Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2019 Mar 1.
Published in final edited form as: Alcohol Clin Exp Res. 2018 Feb 1;42(3):489–491. doi: 10.1111/acer.13593

Commentary on White and Colleagues: Trends in Alcohol-Related Emergency Department Visits in the United States: Results from the Nationwide Emergency Department Sample, 2006–2014 (ACER, 2018)

Megan E Patrick 1,*, Yvonne M Terry-McElrath 1
PMCID: PMC5832598  NIHMSID: NIHMS932982  PMID: 29314078

Epidemiological research has documented a puzzling disconnect between recent alcohol-related trends in the United States. Studies comparing year-to-year prevalence of alcohol use and binge drinking have shown that drinking has been decreasing among adolescents and young adults (Center for Behavioral Health Statistics and Quality, 2015; Miech et al., 2017; Schulenberg et al., 2017). In seeming contradiction to such decreasing use, trends in demand for alcohol-related hospital services—particularly for emergency department (ED) and inpatient services—have been increasing (National Institutes of Health, 2013). New research by White and colleagues (2018) has added further confirmation of increasing demand for alcohol-related health care, documenting that overall ED visits involving both acute and chronic alcohol consumption rose dramatically between 2006 and 2014.

The new results of White and colleagues (2018) also bring attention to a potential solution to the puzzle, by identifying divergence in age-specific trends of alcohol-related ED visits. Specifically, they report that between 2006 and 2014, the rate of change in overall, acute, and chronic alcohol-related ED visits significantly increased for all adult age groups (18 and older), with the greatest increases observed for middle-aged adults. Among adolescents (aged 12–17), overall and acute alcohol-related ED visits significantly decreased, while chronic alcohol-related ED visits significantly increased (White et al., 2018). Identification of different trends in alcohol-related ED visits for adolescents, young adults, and adults highlights the importance of understanding age-specific patterns in alcohol consumption.

Here, we comment on existing, age-specific data consistent with two possibly complementary working theories regarding what may explain the trends in alcohol-related ED visits. First, increases in alcohol-related ED visits may be attributable to an increasing intensity of alcohol use among drinkers (Patrick, 2016; Patrick et al., 2013; Patrick et al., 2017a; White et al., 2018). Second, increased co-ingestion of alcohol with other drugs may be exacerbating risks and contributing to increases in alcohol-related ED visits.

High-Intensity Drinking

One way to examine the intensity of alcohol use is to document changes in high-intensity drinking, defined as consuming twice or three times the typical binge drinking threshold of 5 drinks (or 4 for women and 5 for men) in a row (Patrick, 2016). Developmental trends indicate that the prevalence of high-intensity drinking increases with age from adolescence into young adulthood (Patrick et al., 2016). Based on U.S. data in 2016, having 10 or more drinks in a row in the past two weeks was reported by 1% of 8th graders (Patrick et al., 2017b), 3% of 10th graders (Patrick et al., 2017b), and 4% of 12th graders (Miech et al., 2017). Data from 2005 to 2016 indicate that this level of drinking is reported by 11% of young adults ages 19 to 30 (Schulenberg et al., 2017). From age 30 onward, the prevalence of 10+ drinking decreases with age (Linden-Carmichael et al., 2017).

Historical trends in high-intensity drinking do vary by age. High-intensity drinking among adolescents has decreased over time (Miech et al., 2017; Patrick et al., 2013), although the adolescent prevalence of very high-intensity drinking (15+ drinks in a row) has not decreased as quickly as the prevalence of 10+ drinking (Patrick et al., 2013). White et al. (2018) documented a corresponding significant decrease over time in overall and acute alcohol-related ED visits among those aged 12 to 17; however, the increase in chronic alcohol-related ED visits for this age group remains unexplained by available data regarding trends in high-intensity drinking.

Among adults, Monitoring the Future data have shown decreases in binge and high-intensity drinking among those aged 18–24, relative stability among those aged 25–28, and increases among those aged 29–30 (Patrick et al., 2017a). Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) have shown increased prevalence of alcohol use, binge drinking, and high-intensity drinking in the past 12 months among adults overall when comparing prevalence levels from 2001–2002 with those from 2012–2013 (Grant et al., 2017; Hingson et al., 2017). When NESARC is examined by age group, adults aged 45 and above had greater increases (Grant et al., 2017). Overall, high-intensity drinking appears to be increasing particularly for middle-aged adults and is consistent with the particularly notable increases in acute and chronic ED visits among this age group.

Combined Alcohol and Other Drug Use

Changes in alcohol-related ED visits may also be explained, in part, by changes in the simultaneous use of alcohol and other drugs. Simultaneous use—that is when the effects of alcohol and the other substance overlap—can exacerbate alcohol-related risk. Whether or not alcohol intensity has changed, changes in the prevalence or frequency of combining alcohol with other drugs could lead to changes in acute and chronic alcohol-related problems. White and colleagues (2018) reported that roughly 1 in 6 alcohol-related ED visits involved alcohol use in combination with other drugs. Current evidence points to two particular types of simultaneous use that may be on the rise among adults: use of alcohol with marijuana, and use of alcohol with non-medical prescription drugs.

Simultaneous alcohol and marijuana use is associated with increased alcohol use and negative outcomes including alcohol dependence, harms to self, and drunk driving (Midanik et al., 2007; Subbaraman & Kerr, 2015). Among 12th grade students, simultaneous alcohol and marijuana use also is associated with higher-intensity drinking (Patrick et al., 2017c). Preliminary trend analysis indicated that simultaneous alcohol and marijuana use has been increasing historically among most young adult age groups (Terry-McElrath & Patrick, 2016). Therefore, simultaneous use of alcohol and marijuana may help explain increases in acute and chronic ED visits, at least among young adults.

Co-ingestion of alcohol and non-medical prescription drugs (i.e., opioids, sedatives, stimulants, or tranquilizers) is also significantly and positively associated with high-intensity drinking among 12th grade students in the U.S. (McCabe et al., 2017), and is associated with a range of negative outcomes including blackouts, driving under the influence, illness, and unplanned sex (McCabe et al., 2006). Existing data show that use of nonmedical prescription drugs in the U.S. has decreased in recent years for those aged 18 to 28 (Miech et al., 2017; Schulenberg et al., 2017), has remained generally stable for those aged 26 and older (Center for Behavioral Health Statistics and Quality, 2015), and has significantly increased for those aged 50 and older (Schepis & McCabe, 2016). It remains an open question whether trends for co-ingestion of alcohol with non-medical prescription drugs parallel those for the overall nonmedical use of prescription drugs. If so, increased use of alcohol with nonmedical prescription drugs may help explain the increase in alcohol-related ED visits, at least among middle-aged adults.

Summary and Future Directions

Increased alcohol-related ED visits among adults aged 18 and older are consistent with historical increases in: the prevalence of high-intensity drinking among those aged 29 and older (Grant et al., 2017; Patrick et al., 2017a), simultaneous use of alcohol and marijuana among young adults (Terry-McElrath & Patrick, 2016), and nonmedical prescription drug use among those aged 50 and older (Schepis & McCabe, 2016) that may co-occur with alcohol use. Increased drinking intensity and increased simultaneous use of alcohol with other substances provide two possible theories that support the observed increase in alcohol-related consequences among adults, although trends and explanations differ somewhat based on age. Future research should examine these and other possibilities as explanations for trends in alcohol-related ED visits among adults in the U.S., with particular attention to the specific patterns among adolescents, young adults, middle-age adults, and older adults.

Acknowledgments

Development of this manuscript was supported by National Institute on Alcohol Abuse and Alcoholism research grant R01AA023504 to M. Patrick. The content is solely the responsibility of the authors and does not necessarily represent the official views of the study sponsor.

References

  1. Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50) Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2015. [Google Scholar]
  2. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001–2002 to 2012–2013. JAMA Psychiatry. 2017;74:911–923. doi: 10.1001/jamapsychiatry.2017.2161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Hingson RW, Zha W, White AM. Drinking beyond the binge threshold: predictors, consequences, and changes in the US. Am J Prev Med. 2017;52:717–727. doi: 10.1016/j.amepre.2017.02.014. [DOI] [PubMed] [Google Scholar]
  4. Linden-Carmichael AN, Vasilenko SA, Lanza ST, Maggs JL. High-intensity drinking versus heavy episodic drinking: prevalence rates and relative odds of alcohol use disorder across adulthood. Alcohol Clin Exp Res. 2017;41:1754–1759. doi: 10.1111/acer.13475. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. McCabe SE, Cranford JA, Morales M, Young A. Simultaneous and concurrent polydrug use of alcohol and prescription drugs: prevalence, correlates, and consequences. J Stud Alcohol. 2006;67:529–537. doi: 10.15288/jsa.2006.67.529. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. McCabe SE, Veliz P, Patrick ME. High-intensity drinking and non-medical use of prescription drugs: results from a national survey of 12th grade students. Drug Alc Depend. 2017;178:372–379. doi: 10.1016/j.drugalcdep.2017.05.038. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Midanik LT, Tam TW, Weisner C. Concurrent and simultaneous drug and alcohol use: results of the 2000 National Alcohol Survey. Drug Alc Depend. 2007;90:72–80. doi: 10.1016/j.drugalcdep.2007.02.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the Future national survey results on drug use, 1975–2016: Volume I, secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan; 2017. [Google Scholar]
  9. National Institutes of Health. US Alcohol Epidemiologic Data Reference Manual. Vol. 9. Bethesda, MD: National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism; 2013. Alcohol-related emergency department visits and hospitalizations and their co-occurring drug-related, mental health, and injury conditions in the united states: findings from the 2006–2010 Nationwide Emergency Department Sample and Nationwide Inpatient Sample. [Google Scholar]
  10. Patrick ME. A call for research on high-intensity alcohol use. Alcohol Clin Exp Res. 2016;40:256–259. doi: 10.1111/acer.12945. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Patrick ME, Schulenberg JE, Martz ME, Maggs JL, O’Malley PM, Johnston LD. Extreme binge drinking among 12th grade students in the United States: prevalence and predictors. JAMA Pediatr. 2013;167:1019–1025. doi: 10.1001/jamapediatrics.2013.2392. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Patrick ME, Terry-McElrath YM, Kloska DD, Schulenberg JE. High-intensity drinking among young adults in the United States: prevalence, frequency, and developmental change. Alcohol Clin Exp Res. 2016;40:1905–1912. doi: 10.1111/acer.13164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Patrick ME, Terry-McElrath YM, Miech RA, O’Malley PM, Schulenberg JE, Johnston LD. Current high-intensity drinking among eighth and tenth grade students in the US. Am J Prev Med. 2017b;53:904–908. doi: 10.1016/j.amepre.2017.06.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Patrick ME, Terry-McElrath YM, Miech RA, Schulenberg JE, O’Malley PM, Johnston LD. Age-specific prevalence of binge and high-intensity drinking among US young adults: changes from 2005–2015. Alcohol Clin Exp Res. 2017a;41:1319–1328. doi: 10.1111/acer.13413. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Patrick MD, Veliz PT, Terry-McElrath YM. High-intensity and simultaneous alcohol and marijuana use among high school seniors in the United States. Subst Abus. 2017c;38:498–503. doi: 10.1080/08897077.2017.1356421. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Schulenberg JE, Johnston LD, O’Malley PM, Bachman JG, Miech RA, Patrick ME. Monitoring the Future national survey results on drug use, 1975–2016: Volume II, college students and adults ages 19–55. Ann Arbor: Institute for Social Research, The University of Michigan; 2017. [Google Scholar]
  17. Schepis TS, McCabe SE. Trends in older adult nonmedical prescription drug use prevalence: results from the 2002–2003 and 2012–2013 National Survey on Drug Use and Health. Addict Behav. 2016;60:219–222. doi: 10.1016/j.addbeh.2016.04.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Subbaraman MS, Kerr WC. Simultaneous versus concurrent use of alcohol and cannabis in the National Alcohol Survey. Alcohol Clin Exp Res. 2015;39:872–879. doi: 10.1111/acer.12698. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Terry-McElrath YM, Patrick ME. Trends in simultaneous alcohol and marijuana use among US young adults, 1977–2014. Paper presented at the 2016 Society for Prevention Research; San Francisco, CA. 2016. [Google Scholar]
  20. White A, Slater M, Ng G, Hingson R, Breslow R. Trends in alcohol-related emergency department visits in the United States: results from the Nationwide Emergency Department Sample, 2006–2014. Alcohol Clin Exp Res. 2018 doi: 10.1111/acer.13559. XX:XX-XX. [DOI] [PubMed] [Google Scholar]

RESOURCES