Alcohol and Substance Abuse Evaluation

Quantitative information on the prevalence of substance abuse is difficult to obtain because of the unwillingness of abusers to accurately disclose consumption. Surveys are taken routinely in high schools and door-to-door in communities, but complete figures are not available.

The 2023 National Survey on Drug Use and Health (NSDUH) found that in the United States, 79.1% of people aged 12 years or older reported drinking alcohol at some time in their life. That included 21.6% of youths aged 12-17 years. ^[10]

The 2023 NSDUH also revealed that 62.5% of people aged 12 years or older in the United States reported drinking alcohol in the previous year, including 16.9% of youth aged 12-17 years, while 47.5% of people aged 12 years or older reported having had alcohol in the previous month. ^[10]

According to the survey, heavy alcohol use in the previous month was reported by 5.8% of people aged 12 years or older, with heavy drinking defined for men as at least five drinks on any day or at least 15 drinks per week, and for women as at least four drinks on any day or at least eight drinks per week. For young people aged 12-17 years, 0.5% reported heavy drinking in the previous month. ^{[10, 11]}

The 2023 NSDUH also reported that 10.2% of people aged 12 years or older had an AUD in the previous year. That included 2.9% of youths aged 12-17 years. ^[12]

The survey found that among people aged 12 years or older with an AUD in the previous year, about 8% underwent treatment for it in that year, including 9.7% of young people aged 12-17 years with an AUD. ^[13]

Moreover, the 2023 NSDUH found that 16.8% of people aged 12 years or older had used an illicit drug in the previous month and that overall in 2023, 17.1% of people aged 12 years or older had a substance use disorder (SUD, including those with an AUD) in the previous year. Misuse of opioids, including heroin and prescription pain relievers, in the previous year was reported by 3.1% of the population aged 12 years or older, according to the survey. ^[14]

The Substance Abuse and Mental Health Services Administration (SAMHSA) states that the highly addictive form of amphetamine known as methamphetamine is used by about 2 million people aged 12 years or older in any given year, with about 500 people per day trying it for the first time. ^[15]

There are a number of studies that identify various groups of patients presenting to EDs who are at high risk for substance abuse. Practically, almost every patient is at risk. Even with the time/resource pressures in the ED, it is reasonable and appropriate to ask every patient about use/abuse of tobacco, alcohol, or other drugs. If the patient admits to alcohol use, a pattern of abuse may often be easily elicited with simple questioning, but unless there is obvious abuse a simple screening tool should be used. These are further described below.

There are also many patients who present to the ED requesting help for their drinking or substance abuse. Response to this request will be dependent on local resources, which emergency physicians should be familiar with. There are three components of ED evaluation for persons seeking treatment for a substance abuse problem or those confirmed to have such a problem while in the ED. They are (1) assessment of the need for treatment, (2) placement or referral into appropriate treatment, and (3) determination of physical suitability for treatment. ^[16]

Assessment

In assessing need for treatment, keep in mind that patients frequently underestimate their consumption. This underestimation may be attributed to denial, one of the hallmarks of the disease process of substance abuse. Question patients about their drug or drugs of choice and the frequency, amount, and method of use. Obtain information on prior detoxifications, concomitant use of other substances, date of first use, and time interval from last use. Most physicians know and employ the CAGE questioning technique as follows:

• C - Has anyone ever felt you should Cut down on your drinking?

• A - Have people Annoyed you by criticizing your drinking?

• G - Have you ever felt Guilty about your drinking?

• E - Have you ever had a drink first thing in the morning ( Eye-opener) to steady your nerves or to get rid of a hangover?

A single positive response to the CAGE questions is considered suggestive of an alcohol problem, and two or more positive responses indicate the presence of such a problem with a sensitivity and specificity of approximately 90% in most studies. One report indicated that the CAGE questions are best applied if not preceded by questions attempting to quantify alcohol intake. However, the aforementioned Q&F questions are recommended by ACEP to identify at-risk patients who may not yet have a dependence problem. The Q&F questions are:

• On average, how many days per week do you drink alcohol?
• On a typical day when you drink, how many drinks do you have?
• What is the maximum number of drinks you had on any given occasion during the last month?

A positive response is reached when drinking attains these levels:

• Men >14 drinks/week or >4 drinks/occasion
• Women >7 drinks/week or >3 drinks/occasion
• Over age 65 years >7 drinks/week or >3 drinks/occasion

These questions may not accurately indicate abuse problems when universally applied across gender and cultural lines. For example, the CAGE score has been shown to be less accurate in White females; ^[17] therefore, attempt to gather a complete picture of the patient rather than relying solely on this questioning technique. Several other screening methods exist, with the Brief Michigan Alcohol Screening Test (MAST), the most widely used screen suitable for ED use.

One very brief modification of the MAST, which has a reported sensitivity of 91%, requires a positive response to one of the following two questions:

• Have you ever had a drinking problem?
• When was your last drink? (< 24 h = positive response)

The TWEAK screen has been recommended for White females, and a score of 3 or higher indicates an alcohol problem. The screen involves the following questions:

• Tolerance (2 points) - How many drinks can you hold? (Six or more indicates tolerance.)

• Worried (2 points) - Have close friends or relatives worried or complained about your drinking in the past year?

• Eye openers (1 point) - Do you sometimes take a drink in the morning when you first get up?

• Amnesia (1 point) - Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

• [K] Cut down (1 point) - Do you sometimes feel the need to cut down on your drinking?

Frequent injury and injury while drinking also should prompt screening for alcohol abuse.

Screening and counseling recommendations for reducing alcohol misuse are available from the US Preventive Services Task Force. ^[18]

Placement

Placement into the appropriate treatment program ultimately is the responsibility of the detoxification specialist who follows the patient during rehabilitation. The specialist's initial decisions may be based in large measure on the information gathered by the EP's assessments.

The physical examination should take into account that this population is much less likely to have regular medical care than the general population. The emergency physician must also be aware of the specific symptoms of withdrawal from various substances.

Alcohol withdrawal

Many people with alcoholism experience "the shakes" approximately 12-24 hours after their last drink. The shakes are tremors caused by overexcitation of the CNS.

Tremor may be accompanied by tachycardia, diaphoresis, anorexia, and insomnia.

After 24-72 hours, a person with alcoholism may have rum fits (ie, generalized seizures).

Delirium tremens (DT) begins 3-5 days after the last drink. DT is characterized by disorientation, fever, and visual hallucinations.

DT or significantly symptomatic alcohol withdrawal is a medical emergency and should be treated on an inpatient basis.

Opioid withdrawal

Withdrawal symptoms from opioids may begin just a few hours after last use.

The onset of withdrawal may be delayed in patients abusing long-acting opioids.

Along with a strong craving for the drug, opioid withdrawal produces yawning, tears, diarrhea, abdominal cramping, piloerection, and rhinorrhea.

Symptoms of withdrawal usually peak around 48 hours and again at 72 hours.

Withdrawal usually subsides after 1 week, but some heavily dependent users may have mild symptoms for up to 6 months.

Although physically uncomfortable, opioid withdrawal is not life threatening.

Amphetamine withdrawal

Withdrawal is fairly mild. Patients may complain of depression, increased appetite, abdominal cramping, diarrhea, and headache.

Cocaine and hallucinogen withdrawal

Cocaine and hallucinogens do not have a typical withdrawal pattern. These drugs are considered psychologically addicting rather than physically addicting.

CNS depressant withdrawal

Discontinuing prolonged use or abuse of high doses of CNS depressants can lead to serious withdrawal symptoms. This can result in CNS stimulation to the point of grand mal seizures.

Benzodiazepines are the drug of choice for withdrawal seizures.

Milder symptoms such as agitation, restlessness, and insomnia are more common.

No specific laboratory studies are indicated for the patient seeking detoxification or who presents in an intoxicated state, unless history or examination suggests the need. In the patient with acute intoxication, a screen for substances of abuse and a blood or breath alcohol level may be considered, but these generally do not alter management. Consider electrolytes, glucose, blood urea nitrogen (BUN), and creatinine, because of the dehydration and poor nutrition observed in this population. A complete blood count (CBC) may be sent if gastrointestinal (GI) bleeding, anemia, bone marrow suppression, or infections are concerns. Complications of cocaine intoxication may require a cardiac or CNS evaluation that may include an electrocardiogram (ECG) and brain computed tomography (CT) scan.

Dependence on laboratory abnormalities (eg, elevated mean corpuscular volume of red blood cells, abnormal liver enzymes) to confirm the diagnosis of alcoholism causes the physician to miss the majority of patients with the disease; therefore, the physician should query patients with such abnormalities to determine if substance abuse is an issue.

A patient with an alcohol addiction may require vitamin supplementation with thiamine (200 mg), folic acid (1 mg), and a multivitamin. If the patient develops agitation or tremulousness, benzodiazepines may be needed.

Personnel in a detoxification center perform definitive treatment. Substance abuse is a life-long disease that only can be controlled, not cured. In the detoxification center, treatment initially consists of managing the varied symptoms of withdrawal, which can range from a longing to reuse to hallucinations and seizures. Once physical withdrawal is complete, group and individual counseling begins and continues on an inpatient, outpatient, and group support (eg, Alcoholics Anonymous, Narcotics Anonymous) basis.

At times, patients may refuse offered inpatient detoxication or structured outpatient care or it may not be available. In this circumstance, a physician may choose to offer unstructured outpatient detoxication. Drugs may be prescribed for symptomatic relief of the observed or expected symptoms. Caution should be used in this population due to the obvious potential for misuse or diversion of any medications. Regimens for this type of care are supported primarily by anecdotal evidence, which is another reason for caution. For example, various medications may be used to ameliorate narcotic withdrawal symptoms in outpatients. These should be targeted to the prominent symptoms, and quantities of prescription medication should be strictly limited to minimize possibilities for abuse or diversion.

Suggestions by the authors for symptomatic outpatient treatment of opiate withdrawal are as follows.

• Pain - OTC analgesics or prescribed nonsteroidal anti-inflammatory drugs (NSAIDs)

• Diarrhea - Imodium A-D or diphenoxylate/atropine (Lomotil)

• Sneezing/tearing/runny nose - H1-blocking antihistamines

• Nausea/vomiting - 5-HT3 antagonists such as ondansetron or phenothiazine antiemetics such as promethazine (may also have a sedative effect)

• Tachycardia/hypertension - Clonidine (also may help many of the other symptoms)

• Anxiety/insomnia - H1-blocking antihistamines or benzodiazepines