Room Collaborative Alcohol Analysis Project Research Articles

Epidemiology of alcohol consumption and related problems in Latin American countries: Contributions of psychology.

Alcohol consumption is the leading risk factor for morbi-mortality in many Latin American Countries. However, epidemiologic studies are relatively scarce. Among factors such as limited research capacity, disciplinary traditions and an emphasis on psychopathology within the field of psychology, have been postulated to account for this. The aim of this article is to review epidemiologic research on alcohol in Spanish Speaking Latin American Countries, and to measure the contribution of psychology to the field. A systematic search was performed in English and Spanish using regional and international data bases. We identified 269 articles. Most focused on consumption patterns in youth, with samples from a single school and using a variety of measures. With the exception of multinational efforts like Emergency Room Collaborative Alcohol Analysis Project or those supported by World Health Organization/Pan American Health Organization, studies reviewed reflected little cross country collaboration. Mexico accounted for most of the productivity, while many countries had very few or no articles. Most research was performed by health science researchers with a small contribution from psychology, but which increased significantly over time. The results of this review provide a broad identification of patterns regarding epidemiologic research on alcohol, and demonstrate the need for national scientific policies to promote research on public health topics.

Violence and non-violence-related injuries and alcohol in women from developed and developing countries: A multi-site emergency room study

This study sought to analyze the association between alcohol consumption and the occurrence of injuries in women attending the emergency room (ER) from developing and developed countries. The sample consisted of ER data from women in 15 countries that were collected as part of two multi-site studies using similar methodologies: the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP), and World Health Organization Collaborative Study on Alcohol and Injuries (WHO Study). Women ranged in age from 18 to 98years. Those from developed countries had higher levels of education (43% completed high-school) than women from developing countries (37%). Over half of the women from developing countries reported they had not consumed alcohol in the last 12months (abstentious), while 2% reported drinking every day. In addition, current drinking women from developing countries reported more binge drinking episodes (33% reported 5 to 11 drinks and 15% reported 12 or more drinks on an occasion) compared to those from developed countries (28% and 11%, respectively). Violence-related injury was more prevalent in developing countries (18%) compared to developed countries (9%). An association between injury and the frequency of alcohol consumption in the last 12months was observed in both developing and developed countries. Although women from developing countries who suffered violence-related injuries were more likely to demonstrate alcohol abstinence or have lower rates of daily alcohol consumption, these women drank in a more dangerous way, and violence-related injuries were more likely to occur in these women than in those living in developed countries.

Alcohol as a Trigger for Medical Emergencies

In this paper, our goal is to report relative risks of the impact of alcohol consumption 6 hours prior to medical emergencies presenting in the emergency department for 8,346 patients in seven countries using data from the Emergency Room Collaborative Alcohol Analysis Project. We found that alcohol increased the risk of a medical emergency by 2.17 times (confidence interval: 1.78–2.65), and those without a regular pattern of heavy drinking and those younger showed a greater risk. Acute alcohol is associated not only with injury but also with medical emergencies. More studies are needed on the acute role of alcohol in medical emergencies, preferably with data on the type of medical emergencies.

Alcohol and Violence-Related Injuries Among Emergency Room Patients in an International Perspective

While alcohol has been found to be more closely associated with violence-related injury than with injury from other causes, little data is available which documents heterogeneity in this association across countries or cultures, taking into consideration usual drinking patterns and other socio-cultural variables. Data are reported from 15 countries comprising the Emergency Room Collaborative Alcohol Analysis Project and the WHO Collaborative Study on Alcohol and Injury. Case-crossover analysis was used to analyze the risk of injury (among current drinkers) from drinking six hours prior to the event, based on frequency of usual drinking, for violence-related injuries and separately for non-violence related injuries. Relative risk (RR) for a violence-related injury was significantly greater than for injuries from other causes across all countries (pooled RR=22.22 vs. 4.33), but the magnitude of risk varied considerably (ranging from 4.68 in Spain to 942 in Canada). Pooled effect size was found to be heterogeneous across countries, and was explained, in part, by the level of detrimental drinking pattern in a country. Risk for a violence-related injury was not significantly different by age (<30 and 30+), reporting 5 or more drinks on at least one occasion during the last year, or reporting symptoms of alcohol dependence. A number of methodological concerns suggest that risk of a violence-related injury compared to injuries from other causes may be inflated, and such variables as context of drinking should be taken into consideration in establishing relative risk and alcohol attributable fraction of violence-related injury across countries and cultures.

The Relationship Between Self‐Reported Drinking and BAC Level in Emergency Room Injury Cases: Is it a Straight Line?

While the validity of self-reported consumption based on blood alcohol concentration (BAC) has been found to be high in emergency room (ER) samples, little research exists on the estimated number of drinks consumed given a BAC level. Such data would be useful in establishing a dose-response relationship between drinking and risk (e.g., of injury) in those studies for which the number of drinks consumed is not available but BAC is. Several methods were used to estimate the number of drinks consumed in the 6 hours prior to injury based on BAC obtained at the time of ER admission of n = 1,953 patients who self-reported any drinking 6 hours prior to their injury and who arrived to the ER within 6 hours of the event, from the merged Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study on Alcohol and Injury across 16 countries. The relationship between self-reported consumption and averaged BAC within each consumption level appeared to be fairly linear up to about 7 drinks and a BAC of approximately 100 mg/dl. Above about 7 reported drinks, BAC appeared to have no relationship with drinking, possibly representing longer consumption periods than only the 6 hours before injury for those reporting higher quantities consumed. Both the volume estimate from the bivariate BAC to self-report relationship as well as from a Widmark calculation using BAC and time from last drink to arrival to the ER indicated a somewhat weak relationship to actual number of self-reported drinks. Future studies may benefit from investigating the factors suspected to be driving the weak relationships between these measures, including the actual time over which the reported alcohol was consumed and pattern of drinking over the consumption period.

Gender Differences in the Relationship Between Alcohol and Violent Injury: An Analysis of Cross-National Emergency Department Data

The objectives of the present study were twofold: (1) to determine whether gender differences exist in the roles of drinking in the event (i.e., self-reported drinking before the injury and estimated blood alcohol concentration [BAC] captured after injury) and drinking pattern (i.e., heavy episodic drinking) in explaining violent versus nonviolent injuries and (2) to assess whether these gender differences vary by country. Emergency department data were analyzed from 30 hospitals in 15 countries, as part of the Emergency Room Collaborative Alcohol Analysis Project and the World Health Organization Collaborative Study of Alcohol and Injuries. Interaction effects between gender and alcohol were tested in the prediction of violent versus nonviolent injury for each country. The bivariate analyses revealed significantly larger effects of drinking-in-the-event variables for men than for women in three countries (i.e., 6 hours before the injury in Argentina and having a positive BAC in Belarus and Spain). In the multivariate analyses, restricted to countries with sufficient sample sizes (i.e., Mexico, South Africa, and the United States), no significant gender differences were found between the drinking-in-the-event variables and violent injury. In the bivariate and multivariate analyses, a significant interaction effect between gender and heavy episodic drinking was found in the United States, indicating that heavy episodic drinking predicted violent injury for women but not for men. Although the results are preliminary, treatment and prevention programs may need to target both genders equally or perhaps even focus more on heavydrinking women, particularly in the United States.

Validity of Self-Reported Drinking Before Injury Compared With a Physiological Measure: Cross-National Analysis of Emergency-Department Data From 16 Countries*

Self-reports of alcohol consumption among patients visiting an emergency department (ED) have been used extensively in the investigation of the relationship between drinking and injury. Little is known, however, about the associations between validity of self-reports with patient and injury characteristics and whether these relationships vary across regions or countries. Both of these issues are explored in this article. In the construct of a multilevel logistical model, validity of self-reports was estimated as the probability of a positive self-report given a positive blood alcohol concentration (BAC). The setting included 44 EDs across 28 studies in 16 countries. Participants included 10,741 injury patients from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study of Alcohol and Injuries. Data were analyzed on self-reported drinking within 6 hours before injury compared with BAC results obtained from breath-analyzer readings in all but two studies, which used urine screens. Covariates included demographic, drinking, and injury characteristics and aggregate-level contextual variables. At the individual level, a higher BAC measurement was associated with a higher probability of reporting drinking, as was heavy drinking and sustaining injuries in traffic accidents or violence-related events. At the study level, neither aggregate BAC nor other sociocultural variables affected the validity of self-reported drinking. This study provides further evidence of the validity of self-reported drinking measures in crossnational ED studies based on the objective criterion of BAC estimates.

The Effect of Alcohol Consumption on Emergency Department Services Use Among Injured Patients: A Cross-National Emergency Room Study

Although injured patients in the emergency department (ED) report more frequent use of the ED compared with the general population, and alcohol-related admissions and chronic alcohol misuse have been found to be predictive of future ED admissions, these data are based on only a few U.S. studies. The purpose of this article was to explore the association of alcohol use and ED services use among injured patients cross-nationally. Binary and multinomial logistic regression were used to analyze the association of alcohol consumption with prior ED visits among 9,743 injured patients surveyed in 37 EDs in 14 countries and reported in 23 studies from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and World Health Organization Collaborative Study of Alcohol and Injuries. Drinking within 6 hours before injury was associated with prior ED visits during the last 12 months (odds ratio = 1.25, p < .05), with a positive dose-response relationship. Heavy drinkers and those drinkers who were alcohol-dependent were also significantly more likely to report multiple prior ED visits, reflecting an elevated burden of services use. At the ED level, stigmatization of alcohol use was the only significant contextual variable that consistently predicted cross-ED variation in the relationship between drinking and ED use, in which the association was weaker in areas where alcohol use is less accepted. This study lends additional support to the potential effectiveness of screening for acute and chronic alcohol use among ED injured patients to reduce ED services use and associated costs.

Alcohol and Injury: A Risk Function Analysis from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP)

While emergency room (ER) studies have documented a strong association of alcohol and injury, less is known about the level of risk at which various quantities of alcohol or particular patterns of drinking place the individual for injury. Comparative risk function analyses are carried out in ER samples in seven countries that cover sites in 14 studies included in the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP). Risk of injury is analyzed for the mean number of drinks consumed per day and the number of occasions in which 5 or more drinks were consumed at one time (5+) during the last year. All countries showed similar increases in injury risk to an average volume of about 2 drinks per day, with a leveling off of risk at higher average daily volumes, with the exception of Italy. Risk of injury increased to 12 or more 5+ days for the USA, Canada and Mexico, but leveled off after only 3 5+ days for Argentina and Spain. Poland showed increased risk to 30 5+ days. Similar risk curves were found for both males and females, although females were at lower risk of injury in all countries expect Spain and Poland. In low detrimental drinking pattern societies, risk curves showed higher risk for any drinking and any frequency of 5+ but at higher levels of each, risk levels decreased nearly to levels found for abstainers. Risk functions were also consistent across gender and age groups in low detrimental drinking pattern societies, with higher risk for males and those <30. For those countries with high detrimental drinking patterns, injury risk increased with volume and 5+ drinking primarily among males. This ER-based risk function analysis suggests that risk of injury increases proportionally with increased alcohol consumption at lower consumption levels, but a threshold effect is achieved at relatively low levels of mean daily consumption and higher consumption times. Risk may be culturally specific, dependent, in part, on the manner in which alcohol is used in the culture.

Multi‐level analysis of alcohol‐related injury among emergency department patients: a cross‐national study*

The aim of this analysis was to examine the average rate and variation of alcohol-related injury across emergency department (ED) studies, the effect of usual drinking on likelihood of alcohol-related injury, whether cross-study variation in rate of alcohol-related injury can be explained by between-study difference in usual consumption and whether social-cultural contextual variables help explain cross-study variations, after between-study difference in usual consumption has been controlled. Data were merged from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the WHO Collaborative Study on Alcohol and Injuries, together representing 28 studies in 16 countries, and include 8423 (drinking) injury patients who arrived in the ED within 6 hours after injury. Alcohol-related injury was based, separately, on a positive blood alcohol concentration (BAC) and self-reported drinking within 6 hours prior to injury. A multi-level design and hierarchical generalized linear models were used for analysis in which patients were nested within studies. Overall prevalence of alcohol-related injury was 24% and 29% for positive BAC and self-report, respectively. At the patient level, log-transformed alcohol consumption in the last 12 months was a significant predictor of alcohol-related injury. At the study level significant variation in rates of alcohol-related injury was observed; studies with higher overall average consumption reported a higher rate of alcohol-related injury. When volume was controlled, societies with higher detrimental drinking pattern and higher legal level for intoxication while driving were more likely to have an increased rate of alcohol-related injury. Alcohol-related injury varies across EDs and countries. While it is associated with an individual's usual alcohol consumption, it is also affected by a number of societal drinking characteristics including the aggregate volume of consumption, overall drinking pattern and legislative policies to control drinking and related harms.

Multi-level analysis of causal attribution of injury to alcohol and modifying effects: Data from two international emergency room projects

Although alcohol consumption and injury has received a great deal of attention in the literature, less is known about patient's causal attribution of the injury event to their drinking or factors which modify attribution. Hierarchical linear modeling is used to analyze the relationships of the volume of alcohol consumed prior to injury and feeling drunk at the time of the event with causal attribution, as well as the association of aggregate individual-level and socio-cultural variables on these relationships. Data analyzed are from 1955 ER patients who reported drinking prior to injury included in 35 ERs from 24 studies covering 15 countries from the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the WHO Collaborative Study on Alcohol and Injuries. Half of those patients drinking prior to injury attributed a causal association of their injury with alcohol consumption, but the rate of causal attribution varied significantly across studies. When controlling for gender and age, the volume of alcohol consumed and feeling drunk (controlling for volume) were both significantly predictive of attribution and this did not vary across studies. Those who drink at least weekly were less likely to attribute causality at a low volume level, but more likely at high volume levels than less frequent drinkers. Attribution of causality was also less likely at low volume levels in those societies with low detrimental drinking patterns, but more likely at high volume levels or when feeling drunk compared to societies with high detrimental drinking patterns. These findings have important implications for brief intervention in the ER if motivation to change drinking behavior is greater among those attributing a causal association of their drinking with injury.

Cross-national performance of the RAPS4/RAPS4-QF for tolerance and heavy drinking: data from 13 countries.

There are little data available on the performance of brief screening instruments for alcohol-use disorders cross-nationally; therefore, we analyzed the performance of one such instrument in a number of countries. Performance of the RAPS4 for tolerance and the RAPS4-QF for heavy drinking are analyzed from emergency room data across 13 countries included in the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study on Alcohol and Injuries. The RAPS4 showed good sensitivity and specificity for tolerance across most of the countries, but was higher in countries that were higher on societal-level detrimental drinking patterns. Prevalence of tolerance was also higher in those countries with high detrimental drinking pattern scores. Sensitivity of the RAPS4-QF for heavy drinking was uniformly high across countries, while maintaining good specificity, and did not vary by detrimental drinking patterns. Findings suggest the RAPS4 and RAPS4-QF may hold promise cross-nationally. Future research should more fully address the performance of brief screening instruments for alcohol-use disorders (using standard diagnostic criteria) cross-nationally, with consideration of the impact of societal drinking patterns.

Attributable Risk of Injury Associated With Alcohol Use: Cross-National Data From the Emergency Room Collaborative Alcohol Analysis Project

We sought to determine gender- and age-specific attributable risks of all-cause and violence-related injuries associated with alcohol use. We used meta-analytic techniques to estimate attributable risks observed in emergency room studies conducted in 7 countries (n=17708). In the case of both alcohol consumption before the injury event and individual drinking patterns, pooled attributable risk effect sizes for all-cause injuries were significant but minimal (2% to 6%). Effect sizes for violence-related injuries were 43% for drinking before an injury event and 27% for individual drinking pattern. Risks were greater for men, but no age-specific differences were found. This meta-analysis showed that attributable risk of injury is greater for drinking before the injury event than for drinking pattern; in addition, risks were more pronounced for violence-related injuries. Differences in risk were explained by variables related to sociocultural contexts.

Emergency room injury presentations as an indicator of alcohol-related problems in the community: a multilevel analysis of an international study.

This study describes and examines the development of surrogate measures of acute alcohol-related injury for use in the evaluation of community-based prevention initiatives. An international collaborative study of alcohol and injury, the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP), provided a subset of data on 8580 emergency room (ER) presentations from five countries and 28 ER facilities. Presentations most likely to be alcohol related were those made between 12:00 AM and 4:59 AM (56%), on Fridays, Saturdays or Sundays (26%); and those among injured persons who were male (28%), who were aged between 18 and 45 years (24%) or who were unmarried (24%). Multilevel logistic regression models confirmed the significance of the above variables as predictors of alcohol involvement prior to the injury event. The strongest predictor variable was presentation between 12 midnight and 4:59 AM with an odds ratio of 4.92 (Wald Test chi2 = 397.6, p < .001). Being male had an odds ratio of 3.01 (Wald Test chi2 = 247.25, p < .001), and presenting on a Friday, Saturday or Sunday night had an odds ratio of 1.50 (Wald Test chi2 = 49.6, p < .001), whereas being under 45 (odds ratio [OR] = 1.20, p < .05) and being unmarried (OR = 1.2, p < .01) were less strong predictors. Combining all these values for variables raised the probability of prior alcohol involvement in such injury presentations to 0.65, although only 3.37% of all cases met these criteria, limiting applicability of this combined variable as a surrogate measure for intervention studies. Probabilities of prior alcohol involvement are presented with other combinations of values for the predictor variables. Frequency of nighttime injury presentations to ER facilities, particularly by men, can be used as a reliable surrogate measure of alcohol-related injuries for various epidemiological and evaluation purposes.

The Causal Attribution of Injury to Alcohol Consumption: A Cross‐National Meta‐Analysis From the Emergency Room Collaborative Alcohol Analysis Project

Whereas a substantial literature exists documenting the association of alcohol and injuries, causal associations are less well established. The relationship of drinking-in-the-event variables with attributing a causal association of alcohol consumption and the injury event was examined by using meta-analysis across 13 emergency room studies from 8 countries included in the Emergency Room Collaborative Alcohol Analysis Project. Pooled odds ratios for both log-transformed blood alcohol concentration at the time of the emergency room visit and the amount of alcohol consumed in the 6 hr before injury were positively predictive (1.19 and 1.80, respectively) and heterogeneous across studies. Effect size changed little when age and gender were controlled. When stratifying on reporting five or more drinks on an occasion during the last year (5+ yearly drinkers), the amount consumed was positively predictive of reporting a casual association of drinking and injury only for 5+ yearly drinkers. The effect size of feeling drunk at the time of injury, controlling for the amount of alcohol consumed, was positively predictive (2.04) but heterogeneous across studies. Meta-analysis regression found the level to which alcohol is consumed in a detrimental pattern to be a significant predictor of blood alcohol concentration, and of the amount consumed and feeling drunk at the time of injury, on causal attribution, with a lower detrimental pattern level with a larger effect size. The association of acute use of alcohol on causal attribution may be affected by chronic use to some extent, but this association is negatively affected by the degree to which a society exhibits harmful drinking patterns.

A cross-national meta-analysis of alcohol and injury: data from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP).

To examine the relationship of acute alcohol consumption with an injury compared to a non-injury event in the emergency room across ERs in five countries. Meta-analysis was used to evaluate the consistency and magnitude of the association of a positive blood alcohol concentration (BAC) at the time of arrival in the ER and self-reported consumption within 6 hours prior to the event with admission to the ER for an injury compared to a non-injury, and the extent to which contextual (socio-cultural and organizational) variables explain effect sizes. When controlling for age, gender and drinking five or more drinks on an occasion at least monthly, pooled effect size was significant and of a similar magnitude for both BAC and self-reported consumption, with those positive on either measure over half as likely again to be admitted to the ER with an injury compared to a medical problem. Effect sizes were found to be homogeneous across ERs for BAC, but not for self-report. Trauma center status and legal level of intoxication were positively predictive of self-reported consumption effect size on injury. These data suggest a moderate, but robust association of a positive BAC and self-report with admission to the ER with an injury, and that contextual variables also appear to play a role in the alcohol-injury nexus.