Care for hospitalized patients with unhealthy alcohol use: a narrative review
© Makdissi and Stewart; licensee BioMed Central Ltd. 2013
Received: 18 December 2012
Accepted: 24 May 2013
Published: 5 June 2013
There is increasing emphasis on screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use in the general hospital, as highlighted by new Joint Commission recommendations on SBIRT. However, the evidence supporting this approach is not as robust relative to primary care settings. This review is targeted to hospital-based clinicians and administrators who are responsible for generally ensuring the provision of high quality care to patients presenting with a myriad of conditions, one of which is unhealthy alcohol use. The review summarizes the major issues involved in caring for patients with unhealthy alcohol use in the general hospital setting, including prevalence, detection, assessment of severity, reduction in drinking with brief intervention, common acute management scenarios for heavy drinkers, and discharge planning. The review concludes with consideration of Joint Commission recommendations on SBIRT for unhealthy alcohol use, integration of these recommendations into hospital work flows, and directions for future research.
Alcohol-related problems constitute a tremendous economic and health cost in many countries throughout the world [1, 2]. Screening, brief intervention, and referral to treatment (SBIRT) has become one of the major tools used to combat these problems, and is widely recommended for use in primary care by governments and expert panels [3, 4]. Recently, the Joint Commission on Accreditation for Health Care Organizations (JCAHO), the major accrediting body for hospitals in the US, has advanced SBIRT as a quality indicator for general hospital care . There is no doubt that alcohol problems are a critical issue in hospital care, but there are concerns that the evidence base does not yet justify widespread SBIRT in this setting . This review will consider the nature of unhealthy alcohol use in the general hospital, review means for detecting unhealthy use and categorizing severity, consider the evidence on the effectiveness of SBIRT in the hospital setting, briefly review acute treatment issues, and discuss factors affecting the implementation of SBIRT into general hospital workflows. The goal is to provide an overview of the field that will aid hospital-based clinicians and administrators in their consideration of policies and procedures that will yield the highest quality care for their patients. In this regard, the impact of detecting and treating unhealthy alcohol use is one of many important health care issues that must be evaluated.
Unhealthy alcohol use in the hospital
Unhealthy alcohol use is an umbrella term encompassing any pattern of alcohol use that increases risk for or causes physical problems . At the lower end of severity, unhealthy use is often operationalized as drinking in excess of health-related guidelines. In the US, the National Institute on Alcohol Abuse and Alcoholism defines this as more than one drink daily, more than 7 drinks weekly, or exceeding 3 drinks on a given day for women and for men ≥ 65, and more than two drinks daily, more than 14 drinks weekly, or exceeding 4 drinks on a given day for men < 65 . Pertinent to these guidelines, a standard drink is defined as a volume of beverage containing 14 grams of alcohol. This corresponds to a 12-oz (355 ml) beer containing 5% alcohol by volume, 5 oz. (148 ml) of wine containing 12% alcohol, or 1.5 oz. (44 ml) of spirits containing 40% alcohol. While modestly exceeding these limits in a sustained manner is unlikely to cause traditionally alcohol-related harms, this pattern is variably associated with increased morbidity in the long term relative to lighter drinking [9–11]. At the higher end of severity is the daily or frequent consumption of large amounts of alcohol, with sharply increased risks for alcohol dependence, cirrhosis, upper airway and gastrointestinal tract cancers, dementia, and other highly morbid conditions.
The prevalence of unhealthy use among hospital inpatients will depend on characteristics of hospitals and the populations they serve . However, a systematic review of screening studies suggested an overall average of about 17% will self-report unhealthy use , with a 3-fold increase in men relative to women. This summary estimate is less than the prevalence in the general adult population . However, because unhealthy alcohol use is most common in younger males, unhealthy use is felt to increase the risk for hospitalization after accounting for age and gender . Among general hospital patients who do consume alcohol, regardless of the presence of unhealthy use, about one-quarter will have an alcohol use disorder, which is much higher relative to current drinkers in the general population [15–17]. In addition to their physical health problems, relative to the non-hospitalized alcohol dependent population, hospitalized alcohol-dependent individuals have a higher prevalence of polysubstance use and mental health comorbidities . Thus, while inpatient clinicians provide care for patients representing the broad spectrum of unhealthy alcohol use, there is a particularly high prevalence of complex alcohol dependent patients. Because brief intervention is most effective in patients with less severe unhealthy alcohol use, this has profound implications for the effectiveness of hospital-based SBIRT. Of note, despite these increased health risks, the evidence on severe unhealthy alcohol use and early hospital readmission is mixed [19, 20], and may depend on concurrent abuse of other drugs.
Detecting and categorizing the severity of unhealthy alcohol use
The process of detecting and categorizing the severity of unhealthy alcohol use focuses on two aspects of alcohol involvement. Firstly, the amount of alcohol consumed must be quantified, and this will determine the presence or absence of unhealthy use. Secondly, alcohol-related consequences should be assessed to determine the presence of an alcohol use disorder.
Assessment for unhealthy alcohol use
Selected findings on brief screening tools for unhealthy alcohol use
≥ 4 (men)
86 (80-92) men
89 (85-93) men
Primary care 
≥ 3 (women)
73 (66-79) women
91 (89-93) women
88 (83-94) men
84 (80-89) men
Primary care 
68 (61-75) women
91 (89-93) women
Any heavy days (≥ 4 drinks women, ≥ 5 drinks men)
83 (71-90) men
72 (61-81) men
Primary care 
past year (1 item)
81 (64-91) women
84 (76-89) women
An added complexity of assessing for unhealthy alcohol use in hospitalized patients is illness severity, which may prohibit obtaining information directly from the patient. In such circumstances the presence of unhealthy alcohol use can often be estimated from past medical records or surrogate reporters. When alcohol-related disease is suspected blood alcohol levels can be helpful if heavy drinking occurred in the past 8 to 12 hours (an average elimination is roughly one drink per hour). Gamma-glutamyltransferase also has some utility, but will be less specific for chronic heavy drinking in medical settings . Carbohydrate-deficient transferrin, another biomarker for chronic heavy drinking, has been shown to predict adverse perioperative events , but is limited by modest sensitivity. In addition, results may not be available for several days, limiting use for decision-making in the hospital. Newer alcohol consumption biomarkers that require ethanol for their synthesis (e.g., urine ethyl glucuronide , blood phosphatidylethanol ) are a research focus and clearly have potential clinical utility [32–39]). In general however, pending the development of cost-effective, widely-available assays at the point of care, use of these newer biomarkers in risk-stratifying for alcohol problems at the time of hospitalization is not yet feasible in most locations.
Assessment for alcohol use disorders in patients with unhealthy use
Selected findings on brief screening tools for alcohol use disorders
Importantly, as for any ordinal screening instruments, different cutoff scores will result in a tradeoff between sensitivity and specificity. In addition, relatively low cutoff scores on an instrument that assesses both the magnitude of drinking and alcohol-related consequences can be used to screen for unhealthy alcohol use and alcohol use disorders (e.g., as with the AUDIT ). Ultimately however, a diagnosis of an alcohol use disorder should be based on an assessment of established criteria.
American Psychiatric Association criteria for alcohol use disorders
DSM-IV Alcohol dependence
DSM-IV Alcohol abuse
DSM-V Alcohol use disorder
(≥ 3 of the following)
(≥ 1 of the following)
(≥ 2 of the following)
Continued drinking despite….
• Repeatedly exceeding intended limits
• Increased risk for physical harm
• Repeatedly exceeding intended limits
• Spending a lot of time drinking or recovering from alcohol effects
• Trouble in important relationships
• Spending a lot of time drinking or recovering from alcohol effects
• Failed attempts to cut down or abstain
• Failure to perform important roles
• Failed attempts to cut down or abstain
• Continued drinking despite physical or psychological problems
• Legal problems*
• Continued drinking despite physical or psychological problems
• Spending less time on important activities due to drinking
• Spending less time on important activities due to drinking
• Increased risk for physical harm
• Trouble in important relationships
• Failure to perform important roles
• Craving for alcohol*
Treatment for unhealthy alcohol use
Treatment for non-dependent unhealthy alcohol use
After initial screening and clinical assessment, patients with unhealthy alcohol use will have been categorized as having or not having an alcohol use disorder. In the latter, the clinical effort should be aimed at drinking reduction to levels that are unlikely to contribute to health problems. To accomplish this, the evidence, while mixed, generally favors a modest effect of brief interventions during hospitalization. A meta-analysis  of 4 randomized controlled trials (one in trauma patients did not exclude dependence, two excluded dependence, and one excluded patients with alcohol-related physical problems) concluded that brief intervention for unhealthy drinkers reduced alcohol consumption by an average of approximately 5 drinks/week 6 months post-intervention. Exclusion of the trauma-based trial due to unblinded outcome assessment reduced the magnitude and statistical significance of this estimate. Reported alcohol use at one year was synthesized for 4 other studies (3 with variable exclusion of patients with alcohol use disorders) and, although there was roughly a 2 drink per week reduction in the intervention groups, this was not statistically significant relative to controls. Importantly, while the evidence base for outcomes other than alcohol use is relatively under-developed, this meta-analysis found evidence that brief intervention was associated with decreased mortality at one year. In addition, a US study of trauma patients reported a 47% reduction in recurrent trauma over the 3 years following receipt of brief intervention .
Overall, the evidence tends to favor brief intervention for hospitalized patients with less severe unhealthy alcohol use. A number of different strategies have been studied, but brief intervention in the hospital should include at a minimum feedback about alcohol use (including associations with conditions the patient may have such as hypertension), advice to reduce consumption to safer levels, an explanation of why these limits are recommended, a non-confrontational inquiry to determine a patient’s interest in reducing their drinking, and determination of a plan to achieve drinking goals . This can be delivered by a variety of health care personnel [44, 47], which can lower the cost of brief intervention.
Acute Treatment for alcohol use disorders (typically accompanied by frequent heavy drinking)
Immediate issues in the care of chronic heavy drinkers admitted to the hospital
Assess risk for nutritional deficiency
• Thiamine supplementation.
• Possibly folate and multivitamin supplement.
Assess hydration status and electrolytes (risk for hypocalcemia and hypomagnesemia with or without hypokalemia and hypophosphatemia)
• IV or oral fluids.
• Oral or IV electrolyte replacement.
Risk for acute alcohol withdrawal
• Close observation with validated instrument or prophylactic benzodiazepine, particularly in those with previous withdrawals or history of severe withdrawal (delirium tremens or seizure).
• Prophylaxis still requires close observation for over or under-sedation.
Active alcohol withdrawal
• Symptom-triggered or scheduled benzodiazepine.
• Close observation with validated instrument with either symptom-triggered or scheduled dosing.
• Alternate medication (e.g., phenobarbital) in rare event that benzodiazepine is unsuccessful at controlling agitation.
• Possible beta blocker or clonidine for autonomic manifestations if benzodiazepine alone is insufficient.
• Possible haloperidol if benzodiazepine alone is insufficient for delirium.
• Consider other causes of delirium.
Examples of symptom-triggered regimens for alcohol withdrawal*†
Initial oral medication dose
Diazepam 10 to 20 mg if CIWA-Ar ≥ 8 to 10
Repeat same dose hourly until
Long half-life may provide smoother withdrawal, but may accumulate in elderly or those with liver disease.
CIWA-Ar < 10
Chlordiazepoxide 50 mg if CIWA-Ar > 9
Repeat 50 mg hourly until CIWA-Ar < 10
Intermediate half-life may provide smoother withdrawal than lorazepam.
Lorazepam 2 to 4 mg if CIWA-Ar ≥ 8 to 10
Repeat same dose hourly until
Short half-life may increase withdrawal symptoms between doses. May be better tolerated in elderly and liver disease patients.
CIWA-Ar < 10
Initial treatment of severe withdrawal may require intravenous benzodiazepines (e.g., 2 to 4 mg of lorazepam or 5 to 10 mg of diazepam) and additional dosing as needed to control symptoms. Usually benzodiazepines alone are sufficient, and a strong evidence base supports their use . The rare patient with severe withdrawal who fails benzodiazepine treatment will require intensive monitoring and treatment with barbiturates or propofol . Phenobarbital is most frequently used in this circumstance, with 30 mg having roughly equivalent effects on withdrawal symptoms as 2 mg lorazepam, 25 mg chlordiazepoxide, or 10 mg diazepam . Some centers with expertise in alcohol withdrawal treatment use anticonvulsants (e.g., carbamazepine, gabapentin) as a primary prophylaxis or treatment rather than benzodiazepines, but the evidence base for justifying clinical recommendations is currently under-developed. In particular, anticonvulsants have not been shown to reduce the incidence of alcohol withdrawal seizure or delirium tremens . The use of intravenous alcohol infusions continues in some locations , mainly in surgical specialties, due to some surgeons’ familiarity and comfort with this treatment. This approach has been discouraged due to potential toxicity (remembering that first-pass metabolism can be substantial in chronic heavy drinkers and is bypassed by this route), and evidence shows that this approach is at best no more efficacious for prophylaxis than benzodiazepines , and may have a high failure rate [64, 65].
Pre-operative assessment for patients with an alcohol use disorder
Chronic heavy drinking (e.g., averaging at least 50 to 60 grams of alcohol per day or usually exceeding daily limits) increases perioperative morbidity due to increased risks for acute withdrawal syndrome, pneumonia and ARDS, wound infections, bleeding, myocardial dysfunction, and enhanced stress responses [59, 66]. Thus pre-operative detection should trigger efforts at detoxification and achieving several weeks of abstinence before elective procedures. For the more likely emergent procedures in hospitalized patients, parenteral thiamine, electrolyte replacement, and close monitoring and treatment for post-operative withdrawal are important components of care, and causes of delirium other than withdrawal should be considered as they would be for patients who are not heavy drinkers. Prevention of acute withdrawal with benzodiazepines is an important consideration in this population , and perioperative morphine may reduce post-operative pneumonia by ameliorating neuroendocrine and immune imbalances induced by chronic heavy drinking and peri-operative abstinence . Much of the perioperative management will naturally be directed by the anesthesiologist and surgeon, and any consulting physicians should make certain that these providers are aware of the patient’s heavy drinking. Of note, inappropriate use of symptom-triggered therapy for withdrawal has been observed in surgical patients . It is equally important to communicate to all providers when a known heavy drinker has passed the time when initial manifestations of acute alcohol withdrawal would be expected (within 2 to 3 days of the last drink).
Additional pre-discharge treatment considerations for patients with an alcohol use disorder
Some research suggests hospitalization has the potential to facilitate treatment for alcohol use disorders by increasing recognition of the need to reduce drinking and intent to do so [69–72]. Despite this, brief interventions are unlikely to be effective at reducing drinking for hospitalized patients with alcohol dependence , but factors including avoidance of heavily drinking friends and engaging in alcohol treatment after hospitalization predict drinking reduction . Thus referral for outpatient treatment should be pursued and integrated into brief intervention (i.e., SBIRT), but, even among research participants, overall compliance with referral is modest [73, 74]. Brief intervention may be more effective in enhancing referral for women and younger adults . Some evidence suggests that peer-involvement from volunteer Alcoholics Anonymous members as a supplement to brief intervention can increase treatment initiation and abstinence following hospitalization .
Following hospital discharge, integrated outpatient treatment (i.e., post-discharge care for alcoholism and medical conditions with the same healthcare provider) may be effective under ideal conditions [77, 78]. A related approach involves a chronic disease management strategy in primary care with as-needed addiction specialist support, which may improve the quality of outpatient care and facilitate recovery [79, 80]. Thus it is reasonable to refer patients to this mode of primary care if it exists locally.
Select Effects of Medications on Drinking Outcomes
Factors Influencing Medication Choice
(95% CI or p-value)
Heavy drinking day (≥ 60 grams alcohol)
Relative risk 0.83
Meta-analysis of 50
Avoid in patients with opioid abuse or use; caution in liver disease and advanced kidney disease
randomized controlled trial (RCT’s) 
Relative risk 0.86
Meta-analysis of 24
Avoid with advanced kidney disease
(e.g., creatinine clearance < 30 ml/min)
Slight majority of trials found improved abstinence.
Review of 11 RCT’s 
Avoid if alcohol-disulfiram reaction medically dangerous; number of medical conditions associated with accidental reaction; avoidance of alcohol-containing products
% heavy drinking days
Multicenter RCT 
Caution with advanced liver or kidney disease; risk for metabolic acidosis with predisposing conditions; avoid abrupt discontinuation
Average number of drinks on days alcohol was consumed
If alcoholism onset before age 25, 4.28 relative to 6.9 in placebo(p=0.004)
Not shown to be beneficial for later-onset alcohol dependence; may prolong QT interval
Unhealthy alcohol use and the joint commission
An impetus for a standardized approach to SBIRT for unhealthy alcohol use, is the recent inclusion by JCAHO of SBIRT as a quality care measure for hospitalized patients , and these recommendations have been summarized . In brief, JCAHO has recommended screening for unhealthy use in all patients, brief intervention for patients with unhealthy use, in-hospital treatment or referral for alcohol use disorders, and consideration of medications for alcohol dependence treatment. Performance of these tasks would be measured by self-reported outcomes through phone contact within 2 weeks of discharge.
Potential research topics relevant to patient care and JCAHO quality measures
Potential research foci
Screening and assessment
•Is there reason to use more than a single heavy drinking day question to screen for unhealthy alcohol use?
•Is there a better strategy than screening all admissions?
•How should screening be integrated with electronic work flows?
•What is the role of newer alcohol consumption biomarkers?
•What is the optimal assessment method in the hospital?
•What training will hospital-based clinicians require to enhance their skills and confidence in diagnosing alcohol use disorders?
•How do patients feel about assessment during hospitalization?
•What patients are most likely to respond to brief intervention?
•How can the beneficial effects of brief intervention on alcohol use be increased?
•How do we enhance the success of referral?
•Does pharmacotherapy for relapse prevention work in this population?
•What is the role for joint detection and treatment of other drug and mental health co-morbidities?
•Can computerized support enhance treatment?
•What are the effects of brief intervention on other outcomes such as progression of alcohol problems and hospital readmission?
•What are the most pertinent patient-centered outcomes?
•What is the optimal method for assessing the quality of hospital-based SBIRT?
Implementation barriers and facilitators
In general, major barriers to incorporation of evidence-based care include organizational leadership, work capacity, training, ongoing support, and others , and SBIRT is no exception. A systematic review of qualitative data from 47 studies  identified major SBIRT-implementation barriers to be limited resources, training, support of management, and workload. Most results were from primary-care-based studies, but, consistent with these findings, critical components of implementing and sustaining SBIRT at a rural hospital in Australia included the support of hospital management and a dedicated project worker . Similar issues were also identified for nursing-delivered SBIRT, with the addition of concerns over limited interdisciplinary collaboration about alcohol problems, compatibility with the acute care nursing role, lack of privacy, and concerns about patient attitudes . This latter issue was also identified in a previous hospital-based study on SBIRT . Regarding training needs, SBIRT training programs have been shown to increase provider comfort in assessing alcohol problems and have increased utilization of SBIRT , and on-line instructional programs are available to enhance dissemination (e.g., http://medicine.yale.edu/sbirt/index.aspx; http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/). An additional barrier is the lack of an unambiguous tool for monitoring the quality of SBIRT, which ideally should include assessment of core brief intervention components rather than non-specific provider or patient report of alcohol counseling [6, 95]. Interestingly, implementation of a performance measure and electronic reminders were each associated with an increase in the receipt of brief intervention in outpatient VA settings , and this type of strategy has the potential to enhance SBIRT performance in the hospital .
Unhealthy alcohol use is common in hospitalized patients, with a high prevalence of severe alcohol problems among those with unhealthy use. Detection should include the use of a validated screening instrument to determine the presence of unhealthy use, and assessment of alcohol-related consequences in patients with positive screening results to categorize the severity of unhealthy use. Based on current evidence, patients without an alcohol use disorder should receive a brief intervention to target reduced drinking. Acute care issues for patients with alcohol use disorders have been well described and are standards of care. Additional research is needed to guide discharge planning for inpatients with an alcohol use disorder, but management should include referral to outpatient addiction treatment if available, consideration of medications to prevent a return to heavy drinking, and explicit follow-up on alcohol use in the ambulatory medical setting. JCAHO has advanced SBIRT for unhealthy alcohol use as a quality measure, and barriers to implementation are mainly generic factors rather than specific to SBIRT. Continued research is needed across the spectrum of unhealthy alcohol use to further demonstrate the benefits of hospital-based SBIRT, refine the process, and improve care for hospitalized patients.
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