Alcohol and substance use disorders take a tremendous toll on society as a whole and also require significant emergency department (ED) resources. Alcohol use and abuse in the United States accounts for over 100,000 deaths each year1 and costs more than $185 billion annually.2 A study of the effects of alcohol-related disease and injuries found that the number of patients who presented with these conditions increased by 18% from 1992 to 2000.3
Unfortunately, most emergency care providers do little to reduce the incidence of alcohol and substance abuse. The major impediments to providing better service in the ED are associated with identification, intervention, and referral. In an ideal world, emergency clinicians would identify alcohol or substance abuse in patients, begin intervention in the ED, and ensure that care continues in an outpatient setting.
Many emergency physicians do not think that their role in the ED includes identifying persons with alcohol and substance use disorders, even though organized emergency medicine advocates for the screening of these patients.4 ED physicians who do little to identify patients with this problem probably either lack understanding or have time limitations. However, this condition is no different from any other medical condition that emergency physicians need to identify and manage.
Recognizing symptoms of alcohol or substance abuse in patients presenting to the ED is made more difficult by the subsets of patients who would not be thought of as having these disorders, such as pediatric and elderly patients. A significant number of pediatric and elderly persons who present to the ED with other disorders turn out to have underlying substance abuse or alcoholism that may have contributed to or caused their presenting problem. It is especially important that we do our utmost to identify substance or alcohol abuse in pediatric patients and that they receive treatment early so they are more likely to have success in later life.
Treatment interventions by emergency physicians are varied, if they occur at all. I had one colleague who thought that intervention in the ED was to instruct the patient to stop drinking (or using drugs, or both), get a job, and go to church. The effectiveness of these recommendations has not been tested. However, it has been demonstrated that short interventions in the ED may have a beneficial effect on both children and adults with alcohol problems who present to the ED.5
In this issue of Psychiatric Issues in Emergency Care Settings, Dr Maviglia has drawn an excellent road map addressing important factors related to alcohol and substance use disorders, including their incidence and manifestations, appropriate screening, performing an effective intervention, and identifying patients' levels of motivation for treatment. In addition, the development of management plans and referrals are discussed.
One rather unique aspect of this article is the review of our own feelings and possible biases concerning patients who are addicted to alcohol or illicit substances. Although a number of theories are presented on how health care providers might approach patients with alcohol and substance use disorders, it is probably most important that we focus on harm reduction for patients with these disorders. Dr Buckley's commentary discusses several complementary topics addressing polysubstance abuse and dual diagnosis.
Dr Maviglia also presents 3 cases that highlight some of the points central to his article. The first case illustrates the need to be culturally sensitive when screening patients. The second case focuses on the problems associated with missing the diagnosis. The third case discusses comorbidity and is about a patient with a dual diagnosis--something that we do not commonly think about in patients who present to the ED.
An interesting point brought out by this article is the importance of cultural sensitivity and competency. Unfortunately, the "one size fits all" philosophy does not apply to the treatment of patients who present to the ED with symptoms of alcohol or substance abuse. In the treatment of patients experiencing pain, we must understand how different persons react and respond to pain. This type of understanding should be similarly applied to persons with alcohol and substance use disorders.
The resources to treat patients with alcohol and substance use disorders are sorely underfunded. In my ED, we no longer tell the patient to stop drinking, go to church, and get a job; we now have a mental health care worker in the ED who determines the most appropriate inpatient or outpatient resource for each patient who presents with this condition. Unfortunately, many other EDs in the United States do not have this luxury and are at a loss to find available and adequate resources within their community. However, it is our responsibility to seek out and refer patients to affordable treatment options for their alcohol and substance use disorders.
Leslie S. Zun, MD, MBA
Professor and Chairman
Department of Emergency Medicine
Chicago Medical School at Rosalind Franklin University of Medicine and Science
Department of Emergency Medicine
Mount Sinai Hospital
REFERENCES1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212.2. Harwood HJ. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Rockville, Md: National Institute on Alcohol Abuse and Alcoholism; 2000.3. McDonald AJ 3rd, Wang N, Camargo CA Jr. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Intern Med. 2004;164:531-537.4. D'Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 1: improving detection. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine. Acad Emerg Med. 1998;5:1200-1209.5. D'Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 2: intervention and referral. SAEM Substance Abuse Task Force. Society for Academic Emergency Medicine. Acad Emerg Med. 1998;5:1210-1217.