Multi-level analysis of causal attribution of injury to alcohol and modifying effects: Data from two international emergency room projects

Needs and expectations of healthcare professionals regarding the topic of alcohology: Results of a survey conducted in France in 2022

CONTEXT

Alcohol-related health problems represent a significant public health concern, and it is imperative for the healthcare team to accurately perceive and detect these issues to provide appropriate care. The objective of this survey was to evaluate the knowledge, practices, and educational background of healthcare professionals in the field of alcohol-related health concerns, aiming to identify their information requirements.

METHODS

This study employs a cross-sectional descriptive survey methodology, in which data were gathered through a digital questionnaire designed for healthcare professionals (including those in medical, paramedical, and medico-social professions) working in addictology services as well as other relevant services across France and its overseas departments.

RESULTS

A total of 611 questionnaires were deemed usable for analysis. A considerable percentage of participants reported their knowledge and skills to be insufficient or very insufficient, with rates of 33 % and 36 %, respectively. Moreover, a significant proportion of respondents (≈ 28 %) stated that they had received no education in addictology. Our results highlight differences in levels of knowledge and competence among the various healthcare settings, notably with lower reported levels of satisfaction in hospital settings (public and private), private practice, and in Harm Reduction Centers. Furthermore, certain professions reported unsatisfactory levels of skills and knowledge in alcohol-related issues, particularly support staff, pharmacists, expert patients, administrative staff, and social workers. These findings suggest the need to enhance knowledge and skills by tailoring interventions according to the specific healthcare settings and professions. Additionally, the priority themes and channels for disseminating information varied depending on age, region, and professional category.

CONCLUSION

This survey reveals a low level of knowledge, practice, and education in addictology, emphasizing the critical need for training. The importance of training extends not only to the priority topics addressed but also to the channels used for dissemination, all while customizing them to suit the age, professional category, structure, and region of healthcare professionals.

The Care of the Patients With Alcohol Intoxication in the Emergency Department of a Central Hospital: Nurses' Skills, Knowledge, and Attitudes

AIM

The aim of the study was to describe nurses' skills, knowledge of care, and attitudes toward the care of patients with alcohol intoxication in the emergency department.

METHOD

The data were collected using theme interviews in 2016. The study participants were nurses working in the emergency department (n = 6) that has a sobering unit. The data were analyzed using inductive content analysis.

RESULTS

On the basis of the interviewees' descriptions, five main categories were formed: the skills to discuss the use of alcohol on arrival, safety skills, teamwork skills, the skills to organize follow-up care, and nurses' attitudes and ethics in patients' care. Asking about the use of alcohol as well as the use of a screening tool varied. The interviewees emphasized the skills to anticipate the risk of violence as well as ensuring the safety of the working environment. Nurses' attitudes were seen as the ability to regulate negative emotions raised by the patient. Factors related to nurses' attitudes emerged in patients' behavioral disorders and commitment to treatment. Despite some negative feelings toward patients, nurses thought that it is important to ensure ethicality in patients' care.

CONCLUSIONS

The nurses' skills and knowledge of care and attitudes toward patients with alcohol intoxication varied. There is a need for additional training on issues relating to the treatment of patients with alcohol intoxication.

[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.

Single episode of alcohol use resulting in injury: a cross-sectional study in 21 countries

OBJECTIVE

To examine the empirical basis for including the diagnostic category of "a single episode of harmful substance use" in the 11th revision of the International statistical classification of diseases and related health problems (ICD-11).

METHODS

We used data on patients admitted to emergency departments in 21 countries with alcohol-related injuries (i.e. with drinking within the preceding six hours) who had no sign of alcohol intoxication or withdrawal, no alcohol in blood and no sign of alcohol dependence or harmful drinking as described in the ICD-10. We obtained data on alcohol-related injuries, the patient's causal attribution of injury to drinking, the alcohol amount consumed, blood alcohol concentration and usual drinking pattern. Patients with and without alcohol dependence or harmful drinking were compared.

FINDINGS

We included a representative sample of 18 369 patients. After adjustment for unequal sampling, 18.8% reported drinking in the six hours before injury and 47.1% of these attributed their injury to drinking; 16.3% of those reporting drinking and 10.3% of those attributing their injury to drinking were not alcohol dependent or harmful drinkers. The majority of these last two groups reported never having had five or more drinks on one occasion during the last year and had a blood alcohol concentration less than 0.05%.

CONCLUSION

Some individuals attending emergency departments had alcohol-attributable injuries due to a single episode of drinking but had no history of harmful use or dependence. These findings highlight the public health relevance of including the new diagnostic category in the ICD-11.

Alcohol and Road Traffic Injuries in Latin America and the Caribbean: A Case-Crossover Study

BACKGROUND

This study reports dose-response estimates for the odds ratio (OR) and population attributable risk of acute alcohol use and road traffic injury (RTI).

METHODS

Data were analyzed on 1,119 RTI patients arriving at 16 emergency departments (EDs) in Argentina, Brazil, Costa Rica, Dominican Republic, Guatemala, Guyana, Mexico, Nicaragua, Panama, and Trinidad and Tobago. Case-crossover analysis, pair-matching the number of standard drinks consumed within the 6 hours prior to the RTI with 2 control periods (prior d/wk), was performed using fractional polynomial analysis for dose-response.

RESULTS

About 1 in 6 RTI patients in EDs were positive for self-reported alcohol 6 hours prior to the injury (country range 8.6 to 24.1%). The likelihood of an RTI with any drinking prior (compared to not drinking) was 5 times higher (country range OR 2.50 to 15.00) and the more a person drinks the higher the risk. Every drink (12.8 g alcohol) increased the risk of an RTI by 13%, even 1 to 2 drinks were associated with a sizable increase in risk of an RTI and a dose-response was found. Differences in ORs for drivers (OR = 3.51; 95% CI = 2.25 to 5.45), passengers (OR = 8.12; 95% CI = 4.22 to 15.61), and pedestrians (OR = 6.30; 95% CI = 3.14 to 12.64) and attributable fractions were noted. Acute use of alcohol was attributable to 14% of all RTIs, varying from 7% for females to 19% for being injured as a passenger.

CONCLUSIONS

The finding that the presence of alcohol increases risk among drivers and nondrivers alike may further help to urge interventions targeting passengers and pedestrians. Routine screening and brief interventions in all health services could also have a beneficial impact in decreasing rates of RTIs. Higher priority should be given to alcohol as a risk factor for RTIs, particularly in Latin America and the Caribbean.

[Substance related disorder in emergency services: Which attitudes?]

INTRODUCTION

Substance related disorders are more prevalent in emergency services than in the general population, about 20% of individuals in emergency care test positive for alcohol. Emergency services are strategic places to identify alcohol misuse. Attitudes to individuals presenting substance related disorders are important in developing therapeutic relationships and applying interventions.

OBJECTIVE

This study explores the attitudes of an emergency staff to these individuals across a range of roles, and evolution in face of an addictology care improvement.

METHOD

Data were gathered from an emergency service sample from the emergency department of a general hospital in Morlaix (France). We used a short questionnaire, adapted from previous similar French studies.

RESULTS

Twenty-five persons answered the first questionnaire and 18 the second. A self-administrated attitudes questionnaire showed its interest in our study and helped us to identify attitudes and to initiate a reflection on behaviours in emergency care. Moreover, it helped to change attitudes towards individuals presenting substance related disorders. The daily setting of an addictive disorders specialized unit in emergency changed the point of view on addictive disorders of both physicians and nurses. We showed differences in addictive related disorders prevalence perception among patients attending emergency care between the two evaluations. But we also showed that physicians and nurses stressed that it was more difficult to ask patients in emergency care on the second evaluation, after and despite a daily addictive disorders specialized setting. We showed several limits in emergency staff care relationship with patients with substance related disorders. They identified difficulties to talk about addictive disorders, especially in younger and older patients. Regarding literature, we discuss our study limits and different ways of improving addictology care in emergency services.

Underage drinking, brief interventions, and trauma patients: Are they really special?

BACKGROUND

While the relationship between underage drinking and injury has been well established, few studies have examined whether presenting for an acute injury moderates the efficacy of a brief intervention (BI) on alcohol misuse.

METHODS

Patients (aged 14-20 years) in the emergency department screening positive for risky drinking (Alcohol Use Disorders Identification Test-Consumption score) completed a baseline assessment, were randomized to conditions (a standalone computer-delivered BI [n = 277], a therapist-delivered BI [n = 278], or a control condition [n = 281]), and completed a 3-month follow-up. This secondary analysis of Project U-Connect examined regression models (controlling for baseline values) to examine the main effects of injury and the interaction effects of injury by BI condition on alcohol consumption and consequences.

RESULTS

Among 836 youth enrolled in the randomized controlled trial (mean age, 18.6 years; 51.6% were male; 79.4% were white), 303 (36.2%) had a primary complaint of intentional or unintentional injury. At baseline, injured patients were more likely to be male (p < 0.001) and have higher alcohol consumption (p < 0.01), but were less likely to misuse prescription drugs (p = 0.02) than those presenting for medical reasons. Regression models (controlling for baseline values) demonstrated that injury presentation predicted greater alcohol consumption prior to a BI. The computer BI was more effective at reducing alcohol consequences among those presenting with injury than those presenting for other reasons. Injury did not affect the efficacy of the computer BI on alcohol consumption, and injury did not affect the efficacy of the therapist BI on alcohol outcomes.

CONCLUSIONS

A therapist or computer BI reduced alcohol consumption and consequences among risky drinkers regardless of reason for emergency department presentation highlighting the opportunity to reach a broad array of youth. Although the therapist BI was not moderated by injury presentation, the computer BI was particularly effective at reducing alcohol consequences among those presenting with injury at 3-month follow-up.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

Alcohol Consumption at Any Level Increases Risk of Injury Caused by Others: Data from the Study on Global AGEing and Adult Health

BACKGROUND

Alcohol use is a well-known risk factor for injury. However, information is needed about alcohol drinking patterns and the risk of injury among older adults in low- and middle-income countries as this population grows. We aimed to examine the influence of drinking patterns on the burden of injury and investigate factors associated with different types of injury in older populations in six emerging economies.

METHODS

Data from more than 37,000 adults aged 50 years and older were included from the Study on Global AGEing and Adult Health (SAGE) Wave 1 conducted in six emerging economies, namely, China, Ghana, India, Mexico, Russia, and South Africa. We investigated past-year reported injuries from falls, traffic accidents, and being hit or stabbed. Alcohol drinking patterns were measured as lifetime abstinence, ever but not past- week use, and gender-specific past-week low-risk and high-risk use. We stratified by gender and used logistic regression models to observe the association between alcohol drinking pattern and risk of injury by controlling for other factors.

RESULTS

During the year prior to interview, 627 (2.2%) subjects reported bodily injury resulting from a car accident, 1,156 (4.2%) from a fall, and 339 (0.9%) from being hit or stabbed during the past year. For women, only being a high-risk drinker increased the risk of being hit or stabbed, whereas for men, all levels of drinking were associated with an increased risk of being hit or stabbed. We observed a higher risk of being hit or stabbed from past-week high-risk drinking among women (odds ratio [OR] = 6.09, P < 0.01) than among men (OR = 3.57, P < 0.01). We observed no association between alcohol drinking pattern and injury due to car accidents for either women or men.

CONCLUSIONS

The risk of experiencing injury due to violence increased with level of alcohol exposure of the victim. The increase in alcohol use in emerging economies calls for further study into the consequences of alcohol use and for public health initiatives to reduce the risk of violence in older adult populations, with special attention to the experience of older adult women.

Relationship of Usual Volume and Heavy Consumption to Risk of Alcohol-Related Injury: Racial/Ethnic Disparities in Four U.S. National Alcohol Surveys

OBJECTIVE

National population data on racial/ethnic disparities and risk of alcohol-related injury are scarce. Alcohol-related injury and drinking patterns are examined in a sample of respondents from four (1995, 2000, 2005, 2010) U.S. National Alcohol Surveys using risk function analysis.

METHOD

Self-reported consumption of 15,476 current drinkers was assessed as the average number of drinks consumed monthly and, separately, the frequency of consuming five or more drinks in a day (5+ days) in the last year. Alcohol-related injury was defined as drinking within 6 hours before the event. Risk curves were defined, separately for Whites, Blacks, and Hispanics, using fractional polynomial regression.

RESULTS

Risk was greatest for Hispanics to 110 drinks per month (3-4 drinks per day) and above 240 drinks per month, whereas risk was greatest for Whites between these levels. Blacks were at lower risk at all monthly volume levels when demographic and socioeconomic status characteristics were controlled for. Whites had the highest risk of an alcohol-related injury based on 5+ drinking days at all levels up to nearly daily 5+ drinking, whereas Blacks had the lowest risk at all levels of 5+ drinking.

CONCLUSIONS

A disparity in alcohol-related injury was found for Hispanics compared with Whites at the same average monthly volume of consumption at lower and higher volume levels, but not at the same number of 5+ drinking days, and a lower risk of alcohol-related injury was found for Blacks for both consumption measures when demographic and socioeconomic status characteristics were taken into account. Although exposure to hazards other than alcohol, which could account for some of the racial/ethnic disparity observed, was not taken into account, these mixed findings suggest this is an important area deserving future research attention.

Prevalence and consequences of positive blood alcohol levels among patients injured at work

Aims:

The aim of this study was to characterize positive blood alcohol among patients injured at work, and to compare the severity of injury and outcome of blood alcohol concentration (BAC) positive and negative patients.

Settings and Design:

A retrospective cohort study was performed at a Level 1 academic trauma center. Patients injured at work between 01/01/07 and 01/01/12 and admitted with positive (BAC+) vs negative (BAC−) blood alcohol were compared using bivariate analysis.

Results:

Out of 823, 319 subjects were tested for BAC (38.8%), of whom 37 were BAC+ (mean 0.151 g/dL, range 0.015-0.371 g/dL). Age (41 years), sex (97.2% men), race, intensive care unit (ICU) and hospital length of stay (LOS), and mortality were similar between groups. Nearly half of BAC+ cases were farming injuries (18, 48.6%): Eight involved livestock, five involved all-terrain vehicles (ATVs), three involved heavy equipment, one fell, and one had a firearm injury. Eight (21.6%) were construction site injuries involving falls from a roof or scaffolding, five (13.5%) were semi-truck collisions, four (10.8%) involved falls from a vehicle in various settings, and two (5.4%) were crush injuries at an oilfield. BAC+ subjects were less likely to be injured in construction sites and oilfields, including vehicle-related falls (2.3 vs 33.9%, P < 0.0001). Over half of BAC+ (n = 20, 54%) subjects were alcohol dependent; three (8.1%) also tested positive for cocaine on admission. No BAC+ subjects were admitted to rehabilitation compared to 33 (11.7%) of BAC− subjects. Workers’ compensation covered a significantly smaller proportion of BAC+ patients (16.2 vs 61.0%, P < 0.0001).

Conclusions:

Alcohol use in the workplace is more prevalent than commonly suspected, especially in farming and other less regulated industries. BAC+ is associated with less insurance coverage, which probably affects resources available for post-discharge rehabilitation and hospital reimbursement.

Alcoholism risk reduction in France: a modernised approach related to alcohol misuse disorders

During many years in France, risk reduction strategies for substance abuse concerned prevention strategies in the general population or interventions near users of illicit substances. In this spirit, the reduction of consumption only concerned opiate addicts. With regard to alcohol, the prevention messages relative to controlled consumption were difficult to transmit because of the importance of this product in the culture of the country. In addition, methods of treatment of alcoholism rested on the dogma of abstinence. Several factors have recently led to an evolution in the treatment of alcohol use disorders integrating the reduction of consumption in strategies. Strategies for reducing consumption should aim for consumption below recommended thresholds (two drinks per day for women, three for the men) or, at least, in that direction. It must also be supported by pharmacotherapy and psychotherapy, which offer possibilities. Failure to manage reduction will allow the goals to be revisited and to reconsider abstinence. Finally this evolution or revolution is a new paradigm carried in particular by a pragmatic approach of the disease and new treatments. The aims of this article are to give elements of comprehension relating to the evolution of the practices in France in prevention and treatment of alcohol use disorders and in particular with regard to the reduction of consumption.

Perspectives of "functional failure"

The present dialogue piece briefly examines six perspectives of functional failure (individual-level, societal-level, life spheres impacted, number of severe consequences, attribution of consequences to drug misuse, and socio-environmental generalizability) as they might apply to seven degrees of drug misuse (constant, dependence, heavy, binging, controlled use, "dry," sober). Variation in judgments of failure is posited across the perspectives and across degrees of drug misuse.

Study protocol: Screening and Treatment of Alcohol-Related Trauma (START) - a randomised controlled trial

Background

The incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma.

Methods and design

The study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up.

Discussion

This project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma.

Trial Registration

The trial has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) and Trial Registration: ACTRN12611000135910.

Acute alcohol consumption and motivation to reduce drinking among injured patients in a Swedish emergency department

Injuries constitute a major public health problem. Millions of people are injured each year, and acute drinking is a well-known risk factor for injuries. Research suggests that acknowledgment of alcohol as a factor in an injury enhances willingness to change drinking behavior, possibly because the patient becomes aware of the negative consequences of their drinking. This study aims to investigate the prevalence of acute alcohol consumption (drinking before the event) among injury patients and to examine the importance of factors potentially associated with motivation to reduce alcohol consumption among these patients. All patients aged 18-69 years were requested to answer alcohol-related questions on a touchscreen computer. Fifteen percent of injured patients were categorized as acute drinkers, and of these, 64% reported that their injury was connected to alcohol. There were significant differences for all sociodemographic and drinking characteristics between acute drinkers and nonacute drinkers. Acute drinkers were categorized as risky drinkers to a much higher extent than nonacute drinkers. Acute drinkers had a considerably higher average weekly alcohol consumption and engaged far more frequently in heavy episodic drinking than nonacute drinkers. Acute drinkers were motivated to reduce their alcohol intake to a greater extent than nonacute drinkers; 51% were in the action, preparation, and contemplation stages, compared with 19% of the nonacute drinkers. Acute drinkers had considerably more detrimental alcohol consumption than nonacute drinkers, and the acute drinkers were more motivated to reduce their drinking than the nonacute drinkers.

Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption

Background

Alcohol consumption is a major risk factor for injuries; however, international data on this burden are limited. This article presents new methods to quantify the burden of injuries attributable to alcohol consumption and quantifies the number of deaths, potential years of life lost (PYLL), and disability-adjusted life years (DALYs) lost from injuries attributable to alcohol consumption for 2004.

Methods

Data on drinking indicators were obtained from the Comparative Risk Assessment study. Data on mortality, PYLL, and DALYs for injuries were obtained from the World Health Organization. Alcohol-attributable fractions were calculated based on a new risk modeling methodology, which accounts for average and heavy drinking occasions. 95% confidence intervals (CIs) were calculated using a Monte Carlo simulation method.

Results

In 2004, 851,900 (95% CI: 419,400 to 1,282,500) deaths, 19,051,000 (95% CI: 9,767,000 to 28,243,000) PYLL, and 21,688,000 (95% CI: 11,097,000 to 32,385,000) DALYs for people 15 years and older were due to injuries attributable to alcohol consumption. With respect to the total number of deaths, harms to others were responsible for 15.1% of alcohol-attributable injury deaths, 14.5% of alcohol-attributable injury PYLL, and 11.35% of alcohol-attributable injury DALYs. The overall burden of injuries attributable to alcohol consumption corresponds to 17.3% of all injury deaths, 16.7% of all PYLL, and 13.6% of all DALYs caused by injuries, or 1.4% of all deaths, 2.0% of all PYLL, and 1.4% of all DALYs in 2004.

Conclusions

The novel methodology described in this article to calculate the burden of injuries attributable to alcohol consumption improves on previous methodology by more accurately calculating the burden of injuries attributable to one’s own drinking, and for the first time, calculates the burden of injuries attributable to the alcohol consumption of others. The burden of injuries attributable to alcohol consumption is large and is entirely avoidable, and policies and strategies to reduce it are recommended.

Hospital-admitted injury attributable to alcohol

BACKGROUND

Primary data collection has established that alcohol causes injuries treated in the emergency department. No comparable data exist for injuries admitted to hospital. Data on the injury risks of heavy drinkers relative to other drinkers also are sparse.

METHODS

We estimated (i) whether regular heavy drinkers have higher hospitalized injury risks than other people when alcohol-negative and (ii) how much hospitalized injury risk of regular heavy drinkers and other drinkers rises when alcohol-positive. We combined national alcohol consumption data with alcohol metabolism rates to estimate hours spent alcohol-positive versus alcohol-negative during a year for heavy drinkers versus other people. A literature review provided hospitalized nonfatal injury rates for these groups by alcohol involvement.

RESULTS

Relative to other alcohol-negative people aged 18 and older, heavy drinkers have an estimated relative risk of hospitalized injury of 1.4 when alcohol-negative and 4.3 when alcohol-positive. Others have an estimated relative risk of 1.0 when alcohol-negative and 6.8 when alcohol-positive. Thus, alcohol greatly raises injury risk. The excess risk patterns persist for a wide range of sensitivity analysis values. Of hospitalized injuries, an estimated 21% are alcohol-attributable including 36% of assaults.

CONCLUSIONS

Drinking alcohol is a major cause of hospitalized injury. Heavy drinkers lead risky lifestyles. They tolerate alcohol better than most drinkers, but their injury risks still triple when they drink. Our approach to attribution is a valuable complement to more costly, more precise approaches that rely heavily on primary data collection. It works for any severity of injury. Applying it only requires an existing alcohol consumption survey plus data on alcohol involvement in targeted injuries.

Substance use, violence, and unintentional injury in young holidaymakers visiting Mediterranean destinations

BACKGROUND

Young people's alcohol and drug use increases during holidays. Despite strong associations between substance use and both violence and unintentional injury, little is known about this relationship in young people holidaying abroad. We examine how risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destination on these relationships.

METHODS

A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertaken in airports in Cyprus, Greece, Italy, Portugal, and Spain.

RESULTS

Overall, 3.8% of participants reported having been in a physical fight (violence) on holiday and 5.9% reported unintentional injury. Two thirds reported having been drunk on holiday and over 10% using illicit drugs. Levels of drunkenness, drug use, violence, and unintentional injury all varied with nationality and holiday destination. Violence was independently associated with being male, choosing the destination for its nightlife, staying 8 to 14 days, smoking and using drugs on holiday, frequent drunkenness, and visiting Majorca (both nationalities) or Crete (British only). Predictors of unintentional injury were being male, younger, using drugs other than just cannabis on holiday, frequent drunkenness, and visiting Crete (both nationalities).

CONCLUSIONS

Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonistic nightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit.

Cohabitation, gender, and alcohol consumption in 19 countries: a multilevel analysis

We used an ecological paradigm and multilevel analytic techniques to analyze gender-specific relationships of cohabitation (versus marriage) to drinking in 19 countries (n = 32,922) and to "heavy episodic drinking" (HED) in 17 countries (n = 24,525) in surveys (1996-2004) from Gender, Alcohol, and Culture: An International Study. Cohabitation was associated with elevated risk of HED among drinkers of both genders, controlling for age, education, and societal characteristics. The association between cohabitation and HED tended to be stronger for female drinkers than for male drinkers. HED was more prevalent among younger drinkers, especially among younger women in countries with higher per capita gross domestic product. Cross-culturally, cohabiters deserve special attention in prevention efforts for hazardous drinking, considering both individual-level and societal factors.

Moderators and mediators of two brief interventions for alcohol in the emergency department

OBJECTIVE

To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department.

METHODS

Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking.

RESULTS

Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

CONCLUSIONS

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.

Alcohol-related injury and driving while intoxicated: a risk function analysis of two alcohol-related events in the 2000 and 2005 National Alcohol Surveys

BACKGROUND

National population data on risk of alcohol-related injury or driving while intoxicated (DWI) are scarce.

OBJECTIVE

The association of alcohol-related injury and perceived DWI (PDWI) with both volume and pattern of consumption are examined in a merged sample of respondents from the 2000 and 2005 National Alcohol Surveys using risk function analysis.

METHODS

Self-reported consumption patterns on 8,736 respondents who consumed at least one drink in the last 12 months were assessed as the average daily volume and frequency of consuming 5 or more (5+), 8 or more (8+), and 12 or more (12+) drinks in a day. Risks were defined using CHAID segmentation analysis implemented with SPSS Answer Tree.

RESULTS

For alcohol-related injury (n = 110), those most at risk drank at lower volumes with some high maximum occasions, or at higher volumes, where high maximum occasions had little added effect. Risk was highest for those reporting more than 6 drinks per day (9.7%). For PDWI (n = 696), those most at risk drank at higher volumes and with a greater number of high maximum occasions. Risk was highest for those reporting more than 6 drinks per day and more than one 8+ occasion during the last year (39%).

CONCLUSIONS

Overall risk appears to increase with increasing volume, but at a given volume level, risk also increases with frequency of high maximum occasions. These data lend relatively weak support for previous findings suggesting that less frequent drinkers who only occasionally consume larger quantities may be at greater risk, and any alcohol consumption appears to carry some risk of these harms.

The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together

Alcohol consumption causes injury in a dose-response manner. The most common mode of sustaining an alcohol-attributable injury is from a single occasion of acute alcohol consumption, but much of the injury literature employs usual consumption habits to assess risk instead. An analysis of the acute dose-response relationship between alcohol and injury is warranted to generate single occasion- and dose-specific relative risks. A systematic literature review and meta-analysis was conducted to fill this gap. Linear and best-fit first-order model were used to model the data. Usual tests of heterogeneity and publication bias were run. Separate meta-analyses were run for motor vehicle and non-motor vehicle injuries, as well as case-control and case-crossover studies. The risk of injury increases non-linearly with increasing alcohol consumption. For motor vehicle accidents, the odds ratio increases by 1.24 (95% CI: 1.18-1.31) per 10-g in pure alcohol increase to 52.0 (95% CI: 34.50-78.28) at 120 g. For non-motor vehicle injury, the OR increases by 1.30 (95% CI: 1.26-1.34) to an OR of 24.2 at 140 g (95% CI: 16.2-36.2). Case-crossover studies of non-MVA injury result in overall higher risks than case-control studies and the per-drink increase in odds of injury was highest for intentional injury, at 1.38 (95% CI: 1.22-1.55). Efforts to reduce drinking both on an individual level and a population level are important. No level of consumption is safe when driving and less than 2 drinks per occasion should be encouraged to reduce the risk of injury.

Moderators and mediators of two brief interventions for alcohol in the emergency department

OBJECTIVE

To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department.

METHODS

Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking.

RESULTS

Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

CONCLUSIONS

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.

The Influence of Drinking Pattern, at Individual and Aggregate Levels, on Alcohol-Related Negative Consequences

AIM

To determine the extent drinking patterns (at the individual and country level) are associated with alcohol-related consequences over and above the total alcohol the person consumes.

METHODS

Hierarchical linear models were estimated based on general population surveys conducted in 18 countries participating in the GENACIS project.

RESULTS

In general, the positive association between drinking pattern scores and alcohol-related consequences was found at both the individual and country levels, independent of volume of drinking. In addition, a significant interaction effect indicated that the more detrimental the country's drinking pattern, the less steep the association between the volume of drinking and its consequences.

CONCLUSION

Drinking patterns have an independent impact on consequences over and above the relationship between volume and consequences.

Alcohol, drugs and trauma: consequences, screening and intervention in 2009

Alcohol use is a preventable cause of injury as it doubles the risk of re-injury and increases mortality. For this reason, the American College of Surgeons, Committee on Trauma had mandated a screening and subsequent intervention strategy for all Level I centres, and there is good evidence to support the efficacy of such programmes. Clinicians can play a key role in reducing injury related to alcohol use through their participation in these programmes. Although validated screening tools and evidence to support brief interventions for alcohol use exist, the benefit of these experiences for other recreational drugs awaits further research in this area. In the meantime, the implementation of alcohol screening and brief intervention programmes across all trauma programmes and emergency departments should become a global healthcare priority.

Alcohol and injuries: a review of international emergency room studies since 1995

This paper provides a review of emergency room (ER) studies on alcohol and injury, using representative probability samples of adult injury patients, and focuses on the scope and burden of the problem as measured by estimated blood alcohol concentration (BAC) at the time of the ER visit, self-report drinking prior to injury, violence-related injury and alcohol use disorders. A computerized search of the English-language literature on MEDLINE, PsychINFO and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Alcohol and Alcohol Problems Science Database (ETOH) was conducted for articles published between 1995 and 2005, using the following key descriptors: (1) emergency room/emergency department/accident and emergency, (2) alcohol/drinking and (3) injuries (intentional and unintentional). Findings support prior reviews, with injured patients more likely to be positive for BAC and report drinking prior to injury than non-injured, and with the magnitude of the association substantially increased for violence-related injuries compared to non-violence-related injuries. Indicators of alcohol use disorders did not show a strong association with injury. Findings were not homogeneous across studies, however, and contextual variables, including study-level detrimental drinking pattern, explained some of the variation. This review represents a broader range of ER studies than that reported previously, across both developed and developing countries, and has added to our knowledge base in relation to the influence of contextual variables on the alcohol-injury relationship. Future research on alcohol and injury should focus on obtaining representative samples of ER patients, with special attention to both acute and chronic alcohol use, and to organisational and socio-cultural variables that may influence findings across studies. In-depth patient interviews may also be useful for a better understanding of drinking in the injury event and associated circumstances.

[Acute alcoholic intoxication at the hospital: a clinical stake. A prospective study of one year in a general hospital]

INTRODUCTION

Acute alcoholic intoxications (AAI) are frequent in hospitals. This entails some difficulties to caregivers and their clinical approach is little developed in France. This study aimed at estimating perception of alcohol consumption of hospitalized people with positive alcohol blood test at admission. Alcohol measurements were nonsystematic and ordered by a physician. Then this study assessed the role of a clinical interview the day after an AAI.

METHODS

Each person admitted with a positive alcohol blood test was systematically met by a professional in addictology, referring to a procedure in process for 10 years in this hospital. A prospective collection of the data was performed during 2006.

RESULTS

Nine hundred and seventy-three episodes were identified corresponding to 758 persons (78% of men and 22% of women). The average alcohol blood level was 2.06+/-1.18g/L. Eighty-five percent of those patients were admitted and 52% were interviewed. Damage due to alcohol was identified for 69% and a misuse of alcohol for 92% (19% abuse, 73% dependence according to the DSM IV), without significant correlation to alcohol blood level.

CONCLUSION

Blood alcohol level assay at the hospital admission, when the test has been medically recommended, targets a misusing alcohol group of people. These patients need addictologic care, after a first toxicological stage. This study confirms that in such a case a discussion offer is possible and agreed by diseased people. This offer is a first step towards people who could not express explicitly their need for help and constitute an opportunity to care.

Brief alcohol intervention in the emergency department: moderators of effectiveness

OBJECTIVE

Prior research supports the effectiveness of brief interventions for reducing alcohol misuse among patients in the emergency department (ED). However, limited information is available regarding the mechanisms of change, which could assist clinicians in streamlining or amplifying these interventions. This article examines moderators of outcomes among ED patients, ages 19 and older, who participated in a randomized controlled trial of a brief intervention for alcohol misuse.

METHOD

Injured patients (N= 4,476) completed a computerized survey; 575 at-risk drinkers were randomly assigned to one of four brief intervention conditions, and 85% were interviewed again at 3-month and 12-month follow-ups.

RESULTS

Regression models using the generalized estimating equations approach examined interaction effects between intervention condition (advice/no advice) and hypothesized moderator variables (stage of change, self-efficacy, acute alcohol use, attribution of injury to alcohol) on alcohol outcomes over time. Overall, participants who reported higher levels of self-efficacy had lower weekly consumption and consequences, whereas those with higher readiness to change had greater weekly consumption and consequences. Furthermore, individuals who attributed their injury to alcohol and received advice had significantly lower levels of average weekly alcohol consumption and less frequent heavy drinking from baseline to 12-month follow-up compared with those who attributed their injury to alcohol but did not receive advice.

CONCLUSIONS

This study provides novel data regarding attribution for alcohol-related injury as an important moderator of change and suggests that highlighting the alcohol/injury connection in brief, ED-based alcohol interventions can augment their effectiveness.

Self-experiments and analytical relapse prevention

Patients give many reasons for why they have not kept up with their resolutions; research shows that many of these causal attributions are wrong. This article provides a tool to help patients sort out causes of and constraints on their behavior, in general, and exercise, in particular. Patient's diary data can be analyzed to flag erroneous causal attributions, and thus assist patients to understand their behavior. To start the diary, the clinician works with the patient to assemble a list of possible causes. Using the list, a diary is organized that tracks the occurrences of various causes and the target behavior. At the end of 2 to 3 weeks, the diary data is analyzed using conditional probability models, causal Bayesian networks or logistic regression. A key issue in the analysis of diary data is to separate out the effect of various causes. Typically, causes co-occur, making it difficult to understand their independent effects. Another problem with analysis of diary data is the small size of the data. This article shows how small longitudinal data from patient diaries can be analyzed. The analysis may refute or support causes hypothesized by the client. The patient uses the insights gained from the diary analysis to prevent relapse to unhealthy behaviors. The process is continued for several cycles of organizing, keeping, and analyzing the diary data. In each cycle, the patient gains new insights and makes additional attempts to create a positive environment that allows him or her to succeed even if his or her motivation waivers. This article provides details of how diary data can be analyzed to help patients make correct causal attributions.

Alcohol-related adverse consequences: cross-cultural variations in attribution process among young adults

BACKGROUND

Social norms around what is culturally accepted in terms of alcohol consumption and drunken comportment appear important regarding the acceptance of alcohol-related adverse consequences; however, investigations often neglect to consider differences in terms of attribution. This study aims at assessing cross-cultural differences in the reporting of alcohol-related adverse consequences. It also considers differences across consequences that might explain which type of consequences (mainly acute or mainly chronic) are most affected by an attribution process.

METHODS

Conditional regression models were estimated based on data from eight European countries participating in the Gender, Alcohol and Culture--An International Study (GENACIS) project. Cases were matched to controls based on usual drinking patterns in order to control for average volume of alcohol and frequency of 'risky single occasion drinking' (RSOD).

RESULTS

Differences among the patterns of associations between countries and consequences were evident. The distinction between Nordic and other European countries was persistent. A higher variability of associations was observed for some consequences, namely the mainly acute instances. Finally, the Isle of Man and Switzerland showed specific trends with associations across consequences.

CONCLUSION

Reporting of alcohol-related adverse consequences seemed strongly affected by cultural norms. The latter may be exemplified by viewing drinking as 'time-out' behaviour. Respondents in countries with a stereotypical history of being 'dry' or with a stereotyped 'binge' drinking culture were more likely to attribute consequences to their alcohol consumption than people in 'wet' countries. This was particularly true for consequences that related to episodic 'time-out' heavy drinking.

Addiction sciences and its psychometrics: the measurement of alcohol-related problems

AIMS

The focus of this paper is on psychometric issues related to the measurement of alcohol problems.

METHODS

Taking a broad perspective, this paper first examines several issues around the use of instruments to provide diagnostic categories in surveys, including dimensionality, severity and alcohol consumption. Secondly, a discussion of some of the political issues surrounding measurement of alcohol problems is presented, including some of the conflicts that arise when the psychometric properties of commonly used instruments are questioned. Finally, newer statistical techniques that can be applied to scale development in the alcohol field are examined, including non-linear multivariate analyses and confirmatory/hypothesis-based methods.

RESULTS AND CONCLUSIONS

Continued scholarly discussion needs to be encouraged around these psychometric issues so that instrument development and maintenance in the addiction sciences becomes an ongoing academic pursuit as we strive to measure alcohol problems in the best way possible.

Linking drinking to injury--causal attribution of injury to alcohol intake among patients in a Swedish emergency room

This study analysed the drinking patterns and motivation to change drinking behaviours among injury patients who acknowledged alcohol as a factor in their injuries. A cross-sectional study was conducted over 18 months at a Swedish emergency department. A total of 1930 injury patients aged 18 - 70 years were enrolled in the study (76.8% completion rate). Of those who reported drinking, 10% acknowledged alcohol as a factor in their injury. A patient was more likely to report a causal attribution of the injury to alcohol the higher the weekly intake and the higher the frequency of heavy episodic drinking. The motivation to change variables showed a similar pattern of increased likelihood of attributing a causal link of alcohol and injury with increasing discontent with drinking behaviours and increasing desire to change drinking behaviours. The findings suggest that the ability to measure causal attribution of alcohol to injuries could be a promising tool to help patients explore the association between their injuries and alcohol use and motivate patients to modify drinking behaviours in order to avoid future injuries.

Understanding the health impact of alcohol dependence

PURPOSE

To review the effects of alcohol dependence on physical and mental health.

SUMMARY

Alcohol dependence is wide-spread among people of all ages and socioeconomic groups. Persons with alcohol dependence face enormous health consequences. Alcohol dependence is a major cause of mortality and is associated with psychiatric conditions, neurologic impairment, cardiovascular disease, liver disease, and malignant neoplasms. Psychiatric conditions associated with alcohol dependence include major depression, dysthymia, mania, hypomania, panic disorder, phobias, generalized anxiety disorder, personality disorders, any drug use disorder, schizophrenia, and suicide. Psychiatric comorbidity, in turn, is associated with alcohol-related symptoms of greater severity. Excessive alcohol consumption causes brain damage, as evidenced by brain imaging, and related neurologic deficits, including impairments in working memory, cognitive processing of emotional signals, executive functions, visuospatial abilities, and gait and balance. Whereas moderate alcohol consumption is cardioprotective, heavy drinking is associated with increased risks of hypertension, coronary heart disease, and ischemic stroke, possibly due to alcohol-induced sympathetic activation. Chronic excessive alcohol consumption is a strong risk factor for various types of cancer, particularly cancers of the aero-respiratory tract, but also cancers of the digestive system, liver, breast, and ovaries. Heavy drinking is associated with various forms of alcoholic liver disease, such as cirrhosis. (People with alcohol dependence die from cirrhosis at a much higher rate than is found in the general population.) Alcohol dependence also increases the risk of injury, possibly due to alcohol-related factors such as diminished coordination and balance, increased reaction time, and impaired attention, perception, and judgment.

CONCLUSION

Alcohol dependence has numerous and serious ill effects on physical and mental health and represents a major public health burden.