It’s 7 a.m. and before you’ve even taken the first sips of your morning coffee, you’ve already received sign out. The last person on your list is the young man resting in a hallway bed recovering from a drunken fight. Thankfully he has no major injuries and by the time you get around to evaluating him, he’s clinically sober come up and eager to leave. Ideal discharge? Not so fast. If you spend a few extra minutes with him, an interaction that started as a no-brainer discharge turns into a potentially impactful encounter for a patient who clearly has a problem with drinking.

There’s a misconception that because alcohol is commonplace culturally in the U.S., problem drinking has reached a steady state. Deaths from drinking increased 25 percent from 2019 to 2020 and another 10 percent in 2021. The percentage of suicides while intoxicated with alcohol has increased, particularly among women, and traffic fatalities in 2020 were at their highest point in over a decade.¹ Although there are likely some pandemic-related effects at play, these trends are probably multifactorial.

What is more, over the past few years, media attention has shifted away from alcohol use and toward the opiate epidemic.² Although the opiate epidemic is certainly worthy of attention, it accounts for only about half of the number of deaths annually and only around a quarter of the number of emergency department visits annually relative to alcohol use.¹

Problem drinking is a big problem. It’s getting worse, and it’s not getting the attention that it deserves.

Emergency physicians may think that screening for problem drinking falls squarely within the purview of primary care providers. The United States Preventive Services Task Force (USPSTF) recommends screening for problem drinking in the primary setting, but we know that patients who present to the ED are twice as likely to engage in dangerous drinking, so arguably the ED is an important venue for screening as well.³

The National Commission on Prevention Priorities ranks screening for problem drinking as one of the top five most effective preventive services based on cost-effectiveness and clinically preventable burden of disease. That’s among preventive services like screening for high blood pressure and getting an annual flu shot.⁴

Interestingly, not only is screening efficient, it’s also effective. Simply screening for problem drinking has been shown to lead to at least short-term changes in drinking habits.⁵ When we screen for problem drinking, it shows patients that we care about them and draws their attention to dangerous alcohol use as a serious health concern. ^5,6

Only one in six ED physicians routinely screens for dangerous drinking, and only one in 36 are using a validated screening tool. Reported barriers to screening are lack of time and perceived lack of treatment options.⁴

Screening for dangerous drinking should take no more than 60 seconds. The Modified Single Alcohol Screening Questionnaire (M-SASQ) and Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) are two very brief screening tools that have been validated for identifying problem drinking in the ED. If a patient’s score is moderate or high on either of these screening tools, spend a few minutes speaking with them about whether they are interested in making a change to their drinking habits. If they’re not interested in making a change at present, remind them that the ED can be a resource for them in the future.

If they are interested in change, review the DSM-5 criteria for alcohol use disorder. No need to commit these criteria to memory. They’re readily available online. It’s important to note that patients must have two or more criteria over one year and associated distress or impairment. Notably for ED physicians, one of the criteria is “using [alcohol] in situations that might be dangerous.”⁷ If a patient is presenting to the ED because of accident or injury related to alcohol, or because they are unable to care for their chronic medical conditions because of their drinking, this condition is automatically met.

Once you’ve made a diagnosis, the next step is to offer an intervention. There are three FDA-approved medications for alcohol use disorder. Disulfiram is an abstinence medication, meaning it is not safe to drink while taking this medication. This medication has limited outcomes data and multiple contraindications. Unless a patient has taken disulfiram before or has a compelling reason for wanting to start this medication, I would not routinely prescribe this medication from the ED.

On the other hand, naltrexone and acamprosate are well-tolerated, affordable medications with promising outcomes data for harm reductions and, in some cases, abstinence. Naltrexone is contraindicated in patients with opiate dependence and acute hepatitis or liver cirrhosis, whereas acamprosate is contraindicated in CKD  4. Not all patients are safe to quit drinking cold turkey, but if a patient is able to maintain abstinence for at least four days prior to starting naltrexone or acamprosate, outcomes tend to be better. Several other medications are not FDA approved; however, these medications do not have a robust enough evidence base to merit incorporation into common practice.⁸

Although substance use has a strong psychosocial element, and cognitive behavioral therapy has been shown to decrease heavy drinking and increase number of abstinent days, not all patients want or need therapy as a component of their treatment. Refer to therapy when possible and when patients are amenable.⁹

Back to the patient. He wasn’t ready to make a change that morning. But when his partner broke up with him after yet another drunken fight, and his boss fired him after he showed up to his job hungover for the fourth time this month, he saw the bottom coming up at him and realized that it was time for a change. He returned to the emergency department, and you had the great privilege of saving his life.

Dr. Miller is an emergency physician at the University of Maryland School of Medicine, Department of Emergency Medicine.

Dr. Jasani is an emergency physician at the University of Maryland School of Medicine, Department of Emergency Medicine.

References

1. National Institute on Alcohol Abuse and Alcoholism. Alcohol’s effects on health: research-based information on drinking and its impact. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states. Published 2024. Accessed June 15, 2024.
2. Pilar MR, Eyler AA, Moreland-Russell S, et al. Actual causes of death in relation to media, policy, and funding attention: examining public health priorities. Front Public Health. 2020:8;279. doi:10.3389/fpubh.2020.00279.
3. Cherpitel CJ, Ye Y. Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: Data from the 2005 National Alcohol Survey. Drug Alcohol Depend. 2008;97(3):226-230. doi:10.1016/j.drugalcdep.2008.03.033.
4. Uong S, Tomedi LE, Gloppen KM, et al. Screening for excessive alcohol consumption in emergency departments: a nationwide assessment of emergency department physicians. J Public Health Manag Pract. 2022;28(1):E162-E169. doi:10.1097/PHH.0000000000001286.
5. Barata IA, Shandro JR, Montgomery M, et al. Effectiveness of SBIRT for alcohol use disorders in the emergency department: a systematic review. West J Emerg Med. 2017;18(6):1143-1152. doi:10.5811/westjem.2017.7.34373.
6. Curry SJ, Krist AH, Owens DK, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(18):1899-1909. doi:10.1001/jama.2018.16789.
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Fifth Edition. Washington, D.C.: American Psychiatric Association Publishing; 2022.
8. Mason BJ, Heyser CJ. Alcohol use disorder: the role of medication in recovery. Alcohol Res. 2021;41(1):07. doi:10.35946/arcr.v41.1.07.
9. Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003-2017