Decriminalising public drunkenness: Accountability and monitoring needed in the ongoing and evolving management of public intoxication.

In light of the recent announcement from the Victorian (Australia) state government that they are moving to decriminalise public drunkenness and replace it with a 'health-based response', it is timely to reflect on a number of important considerations identified from the academic literature on this topic. We briefly review a number of models of health-care delivery that have been utilised in other jurisdictions, and suggest there are opportunities at a more principled level to respond more adequately to the decriminalisation of public drunkenness in Victoria (and elsewhere). First, embedding research and evaluation, particularly that draws on the needs, views and experiences of those who are deemed to be drunk in public, is essential from the outset, and must be ongoing to enable the continual refinement of models of care. Second, significant funding and intersectoral support are needed to ensure that the laws are not tokenistic and do not remain the responsibility of police. Third, there are opportunities to put policies and principles in place to ensure that police do not use more coercive powers to address concerns around public drunkenness. Most importantly, state-wide education and training efforts are needed alongside the repeal of the law to ensure that emergency services and health-care workers (as well as the community), have a good understanding of the contexts and needs of people who are considered drunk in public, and consequently treat them with care and respect.

Controlled observational study and economic evaluation of the effect of city-centre night-time alcohol intoxication management services on the emergency care system compared with usual care.

BACKGROUND: Alcohol intoxication management services (AIMS) provide an alternative care pathway for alcohol-intoxicated adults otherwise requiring emergency department (ED) services and at times of high incidence. We estimate the effectiveness and cost-effectiveness of AIMS on ED attendance rates with ED and ambulance service performance indicators as secondary outcomes. METHODS: A controlled longitudinal retrospective observational study in English and Welsh towns, six with AIMS and six without. Control and intervention cities were matched by sociodemographic characteristics. The primary outcome was ED attendance rate per night, secondary analyses explored hospital admission rates and ambulance response times. Interrupted time series analyses compared control and matched intervention sites pre-AIMS and post-AIMS. Cost-effectiveness analyses compared the component costs of AIMS to usual care before with results presented from the National Health Service and social care prospective. The number of diversions away from ED required for a service to be cost neutral was determined. RESULTS: Analyses found considerable variation across sites, only one service was associated with a significant reduction in ED attendances (-4.89, p<0.01). The services offered by AIMS varied. On average AIMS had 7.57 (mean minimum=1.33, SD=1.37 to mean maximum=24.66, SD=12.58) in attendance per session, below the 11.02 diversions away from ED at which services would be expected to be cost neutral. CONCLUSIONS: AIMSs have variable effects on the emergency care system, reflecting variable structures and processes, but may be associated with modest reductions in the burden on ED and ambulance services. The more expensive model, supported by the ED, was the only configuration likely to divert patients away from ED. AIMS should be regarded as fledgling services that require further work to realise benefit. TRIAL REGISTRATION NUMBER: ISRCTN63096364.

The acceptability of alcohol intoxication management services to users: A mixed methods study.

INTRODUCTION AND AIMS: Alcohol Intoxication Management Services (AIMS) provide basic care for intoxication and minor injuries, have been increasingly implemented in urban areas characterised by a large number of premises licensed for the sale and on-site consumption of alcohol, with the goal of reducing alcohol's burden on emergency services, including referrals into hospital emergency departments. The acceptability of new health services to users is a key effectiveness outcome. The aim was to describe patient experiences when attending an AIMS and document the acceptability of AIMS to users. DESIGN AND METHODS: A sequential mixed methods study was undertaken involving semi-structured interviews with participants from four AIMS followed by a survey of users recruited from six AIMS. RESULTS: Interviewees (N = 19) were positive about the care they received in AIMS and appreciated the friendly, non-judgemental atmosphere. Survey respondents rated their experience in AIMS positively (on a 0 to 10 Likert scale, mean = 9.34, SD = 1.38, n = 188). Frequently given reasons for attendance included drinking alcohol (57%) and minor injury (42%); 24% said they would have attended the emergency department had the AIMS not been available and 6% said they would have preferred to go to the emergency department; 31% indicated they would have felt unsafe without the AIMS. DISCUSSION AND CONCLUSIONS: AIMS are acceptable to users. AIMS are likely to address previously unmet demand for a safe space within the night-time environment.

Public Intoxication: Sobering Centers as an Alternative to Incarceration, Houston, 2010-2017.

In 2010, the Houston police department admitted 20 508 publicly intoxicated individuals into its jail. To address jail overcrowding, the city created a jail diversion policy that allowed law enforcement to admit publicly intoxicated individuals into a new sobering center. By 2017, public intoxication jail admissions had decreased by 95%, freeing valuable resources. A promising public health intervention, sobering centers offer an alternative to incarceration and relieve overuse of emergency services while assisting individuals with substance use issues.

Assessment of Cardiovascular Function and Microvascular Permeability in a Conscious Rat Model of Alcohol Intoxication Combined with Hemorrhagic Shock and Resuscitation.

Hypotension, cardiac depression, and elevated microvascular permeability are known problems that complicate resuscitation of patients following traumatic injury, particularly those who are also intoxicated from alcohol consumption. A conscious rat model of combined alcohol intoxication and hemorrhagic shock has been used to study the hemodynamic mechanisms involved. Here, we describe using this model to study microvascular leakage and cardiac electrical activity.

How Do People Who Frequently Attend Emergency Departments for Alcohol-Related Reasons Use, View, and Experience Specialist Addiction Services?

BACKGROUND: People who frequently attend emergency departments (EDs) for alcohol-related reasons, cost health systems greatly. Although specialist addiction services may be more appropriate for their needs, drinkers often experience barriers accessing specialist alcohol-related support. OBJECTIVES: This study explores how people who frequently attend EDs for alcohol-related reasons use, view, and experience specialist addiction services. METHODS: We conducted semi-structured interviews with 30 individuals recruited from six EDs across London, United Kingdom. Data relating to participants' socio-demographic characteristics and service use were systematically coded using qualitative software, and analyzed following the Framework. RESULTS: ED usage over the last 12 months was high, whereas current use of specialist addiction services was low. We found little evidence that structural barriers were preventing participants from attending specialist services; rather, participants seemed not to require help with their alcohol use. When asked what support they desired for their drinking, only 11/30 participants identified alcohol-specific treatment. More commonly, they wanted help relating to mental health problems; social contact; paid or voluntary work; housing-related issues; or gym access. Women were more likely to be receiving, and to have support from a specialist addiction service. Conclusions/Importance: People who frequently attended EDs for alcohol-related reasons expressed low levels of interest in, and motivation for, alcohol-specific treatment but desired broader psychosocial support. Case management and assertive outreach appear to be valuable models of service delivery for this population (particularly for men). However, further qualitative and quantitative research is now needed to verify these findings in different countries, regions, and health care systems.

Recognizing and Caring for the Intoxicated Patient in an Outpatient Clinic.

Recognizing an intoxication syndrome in patients presenting to an outpatient clinical practice with behavior or mental status change requires initial consideration of a broad differential diagnosis. After a thorough evaluation, management may include treatment of the presenting concern, triage to a higher level of care, and management substance withdrawal. Providers should be aware of the medico-legal aspects of caring for intoxicated patients related to privacy, informed consent, and risk of harm to self and others upon leaving clinic. An essential aspect of care for patients presenting to clinic intoxicated is the follow up assessment and management of substance use disorders.

Women and Men Admitted for Alcohol Intoxication at an Emergency Department: Alcohol Use Disorders, Substance Use and Health and Social Status 7 Years Later.

AIMS: To assess the prevalence of alcohol use disorder (AUD), substance use, mental health and social status 7 years following an Emergency Department (ED) admission for alcohol intoxication. To assess gender differences in these prevalences. METHODS: Cohort of 631 patients aged 18-30 years admitted for alcohol intoxication in 2006-2007 at a tertiary referral hospital in Switzerland, contacted for an interview in 2014. Assessment consisted of demography, Alcohol Use Disorders Identification Test-Consumption, Mini International Neuropsychiatric Interview for AUD, Patient Health Questionnaire (depression, anxiety) and lifetime/past year use of tobacco/illegal drugs. Gender differences were assessed with Chi-square tests, t-tests and Wilcoxon tests. RESULTS: In 2014, 318/631 (50.4%) completed the interview. Study completers were not different from non-completers on baseline characteristics (all P > 0.2). Of study completers, 36.8% were unemployed, 56.9% reported hazardous alcohol use, 15.1% alcohol dependence, 13.2% harmful use, 18.6% depression, 15.4% anxiety disorder. Prevalence of any use (lifetime/past year) was 93.4%/80.2% for tobacco, 86.6%/53.1% for cannabis, 54.7%/22.6% for cocaine, 25.6%/13.5% for sedatives, 40.9%/11.0% for stimulants, 21.7%/7.2% for opioids. Men reported significantly more binge drinking, AUD, cannabis use (past year) and more lifetime cannabis, cocaine and stimulants use (all P < 0.05). There was no gender difference in the prevalence of hazardous alcohol use and tobacco use. The prevalence of psychiatric disorders was significantly higher in women (P < 0.05). CONCLUSIONS: Seven years after being admitted for alcohol intoxication, young patients are likely to present substance misuse, mental health disorders and social problems, suggesting  that they should be offered secondary prevention measures while in the ED. SHORT SUMMARY: We studied a cohort of patients aged 18-30 and admitted for alcohol intoxication in 2006-2007 at a tertiary hospital. Participants were interviewed in 2014. Seven years after an admission for alcohol intoxication, patients are likely to present AUDs, substance misuse, mental health disorders and social problems.

The Impact of a Mandated Trauma Center Alcohol Intervention on Readmission and Cost per Readmission in Arizona.

BACKGROUND: Persons appearing in trauma centers have a higher prevalence of unhealthy alcohol use than the general population. Screening and brief intervention (SBI) is designed to moderate drinking levels and avoid costly future readmissions, but few studies have examined the impact of SBI on hospital readmissions and health care costs in a trauma population. RESEARCH DESIGN: This study uses comparative interrupted time-series and the Arizona State Inpatient Database to estimate the effect of the American College of Surgeons Committee on Trauma SBI mandate on the probability of readmission and cost per readmission in Arizona trauma centers. We compare individuals with and without an alcohol diagnosis code before and after the mandate was implemented. RESULTS: The mandate resulted in a 2.2 percentage point reduction (44%) in the probability of readmission. Total health care and readmission costs were not affected by the mandate. CONCLUSIONS: The estimates are consistent with a differential effect of SBI: SBI reduces readmissions among those who present with a less serious alcohol-related problem. Persons with more serious alcohol problems are less likely to respond to SBI. These higher risk individuals likely have a higher cost, which may explain the lack of change in readmission costs. Our study is a macrolevel intent-to-treat analysis of SBI's impact that corroborates the potential of SBI implied by efficacy studies in trauma centers and other settings. This study provides a framework for future research involving more states and health systems and evaluating other SBI policies.

Linked randomised controlled trials of face-to-face and electronic brief intervention methods to prevent alcohol related harm in young people aged 14-17 years presenting to Emergency Departments (SIPS junior).

BACKGROUND: Alcohol is a major global threat to public health. Although the main burden of chronic alcohol-related disease is in adults, its foundations often lie in adolescence. Alcohol consumption and related harm increase steeply from the age of 12 until 20 years. Several trials focusing upon young people have reported significant positive effects of brief interventions on a range of alcohol consumption outcomes. A recent review of reviews also suggests that electronic brief interventions (eBIs) using internet and smartphone technologies may markedly reduce alcohol consumption compared with minimal or no intervention controls. Interventions that target non-drinking youth are known to delay the onset of drinking behaviours. Web based alcohol interventions for adolescents also demonstrate significantly greater reductions in consumption and harm among 'high-risk' drinkers; however changes in risk status at follow-up for non-drinkers or low-risk drinkers have not been assessed in controlled trials of brief alcohol interventions. DESIGN AND METHODS: The study design comprises two linked randomised controlled trials to evaluate the effectiveness and cost-effectiveness of two intervention strategies compared with screening alone. One trial will focus on high-risk adolescent drinkers attending Emergency Departments (Eds) and the other will focus on those identified as low-risk drinkers or abstinent from alcohol but attending the same ED. Our primary (null) hypothesis is similar for both trials: Personalised Feedback and Brief Advice (PFBA) and Personalised Feedback plus electronic Brief Intervention (eBI) are no more effective than screening alone in alcohol consumed at 12 months after randomisation as measured by the Time-Line Follow-Back 28-day version. Our secondary (null) hypothesis relating to economics states that PFBA and eBI are no more cost-effective than screening alone. In total 1,500 participants will be recruited into the trials, 750 high-risk drinkers and 750 low-risk drinkers or abstainers. Participants will be randomised with equal probability, stratified by centre, to either a screening only control group or one of the two interventions: single session of PFBA or eBI. All participants will be eligible to receive treatment as usual in addition to any trial intervention. Individual participants will be followed up at 6 and 12 months after randomisation. DISCUSSION: The protocol represents an ambitious innovative programme of work addressing alcohol use in the adolescent population. TRIAL REGISTRATION: ISRCTN45300218. Registered 5th July 2014.

Treatment Needs of Driving While Intoxicated Offenders: The Need for a Multimodal Approach to Treatment.

OBJECTIVE: This study aimed to characterize and compare the treatment needs of adults with driving while intoxicated (DWI) offenders recruited from a correctional residential treatment facility and the community to provide recommendations for treatment development. METHOD: A total of 119 adults (59 residential, 60 community) with at least one DWI offense were administered clinical diagnostic interviews to assess substance use disorders and completed a battery of questionnaires assessing demographic characteristics, legal history, psychiatric diagnoses, medical diagnoses, and health care utilization. RESULTS: Almost all (96.6%) DWI offenders met clinical diagnostic criteria for an alcohol use disorder, approximately half of the sample also met diagnostic criteria for comorbid substance use disorders, and a substantial proportion also reported psychiatric and medical comorbidities. However, a high percentage were not receiving treatment for these issues, most likely as a result of having limited access to care, because the majority of participants had no current health insurance (64.45%) or primary care physician (74.0%). The residential sample had more extensive criminal histories compared to the community sample but was generally representative of the community in terms of their clinical characteristics. For instance, the groups did not differ in rates of substance use, psychiatric and medical health diagnoses, or the treatment of such issues, with the exception of alcohol abuse treatment. CONCLUSIONS: DWI offenders represent a clinical population with high levels of complex and competing treatment needs that are not currently being met. Our findings demonstrate the need for standardized screening of DWI offenders and call for the development of a multimodal treatment approach in efforts to reduce recidivism.

Risk assessment in patients with acute alcohol intoxication.

AIM: Patients with acute alcohol intoxication present a serious and still growing problem for pre- and intra-hospital emergency services. Data on the clinical risk assessment of alcohol-intoxicated patients are sparse. The aim of the present work was, therefore, to collect and assess relevant risk parameters. MATERIALS AND METHODS: At the Mannheim University Hospital, the medical records of 844 alcohol-intoxicated Emergency Department patients were retrospectively studied and evaluated. RESULTS: The patients with alcohol intoxications were predominantly males with an average age of 45 years. Mean blood alcohol concentration was 0.28%. The rate of haemodynamic, respiratory or metabolic complications in these patients was low. In 43% of cases, there was moderately to severely impaired consciousness. About half of the patients were treated on an outpatient basis. CONCLUSION: Our data demonstrate a low clinical risk for alcohol-intoxicated patients. Nevertheless, it is necessary to provide a defined monitoring standard in order to also be prepared for the few potential complications of alcohol intoxication and the possible differential diagnoses of impaired consciousness.

Correlates of caring for the drinkers and others among those harmed by another's drinking.

INTRODUCTION AND AIMS: This study identifies the correlates of caring for harmful drinkers and others, and examines how caring for that person impacts on respondents' well-being and use of services. DESIGN AND METHODS: The study utilises the data from the 2008 Australian Alcohol Harm to Others Survey (n = 2649), in which 778 respondents reported they were harmed because of the drinking of someone they knew. Respondents were asked about the person they were most adversely affected by and whether they spent time caring for this person because of their drinking. Logistic regression models are developed to examine which factors were associated with the prevalence of caring for others. RESULTS: The study reveals that the respondents who cared for others because of the other's drinking reported lower quality of life than the respondents who did not have to do this. The results of the logistic regression suggest that respondents were more likely to care for the drinker if the drinker drank more (as the usual quantity of alcohol consumed increased), but less likely to care for the drinker if the drinker drank five or more drinks on more than four days per week. DISCUSSION AND CONCLUSIONS: The findings of the study suggest that the drinking of family and friends can be a substantial burden for their households, families, friends and others. Policy approaches that reduce the amount of heavy drinking, particularly heavy drinking in a single occasion, are likely to reduce the burden of caring for others because of other's drinking.

Ambulance triage and treatment zones at major rugby events in Wellington, New Zealand: a sobering experience.

AIMS: A prospective analysis was undertaken of the workload of prehospital triage and treatment facilities established in Wellington for the 2011 and 2012 International Rugby Sevens, and the Rugby World Cup 2011 (RWC). The introduction of an alcohol intoxication pathway, the impact of the initiative on ambulance and Emergency Department (ED) workload, and its cost effectiveness were assessed. METHODS: A log of patients seen and their diagnoses and treatment was maintained. An alcohol questionnaire was completed when applicable. Patients intoxicated with alcohol were managed in accordance with a flowchart designed for paramedic use. Costs and savings were calculated. RESULTS: Half the patients were New Zealanders. The average age was 25 years with a slight female preponderance (52.9% female). 30% were students. Alcohol was a contributory or causative factor for the patient's attendance in 80-90% of cases. Approximately 60% of the 121 patients seen at the last two events would have had to be transferred to the ED in the absence of the treatment centre. Cost savings for the ambulance service and ED for the RWC and 2012 Sevens are estimated to be NZ$70,000. No adverse clinical event was identified. CONCLUSIONS: With minimal supervision, event medics and paramedics can safely care for the majority of patients attending large rugby events in New Zealand, easing the pressure on ambulances and the ED, and generating significant cost savings for those services.

Safe sobering: San Francisco's approach to chronic public inebriation.

Dedicated to the care of alcohol dependent people, the San Francisco Sobering Center cares for intoxicated clients historically treated via emergency services. With 29,000 encounters and 8,100 unduplicated clients, the Sobering Center safely and efficiently provides sobering and health care services to some of the City's most vulnerable people.

Emergency department visits due to alcohol intoxication: characteristics of patients and impact on the emergency room.

AIMS: The aim of the study was to describe the epidemiology, management and cost of emergency department (ED) visits due to alcohol intoxication. METHODS: A retrospective review of medical records of all episodes of alcohol intoxication was made, excepting those where another diagnosis such as trauma or psychiatric illness was primary, in patients older than 16 years, who presented to the ED of a large university hospital in Belgium over a 12-month period from 1 January 2009. RESULTS: A total of 635 such patients accounted for 1.2% of all ED visits; 429 were males and 48.3% were aged between 41 and 60 years; 63.8% of the patients had a history of alcohol use disorder and 60.3% had a history of psychiatric disorder; 74.3% of the patients received some form of medical treatment and 62% were seen by a psychiatrist. Of the total, 57.5% of the patients were admitted to the ED observation ward, with a mean length of stay of 8.4 h. The estimated total cost was €318 838.25, with an average of €541.32 per patient. CONCLUSION: Alcohol intoxication leads to a financial burden on the community. In addition to imposing physical, social and psychological stress on the community, the often agitated or aggressive patient imposes stress on ED staff. Close surveillance of trends in alcohol abuse is warranted, and the ED should consider implementing a questionnaire method of screening for alcohol abuse.

Individual-level interventions for alcohol-related violence: a rapid evidence assessment.

BACKGROUND: Alcohol-related violence is of major concern to society. Around half of all violent crimes are alcohol related, and yet interventions for alcohol-related violence are under-developed. Often, offenders receive treatment for substance use or violence, but not the two in nexus. AIM: My aim was to conduct a Rapid Evidence Assessment of interventions with a focus on treating established nonsexual violence in the context of alcohol use, to describe the content of these interventions, where they take place and their effectiveness in reducing alcohol problems and/or violence. METHODS: The electronic databases Embase, Medline, National Criminal Justice Reference Service, Cumulative Index to Nursing and Allied Health Literature were searched together with the Campbell Collaboration; Cochrane Reviews and selected government websites using terms for alcohol, violence and treatment/interventions. The search excluded sexual and intimate partner violence. The focus was on psychosocial interventions with people already in difficulties, not prevention. All empirical study types with people of any age and in any setting (criminal justice, health, social services or education) were included. The principal outcomes of interest were change in alcohol use, violence and alcohol-related violence. RESULTS: Only four studies of two different interventions were identified. Control of Violence for Angry Impulsive Drinkers has been evaluated with small samples using a nonequivalent comparison group and a single case methodology. Changes were evident on measures of alcohol-related aggression. In a randomised controlled trial, SafERteens participants showed greater improvements in attitudes to alcohol and violence compared with a leaflet only condition. DISCUSSION: Directions for developing interventions based on alcohol and aggression research are discussed. Interventions targeting primarily alcohol consumption, primarily violence and alcohol-related violence in nexus should be compared. In evaluating these interventions, robust outcome measures should be used across studies to allow comparisons to be made. CLINICAL IMPLICATIONS: Skills for coping with perceived provocation may be taught, so that nonviolent options are available and so that they become more accessible when people are under the influence of alcohol. Alcohol's effect on reducing self-awareness may be counteracted by teaching mindfulness techniques and the ability to 'act sober' in provocative situations. Setting individual implementation intentions may facilitate harm avoidance in high-risk social situations through preplanning of specific sensible behavioural strategies.

A pilot study of emergency medical technicians' field assessment of intoxicated patients' need for ED care.

OBJECTIVE: Alcohol-intoxicated individuals account for a significant proportion of emergency department care and may be eligible for care at alternative sobering facilities. This pilot study sought to examine intermediate-level emergency medical technician (EMT) ability to identify intoxicated individuals who may be eligible for diversion to an alternative sobering facility. METHODS: Intermediate-level EMTs in an urban fire department completed patient assessment surveys for individual intoxicated patients between May and August 2010. Corresponding patient medical records were retrospectively reviewed for diagnosis, disposition, and blood alcohol content. Statistical analysis was conducted to determine correlates of survey response, diagnosis, and disposition; and survey sensitivity and specificity were calculated. RESULTS: One hundred ninety-seven patient transports and medical records were analyzed. Emergency medical technicians indicated 139 patients (71%) needed hospital-based care, and 155 patients (79%) had a primary ethanol diagnosis. Fourteen patients (7%) were admitted to the hospital, and EMTs identified 93% of admitted patients as requiring hospital-based care. Overall sensitivity and specificity of the survey were 93% (95% confidence interval, 66.1-99.8) and 40% (95% confidence interval, 33.3-47.9), respectively. CONCLUSION: Intermediate-level EMTs may be able to play an important role in facilitating triage of intoxicated patients to alternate sobering facilities.

Improving the care of mentally ill patients in a tertiary emergency department: development of a psychiatric assessment and planning unit.

OBJECTIVE: The aim was to describe the Psychiatric Assessment and Planning Unit (PAPU), established at the Royal Melbourne Hospital (RMH) to improve access to psychiatric care for patients presenting via the Emergency Department (ED). METHOD: PAPU was opened in January 2007. Data was recorded from RMH ED databases to compare ED lengths of stay (LOS) prior to and after establishing PAPU. Interventions including requirement for one-to-one nursing (i.e. one nurse dedicated to the care and observation of one patient) and mechanical restraint and unarmed security threats are routinely documented and were compared before and after PAPU opened. Demographic data and inpatient LOS information was collected by clinicians in PAPU. RESULTS: During the 12 months of initial evaluation we found that PAPU assisted with reducing the number of patients waiting excessive LOS in the RMH ED essentially to zero, due to both expedient transfers from ED and increased direct admissions from the community. We were also able to demonstrate a reduction in mechanical restraint, security codes for unarmed threats and one-to-one nursing in the ED. CONCLUSIONS: The establishment of the PAPU at RMH has resulted in significant improvement in the care of patients with mental illness in the least restrictive environment, based on decreased LOS and need for interventions.