Treatment of alcohol intoxication at university health services: examining clinical characteristics, drinking patterns, and adherence with referral.
Objective: This study examines' demographics, clinical characteristics and drinking patterns of students presenting with alcohol intoxication at a university health service. Participants: The sample included one hundred students (50% female, 48% freshmen) treated for alcohol intoxication at university student health services. Complete medical charts were obtained for 80 students (43% female, 46% freshmen). Methods: A prospective case review was performed between September 2005 and March 2006. Results: Although males reported having more drinks before admission, drinking more frequently, and having more drinks per drinking day than females, there were no other gender differences. Freshmen comprised almost half the admissions, but there were no significant differences in drinking patterns across school years'. While only 54% of students were given follow-up referrals, 72.2% of students complied with recommended referrals. Additional assessment information included alcohol use disorders sceening scores, history of previous alcohol intoxication, problems related to use, symptoms of anxiety and depression, and use of antidepressant medication. Conclusions." These results suggest that further investigations of student characteristics and experiences prior to contact with university health services are warranted and may be necessary to the development and implementation of programs to reduce harmful alcohol consumption.
Rates of binge drinking among college students (five or more drinks per occasion for men and four or more drinks per occasion for women) have remained relatively stable: Approximately forty-four percent of all college students report binge drinking over the course of a school year, with roughly half reporting occasional binge drinking and half reporting frequent binge drinking (Wechsler et al., 2002). The Monitoring the Future project that took place in 2005 reported similar findings. The majority (83.0%) of full-time college students reported consuming alcohol within the last year, and 40.1% of students reported drinking five or more alcoholic beverages in a row in the past two weeks (Johnston, O'Malley, Bachman, & Schulenberg, 2006). Additionally, college students reported a significantly greater number of heavy drinking episodes than their same-age peers not enrolled in college. College students were also more likely to confine their drinking to a limited number of days per week but drink in greater quantities during those days compared to non-students their ages (Johnston, O'Malley, Bachman, & Schulenberg, 2006).
Binge drinking by college students has been associated with numerous negative long-term and short-term consequences including increased incidence of health problems, risk of unintentional injury, poor academic performance, and driving under the influence (Barnett et al., 2003; Cherpitel, 1993; Wechsler et al., 2002). In addition, students who binge drink are at an increased risk for date rape, sexual assault, engaging in unwanted sexual activity, and not using adequate protection against pregnancy and sexually transmitted diseases while intoxicated (Wechsler, Lee, Kuo, & Lee, 2000; Wechsler et al., 2002). Furthermore, consequences of heavy episodic or binge drinking are not limited to drinkers themselves, but may also result in negative consequences, or "secondhand effects," for non-drinking college students. For example, students report unwanted sexual advances, engagement in physical or verbal fights, and study or sleep interruption as a result of binge drinkers' behaviors (Turner & Shu, 2004).
The use of emergency medical treatment following severe intoxication among college students has been documented by previous research (Barnett et al., 2003; Helmkamp et al., 2003; Wright, Norton, Dake, Pinkston, & Slovis, 1999; Wright & Slovis, 1996); however, fewer studies have focused on the reasons why some college students consume enough alcohol to require medical attention. While the use of alcohol by college students is widespread, and roughly half of these drinkers report binge drinking, far fewer receive medical care following acute intoxication (Helmkamp et al., 2003; Wright & Slovis, 1996). This suggests that students presenting for urgent treatment with acute alcohol intoxication may be a unique subgroup; however, little is known regarding how these individuals may differ from their binge drinking peers who do not seek medical care.
Previous studies have reported similar rates for males and females receiving treatment for alcohol-related emergencies as well as a greater frequency of admissions for college freshmen (Barnett et al., 2003; Wright, Norton, Dake, Pinkston, & Slovis, 1999; Wright & Slovis, 1996). Wright and Slovis (1996) reviewed admissions of college students to a university hospital emergency department and found an overall incidence of 3.9 students per 1,000 per year requiring medical treatment for alcohol intoxication. This rate was almost 2 1/2 times greater for first year students who had an incidence of 9.3 per 1,000 students per year. However, they found no significant difference between proportions of males and females who presented for treatment (Wright & Slovis, 1996). In another recent study, Reis and colleagues (2004) interviewed 50 first-year college students after transport for medical care following alcohol intoxication. In general, these first year students did not view themselves as being at risk for alcohol overdose before the overdose event, and stated that the event was due to bad decision making rather than a typical pattern of heavy drinking (Reis, Harned, & Riley, 2004).
While prior research has addressed characteristics of college students treated at Emergency Departments (EDs) for alcohol intoxication, research has generally not adequately addressed utilization of university health services among college students for both acute alcohol-related problems as well as for follow-up interventions. The aims of the current study were to (1) examine characteristics of students treated at university health services following alcohol intoxication, and (2) explore the rate of compliance with the recommendation to seek further evaluation among students referred for follow-up.
Based on existing literature, we hypothesized that males and females would present for acute alcohol treatment to university health services at similar rates, but that drinking patterns (especially rates of binge drinking) would differ significantly by gender. We also hypothesized that freshmen students would be more likely than those in upperclasses to seek treatment for alcohol intoxication. In addition, we explored other characteristics of these students including their CRAFFT scores (an acronym mnemonically based on key words of the 6-question alcohol screening test, Knight et al., 1999), symptoms of anxiety and depression, previous history of admissions for alcohol intoxication, history of alcohol consumption, and other alcohol related problems. Finally, we analyzed the rate at which follow-up appointments were made and the rate of compliance among students who were referred for follow-up.
A review of the medical records of consecutive admissions for alcohol intoxication to University Health Services (UHS) After Hours Urgent Care Center was performed between September 1, 2005 and March 12, 2006. IRB approval was obtained from both McLean Hospital and Harvard University. The urgent care center provides 24-hour care for the university community. Students presented for treatment to UHS by self-referral, referral by a concerned friend, or referral by university personnel (e.g., residential life staff or university police). Students who were agitated or were so intoxicated that they required closer monitoring were sent to a local emergency department for stabilization, but were typically transferred to UHS prior to returning to campus.
As a part of the UHS evaluation, nurses administered an alcohol assessment questionnaire that included the CRAFFT questions which were developed to screen for alcohol dependence in the adolescent population (Knight, Sherritt, Harris, Gates, & Chang, 2003; Knight et al., 1999), selected questions from the Alcohol Use Disorders Identification Test (AUDIT) screening tool (Saunders, Aasland, Babor, de la Fuente, & et al., 1993), and questions screening for symptoms of depression and anxiety. Knight and colleagues (2003) reported that a score of two or more positive answers on the CRAFFT questionnaire indicates a need for intensive treatment, and a score of 1 positive answer warrants further evaluation. Several studies have demonstrated that the instrument has high sensitivity and specificity for treatment need as well as identification of alcohol use disorders (Knight, Sherritt, Harris, Gates, & Chang, 2003; Knight, Sherritt, Shrier, Harris, & Chang, 2002; Knight et al., 1999) The AUDIT questions included in the measure were "How many drinks of alcohol do you have on a typical day when you're drinking?" and "How often do you have 5 or more drinks at one sitting (4 for women)?"
Follow-up care for students admitted for alcohol intoxication is provided at UHS by the student's primary care doctor. In certain cases, an additional appointment is made for the student with a clinician in Mental Health Services or with the director of Alcohol and Substance Abuse Services for educational programming. Specific follow-up care plans for students in this study were recommended on a case-by-case basis by the UHS physician who saw the students in the urgent care center prior to discharge. At the time of this study, there was no standard procedure for recommending follow-up medical care or mandated administrative sanctions for these students.
To compare gender and year in school by background variables, chi-square analyses were used for categorical variables and independent t-tests for continuous variables. Number of drinks prior to admission, drinks per typical drinking day, and frequency of binge drinking (defined as 5 drinks in one sitting for males and 4 for women) were examined using independent t-tests. Total CRAFFT scores were also examined using independent t-tests. Finally, chi-square analyses were used to investigate differences in early semester admissions (defined as admission to UHS during the months of September and October) between freshmen and other upperclassmen and between females and males. All analyses used SPSS 14.0 for Windows.
One hundred (50.0% female) students were admitted to the university after hours acute care service for alcohol intoxication during the study period. Complete charts were obtained from 80 (53.8% females) students. Table 1 presents the characteristics of the entire sample. The mean age for all students was 19.32 ([+ or -] 1.78). The majority of students (78.0%) were below the legal drinking age. Forty-eight percent of students admitted for alcohol intoxication were freshmen, 22.0% were sophomores, 11.0% were juniors, 14.0% were seniors, and 5.0% were graduate students. The majority of students admitted were white (59.3%). There were no significant gender differences across background variables (Table 1). Differences in background variables across school year were significant only for age. Five students required transfer to an ED for additional treatment after presenting to UHS. An additional 30 students were sent directly to an ED without first being seen at UHS. On discharge from the ED, the university requested that students be transferred to UHS for clearance prior to discharge back to their residences.
Gender differences in drinking characteristics and year in school
The mean ([+ or -] SD) drinks prior to admission for all students with complete charts was 8.06 ([+ or -] 5.07). Females reported drinking significantly less than males prior to admission to UHS (t (28.43) = 3.38,p <.01). Women also reported having fewer drinks per typical drinking day (t (76) = 3.45,p <.001) compared to men. In fact, 4.8% of females compared to 25.0% of males reported drinking at least 7 standard drinks on a typical drinking day. Females also reported lower binge drinking frequency than males, with 67.4% of females and 97.3% of males reporting ever having at least one episode of binge drinking (t (78) = -3.67, p < .001). 14 (32.5%) females compared to only one male (3.7%) reported never binge drinking (see Table 1).
Year in School Differences by Month of Admission and Other Characteristics
There was a significant difference in month of admission between freshmen and upper-class students (Figure 1). Freshmen were significantly more likely than upper-class students to be admitted in the first two months of the year (55.8%, p < .05). Furthermore, freshmen were significantly more likely to be admitted in the first two months than later in the academic year (60%, p < .05). There was no significant difference between males and females in month of admission. In fact, males and females were equally likely to have been admitted early in the semester (50.0% females admitted during September and October). Although freshmen were overrepresented in our sample, there were no significant differences between freshmen and upper-class students in the overall mean drinks prior to admission to UHS, mean drinks per drinking day, frequency of binge drinking, or CRAFFT scores.
Drinking Histories and Symptoms of Anxiety and Depression
Of the students with complete medical records, twenty-five (31.3%) reported experiencing anxiety in the two weeks prior to admission, eighteen (22.5%) endorsed one or more symptoms of depression in the preceding two weeks, one reported having "thoughts of harming self or recurrent thoughts of death," and eight (10.0%) reported taking antidepressant medications. Of all students admitted to UHS, twenty-nine (29.0%) had been previously seen by UHS mental health services and six (6.0%) had a documented history of alcohol related problems. Ten students (10.0%) were admitted to urgent care more than once for alcohol intoxication.
The mean CRAFFT score for students with complete charts was 1.44 ([+ or -]1.32). The range of CRAFFT scores in our sample was 0-5, with 26 students (32.5%) endorsing two or more criteria. The most frequently reported CRAFFT item was forgetting things done under the influence, which was endorsed by 48 students (60.0%). Twenty-four students (30.4%) reported doing something while intoxicated that they would not have done otherwise. CRAFFT scores and anxiety and depression symptoms did not differ significantly between male and female students.
Adherence to Recommendation for Further Evaluation
Students were discharged with a scheduled follow-up appointment in primary care in 54% of cases. Thirty-nine (72.2%) of these 54 students followed through with the primary care appointment that was scheduled for them.
As expected, we found an overrepresentation of freshman students admitted to university health services for alcohol intoxication. These findings are consistent with previous research demonstrating that freshmen are more likely to present for alcohol-related medical treatment compared with their upper-class peers (Wright, Norton, Dake, Pinkston, & Slovis, 1999; Wright & Slovis, 1996) We also found that freshmen students were more likely than their upper-class counterparts to present for treatment within the first two months of school (Figure 1). This finding may suggest a degree of drinking inexperience that leads to drinking too much too fast, and this pattern may differ from that of students admitted with alcohol intoxication later in the year (Barnett et al., 2003).
As expected, there was no gender difference in the rate of admission for alcohol intoxication. However, drinking patterns differed significantly by gender. Female students presented for treatment after using significantly less alcohol than males in the hours preceding admission. In our sample, males reported significantly greater numbers of drinks per typical drinking day and greater frequency of binge drinking episodes than females. These findings replicate other studies indicating increased vulnerability of females to the acute effects and other consequences of drinking at lower doses than their male counterparts, due in part to differences in physiologic sensitivity and alcohol metabolism (Ely, Hardy, Longford, & Wadsworth, 1999; Greenfield et al., 2007). This finding may also reflect gender differences in perceptions about what is an acceptable level of intoxication for college women versus men as many referrals were made by concerned friends. In this study, females reported fewer binge episodes and drank fewer drinks per occasion, but the number of female admissions to UHS and their CRAFFT scores were not significantly different from males.
In our sample, 54% of students were referred for a follow-up appointment with a primary care physician (PCP), and 10% of these students were also referred to a mental health clinician or other counselor for further evaluation of their drinking behaviors. Different attitudes of urgent care physicians regarding binge drinking may have contributed to inconsistencies in the recommended follow-up. Alternatively, physicians may have used their own clinical judgment to refer only those students for whom the intoxication appeared to be more than an isolated event. Our sample was too small to capture potential differences between students who did and did not receive referrals. It is particularly notable that when primary care follow-up appointments were made for students at the time of discharge from UHS, the rate of compliance was high (72.2%). This finding is encouraging given previous data about college students' low rates of follow-up with recommended alcohol evaluation following routine screening (Greenfield et al., 2003). In a follow-up study of National Alcohol Screening Day, Greenfield and colleagues (2003) found that only 20% of college student participants followed through with recommended additional evaluation compared with 50% of non-college community participants.
However, students that have had a specific incident, such as one that resulted in evaluation at UHS, may be more motivated to comply with recommended follow-up than students in a routine screening setting. This higher rate of compliance with follow-up recommendations in the setting of acute alcohol intoxication is consistent with studies in other populations treated in emergency room settings (Helmkamp et al., 2003). It is possible that follow-up appointments with a primary care physician are perceived by students as less stigmatizing. In addition, students may be more likely to participate in follow-up that does not involve a commitment to multiple visits. This finding is also encouraging given that students are likely to benefit from even a single follow-up meeting when motivational enhancement techniques are employed. Other research has demonstrated that students who presented to an ED for treatment responded well to brief interventions (Ehrlich, Haque, Swisher-McClure, & Helmkamp, 2006; Helmkamp et al., 2003). Therefore, student health services may be a venue where a motivational interviewing approach may be especially useful.
Our study indicates that routine referral by university health services in the setting of acute intoxication can provide an opportunity for education and intervention in the college population. Since this data were gathered, the university health services implemented a new procedure in which all UHS students who present for treatment of alcohol intoxication are provided a follow-up appointment with their PCP and invited to meet with the director of Alcohol and Substance Abuse Services. This decision is no longer left to the discretion of the discharging clinician. Together, our results suggest that scheduling an appointment with the student prior to discharge is likely to improve compliance with recommended follow-up, and incorporating motivational interviewing techniques may further enhance the effectiveness of this intervention.
Our study provides preliminary evidence for certain subgroups of students who present with alcohol intoxication. Many of the students in our sample endorsed symptoms of anxiety or depression prior to their most recent drinking episode; however, despite the fact that nearly one third had previously been seen in mental health, few had been formally diagnosed with a mood or anxiety disorder. While we did not have data regarding the proportion of these students who were engaged in ongoing counseling or behavioral treatment, very few of these students reported receiving pharmacologic treatment for anxiety or depression. Previous work has suggested that most college students drink for social reasons rather than to "self-medicate" for psychiatric symptoms (Reifman & Watson, 2003). However, students with anxiety and depression report that their psychiatric symptoms often pre-date their alcohol related problems (Ross & Tisdall, 1994). Research has also found that students with higher levels of anxiety and depression indicate greater readiness to change drinking behaviors, perhaps due their self reflection regarding the consequences of drinking (Smith & Tran, 2007). Therefore, our results suggest a need for ongoing screening and treatment for these conditions in the college population, particularly in students with problematic drinking patterns.
A small number of students in our sample had been previously identified as having alcohol use problems, and 10% of students presented to UHS with intoxication more than once. It is possible that these students represent a sub-group with more significant alcohol problems that require a more intensive level of intervention. In addition, 35% of students in our sample required treatment at a local ED for medical stabilization due to their degree of intoxication. Our sample size was too small to capture whether this sub-group may also differ from the larger population in drinking patterns, consequences of use, or other clinical characteristics. One third of our sample endorsed two or more CRAFFT criteria, thus crossing the previously defined threshold suggestive of an alcohol problem needing intensive treatment. In addition, nearly one fourth of the students reported having done something while intoxicated that they would not have otherwise done and sixty percent reported blackouts or forgetting things done while intoxicated. It is possible that students reporting these negative consequences of drinking carry a different level of risk for future problems than their counterparts for whom a single presentation for the treatment of alcohol intoxication represents an isolated incident. Students who report some negative consequences related to their drinking also represent a group that may be quite amenable to brief motivational enhancement interventions. Longitudinal studies explicating the course of student's drinking behaviors and exploring the relationship of other variables such as anxiety and depression will be necessary to better serve this population.
Our study design limits the generalizability of our results in several important ways. The sample consisted primarily of White and non-Hispanic young adults. Also, these results are based on a convenience sample of students seeking treatment for alcohol intoxication in one student health services' urgent care setting. Since only students admitted for treatment of acute intoxication completed the alcohol use questionnaire, we have no comparison of drinking patterns and binge drinking rates with other non-treatment seeking university students. Information about family history of alcohol use disorders or psychiatric illness was not available for the majority of students in our sample. Given the association between family history and development of alcohol use disorders, this is an important measure of potential risk. University health centers should be encouraged to gather both general information about students' patterns of alcohol and other drug use as well as family history of addictive disorders as a part of routine evaluation of college students, and in particular those who present for treatment of intoxication.
In spite of these limitations, this study contributes new information regarding characteristics of college students presenting for medical treatment for alcohol intoxication and their rates of follow-up with recommendations for further evaluation. In addition, our results suggest that university health services can provide a critical venue for alcohol education and intervention, and that targeting freshman early in their first semester of college may be especially warranted. Screening and brief interventions have been noted to be successful in many populations (Ehrlich, Haque, Swisher-McClure, & Helmkamp, 2006; Helmkamp et al., 2003). The university urgent care service can have an important role delivering these interventions to the significant minority of students most at risk for developing alcohol use disorders: those presenting with threshold screening scores, specific negative consequences of their drinking such as blackouts or unwanted behaviors while intoxicated, as well as histories of depressive or anxiety symptoms that preceded the drinking episode requiring evaluation. Finally, more research is necessary to demonstrate the most effective means to provide prevention of binge and problematic alcohol use especially before or within the first semester.
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Margaret M. Benningfield, MD
Cambridge Health Alliance
Elisa M. Truceo, BA
State University of New York at Buffalo
Paul J. Barreira, MD
Harvard Medical School
Shelly F. Greenfield, MD, MPH
Harvard Medical School
Correspondence concerning this article should be addressed to: Shelly F. Greenfield, 115 Mill Street, Belmont, MA 02478; Phone: (617) 855-2241; Fax: (617) 855-2699; email: email@example.com.
TABLE 1 Comparison of women and men by background characteristics Women (n=50) Men (n= 50) Back round variables Age Mean [+ or -] SD) 19.28 [+ or -] 1.75 19.36 [+ or -] 1.82 Race n (%) a Caucasian 26 (61.9%) 25 (56.8%) 16 (38.1%) 19 (43.2%) Other Year in Class Freshmen 21 (42.0%) 27 (54.0%) Sophomores 14 (28.0%) 8 (16.0%) Juniors 3 (6.0%) 8 (16.0%) Seniors 10 (20.0%) 4 (8.0%) Drinking variables Drinks prior to 6.03 [+ or -] 2.70 10.70 [+ or -] 6.18 admissions (a) Mean [+ or -] SD) * Drinks per drinking day (%) 1-2 rinks 12 (28.6%) 2 (5.6%) 3-4 drinks 18 (42.9%) 13 (36.1%) 5-6 drinks 10 (23.8%) 12 (33.3%) 7-8 drinks 1 (2.4%) 8 (22.2%) 9+ drinks 1 (2.4%) 1 (2.8%) Binge drinking frequency (%) ** Weekly 6 (14.0%) 12 (32.4%) Monthly 8 (18.6%) 13 (35.1%) Less than monthly 15 (34.9) 10 (27.0%) Never 14 (32.6%) 1 (3.7%) CRAFFT score 1.33 [+ or -] 1.22 1.56 [+ or -] 1.42 (Mean [+ or -] SD) Total (n = 100) Back round variables Age Mean [+ or -] SD) 19.32 [+ or -] 1.78 Race n (%) a Caucasian 51 (59.3%) 35 (40.7%) Other Year in Class Freshmen 48 (48.0%) Sophomores 22 (22.2%) Juniors 11 (11.0%) Seniors 14 (14.0%) Drinking variables Drinks prior to admissions (a) Mean [+ or -] SD) * Drinks per drinking day (%) 1-2 rinks 3-4 drinks 5-6 drinks 7-8 drinks 9+ drinks Binge drinking frequency (%) ** Weekly Monthly Less than monthly Never CRAFFT score (Mean [+ or -] SD) * p<.01 ** p<.001 (a) n=86, race undisclosed 8, race missing
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|Author:||Benningfield, Margaret M.; Truceo, Elisa M.; Barreira, Paul J.; Greenfield, Shelly F.|
|Publication:||Journal of Alcohol & Drug Education|
|Date:||Apr 1, 2009|
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