ED evaluation of the person seeking treatment for a substance abuse problem or those confirmed to have such a problem while in the ED should have three components: assessment of the need for treatment, placement into appropriate treatment and determination of physical suitability for treatment.

In the assessment of need for treatment, the physician must elicit information from patients who frequently underestimate the severity of their consumption. This underestimation may be attributed to denial, one of the hallmarks of the disease process of substance abuse. It is important to question patients about their drug or drugs of choice, the frequency of use, quantity used and method of use. Information on prior detoxifications, concomitant use of other substances, date of first use and time interval from last use should be obtained.


Most physicians are aware of and employ the use of CAGE questions:

C - Has anyone ever felt you should CUT down on your drinking?

A - Have people ANNOYED you by criticizing your drinking?

G - Have you ever felt GUILTY about your drinking?

E - Have you ever had a drink first thing in the morning (EYE-OPENER) to steady your nerves or get rid of a hangover?

One positive response to the CAGE questions is considered suggestive of an alcohol problem and two or more positive responses indicate the presence of such a problem with a sensitivity and specificity around 90% in most studies. One report indicated that the CAGE questions are best if not preceded by questions attempting to quantify alcohol intake.

These questions may not accurately indicate abuse problems when universally applied across gender and cultural lines. For example, the CAGE score has been shown to be less accurate in white females. Therefore, the physician should make an attempt to gather a complete picture of the patient rather than completely relying on this questioning technique. Several other screening methods exist with the brief MAST (Michigan Alcohol Screening Test) being the most widely used screen suitable for ED use.

One very brief modification of the MAST with a reported sensitivity of 91% requires a positive response to one of the following two questions:

(1) Have you ever had a drinking problem?
(2) When was your last drink?
(< 24 hours is a positive response.)

The TWEAK screen has been recommended for white females and involves the following questions with a score of three or higher indicating an alcohol problem:

T-Tolerance (2 pts): How many drinks can you hold? (6 or more indicates tolerance)

W- Worried (2 pts): Have close friends or relatives worried or complained about your drinking in the past year?

E- Eye openers (1 pt): Do you sometimes take a drink in the morning when you first get up?

A- Amnesia (1 pt): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

K- Kut down (1 pt): Do you sometimes feel the need to cut down on your drinking?

Frequent injury and injury while drinking should also prompt screening for alcohol abuse.

Placement into the appropriate treatment program will ultimately be done by the detoxification specialist who will follow the patient during her or his rehabilitation. The specialists' initial decisions may be based in large measure on the information gathered by assessments of the examining physician.

The physical exam should be a complete assessment of the patient with special consideration given to the fact that this population is much less likely to have regular medical care than the general population. In order to accurately assess the patient, the examining physician must be aware of the specific symptoms of withdrawal from various substances.

Alcohol Withdrawal:

Many alcoholics experience the shakes approximately 12-24 hours after their last drink. The shakes are simply tremors caused by overexcitation of the CNS. The shakes may be accompanied by tachycardia, diaphoresis, anorexia and insomnia. After 24-72 hours, the alcoholic may have rum fits, which are generalized seizures. Delirium tremens (DT's) begin 3-5 days after the last drink. DT's are characterized by disorientation, fever and visual hallucinations. DT's are a medical emergency and should be treated on an inpatient basis.