Alcohol Problems


among


Emergency Department Patients


Proceedings of a


Research Conference on


Identification and Intervention


March 19–21, 2001 

Arlington, Virginia 

Editors 

Daniel W. Hungerford, DrPH 

Daniel A. Pollock, MD 
Alcohol Problems Among Emergency Department Patients: Proceedings of a 

Research Conference on Identification and Intervention is a publication of the 

National Center for Injury Prevention and Control, part of the Centers for 

Disease Control and Prevention. 

Centers for Disease Control and Prevention 

Julie L. Gerberding, MD, MPH 

Director 

National Center for Injury Prevention and Control 

Sue Binder, MD 

Director 

Acknowledgments 

The editors wish to thank the Agency for Healthcare Research and Quality, the 

Health Care Financing Administration (now the Centers for Medicare and 

Medicaid Services), the National Highway Traffic Safety Administration, the 

National Institute on Alcohol Abuse and Alcoholism of the National Institutes 

of Health, and the Center for Substance Abuse Treatment of the Substance Abuse 

and Mental Health Services Administration for co-sponsoring this conference. 

They also wish to acknowledge Carole Craft for editorial assistance and Sandra 

Emrich for layout and design, Mary Ann Braun for cover design, and Marilyn 

Kirk for charts and graphs. 

Disclaimer 

The recommendations presented in this publication were generated 

during a meeting of diverse public and private organizations and 

agencies. They do not necessarily represent the official policy or 

opinions of the Centers for Disease Control and Prevention or the 

Department of Health and Human Services. Rather, they represent 

the priorities identified by an expert group convened by this agency. 

Suggested Citation: Hungerford DW, Pollock DA, editors. Alcohol Problems 

Among Emergency Department Patients: Proceedings of a Research Conference 

on Identification and Intervention. Atlanta (GA): National Center for Injury 

Prevention and Control, Centers for Disease Control and Prevention; 2002. 
Table of Contents 

Foreword i


Thomas F. Babor, PhD, MPH


Foreword iii


Daniel A. Pollock, MD


Introduction 1


Steering Committee 4


Speakers 5


Participants 6


Recommendations for Alcohol Screening and 9


Intervention in the Emergency Department


Conference Proceedings 15


Introduction 16


Daniel W. Hungerford, DrPH


Session 1. The Spectrum of Alcohol Problems and the 21


Scope of Emergency Medicine Practice


Presentation — Ronald F. Maio, DO, MS 21


Respondents — Jeffrey W. Runge, MD 32


David C. Lewis, MD 37


General Discussion 42


Session 2. Identifying ED Patients with Alcohol Problems: 51


Research Findings and Prospects


Presentation — Robert H. Woolard, MD 51


Respondents — Cheryl J. Cherpitel, DrPH 68


Richard L. Brown, MD 75


General Discussion 80

Session 3. Intervening with Alcohol Problems in 89


Emergency Settings


Presentation — Carlo C. DiClemente, PhD 89


Respondents — Gail D’Onofrio, MD 108


Kristen L. Barry, PhD 113


General Discussion 119


Session 4. Implementing Preventive Interventions in 133


Emergency Medicine: Strategic Considerations


Presentation — Larry M. Gentilello, MD 133


Respondents — Stephen M. Hargarten, MD, MPH 152


Linda C. Degutis, DrPH 155


General Discussion 163


Discussion of Draft Recommendations
 171 
Foreword 

Alcohol screening and early intervention in medical settings has been 

a rapidly growing area of public health research with enormous implications for clinical practice. Indeed, for many years we have heard that 

the best way to “broaden the base” of treatment for alcohol problems 

is to expand these emerging clinical preventive services into the primary 

care setting. But as the contents of this publication suggest, this emphasis may have been misdirected, if not misplaced, to the extent that only 

cursory attention has been devoted to what is perhaps the most important and neglected setting for case finding and risk identification: the 

emergency department (ED). 

Although no volume can recapture the sense of excitement that 

pervaded the audience as these papers were being presented at the 

March 19–21, 2001, conference, the impressive array of scholarship, 

thoughtfulness, and common sense in these written proceedings certainly captures the spirit of the meeting. Literary scholars use the word 

epiphany to describe a sudden revelation of the inner essence of a 

situation or experience. It was clear to the people who attended the 

conference that a series of epiphanies took place at the meeting. One 

realization was the absurdity of treating patient after patient, time after 

time, in hospital after hospital when both patients and practitioners 

know that the presenting problems, usually accidents and injuries, are 

caused by alcohol intoxication, a condition that is almost universally 

ignored in the interests of expediency. It is not that the people who 

operate the emergency medical system are uncaring or misinformed. 

Rather, an institutional inertia seems to have prevented those responsible for health care policy from taking the initiative to design a better 

system, one that would devote as many resources to managing the 

patient’s drinking as it does to treating the medical consequences of 

alcohol intoxication. The contents of this volume argue forcefully that 

while more research may be needed, enough is known at present to 

warrant a change in policies and procedures about alcohol. 

Another epiphany was the realization that the prototypical skid row 

alcoholic is no longer the major or even the most visible problem 

drinker encountered by emergency department staff. Risky drinking 

(i.e., drinking to intoxication), which is the prime culprit in most 
alcohol-related accidents, injuries, and overdoses, is much more typical 

of college students and suburban twenty-somethings, in part because 

these heavy drinkers—who are not considered alcoholics— are much 

more numerous in the general population than are chronic alcoholics. 

A third epiphany was that applied research on alcohol screening 

and behavioral interventions, guided by careful conceptualization and 

sound methodology, can make a difference in creating a knowledge base 

to change health policy. Insurance reimbursement, legal obstacles, and 

time constraints are all important reasons why drinking behavior is not 

addressed in ED settings. But once the elements of a solution are shown 

to be both feasible and scientifically compelling, the transfer of this 

knowledge to clinical practice can no longer be postponed, ignored, 

or opposed. 

This conference and its proceedings may be viewed above all as an 

attempt to develop a sense of coherence, relevance, and direction for 

a great variety of groups facing an extraordinary diversity of alcohol 

problems. Far from being a quixotically ambitious undertaking, 

considering the long-standing tendency to avoid constructive action 

on alcohol, the ED specialists, alcohol researchers, and research policymakers who participated in the conference left it with a renewed sense 

of direction about what should be done. 

With the enormous increase in epidemiologic evidence and intervention research, the time is right for a new approach to alcohol problems— 

one that puts resources, technologies, and expertise where they can do 

the greatest good for the greatest number of people. To those who were 

at the conference, who participated, presented, listened, discussed, 

argued, agreed, and questioned, the contents of this volume will faithfully represent the epiphanies they experienced. To those who were not 

there, this publication will provide an equally rewarding set of revelations that speak forcefully to the critical issues facing the patients, 

providers, and researchers whose lives intersect all too often in the 

unfortunate context of the emergency department. 

Thomas F. Babor, PhD, MPH


Professor and Chair


Department of Community Medicine


University of Connecticut School of Medicine


ii Alcohol Problems Among Emergency Department Patients 
Foreword 

Emergency physicians and their clinical and research colleagues are well 

aware of alcohol’s role in the injuries and illnesses that lead to millions 

of emergency department (ED) visits each year. Even though clinicians 

working in EDs do not identify or report alcohol’s role consistently or 

completely, they treat ED patients with alcohol problems often enough 

to recognize the pervasiveness and perniciousness of hazardous drinking. Further, many clinical and epidemiologic studies confirm the 

magnitude and seriousness of alcohol problems among ED patients. 

Spurred in large part by the enormous toll taken by hazardous alcohol 

use and by mounting interest in delivering clinical preventive services 

during acute care episodes, screening and intervention for alcohol 

problems in the ED has gained new visibility and importance. The 

March 19–21, 2001, meeting on this topic, organized and convened 

by six federal agencies, provided a national forum for practitioners, 

researchers, and other stakeholders to share findings and perspectives, 

take stock of current knowledge, and identify research priorities. 

As can be seen from the presentations and discussions at the meeting, 

the need for an in-depth assessment and exchange of information about 

screening and intervention for alcohol problems extends across fields 

and disciplines. Many emergency physicians, trauma surgeons, and 

other front-line practitioners are seeking evidence-based recommendations and practical guidance about ways to systematically identify and 

reduce hazardous alcohol use among their patients. Alcohol researchers 

working in this field seek to disseminate their findings to practitioners 

and collaborate with them on new investigations. Public health professionals seeking to reduce the societal burden of alcohol problems 

recognize that strengthening the knowledge base for clinical preventive 

services can yield benefits for the general population as well as individual patients. Policymakers and payers recognize the potential value 

of preventive care, but they seek evidence for cost effectiveness before 

making health insurance coverage decisions. 

The March 19–21, 2001, meeting was the first national conference 

devoted exclusively to research on clinical preventive services for alcohol 

problems among ED patients. The knowledge, commitment, and 

collaborative spirit of the speakers, discussants, and participants 
combined to produce important insights and a valuable set of research 

recommendations. These are gratifying contributions. But what will 

make the effort truly worthwhile is using the meeting and proceedings as 

catalysts for new research and services that reduce the effects of hazardous alcohol use on patients and society. 

Daniel A. Pollock, MD


Medical Epidemiologist


National Center for Injury Prevention


and Control


Centers for Disease Control and Prevention


iv Alcohol Problems Among Emergency Department Patients 
Introduction 

For two-and-one-half days in March 2001, emergency physicians, 

trauma surgeons, policymakers, psychologists, psychiatrists, epidemiologists, and alcohol researchers gathered to share information 

and perspectives on screening methods and interventions for emergency 

department (ED) patients with alcohol problems. After considering 

the current state of knowledge in the field, their goal was to design a 

research agenda that would improve our ability to identify and help 

these patients. 

For years, anecdotal reports from ED staff indicated that many 

patients had alcohol problems, and during the 1990s, systematic screening studies validated those reports.1,2 In 1990, the Institute of Medicine 

issued a landmark report recommending that patients in EDs and other 

medical settings be screened for a broad spectrum of alcohol-related 

problems and that screen-positive patients receive a brief intervention 

or a referral to specialized treatment.3 As the decade progressed, further 

evidence from controlled studies confirmed the efficacy of brief interventions for alcohol problems in primary care settings.4,5 The demonstrated efficacy of these interventions combined with their brief nature 

led to calls for emergency physicians to address alcohol problems among 

their own patients.6–11 Although increased interest led to ED-based 

research, early efforts were beset by the unique operational difficulties 

presented by the ED clinical setting.

12 Increased interest was tempered 

by emergency physicians’ preference for treating acute conditions rather 

than underlying risk factors and the lack of controlled research on 

interventions in ED settings. 

Recognition of these circumstances led staff from the Centers for 

Disease Control and Prevention (CDC) to invite other federal agencies 

to support a national effort to summarize the current state of knowledge 

and consider important directions for research on screening and interventions for ED patients with alcohol problems. Five other agencies 

joined CDC to co-sponsor this conference: the Agency for Healthcare 

Research and Quality, the Health Care Financing Administration (now 

the Centers for Medicare and Medicaid Services), the National Highway 

Traffic Safety Administration, National Institute on Alcohol Abuse and 

Alcoholism of the National Institutes of Health, and the Center for 
Substance Abuse Treatment of the Substance Abuse and Mental Health 

Services Administration. A steering committee composed of agency 

representatives as well as emergency medicine, trauma surgery, and 

alcohol researchers was formed to plan the conference. 

Since research in this clinical setting was relatively new and included 

representatives from disciplines that do not normally collaborate, the 

committee structured the conference to allow ample time for both 

presentations and discussion. The committee commissioned presentations on four broad topics: 1) the role of emergency medicine in identifying and treating patients with alcohol problems; 2) screening ED 

patients for alcohol problems; 3) intervention strategies for ED patients 

with alcohol problems; and 4) strategic considerations for implementing 

preventive interventions in the ED. During the first two days of the 

conference, participants heard the commissioned presentations and 

responses from invited discussants and joined in discussions to evaluate 

what is known and to identify critical gaps in systematic research. On the 

last half day of the conference, the assembled group responded to draft 

research recommendations presented by the steering committee. After 

the conference concluded, CDC staff incorporated feedback from 

discussions into a revised set of research recommendations for steering 

committee input and approval. 

The research recommendations, the text of the formal presentations, 

and the proceedings of the conference comprise the contents of this 

report. For the busy reader, the final research recommendations can 

serve as an executive summary of conference results. The four presentations, each accompanied by two respondents and a comprehensive 

summary of lively discussions, provide an introduction to the field of 

alcohol problems and the ED as a clinical setting. Conference participants represented a wide range of disciplines and perspectives. This 

variety combined with the ample time allotted for discussion generated 

an enthusiastic and rich exchange of experience and ideas. It is the hope 

that this report conveys that intellectual vigor and that funding agencies, 

researchers, and policymakers will carefully consider the research 

recommendations, which are designed to improve the quality of care 

ED patients receive for alcohol problems. 

2 Alcohol Problems Among Emergency Department Patients 
References 

1. Lowenstein SR, Koziol-McLain J, Thompson M, et al. Behavioral risk factors 

in emergency department patients: a multisite survey. Acad Emerg Med 1998; 

5:781–7. 

2. Cherpitel CJ. Performance of screening instruments for identifying alcohol 

dependence in the general population, compared with clinical populations. 

Alcohol Clin Exp Res 1998;22:1399–404. 

3. Committee for the Study of Treatment and Rehabilitation Services for 

Alcoholism and Alcohol Abuse, Institute of Medicine, Division of Mental Health 

and Behavioral Medicine, National Academy of Sciences. Broadening the Base of 

Treatment for Alcohol Problems. Washington (DC): National Academy Press; 1990. 

4. Nilssen O. The Tromso study: identification of and a controlled intervention 

on a population of early-stage risk drinkers. Prev Med 1991;20:518–28. 

5. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician 

advice for problem alcohol drinkers. A randomized controlled trial in 

community-based primary care practices. JAMA 1997;277:1039–45. 

6. Maio R. Alcohol and injury in the emergency department: opportunities for 

intervention. Ann Emerg Med 1995;26:221–3. 

7. Bernstein E. Speaking sober in the emergency department. Acad Emerg Med 

1995;2:762–4. 

8. Zink BJ. Alcohol use and the emergency department: lessons in heterogeneity 

and homogeneity. Acad Emerg Med 1996;3:95–7. 

9. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 1: 

improving detection. SAEM Substance Abuse Task Force. Society for Academic 

Emergency Medicine. Acad Emerg Med 1998;5(12):1200–9. 

10. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 2: 

intervention and referral. SAEM Substance Abuse Task Force. Society for 

Academic Emergency Medicine. Acad Emerg Med 1998;5(12):1210–7. 

11. D’Onofrio G. Screening and brief intervention of alcohol and other drug 

problems: what will it take? Acad Emerg Med 2000;7:69–71. 

12. Peters J, Brooker C, McCabe C, et al. Problems encountered with 

opportunistic screening for alcohol-related problems in patients attending 

an accident and emergency department. Addiction 1998;93:589–94. 

Introduction 3 
Steering Committee 

Chair: 

Daniel W. Hungerford, DrPH, National Center for Injury Prevention 

and Control 

Centers for Disease Control and Prevention 

Members: 

Herman I. Diesenhaus, PhD, Office of Evaluation, Scientific Analysis 

and Synthesis 

Substance Abuse and Mental Health Services Administration 

Gail D’Onofrio, MD, Section of Emergency Medicine 

Yale University School of Medicine 

Mary C. Dufour, MD, MPH, Deputy Director 

National Institute on Alcohol Abuse and Alcoholism 

Herbert G. Garrison, MD, MPH, Department of Emergency Medicine 

East Carolina University 

Larry M. Gentilello, MD, Department of Surgery 

University of Washington 

Catherine Gordon, RN, MBA, Health Promotion and Disease Prevention 

Health Care Financing Administration 

David C. Lewis, MD, Center for Alcohol and Addiction Studies 

Brown University 

Ronald F. Maio, DO, MS, Department of Emergency Medicine 

University of Michigan 

Daniel A. Pollock, MD, National Center for Injury Prevention and Control 

Centers for Disease Control and Prevention 

Susan Ryan, MS, Impaired Driving Division 

National Highway Traffic Safety Administration 

Elinor Walker, PhD, Center for Quality Measurement and Improvement 

Agency for Healthcare Research and Quality 

Robert Woolard, MD, Section of Emergency Medicine 

Brown University 

4 Alcohol Problems Among Emergency Department Patients 
Speakers 

Kristen Lawton Barry, PhD, University of Michigan 

Department of Psychiatry, Department of Veterans Affairs 

Richard Brown, MD, Department of Family Medicine 

University of Wisconsin 

Cheryl Cherpitel, DrPH, Alcohol Research Group 

Public Health Institute 

Gail D’Onofrio, MD, Section of Emergency Medicine 

Yale University School of Medicine 

Linda Degutis, DrPH,Section of Emergency Medicine 

Yale University 

Carlo DiClemente, PhD, Psychology Department 

University of Maryland at Baltimore County 

Larry Gentilello, MD, Department of Surgery 

University of Washington 

Stephen Hargarten, MD, MPH, Emergency Medicine Department 

Medical College of Wisconsin 

Daniel W. Hungerford, DrPH, National Center for Injury Prevention 

and Control 

Centers for Disease Control and Prevention 

David Lewis, MD, Center for Alcohol and Addiction Studies 

Brown University 

Ronald Maio, DO, MS, Department of Emergency Medicine 

University of Michigan 

Jeffrey Runge, MD, Department of Emergency Medicine 

Carolinas Medical Center 

Robert Woolard, MD, Section of Emergency Medicine 

Brown University 

Introduction 5 
Participants 

Thomas Babor, PhD, MPH, Department of Community Medicine 

University of Connecticut Health Center 

Bruce Becker, MD, MPH, Department of Emergency Medicine 

Rhode Island Hospital 

Edward Bernstein, MD, Department of Emergency Medicine 

Boston University 

Fred Blow, PhD, Department of Psychiatry 

University of Michigan 

Charles Bombardier, PhD, Department of Rehabilitation Medicine 

Harborview Medical Center 

Phillip Brewer, MD, Section of Emergency Medicine 

Yale University School of Medicine 

Amy Berning, MS, Office of Research and Traffic Records 

National Highway Traffic Safety Administration 

Mady Chalk, PhD, Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 

Gail Cooper, Administrator, Office of Public Health 

County of San Diego 

Pat Dischinger, PhD, National Study Center for Trauma 

University of Maryland 

Christopher Dunn, PhD, Department of Psychiatry 

University of Washington 

Marlene Echohawk, PhD, Division of Behavioral Health 

Indian Health Service 

Vivian Faden, PhD, Division of Biometry and Epidemiology 

National Institute of Alcohol Abuse and Alcoholism 

David Fiellin, MD, Department of Internal Medicine 

Yale University School of Medicine 

Laurie Flaherty, RN, MS, CEN, Office of Communications and Outreach 

National Highway Traffic Safety Administration 

Richard Fuller, MD, Division of Clinical and Prevention Research 

National Institute on Alcohol Abuse and Alcoholism 

6 Alcohol Problems Among Emergency Department Patients 
Valerie Gompf, MA, Impaired Driving Division 

National Highway Traffic Safety Administration 

Jim Helmkemp, PhD, Center for Rural Emergency Medicine 

West Virginia University 

John Higgins-Biddle, PhD, Department of Community Medicine 

University of Connecticut Health Center 

Kimberly Horn, EdD, Center for Rural Emergency Medicine 

West Virginia University 

Dennis Kelso, PhD 

Altam Associates, Inc. 

Janet Lassman, RN, BS 

Emergency Nurses Association 

Pat Lenaghan, RN, MS, CEN 

Emergency Nurses Association 

Guohua Li, MD, DrPH, Department of Emergency Medicine 

Johns Hopkins University 

Jacqueline Lloyd, PhD, MSW, Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 

Richard Longabaugh, EdD, Center for Alcohol and Addiction Studies 

Brown University 

Robert Lowe, MD, MPH, Center for Clinical Epidemiology and Biostatistics 

University of Pennsylvania 

Ann Mahoney, MPH, Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 

William Manley, RN, CEN, Center for Rural Emergency Medicine 

West Virginia University 

Mary McCue, RN, National Outreach Division 

National Highway Traffic Safety Administration 

Jane McDonald, MEd, CHEN, National Center for Injury 

Prevention and Control 

Centers for Disease Control and Prevention 

Paul McGann, Section on Gerontology and Geriatric Medicine 

Wake Forest University 

Sam McLean, MD, MPH, Department of Emergency Medicine 

University of Michigan 

Introduction 7 
Peter Monti, PhD, Center for Alcohol and Addiction Studies 

Brown University 

Alison Moore, MD, MPH 

University of California, Los Angeles 

John Moulden, President 

National Commission Against Drunk Driving 

Patricia Perry, PhD, RN, Research Foundation for Mental Hygiene 

New York State Office of Alcoholism and Substance Abuse Services 

Richard Ries, MD, Department of Psychiatry 

University of Washington 

Susan Rook, Public Affairs Director 

Step One Substance Abuse Services 

Peter Rostenberg, MD 

American Society of Addiction Medicine 

Jean Shope, PhD, MSPH, Transportation Research Institute 

University of Michigan 

Gordon Smith, MD, MPH, Center for Injury Research and Policy 

John Hopkins University 

Carl Soderstrom, MD, National Study Center for Trauma 

University of Maryland 

Marilyn Sommers, PhD, RN, College of Nursing 

University of Cincinnati 

Janet Williams, MD, Center for Rural Emergency Medicine 

West Virginia University 

8 Alcohol Problems Among Emergency Department Patients 
◆

◆

Recommendations for Alcohol Screening and 

Intervention in the Emergency Department 

Conference participants were given draft recommendations for review 

and discussion. The final recommendations that follow, approved by the 

Steering Committee, incorporate feedback from that discussion. The 

order in which these recommendations are presented does not imply 

level of priority or importance. 

◆ Research on screening and intervention should address the 

full spectrum of alcohol-related problems—from risky drinking 

to alcohol abuse and dependence—among ED patients. 

Alcohol-related problems occur across a continuum of severity––from 

social censure, injuries, or legal problems associated with episodic, 

excessive drinking to the more severe psychological, social, and medical 

conditions associated with alcohol dependence. Screening can identify 

patients with alcohol-related problems at various points along this 

spectrum. Intervention programs can also be designed to help patients 

wherever their problems lie on the spectrum and can vary from brief, 

on-site counseling provided by non-specialists to referral to intensive, 

off-site specialist care. The prevailing practice in EDs is to treat the 

presenting medical conditions of patients with obvious and severe 

alcohol-related problems, often without directly addressing the underlying cause. This emphasis tends to overlook individuals whose problems may be less severe but more amenable to intervention. Although 

it is reasonable for individual research studies to address particular 

segments of the severity spectrum or particular modes of service 

delivery, the portfolio of research in EDs should cover the full spectrum 

of care for alcohol-related problems—from preventive services for 

excessive drinking and associated injury risks to treatment for alcoholism and resulting complications. 

◆ Research on alcohol-related problems in other clinical settings 

has produced effective interventions. Future research should 

capitalize on this work by developing, implementing, and 

evaluating ED-based intervention studies. 

Recommendations for Alcohol Screening and Intervention 9 
◆

Interventions for patients with alcohol-related problems have been 

successful in a variety of clinical settings. Many ED patients should also 

respond favorably to such interventions. However, few interventions 

have been studied in ED settings. Research that adapts lessons learned 

in other clinical settings for use in the ED environment is a top research 

priority and should include cost-effectiveness studies. In operational 

terms, this means developing and implementing protocols in the ED 

that take appropriate elements from other clinical settings and enabling 

the unique characteristics of the ED and its patient populations to 

influence the design and development of new methods. In particular, 

protocols must address issues of large patient volumes, indifference or 

resistance from ED staff, and financial and time constraints. As feasible 

ED-based protocols are developed, evaluated, and refined, individualsetting and multi-center trials that evaluate efficacy and effectiveness 

will become the next research priority. 

◆ Future research on screening methods should evaluate the 

operational practicality of screening instruments in the context of protocols that provide interventions and referrals for 

alcohol treatment. 

To date, ED-based research on screening instruments has focused on 

performance characteristics. However, screening instruments with high 

marks for sensitivity and specificity will not be used if they are timeconsuming, expensive, unacceptable to patients, or difficult to use. In 

addition, studies have evaluated screening instruments in isolation from 

their intended use as the first step in a sequence that provides on-site 

interventions or referrals to patients with alcohol problems. Although 

acceptable levels of sensitivity and specificity remain important, future 

research should address feasibility issues in real-world settings. Which 

instrument is most acceptable to ED patients? To ED staff? Which 

instrument will enable the largest number of patients to be screened? 

Which instrument best helps the practitioner explain screening results 

and provide counseling? How long does it take to train practitioners to 

use screening instruments reliably? Which instruments can be easily 

integrated into protocols that provide on-site counseling? Which ones 

are best for protocols that only refer patients to off-site intervention 

10 Alcohol Problems Among Emergency Department Patients 
◆

◆

services? To the extent possible, future research on screening should not 

be divorced from efforts to provide interventions for patients with 

alcohol problems. 

◆ Programs that screen for and help patients with alcohol problems collect sensitive, patient-identifiable data. Research is 

needed to determine what effects public and private sector 

policies have on the confidentiality of these data and on 

program operations. 

Programs collect and share sensitive, patient-identifiable data for 

important clinical, research, and administrative purposes. Practitioners 

need to share data with other practitioners to ensure treatment during 

the current visit and in the future. Researchers need data to evaluate 

possible causal associations and devise effective interventions. Administrators need to share data to process payment for treatment. However, if 

practitioners and patients suspect that data will be misused, they will 

resist projects that collect it, placing projects that address alcohol problems in jeopardy. Also, laws in many states allow insurance companies 

to withhold payment for medical services provided to patients with 

alcohol-related trauma. In the private sector, many insurance policies 

prohibit or severely restrict payment for alcohol treatment. When public 

and private sector policies and practices do not fund services to identify 

and help patients with alcohol problems, physicians and administrators 

resist introducing those services. Research is needed to catalogue and 

evaluate public and private sector policies and practices that influence 

sharing of data and affect the viability of programs that screen and help 

patients with alcohol problems. 

◆ Research is needed to determine how cultural and demographic factors affect patients’ access to services for 

alcohol-related problems, delivery of those services in 

EDs, and patient outcomes. 

Studies of access to care for a wide range of health services indicate that 

patient factors such as age, gender, ethnicity, and language, as well as 

structural factors like how care is organized and who provides it are key 

determinants of who receives services and of patient outcomes. Some 

factors have been shown to facilitate access and others to impede it. 

Recommendations for Alcohol Screening and Intervention 11 
◆

◆

Similar lines of research are needed to improve our understanding of 

how best to deliver alcohol interventions in the ED. For example, studies 

are needed to help target interventions to different groups of at-risk 

patients and to identify which practitioners (e.g., physicians, nurses, 

social workers, prevention specialists) and practitioner characteristics 

(e.g., attitudes, training, work load) foster the best outcomes. 

◆ Research is needed on practice behavior, clinical guidelines, 

and policy changes required to implement, institutionalize, and 

maintain screening and interventions for alcohol problems in 

EDs inside and outside of academic medical settings. 

Private and public funds have supported individual research groups to 

demonstrate the efficacy and effectiveness of screening and interventions 

for alcohol problems in clinical settings other than the ED. Funding 

should be provided to implement similar research in EDs. However, 

knowledge that alcohol problems can be treated successfully in EDs is 

not sufficient to induce individual practitioners and institutions to 

change standards of practice. Therefore, future research should clarify 

how changes in clinical practice can be established and maintained at 

the individual practitioner and institutional levels. To assure broad 

applicability, implementation, acceptance, and institutionalization, 

this research should be designed and conducted in partnership with 

stakeholders outside academic medical settings. 

◆ Research is needed to explore and evaluate the role of information and communication technology in facilitating screening, intervention, and referral for alcohol treatment among ED 

patients. 

Most ED patients have time during their visit to be screened for alcohol 

problems and to receive an intervention. However, practitioners and 

administrators resist providing new services because ED staff have little 

time for additional duties, and ED budgets are too constrained to hire 

more staff. Technologies such as televisions, video and compact disc 

players, personal digital assistants, and computers with touch screens 

might provide new ways to overcome this mismatch between resources 

and problems. Because devices based on computer technology can 

handle complex algorithms easily, they could make it possible to tailor 

services to patients’ age, gender, reading ability, problem severity, 

12 Alcohol Problems Among Emergency Department Patients 
◆

and readiness to change their behavior. However, research is needed to 

develop their potential for screening, counseling, and referring ED 

patients with alcohol problems and to evaluate whether they are 

efficient and cost-effective. If ED patients are willing to use these technologies to address a range of problems, they could make preventive 

clinical services in the ED more acceptable to staff and administrators. 

If communications and information technologies demonstrate their 

value for addressing alcohol problems in the ED, they can be adapted 

and evaluated for use with other preventive clinical services. The potential to provide multiple services that improve patient care and decrease 

long-term costs could make it easier to find funding and justify research 

and start-up costs for new preventive services. 

◆ Funding agencies should increase support for research in 

screening and interventions for alcohol problems among ED 

patients and take steps to involve more ED physicians and 

nurses in research. 

The preceding seven research recommendations endorse a research 

agenda that will require substantial funding. Nonetheless, increased 

funding is justified because alcohol problems are so common in EDs 

that they consume an inordinate amount of ED resources. By addressing 

this pervasive risk factor, opportunistic interventions in EDs could 

simultaneously help untreated patients, prevent future alcohol-related 

harm, and decrease health system costs. Increased funding for research 

on alcohol interventions in EDs should also improve the quality of 

research in the larger fields of alcohol research and clinical preventive 

services research, particularly in the emergency care setting. At present, 

however, it is difficult to develop and evaluate protocols under realworld conditions because few emergency medicine researchers are 

involved. The field is so new that they are not aware of funding opportunities, procedures, and agencies. To address this situation, funding 

agencies need to actively recruit researchers from the field of emergency 

medicine and make mechanisms of research support better known to 

potential emergency medicine applicants. This effort should include 

communications focused on the funds currently available. In the long 

run, it should involve increased funding to address the research recommendations described previously. 

Recommendations for Alcohol Screening and Intervention 13 

Conference Proceedings


Introduction


Session 1


Session 2


Session 3


Session 4


Draft Recommendations

Introduction 

Daniel W. Hungerford, DrPH 

For as long as emergency medicine has existed, emergency physicians 

and nurses have encountered and helped patients with alcohol problems. 

However, because most alcohol problems are occult and screening is not 

routine, emergency department (ED) patients who have alcohol problems are not generally identified, offered on-site interventions, or 

referred to assistance outside the ED. Empirical research on the best ways 

to identify ED patients who have alcohol problems and the best ways to 

help them is a relatively new endeavor. Consequently, the primary goal 

of this conference is to identify research topics that need further study in 

order to improve interventions for ED patients with alcohol problems. A 

set of recommendations from prominent experts in the field should 

benefit organizations and individuals who design, fund, and implement 

such research. The conference and the recommendations will be an 

initial step toward a shared understanding of the kinds of research 

needed to improve interventions and increase the chance they will be 

broadly implemented. 

When practitioners contemplate using a new intervention, one of the 

first things they consider is whether research has demonstrated its 

efficacy. However, given prevailing conditions in EDs and the health care 

climate in the United States, they are unlikely to adapt new interventions 

on the basis of efficacy studies alone. Julius Richmond and Milton 

Kotelchuck developed a conceptual model

1

 that enhances our understanding of how research, public policy, and individual practice patterns 

interconnect (Figure 1). In this model, three factors—knowledge base, 

social strategy, and political will—interact to influence public policy. For 

the purposes of this conference, knowledge base, at its most basic level, 

represents accumulated, empirical evidence about which interventions 

for alcohol problems are efficacious and which ones are not. In addition 

to an understanding of efficacy at the clinical level, this knowledge base 

includes the social, economic, and health care delivery factors that 

influence alcohol problems and their treatment. Social strategy is a set of 

established goals and a plan for transforming the knowledge base into 

policies and practical programs that address alcohol problems efficiently 

and effectively in non-research settings. Political will is a measure of 

16 Alcohol Problems Among Emergency Department Patients 
institutional support for those policies and programs. Because official 

public policy represents the broadest expression of political will, influential constituencies try to shape political will and, hence, official public 

policy. 

From the perspective of physicians, research seems more directly 

associated with the knowledge base than with social strategy or political 

will. Naturally, a knowledge base exists primarily as the result of research 

activities. However, when research is expensive, a knowledge base will 

not emerge until the political will to support it is gathered. Even when a 

well-developed knowledge base does exist, it does not automatically 

translate into well-designed policies and efficient, broadly implemented 

programs that retain the efficacy of interventions performed in research 

settings. Translating the knowledge base into a social strategy for fostering widespread implementation of new services typically requires 

additional research. The Richmond-Kotelchuck model illustrates the 

interconnection of these three factors—their mutual influence on one 

another as well as on health policy. Although research is not an explicit 

component of the model, it is essential to the development and integration of all three of the factors that influence health policy. The goal of 

this conference is to consider the most important research needed in all 

three domains of the Richmond-Kotelchuck model. The presentations 

and discussions will attempt to identify the research topics required to 

improve the knowledge base, define better social strategies, and increase 

political will. 

The Richmond-Kotelchuck model clarifies the broad categories of 

research that are necessary to improve the practice of emergency 

medicine in caring for patients with alcohol problems. Another conceptual model introduced by Holder, Flay, and colleagues2

 characterizes 

the different phases of research as the focus changes from understanding etiology to evaluating potential interventions to implementing 

proven interventions. By categorizing research into five phases along a 

continuum—foundational, developmental, efficacy, effectiveness, and 

diffusion—this model facilitates the task of summarizing the current 

state of the knowledge base for specific interventions, evaluating the 

level of scientific support for them, and identifying gaps in the literature. 

For any particular disease, foundational research determines incidence 

or prevalence, identifies risk factors, and hypothesizes working causal 

Conference Proceedings 17 
models of the disease process. This process provides a working understanding from which to develop and test preventive measures or treatments. During the developmental phase of research, pilot or feasibility 

studies of interventions are implemented to evaluate outcomes, safety, or 

cost. During the efficacy phase of research, the central question becomes 

whether, under optimal conditions, the intervention can reduce, cure, or 

prevent the disease. Efficacy studies go to great lengths to ensure that 

patients receive uniform, high-quality treatment and that study conditions maximize patient compliance. They are ordinarily randomized 

controlled trials, so any improvement in patient outcomes can be 

attributed to the intervention. During the effectiveness phase of research, 

the fundamental research question shifts to how variations in implementation and acceptance influence patient outcomes. In medical 

settings outside academic institutions, interventions are implemented 

differently in response to different patient populations, different implementation staff, and different operational conditions related to the 

clinical setting. How much does variation in these factors influence 

intervention success? Diffusion research focuses on effectiveness as 

interventions become broadly disseminated as well as acceptance of 

interventions by practitioners and institutions who implement them. 

Although the phases of research model appears linear, research often 

proceeds at multiple levels simultaneously, particularly when research 

results are being translated from one clinical setting to another. Two 

types of research activities tend to occur in all phases: 1) developing and 

testing methods and 2) refining causal models and redefining the 

condition of interest. 

Together the two models are useful heuristics for identifying research 

issues a field must address in order to move forward and for placing 

those issues in a broader public health context. They also help us evaluate whether the scientific evidence for particular interventions and 

political and professional environments bode well for widespread 

dissemination. 

Research on alcohol problems has a long history as a field. However, 

research on alcohol problems among ED patients began relatively 

recently. During this conference, these conflicting realities will emerge 

repeatedly. Can screening and intervention methods proven efficacious 

in other medical and non-medical clinical settings be easily imported for 

use in EDs? This question must be addressed persuasively. If research is 

18 Alcohol Problems Among Emergency Department Patients 
to be translated into new practice patterns in EDs, those changes will 

require support from emergency nurses and physicians. They will not be 

convinced by successful research in primary care or community health 

settings. They will want to see successes with ED patient populations 

and in the unique clinical circumstances experienced in emergency 

medicine. Studies will have to succeed in the context of the realities of 

ordinary EDs. 

For the next three days, four sets of presentations will address the 

operational realities of the ED, the various ways patients with alcohol 

problems present to the ED, and the current state of our knowledge base 

about screening methods and interventions for ED patients with alcohol 

problems. After the presentations, we will discuss which research 

projects provide the most important opportunities to improve the 

practice of emergency medicine for patients with alcohol problems and 

increase acceptance of those practices. 

References 

1. Richmond JB, Kotelchuck M. The effects of political process on the delivery 

of health services. In: McGuire CH, Foley RP, Gorr A, Richards RW, editors. 

Handbook of the Health Professions Education. San Francisco: Jossey-Bass 

Publishers; 1983. p. 386–404. 

2. Holder H, Flay B, Howard J, Boyd G, Voas R, Grossman M. Phases of alcohol 

problem prevention research. Alcohol Clin Exp Res 1999;23(1):183–94. 

Conference Proceedings 19 
Figure 1.


The Development of Public Policy:


Three-Part Health Policy Model


Political 

Will 

Social 

Strategy 

Knowledge 

Base 

Public 

Policy 

Source: Richmond and Kotelchuck, 1983, p.386. 

20 Alcohol Problems Among Emergency Department Patients 
Session 1.


The Spectrum of Alcohol Problems and the


Scope of Emergency Medicine Practice


Ronald F. Maio, DO, MS* 

Rebecca E. Cunningham, MD 

The economic cost of alcohol problems in the United States is stagger­


ing, amounting to $184.6 billion in 1998.1

 These costs include the acute


and long-term physical effects of alcohol use. Although no area of


medicine is immune from addressing the effects of alcohol misuse,


emergency medicine physicians are in the unique position of seeing the


full spectrum of the acute and chronic health problems associated with


alcohol use. Some of these problems arise secondary to acute alcohol


use, such as injury, while others may present acutely but are secondary to


underlying disease from chronic alcohol use, such as hepatic failure


secondary to cirrhosis.


The Centers for Disease Control and Prevention has convened this


meeting to discuss the role that the emergency department (ED) might


play in identifying problem drinking and intervening. An integral part


of this meeting is the commission of several papers to address the issue.


This paper will serve as a broad overview of the range of alcohol prob­


lems seen in the ED and the scope of emergency medicine in addressing


these problems. It will “set the stage” for subsequent papers by answer­


ing the following questions: What are alcohol problems? How do


patients with alcohol problems present to the ED? How do ED physi­


cians and staff handle these patients? What are the implications for


future research?


What are alcohol problems?


In the Institute of Medicine’s Broadening the Base of Treatment for


Alcohol Problems, alcohol problems are defined broadly and simply as


those problems that may arise in individuals around their use of alco-


hol.2 “Use of alcohol” specifically refers to the pattern of alcohol con­


sumption: how much, and how often. Alcohol use or consumption is


often defined as the number of standard drinks, over a certain period


* Presenter 

Spectrum of Alcohol Problems 21 
of time. It ranges from no use, or abstinence, to heavy use. As consumption increases, so does the risk for problems. The National Institute on 

Alcohol Abuse and Alcoholism (NIAAA) at the National Institutes of 

Health has set guidelines for determining the levels of consumption at 

which drinkers are at increased risk to develop alcohol-related problems: 

for men, on average, that level is no more than two drinks per day or no 

more than four drinks per occasion; for women, on average, no more 

than one drink per day or no more than three drinks per occasion.3 

Drinkers who exceed this recommended level of consumption are 

considered to be engaging in “risky” drinking or are “at-risk drinkers.” 

Alcohol problems are adverse consequences of drinking and can be 

defined in three different dimensions: type, severity, and duration. The 

type of problem can be physical, such as coma from alcohol intoxication; emotional, such as depression or anxiety disorder; or social, such 

as being late to work because of a previous night of being sick due to 

excessive drinking. Just as alcohol consumption varies from none to 

heavy, alcohol problems fall along a spectrum from none to severe— 

ranging from problems that cause temporary discomfort, such as 

nausea and vomiting following excessive consumption of alcohol, to 

those that can be life-threatening, such as severe multi-system trauma 

that is experienced by an intoxicated driver involved in a motor vehicle 

crash. 

Alcohol problems can also vary in duration: acute, such as the 

21-year-old who becomes intoxicated during her first experience with 

alcohol; intermittent, such as the individual who goes on a binging 

episode during the holidays; and chronic, such as the business executive 

who drinks a fifth of scotch a day and has recurrent pancreatitis. 

Chronic excessive alcohol use can also result in dependence or alcoholism. This diagnosis is made by considering both the specific manner 

of alcohol use and the specific types of consequences that the person is 

experiencing. 

Individuals who develop alcohol problems usually go through a 

sequence, starting with alcohol use, followed by risky drinking, then 

experiencing alcohol-related problems and for some, alcohol dependence. This progression, however, does not always occur in a linear 

progressive fashion.

4

 It is possible for an individual to have a serious 

consequence from his or her first use of alcohol. Furthermore, it is 

22 Alcohol Problems Among Emergency Department Patients 
possible for some alcohol-related problems, such as pancreatitis or 

cirrhosis, to persist even if an individual stops drinking. Because of 

the strong relationship between the level of alcohol consumption and 

alcohol problems, risky drinking is considered by many to be a 

“problem” itself, or more precisely, a problem in regard to pattern of 

alcohol use. Thus, patients with alcohol problems include both those 

who drink at risky levels and do not experience adverse consequences 

and those who drink at risky levels and do experience adverse consequences of risky alcohol use, including dependence. 

How do patients with alcohol problems present to the ED? 

Individuals with alcohol problems may present to the ED for medical 

problems directly related to their alcohol use or for medical complaints 

that have nothing to do with their alcohol use. Furthermore, some 

patients present in a manner that makes their alcohol problems readily 

apparent, while others may present in a manner that does not suggest 

alcohol problems. The following cases illustrate these points. 

John is a 25-year-old automobile mechanic who usually drinks one or 

two beers a day during the week, but on the weekends he goes through 

three or four six-packs of beer. He may present to the ED in one of 

several ways. 

Case #1: 

Chief complaint alcohol-related 

Patient with obvious alcohol problem 

After drinking all night with his friends, John drives off 

the road and into a tree. 

ED Presentation: Saturday 2 a.m.: 25-year-old driver in a motor 

vehicle crash; open fractured femur; altered 

mental status; alcohol smell on breath; open, 

empty beer cans found in car by paramedics. 

Blood pressure 90/50 and pulse 140. 

Spectrum of Alcohol Problems 23 
Case #2: 

Chief complaint alcohol-related 

Patient with not-so-obvious alcohol problem 

Very early Sunday morning, after drinking all night and 

still intoxicated, John and his friends decide to play flag 

football on a dark, muddy field. John takes numerous 

tumbles. On Sunday afternoon he wakes up to find his 

ankle swollen and painful. He ices and elevates it with 

some relief. He goes to work on Monday and has a very 

difficult time because of pain. He finishes the workday 

but is so uncomfortable he decides to go to the emergency 

department. 

ED presentation: Monday 6 p.m.: 25-year-old male, chief 

complaint of ankle pain; twisted ankle while 

playing flag football over the weekend. 

Case #3: 

Chief complaint not alcohol-related 

On Wednesday, John develops ear pain. The pain persists, 

and he develops a low-grade fever. His primary care doctor 

has no appointments available until next week; he suggests 

John go to the ED. 

ED presentation: Friday 11 a.m.: 25-year-old male, chief 

complaint of right ear pain and low-grade 

fever. 

24 Alcohol Problems Among Emergency Department Patients 
How do emergency medicine physicians and staff handle 

alcohol problems? 

How a patient’s acute or chronic alcohol use influences what the ED 

physician does for the patient is related to the nature of the complaint 

(injury or non-injury), its severity, and the disposition of the patient. 

Following are examples of how ED physicians would address the 

alcohol problems of the hypothetical patient presented in the previously 

described case scenarios. 

In Case #1, John’s drinking is clearly evident to anyone taking care of 

him. While alcohol intoxication might indeed be one factor responsible 

for his altered mental status, his condition indicates significant injury, 

which could very likely include traumatic brain injury. Whether or not 

John has been drinking, or the nature of his routine use of alcohol, has 

little effect on his immediate evaluation and treatment. If John had not 

been drinking, and his medical presentation was exactly the same, his 

evaluation and treatment would remain the same. Unfortunately, a 

substantial number of emergency physicians and trauma surgeons 

would not even consider how obtaining a blood alcohol concentration 

(BAC) could facilitate addressing a patient’s problematic alcohol use in 

the recovery and rehabilitation phase.4–6 In fact, the American College 

of Surgeons Committee on Trauma has recently removed laboratory 

testing for alcohol and drug use as essential testing for the trauma 

patient.7

 Furthermore, most ED physicians and trauma surgeons would 

not consider asking John any questions to determine how he was using 

alcohol.4–6 

If John’s injuries after the crash were not so obviously severe, how 

would his alcohol use affect what is done for him in the ED? Let’s assume 

that everything about John’s crash and presentation is the same except 

that his vital signs are normal, he has no clinical signs of fracture, and he 

is only slightly disoriented. The initial impression of the ED physician is 

that there is a very low likelihood that John will have to be admitted to 

the hospital. However, the ED physician may elect to get a BAC to gain 

some insight into John’s altered level of consciousness. If the BAC is 

substantially elevated, alcohol may help explain this disorientation. Yet, 

even if the BAC is elevated, it would not preclude a concomitant brain 

injury. If John’s BAC is elevated, the ED physician and nursing staff 

would want to make sure that siderails are up on gurneys to prevent 

falling and that the patient is assisted in going to the bathroom, lab, 

Spectrum of Alcohol Problems 25 
or X-ray. Furthermore, the ED physician would want to insure that John 

is not discharged from the ED until he is completely sober or can be 

assisted and observed at home by friends and family. Unfortunately, 

the overwhelming odds are that no one in the ED will address John’s 

drinking behavior. As few as 15% of ED patients with obvious alcohol 

problems ever have their drinking behavior addressed while in the ED 

or through an ED referral for problem drinking.

4,5 

For the patient in Case #2, the ED physician would do a focused 

history and physical exam. It is very unlikely that any questions would 

be asked about risky health behaviors such as drinking or smoking. The 

patient’s acute use of alcohol at the time of injury or his regular use of 

alcohol will play no role in how the ED physician evaluates and treats 

the patient for a sprain or fracture. Furthermore, it is very unlikely that 

the patient would volunteer information that he was intoxicated when 

the injury occurred. Even if the information was volunteered, based on 

previously cited ED studies,4,5 it is very unlikely that the ED physician 

would address the patient’s use of alcohol. 

In Case #3, the ED physician would do a focused history and physical 

exam. In this presentation also, it is very unlikely that the ED physician 

would solicit any information about John’s use of alcohol. It is also very 

unlikely that John would ever say anything about his alcohol use because 

it is unrelated to the problem for which he came to the ED. Furthermore, 

it is extremely unlikely that the ED physician would address John’s 

drinking behavior even if it was revealed during the patient encounter. 

These case scenarios illustrate that the clinical imperative of the 

emergency medicine physician is “treat ‘em and street ‘em.” The main 

mission is to deal with the patient’s chief complaint. No emergency 

physician would ever question the appropriateness of addressing the 

patient’s alcohol consumption or alcohol problems if they were immediately relevant to the evaluation, treatment, and disposition of the patient. 

But the focus is on treatment of the chief complaint, not long-term 

modification of health behaviors or disease or injury prevention. 

Emergency medicine’s first concern for the patient is whether or not 

there is an immediate threat to life. If the patient is not breathing or has 

no pulse, whether the patient has recently ingested alcohol or has an 

alcohol problem will have essentially no effect on the manner of intervention the ED physician chooses. Once immediate threats to life are 

ruled out or treated, the ED physician next wants to obtain information 

26 Alcohol Problems Among Emergency Department Patients 
that is relevant to the evaluation, treatment, and disposition of the 

patient. What is important to the ED physician about the patient’s 

alcohol use is how it may influence these three activities. The initial 

concern is the acute alcohol use status of the patient. This is particularly 

relevant for patient and staff safety issues. Furthermore, extensive testing 

may be required because of inability to obtain an appropriate history or 

because acute alcohol effects mimic other pathology. Finally, disposition 

may be affected by the patient’s inability to drive safely, or even walk, 

because of intoxication. 

There are additional reasons for ED physicians’ not addressing a 

patient’s alcohol problem in depth. One reason is ignorance. When 

many ED physicians hear the words “alcohol problems” they think 

“alcoholic”: the disheveled, homeless, intoxicated patient. They are not 

aware of the spectrum of alcohol use and its associated problems. They 

are also not aware that a substantial percentage of their patients may be 

using alcohol in a risky fashion, even if those patients present with 

problems that are not obviously alcohol related. Furthermore, many 

ED physicians are not aware of research that shows that brief interventions for drinkers with alcohol problems can be effective and can be 

delivered in the acute care setting.

8 

Another reason the ED physician does not address a patient’s alcohol 

problem in depth is attitude. Many think that alcoholism or heavy 

drinking is not something to be treated, but something to be overcome 

by the patient, or that the ED is not an appropriate place to conduct 

interventions.9

 Lack of time and lack of support are also important 

issues. Even ED physicians who support interventions to change drinking behaviors among ED patients do not think they or the staff has the 

time or expertise to deal with alcohol problems.9

 Furthermore, they 

often wonder, “Who is going to pay for this?” Thus, in general, the ED 

physician is concerned with addressing the consequences of the patient’s 

alcohol problem, but not the alcohol use that leads to the problem. 

However, action is being taken that may eventually help to change 

ED physicians’ perspectives and attitudes. Academic leaders, through 

the Society of Academic Emergency Medicine and clinical leaders in 

the American College of Emergency Physicians (ACEP) have urged 

ED physicians to integrate a public health approach into their practice, 

which includes addressing patients’ use of alcohol.9–15 

Spectrum of Alcohol Problems 27 
Many ED patients do not have access to primary care physicians for 

prevention, and many primary care providers do not provide preventive 

services. Furthermore, the ED visit is now seen as a teachable moment 

during which preventive services may be particularly effective.9–10 

Also, ACEP has already published policies on primary injury 

prevention, alcohol abuse and motor vehicle safety, and substance 

abuse education.13–15 

Implications for future research 

The purpose of this conference is to consider the role of the ED in 

identifying patients currently experiencing or at risk for alcohol-related 

problems and in delivering appropriate interventions. Subsequent 

presentations in the conference will address the issues of screening, 

intervention, and implementation, and the research issues that surround 

these topics. We must answer these questions: What types of patients do 

we want to identify? How do we identify them? Which interventions are 

effective in the ED? Who will deliver these interventions? Who will pay 

for these interventions? Are these interventions cost-effective compared 

with interventions in other venues? What will it take to implement 

effective screening and intervention strategies nationwide? We must 

also address knowledge-based deficiencies or attitudes, which may be 

obstacles to widespread implementation of efficacious research, and 

explore strategies such as resident training and post-graduate education 

to overcome these obstacles. 

The research agenda that results from this conference must acknowledge the logistic realities of the ED. If an intervention targets a substantial proportion of ED patients, such as patients who exceed the NIAAA 

guidelines for drinking, then that intervention should be compatible 

with the physical realities of the way emergency medicine is currently 

practiced. It seems unreasonable, given today’s extremely busy ED staff, 

to anticipate that current staff alone can screen and intervene for a 

problem that affects 20% or more of patients without a substantial 

increase in resources.16,17 

Regardless of the specific issues that need to be addressed, any research 

agenda that is developed must be based on an integrative approach. We 

must remember that the ED does not operate in a vacuum (Figure 1). 

Our colleagues in surgery, internal medicine, adolescent medicine, and 

28 Alcohol Problems Among Emergency Department Patients 
psychiatry also have to treat patients with a wide range of alcohol problems. Perhaps joining forces with them may be one way to overcome 

logistic difficulties. It also must be noted that it is not just those in the 

health care arena who have to address alcohol problems, but also social 

service workers, workplace supervisors, and law enforcement personnel. 

The ED is the 24/7 interface with the hospital and the community and is 

there as a safety net when other community resources fail. Strategies 

need to be developed so that the ED can work with the community to 

optimize interventions for alcohol problems. 

Alcohol problems are not only an ED problem, but also a major 

societal problem. Emergency medicine has a major role to play in 

society’s response to that problem. 

References 

1. National Institute on Alcohol Abuse and Alcoholism. The economic costs of 

alcohol abuse. In: Special Report to the U.S. Congress on Alcohol and Health; 

Highlights from Current Research. Washington (DC): U.S. Department of Health 

and Human Services; 2000. p. 364–71. NIH Publication No. 00–1583. 

2. Committee for the Study of Treatment and Rehabilitation Services for 

Alcoholism and Alcohol Abuse, Institute of Medicine, Division of Mental 

Health and Behavioral Medicine, National Academy of Sciences. Broadening 

the Base of Treatment for Alcohol Problems. Washington (DC): National Academy 

Press; 1990. 

3. National Institute on Alcohol Abuse and Alcoholism. The Physician’s Guide to 

Helping Patients with Alcohol Problems. Washington (DC): U.S. Department of 

Health and Human Services; 1995. NIH Publication No. 95–3769. 

4. Lowenstein SR, Weissberg MP, Terry D. Alcohol intoxication, injuries, and 

dangerous behaviors—and the revolving emergency department door. J Trauma 

1990;30(10):1252–8. 

5. Cherpitel CJ, Soghikian K, Hurley LB. Alcohol-related health services use and 

identification of patients in the emergency department. Ann Emerg Med 1996; 

28(4):418–23. 

6. Danielsson PE, Rivara FP, Gentilello LM, Maier RV. Reasons why trauma 

surgeons fail to screen for alcohol problems. Arch Surg 1999;134(5):564–8. 

Spectrum of Alcohol Problems 29 
 7. Committee on Trauma, American College of Surgeons. Resources for Optimal 

Care of the Injured Patient: 1999. Chicago (IL): American College of Surgeons; 

1998. 

8. Graham DM, Maio RF, Blow FC, Hill EM. Emergency physician attitudes 

concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report. J Addict Dis 2000;19(1):45–53. 

9. Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency 

department, part I: clinical preventive services—are they relevant to emergency 

medicine? Society for Academic Emergency Medicine, Public Health and 

Education Task Force, Preventive Services Work Group. Acad Emerg Med 2000; 

7(9):1036–41. 

10. Babcock Irvin C, Wyer PC, Gerson LW. Preventive care in the emergency 

department, part II: clinical preventive services—an emergency medicine 

evidence-based review. Society for Academic Emergency Medicine, Public Health 

and Education Task Force, Preventive Services Work Group. Acad Emerg Med 

2000;7(9):1042–54. 

11. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 1: 

improving detection. SAEM Substance Abuse Task Force. Society for Academic 

Emergency Medicine. Acad Emerg Med 1998;5(12):1200–9. 

12. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 2: 

intervention and referral. SAEM Substance Abuse Task Force. Society for 

Academic Emergency Medicine. Acad Emerg Med 1998;5(12):1210–7. 

13. Alcohol Abuse and Motor Vehicle Safety. American College of Emergency 

Physicians. [Policy 400195]:Approved January 1998. 

14. The Role of the Emergency Physician in Injury Prevention and Control. 

American College of Emergency Physicians. [Policy 400197]:Approved 

March 1998. 

15. Substance Abuse Education. American College of Emergency Physicians. 

[Policy 400265]:Approved March 1999. 

16. Cherpitel CJ. Screening for alcohol problems in the emergency department. 

Ann Emerg Med 1995;26(2):158–66. 

17. Maio RF, Waller PF, Blow FC, Hill EM, Singer KM. Alcohol abuse/dependence 

in motor vehicle crash victims presenting to the emergency department. 

Acad Emerg Med 1997;4(4):256–62. 

30 Alcohol Problems Among Emergency Department Patients 
Figure 1.


Alcohol Problems and the Emergency Department:


A Collaborative Approach


Community Hospital 

Emergency 

Department 

Social Work 

Trauma Surgery 

Internal Medicine 

Psychiatry 

Adolescent Medicine 

Police Businesses EMS Community Physicians Community Social Services Specialized Treatment Centers 

Spectrum of Alcohol Problems 31 
Screening and Intervention for Alcohol Problems


in the Emergency Department:


Ideal Versus Reality


Jeffrey W. Runge, MD 

As part of this introductory session, it will be helpful if we are all “on the 

same page,” regardless of our backgrounds. The audience is composed 

of people from emergency medicine, the psychological and psychiatric 

communities, the treatment community, and the regulatory agencies. 

We all have different perspectives on the issue. That we have to hold a 

meeting on screening and intervention in the emergency department in 

the first place suggests a problem. If screening and intervention are such 

good ideas, why isn’t everyone doing them? 

Treating alcohol-use problems has obvious public health and societal 

benefits. Successful treatment of alcohol abuse and dependency is well 

recognized to be beneficial not only for the individuals who have the 

disease, but also for virtually everyone in their families, at their workplaces, and on the road. Why should emergency medicine physicians be 

involved in screening and intervention for alcohol problems? Because it 

is good for patients, it is good for society, and physicians have a moral 

imperative to treat disease. 

Emergency physicians are frequently the only doctors some people 

will ever see. We see patients at their worst, usually with illnesses or 

injuries that denote obvious risk factors for further illness or injury, 

and those factors should be addressed. We do the same for other disease. 

We would never consider sending anyone with stable angina out of the 

emergency department if they had blood pressure or diabetes that was 

out of control. We would never send a child out of the emergency 

department with an intentional injury without a full investigation of 

the social risk factors. Yet, it is commonplace to discharge people with 

stable pancreatitis, alcoholic gastritis, and motor vehicle trauma 

without attention to the underlying risk factor of alcohol abuse or 

dependency. 

Numerous studies have been published over the last 15 years documenting that injured drivers impaired by alcohol are not charged or 

convicted for driving while impaired. A brief review of the literature 

32 Alcohol Problems Among Emergency Department Patients 
reveals at least 14 studies conducted since the mid-1980s with prosecution rates between 0% and 30%, and usually only around half of those 

are convicted of driving while intoxicated. While most of those studies 

were conducted on admitted patients in trauma centers, the study by 

Runge et al.1

 looked at ED patients, regardless of admission or discharge. 

We found that in this group, only 28% of drivers were charged with 

DWI and 17% were convicted, even though the average blood alcohol 

concentration in this population was more than 0.20 g/dl. Many physicians, therefore, have become complacent about directing attention 

towards alcohol problems of drivers, since law enforcement and society 

at large do not choose to act. 

Other tactics have been advocated to intercede with these individuals. 

In a study by Runge et al.,2

 2,787 patients who were seen in the ED 

following a motor vehicle crash were screened for alcohol use problems 

using the TWEAK screening instrument. Of them, nearly 14% screened 

positive for high risk of alcohol abuse or alcohol dependency. These 

patients were randomized 1:1 to receive either a brief intervention in the 

emergency department or only a follow-up phone call in three and six 

months. Of those who received the intervention, 28% agreed to further 

evaluation for alcohol use problems, and 72% refused. Of those who 

agreed to an evaluation, 49% actually received follow-up by alcohol 

treatment professionals, a follow-up rate 20 times that of controls or 

those who refused evaluation. Although long-term follow-up data from 

this group is not available, this study does show that screening patients 

for alcohol use disorders and using a brief intervention for those at risk 

resulted in a follow-up rate much higher than the current U.S. standard 

of practice. 

The American College of Emergency Physicians, the Emergency 

Nurses Association, and the National Highway Traffic Safety 

Administration are currently preparing a set of recommended practices 

for physicians, nurses, and paramedics with respect to alcohol use 

disorders. Although these are not yet published and available for 

dissemination, screening and intervention are recommended as part of 

standard practice to detect patients with alcohol use disorders. (Editor’s 

note: These recommendations are now available online at http:// 

www.nhtsa.dot.gov/people/injury/alcohol/EmergCare/index.htm.) 

If screening and intervention are effective, why are they not part of the 

standard of care for emergency medicine, emergency nursing, or other 

Spectrum of Alcohol Problems 33 
specialities that deal with high-risk patients? The reality is that each 

patient intervention, whether it is looking in an ear or performing a 

spinal tap, requires time. Time is the currency that determines whether 

patients are generally satisfied with their ED visit. Patient satisfaction 

surveys from across the country uniformly show that time spent waiting 

for treatment and overall time spent in the ED are directly related to 

patients’ perceptions of quality of service. This affects marketability, 

morale of the physicians and staff, and the economic survivability of 

EDs. Remuneration for physicians and hospitals is based on the “level of 

service” provided to each patient and on patient volume. Any time spent 

on interventions that are not reimbursable, do not increase the level of 

service, or do not reduce patient flow negatively affects the economics of 

the emergency department. Currently, there is no procedure billing code 

that is reimbursable for screening and intervention in the ED, in spite of 

the patient’s need for it or its obvious advantages. 

There are other barriers to the performance of screening and intervention. Many physicians have encountered insurance companies that 

refuse to reimburse for services required because of injury that occurs 

while the patient is under the influence of alcohol. Therefore, there has 

been a disincentive to even collect blood alcohol levels or to mention 

alcohol intoxication on the medical record. Many emergency departments in this country have no referral destination for a patient who 

screens positive, irrespective of the patient’s willingness to enter into 

evaluation or treatment. 

An informal survey of physicians indicates that there is relatively little 

confidence in the “cure” for alcohol use disorders among the patient 

population seen in the ED. This may be due in part to the perception 

that those who require treatment are limited to the “street drunk” or the 

incorrigible patient with long-standing disease who frequents the ED. 

Many physicians do not understand that many patients who are sober 

and otherwise motivated to be healthy also have treatable alcohol 

problems. 

Emergency departments in many hospitals were not constructed with 

patient privacy in mind. Often, only a curtain separates gurneys, if that, 

making it difficult to have a conversation with a patient that would make 

screening and intervention feasible in such a setting. 

34 Alcohol Problems Among Emergency Department Patients 
Another problem is physicians’ overall lack of familiarity with screening tools and how to perform a brief intervention in the ED, because it 

is not part of standard medical curricula. Physicians have questioned 

whether some common screening tools are overly sensitive for use in the 

ED and constitute an unnecessary intrusion for patients. For example, 

the alcohol intake questions recommended by the National Institute on 

Alcohol Abuse and Alcoholism may be overly sensitive and not very 

specific for a problem that requires treatment, and the lifetime consumption history that one gets with the CAGE test results in too many 

positive screens. Many physicians are also troubled by screening that is 

used on patients who do not have physical sequelae of alcohol problems 

or may present with an unrelated problem, such as a sprained ankle, and 

the appropriateness of entering into a discussion about alcohol use in 

that setting. 

There are other imperatives that consume the day of an emergency 

physician, such as taking good care of the other three patients per hour 

who are in the waiting room, spending inordinate amounts of time on 

the phone with consultants, solving administrative problems, and the 

myriad of interruptions that occur minute-to-minute during a shift in 

the emergency department. Therefore, adding another imperative may 

not be well accepted. 

In summary, screening and intervention in the emergency department 

will probably never be part of the standard practice until: 

● The process is made streamlined and efficient; 

●	 It is recognized as part of the provision of good care and is 

consequently reimbursed by insurers; 

●	 Screening intervention tools that are sensitive, specific, and 

brief become part of the standard medical curriculum; and 

●	 The existing societal and economic disincentives are 

removed for seeking out this illness for potential treatment. 

Spectrum of Alcohol Problems 35 
References 

1. Runge JW, Pulliam CL, Carter JM, Thomason MH. Enforcement of drunken 

driving laws in cases involving injured intoxicated drivers. Ann Emerg Med 1996; 

27:66–72. 

2. National Highway Traffic Safety Administration. Developing Best Practices 

of Emergency Care for the Alcohol-impaired Patient: Recommendations from 

the National Conference. Washington (DC): National Highway Traffic Safety 

Administration; 2000. 

36 Alcohol Problems Among Emergency Department Patients 
A Commentary on Substance Abuse Screening and 

Intervention in the Emergency Department 

David C. Lewis, MD 

My compliments to Ronald Maio on an outstanding presentation about 

which I have no disagreement. Yes, the teachable moment is a real asset 

in the emergency department, where crisis makes the patient more 

attentive and less grasping of denial. 

I want to reflect on the presentations of Drs. Maio and Runge by 

looking at some of the structural issues that influence screening and 

intervention in the emergency department. But first, I propose a motto 

for this conference: “Make screening (and intervention, if indicated) 

for alcohol problems in emergency departments a vital sign.” In other 

words, screening should be routine, not performed only when problems 

are suspected. 

Two fundamental medical facts bear on this issue. First, drinking 

problems present themselves in many ways and can masquerade as 

other surgical and medical problems. Therefore, it is commonplace to 

miss the drinking diagnosis and to treat the complications. How can 

we tolerate a medical practice that focuses on treating complications 

when the treatable underlying condition goes undiagnosed and 

untreated? That we do raises fundamental medical, public health, 

ethical, and legal issues. 

The second medical fact germane to this discussion is the importance 

of drug interactions in emergency assessment and care. Clearly, ethanol 

interacts in important ways with prescription, over-the-counter, and 

illegal drugs. I believe that you can justify taking a routine drinking 

history to assess the role of ethanol/drug interactions in the emergency 

care setting. 

Turning now to the structural issues that influence emergency 

screening and intervention practice, I use two illustrations. Figure 1 is 

modified from the National Academy of Sciences, Institute of Medicine 

report Broadening the Base of Treatment for Alcohol Problems.

1

 That 

report not only emphasizes the heterogeneity of alcohol problems, but 

also sets forth a public health model of screening and intervention in 

many settings, including prisons, workplaces, schools, and health care 

Spectrum of Alcohol Problems 37 
settings. The study also recommends a social and professional support 

structure that, if implemented, would make emergency department 

screening and intervention less unique and conceptually easier. 

Figure 2 illustrates the ways in which training, expectations, and the 

environment interact to influence health outcomes. Each component is 

important. For effective care, we must take into account the social 

context in which training occurs; the personal perspective that medical 

students, residents, and attending physicians bring to the clinical task; 

the role models we empower as mentors and teachers; and the acquisition and application of essential knowledge and skills. 

As for more support from the surrounding medical culture, I think 

that we should fundamentally change primary care practice, a setting 

that should facilitate alcohol screening and intervention. I think we have 

been much too patient with the performance of the primary care system. 

It is very frustrating for those of us who have worked in medical education to see the low screening rates for alcohol problems persist year after 

year. More than 100 articles document need for and barriers to addressing these problems in the context of routine medical care. Primary care 

practices should routinely screen and intervene for alcohol problems 

rather than screen at the current rate of 20% to 30%. 

And how do we change the system? One problem we have is that we 

focus too much on barriers, and not enough on incentives. There are 

efforts that seek to focus on incentives that I believe will be of interest to 

this conference. One is a project by a group called Physician Leadership 

on National Drug Policy.

2 Called “Project Vital Sign,” it seeks to lay the 

groundwork for a national clinical demonstration on screening and 

intervention in clinical practices. While not limited to alcohol problems, 

the goal of this demonstration is a major expansion in the screening, 

diagnosis, intervention, and referral of individuals with alcohol, tobacco, 

and other drug problems. The strategy is for states to collaborate with 

health care organizations to design and implement the proposed 

national demonstration. A key informant study is underway, which will 

include several participants from this conference. 

Another initiative is sponsored by Join Together, a national communication and networking resource for communities. Called 

“Demand Treatment,” this project, located initially in 16 cities, engages 

community activists and a diverse group of professionals in order to 

build consumer demand for substance abuse treatments.3

 Some of the 

38 Alcohol Problems Among Emergency Department Patients 
“Demand Treatment” sites have concentrated on emergency department 

screening and intervention. (Editor’s note: The website was launched in 

April 2001 and can be accessed at http://www.alcoholscreening.org. It 

had about 20,000 visits in its first three months.) This use of electronic 

technology is another example of educating the public in a way that 

should facilitate addressing alcohol problems in the ED. These projects 

are examples of initiatives that will improve the context in which increased attention to alcohol problems in emergency department settings 

can occur. 

Finally, in developing the research agenda, it is important to identify 

factors that facilitate or impede translating research into practice in the 

emergency department and to study the incremental costs for screening 

and intervention—particularly the intervention and referral process in 

emergency departments. 

References 

1. Committee for the Study of Treatment and Rehabilitation Services for 

Alcoholism and Alcohol Abuse, Institute of Medicine, Division of Mental Health 

and Behavioral Medicine, National Academy of Sciences. Broadening the Base of 

Treatment for Alcohol Problems. Washington (DC): National Academy Press; 

1990. 

2. Physician’s Leadership on National Drug Policy (PLNDP). Available from: 

URL: http://caas.caas.biomed.brown.edu/plndp. 

3. Join Together Online. Available from: URL: http://www.jointogether.org/ 

home. 

Spectrum of Alcohol Problems 39 
CONTINUITY OF CARE 

Health 

Care Schools Criminal 

Justice 

Workplace Social Agencies 

Modality and 

Setting #1 

Modality and 

Setting #2 

Modality and 

Setting #3 

Modality and 

Setting #4 

Modality and 

Setting #5 

Identification and 

Brief Inter

vention 

Inter

vention 

and 

Treatment 

Assessment 

Feedback Outcome Follow-up 

Community 

Treatment 

Community 

Treatment 

Specialist 

Treatment 

Specialist 

Treatment 

Assessment and Treatment of Substance Abuse


in Primary Care Settings


Figure 1.


 CARE O F CONTINUITY 

40 Alcohol Problems Among Emergency Department Patients 
Figure 2.


Equation for Effective Health and Medical Care


Acceptance Trained of need to health care care for professionals alcohol and +/- and 

other drug intervention 

problems workers 

+/-

Outcome of 

+	 x + = intervention 

and treatment 

Effective and Environment 

suitable early where early 

intervention +/- intervention 

and treatment and treatment methods occurs 

+/-

Spectrum of Alcohol Problems 41 
General Discussion 

David Lewis started the discussion by noting that additional training for 

medical staff on screening and interventions for alcohol problems is not 

adequate to change the stigma and attitudes that shape practitioners’ 

interactions with patients. However, since the evidence of intervention 

efficacy has grown more compelling, training can influence “the surrounding professional culture [that] will affect what is supported and 

financed.” 

Daniel Pollock noted that the presentations covered five general areas: 

the spectrum of alcohol problems; the schematic diagram and concepts 

that emerged from the IOM report, Broadening the Base of Treatment for 

Alcohol Problems; the scope of emergency medicine practice; the way 

alcohol-related problems are recognized or overlooked in the ED; and 

obstacles to changing emergency medicine practice. 

John Moulden asked how interventions the conference speakers agree 

are efficacious could be more broadly implemented “given that the 

major physician organizations are not supportive of recommendations 

to make them standard.” 

Lewis pointed out the risk of having physicians who could benefit 

financially be the major proponents for change. He maintained that 

changes can occur more readily if support also comes from other 

interested parties such as the business community. 

Jeffrey Runge noted that the National Highway Traffic Safety Administration collaborated with the American College of Surgeons and the 

American College of Emergency Physicians “to develop a set of normative statements for emergency nurses, emergency physicians, trauma 

surgeons, and paramedics that assert that screening and intervention are 

part of the ED’s roles.” He noted, however, that most acute care physicians still believed that alcohol treatment is “futile care.” 

This led to a discussion of the mission of EDs and the role of emergency 

physicians in providing care for patients with alcohol-related problems. 

David Fiellin speculated that a systems-wide approach was required. 

42 Alcohol Problems Among Emergency Department Patients 
Ronald Maio agreed because the alcohol problems of injured patients 

admitted to the hospital are often overlooked by both ED and trauma 

staff. 

Pollock asked whether Fiellin was referring to a system of preventive 

care or a broader system that would encompass multiple specialities and 

settings. 

Fiellin replied that he envisioned certain tasks being assigned to specific 

individuals who have roles in the ED to make sure that the important 

aspects of the quality of care are conducted, so that responsibilities are 

clear. 

Richard Ries noted that most of the people who take vital signs, in any 

medical setting, are not doctors, but support staff. Therefore, issues of 

training and responsibility become very important. 

Peter Rostenberg agreed that defining roles and who fills them was an 

important element in assuring that services are actually delivered. He 

also raised the issue of how medical staff could cooperate with legal and 

law enforcement personnel to access alcohol-related medical information without compromising their traditional role of focusing on the 

patient’s needs. 

Thomas Babor noted that both primary care and emergency physicians 

have similar problems with respect to time limitations, perceived competency of practitioners, and the effectiveness of interventions for 

alcohol problems. The issue is not so much the efficacy of interventions 

for alcohol problems as getting health care systems to respond to identified need. He noted that several models have emerged. The traditional 

model integrates screening and intervention into the normal routine of 

the health care team. However, that approach has come up against 

managed care and reduction in resources, creating problems when 

physicians are expected to do everything in the same amount of time 

with patients. A second model transfers responsibility to a specialist such 

as a nurse practitioner, trained health educator, or hired worker. A third 

model incorporates screening for types of problems and risk factors 

likely to fit a health care setting’s population. For instance, in emergency 

Spectrum of Alcohol Problems 43 
medicine, screens include seat belt use and risky driving. A fourth model 

utilizes technology, such as handheld computers. He concluded that 

different models make adoption more likely. 

Pollock noted that planned follow-up does not occur in the emergency 

setting. He questioned whether this is a barrier to performing these 

preventive services. 

Babor replied that little follow-up occurs in other medical settings as 

well. The central question is: Will the encounter bring about a lifetime 

change in drinking behavior? Probably not. Will it produce a reduction 

in drinking in some patients? Yes. 

Lewis hoped that alcohol problems would not be considered a behavioral problem and therefore not be addressed in general medical settings. 

Phillip Brewer commented that despite the large burden placed on 

medical systems by alcohol problems, medical schools provide little 

training on alcohol and substance abuse. 

Runge replied that if data show interventions are effective, that will 

encourage institutions to implement services. 

Brewer responded that patients are already asked screening questions 

about organ donation and a living will, but he wondered why they are 

not asked more obvious and immediate questions. 

Bruce Becker said the issue was not lack of time, but how the time is 

used. For example, his ED has advocates on call around the clock to 

facilitate consultation for patients who are victims of domestic violence 

or violence against women. The screening rate for these problems was 

very low before the advocates became available. Becker noted that 

something can be accomplished even with a two-minute encounter with 

a physician in the ED. Brief, smoking interventions in the primary care 

setting can increase spontaneous quit rates from 1% to almost 5%. 

Edward Bernstein commented that interest in ED-based screening is 

escalating because journal articles are being published on the topic. 

Even though emergency physicians work in acute care, they must 

address chronic problems. Patients with alcohol or drug problems will 

44 Alcohol Problems Among Emergency Department Patients 
return multiple times, much like asthmatic patients. McLellan’s JAMA 

article on dependent drinkers showed that alcohol interventions have 

better outcome rates than interventions for chronic diseases.1

 An intervention in which the doctor listens to and respects the patient is key. A 

social policy, the public health perspective, and resources are missing, he 

said. Resources include training, protocols, and additional personnel. 

Larry Gentilello doubted ED physicians could be convinced that their 

role is to screen patients for alcohol problems. He suggested handing the 

responsibility to people who think that interventions are worthwhile and 

are trained to do them. There are two studies on alcohol interventions in 

EDs, he said, and both of them used a collaborative care approach in 

which physicians set the stage, and then trained staff performed the 

interventions. There have been two decades of research into how to 

integrate psycho-social services into primary care medicine, and that 

research uses a collaborative care model. Every ED should have staff 

available for a brief intervention, and he wondered why they did not. 

Maio responded that the work load can be increased by the way we 

define “alcohol problems.” We might be able to intervene with problem 

drinkers with current hospital resources. However, if we want to help 

patients who drink more than NIAAA recommendations, then in most 

EDs, we will have to deal with 30% to 45% of all patients. To whom 

should those people be referred? Many patients in EDs do not have 

primary care physicians, so there is no guarantee that their issues will be 

addressed. Maio agreed that the intervention should not be the responsibility of the emergency physician. He described a study using handheld 

computers, which are not bulky or intrusive, and suggested that such 

technologies could facilitate broader implementation. 

Susan Rook asked whether a uniform and accepted definition of a 

“cure” is available. She also wondered whether it would be helpful to 

develop a partnership with the recovery community so that ED personnel can learn from former patients whether their interventions had an 

impact. 

Runge reiterated that most physicians do not believe alcoholism can be 

cured. In the case of hypertension, for instance, medicine can successfully treat a patient. However, positive outcomes from interventions for 

Spectrum of Alcohol Problems 45 
alcohol problems have not been stressed. He agreed that there is a 

potential role for the recovery community in the effort to increase 

awareness in the ED. 

Richard Brown appreciated the focus on incentives to increase screening. He noted that doctors want to provide quality care and want a sense 

that their work improves patient outcomes. Another incentive might be 

that interventions for alcohol problems could lower costs. Like asthmatics who smoke and heart failure patients who do not take their medications, patients with alcohol problems who return to the ED often cause 

frustration. However, if they are treated like patients with other chronic 

disease, doctors can see results. While ED physicians might not deliver 

the interventions themselves, they must align behind the programs. 

Richard Longabaugh added that in a study at his university, substance 

abuse specialists decreased the negative consequences of alcohol consumption of sub-critically injured patients, and two-thirds of them 

returned for a second appointment 7 to 10 days later. They used a 

motivational-enhancement intervention because the teachable moment 

in the ED alone was not sufficient. 

Linda Degutis said there is time to do the screening, especially with the 

help of nurses or technicians. She described a project in which physicians screened ED patients with minor injuries for alcohol problems. 

One physician ensured that screening occurred 70% of the time, but the 

average screening rates were 40%. With increases in patient loads, no 

increase in physician staff, and decreases in nursing and social work staff, 

she doubted that the hospital would agree to fund new staff to conduct 

interventions and screens. She added that personal bias was one barrier 

to screening that had not been addressed. 

Robert Woolard returned to the topic of scope of practice. Patients 

might be ready for an intervention but associate this type of intervention 

with their primary care doctor. They might be ready, but the institution 

might not be ready to let it happen in an ED. For example, he designed a 

study that involved a saliva test. Even though the patient’s record would 

be confidential, the legal and ethics committees of the hospital were not 

supportive. 

46 Alcohol Problems Among Emergency Department Patients 
Peter Monti suggested that the “cure” model could be broadened to 

include the idea of “harm reduction.” In his work with younger adults, 

he found strong harm reduction effects after a brief intervention for 

alcohol problems. This might not be a cure for abuse, but the intervention did reduce risk-taking behavior. 

Ries reminded the group that if an institution has a professionally 

certified drug or alcohol treatment service, that service may fall under 

confidentiality rules that make interdisciplinary research involving the 

ED difficult to undertake. 

Ann Mahoney noted that records for the emergency room visit do not 

normally fall under 42 C.F.R. Part 2, the regulation that covers the 

confidentiality of alcohol and drug abuse patient records. However, they 

may if the patient receives treatment from a specialized drug or alcohol 

unit or staff whose primary function is to provide drug or alcohol 

services. Because the rules are complicated, she suggested consulting the 

regulations, which can be found at http://www.treatment.org. 

Gordon Smith supported the concept of using the ED visit as a teachable moment, but the concept is difficult to find in the literature. He 

suggested that the teachable moment might not always apply to the 

ED visit. For example, mothers with injured children might not be as 

receptive to a preventive intervention during an ED visit as during a 

primary care visit. 

Gail D’Onofrio noted that the current emergency medicine curriculum 

does not address screening and brief intervention for alcohol problems. 

At Yale, training for residents led to improved performance and attitudes 

about role models and resources. She concluded that change would start 

with the training of residents and faculty members. 

Becker described an unpublished study about the teachable moment 

conducted at Brown that showed there was no relationship between the 

chief complaint of the patient and his or her ability to retain either 

general or specific information except in motor vehicle crashes. Patients’ 

ability to retain information was related to their degree of stress and 

their perceived degree of illness. 

Spectrum of Alcohol Problems 47 
Runge noted that the concept of teachable moment applies to institutions as well, and that there is literature on the topic in community 

mental health. 

Fred Blow commented that there is a social role of the ED in caring for 

the most disadvantaged in society. For a variety of groups, the ED is the 

only access point in health care. He urged the conference to contextualize the role of preventive services in the only place that many people 

get health care. In those terms, alcohol screening and interventions 

become imperative. 

Carl Soderstrom noted that studies indicate about 50% of medical 

schools have some alcohol education. He often surveys residents informally during his lectures to assess whether they are familiar with alcohol 

intervention and screening tools. Most have heard of the CAGE and 

indicate they learned about it in medical school. He did not know of any 

good studies or surveys on this topic in the area of emergency medicine. 

Charles Bombardier noted that the existence of a teachable moment 

results not just from the context in which the patient is involved, but 

also from the dynamic between the patient and the practitioner. How 

a care provider interacts with a patient can generate either resistance 

or openness to talking about alcohol problems. To a large degree, the 

clinician is responsible for creating a teachable moment. 

Runge noted that the first moment that a person or a family member 

arrives at the ED is not generally a teachable moment. Once the stress 

is alleviated, then patient education can occur. 

Guohua Li added that the mismatch between the patients and the 

physicians can be an important barrier to successful interventions. For 

instance, at Johns Hopkins, 85% of the patients are African Americans, 

and there is only one African American attending physician. This is 

not so much an issue of race as a problem for interventions that rely 

on patient-physician communication, compounded by the age of 

physicians in training. Another barrier to acceptance is interdisciplinary 

conflict. While alcohol poses a health threat, the American Heart 

48 Alcohol Problems Among Emergency Department Patients 
Association maintains that moderate alcohol use has cardiovascular 

benefits. Patients can be confused by these messages in the media. 

He concluded that there is much to do even within the medical health 

community. 

Reference 

1. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic 

medical illness: implications for treatment, insurance, and outcomes evaluation. 

JAMA 2000;284(13):1689–95. 

Spectrum of Alcohol Problems 49