Global EM Alcohol Misuse and Its Impact on Emergency Medicine Across the Globe

Alcohol Misuse and Its Impact on Emergency Medicine Across the Globe

By Alena Pauley, MScGH; Frida Shayo, MD, MMed; and Catherine Staton, MD, MScGH on behalf of the SAEM Global Emergency Medicine Academy

As a core component of the health care safety net, emergency departments (EDs) have always seen epidemics before or as they rise; our worsening rates of alcohol use disorder are no different. This alarming trend joins the other sociocultural factors impacting who uses and frequents EDs, bringing now more women into this environment. Just within the United States (U.S.), for example, the last 20 years have seen over 50% more alcohol-related ED visits, disproportionately so from women. One study found that from 2006 to 2014, there was a 70% increase in alcohol-related ED visits in U.S. women compared to a 58% increase in men. To effectively tackle this trend that stands to have a tremendous impact at both the local ED and wider population level, multi-pronged approaches that focus on systemic, preventative care and greater resources to EDs worldwide will be needed. What exactly will this increase in alcohol use mean for emergency medicine? In the short term, the growing number of alcohol-related visits stand to create greater disruptions around ED patient flow and care. As most ED physicians can attest, intoxicated patients not only tend to be more aggressive—potentially causing harm to themselves, health care staff, and/or other patients—but their altered status makes their complaints more difficult to identify and treat. When EDs across the U.S. are already overwhelmed with critically ill and injured patients packed in overcrowded waiting rooms most days of the week, a rise in intoxicated

“...the growing number of alcohol-related visits stand to create greater disruptions around ED patient flow and care.”

patients is yet another factor with which our overstressed clinics must contend.

At the population level is the disproportionate physiological harm women stand to face from increased alcohol intake. For a myriad of reasons, women have higher blood alcohol concentrations at similar or lower amounts of drinking. Women who drink unhealthy amounts of alcohol are also at higher risk for heart disease, brain damage, and liver damage than men. With the ED serving as health care's catch-all, this could mean a higher incidence of chronic conditions, cardiac arrests, or psychiatric complaints down the line.

These trends are rising at a concerning pace, even more rapidly on a global scale, and especially so in low- and middle-income countries. Global per capita alcohol use has surged by almost 30% in the last 25 years, with countries like China and India driving this uptick. In settings that have limited resources and trained personnel to help treat alcohol use disorders and related issues, the social, physical, and financial strain this could place on patients, communities, and local EDs is daunting. To illustrate this, the U.S. has similar rates of alcohol consumption as Uganda (in both locations, the average person drinks between 9.5 to 10 liters of alcohol every year). However, Uganda has a gross domestic product (GDP) per capita more than 75 times less than that of the U.S., leaving Uganda with comparatively little funds available to devote to alcohol-related services.

The Duke Global Health Institute’s Global Emergency Medicine Innovation and Implementation ((GEMINI) Research Center has held a long-term interest in alcohol use in global ED settings, facilitated by a strong, ongoing partnership with the Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.

For us at GEMINI and KCMC, the global rise in women’s alcohol use parallels our growing research interest in this area, which emerged after the implementation of an ED-based intervention to minimize excessive alcohol consumption. It was in this clinical trial housed within KCMC that we first observed significant inequities in how Tanzanian women access alcohol-related treatment services, even when controlling for the higher rates of use among men.

To better understand this discrepancy, we conducted a study at KCMC that explored gender differences in alcohol use. In the interviews completed as part of this, several participants noted that some men and women in Tanzania now drink almost equal amounts. Shifting gender roles has been a primary driver of this change, with more Tanzanian women working outside the home and being financially productive or independent. In a society where this behavior among women was unheard of only twenty years ago, this upward trend is arguably even more dramatic than in the U.S., with profound implications for the future of global emergency medicine.

While current treatments like the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model adopted and adapted from high-income countries are effective linkages to care, those resources in many settings don’t exist to meet the demand. Just like in high-income settings, a renewed focus on infrastructure development, mental health, and substance abuse treatment services must be a priority to understand and avert the sociocultural drivers of unhealthy alcohol use. It is these changes, paired with concrete policy change, that will enable us to protect our coming generations.

ABOUT THE AUTHORS

Alena Pauley is a Peace Corps Volunteer in Nepal and a recent graduate of the Masters in Global Health program at Duke’s Global Health Institute. She works currently as a clinical research coordinator within Duke University’s emergency department which she balances alongside her ongoing research endeavors.

Dr. Shayo is a practicing emergency medicine physician at the Kilimanjaro Christian Medical Center, Moshi, Tanzania.

Dr. Staton is an associate professor of emergency medicine, neurosurgery, and global health with tenure at Duke University; cofounder of the Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center in the Duke Department of Emergency Medicine and the Duke Global Health Institute.

About GEMA

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