Alcohol in combination with illicit drugs among fatal injuries in Sao Paulo, Brazil: An epidemiological study on the association between acute substance use and injury

Injury deaths have a major impact on public health systems, particularly in the Latin American region; however, little is known about how different drugs, in combination or not with alcohol, interact with each injury type. We tested an epidemiological protocol for investigating alcohol and other drug acute use among fatally injured victims taking into account the injury context for all injury causes in Sao Paulo, Brazil. Blood alcohol and drug content were fully screened and confirmed following a probability sample selection of decedents (n = 365) during 19 consecutive months (2014-2015). Drug concentrations, including benzodiazepines, cannabis, cocaine, and opioids were determined by gas chromatography-mass spectrometry (GC-MS) or liquid chromatography tandem mass spectrometry (LC-MS/MS). Toxicology data were interpreted in combination with injury context retrieved from police records regarding cause, place of injury, and victims' criminal history. More than half of all fatally injured victims studied were under the influence of at least one substance (55.3%). Alcohol was the leading substance consumed before a fatal injury event (30.1%), followed by cocaine (21.9%) and cannabis (14%). Illicit drug use (cocaine and cannabis) comprised more than two thirds of all drug-related deaths. Alcohol-positive deaths are over-represented among road traffic injuries, while drug-positive deaths are more prevalent among intentional injuries. Victims who had previous criminal convictions were significantly more likely to have used illicit drugs compared to those who did not have a criminal background. We estimated that one in every two fatal injuries in the city of Sao Paulo is associated with acute substance use by the victim. The health burden attributed to alcohol- and drug-related fatal injury events has reached significant higher levels in Latin American cities such as Sao Paulo compared globally.

Hazardous drinking and exposure to interpersonal and community violence on both sides of the U.S. -Mexico border

Objective

Different patterns of heavy drinking occur by country and proximity to the U.S. Mexico border. Few studies describe the impact of violence on drinking between countries and along the border.

Methods

Survey data is from U.S. Mexican origin adults living in Texas and Mexican border and non-border cities, N=4,796. Participants were asked about alcohol consumption, interpersonal physical violence (IPV) and exposure to community violence. Monthly hazardous drinking (5+/4+ for men/women) was the primary outcome. Multivariate logistic regression model comparisons identified best predictors.

Results

In the U.S. hazardous drinking was associated with past year IPV (OR_adj=2.5; 1.8-3.5) and community violence (OR_adj=1.4; 1.1-1.8). In Mexico, IPV (OR_adj=3.9; 2.0-7.4) and border proximity (OR_adj=0.5; 0.4-0.8) were associated with hazardous drinking but not community violence.

Conclusion

Hazardous drinking is associated with IPV in both countries, but violence did not explain border hazardous drinking differences where they existed in Mexico.

Reducing the legal blood alcohol concentration limit for driving in developing countries: a time for change? Results and implications derived from a time-series analysis (2001-10) conducted in Brazil

AIMS

In Brazil, a new law introduced in 2008 has lowered the blood alcohol concentration limit for drivers from 0.06 to 0.02, but the effectiveness in reducing traffic accidents remains uncertain. This study evaluated the effects of this enactment on road traffic injuries and fatalities.

DESIGN

Time-series analysis using autoregressive integrated moving average (ARIMA) modelling.

SETTING

State and capital of São Paulo, Brazil.

PARTICIPANTS

  A total of 1,471,087 non-fatal and 51,561 fatal road traffic accident cases in both regions.

MEASUREMENTS

Monthly rates of traffic injuries and fatalities per 100,000 inhabitants from January 2001 to June 2010.

FINDINGS

The new traffic law was responsible for significant reductions in traffic injury and fatality rates in both localities (P<0.05). A stronger effect was observed for traffic fatality (-7.2 and -16.0% in the average monthly rate in the State and capital, respectively) compared to traffic injury rates (-1.8 and -2.3% in the State and capital, respectively).

CONCLUSIONS

Lowering the blood alcohol concentration limit in Brazil had a greater impact on traffic fatalities than injuries, with a higher effect in the capital, where presumably the police enforcement was enhanced.

Drinking patterns and problems and drinking in the injury event: an analysis of emergency room patients by ethnicity

While a substantial literature exists on the association of alcohol consumption and injury, less is known about the context in which drinking occurs within specific ethnic groups in the United States. This paper analyzes drinking patterns, alcohol-related problems and drinking-in-the-event variables among a probability sample of 359 black, 528 Hispanic and 458 white patients who were breathalyzed and interviewed after admission to the emergency room. Injured patients among both Hispanics and whites were more likely to be positive on the breathalyzer and to report heavy drinking and more frequent drunkenness during the preceding year than their non-injured counterparts. Blacks were less likely than either Hispanics or whites to report a larger number of drinks prior to injury, feeling drunk at the time, or a causal association of alcohol and the injury event. These data suggest a differential role of alcohol in injury occurrence within ethnic groups, with alcohol possibly playing less of a role in the injury event for blacks than for Hispanics or whites.

Violence related injuries in the emergency room: alcohol, depression, and conduct problems

OBJECTIVE

The aim of this study was to obtain epidemiological measures of the association between alcohol consumption and emergency room (ER) attendance due to violence, compared to the general population in the city of Pachuca, Mexico, during October-November, 1996 and June-July, 1997.

METHOD

The study was a population-based case-control design.

INTERVENTION AND MEASUREMENTS

Data consisted of an interviewer-administered questionnaire, collected on a 24-h basis, during the entire week.

SETTING AND PARTICIPANTS

Cases were 127 patients (78% male) admitted to the ER because of an injury that was the result of violence (being in a fight or being attacked by someone). A sample of residents from Pachuca (n = 920) was the comparison group.

RESULTS

Patients reporting drinking within 6h compared to nondrinkers were more likely to suffer a violence-related injury [34.0 (17.5-66.2)] and alcohol dependent patients were more likely to be involved in a violence-related injury [7.4 (3.5-15.6)] compared to noncurrent drinkers. When both alcohol prior and alcohol dependence were considered simultaneously in multiple models among current drinkers, patients with violence-related injuries were more likely to report alcohol prior but not to be positive for alcohol dependence. Depressive symptoms, but not conduct problem behavior, were also associated with violent injury in simultaneous regressions that included alcohol variables.

CONCLUSIONS

In the city of Pachuca, Mexico, a large relationship between drinking prior to the event and violence-related injury, regardless of alcohol dependence, was found. Depression was also related to violence, suggesting the need for more comprehensive intervention with these patients.

Episodic alcohol use and risk of nonfatal injury

Usual and acute alcohol consumption are important risk factors for injury. Although alcohol-dependent people are thought to be at increased risk of injury, there are few reports suggesting that their risk is greater than that of nondependent alcohol users in a given episode of alcohol use. The authors conducted a case-crossover analysis of data on 705 injury patients from a hospital emergency department in Mexico City, Mexico, collected in 2002. The majority of the sample was male (60%) and over 30 years old (51%). With use of a multiple matching approach that took into account three control time periods (the day prior to the injury, the same day in the previous week, and the same day in the previous month), the estimated relative risk of injury for patients who reported having consumed alcohol within 6 hours prior to injury (17% of the sample) was 3.97 (95% confidence interval: 2.88, 5.48). This increase in the relative risk was concentrated within the first 2 hours after drinking; there was a positive association of increasing risk with increasing number of drinks consumed. These data suggested that relative risk estimates were the same for patients with and without alcohol use disorders.

Alcohol, tobacco, and drug use and the onset of type 2 diabetes among inner-city minority patients

BACKGROUND

We examined the prevalence of alcohol, tobacco, and drug use and their relation to the age of onset of type 2 diabetes among inner-city minority diabetic patients who sought routine care at medical clinics in south central Los Angeles.

METHODS

A cross-sectional study design was used to sample 392 diabetic patients. Consecutive patients from seven different primary care clinics were interviewed to determine their alcohol, tobacco, and drug use histories and the age of onset of diabetes.

RESULTS

The study sample was 61% Hispanic and 64% female and had a mean age of 53 years. Seventy-one diabetic patients (18%) reported that they recently consumed alcohol. Sixty-nine patients (17%) reported smoking within 30 days of their interview. Thirty-eight diabetic patients reported a history of regular illicit drug use. Multiple regression analysis showed that diabetic patients who used alcohol, illicit drugs, or combined substances (alcohol and illicit drugs), but not tobacco alone, reported an earlier onset of type 2 diabetes.

CONCLUSIONS

This hypothesis-generating study suggests that alcohol and illicit drugs, when used alone or in combination, might be associated with an earlier onset of type 2 diabetes. Additional research, however, is required to evaluate further these preliminary findings.

A comparison of substance use and injury among Mexican American emergency room patients in the United States and Mexicans in Mexico

BACKGROUND

Emergency room (ER) studies have found differences in the association of alcohol with injury (intentional and unintentional) across cultures. These differences may be due to differences in drinking patterns across cultures. Few comparative data have been reported on associations of alcohol and injury between Mexican American ER patients and ER patients living in Mexico, and general population studies suggest that Mexican Americans may adopt more frequent heavy drinking patterns after migrating to the United States.

METHODS

A comparative analysis of drinking, drug use, and injury was performed in probability samples of 550 ER patients from Santa Clara County (San Jose, CA) and 1417 ER patients in Pachuca (Hidalgo), Mexico.

RESULTS

Both injured and uninjured (i.e., medical conditions) patients in Pachuca were less likely to report heavy drinking, drug use, drunkenness, or alcohol-related problems compared with those in Santa Clara. Those scoring high on level of acculturation in Santa Clara were more likely to report both drinking and drug use before the event, and heavy drinking, drug use, and consequences related to drinking in the last year compared with those scoring lower. Those scoring low on acculturation were similar on substance use variables to those in the Pachuca sample.

CONCLUSIONS

Findings suggest that alcohol's association with injury may not just reflect typical drinking patterns in a culture. Among Mexican Americans, this association my vary by acculturation, and those migrating to the United States may be at increased risk for alcohol-related injury as their drinking patterns undergo change to those of the dominant culture. The ER, in this context, may take on increasing importance as a site for health services providers to implement intervention and prevention services for alcohol-related consequences in this ethnic group.

Selection of screening items for alcohol abuse and alcohol dependence among Mexicans and Mexican Americans in the emergency department

OBJECTIVE

This article reports on the selection of screening items to detect Mexican or Mexican-American patients in the emergency department (ED) who have alcohol problems and could benefit from an intervention or a referral for treatment. Items are tested against the Rapid Alcohol Problems Screen (RAPS), which has been optimized from standard screening instruments and has outperformed these instruments.

METHOD

The performance of individual items from standard screening instruments (CAGE, TWEAK, AUDIT, TRAUMA and BMAST) against International Classification of Diseases, Tenth Revision and Diagnostic and Statistical Manual, Fourth Revision criteria for alcohol abuse and dependence was evaluated in a merged probability sample (N = 869; 72% men) of 537 ED patients from three hospitals in Pachuca, Mexico, and 332 Mexican-American ED patients in Santa Clara County, CA. Logistic regression and tree-classification models were used for item selection.

RESULTS

We found a prevalence of 15% for alcohol dependence and a prevalence of 28% for alcohol abuse or dependence in the merged sample. The RAPS items did not perform as well in terms of sensitivity (93%) as the optimal five items identified in these analyses (sensitivity = 98%) for alcohol dependence, but did demonstrate better specificity (79%) than the optimal five items (65%), which is an important consideration in a time of cost containment. Both sets of items showed better sensitivity and positive predictive value but similar Receiver Operating Characteristic values for respondents in the high acculturation group compared to those at other levels of acculturation. Differences in positive predictive value across all subgroups tended to increase at increased cutpoints, especially for the RAPS.

CONCLUSIONS

These analyses suggest that the RAPS performs favorably compared to those items optimized, in this sample of Hispanic ED patients. Based on comparative item performance in these analyses, the RAPS may hold promise as a useful tool for screening for alcohol dependence, but requires further evaluation as a stand-alone instrument in comparison with other standard screening instruments.

Differences in services utilization between white and Mexican American DUI arrestees

BACKGROUND

Hispanics traditionally have been considered an underserved population in relation to medical care and related services utilization.

METHODS

Selected health and social services utilization (both alcohol-specific and non-alcohol-specific) during the last year was compared between a sample of 249 Mexican American (half of whom were born in Mexico) and 250 white participants interviewed in all five DUI (driving under the influence) treatment programs in one northern California county.

RESULTS

Among those who met DSM-IV criteria for alcohol dependence and/or alcohol abuse, 49% of the white subjects compared with 59% of the Mexican American subjects reported no utilization, 77% of whites and 82% of Mexican Americans reported no utilization in which drinking was a factor, and 70% of whites and 80% of Mexican Americans reported no contact with an alcohol program. Mexican Americans were also significantly less likely to report contact with more than one program, and among Mexican Americans, those born in Mexico were significantly less likely to report utilization than those born in the U.S.

CONCLUSIONS

The data suggest that despite the higher rates of heavy drinking found among Mexican American DUI arrestees (especially those born in Mexico) in this sample, Mexican Americans with an alcohol use disorder are less likely to use health and social services than whites, and this may be related to country of birth and related variables that include health insurance.

SIGNIFICANCE

The data suggest that DUI programs may offer one of the few opportunities Mexican American problem drinkers have of establishing contact with the health and social service system and, as such, would be well positioned to also offer other types of alcohol-related health and social services and referrals to this underserved population. These findings have implications for intervention efforts for problem drinking and prevention of DUI among Mexican Americans, which are a rapidly growing ethnic minority in California.

Performance of screening instruments for alcohol problems in the ER: a comparison of Mexican-Americans and Mexicans in Mexico

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender, injury, and acculturation subgroups suggests attention should be given to choosing the "best" instrument.

Variables associated with DUI offender status among whites and Mexican Americans

OBJECTIVE

Arrests of Hispanics have been found to be overrepresented among arrests for driving under the influence of alcohol (DUI) in California. Variables associated with offender status (first vs multiple) among Mexican-American and white DUI arrestees are analyzed to test the hypothesis that acculturation will be related to DUI among Mexican Americans while risk-taking dispositional variables will be related to DUI among whites.

METHOD

A sample of 249 Mexican-American clients (with an oversampling of foreign-born) and 250 white clients were interviewed in all five DUI treatment programs in one northern California county.

RESULTS

In univariate analysis, risk taking/impulsivity and sensation seeking were positively associated with multiple offender status among Mexican Americans, but not among whites. Multiple logistic regression found age as the only significant predictor of offender status in either ethnic group; however, path models found significant indirect effects on offender status of attitudes regarding DUI arrest through alcohol consumption, with those reporting having little chance of being arrested for DUI if stopped being less likely to report consuming five or more drinks at a sitting at least weekly, and with Mexican Americans being more likely than whites to believe they will not be arrested and to consider that DUI is not a problem.

CONCLUSIONS

The data suggest that there are significant ethnic differences in attitudes and norms toward DUI that are related to frequency of drinking large amounts at one sitting, and future research is needed to determine how these variables along with dispositional and acculturation variables may be associated with DUI offender status.

Screening instruments for alcohol problems: a comparison of cut points between Mexican American and Mexican patients in the emergency room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.

A brief screening instrument for problem drinking in the emergency room: the RAPS4. Rapid Alcohol Problems Screen

OBJECTIVE

While a number of brief screening instruments for identifying problem drinkers have been tested in clinical settings, instruments have not been found to perform as well for women as for men, or to perform uniformly across ethnic groups. The purpose of this study was to evaluate a shortened version of the RAPS (Rapid Alcohol Problems Screen) in an emergency room (ER) sample (N = 1,429; 51% female) and to determine the most efficient ordering of the items.

METHOD

The sensitivity and specificity of each of the RAPS items were examined against current ICD-10 and DSM-IV criteria for alcohol dependence, and separately for harmful drinking or abuse. A four-item version of the RAPS (the RAPS4) was analyzed separately for men and for women, and for blacks, Hispanics and whites/others.

RESULTS

Among the five original RAPS items, four items were found to be most efficient, with the single item of feeling guilt or remorse after drinking identifying 83% of those with alcohol dependence and 44% of those meeting criteria for harmful drinking or abuse. A positive response to any one of the four items (RAPS4) gave a sensitivity of 93% and specificity of 87% for alcohol dependence, and sensitivity and specificity were consistently high across gender and ethnic subgroups. Sensitivity and specificity for harmful drinking or abuse were lower (55% and 79%, respectively).

CONCLUSIONS

Because of its brevity and high performance across demographic subgroups, the RAPS4 may hold promise in screening for alcohol use disorders in patient populations, and its utility warrants further evaluation in clinical settings.

Drinking patterns and alcohol dependence: a comparison of primary care patients in a southern county with the regional general population

OBJECTIVE

Alcohol-related problems are thought to be overrepresented in primary care settings compared to the general population; however, studies comparing alcohol use problems within primary care settings and within the general population from the same area are relatively rare.

METHOD

Data on drinking patterns and alcohol dependence are reported on a probability sample of 767 patients in a primary care system and 1,536 general population respondents sampled from the same region.

RESULTS

No differences were found regarding heavy drinking, frequency of drunkenness or prior alcohol treatment, between the primary care sample and those in the general population who reported primary care use during the previous year, although those in the primary care sample were significantly less likely to be alcohol dependent. Compared to those in the general population who reported not using primary care services during the preceding year, the primary care sample was significantly less likely to report frequent drunkenness or prior alcohol treatment. Controlling for the demographic disparity between samples in multivariate analysis, drinking characteristics were not positively predictive of belonging to the primary care sample.

CONCLUSIONS

The data suggest that problem drinking does not appear to be overrepresented in this primary care sample, nor among those reporting primary care use in the general population of the region, and that all primary care settings may not hold equal promise for screening for problem drinking patients.

Alcohol and injury: a comparison of emergency room populations in two Canadian provinces

The few comparative emergency room (ER) studies reported have found alcohol's role in injury occurrence to vary and suggest that regional and cultural differences in drinking patterns may account, in part, for this variation. To further this research, a probability sample of 1708 ER patients was interviewed regarding the role of alcohol in the event, usual drinking patterns, and alcohol-related problems and a urine sample was obtained to estimate blood alcohol concentration (BAC). The sample was from ERs in two Canadian provinces with distinctly different cultures: primarily English-speaking Alberta and French-speaking Quebec. While differences in demographic and drinking characteristics between injured and noninjured in both the Alberta and Quebec ERs were similar to those in other ER studies, the injured in the Alberta ER were more likely to be positive for estimated BAC; to have higher BAC levels; to report drinking prior to the event; and, among those reporting drinking, to have consumed a larger number of drinks and to report feeling drunk at the time of injury compared to those in Quebec. These differences may be associated with cultural differences in typical drinking patterns, with higher rates of abstinence reported in the Alberta ER, but also with higher rates of heavy drinking and alcohol-related problems, while those in the Quebec ER were more likely to report consuming smaller quantities with greater frequency (typical of wine-drinking cultures). Additional research is needed to explicate further alcohol's role in injury occurrence for planning effective prevention strategies that are both culturally relevant and specific.

Screening for alcohol problems in the U.S. general population: a comparison of the CAGE and TWEAK by gender, ethnicity, and services utilization

OBJECTIVE

The purpose of this study was to compare the performance of two screening instruments for alcohol problems, the CAGE and the TWEAK, against ICD-10 and DSM-IV criteria for alcohol dependence by gender and ethnicity, and to evaluate whether characteristics associated with health services utilization may affect the performance of screening instruments, in a representative sample of the U.S. adult general population.

METHOD

Data are from the Alcohol Research Group's 1995 National Alcohol Survey; these were weighted to account for the design effect inherent in multistage cluster sampling and oversampling of blacks and Hispanics. Effective sample size was 2,443: 797 blacks, 642 Hispanics and 1,004 whites and others (primarily Asian and Native American). Sensitivity and specificity were examined for both screening instruments. Logistic regression was used to evaluate the predictive value, separately, for the CAGE and TWEAK, controlling for gender, ethnicity, region of the country and service use (primary care and emergency room).

RESULTS

The TWEAK was more sensitive for men than for women, but no differences were found by service use, while the CAGE was more sensitive for men who had used the emergency room during the preceding year compared with those who had not. The TWEAK was more sensitive than the CAGE among white and Hispanic men, among men who had not used the emergency room and among whites who had no service use. Performance of neither the CAGE nor the TWEAK was found to vary by region of the country.

CONCLUSIONS

Data suggest that while the performance of screening instruments may vary across demographic subgroups in the general population, instruments may perform equally well for identifying problem drinkers in general populations as in clinical populations.

Emergency room and primary care services utilization and associated alcohol and drug use in the United States general population

Heavy and problem drinking have been found to be over-represented in some studies of clinical populations, but little is known of the association of alcohol and drug use with health services utilization in the general population. General population data are reported on the association of alcohol, drug use, and demographic characteristics with use of the Emergency Room (ER) or other primary care services during the preceding year. Data analysed are from the 1995 National Alcohol Survey of respondents living in households in the 48 contiguous states. Logistic regression was used to analyse the association of substance-use variables with ER and primary care services use by gender within three ethnic groups: white (n = 1636), black (n = 1582) and Hispanic (n = 1585). Variables found to be associated with ER use were not associated with primary care services use and vice versa. Drinking and drug-use characteristics appeared to be more associated with ER use than with primary care use, and varied across ethnic and gender subgroups. The data suggest an association between treatment for alcohol or drug problems and services use, particularly among blacks and Hispanics. The data support findings from clinical studies that over-representation of substance-use problems in some clinical settings may be due to the socio-demographic characteristics of those using the facility under study, and suggest that ER and other primary care service settings may be useful for identifying those with alcohol and drug-regulated problems among specific gender/ethnic groups.

Demographic and substance use factors related to violent and accidental injuries: results from an emergency room study

OBJECTIVE

The primary goal of this study was to identify demographic and substance use factors associated with violent injuries, accidental injuries, and medical conditions or illnesses (non-injured).

METHOD

Data were examined from a sample of 1701 admissions to emergency rooms at two Canadian hospitals. These patients were interviewed and provided urine samples to detect the presence of drug metabolites for alcohol, THC, benzodiazepines, barbiturates, morphine, and codeine.

RESULTS

Those with violent injuries were significantly (P<0.0001) more likely to be male and have lower incomes compared with both the accidental injury and non-injury groups. About 37% of violent injuries occurred at a bar or restaurant, which was significantly more than 3% for accidental injuries and 2% for non-injuries (P<0.00001). The violent injury group was significantly more likely than the other two groups to report feeling the effects of alcohol at the time of the injury and to report negative consequences of alcohol use (P<0.00001). Furthermore, about 42% of those with violent injuries had a blood alcohol level (BAL) over 80 mg% compared to only 4% with accidental injuries (P<0.00001) and 2% of non-injuries (P<0.00001). In terms of drug tests for other substances, the violent injury group was significantly more likely to test positive for benzodiazepines than the accidental injury group (P<0.01) while all between group comparisons for other drugs were not significant.

Drinking patterns and problems: a comparison of two black primary care samples in two regions

This paper explores the effect of regional ("wet" vs. "dry") variation in drinking patterns and problems on the prevalence of alcohol-related problems among those seeking care in primary care settings. A sample of black primary care patients interviewed in Hinds County, MS (n = 740) and in Contra Costa County, CA (n = 93) are compared on quantity and frequency of usual drinking, drunkenness, consequences of drinking, and alcohol dependence. Controlling for demographic differences in logistic regression analysis, drinkers in Contra Costa, while no more likely to report heavy drinking, were four times more likely to report alcohol-related consequences, more than five times more likely to report alcohol dependence experiences, and more than nine and a half times more likely to report ever having had treatment for an alcohol problem than those in Hinds County. Data suggest that regional variations in drinking patterns may be reflected in alcohol involvement in primary care caseloads, and that the large variation in the prevalence of alcohol-related problems found in primary care settings may, in part, be attributable to this. All primary care settings do not appear to hold equal promise for screening for and intervening with problem drinking, and further research is needed in determining those settings that provide the greatest potential for targeting prevention efforts.

Drinking patterns and problems, drug use and health services utilization: a comparison of two regions in the US general population

While substance abuse has been found to be over-represented in some primary care settings, we do not know under what circumstances this association may vary, and whether it may be linked to differences in attitudes regarding alcohol use as reflected in regional rates of abstention and heavy or problem drinking. Data are reported from the Southern and Western regions of the 1995 National Alcohol Survey. Alcohol consumption variables were not found to be predictive of primary care utilization. Main effects were found for heavier drinking on emergency room (ER) use for an injury, and interactive effects of region were found for consequences of drinking, with those in the South who reported consequences more likely to have used the ER for either an injury or illness than those in the West. These data suggest that ER utilization may be related to regional differences in drinking patterns, while primary care utilization may not be.

Gender, injury status and acculturation differences in performance of screening instruments for alcohol problems among US Hispanic emergency department patients

The sensitivity and specificity of several screening instruments including the CAGE, brief MAST, AUDIT, TWEAK, RAPS, and Trauma Scale, were evaluated against both ICD-10 and DSM-IV criteria for alcohol dependence and for harmful drinking and abuse in a probability sample of 586 Hispanic emergency department patients. Screening instruments were not as sensitive for females as for males, for those in the low acculturation group, or for non-dependent drinkers. Acculturation was positively associated with the likelihood of being a current drinker and among current drinkers, was positively associated with alcohol dependence and with harmful drinking or alcohol abuse.

Substance use, injury, and risk-taking dispositions in the general population

Alcohol consumption has been found to be associated with injury occurrence and with risk-taking dispositions, and these dispositions, themselves, have been found to be associated with injury. Few studies have analyzed both alcohol consumption and risk-taking dispositions, or illicit drug use, on risk of injury across all types of injuries. Data on risk perception, risk-taking/impulsivity, sensation seeking, alcohol and drug use, demographic characteristics, and injury in the last year are reported from the 1995 National Alcohol Survey of 4925 respondents living in households in the 48 contiguous states. Moderate drinking, alcohol treatment, drug use, simultaneous use of alcohol and drugs, and risk-taking dispositions were all positively associated with reporting an injury. In multiple logistic regression, only risk-taking dispositions maintained significance when other variables were controlled. In separate regressions by ethnicity, risk-taking dispositions were significant predictors of injury for whites, whereas none of the variables were significant for blacks or Hispanics. Data suggest that risk-taking dispositions may be more important predictors of injury than either drinking or drug use variables, but this may vary by ethnicity. Risk-taking disposition may influence the effectiveness of strategies to reduce alcohol-related injuries; future research is important, therefore, for informing intervention and prevention efforts.

Alcohol consumption in emergency room patients and the general population: a population-based study

Our purpose was to obtain epidemiological measures of the association between habitual alcohol consumption, alcohol consumption before the event and alcohol abuse/dependence, and emergency room (ER) attendance compared to the general population in Pachuca-Hidalgo, a city located in the central area of Mexico. The study was a population based case-control design. Data consisted of breath samples to estimated blood alcohol concentration, as well as an interviewer-administered questionnaire, collected on a 24-hr basis, during the entire week, in each of the three main ERs of Pachuca. Cases were all patients who visited the three main hospitals ERs during the study period, classified according to their status as an injured or noninjured (medically ill) patient (n = 1511). The general population sample (n = 920) serves as a comparison group for both types of patients. Injured patients in the ER sample were significantly more likely to report high frequency/high quantity of drinking during the last 12 months than the general population [odds ratio and 95% confidence intervals = 5.55 (1.72-17.97)] and to report drinking within 6 hr before the injury. These relationships did not hold for noninjured patients. Both types of patients were more likely to report high frequency of drunkenness during the preceding 12 months, to be positive for alcohol dependence and to report drug use. We found in the city of Pachuca, a large relationship between habitual alcohol consumption and ER injuries. These findings support associations of alcohol consumption and admission to an emergency room found in ER and general population studies in other countries. Due to the increases in the risk found for abuse/dependent in both injured and noninjured patients, they both would benefit with a brief intervention strategy for reducing their alcohol consumption.

Performance of screening instruments for identifying alcohol dependence in the general population, compared with clinical populations

Screening instruments for problem drinking have been developed in clinical populations, and little is known of their performance in the general population. Sensitivity and specificity of the CAGE and the TWEAK for ICD-10 and/or DSM-IV criteria for alcohol dependence are compared among those sampled from the southern region in the 1995 National Alcohol Survey (n = 776), and from emergency room (ER) (n = 1327) and primary care clinic (n = 767) samples in Jackson, MS. Sensitivity of the CAGE was higher in both the ER (85%) and primary care (82%) samples than in the general population (75%), although differences were not significant, and this held for males and females alike. Sensitivity of the TWEAK was lower in the general population sample (83%) than in the ER sample (89%), but higher than in the primary care sample (75%). In the general population, sensitivity of both screeners was better (although not significantly so) among those making an ER or primary care visit during the last year than among those not doing so, with the largest difference found for the CAGE (85% vs. 65%, respectively). In a merged sample of the three sites, the interaction of site by screening instrument was not a significant predictor of alcohol dependence for either the CAGE or TWEAK. Data suggest that screening instruments may not perform as well in the general population as in some clinical populations, with more variation apparent across groups for some screeners than for others. Although further analysis is necessary to explore this issue further, attention should be given to selection of the best instrument for use in a given population.

Differences in performance of screening instruments for problem drinking among blacks, whites and Hispanics in an emergency room population

OBJECTIVE

The purpose of this study was to compare the performance of a number of standard screening instruments for alcohol dependence and harmful drinking/abuse by ethnicity (black, Hispanic and white) and by ethnicity and gender in an emergency room setting.

METHOD

A probability sample of patients (N = 1,429) was breath analyzed and interviewed at the Santa Clara Valley Medical Center in San Jose, California. Sensitivity and specificity were analyzed among current drinkers (n = 857) for the CAGE, Brief MAST, AUDIT, TWEAK, RAPS and other items against combined ICD- 10 or DSM-IV criteria for alcohol dependence and separately for alcohol dependence or harmful drinking or abuse.

RESULTS

Screening measures were not found to perform equally well by ethnicity or gender, with lower sensitivity found for women compared to men. Consistency in sensitivity of measures was found to vary considerably across ethnic and gender groups, with some measures (most notably the RAPS and the AUDIT) showing consistently high sensitivity across subgroups. None of the instruments performed nearly as well for identifying alcohol dependence or harmful drinking or abuse combined as for alcohol dependence alone.

CONCLUSIONS

Analyses suggest that, while the RAPS may hold promise for identifying problem drinkers across ethnic and gender subgroups, it and other screening instruments currently in use require additional evaluation in a variety of settings to determine their usefulness for identifying those who could benefit from a brief intervention or referral for problem drinking.

Alcohol consumption, sensation seeking and ski injury: a case-control study

OBJECTIVE

Alcohol consumption is known to be associated with both risk of accidental injury and with sensation seeking, and sensation seeking has been found to be common among those engaging in such high-risk activities as skiing. However, few studies have examined the joint association of alcohol consumption and sensation seeking on injury.

METHOD

Alcohol consumption prior to injury and sensation-seeking disposition are analyzed on 389 injured skiers (clinic sample) and 899 randomly selected uninjured skiers (trailside sample) at a Northeastern ski resort. Cases and controls were asked questions pertaining to drinking within 24 hours, amount consumed, time lapsed between the last drink and the event, skiing ability, and sensation seeking.

RESULTS

The clinic sample was more likely to be female, to have less skiing experience, to score lower on sensation seeking and to have been drinking within 24 hours compared to the trailside sample. However, they were less likely to have had six or more drinks within 24 hours and were more likely to report a greater time lapse between the last drink and injury or interview. A larger proportion of those who reported drinking in both samples scored high on sensation seeking compared to those who reported not drinking. Logistic regression analysis found the following variables predictive of ski injury: female, low on sensation seeking, amount of alcohol consumed prior to the event, a longer time lapsed between drinking and the event, time of day (later) and day of the week (weekend).

CONCLUSIONS

The data suggest that, while drinking within 24 hours is positively associated with sensation seeking, drinking and not sensation seeking is positively predictive of injury. Drinking at least 12 hours prior to skiing, not drinking in close proximity to skiing, may increase risk for accidental injury, possibly due to a hangover or residual alcohol effect in which fatigue may play a part.

Male drinking and violence-related injury in the emergency room

AIMS

To present epidemiological measures of associations between violence-related injuries (assaults and fights), alcohol consumption prior to the event, and drinking patterns among males attending hospital emergency rooms (ERs) in Mexico City.

DESIGN

All patients were interviewed and breath tested for alcohol consumption. The data were analyzed using a case-control design.

SETTING

Eight ERs in Mexico City that were representative of the types of emergency care systems available in that city (from public, private and social security systems hospitals).

PARTICIPANTS

Cases were males patients (n = 445) admitted to the ER because of a fight or an assault. The control group was comprised of patients (n = 320) admitted to the ER because of accidents that are less frequently reported a alcohol-related (i.e. work-place accidents, animal bites or recreational accidents excluding near drowning).

MEASUREMENTS

A breath sample to estimate BAG, as well as an interviewer-administered questionnaire were used.

FINDINGS

Alcohol consumption prior to injury was found to be a more important risk factor than usual drinking for injuries resulting from violence, while quantity of usual alcohol consumption was more predictive of violence-related injuries than frequency of drinking.

CONCLUSIONS

These data suggest the importance of using more appropriate control groups when estimating associations of alcohol and violence-related injuries so that associations will not be underestimated. More research is needed to establish unbiased estimates of alcohol-related violence.

Comparison of screening instruments for alcohol problems between black and white emergency room patients from two regions of the country

A number of brief screening instruments to identify alcohol dependence exist, but the validity of these instruments across ethnic groups or regions of the country is not well established. The sensitivity and specificity of a number of standard screening instruments (CAGE, brief MAST, AUDIT, TWEAK, and RAPS), as well as other measures (History of Trauma Scale, breathalyzer reading, self-reported drinking before the event, and consuming five or more drinks at a sitting at least monthly) are compared against ICD-10 and DSM-IV criteria for alcohol dependence between probability samples of Black and White emergency room patients in Santa Clara County, CA (n = 716) and in Jackson, MS (n = 1330). Variability in the sensitivity of screening instruments among current drinkers was found to be greater between samples for both Blacks and Whites, than for Blacks compared with Whites within the same sample. The AUDIT, TWEAK, and RAPS seemed to perform well by gender and injury status for both Blacks and Whites in the two samples, and no significant differences were found in the performance of these instruments across sample sites. To evaluate the influence of regional differences in alcohol dependence on differences found in the performance of screening instruments, using logistic regression with the simultaneous entry of demographic variables (age, gender, ethnicity, injury status, and site) and drinking variables (breathalyzer reading, self-reported drinking before the event, and drinking five or more drinks at a sitting at least monthly) to predict alcohol dependence in a merged sample of these patients (Jackson vs. Santa Clara) site was not found to be significant. Data suggest that, whereas region of the country may not be important in predicting alcohol dependence in emergency room populations, regional differences in the performance of screening instruments for alcohol dependence may exist, even when ethnicity is taken into account. Given distinct regional differences in drinking patterns and problems in the U.S., further research on commonly used screening instruments is needed to determine those screeners most efficient for identifying problem drinking.

Alcohol and injury: a comparison of three emergency room samples in two regions

OBJECTIVE

Alcohol's involvement in injury has been found to vary greatly depending on the type and location of emergency room (ER), and associations may also vary by regional variations in drinking patterns. Similar data on alcohol and injury are compared in patients from three distinctly different ER types (trauma center vs county/ community and HMO) in two regions of the country (Mississippi and California).

METHOD

Representative samples of injured ER patients from the University of Mississippi Medical Center in Jackson (n = 356), San Francisco General Hospital (SFGH) (n = 555) and Contra Costa County, California, (n = 1,630) were breath analyzed and interviewed at the time of ER admission.

RESULTS

Men in the Jackson sample were less likely than those in SFGH, but more likely than those in Contra Costa, to be positive on the breath analyzer and to report drinking prior to the event, while women in Jackson were less likely to be positive than those in the other two samples. Similar rates of heavy problem drinking were found for those in Jackson and Contra Costa and both rates were lower than those in SFGH. Subjects in Jackson were more likely to be drinking in their own home, to be drinking an alcoholic beverage other than wine and to report a shorter time lapse between the last drink and the event, compared to the other two samples. Quantity-frequency of drinking was found to be predictive of injury in addition to breath analyzer reading and reporting drinking prior to the event, and significant interaction terms were found for drinking variables by site.

CONCLUSIONS

The data suggest that breath analyzer readings may be closely associated with type of ER, urbanicity of the area and socio-demographic characteristics of the clientele, while drinking prior to the injury may be closely associated with regional variations in drinking. Drinking variables appear to be more important predictors of injury in the Jackson sample than in Contra Costa or SFGH.

Alcohol and injuries resulting from violence: a comparison of emergency room samples from two regions of the U.S

Data on representative samples of emergency room patients from a wet region of the U.S. (Contra Costa County, California) and a dry region (Jackson, Mississippi) were analyzed to explore the influence of drinking patterns, rates of abstinence, and per capita consumption with respect to alcohol's role in injuries involving violence. In both samples those with violence-related injuries were more likely to have a positive breathalyzer reading, to report drinking within six hours prior to the event and to report drunkenness and alcohol-related problems compared to those with other injuries. A larger proportion of those with violence-related injuries in the Jackson sample reported consuming more drinks prior to injury and a shorter time lapse between drinking and the event than those in Contra Costa. They were no more likely, however, to report feeling drunk at the time or to attribute a causal association between drinking and the event. The data suggest there may be a closer association of alcohol with violence in the Jackson sample compared to Contra Costa.

Alcohol and violence-related injuries in the emergency room

This chapter reviews data on estimated blood alcohol concentration (BAC), self-reported consumption, and drinking patterns and problems from emergency room (ER) studies of alcohol and violence-related injury. These studies used probability samples of all injured patients that were representative of the population served by the ER where the data were collected. Those with violence-related injuries were more likely to be admitted to the ER with a positive BAC, to report drinking prior to the event, and to report more frequent heavy drinking and alcohol-related problems than those admitted to the same ER during the same time period with injuries from other causes. Limitations to these ER studies, including representativeness of samples, alcohol's presence and role in violence perpetration compared to violence victimization, the presence of other psychoactive substances, and the actual risk at which alcohol places the individual for injuries resulting from violence are discussed.

Alcohol-related health services use and identification of patients in the emergency department

STUDY OBJECTIVE

To determine the relationship between alcohol-related emergency department visits and alcohol-related outpatient visits and the extent of identification and referral of these ED patients for alcohol treatment.

METHODS

A representative sample of ED patients in three medical centers of a large northern California health maintenance organization were interviewed and given breath alcohol tests, and their medical records were reviewed. An alcohol-related ED visit was defined as a visit meeting one or more of the following criteria: positive breath alcohol test result (.01 mg/dL or more), report of drinking in the 6 hours before the presenting injury or illness, ED visit for an alcohol-related problem, and a medical record notation of excessive alcohol use or an alcohol problem.

RESULTS

Among 988 ED patients, 91 were found to have an alcohol-related ED visit. Of the 91, 6 made an alcohol-related outpatient visit in the 12 months before the ED visit, and 10 made such a visit in the following 6 months. Among the 91 patients, 10 were identified as having an alcohol problem by the ED staff, and 1 was referred for alcohol treatment.

CONCLUSION

The ED is an important point for the early identification and referral for treatment of alcohol-dependent and problem drinkers. The patient may make an alcohol-related ED visit relatively early in the pattern of alcohol-related health care use.

Drinking patterns and problems and drinking in the event: an analysis of injury by cause among casualty patients

The association of alcohol and injury might be expected to vary by the specific cause of injury, but few studies have examined such associations across all causes of injury coming from the same population, largely because of the lack of a sufficient number of cases. This study examines the association of drinking patterns and problems and drinking-in-the-injury-event for six mutually exclusive causes of injury (falls, penetrating trauma, motor vehicle accidents, fires, violence, and other causes) in a merged sample of 3109 patients from four emergency room/trauma center studies that used identical study methodology. The predictive value of drinking and demographic variables are examined separately for each cause of injury, and variables predictive of reporting drinking before the event, feeling drunk at the time of injury, and attributing a causal association of drinking and the injury. Injuries sustained from violence and falls had the greatest association with drinking variables, with those with positive breathalyzer readings, and those who reported drinking before injury, frequent heavy drinking, and frequent drunkenness overrepresented in these two causes. Those who reported a larger number of drinks consumed before injury and those who reported feeling drunk at the time were also overrepresented among those with injuries related to violence and falls. A larger proportion than expected of those who attributed a causal association of drinking with the event sustained injuries related to violence, whereas a smaller proportion sustained injuries from falls. Demographic characteristics were more predictive than drinking characteristics of each cause of injury, whereas drinking characteristics, particularly positive breathalyzer readings, were more predictive of drinking before specific causes of injury. These data provide information that may be useful in developing brief interventions for the prevention of alcohol-related injuries in the emergency room or trauma center setting.

Regional differences in alcohol and fatal injury: a comparison of data from two county coroners

OBJECTIVE

While alcohol has been found to be associated with fatal injury, this association may vary in different regions of the United States where drinking patterns and problems are known to vary. The purpose of this study was to analyze alcohol in injury fatalities in a "dry" area of the country (Hinds County, Miss.) compared to a "wet" area (Contra Costa County, Calif.).

METHOD

Data on all unnatural causes of death during a 1-year period among those 18 years and older were abstracted from county coroner records in Hinds County, Miss. (n = 222) and Contra Costa County, Calif. (n = 304).

RESULTS

Across all causes of death, those in Hinds County were more likely to be alcohol-involved (57%) compared to those in Contra Costa (40%). Those in Hinds County were twice as likely as those in Contra Costa to have died from homicide (32% vs 17%), but the proportion of homicides which was alcohol positive did not differ between the two regions (51% vs 46%). Using logistic regression, gender (male) and region (South) were predictive of a positive blood alcohol concentration across all causes of fatality combined. Age (younger) and ethnicity (black) were predictive of homicide. Ethnicity (non-black), a negative blood alcohol concentration and a positive drug screen were predictive of suicide, while age (younger), ethnicity (non-black), a positive blood alcohol concentration and a negative drug screen were predictive of motor vehicle accidents.

CONCLUSIONS

These data suggest that regional variations in alcohol's association with fatal injury do exist, and vary by demographic characteristics and cause of death. In addition, areas of the country that have relatively low rates of per capita consumption may have higher rates of alcohol-related injury fatalities than areas with greater per capita consumption.

Alcohol in fatal and nonfatal injuries: a comparison of coroner and emergency room data from the same county

Although alcohol is thought to be associated with severity of injury, relatively little data are available that compares alcohol's involvement in injury cases treated in the emergency room (ER) with coroner cases of injury fatality, both coming from the same county. Data from a probability sample of casualty patients 18 years and older treated at the University of Mississippi Medical Center ER in Jackson during a 6-month period (n = 275) are compared with data from coroner reports of all fatalities from unnatural causes among those 18 and older in the same county during a 1-year period surrounding the 6 months of data collection in the ER (n = 222). The two samples are compared on demographic characteristics, cause of injury, place of injury, and alcohol use before the event. A significantly larger proportion of the coroner sample was positive for alcohol (57%) and intoxicated (36%), compared with the proportion of those in the ER sample breathalyzed within 6 hr of injury, and reporting no drinking after the event who were positive (15%) and intoxicated (6%). Differences were most pronounced for motor vehicle accidents and fires. Violence-related injuries were more likely in the coroner sample (32%) than in the ER sample (16%), and they were more likely to involve alcohol at levels of intoxication. Those in the coroner sample were also more likely to be alcohol-positive for injuries occurring in all places except the home of another and the workplace. Using logistic regression, gender (male) and site (coroner) were predictive of a positive blood alcohol across all causes of injury combined. Gender (female), being alcohol-positive and site (coroner) were significantly predictive of motor vehicle accidents. Alcohol was not found to be a significant predictor for falls, other accidents, or injuries resulting from violence. Data suggest that alcohol's association with severity of injury varies by cause of injury.

Alcohol use and medical care utilization among health maintenance organization patients in the emergency department

OBJECTIVE

To determine the association of an alcohol-related ED visit with medical care utilization during a two-year period surrounding the ED visit in an HMO.

METHODS

A probability sample of ED patients were interviewed and underwent breath analysis in a large HMO in a Northern California county. Based on recent alcohol intake or documentation of an alcohol-related ED visit, the patients were assigned to an alcohol group (n = 91) or a non-alcohol group (n = 897). A 10% random sample of the health plan membership of the same county (n = 19,968) served as a comparison group. Utilization data were obtained from computerized files. Multiple linear regression was used to determine differences in subsequent outpatient visit rates between the alcohol and the non-alcohol groups. Logistic regression was used to compare the risks of hospitalization in the two groups.

RESULTS

Annual outpatient visit rates were 7.8 in the alcohol group and 8.3 in the non-alcohol group (p = 0.65), controlling for gender, age, and injury status, and were significantly different from the visit rate of 5.5 for the random health plan sample (p = 0.0001). No difference was found between the alcohol and the non-alcohol groups for risk of hospitalization; however, those in the health plan sample were less than half as likely to be hospitalized as were those in the non-alcohol group (odds ratio 0.44, p = 0.002).

CONCLUSIONS

No difference was found in utilization of medical services between the alcohol and the non-alcohol groups in this predominantly white, well-educated HMO ED population. However, both groups used significantly more inpatient and outpatient services than did the general HMO membership.

Screening for alcohol problems in the emergency room: a rapid alcohol problems screen

This paper compares the sensitivity and specificity of a five-item Rapid Alcohol Problems Screen (RAPS) optimized in this sample with the CAGE, brief MAST, AUDIT, TWEAK, History of Trauma Scale and breathalyzer reading against ICD-10 criteria for alcohol dependence or harmful drinking, by gender, ethnicity and injury status in a probability sample of emergency room patients (n = 1330) from the University of Mississippi Medical Center. The RAPS performed better than all other screening instruments for the total sample of current drinkers who reported ever having had three or more drinks at one time (sensitivity of 90%, specificity of 78%), and performed consistently better across all subgroups than any other single instrument, even at alternate cut points. The Rapid Alcohol Problems Screen may hold promise for use in clinical settings in identifying those who could benefit from a brief intervention or referral for problem drinking, particularly since the instrument is short and patients need not be asked additional questions after screening positive on one of the five items. Further research is necessary to analyze and compare the performance of the RAPS with other screening instruments across demographic subgroups in other emergency room and primary care settings.

Analysis of cut points for screening instruments for alcohol problems in the emergency room

OBJECTIVE

The purpose of this study is to evaluate the performance of a number of alcohol screening instruments (CAGE, Brief MAST, AUDIT, TWEAK), in an emergency room population, against ICD-10 criteria for harmful drinking and for alcohol dependence from the CIDI, by gender, race and injury status.

METHOD

A probability sample of patients were interviewed (N = 1,330) at the University of Mississippi Medical Center. Analyses were carried out on only current drinkers (n = 771; 58% of the sample). Instruments were compared on sensitivity, specificity and area under the curve using receiver operating characteristic (ROC) analysis to determine optimum cut points.

RESULTS

Overall the TWEAK and AUDIT performed best (in relation to sensitivity and area under the ROC curve) at standard cut points (3 and 8, respectively) for both harmful drinking and alcohol dependence. These instruments did not perform equally well across all subgroups, however, particularly among women, and among whites where the CAGE, with a cut point of 1, outperformed both the TWEAK and AUDIT at standard cut points. The TWEAK at a cut point of 2 also did as well as the CAGE at a cut point of 1 among women.

CONCLUSION

These data suggest that standard screening instruments do not perform equally well across ethnic and gender subgroups and that consideration of alternative cut points may be appropriate in some populations.

Alcohol and non-fatal injury in the U.S. general population: a risk function analysis

This paper reports a risk function analysis of average daily volume of alcohol consumed and the frequency of consuming 5 or more drinks during a single day with reporting an injury in a probability sample of the U.S. adult household population living in the 48 contiguous states. The data are from the 1990 National Alcohol Survey on a weighted sample of 1150 respondents, 748 of whom were current drinkers. Risk of injury was found to increase with an average daily volume of 1 drink for both males and females and for those 30 and younger and those over 30, and to increase with a frequency of consuming 5 or more drinks on one day more often than twice a year. These data suggest that risk for injury may be increased at relatively low levels of consumption and, if so, that preventive efforts aimed at more moderate drinkers may have a greater impact on the reduction of alcohol-related accidents than efforts focused on heavier drinkers who are fewer in number.

Screening for alcohol problems in the emergency department

STUDY OBJECTIVE

To evaluate the sensitivity and specificity of several alcohol screening instruments (CAGE, brief MAST, AUDIT, TWEAK, History of Trauma Scale) and other measures (breath alcohol analyzer reading and reporting of drinking before the event), in an emergency department population, against International Classification of Disease, revision 10 (ICD-10) criteria for harmful drinking and for alcohol dependence from the Composite International Diagnostic Interview (CIDI) by gender, race, and injury status.

DESIGN

A probability sample of patients was subjected to breath alcohol analysis and interviewed (N = 1,330.)

SETTING

University of Mississippi Medical Center.

RESULTS

Overall, the TWEAK and AUDIT methods were the most sensitive, identifying 84% and 81%, respectively, of patients who were positive for alcohol dependence. Sensitivity was not as high for females, whites, or the noninjured. Sensitivities for the breath alcohol analysis and self-reported drinking were 20% and 29%, respectively.

CONCLUSION

These data suggest that the effectiveness of screening instruments varies by gender, race, and injury status and that positive breath alcohol analysis readings and reporting of drinking before the event are not good indicators of alcohol dependence in this population.

Ethnic differences in performance of screening instruments for identifying harmful drinking and alcohol dependence in the emergency room

This study examines sensitivity and specificity figures associated with screens used to predict harmful drinking and alcohol dependence among current drinkers. The study population comes from a probability sample of emergency room patients in Jackson, MS. Data are presented by gender and injury status (injured versus noninjured) for Blacks and for Whites. The Composite International Diagnostic Interview was used to assess ICD-10 criteria for harmful drinking and alcohol dependence, which were taken as standards. Predictors include screening instruments (CAGE, AUDIT, brief MAST, TWEAK, and History of Trauma Scale), breathalyzer reading, self-reported consumption before the injury or noninjury event, quantity and frequency of drinking, and an abbreviated alcohol dependence experiences measure used in general population surveys. Single items from these screening instruments were also tested as predictors. Overall, the TWEAK and the AUDIT performed best in terms of sensitivity and specificity, but variation across subgroups suggests that the search for a good screening instrument for general use must be continued.

Alcohol use among HMO patients in the emergency room, primary care and the general population

OBJECTIVE

Although heavy drinking and alcohol-related problems are overpresented among patients seen in some primary care settings compared to the general population, it is not known whether those seen for noninjury problems in emergency rooms (ERs) are similar in demographic and drinking characteristics to those seen in primary care clinics. Nor do we know whether alcohol-related problems are over-represented in both of these settings compared to the general population when equal access to health care services is provided, as by membership in the same HMO. Reported here are data from a single northern California health maintenance organization (HMO).

METHOD

Probability samples of noninjured patients seen in the ERs of the HMO (n = 579) are compared on demographic characteristics and drinking patterns and problems to those seen in the primary care clinics of the same HMO (n = 295) and to those in the general population of the same county who reported membership in the HMO (n = 737).

RESULTS

No differences in drinking patterns, alcohol-related problems or gender or age distribution were found between the clinic patients and the noninjured ER patients. Both the noninjured ER patients and the clinic patients were less likely to report heavy and problem drinking, or treatment for an alcohol-related problem during the last year, as compared to those in the general population.

CONCLUSIONS

The data from this HMO study suggest that noninjured patients seen in these particular emergency rooms resemble those seen in primary care, and that, contrary to the commonly held belief that alcohol-related problems are overrepresented in primary care, primary care patients in this HMO population may be less likely to be problem drinkers than those in the general population from which they come.

Alcohol and casualties: comparison of county-wide emergency room data with the county general population

A representative sample of patients in hospital emergency rooms (ERs) in a Northern California county (n = 3731) were compared with a household probability sample of those living in the same county (n = 2101). The injured in the ER sample were more likely to be black and under 30 than those in the general population sample who reported an injury during the last year which was treated in the ER. ER injured were more likely to be abstainers than injured in the general population and among drinkers, they were also more likely to report social consequences of drinking, but were no more likely to report experiences associated with alcohol dependence. Similar differences were found between the injured and the non-injured in the two samples, with the injured more likely to be male, younger, never married and to report heavy drinking, drunkenness, social consequences of drinking and alcohol dependence experiences. The data suggest that associations of alcohol and injury found in representative samples of the ER population may be generalizable to the injured in the general population from which these patients come, with differences which do exist most likely attributable to characteristics associated with emergency room usage.

Alcohol and injury in the general population: data from two household samples

OBJECTIVE

While a large literature exists on the association of alcohol and injury, coming largely from studies carried out in hospital emergency rooms (ERs), it is not known how representative ER patients are of those who are injured and treated elsewhere, or of those who are injured and receive no treatment. This article reports data on alcohol, injury and ER treatment in the general population.

METHOD

Data were collected in two household probability samples: a national sample (N = 1,144) and a California county sample (N = 3,065).

RESULTS

In the national sample those treated in the ER for an injury were more likely to be younger, black and heavier drinkers, and were more likely to report experiences associated with alcohol dependence compared to those with other injuries, treated or untreated. In the county sample, those treated in the ER were more likely to have been drinking prior to the injury event, to be injured on the street and to report the event to be related to violence compared either to those whose injuries were treated elsewhere or to those who received no treatment for their injuries.

CONCLUSIONS

These data support the contention that findings on associations of alcohol and injury obtained from ER studies cannot be generalized to other injuries in the same population or to other populations.

Alcohol use among primary care patients: comparing an HMO with county clinics and the general population

A probability sample of all patients seen in the four health maintenance organization (HMO) primary care clinics in one Northern California county (N = 314) are compared to patients from all five of the county-operated primary care clinics in the same county (N = 394) and to the general population of the county (N = 3069) on demographic characteristics, drinking patterns and alcohol-related problems. The HMO clinic patients were less likely to report frequent, heavy drinking, drunkenness or alcohol-related problems during the last year compared to those in the county clinics sample, and they were also less likely to report heavy and problem drinking compared to those in the general population. These data suggest problem drinking may not be over-represented in primary care practice in general, but rather may be more closely associated with characteristics of clientele served by a primary care practice than with those characteristics associated with a need for medical attention.

Injury and the role of alcohol: county-wide emergency room data

The purpose of this study is to describe variables associated with injury in an emergency room (ER) sample that is representative of an entire U.S. county. A probability sample (n = 3717) of ER patients from the county hospital, 3 of the 6 community hospitals, and the three health maintenance organization hospitals in a single Northern California county were breath-analyzed and interviewed at the time of the ER visit. Injured were most likely to consume only 1 or 2 drinks within < 1 hr of injury occurrence. Twenty-three percent reported feeling drunk at the time of the event, and of these, 45% felt the event would not have happened if they had not been drinking. Breathalyzer reading, feeling drunk at the time of the event, and quantity-frequency (Q-F) of usual drinking were found to be predictive of admission to the ER with an injury, whereas breathalyzer reading, Q-F, and being injured in someone's home were predictive of reporting drinking prior to injury. Although feeling drunk at the time of the event and usual drinking patterns are predictive of injury occurrence, drinking prior to the event may not entail large quantities of alcohol consumed, but relatively small amounts consumed in close proximity to the injury event. These alcohol consumption variables may vary, however, depending on the type, cause, and severity of injury.