Having some drinks: A normal part of growing up or a signal of a larger problem?

A 13-year-old boy is brought to the emergency department by his friend’s parents. The parents had returned home after a panicked call from their son saying his friend would not wake up and was starting to retch.

A group of teenagers had been playing ‘drinking games’ in the basement. They were drinking alcohol they each brought from home, mixed with energy drinks. They reported that their friend had consumed the most drinks (>12 shots in the previous 2 h), began to slur his words, fell and hit his head on the edge of the table while trying to get up. He vomited once and then became very drowsy and was difficult to rouse. The friends believed he had sustained a concussion.

In the emergency department, the adolescent was confused, mumbling and unable to give any additional history about his past medical and psychiatric health, or previous exposures and ingestions. He had a minor laceration on his forehead, was very unsteady on his feet, was combative with staff and had vomited once since arrival. He was protecting his airway and breathing well. His neurological examination was normal aside from his presenting decreased level of consciousness, which improved with intravenous fluid administration; therefore, neuroimaging was not performed.

A urine toxicology screen was positive for alcohol and marijuana, and his blood alcohol level was high. His treatment included intravenous fluids, a mild sedative and oxygen administered by nasal prongs. His parents were initially not reachable by telephone at home. A consultation with a social worker was requested.

On waking, a history based on a behavioural health screening tool revealed previous episodes of drunkenness, both alone and with friends to relax, and trials of marijuana and ecstasy. He had been previously diagnosed with attention-deficit hyperactivity disorder and reported only intermittent use of his prescribed long-acting stimulant. School difficulties and conflict with family were additional risk factors identified by the social worker, whose involvement was important in resolving the situation. Given his young age at initial presentation and history of previous substance use, he was believed to be at high risk for ongoing problematic use. On discharge, the adolescent and his family were referred to community mental health services to address identified medical, familial and educational problems.

LEARNING POINTS

• Alcohol remains the most commonly used drug among adolescents 12 to 18 years of age (46% to 62% overall) (1–3).

• Binge drinking is defined as three or more drinks in children nine to 13 years of age or girls 14 to 17 years of age, and four or more drinks in boys 14 and 15 years, on one occasion (4). The prevalence of binge drinking remains high among adolescents (as high as 19% to 30%) and rates have been rising, reaching almost one-half of students in grade 12 (1–3,5).

• Early alcohol use, while the brain is still developing, has been associated with poor school performance, greater sexual risk-taking (including unprotected sex, multiple partners and unwanted sexual advances), abuse of other substances, delinquent behaviour and increased risk of mental health disorders (3,6,7).

• Adolescents commonly have coingestions with illicit drugs (most often cannabis, up to 15%), nonmedical use of prescription drugs and energy drinks. Those with higher consumption of energy drinks reported higher rates of alcohol consumption (2,5,8).

• Health care providers should conduct routine annual substance use screening of all adolescents. CRAFFT (a mnemonic acronym of the first letters of key words in the six screening questions: Car, Relax, Alone, Forget, Friends, Trouble) is an easy-to-use, validated behavioural health screening tool (6).

• Identifying risk factors for problematic use (earlier age of first use, coingestions, comorbidities) may help to identify individuals at greatest risk (3).

• The Canadian Paediatric Surveillance Program study of severe alcoholic intoxication in adolescents was launched in March 2013. In the first four months of surveillance, 11 cases were reported. Study data will help facilitate the development of harm reduction strategies.