Alcohol and Alcoholism Advance Access originally published online on June 2, 2006
Alcohol and Alcoholism 2006 41(5):553-559; doi:10.1093/alcalc/agl041
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ALCOHOL AND ILLICIT DRUG USE AMONG EMERGENCY ROOM PATIENTS IN THE NETHERLANDS
1 Addiction Research Institute (IVO), Heemraadssingel 194, 3021 DM Rotterdam, 2 Meander Medical Center, Department of Internal Medicine, PO Box 1502, 3800 BM Amersfoort and 3 Faculty of Social and Behavioural Sciences, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
* Author to whom correspondence should be addressed at: Addiction Research Institute (IVO), Heemraadssingel 194, 3021 DM Rotterdam, the Netherlands. Tel.: +31 10 4253366; Fax: +31 10 2763988. E-mail: vitale{at}ivo.nl
(Received 10 November 2005; first review notified 25 November 2005; in revised form 17 March 2006; accepted 11 April 2006)
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Aims: To clarify alcohol and illicit drug use within the emergency room population in three different regions in The Netherlands, focusing on whether interventions for these substances should be region specific. Methods: Alcohol and illicit drug use were assessed using a self-report questionnaire filled in by the patients, and by combining self-report with staff judgement on alcohol and illicit drug use. Results: Data on alcohol use (self-reported and staff judgement combined) resulted in prevalence rates of 4.9–18.2%. Patients positive for alcohol are more likely to be male, aged 48–58 years, more likely to be a frequent excessive drinker, and to have injuries as a result of violence. Patients positive for illicit drugs are more likely to be male, aged 28–38 years, unemployed, and frequent excessive drinkers. Among men aged 18–35 years with a Dutch cultural background, some differences emerge regarding alcohol consumption between the various hospitals, but most variation exists in the case of illicit drug use. Conclusions: This paper confirms that the emergency room seems to provide an opportunity to initiate interventions regarding alcohol use and seems to suggest that this is independent of the region concerned. However, in the case of illicit drug use interventions seem to be more region specific.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Both alcohol and illicit drug use are associated with injuries. In particular, the relationship between alcohol and injuries is well documented (Cherpitel, 1993
; El-Guebaly et al., 1998; Cherpitel et al., 2003; Cherpitel et al., 2004). Characteristics of the injured population positive for blood alcohol are more likely to be male, aged 25–45 years, being admitted to the emergency room during the weekend evening or early morning hours (Cherpitel, 1993), and a causal role of alcohol in injuries related to violence has been found (Macdonald et al., 2005). In contrast to alcohol, illicit drug use in relationship to injuries is less well studied, but a possible correlation has been shown (Macdonald et al., 2003; Blondell et al., 2005). A recent review on injury risk associated with cannabis and cocaine use (Macdonald et al., 2003) indicates their relationship with intentional injuries and injuries in general among non-clinical samples. Among emergency room patients illicit drug use seems to be more common in men aged 20–40 years and is strongly associated with violence-related injuries (Vitale and Van de Mheen, 2006). Different associations between monthly and lifetime drug use and emergency room visits have been established, whereby monthly drug use was associated with emergency room treatment for illness (Cherpitel, 1999), and ‘lifetime’ illicit drug use was associated with injury (Chipman, 1995). Alcohol use also plays an important role in traffic accidents, and illicit drugs and certain medicinal drugs are known to impair driving skills and can increase crash risk (EMCDDA, 1999). The combination of illicit drug and alcohol use negatively influences driving behaviour (Del Rio and Alvarez, 1995), and both illicit and licit drugs influence driving skills (Schmitt et al., 2002). Results from emergency room studies differ between studies and between countries (Cherpitel, 1993). Comparative findings on the association between alcohol and casualties across countries and cultures appear to reflect usual drinking patterns within the countries concerned (Cherpitel, 1993); therefore, information from different countries is needed. The Netherlands lacks complete data on alcohol and illicit drug use among emergency room patients. Because the associations between substance use and injuries can differ between countries and between cities in the same country (Buss et al., 1995; Cherpitel et al., 2004), this is the first study to explore emergency room data on substance use from three different hospitals in three different cities in The Netherlands. In addition, because of the expected variations in emergency room populations (Cherpitel et al., 2004), the risk group of men aged 18–35 years with a Dutch cultural background was selected based on findings from previous studies (Cherpitel, 1993; Vitale and Van de Mheen, 2006) and was further explored regarding the characteristics of alcohol and illicit drug use characteristics. This contributes to the international emergency room literature by elucidating the influence of demographic differences between hospital samples, and allows more conclusions to be drawn about regional differences. The positive identification of patients under the influence of alcohol and illicit drugs in the emergency room is necessary for appropriate treatment and to develop suitable intervention programmes. Outside The Netherlands, brief counselling interventions for alcohol use have proven effective (Longabagaugh et al., 2001; Woolard et al., 2003; Crawford et al., 2004). However, before developing such intervention programmes in The Netherlands, more data are required on whether these interventions should be region specific. Therefore, the present study also explores this topic by comparing the different regions involved. |
MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Data collection
This study was conducted at three emergency rooms in different parts of The Netherlands, and involved the participation of one university hospital (Erasmus Medical Center) and two general hospitals (Meander Medical Center and Scheper Ziekenhuis). The Meander Medical Center (MMC) in Amersfoort (
130 000 inhabitants) is located in the central part of The Netherlands and its emergency room has 35 000 patients per year. The Scheper Ziekenhuis Emmen (SZE) is located in a city (100 000 inhabitants) to the north and the emergency room sees 12 000 patients a year. The Erasmus Medical Center (EMC) is located to the west in the city of Rotterdam (600 000 inhabitants) and the emergency room sees 24 000 patients a year. The medical review boards of the hospitals involved approved the study protocol. Data collection in the MMC took place from July 2003 to May 2004; in the SZE from August 2003 to April 2004; and in the EMC during seven consecutive weeks in November and December 2004. All research sites used the same inclusion/exclusion criteria and measurements. Patients, aged 12 years and older, treated in the emergency room for injuries or illness were included; excluded were those attending for a control visit and those without sufficient command of the Dutch language. Instruction on the study procedures was given to the emergency room and research staff by the main researcher. The researchers made site visits to check these procedures. Owing to organizational differences between the three hospitals there was some variation in the research procedure. In the SZE and EMC administrative staff were present at the emergency room entrance, so in these two hospitals patients were approached in two ways. Patients with minor injuries/illnesses meeting the inclusion criteria were given a questionnaire by the administrative staff shortly after entering the emergency room; the questionnaire was then completed in the waiting room. Patients with more serious/severe injuries/illness were approached in the treatment room by the staff before or shortly after treatment; the patient then filled in the questionnaire. In the MMC, because administrative staff was not available 24 h a day at the entrance of the emergency room, research staff was hired (24 h a day) to approach patients for this study. In this procedure, research staff handed out the questionnaire. Patients with minor injuries/illness were approached to participate whilst waiting for treatment (i.e. shortly after entering the emergency room). Patients with more severe injuries/illness were approached after consultation of the emergency room personnel by the research staff before or shortly after treatment; the patient then filled in the questionnaire.
Questionnaire
A patient questionnaire was used in order to obtain more detailed information about the patient's substance use. Studies have concluded that self-report is a valid method to measure alcohol use prior to the injury event (Cherpitel, 1993; El-Guebaly et al., 1998; Treno et al., 1998; Vitale et al., 2006). The questionnaire contained a number of demographic data including cultural background and occupational situation. Cultural background was defined as being either from native Dutch origin or from other origins. Occupational situation included employed, unemployed, disability pension, retirement, housekeeping, student, and others. Age, gender, and the time of entering the ER were registered, as well as the day of the week. Reason for visit was either injury or illness, whereas type of visit included traffic accident, accident, violence, illness, and suicide attempt/self mutilation. Location of accident could be either at home, or in public or in other locations, and referral could be ambulance, own initiative, general practitioner, or others.
Alcohol: Patients were asked for their use of alcohol within 6 and 24 h prior to their injury/illness event, as well as the location of consumption. Apart from these questions about the acute use of alcohol, general alcohol consumption pattern was analysed as well (number of drinking days in the weekend and during the week, and average number of consumptions on a drinking day in the weekend and during the week). Frequencies are based on drinking six or more units (1 unit is equivalent of 1 glass of beer, wine or spirit, and this is 8–10 g of pure ethanol) in 1 day. Based on this pattern, patients were classified as abstainers (never drinking alcohol at all), moderate drinkers (once a month; less than once a month; never drinking six or more units in 1 day), occasional excessive drinkers (once a week; 2 or 3 times/month) and frequent excessive drinkers (every day; >3 times/week; 2 or 3 times/week). This classification was introduced by Garretsen in 1983 and has proven useful in other studies (Lahaut et al., 2002; Van Dijck and Knibbe, 2005).
Illicit drug use: The questionnaire asked about the use of cannabis, amphetamins, ecstacy, heroin, cocaine, hallucinogenics, hydroxybutyric acid (GHB), and methadone 24 h prior to the injury/illness as well as the use of these drugs during the previous year.
Staff judgement on patients' alcohol and illicit drug use was included to obtain information on alcohol and illicit drug use among those patients that are unable to fill in the questionnaire due to their medical condition. Self-reported substance use and together with staff judgement on substance use is considered to be more accurate than self-report alone (El-Guebaly et al., 1998).
Data analysis
Patients with a questionnaire (Q+) and those without a questionnaire (Q–) available were compared on demographics and emergency room characteristics using bivariate cross-tabulation. Data on the Q+ patients were analysed after distinguishing between injured (intentional and unintentional) and non-injured (illness) patients; between alcohol positive patients (alcohol use <6 h prior to the onset of illness or injury event) and alcohol negative (no alcohol for >6 h prior to the onset of illness or injury event) and between patients using illicit drugs (24 h prior to the the onset of illness or injury event) and not using illicit drugs (no illicit drug use for >24 h prior to the onset of illness or injury event). Prevalence rates of alcohol use, alcohol consumption, and licit/illicit drug use were estimated using frequency statistics. Data from each hospital were analysed separately when comparing alcohol positive/negative patients, and illicit drug positive/negative patients. Data on patients positive for alcohol and illicit drug use are based on self-report and staff judgement combined. Information obtained from the questionnaire was not available for those patients for whom staff judgement alone was used. This resulted in differing numbers of patients, because for those patients who were judged on their substance use solely by the staff, no information from the questionnaire was available. Data were compared using bivariate cross-tabulation, and chi-squared and Fisher's exact tests (used for cells with less than five respondents) were used to determine significance. All results were regarded significant at P < 0.05, except for those variables with more than two categories, where the Bonferroni correction was applied in which case results were significant at P < 0.05/n (= number of variable categories).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Response rates
Although it was the intention to hand out questionnaires to all patients older than 12 years of age (excluding control visits), only a minority of the patients in the three hospitals received the questionnaire: EMC 30.3%, MMC 19% and SZE 36.6%, respectively (not shown in table). The main reasons for these low figures were non-availability of secretarial assistance (evenings and nights) understaffing of ER personnel, other priorities, and/or reserve of ER personnel to hand out the questionnaire. The highest rate was reached when patients were approached by administrative staff not involved in ER activities (SZE). Of those patients that were approached,
80% consented to participate in the study and filled in the questionnaire. The main reasons for patients (that were approached) not filling in the questionnaire were medical condition (46.3–75.1%), refusal (11–32%), and insufficient command of the Dutch language (5.1–30.3%). Comparing patients who filled in the questionnaires (Q+) with those who did not (Q–), Q+ patients were more likely to be male, younger, visiting the ER during the daytime, being referred by a GP, and not brought in by ambulance.
Alcohol
Table 1 presents prevalence rates for alcohol and illicit drug use prior to the injury/illness event (<6 and 24 h, respectively). Based on self-report the prevalence ranges from 5.5% (MMC) to 11.4% (EMC and SZE). Combined with staff judgement, the prevalence rate increases to 11.3–18.2%. General alcohol consumption patterns among these ER visitors show excessive drinking (occasional and frequent) ranging from 11% in the SZE to 15.8% in the EMC, with only the percentage of occasional excessive drinkers being higher in the EMC compared with the SZE. The percentage of abstainers and moderate drinkers varied between the three hospitals.
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Characteristics of the patients positive for alcohol use prior to the ER visit are given in Table 2. Alcohol positive (A+) patients are likely to be males rather than females with a mean age ranging from 32.7 years (EMC) to 58 years in the SZE. In the northern more rurally situated Scheper Ziekenhuis, unexpectedly, relatively more women and older age were observed than in the other two hospitals; in that hospital alcohol positive patients were more likely to be unemployed (12.4 versus 3.7%) compared with alcohol negative patients. No differences were found with regard to cultural background and occupational situation in the other hospitals.
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Compared with alcohol negative (A–) patients, visits of A+ patients to the ER were more often made during evening/night hours and during the weekends. In case of an injury the percentage of A+ patients was significantly higher than that of A– patients in two of the three hospitals, and in all hospitals this was the case for injuries as a result of violence. A+ patients were more likely to be brought in by ambulance (MMC and SZE), while especially in the EMC injuries mostly took place in public locations (67.4 vs 26.4%) (not shown in table). Alcohol was mostly consumed outdoors. In all hospitals the A+ group scored higher than the A– group with regard to frequent excessive drinking and illicit drug use during the previous year, with the difference in the EMC not being statistically significant.
Illicit drug use
Self-reported drug use 24 h prior to the injury/illness ranged from 1.4% in SZE to 10.1% in EMC (Table 1). Prevalence rates did not increase when staff judgement was included. Drugs most frequently used were cannabis and cocaine with hard drugs more prevalent in the EMC (not shown in table). Illicit drug use during the previous year was also more prevalent in the EMC than in the other hospitals (18.7 vs 3.1 and 6.7%, respectively). All three hospitals showed differences regarding illicit drug use (self-report, self-report combined with staff judgement) and illicit drug use in the previous year, with the highest percentages in the EMC and the lowest percentages in the SZE.
Characteristics of patients positive for illicit drug use <24 h prior to the injury/illness event are given in Table 3. In all hospitals, illicit drug positive (D+) patients were younger (18–35 years) than the drug negative (D–) patients and are more likely unemployed. D+ patients mostly arrived during the night hours and in 30–50% this was because of an injury other than a car accident. In 50–60% this injury or illness occurred at home (not shown in table). In all three hospitals D+ patients were more likely to have used drugs during the previous year than D– patients, and 75% of them consumed these drugs at home (not shown in table). D+ patients were also more likely to be excessive alcohol consumers.
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Risk group for substance use prior to the ER visit: men aged 18–35 years, Dutch cultural background
Table 4 shows that alcohol use 6 h prior to the injury, based on self-report and staff judgement combined, ranged from 10 to 20%. Differences emerged between the three hospitals, with the EMC showing higher alcohol prevalence compared with the other two hospitals. Among the group of men aged 18–35 years with a Dutch cultural background,
30–40% can be classified as excessive drinkers, showing no differences between the hospitals. Illicit drug use (self-report and staff judgement) ranged from almost 5% (SZE) to 14% in the EMC. Illicit drug use in the previous year ranged from 11 to 26%. Differences were found among the three hospitals, with the EMC showing both more illicit drug use during the 24 h prior to the injury and more illicit drug use in the previous year.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The present study shows that from all patients looking for medical help at an emergency room in a Dutch hospital, 11–18% has used alcohol within 6 h prior to their injury/illness event. These percentages are relatively consistent for the hospitals studied irrespective of the size, type (university, regional, or local), and location in The Netherlands. In contrast to alcohol, illicit drug use 24 h prior to the ER visit ranged from 1.4% in a rural area to 10.1% in the city of Rotterdam.
Patients positive for alcohol are more likely to be male, aged 36–60 years, more likely to be excessive drinkers, and to have an injury as a result of violence. Patients positive for illicit drug use are younger compared with patients positive for alcohol, and are 28–38 years of age, unemployed, and frequent excessive drinkers. Studies on alcohol use among ER populations in countries such as the United States and United Kingdom report similar alcohol prevalence rates (El-Guebaly et al., 1998). The present study shows that, even within a small country like The Netherlands, large variations exist between ER samples and, as a result, variations also exist regarding alcohol and illicit drug prevalence rates and patient characteristics. This is confirmed by the finding that, also among the specific risk group of men aged 18–35 years with a Dutch cultural background, differences between the three hospitals emerge. Therefore, differences between regions are due to different demographic characteristics of the ER population. Despite this, no differences exist between the hospitals regarding general alcohol consumption, and alcohol use prior to the injury/illness varies. Regarding illicit drug use, the differences between hospitals are more pronounced. These findings on alcohol and illicit drug use among ER populations suggest that data from three different hospitals from three different regions in one country do not represent data for the whole country.
The present study was not designed to detect a causal relationship between the use of alcohol and/or drugs and ER visit, but rather to look for specific characteristics of the users. However, certain data do suggest such a relationship, with alcohol positive visitors being more likely to be excessive drinkers and to use drugs than those negative for alcohol. Injuries (especially those resulting from violence) were more prevalent in the alcohol positive group. Such a causal role for alcohol in violent acts has been reported recently by others (Macdonald et al., 2005; Cherpitel et al., 2005). Although a higher incidence of accidents, especially car accidents, has been attributed to the use of alcohol (ELDD, 2003; Kurzthaler et al., 2003; Ramaekers et al., 2004), this association was not found in our study. This may be the result of a more reserved attitude of the Dutch population in recent years towards drinking and driving, but may also be due to study bias. Study bias can occur because in critical situations involving considerable work and pressure on the ER team (e.g. owing to traffic accidents with many people) the handing out of questionnaires as well as judging and filling in the forms obviously has a low priority. In those situations patients themselves are often not able to fill in the forms, while bystanders do not feel competent to offer adequate judgement. Because alcoholic drinks are most frequently consumed during evenings and in the weekends, the higher rate of alcohol positive persons arriving during the evening/night hours and in the weekends was not a surprise.
ER visits by illicit drug users seem to be much more concentrated in the western part of The Netherlands reflecting differences in population characteristics compared with the rest of the land. In the EMC, drug positive patients were seen during all parts of the day whereas in the other two hospitals (representing another part of The Netherlands) such patients were mostly seen during the night (0.00–8.00 a.m.). Cannabis was the most frequently reported drug followed by cocaine, which is in accordance with reports from other western nations (Macdonald et al., 2003; Vitale and Van de Mheen, 2006).
A positive answer concerning the use of drugs within the 24 h prior to the visit seems predictive for chronic use and also for excessive alcohol consumption. It was remarkable that in most cases (and in contrast to general public ideas) the drugs were used at home where the problems leading to ER visit also arose. However there is no really clear association between injury/illness characteristics and drug use, a finding also reported by others (Blondell et al., 2005; Vitale and Van de Mheen, 2006).
A limitation of the present study is the low response rate at all sites, which led to selection bias because not all eligible patients could be interviewed, e.g. fatally and seriously injured patients. This type of sample selection bias was also identified by Treno et al. (1998). Previous studies did not find a relationship between injury severity and substance use (Cherpitel, 1993; Vitale and Van de Mheen, 2006). The present sample most probably was not biased regarding the main objective of this study; i.e. alcohol and illicit drugs prevalence rates.
The best results are obtained when questionnaires are handed out either by a special team not involved in ER activities or by motivated secretarial personnel. Because nursing and medical staff are heavily involved in medical care they may not find time for the questionnaires, although they are better than research staff in judging the involvement of alcohol or drugs (Vitale et al., 2005). Furthermore, they may find it difficult to broach topics such as alcohol or drug use, especially in case of fatalities or aggressive behaviour from ER visitors. When the patients are handed a questionnaire they tend to be very cooperative, as reflected in the response rate of 80% in this study.
The results of this study stress the importance of prevention activities, since particularly alcohol use places a considerable burden on healthcare facilities (such as ERs and ambulances) as well as on budgets. Because of the low prevalence rates of illicit drug use and the indistinct relationship between types of injuries/illnesses and drugs, it is not yet clear whether such an approach is also useful in case of drug use. Based on the characteristics found, the ER is a location where patients with alcohol problems can be identified. In particular, our data show that more variation exists between the regions regarding illicit drug use compared to alcohol use. This may suggest that interventions on alcohol use can be initiated in all hospitals and focus on men aged 18–35 years with a Dutch cultural background, because almost 40% of this group is an excessive drinker. Interventions aimed at illicit drug use should focus more specifically on hospitals serving an at-risk region and population; this may initiate interventions already proven effective (Longabagaugh et al., 2001; Woolard et al., 2003; Crawford et al., 2004) using motivational interviewing techniques. However, because this study shows that the contact between emergency room staff and the patients is brief and does not provide an occasion to talk about a patient's alcohol or illicit drug use, interventions should not take place during the emergency room visit, but after the medical treatment has taken place.
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ACKNOWLEDGEMENTS |
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The study was funded by the Dutch Ministry of Health, Welfare and Sports.
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