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In EDs around the world, on every shift, patients present for our care because of 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, diagnosis, and treatment of acute alcohol and drug emergencies and their secondary complications, but often fail to ask about drinking and substance abuse. ED failure to screen and detect substance abuse could contribute significantly to adverse drug reactions or delays in instituting appropriate treatment. Management and disposition are often challenging and frustrating because of factors outside our control that co-vary with unhealthy alcohol and drug use, such as psychiatric illness, homelessness, low level of health literacy, lack of insurance coverage or ability to pay for medications, criminal justice involvement, and absence of family support for caregiving.

The scope of substance abuse includes alcohol, even in moderate drinkers; illicit drugs; and nonmedicinal use of prescription drugs. Treatment for substance abuse is as effective as treatment for diabetes, hypertension, and other chronic diseases,1 but only a small fraction of those needing treatment actually get it.2 Over the last 25 years, the science of addiction has evolved and encouraged us to view substance abuse as a chronic medical problem, much like asthma, hypertension, and diabetes. Addiction is thought to result from the interaction of (1) genes with the environment, (2) the duration and intensity of drug exposure, and (3) an individual’s balance between personal risk and socioeconomic protective factors in the home, school, and community. Emergency medicine now faces the challenge to bring our practice in line with the current scientific knowledge of addiction and other alcohol and drug use disorders.

This chapter covers the definitions of alcohol and substance abuse, acute treatment of withdrawal, and guidelines for referral for detoxification and rehabilitation.

Alcohol Misuse and Abuse

More than 75,000 deaths and 2.3 million years of potential life lost has been related to unhealthy alcohol use,3 at an estimated cost of $185 billion a year.4 In 2001 to 2002, 17.6 million adult Americans met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (text revision) (DSM-IV-TR), criteria for alcohol abuse or alcohol dependence.5 Alcohol-attributable ED visits between 1992 and 2000 were estimated at 68.6 million or 7.9% of all ED visits.6 In 2001, there were an estimated 1.5 billion binge drinking episodes, and 73% were moderate drinkers.7

Drug Abuse

The overall cost of drug abuse in the U.S. was estimated at $181 billion in 2000. Productivity losses accounted for 71%, health care costs 9%, and crime/legal other costs 20%.8 In 2006, an estimated 20.4 million Americans over the age of 12 years old (8.3% of the U.S. population) had used illicit drugs in the previous month.2


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