address this critical public health issue.

Identifying alcohol problems among suicide attempters visiting the emergency department

BACKGROUND

Many suicide attempters brought to our emergency department (ED) have been found to have alcohol problems, and this should be taken serious consideration because alcohol use disorder is a risk factor for suicide reattempt. In this study, we aimed to estimate the effectiveness of alcohol-related biochemical markers and Alcohol Use Disorder Identification Test Consumption (AUDIT-C) in suicide attempters who visited our ED based on the gold standard for clinical diagnosis used by psychiatrists for alcohol use disorder. Moreover, we aimed to search for a significant standard when clinicians make correct predictions about alcohol use disorder using these markers.

METHODS

Among the subjects who visited ED following a suicide attempt, a total of 203 subjects were selected. Following a psychiatric interview, the subjects who met the criteria for alcohol abuse or alcohol dependence according to DSM-IV-TR in the past year were defined as the "alcohol use disorder" group. Although some subjects did not meet these criteria, men with a weekly alcohol intake of ≥14 drinks and women with a weekly alcohol intake of ≥7 drinks were classified as the "risky drinking" group. AUDIT-C was used as a self-report; further, aspartate aminotransferase, gamma-glutamyltransferase (GGT), and carbohydrate-deficient transferrin (CDT) were assayed using standard methods, and GGT-CDT was calculated using this formula: 0.8 × ln(GGT) + 1.3 × ln(%CDT).

RESULTS

In total, 88 subjects met the criteria for alcohol use disorder and 115 were included in the reference group. In the screening for alcohol use disorder, the AUC of AUDIT-C was 0.89 for men and 0.87 for women. In the screening for risky drinking, the AUC of AUDIT-C was 0.99 for men and 0.93 for women. Compared with other biochemical markers, AUDIT-C showed the highest AUC value for screening for both alcohol use disorder and risky drinking, with the trend being more prominent in men.

CONCLUSIONS

Among the biochemical markers, AUDIT-C yielded the highest sensitivity, specificity, and accuracy in diagnosing alcohol use disorder among suicide attempters in ED. Comparison of results revealed that the use of AUDIT-C with biochemical markers or its use alone can help screen for alcohol use disorder or risky drinking in clinical settings.

[Alcohol and emergencies]

Thirty percent of emergency department admissions are related to an alcohol misuse. Eighty percent of acute intoxications admitted in emergency departments concern patients with alcohol addiction. Care protocols validated in all of emergency departments are necessary for prevention of alcohol withdrawal syndrome. Risky uses require ultra-brief interventions, situations of abuse (light use disorders) require brief interventions and situations of dependence (moderate to severe use disorders) require motivational interviews to promote the emergence of a process of change. The key word for alcohol intervention in emergencies is: empathy. Search addictive comorbidities (tobacco and cannabis) and psychiatric comorbidities (depression and suicidal risk) must be systematic. The coordination between emergency departments and addictology departments is essential. In the emergency department, the goal is to optimise patient care path for all addictive behaviors.

[Epidemiology of alcohol dependence]

Excessive alcohol consumption is the second leading preventable cause of death in France (49,000/year), after tobacco consumption. Several recent studies found that the alcohol-related negative health consequences may occurs with small amounts of alcohol, in particular cancers. Therefore, the risk thresholds for alcohol consumption have been recently recommended not to be higher than 100g/week. Early age of onset of alcohol use is a strong predictor of alcohol use disorders and alcohol-related negative health outcomes. Subjects with alcohol use disorders are underdiagnosed and undertreated, with less than 10-15% of patients with severe alcohol use disorders per DSM-5 criteria receiving treatment. Early treatment of patients with alcohol use disorders decreases the alcohol-related negative health outcomes.

Utilization of a Sobering Center for Acute Alcohol Intoxication

OBJECTIVE

The objective was to describe the population utilizing a sobering center for public alcohol intoxication and compare between single-visit users, repeat users, and high users.

METHODS

We conducted a secondary analysis of 1,271 adults cared for in a sobering center from July 2014 to June 2015. We divided the population into three groups-single use (one visit), repeat users (two to five visits), and high (six or more) users-and evaluated demographics, lifetime health diagnoses utilizing the Elixhauser Comorbidity Index, rates of public service utilization including ambulance and emergency department, and related costs.

RESULTS

The population was primarily male, middle-aged, and ethnically diverse. Compared to single-visit users (n = 869), repeat (n = 287) and high users (n = 115) were older, were more likely to be currently homeless, and had spent more time homeless. Repeat and high users had significantly higher rates of hypertension, liver disease, diabetes, depression, psychoses, and drug abuse diagnoses compared to single-visit users. In addition to sobering visits, utilization of ambulance and ED and related costs were significantly greater for the high users compared to repeat and single-visit users.

CONCLUSIONS

From an overall heterogeneous population, more frequent utilizers of the sobering center, both high and repeat users compared to low users, had significantly greater prevalence of chronic disorders, service utilization, and homelessness. Findings indicate that a sobering center can have a prominent role in the care for those with acute alcohol intoxication, particularly those individuals with chronic public intoxication who are likewise homeless. Further longitudinal research could offer important insights as to the population served over time, investigating changes in utilization and efforts toward health and housing stabilization.

Tests of Theories of Crime in Female Prisoners

Several general theories of crime were tested with path models on 293 female prisoners in a U.S. State prison. The theories tested included Social Bond and Control, Thrill/Risk Seeking, and a new attachment-based Developmental Dynamic Systems model. A large battery of different instruments ranging from measures of risk taking, to a crime addiction scale, to Childhood Adverse Events, to attachments and clinical issues were used. The older general theories of crime did not hold up well under the rigor of path modeling. The new dynamic systems model was supported that incorporated adverse childhood events leading to (a) peer crime, (b) crime addiction, and (c) a measure derived from the Attachment and Clinical Issues Questionnaire (ACIQ) that takes individual differences in attachments and clinical issues into account. The results were discussed in terms of new approaches to Research Defined Criteria of Diagnosis (RDoC) and new approaches to intervention.

Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level?

INTRODUCTION AND AIMS

Acute harm from heavy drinking episodes is an increasing focus of public health policy, but capturing timely data on acute harms in the population is challenging. This study aimed to evaluate the precision of readily available administrative emergency department (ED) data in public health surveillance of acute alcohol harms.

DESIGN AND METHODS

We selected a random sample of 1000 ED presentations assigned an ED diagnosis code for alcohol harms (the 'alcohol syndrome') in the New South Wales, Australia, automatic syndromic surveillance system. The sample was selected from 68 public hospitals during 2014. Nursing triage free-text fields were independently reviewed to confirm alcohol consumption and classify each presentation into either an 'acute' or 'chronic' harm. Positive predictive value (PPV) for acute harm was calculated, and predictors of acute harm presentations were estimated using logistic regression.

RESULTS

The PPV of the alcohol syndrome for acute alcohol harm was 53.5%. Independent predictors of acute harm were ambulance arrival [adjusted odds ratio (aOR) = 3.4, 95% confidence interval (CI) 2.4-4.7], younger age (12-24 vs. 25-39 years: aOR = 3.4, 95% CI 2.2-5.3), not being admitted (aOR 2.2, 95% CI 1.5-3.2) and arriving between 10 pm and 5.59 am (aOR 2.1, 95% CI 1.5-2.8). PPV among 12 to 24-year-olds was 82%.

DISCUSSION AND CONCLUSIONS

The alcohol syndrome provides moderate precision as an indicator of acute alcohol harms presenting to the ED. Precision for monitoring acute harm in the population is improved by filtering the syndrome by the strongest independent predictors of acute alcohol harm presentations. [Whitlam G, Dinh M, Rodgers C, Muscatello DJ, McGuire R, Ryan T, Thackway S. Diagnosis-based emergency department alcohol harm surveillance: What can it tell us about acute alcohol harms at the population level? Drug Alcohol Rev 2016;35:693-701].

Women and Men Admitted for Alcohol Intoxication at an Emergency Department: Alcohol Use Disorders, Substance Use and Health and Social Status 7 Years Later

AIMS

To assess the prevalence of alcohol use disorder (AUD), substance use, mental health and social status 7 years following an Emergency Department (ED) admission for alcohol intoxication. To assess gender differences in these prevalences.

METHODS

Cohort of 631 patients aged 18-30 years admitted for alcohol intoxication in 2006-2007 at a tertiary referral hospital in Switzerland, contacted for an interview in 2014. Assessment consisted of demography, Alcohol Use Disorders Identification Test-Consumption, Mini International Neuropsychiatric Interview for AUD, Patient Health Questionnaire (depression, anxiety) and lifetime/past year use of tobacco/illegal drugs. Gender differences were assessed with Chi-square tests, t-tests and Wilcoxon tests.

RESULTS

In 2014, 318/631 (50.4%) completed the interview. Study completers were not different from non-completers on baseline characteristics (all P > 0.2). Of study completers, 36.8% were unemployed, 56.9% reported hazardous alcohol use, 15.1% alcohol dependence, 13.2% harmful use, 18.6% depression, 15.4% anxiety disorder. Prevalence of any use (lifetime/past year) was 93.4%/80.2% for tobacco, 86.6%/53.1% for cannabis, 54.7%/22.6% for cocaine, 25.6%/13.5% for sedatives, 40.9%/11.0% for stimulants, 21.7%/7.2% for opioids. Men reported significantly more binge drinking, AUD, cannabis use (past year) and more lifetime cannabis, cocaine and stimulants use (all P < 0.05). There was no gender difference in the prevalence of hazardous alcohol use and tobacco use. The prevalence of psychiatric disorders was significantly higher in women (P < 0.05).

CONCLUSIONS

Seven years after being admitted for alcohol intoxication, young patients are likely to present substance misuse, mental health disorders and social problems, suggesting  that they should be offered secondary prevention measures while in the ED.

SHORT SUMMARY

We studied a cohort of patients aged 18-30 and admitted for alcohol intoxication in 2006-2007 at a tertiary hospital. Participants were interviewed in 2014. Seven years after an admission for alcohol intoxication, patients are likely to present AUDs, substance misuse, mental health disorders and social problems.

[Forensic aspect of acute drunkenness]

Alcohol consumption in itself is not forbidden in France. Two situations are reprehended by the law: public drunkenness - where only the behavior is sanctioned and not the alcohol level - and driving with a level of alcohol superior to 0.5g per liter. The management of a severe state of drunkenness - even though frequent - is on the one hand poorly managed and on the other hands badly mastered by doctors. The management of drunken patients lies essentially in a strong monitoring of the possible complications. The inherent question of the returning-back-home for a drunken patient should be approached according to the state of consciousness rather than the alcohol rate in the blood. No matter what the rate is, the authorization to release a patient depends on the preservation of his judgmental capacities. If those are altered, the doctor can then decide to keep - even against his will - the patient temporarily and until he has recovered his discernment. Patients still keep their right to refuse any medical treatment. Indeed, the law does not provide any answer concerning the particular issue of the refusal of medical care by the patient, especially in case of a severe alcoholic intoxicated state that let the patient incapable to express his will and to understand the range of the given information. There is no legal measure that can able a doctor to firmly forbid a drunk patient to be released and to take the wheel. Doctors have to try to dissuade them by proposing other alternatives but they cannot physically oppose themselves to the patient decision. However, proofs that the doctor tried his best to convince the patient not to drive while under the influence of alcohol can be demanded. Doctors have the duty to inform patients on every risk that alcohol can bring while driving but do not have any measure of pressure.

Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis

BACKGROUND

There is much interest in ultra-short alcohol screening in primary care that may support brief alcohol interventions. Brief screening consisting of one or two questions might be used alone or in combination with longer tests as recommended by the Primary Care Service Framework.

AIM

To investigate whether a simple one and two question screening might prove an accurate and acceptable screening method in primary care.

DESIGN AND SETTING

A systematic literature search, critical appraisal and meta-analysis were conducted.

METHOD

A comprehensive search identified 61 analyses of single questions to detect alcohol problems including 17 that took place in primary care, using a robust interview standard. Despite focusing alcohol-use disorder in primary care settings, heterogeneity remained high, therefore random effects and bivariate meta-analyses were used.

RESULTS

After adjustments, diagnostic accuracy of a single-question approach was given by a sensitivity of 54.5% (95% CI = 43.0% to 65.5%) and a specificity of 87.3% (95% CI = 81.5% to 91.5%) using meta-analytic weighting. Two questions had a sensitivity of 87.2% (95% CI = 69.9% to 97.7%) and specificity of 79.8% (95% CI = 75.7% to 83.6%). Looking at each question individually, the most successful single question was a modification of the Single Alcohol Screening Question (SASQ) namely, 'How often do you have six or more drinks on one occasion?'. The optimal approach appears to be two questions followed by the CAGE questionnaire, which achieved an overall accuracy of 90.9% and required only 3.3 questions per attendee.

CONCLUSION

Two brief questions can be used as an initial screen for alcohol problems but only when combined with a second-step screen. A brief alcohol intervention should be considered in those individuals who answer positively on both steps.

How CAGE, RAPS4-QF, and AUDIT Can Help Practitioners for Patients Admitted with Acute Alcohol Intoxication in Emergency Departments?

AIMS

To help clinicians to identify the severity of alcohol use disorders (AUDs) from optimal thresholds found for recommended scales. Especially, taking account of the high prevalence of alcohol dependence among patients admitted to the emergency department (ED) for acute alcohol intoxication (AAI), we propose to define thresholds of severity of dependence based on the AUDIT score.

METHODS

All patients admitted to the ED with AAI (blood alcohol level >0.8 g/L), in a 2-month period, were assessed using the CAGE, RAPS-QF, and AUDIT, with the alcohol dependence/abuse section of the mini international neuropsychiatric interview (MINI) used as the gold standard. To explore the relation between the AUDIT and the MINI the sum of the positive items on the MINI (dependence) as a quantitative variable and as an ordinal parameter were analyzed. From the threshold score found for each scale we proposed intervals of severity of AUDs.

RESULTS

The mean age of the sample (122 males, 42 females) was 46 years. Approximately 12% of the patients were identified with alcohol abuse and 78% with dependence (DSM-IV). Cut points were determined for the AUDIT in order to distinguish mild and moderate dependence from severe dependence. A strategy of intervention based on levels of severity of AUD was proposed.

CONCLUSION

Different thresholds proposed for the CAGE, RAPS4-QF, and AUDIT could be used to guide the choice of intervention for a patient: brief intervention, brief negotiation interviewing, or longer more intensive motivational intervention.

Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis

BACKGROUND

Clinicians have considerable difficulty identifying and helping those people with alcohol problems but no previous study has looked at this systematically.

AIMS

To determine clinicians' ability to routinely identify broadly defined alcohol problems.

METHOD

Data were extracted and rated by two authors, according to PRISMA standard and QUADAS criteria. Studies that examined the diagnostic accuracy of clinicians' opinion regarding the presence of alcohol problems as well as their written notation were evaluated.

RESULTS

A comprehensive search identified 48 studies that looked at the routine ability of clinicians to identify alcohol problems (12 in primary care, 31 in general hospitals and 5 in psychiatric settings). A total of 39 examined alcohol use disorder, 5 alcohol dependence and 4 intoxication. We separated studies into those using self-report and those using interview. The diagnostic sensitivity of primary care physicians (general practitioners) in the identification of alcohol use disorder was 41.7% (95% CI 23.0-61.7) but alcohol problems were recorded correctly in only 27.3% (95% CI 16.9-39.1) of primary care records. Hospital staff identified 52.4% (95% CI 35.9-68.7) of cases and made correct notations in 37.2% (95% CI 28.4-46.4) of case notes. Mental health professionals were able to correctly identify alcohol use disorder in 54.7% (95% CI 16.8-89.6) of cases. There were limited data regarding alcohol dependency and intoxication. Hospital staff were able to detect 41.7% (95% CI 16.5-69.5) of people with alcohol dependency and 89.8% (95% CI 70.4-99.4) of those acutely intoxicated. Specificity data were sparse.

CONCLUSIONS

Clinicians may consider simple screening methods such as self-report tools rather than relying on unassisted clinical judgement but the added value of screening over and above clinical diagnosis remains unclear.

CAGE, RAPS4, RAPS4-QF and AUDIT screening tests for men and women admitted for acute alcohol intoxication to an emergency department: are standard thresholds appropriate?

AIMS

A number of screening instruments are routinely used in Emergency Department (ED) situations to identify alcohol-use disorders (AUD). We wished to study the psychometric features, particularly concerning optimal thresholds scores (TSs), of four assessment scales frequently used to screen for abuse and/or dependence, the cut-down annoyed guilty eye-opener (CAGE), Rapid Alcohol Problem Screen 4 (RAPS4), RAPS4-quantity-frequency and AUD Identification Test (AUDIT) questionnaires, particularly in the sub-group of people admitted for acute alcohol intoxication (AAI).

METHODS

All included patients [AAI admitted to ED (blood alcohol level ≥0.8 g/l)] were assessed by the four scales, and with a gold standard (alcohol dependence/abuse section of the Mini International Neuropsychiatric Interview), to determine AUD status. To investigate the TSs of the scales, we used Youden's index, efficiency, receiver operating characteristic (ROC) curve techniques and quality ROC curve technique for optimized TS (indices of quality).

RESULTS

A total of 164 persons (122 males, 42 females) were included in the study. Nineteen (11.60%) were identified as alcohol abusers alone and 128 (78.1%) as alcohol dependents (DSM-IV). Results suggest a statistically significant difference between men and women (P < 0.05) in performance of the screening tests RAPS4 (≥1) and CAGE (≥2) for detecting abuse. Also, in this population, we show an increase in TSs of RAPS4 (≥2) and CAGE (≥3) for detecting dependence compared with those typically accepted in non-intoxicated individuals. The AUDIT test demonstrates good performance for detecting alcohol abuse and/or alcohol-dependent patients (≥7 for women and ≥12 for men) and for distinguishing alcohol dependence (≥11 for women and ≥14 for men) from other conditions.

CONCLUSION

Our study underscores for the first time the need to adapt, taking into account gender, the thresholds of tests typically used for detection of abuse and dependence in this population.

Choline supplementation mitigates trace, but not delay, eyeblink conditioning deficits in rats exposed to alcohol during development

Children exposed to alcohol prenatally suffer from a range of physical, neuropathological, and behavioral alterations, referred to as fetal alcohol spectrum disorders (FASD). Both the cerebellum and hippocampus are affected by alcohol exposure during development, which may contribute to behavioral and cognitive deficits observed in children with FASD. Despite the known neuropathology associated with prenatal alcohol exposure, many pregnant women continue to drink (heavy drinkers, in particular), creating a need to identify effective treatments for their children who are adversely affected by alcohol. We previously reported that choline supplementation can mitigate alcohol's effects on cognitive development, specifically on tasks which depend on the functional integrity of the hippocampus. The present study examined whether choline supplementation could differentially mitigate alcohol's effects on trace eyeblink classical conditioning (ECC, a hippocampal-dependent task) and delay ECC (a cerebellar-dependent task). Long-Evans rats were exposed to 5.25 g/kg/day alcohol via gastric intubation from postnatal days (PD) 4-9, a period of brain development equivalent to late gestation in humans. A sham-intubated control group was included. From PD 10-30, subjects received subcutaneous injections of 100 mg/kg choline chloride or vehicle. Beginning on PD 32-34, subjects were trained on either delay or trace eyeblink conditioning. Performance of subjects exposed to alcohol was significantly impaired on both tasks, as indicated by significant reductions in percentage and amplitude of conditioned eyeblink responses, an effect that was attenuated by choline supplementation on the trace, but not delay conditioning task. Indeed, alcohol-exposed subjects treated with choline performed at control levels on the trace eyeblink conditioning task. There were no significant main or interactive effects of sex. These data indicate that choline supplementation can significantly reduce the severity of trace eyeblink conditioning deficits associated with early alcohol exposure, even when administered after the alcohol insult is complete. These findings have important implications for the treatment of fetal alcohol spectrum disorders.

Validity study of Kessler's psychological distress scales conducted among patients admitted to French emergency department for alcohol consumption-related disorders

BACKGROUND

Alcohol-related disorders (ARD) encountered in emergency departments (ED) have a high prevalence and are underestimated. It is necessary to provide professionals with a tool to identify patients in whom there is a risk that alcohol-related and mental health problems may be associated. Kessler's K6/10 psychological distress scales are fast, easy-to-use, and have been shown to achieve a good performance in the identification of psychological distress associated with ARD.

AIM

The aim of this study was to evaluate the psychometric properties of the Kessler scales, version 6 and 10, with a sample of patients admitted to EDs for alcohol consumption.

METHODS

On the day after their admission, with a zero "blood" alcohol concentration, 71 patients were randomly assigned to be assessed using 6 or 10 items version. The internal consistency and factor structure of the K6/10 versions were examined. Convergent validity was measured using the Hospital Anxiety and Depression Scale (HADS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

The prevalence of psychological distress in our sample was approximately 60%. The selected threshold scores were 10 for K6 (Sensitivity: 0.92; Specificity: 0.62) and 14 for K10 (Sensitivity: 0.95; Specificity: 0.54). The Cronbach coefficients for K6 and K10 were 0.76 and 0.84, respectively. The factor analyses indicated the multidimensional nature of K6/10. The 2 versions, containing 6 and 10 items respectively, correlated better with the HADS (0.83 and 0.70, respectively) than with the HDRS (0.51 and 0.49, respectively). The areas under the ROC Curve indicated a high level of accuracy for both the K6 (0.87) and the K10 (0.77). The difference was not statistically significant.

CONCLUSIONS

This study confirms the good psychometric characteristics of Kessler's psychological distress scale. Even though similar performances were observed for K6/10, the brevity of the K6 makes it more suitable for use in EDs.

How is alcohol withdrawal syndrome best managed in the emergency department?

Alcohol abuse is a major cause of morbidity and mortality and subsequently presents a substantial burden on the NHS. Whether presentations are directly or indirectly linked, the emergency department (ED) holds a predominant role in dealing with this matter. Alcohol withdrawal syndrome is a common complication of alcohol misuse. Given its pathophysiology and manifestation of symptoms, early recognition and treatment is paramount in preventing a medical emergency. From a review of the associated literature, a standardised protocol for its management in ED is consequently advocated. This includes: Identification of those at risk via routine screening; Monitoring progression and severity using an alcohol withdrawal scale; Implementation of symptom-triggered therapy on the basis of objective evidence collected. Nonetheless, further studies are required to aid the choice of tools and ascertain the efficacy of such protocols within the ED department. Due to time constraints of this real-world setting, feasibility may be considered as important as reliability and validity if new practices are to be considered.

[Acute ethanol intoxication in a paediatric emergency department]

INTRODUCTION AND AIM

Patients arriving in Paediatric Emergency Departments due to alcohol abuse is fairly common. The aim of this study is to determine the profile of the patients seen in the emergency room for acute ethanol intoxication.

MATERIAL AND METHOD

A descriptive study was performed on all patients seen in the emergency department with an acute ethanol intoxication over a 12-month period (2007). Patients with accidental poisoning or with related chronic illness were excluded.

RESULTS

A total of 104 patients were included (50% males). Their mean age was 16.2 years (standar desviation [SD] 1.2 years); 95.8% were older than 14 years. There was on patient who was seen twice for the same reason. The majority, 72.4%, were seen on holiday days; 82.9%, from 8:00 pm to 8:00 am. A total of 81.9% of the patients were brought in by ambulance. No cases of hypoglycaemia were detected and 7.5% of the patients had hypothermia. Ethanol levels and urine toxicology were measured in 66 cases. The mean blood ethanol was 186.1mg/dl (SD 56.2mg/dl); 21.2% were slightly intoxicated, 75.8% moderate and 3% severe. Cannabis was detected in seven cases and amphetamines in three. Three patients needed hospital admission.

CONCLUSIONS

The profile of the patient who arrives to emergency department with acute ethanol intoxication is a teenager who is seen on holiday nights, after a consumption of high proof alcoholic drinks, presents a moderate intoxication, and does not require hospitalisation.

Pre-hospital treatment of acute poisonings in Oslo

Background

Poisoned patients are often treated in and discharged from pre-hospital health care settings. Studies of poisonings should therefore not only include hospitalized patients. Aims: To describe the acutely poisoned patients treated by ambulance personnel and in an outpatient clinic; compare patients transferred to a higher treatment level with those discharged without transfer; and study the one-week mortality after pre-hospital discharge.

Methods

A one-year multi-centre study with prospective inclusion of all acutely poisoned patients ≥ 16 years of age treated in ambulances, an outpatient clinic, and hospitals in Oslo.

Results

A total of 3757 health service contacts from 2997 poisoning episodes were recorded: 1860 were treated in ambulances, of which 15 died and 750 (40%) were discharged without transfer; 956 were treated in outpatient clinic, of which 801 (84%) were discharged without transfer; and 941 episodes were treated in hospitals. Patients discharged alive after ambulance treatment were mainly poisoned by opiates (70%), were frequently comatose (35%), had respiratory depression (37%), and many received naloxone (49%). The majority of the patients discharged from the outpatient clinic were poisoned by ethanol (55%), fewer were comatose (10%), and they rarely had respiratory depression (4%). Among the hospitalized, pharmaceutical poisonings were most common (58%), 23% were comatose, and 7% had respiratory depression. Male patients comprised 69% of the pre-hospital discharges, but only 46% of the hospitalized patients. Except for one patient, who died of a new heroin overdose two days following discharge from an ambulance, there were no deaths during the first week after the poisonings in the 90% of the pre-hospital discharged patients with known identity.

Conclusion

More than half of the poisoned patients treated in pre-hospital treatment settings were discharged without transfer to higher levels. These poisonings were more often caused by drug and alcohol abuse than in those who were hospitalized, and more than two-thirds were males. Almost half of those discharged from ambulances received an antidote. The pre-hospital treatment of these poisonings appears safe regarding short-term mortality.

A Swedish alcohol ignition interlock programme for drink-drivers: effects on hospital care utilization and sick leave

AIMS

This project evaluates health outcomes following an alcohol ignition interlock programme (AIIP) by assessing hospital care utilization and sick-leave register data relative to controls with revoked licences, but with no comparable opportunity to participate in an AIIP.

SETTING

In Sweden, driving while impaired (DWI) offenders can now select voluntarily a 2-year AIIP in lieu of 12 months' licence revocation. The AIIP includes regular medical check-ups designed to alter alcohol use.

DESIGN

The study is a quasi-experimental intent-to-treat design; accordingly, the intervention group includes 48% of the participants who were dismissed from the AIIP before completion.

FINDING

The control group (865 individuals) showed increased hospital care and sick leave after licence revocation following the DWI. Among the 1266 people in the AIIP, however, significantly fewer needed hospital care relative to controls, and relative to their own care utilization before the DWI offence. This occurred whether care reflected all diagnosis or only alcohol-related diagnosis. Also, sick-leave data showed significantly fewer AIIP group individuals using sick leave relative to the control group, and relative to their own pre-treatment period. These significant health benefits disappear in the post-treatment period. However, among those who actually do complete the entire AIIP, sustained positive health effects are observed 3 and 4 years after the DWI offence.

CONCLUSIONS

Voluntary participation in an AIIP has favourable effects with less need for hospital care or sick leave. This is probably linked to reduced alcohol consumption during the programme and to the ability to continue driving.

The acute effects of gabapentin in combination with alcohol in heavy drinkers

BACKGROUND

Alcohol effects in humans involve gamma-amino butyric acid (GABA) neurotransmission. It has been proposed that GABAergic medications may be effective in the treatment of alcohol dependence. This study evaluated the acute effects of gabapentin, an anticonvulsant that increases extracellular GABA, on the subjective, physiological, and performance effects of alcohol in heavy (mean 34 drinks per week) alcohol drinkers.

METHODS

Seventeen volunteers without alcohol dependence were tested using a double-blind design with three 3-day long inpatient phases, each separated by at least a 1-week wash-out period. Each phase, gabapentin (0, 1000, or 2000mg) was administered 4h before alcohol (0.75g/kg), which was given in four divided doses every 20min.

RESULTS

Gabapentin impaired the ability to balance without producing changes in subjective, physiological or other performance measures. Pretreatment with gabapentin did not significantly alter subjective and performance effects of alcohol and did not alter alcohol craving. Gabapentin, dose-dependently enhanced alcohol-induced tachycardia.

CONCLUSIONS

Acute gabapentin administration was well tolerated in combination with alcohol, but did not alter the effects of alcohol.

From data to evidence, to action: findings from a systematic review of hospital screening studies for high risk alcohol consumption

OBJECTIVE

To conduct a systematic review of hospital alcohol screening studies to identify effective and efficient evidence-based strategies.

METHOD

Sixty-five studies (N=100,980) of alcohol problem prevalence amongst hospital patients were reviewed.

RESULTS

Prevalence of positive alcohol screens varied according to hospital location, screening tool and patient characteristics. BAC measures (26%) were nearly twice as likely (OR=1.92, p<.001) to reveal positive screens in the ED than self-reports (16%). No difference was found in prevalence of self-report positive screens between ED (16%) and ward settings (17%). Males were two to four times more likely than females to screen positive (BAC: OR=2.37, p<.001, ED self-report: OR=3.07, p<.001, ward self-report: OR=4.30, p<.001). ED patients aged 20-40 years and ward patients aged 30-50 years had the highest prevalence of positive screens.

CONCLUSIONS

Prevalence of risky or problematic drinking among hospital patients is high and warrants systematic screening and intervention. Many hospitals lack sufficient resources to undertake widespread screening programs. For optimum return on resources, it is recommended to screen males in the ED using BAC measures. Established protocols applying priority criteria and staff training can increase screening accuracy and effectiveness.

Carbohydrate-deficient transferrin (CDT) as a marker of alcohol abuse: a critical review of the literature 2001-2005

The diagnosis of alcohol abuse based on objective data is a necessary requirement in both clinical and forensic environments. Among the different biomarkers of chronic alcohol abuse, carbohydrate-deficient transferrin (CDT) is world wide recognized as the most reliable indicator. However, several problems about the real meaning of CDT and the reliability of its use for the diagnosis of alcohol abuses are still open, as reported by numerous research articles and reviews. The present article presents a critical review of the literature on CDT appeared in the period from 2001 to 2005 (included). The article is organized in the following sections: (1) introduction, (2) definition and structure of human serum CDT, (3) pathomechanisms of the ethanol-induced CDT increase, (4) preanalysis, (5) analysis, (6) data interpretation, (7) review papers, (8) conclusions. As many as 127 papers appeared in the international literature and retrieved by the search engines PubMed and Scopus are quoted.

Multicenter Validation Study of the %CDT TIA Kit in Alcohol Abuse and Alcohol Dependence

BACKGROUND

Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (GGT) are used as biomarkers of alcohol misuse. The aim of this study was to evaluate, in terms of sensitivity and specificity, the performance of the new Bio-Rad %CDT TIA kit and GGT assay for identifying alcohol abuse and alcohol dependence (according to the DSM-IV criteria).

METHODS

An open multicenter study (30 centers) over 3 months, including patient groups of "abusers," "dependents," and controls, was conducted in France.

RESULTS

In alcohol abuse, the sensitivity of GGT was 0.56, and that of CDT was 0.80; in alcohol dependence, the sensitivity of GGT was 0.86, and that of CDT was 0.91. The specificity of GGT was 0.77, and that of CDT was 0.83. The association of GGT with CDT increased sensitivity for alcohol abuse to 0.90 and for alcohol dependence to 0.99, but it appreciably decreased specificity (0.63).

CONCLUSIONS

%CDT is the better screening marker for alcohol abuse and dependence, but GGT is still a useful marker for the detection of alcohol dependence. As an assay method, the second-generation Bio-Rad %CDT immunoassay can be recommended for routine CDT measurement.

The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach

BACKGROUND

A large number of patients seen in clinical practice have an underlying alcohol problem. There is a pressing need for accurate methods to diagnose alcohol over-consumption objectively. Our aim was to determine how best to use biological markers to objectify alcohol problems in patients with clinical suspicion of alcohol misuse.

METHODS

A 6-month longitudinal multicenter trial was conducted, using four study groups (alcohol abusers, alcohol-dependents, healthy controls and consulting controls). CDT, GGT and MCV were measured. Statistical analyses used a computer learning system that created classification systems displayed in decision trees.

RESULTS

In 379 subjects the marker that best discriminated those with alcohol problems from controls was CDT. GGT then helped to differentiate between alcohol abuse and alcohol dependence in cases of high CDT. MCV, age and gender provided no extra information.

DISCUSSION

We recommend CDT as a first-line biological marker to confirm or disprove suspected alcohol misuse. High CDT plus GGT above normal points to alcohol dependence, while high CDT plus GGT below normal is evidence of alcohol abuse.

The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis

OBJECTIVE

To perform a meta-analysis to assess diagnostic characteristics of the CAGE in screening for alcohol abuse or dependence in a general clinical population and to test a new method for pooling of ROC curves.

METHODS

Medline search performed over the period 1/1/1974 to 31/12/2001.

MEASUREMENT

Calculation of diagnostic values.

RESULTS

We identified 35 articles using the DSM criteria as the gold standard to test the diagnostic value of the CAGE. Only 10 studies could be included for the meta-analysis. With a cutoff point > or =2, the pooled sensitivity is far better in inpatients (0.87) than in primary care patients (0.71) or ambulatory patients (0.60). The pooled specificity also differs for each group. The likelihood ratios seem to be relatively constant over the populations (overall LR+:3.44;LR-:0.18). We calculated a pooled AUC of 0.87 (95% CI 0.85-0.89). At low specificity values, the sensitivity was homogeneous over the studies, and at a low sensitivity, the specificity was heterogeneous.

CONCLUSION

The diagnostic value of the CAGE is of limited value using this test for screening purposes at his recommended cutpoint of > or =2.

The influence of gingival margin recession on loss of clinical attachment in alcohol-dependent patients without medical disorders

BACKGROUND

The objective of this study was to examine the effects of alcohol and cocaine misuse on periodontal status in a group of alcohol-dependent patients.

METHODS

Forty verified alcoholics, either exclusively (n = 10) or with cocaine abuse (n = 30), and a matched comparison group of 25 non-alcoholic subjects, 14 of whom abused cocaine, were entered in the study. All subjects were free from systemic illnesses. Blood levels of gamma glutamyl transpeptidase (GGTP), a liver enzyme indicator of alcohol drinking, were determined. A comprehensive periodontal examination was performed on 6 sites per tooth. The gingival index (GI) and plaque index (PI) were recorded. Attachment levels (AL) were computed as probing depth (PD) plus gingival margin level (GM).

RESULTS

No statistically significant differences were noted between the groups for average AL, PD, GM, GI, and PI. In alcoholics, Pearson correlation showed a positive association between GGTP levels and loss of periodontal attachment (P<0.05). A series of regression analyses predicting AL from selected periodontal and demographic factors showed that alcoholics manifest AL by greater increases in GM than non-alcoholics (P<0.07). Severe alcohol use as measured by GGTP >51 iu/l worsens PI (P<0.07), which adversely impacts GM, GI, PD, and ultimately AL. No significant associations were found between cocaine use and AL.

CONCLUSIONS

The results suggest that persistent alcohol abuse increases periodontitis development by heightening the loss of attachment through recession of gingival margins.

Efficacy of metadoxine in the management of acute alcohol intoxication

This randomized, open-label study evaluated the efficacy of 300 mg metadoxine (given intravenously) added to standard treatment compared with standard treatment alone in managing the physical and psychological signs of acute alcohol intoxication. Fifty-two acutely intoxicated patients were randomly assigned to one of two groups and followed during a 2-h period. Changes in clinical symptoms, degree of intoxication, and blood alcohol level were monitored. More patients receiving metadoxine in addition to standard therapy significantly improved by at least one degree of intoxication (one clinical category) compared with those receiving standard treatment alone (76.9% versus 42.3%, respectively). Metadoxine-treated patients also exhibited a significantly greater decrease in blood alcohol concentration compared with those receiving standard treatment alone (-105.4 +/- 61.5 mg/dl versus -60.1 +/- 38.6 mg/dl, respectively). Metadoxine improved the clinical signs of acute alcohol intoxication and accelerated alcohol clearance from the blood, thus supporting existing data. In contrast to previous data, these effects were concurrent but independent. No adverse effects were observed with metadoxine therapy.