The Case 

A 53-year-old male known to have a substance use disorder presents to the emergency department. EMS reports finding an empty bottle of vodka at the scene, the patient had a decreased level of consciousness, and alcohol intoxication is suspected. This is the patient’s third visit to the emergency department in a week with a similar presentation. He is observed for six hours while his mental status improves and is discharged after demonstrating clinical sobriety and that he can ambulate safely.

Clinical Question

What is the association between visits to the emergency department for alcohol-related issues and one-year all-cause mortality?

Background

Alcohol consumption is known to be a major contributor to morbidity and mortality.¹ It is estimated that around 3 million deaths globally can be ascribed to the consumption of alcohol, representing 5 percent of all deaths.² In the United States, close to 100,000 people per year die from alcohol-related causes.³ This makes alcohol-related illnesses the third leading preventable cause of death. The single greatest risk factor for ill health worldwide among people ages 15 to 49 years, according to the 2016 Global Burden of Disease Study, is alcohol.⁴ 

Alcohol-related ED visits have increased more than the overall rate of ED visits in the United States.⁵ This trend of increasing alcohol-related ED visits has been reported in Canada, England, and Australia.^6–8

Reference: Hulme J, Sheikh H, Xie E, et al. Mortality among patients with frequent emergency department use for alcohol-related reasons in Ontario: a population-based cohort study. CMAJ. 2020;192(47):E1522-E1531.

Population: Adults ages 16 to 105 years who made two or more ED visits for alcohol-related reasons in a year.

Excluded: Data inconsistencies, not Ontario residents, age <16 or >105, or death at discharge.

Exposure: Patients with ED visits for alcohol-related mental and behavioral disorders, using the Canadian ICD-10 (ICD-10-CA) code of F10. 

Comparison: Comparisons were made between groups of frequent ED users for alcohol-related reasons. Frequent use was categorized into either two visits per year, three or four visits per year, or more than four visits per year. 

Outcome:

Primary Outcome: One-year mortality, adjusted for age, sex, income, rural residence, and presence of comorbidities.

Secondary Outcomes: Mental and behavioral disorders, diseases of the circulatory system, diseases of the digestive system, and external causes of morbidity and mortality (eg, accidents, including accidental poisoning, accidental injuries, injuries, intentional self-harm, and assault) with frequency greater than 5 percent. Cause of death using alcohol-attributable ICD-10-CA codes as well as ICD-10-CA codes for death by suicide.

Table 1: Patients with Multiple Alcohol-Related ED Visits

Authors’ Conclusions

“We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.”

Key Results

The cohort included 25,813 unique patients who had more than one ED visit related to alcohol during the previous 12 months (see Table 1). The median age was 45 years, two-thirds were male, 88 percent lived in urban areas, 59 percent arrived by EMS, and 13 percent were admitted to hospital on their index visit.

One in 20 people presenting to the emergency department with two or more alcohol-related visits within 12 months dies within one year. Death due to an external cause (eg, suicide or accidents) was most common.

Evidence-Based Medicine Commentary

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1) Observational Study: Multiple visits to the emergency department for alcohol-related issues may be a surrogate marker for other factors causing or contributing to the increase observed in all-cause mortality. Despite the authors’ adjusting for age, sex, income, rural residence, and presence of comorbidities, there could be other unmeasured confounders responsible for the results.

2) ICD-10-CA Codes: Validation of the use of ICD-10-CA code F10 to ascertain alcohol use disorders among patients presenting to the emergency department has not been published. This lack of validation does not mean that it is invalid to use this method of identifying cases, but we should use extra caution when interpreting the results. 

3) Effective Intervention: In the article’s introduction, it is stated that a screening and brief intervention for alcohol-related problems in the emergency department is a promising approach for reducing problematic alcohol consumption.⁹ However, there were no references in the discussion of any high-quality evidence that any interventions prevent the need for hospital use or all-cause mortality.

4) Access to Care: Even if there were an effective treatment for alcohol use disorder that prevented mortality, access to care can be a challenge. Just over 10 percent of the cohort came from rural areas, where access to health care services is often limited.  

5) Comparison: Other chronic conditions lead to frequent emergency department use, such as type 2 diabetes, chronic obstructive pulmonary disease, and congestive heart failure. This study did not compare these one-year mortality rates to those of patients with alcohol-related evaluation and treatment. 

Bottom Line

A higher frequency of ED visits for alcohol-related issues is associated with an increase in all-cause one-year mortality. 

Case Resolution

You offer the patient information on a local low-barrier (no referral, no cost) substance use disorder clinic. He takes the information and says he will consider visiting the clinic for help. You also offer him the anti-craving medication naltrexone starting at 50 mg orally daily for one week since he has no contraindications (eg, opioid use in the last 10 days).¹⁰ He takes the prescription and says he will consider this option.   

Thank you to Dr. Hasan Sheikh, an emergency and addictions physician in Toronto and a lecturer at the University of Toronto, for his help with this review.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. 

References

1. Rehm J, Mathers C, Popova S, et al. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373(9682):2223-2233.
2. Poznyak V, Rekve D. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018.
3. Alcohol and public health: alcohol-related disease impact (ARDI). Annual average for United States 2011-2015 alcohol-attributable deaths due to excessive alcohol use, all ages. Centers for Disease Control and Prevention website. Accessed Feb. 8, 2021.
4. GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1345-1422.
5. Mullins PM, Mazer-Amirshahi M, Pines JM. Alcohol-related visits to US emergency departments, 2001-2011. Alcohol Alcohol. 2017;52(1):119-125. 
6. Myran DT, Hsu AT, Smith G, et al. Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study. CMAJ. 2019;191(29):E804-E810.
7. Green MA, Strong M, Conway L, et al. Trends in alcohol-related admissions to hospital by age, sex and socioeconomic deprivation in England, 2002/03 to 2013/14. BMC Public Health. 2017;17(1):412.
8. O’Donnell M, Sims S, Maclean MJ, et al. Trends in alcohol-related injury admissions in adolescents in Western Australia and England: population-based cohort study. BMJ Open 2017;7(5):e014913. 
9. D’Onofrio G, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med. 2002;9(6):627-638.
10. Rösner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867.