INTRODUCTION AND EPIDEMIOLOGY
In EDs around the world, on every shift, patients present for medical conditions related to the consequences of unhealthy drinking or drug use. Sometimes the cause of the presenting problem is obvious, but just as often, the connection of substance use with its medical consequences remains undiscovered. Emergency physicians are experts in stabilization, rapid diagnosis, and treatment of acute alcohol and drug emergencies and their secondary complications but often fail to identify and discuss drinking and drug use as a component of medical care. Factors that often accompany unhealthy alcohol and drug use, such as psychiatric illness, trauma, homelessness, low level of health literacy, inability to pay for medications, criminal justice involvement, absence of family support, and limited availability of treatment and recovery support services, make patient management and disposition difficult.
The scope of substance use disorders includes unhealthy use of alcohol, use of illicit drugs, and nonmedical use of prescription drugs. Severe substance use disorders (addictions) resemble asthma, diabetes, hypertension, and other chronic diseases in that they have genetic components and patients have problems with adherence to medication, loss to follow-up, repeat visits to the ED, and hospital admissions, yet only a small fraction of those needing alcohol or drug treatment are actually receiving indicated therapy, compared with a much higher fraction of patients with chronic medical conditions.1
Substance use is a significant global problem. The World Health Organization reports worldwide 185 million illicit drug users, 2 billion alcohol users, and 1.3 billion smokers. In 2000, tobacco, alcohol, and illicit drugs accounted for about 12% of all deaths worldwide.2
Those who begin drinking before age 15 have a fourfold increased risk of developing dependence than those who begin drinking later.3 Underage drinking and drug use have a profound impact on the developing nervous system, so early intervention is needed to mitigate life-altering consequences.4
The term unhealthy alcohol use describes a spectrum of alcohol consumption ranging from "risky" or hazardous use (no consequences experienced), to harmful use (experience of consequences), to what was previously called alcohol dependence but is now termed alcohol use disorders.5 The National Institute on Alcohol Abuse and Alcoholism defines low-risk drinking as follows6: for men, no more than 14 drinks per week and no more than four drinks over a 2-hour occasion. Women of all ages and men >65 years old are advised to drink no more than seven drinks per week and no more than three drinks over a 2-hour occasion because of gender and age differences in volume distribution and concentrations of alcohol dehydrogenase in the liver. Binge drinking (drinking too much too fast) is alcohol consumption that results in a blood alcohol level over the U.S. legal limit of 0.08 gram/dL, which for the average male is the result of more than four drinks ...