🧭 REBEL Rundown
📌 Key Points
- 📈 Rising Crisis: Alcohol-related ED visits have increased by nearly 50% in the past decade, now double those linked to opioids.
- 🧪 Simple Screening: Use SASQ or STAD at triage for fast, effective identification of at-risk patients.
- 📝 Follow Up: Positive screens → complete AUDIT-C to stratify risk and guide next steps.
- 💊 Effective Treatment Exists: Naltrexone is easy to prescribe with a NNT of 12 to prevent relapse.
- 🤝 ED Leadership Role: Universal screening and early intervention can save lives and reduce repeat ED visits.
📝 Introduction
Each year, about 1 in 7 men and 1 in 11 women in the United States meet criteria for alcohol use disorder (AUD)—affecting nearly 29 million people, roughly the entire population of Texas.1,2 Patients with AUD face staggering health risks: they are 3.5 times more likely to die than the general population, and their life expectancy is up to 25 years shorter.3,4 Over the past decade, alcohol-related emergency department (ED) visits have climbed by nearly 50%. Between 2021 and 2023 alone, alcohol accounted for approximately 8.6 million substance use-related ED visits—double the number linked to opioids.5-8
Effective treatments and resources for AUD are underutilized and screening rates in the ED are as low as 8%, leaving millions of high-risk patients unidentified and untreated.9,10 This mismatch between disease burden and screening represents a critical missed opportunity. Closing this gap is possible. Naltrexone, for example, has a number needed to treat of just 12 to prevent relapse into heavy drinking. It is widely available, easy to prescribe, and can be life-altering—even life-saving.11
This post highlights practical screening tools for identifying it in the ED, and offers recommendations for seamlessly integrating these approaches into everyday workflow to deliver more comprehensive patient-centered care.
🩺 Diagnosing AUD
AUD is defined in the DSM-5 as “a problematic pattern of alcohol use leading to clinically significant impairment or distress.” A diagnosis requires the presence of two or more of 11 criteria within a 12-month period.12
AUD Severity Categories:
- Mild: 2–3 symptoms
- Moderate: 4–5
- Severe: ≥6
In the ED, many patients presenting with alcohol-related complaints will meet criteria for at least mild or moderate AUD. 13 Yet despite its prevalence, fewer than 1% of patients in the United States and Canada receive anti-craving medications each year.2,7,14,15 ED clinicians are uniquely positioned to change this trajectory: by familiarizing themselves with the burden of disease, practical screening tools, and effective therapies, they can identify high-risk patients and initiate evidence-based interventions.16
📝 Screening for AUD
Identifying AUD in the ED is challenging but crucial. Even in a fast-paced environment, recognizing and treating at-risk patients remains a priority. We never hesitate to reverse an opioid overdose or manage diabetic ketoacidosis; AUD deserves the same urgency, given its profound association with morbidity and mortality.
There are numerous tools to identify AUD patients. However, tools like AUDIT, MAST, and sMAST, are between 10 and 25 questions each, making them both difficult to efficiently utilize, and integrate into routine ED workflow. ED Operations teams should implement streamlined screening tools, ensuring at-risk patients are identified without adding burden to frontline clinicians.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an overarching paradigm that is used to identify, counsel, and then treat patients with a variety of substance use disorders. When specifically applied to AUD, this approach includes screening patients with tools such as AUDIT-C, SASQ, etc., motivational interviewing, initiation of medications for alcohol use disorder, and then referral for follow-up with an outpatient addiction medicine physician. Following the SBIRT approach reduces substance use in primary care settings.20-23
Just as the ED rose to the challenge of the opioid crisis, we must now take the lead in tackling AUD. Utilizing more streamlined screening modalities such as SASQ, STAD, or AUDIT-C may allow for targeted screening in patients who would most benefit from linkage to resources. Patients who screen positive would then warrant a brief conversation, connection to outpatient resources, and initiation of anti-craving medications. Our goal and focus should be on universal screening throughout all EDs, to identify and treat patients and connect them with necessary outpatient resources.
💡 Our Recommendations
- Implement Universal Screening
Establish a standardized screening program for alcohol use disorder (AUD) in the ED. - Screen at Intake/Triage
Have nursing staff administer a brief, validated tool during intake:- Single Alcohol Screening Question (SASQ):
- “How many times in the past year have you had five or more drinks in a day? (Four or more for women)”
- A response of “one” or more positive answers indicates a need for a more thorough follow-up and intervention.
- Screening Test for At-Risk Drinking (STAD):
- “How often do you have six or more drinks (for women, four or more) on one occasion?”
- “How often during the last year have you felt guilt or remorse after drinking?”
- A response of “one” or more positive answers indicates a need for a more thorough follow-up and intervention.
- Single Alcohol Screening Question (SASQ):
- Integrate EMR Alerts
Work with ED leadership and IT to build electronic notifications that automatically flag positive screens in the patient’s chart. - Use AUDIT-C for Positive Screens
For patients who screen positive, complete the AUDIT-C to stratify risk:- Frequency: “How often do you have a drink containing alcohol?” (scored 0 for never, up to 4 for ≥4 times/week)
- Quantity: “On a typical drinking day, how many drinks do you have?” (0 for 1–2 drinks, up to 4 for 10+ drinks)
- Binge Drinking: “How often do you have six or more drinks (for women, four or more) on one occasion?” (0 for never, up to 4 for daily/almost daily)
- Positive Screens:
- For Men: A score of 4 or more is considered positive.
- For Women: A score of 3 or more is considered positive.
- Implement Universal Screening
🚨 Clinical Bottom Line
Universal screening for AUD in the ED is feasible—have nursing staff use SASQ or STAD at intake and follow up positive screens with AUDIT-C to guide care. Connecting patients with resources or treatments earlier on, will hopefully lead to decreased use of EDs, and improvement in overall health for many patients with AUD.
🔄 REBEL Recap
📚 References
- Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed July 18, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
- 2023 NSDUH Detailed Tables | CBHSQ Data. Accessed September 12, 2024. https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables
- Laramée P, Leonard S, Buchanan-Hughes A, Warnakula S, Daeppen JB, Rehm J. Risk of All-Cause Mortality in Alcohol-Dependent Individuals: A Systematic Literature Review and Meta-Analysis. EBioMedicine. 2015;2(10):1394-1404. PMID: 26629534.
- Westman J, Wahlbeck K, Laursen TM, et al. Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden. Acta Psychiatr Scand. 2015;131(4):297-306. PMID: 25243359.
- Drug Abuse Warning Network (DAWN) Short Report | Alcohol-related ED visits. https://www.samhsa.gov/data/sites/default/files/reports/rpt44498/DAWN-TargetReport-Alcohol-508.pdf
- White AM, Slater ME, 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 to 2014. Alcohol Clin Exp Res. 2018;42(2):352-359. PMID: 29293274.
- Mintz CM, Hartz SM, Fisher SL, et al. A Cascade of Care for Alcohol Use Disorder: Using 2015–2019 National Survey on Drug Use and Health Data to Identify Gaps in Past 12-Month Care. Alcohol Clin Exp Res. 2021;45(6):1276-1286. PMID: 33993541.
- Xierali IM, Day PG, Kleinschmidt KC, Strenth C, Schneider FD, Kale NJ. Emergency department presentation of opioid use disorder and alcohol use disorder. J Subst Abuse Treat. 2021;127:108343. PMID: 34134862.
- Uong S, Tomedi LE, Gloppen KM, et al. Screening for Excessive Alcohol Consumption in Emergency Departments: A Nationwide Assessment of Emergency Department Physicians. J Public Health Manag Pract JPHMP. 2022;28(1):E162-E169. PMID: 33729185.
- Cunningham RM, Harrison SR, McKay MP, et al. National survey of emergency department alcohol screening and intervention practices. Ann Emerg Med. 2010;55(6):556-562. PMID: 20363530.
- Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900. PMID: 24825644.
- Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5 | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed July 18, 2025. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-use-disorder-comparison-between-dsm
- Suen LW, Makam AN, Snyder HR, et al. National Prevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014–2018. J Gen Intern Med. 2022;37(10):2420-2428. PMID: 34518978.
- Abbott K, Hyrsak R, Bolton JM, et al. Trend in Prescription Medication Utilization for Opioid Use Disorder and Alcohol Use Disorder From 2015 to 2021: A Population-wide Study in a Canadian Province. J Addict Med. 2024;18(6):683-688. PMID: 39012008.
- Spithoff S, Turner S, Gomes T, Martins D, Singh S. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Can Fam Physician. PMID: 28500210.
- Strayer RJ, Friedman BW, Haroz R, et al. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med. 2023;64(4):517-540. PMID: 36997435.
- Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary Care Validation of a Single-Question Alcohol Screening Test. J Gen Intern Med. 2009;24(7):783-788. PMID: 19247718.
- Bae SJ, Kim E, Lee JH. Validation of the screening test for at-risk drinking in an emergency department using a tablet computer. Drug Alcohol Depend. 2022;230:109181. PMID: 34847505.
- Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA, for the Ambulatory Care Quality Improvement Project (ACQUIP). The AUDIT Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test for Problem Drinking. Arch Intern Med. 1998;158(16):1789-1795. PMID: 9738608.
- van Gils Y, Franck E, Dierckx E, van Alphen SPJ, Saunders JB, Dom G. Validation of the AUDIT and AUDIT-C for Hazardous Drinking in Community-Dwelling Older Adults. Int J Environ Res Public Health. 2021;18(17):9266. PMID: 34501856.
- Parthasarathy S, Kline-Simon AH, Jones A, et al. Three-Year Outcomes After Brief Treatment of Substance Use and Mood Symptoms. Pediatrics. 2021;147(1):e2020009191. PMID: 33372122.
- Hargraves D, White C, Frederick R, et al. Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. Public Health Rev. 2017;38:31. PMID: 29450101.
- 23. McCance-Katz EF, Satterfield J. SBIRT: A Key to Integrate Prevention and Treatment of Substance Abuse in Primary Care. Am J Addict Am Acad Psychiatr Alcohol Addict. 2012;21(2):176-177. PMID: 22332862.
Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)
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