Monthly Archives: June 2013

Relationship Between Blood Alcohol Concentration and Observable Symptoms of Intoxication in Patients Presenting to an Emergency Department

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  1. Kalen N. Olson1,
  2. Stephen W. Smith2,
  3. Julie S. Kloss1,
  4. Jeffrey D. Ho2 and
  5. Fred S. Apple1,*
  1. 1Department of Laboratory Medicine and Pathology, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415, USA
  2. 2Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN 55415, USA
  1. *Corresponding author. Hennepin County Medical Center, 701 Park Ave., Clinical Labs P4, Minneapolis, MN 55415, USA. Tel.: +1-612-873-2990; Fax: +1-612-904-4229; E-mail: apple004{at}umn.edu
  • Received January 30, 2013.
  • Revision requested March 18, 2013.
  • Revision received April 15, 2013.
  • Accepted April 16, 2013.

Abstract

Aims: Clinical and medico-legal decisions often require knowledge of alcohol impairment that is not necessarily revealed by an individual's appearance, and in turn, may not necessarily reflect level of blood alcohol. This study compares clinical signs and symptoms with measured and estimated blood alcohol concentrations (BACs). Method: Individuals (n = 384) perceived to be under the influence of alcohol at presentation to an emergency department were assessed by physicians and nurses for clinical features of alcohol intoxication (alcohol symptom checklist, ASC), who were asked to estimate the patient's BAC. Relation to measured BACs was assessed by correlation. Results: BACs ranged from 0 to 418 mg/100 ml. The correlation between the estimated BAC and measured BAC was r = 0.513. Measured BAC correlated with ASC r = 0.250. In subjects without a history of chronic drinking (n = 134) there was a better (P < 0.05) correlation with the ASC score (r = 0.363) versus measured BAC compared with that for chronic drinkers (r = 0.154). The positive predictive value of estimating BAC at or above a particular BAC cut-off decreased from 93.2% at 100 mg/100 ml to 37.7% at 300 mg/100 ml (P < 0.05). Conclusions: Measured BAC does not correlate well with the outward physical signs of intoxication, especially for chronic drinkers. There is a need for further education on how tolerance masks clinical signs of intoxication for the chronic drinker. BACs should be measured especially in the obtunded where no history (symptoms) can be given by the patient.

  1. Alcohol and Alcoholism

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The {micro}-Opioid Receptor and Treatment Response to Naltrexone

  1. Annika Thorsell*
  1. Department of Clinical and Experimental Medicine, Linköping University, SE-581 83 Linköping, Sweden
  1. *Corresponding author: Tel.: +46-10-103-39-06; Fax: +46-10-103-41-49; E-mail: annika.thorsell{at}liu.se
  • Received August 26, 2012.
  • Revision requested September 19, 2012.
  • Revision received March 1, 2013.
  • Accepted March 12, 2013.

Aims: To evaluate the pharmacogenetic evidence relating to the use of opioid antagonists (in particular naltrexone) in treating patients with alcohol abuse problems. Methods: Narrative review of pre-clinical and clinical published research regarding genetic modulation of psychotropic effects produced by alcohol and the therapeutic effects of opioid antagonists. Results: Alcohol activates brain reward pathways, leading to positive reinforcement of alcohol seeking and consumption. Thus, the underlying biological mechanisms may be targets for treatment, particularly in the early stages of addiction development. Alcohol reward is in part mediated by endogenous opioids. A single-nucleotide polymorphism (SNP) within the OPRM1 gene, A118G, leading to an amino acid change (Asn40Asp) in the extracellular portion of the receptor, has been implicated in alcoholism as well as in drug addiction, pain sensitivity and stress response, and in animal and human studies relates to the alcohol-dependent phenotype as well as to the treatment response to the µ-opioid antagonist naltrexone. Conclusion: The effect size reported in naltrexone clinical studies is often small, which may be due to heterogeneity among patients. Pharmacogenetic approaches may help guide us in the search for the appropriate treatment optimal for one patient's need.

Acute Alcohol Intoxication Characteristics in Children

Aims: To describe clinical, mental and physical signs in children with different severity acute alcohol intoxication (AAI) determined either by serum alcohol concentration (SAC) or by blood alcohol concentration (BAC) to study the diagnostic performance characteristics of clinical assessment and to establish the ratio of SAC:BAC in children. Methods: Data were analysed from 256 children aged 8.4–17.9 years who were hospitalized at Estonia's two children's hospitals over a 3-year period. In each case, the on-call paediatrician completed a special form about the clinical, mental (consciousness, balance and speech) and physical (muscle tone, blood pressure, pulse and body temperature) signs of AAI. Blood samples were drawn for measurements of SAC and BAC. Diagnostic performance characteristics (sensitivity, specificity, efficiency) of the clinical assessments and the SAC:BAC ratio were calculated. Results: The most correctly described signs in children in different SAC groups were consciousness (rs = 0.16) and speech (rs = 0.13) (P < 0.0001). The severity of alteration of consciousness and degrees of disturbance in balance and speech were positively correlated with SAC (P < 0.001). The clinical judgment matched better with AAI determined by SAC rather than by BAC with the mean efficiency. The mean ratio between SAC and BAC was 1.19 ± 0.13 (P < 0.001) in children. Conclusion: The level of consciousness is the leading sign in the clinical evaluation of children with AAI and correlates well with SAC. The severity of AAI judged by clinical assessment matched better with AAI severity stages determined by SAC than by BAC. For legal cases where BAC is required, the SAC:BAC ratio of 1.19:1 should be used in children regardless of their gender or age.

Rape, Consent and Intoxication: A Legal Practitioner’s Perspective

  1. Joe Stone QC*
  1. Doughty Street Chambers, 53-54 Doughty Street, London, UK
  1. *Corresponding author: Doughty Street Chambers, 53-54 Doughty Street, London WC1N 2LS, UK; Tel.: +44-020-7404-1313; Fax: +44-020-7269-1272; E-mail: j.stone{at}doughtystreet.co.uk

A common theme of rape trials between two adults is the issue of consent. The prosecution will seek to prove that there was no consent given by the complainant at the time of the alleged offence. The defence will seek to show that there was or might have been consent at the material time. Consent in itself is a fairly straightforward concept and is defined in English Law Section 74 Sexual Offences Act 2003 as ‘where a person agrees by choice and has the freedom and capacity to make that choice’. If the tribunal of fact (the jury) are sure there was no consent, they will convict the defendant, and if less than sure, they will acquit. The issue of intoxication significantly complicates this issue from both a prosecution/defence perspective and for the jury in reaching a true verdict on the specific facts of the case. It is important, therefore, that both sides should be aware of the inherent problems that are generated when issues of intoxication bear on the issue of consent.

Academic studies have shown that if the female complainant is portrayed as drunk, she is perceived as less credible and the defendant is seen as less likely to be criminally culpable compared with a sober victim (Stormo et al., 1997; Wenger and Bornstein, …

Breath Alcohol Estimation Training: Behavioral Effects and Predictors of Success

  1. Elizabeth R. Aston1,
  2. Rebecca H. Neiberg2 and
  3. Anthony Liguori1,3,*
  1. 1Neuroscience Program, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
  2. 2Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
  3. 3Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
  1. *Corresponding author: Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA. Tel.: +1-336-716-8543; Fax: +1-336-716-8501; E-mail: aliguori{at}wakehealth.edu
  • Received December 14, 2012.
  • Revision requested January 21, 2013.
  • Revision received April 23, 2013.
  • Accepted April 25, 2013.

Aims: Breath alcohol concentration (BrAC) estimation training has been effective in increasing estimation accuracy in social drinkers. Predictors of estimation accuracy may identify populations to target for training, yet potential predictors typically are not evaluated. In addition, the therapeutic efficacy of estimation training as a preventive strategy for problematic drinking is unknown. Methods: Forty-six social drinkers with a recent binge history were randomly assigned to an intervention or control group (n = 23 per group). In each of three sessions (pretraining, training, testing), participants consumed alcohol (0.32, 0.24, 0.16 and 0.08 g/kg, in random order) every 30 min (total dose: 0.8 g/kg). Participants provided five BrAC estimates within 3 h of alcohol administration. The intervention group, but not control group, received internal and external training. During testing, participants provided BrAC estimates, but received no feedback. Participants returned for two follow-up visits to complete self-report measures. Results: BrAC estimation training improved intervention group estimation accuracy within the laboratory. Together, training, low trait anxiety and low risk expectancy predicted high testing accuracy. There were no significant group differences in subsequent alcohol consumption, behavior under the influence or risk expectancy regarding potentially hazardous behaviors. Conclusion: BrAC estimation training is effective in the laboratory but may not translate into naturalistic settings.

30th Anniversary of Alcohol and Alcoholism

  1. Allan D. Thomson1,2 and
  2. E. Jane Marshall2,3,*
  1. 1Molecular Psychiatry Laboratory, Rockefeller Building, University College London, London, UK
  2. 2Institute of Psychiatry, King's College London, 4 Windsor Walk, London SE5 8AF, UK
  3. 3South London and Maudsley NHS Foundation Trust, London, UK
  1. *Corresponding author: E-mail: jane.marshall{at}slam.nhs.uk

The first author, ADT, was the Founding Editor when Alcohol and Alcoholism was launched 30 years ago with the help of my able colleagues, Deputy Editor Dr Spencer Madden and Assistant Editor Dr Abdulla Badaway. It has been a great pleasure to watch the journal develop through a succession of very dedicated editors, and especially our present editors Professors Jonathan Chick and Philippe de Witte, into one of the leading alcohol journals in the world.

Alcohol and Alcoholism is the journal of The Medical Council on Alcohol (MCA) and the official journal of the European Society for Biomedical Research on Alcoholism (ESBRA). The MCA was founded in London, in 1967, by a group of doctors from a range of different specialties, at a time when services for alcohol problems were poorly developed in the UK (Walton et al., 1966).

In an effort to highlight the health problems caused by alcohol, the MCA originally produced a journal called The British Journal on Alcohol and Alcoholism (the ‘blue’ journal) and this was distributed free of charge, quarterly, to General Practitioners throughout the UK. The primary objective of the journal was to provide reliable information and to raise awareness of the growing problem of alcoholism, especially to medical and paramedical practitioners and it was extremely successful in achieving this (Evans, 1990). The next logical step was to develop the journal as a multi-disciplinary, international research journal and it was re-launched in 1983 as Alcohol and Alcoholism (the ‘red’ journal). The red journal was distinct and different from the outset and was aimed at the international community and focused on advancing alcohol research and integrating new knowledge into clinical practice.

The International Society for Biomedical Research on Alcoholism (ISBRA) had its inaugural meeting in Cardiff in 1980 and the ESBRA was …