Alcohol-Related Emergency Department Utilization: A Systematic Review of Trends, Determinants, and Interventions

Alcohol-Related Emergency Department Utilization: A Systematic Review of Trends, Determinants, and Interventions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Alcohol-Related Emergency Department Utilization: A Systematic Review of Trends, Determinants, and Interventions Andre Christie, Krista Whitley, Melissa Facey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9337750/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Alcohol use contributes to morbidity‚ mortality and healthcare utilization․ Emergency departments (EDs) are often the first point of contact for alcoholrelated problems‚ including intoxication‚ injuries and chronic alcohol use complications․ While the literature on healthcare utilization related to alcohol is substantial and growing‚ to date‚ there has been no thorough‚ up-to-date overview of evidence from the ED perspective on trends‚ determinants‚ aetiology‚ economic burden and impact of interventions․ Methods: This systematic review was performed following the PRISMA 2020 guideline․ PubMed‚ MEDLINE (Ovid)‚ Embase‚ CINAHL and Google Scholar were searched․ Grey literature was also sourced from the World Health Organization and Agency for Healthcare Research and Quality․ Eligible studies published from January 2007 to March 2025 were quantitative epidemiological studies on alcohol-related ED presentations reporting on prevalence‚ trends‚ sociodemographic and socioeconomic factors‚ costs‚ or interventions․ Two reviewers independently screened studies for eligibility at the abstract and full-text level‚ with discrepancies resolved through consensus between the reviewers․ Study quality was assessed using the Newcastle-Ottawa Scale․ Given the heterogeneity between studies in terms of design‚ population‚ and outcomes‚ a narrative synthesis was used․ Results: Thirty-eight studies met inclusion criteria․ Presentation to the ED for alcohol use disordered ranged between 10 and 40% in different healthcare settings․ Most jurisdictions‚ especially in high-income countries‚ experienced an upward time trend in alcohol-related ED visits․ Demographic variables (sex and age) of affected populations were stable (predominantly males and younger adults‚ apart from older adults in new evidence in high-income countries)․ Socioeconomic disadvantage (especially income and geographic inequities) was a strong and consistent predictor of ED visits‚ consistent with the alcohol harm paradox․ Several included studies described racial or ethnic inequities․ The economic evidence was based on substantial and increasing economic impact‚ with national costs for both high-income and low- and middle-income countries in the hundreds of billions of US dollars annually․ The evidence from a number of studies found that ED-based interventions including SBIRT showed effectiveness for short-term reductions in alcohol consumption and increases in referral to treatment․ Results on long-term effects and implementation of SBIRT were also mixed․ Conclusions: The burden on health systems from alcohol-related ED utilization is large and increasing․ Further‚ it is not evenly distributed across the population․ EDs provide an important site of acute care and possible early intervention․ Policy implementation should adopt an integrated approach‚ combining ED-based implementations such as SBIRT with population-based alcohol control policies and targeting the collection of socioeconomic and structural determinants of health․ Future research should focus on implementation science‚ the sustainability and effectiveness of interventions over time‚ and the experience in low- and middle-income settings․ Alcohol consumption Emergency department Healthcare utilization SBIRT Public health COVID-19 Systematic review Figures Figure 1 Figure 2 Figure 3 1. Background Alcohol consumption represents one of the major health challenges of the modern era. Its health effects range from immediate issues, such as intoxication and injuries, to long-term problems. These include liver disease, heart disease, cancer, and early death. In 2016, alcohol was responsible for an estimated 2.8 million deaths. It ranked as the seventh leading risk factor in the global disease burden for that year. The impact was especially noticeable among people aged 15 to 49. In this age group, alcohol was the top risk factor, accounting for 12.2% of male deaths and 3.8% of female deaths in 2016. According to the GBD 2016 Alcohol and Drug Use Collaborators, alcohol use resulted in 99.2 million disability-adjusted life years. This portion represented 4.2% of total DALYs in 2016. The World Health Organization demonstrated the alcohol burden as a public health emergency of international concern. The organization urged immediate review and reform of alcohol control policies worldwide. Alcohol-related harm remains a dynamically developing phenomenon, even though its effects are well documented on a global scale, as changing consumption patterns, disparities in access to healthcare, and other changes in society, such as the impact of the COVID-19 pandemic, are contributing to this phenomenon. Such dynamics underscore the need for current evidence synthesis to guide healthcare planning and policy responses. Emergency departments are the main site for unscheduled care related to alcohol. Patients may present with acute intoxication, alcohol-related injuries, or complications from long-term drinking. Frequent repeat visits often reflect difficulty accessing primary or community healthcare, increasing the burden on the system. Emergency departments are well placed to identify acute and chronic manifestations of alcohol-related harm; therefore, it is a critical place to conduct surveillance, early intervention, and health system planning. Knowledge of ED utilization patterns can thus serve as a useful indicator of current healthcare burden and trends in overall population health. This trend has been generally consistent in multiple studies. White et al. ( 2018 ) examined the Nationwide Emergency Department Sample database. They found that alcohol-related emergency visits in the United States increased from approximately 3.9 million in 2006 to over 5.1 million in 2014. This represents a 31% rise over eight years across all demographic groups. A similar pattern was seen in a decade-long U.S. study of alcohol-related emergency visits from 2001 to 2011 by Mullins et al. ( 2017 ). They noted that males and young adults were disproportionately represented in these visits. At the national level, Suen et al. ( 2022 ) reported that about 15% of all emergency visits and hospitalizations in the U.S. from 2014 to 2018 involved alcohol or other substance use disorders. These statistics are not exclusive to the U.S. Cholerzynska et al. ( 2023 ) observed a comparable trend in a large European city hospital, where alcohol-related emergency visits occurred throughout the entire week. The social distribution of alcohol-related emergency visits further complicates the issue. Collins ( 2016 ) observed that individuals from lower socioeconomic groups are more likely to experience greater harm from alcohol. This can occur at the same or even lower levels of consumption than those of higher socioeconomic groups. This phenomenon is known as the alcohol harm paradox. Myran et al. ( 2022 ) found that income-related and geographic disadvantages were both independent predictors of alcohol-related emergency visits in Ontario, Canada, over fourteen years. This finding was recently supported by a population-level study in the same province by Smith et al. ( 2025 ). The study noted that the socioeconomic gradient in alcohol-related emergency visits persisted, even after adjusting for alcohol consumption patterns. However, COVID-19 has affected this in complex ways that are not yet fully understood. For example, a study by Esser et al. ( 2022 ) found a 34% decrease in acute alcohol-related emergency department visits in the U.S. during the initial 2020 lockdown. Similarly, overall U.S. statistics indicated a 16% reduction in avoidable healthcare visits (Gottlieb et al., 2023 ). However, Myran et al. ( 2021 , 2023 ) found a 13% increase in alcohol-related health service use in Canada during the same period, especially among individuals with pre-existing alcohol-related health diagnoses. This suggests that while overall health service utilization rates appeared to decrease, the most vulnerable populations experienced a pandemic-induced rise in alcohol-related health service use. Although the literature on alcohol-related healthcare utilization has continued to expand, a recent in-depth synthesis on emergency department settings among varied populations and health systems is lacking. Geographic boundaries, geocentric subpopulations, or limited outcome measurement often limit the current literature. Moreover, new developments such as COVID-19 and changing socioeconomic differences require a reassessment of trends, risk factors, and the efficacy of interventions. Accordingly, the proposed systematic review will summarize the existing data on alcohol-related ED usage, its prevalence, demographic and socioeconomic factors, cost-imposed burden, and efficacy of ED-based interventions. 2. Method A‌ systematic literature review was conducted to identify and review the evidence for alcohol-related ED presentations according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA 2020) guidelines․ The systematic review protocol was not pre-registered (e․g․ PROSPERO)‚ however all eligibility criteria‚ search strategies‚ and analyzes were defined a priori to ensure‌ methodological transparency and reproducibility․ The inclusion criteria applied to the‌ systematic review were original peer-reviewed quantitative studies (retrospective cohort‚ cross-sectional‚ randomized controlled trial‚ and systematic reviews)․ Studies had‌ to be published in English‚ between January 2007 and March 2025․ Outcomes were measured using alcohol-related Emergency department utilization‚ including prevalence and trends of usage‚ demographics and socioeconomic characteristics‚ costs‚ and‌ effectiveness of interventions․ Studies that only‌ focused on children‚ non-ED settings‚ case reports‚ editorials and commentaries were excluded․ The primary outcomes were‌ the prevalence and trend of alcohol-related ED visits․ Secondary outcomes included the sociodemographics‚ the socioeconomic status‚ the‌ costs of ED visits‚ and the effectiveness of ED-based intervention of Screening‚ Brief Intervention‚ and Referral to Treatment (SBIRT)․ All‌ relevant databases were searched (PubMed‚ MEDLINE (Ovid)‚ Embase‚ CINAHL‚ and Google Scholar)․ Grey literature was also searched using the websites of the World Health Organization‚‌ Agency for Healthcare Research and Quality‚ Global Burden of Disease‚ and Canadian Institute of Health Information․ Relevant articles were identified using controlled‌ vocabulary terms for alcohol use‚ emergency care‚ healthcare utilization‚ and intervention strategies‚ as well as keywords in these areas․ A complete search strategy‌ is reported in Appendix A․ The selection of studies was performed through two steps (title and abstract screening‚ then full-text screening)‚ which were conducted independently by three reviewers․ Disagreements were resolved by discussion and consensus so as to reduce the potential risk of selection bias․ Using multiple reviewers also improves the validity and reliability of study inclusion․ Data extraction was performed for studies on study and participant characteristics‚ outcomes‚ and key findings․ Methodological quality of observational studies was assessed using the Newcastle-Ottawa Scale․ Due to the heterogeneity in populations‚ design of the studies and definition and measurement of alcohol-related emergency department utilization‚ we performed no meta-analysis․ Heterogeneity can be defined as clinical (between different populations and settings)‚ methodological (between different study designs) and outcome (between different alcohol-related measures of emergency department utilization)․ Thus‚ a narrative synthesis approach was utilized․ Consideration was given to the potential for bias in the results of each study‚ such as bias introduced by the use of administrative data‚ the misclassification of alcohol-related diagnoses‚ or residual confounding associated with observational study designs‚ which could have affected the findings of these studies․ 3. Quality evaluation The quality of the methodologies used in the studies was assessed using appropriate tools tailored to each study design. For observational studies, the Newcastle-Ottawa Scale was applied. This scale allows a researcher to score a maximum of 4 points for study selection, 2 points for study comparability, and 3 points for outcome assessment. Therefore, the highest possible score on the Newcastle-Ottawa Scale is 9 points. The credibility of government reports and clinical guidelines was evaluated based on the reliability, methodology, and validity of the data from the sources. The quality of the methodology used in the studies is summarized in Table 1 . The quality scores of the included studies, assessed with the Newcastle-Ottawa Scale, ranged from 6/9 to 8/9. All government reports and guidelines were rated highly credible. Most of the studies were also rated as High quality. Specifically, 82% of the studies were classified as High quality, while 7 were rated Moderate-High quality. No studies were excluded from the analysis on quality grounds, as all met the methodological quality criteria. Table 1 Quality assessments of the 38 included studies. SN Source Tool Selection Comparability Outcome Total 1 White et al. ( 2018 ) NOS 3 2 2 7/9 2 Mullins et al. ( 2017 ) NOS 3 1 2 6/9 3 Rocha et al. ( 2025 ) NOS 3 2 2 7/9 4 Morin et al. ( 2025 ) NOS 3 2 2 7/9 5 World Health Organization ( 2018 ) Credibility — — — High 6 Suen et al. ( 2022 ) NOS 3 2 2 7/9 7 Myran et al. ( 2019 ) NOS 4 2 2 8/9 8 Myran et al. ( 2021 ) NOS 3 2 2 7/9 9 Myran et al. ( 2022 ) NOS 4 2 2 8/9 10 Myran et al. ( 2023 ) NOS 3 2 2 7/9 11 Esser et al. ( 2022 ) NOS 3 2 2 7/9 12 Cholerzynska et al. ( 2023 ) NOS 3 1 2 6/9 13 Smith et al. ( 2025 ) NOS 3 2 2 7/9 14 Collins ( 2016 ) NOS 3 1 2 6/9 15 Choi et al. ( 2015 ) NOS 3 1 2 6/9 16 Bhagavathula & Aldhaleei ( 2024 ) NOS 3 2 2 7/9 17 Legome et al. ( 2025 ) NOS 3 1 2 6/9 18 Sacks et al. ( 2015 ) NOS 3 2 2 7/9 19 Ozluk et al. ( 2022 ) NOS 3 1 2 6/9 20 Parkinson et al. ( 2016 ) NOS 3 1 2 6/9 21 Oliveras et al. ( 2024 ) NOS 3 2 2 7/9 22 Bruguera et al. ( 2018 ) NOS 3 2 2 7/9 23 Academic ED SBIRT Collaborative (2007) NOS 3 2 2 7/9 24 Academic ED SBIRT Collaborative (2010) NOS 3 2 2 7/9 25 Vaca & Winn ( 2007 ) NOS 3 1 2 6/9 26 Blake et al. ( 2023b ) NOS 3 2 2 7/9 27 Blake et al. ( 2023a ) NOS 3 2 2 7/9 28 Borgundvaag et al. ( 2024 ) Credibility — — — High 29 Shenvi et al. ( 2022 ) NOS 3 2 2 7/9 30 Joyce et al. ( 2024 ) NOS 3 1 2 6/9 31 Bernstein et al. ( 2025 ) NOS 3 2 2 7/9 32 Zhang et al. ( 2021 ) NOS 3 2 2 7/9 33 Urbanoski et al. ( 2018 ) NOS 3 2 2 7/9 34 Pines et al. ( 2021 ) NOS 3 1 2 6/9 35 Venkatesh et al. ( 2022 ) NOS 3 2 2 7/9 36 Gottlieb et al. ( 2023 ) NOS 3 1 2 6/9 37 Owens & Moore ( 2023 ) Credibility — — — High 38 Page et al. ( 2021 ) Credibility — — — High Note. NOS = Newcastle-Ottawa Scale (maximum score 9). Credibility = an assessment of the source credibility of government reports and guidelines. (—) = not applicable to this instrument. 4. Results The study selection process is summarized in Fig. 1 , following PRISMA 2020 reporting guidelines. Of 3,861 records retrieved from all databases and grey literature, 2,948 were retained after duplicates were removed. The title and abstract screening stage eliminated an additional 2,691 articles. A total of 222 articles required full-text retrieval, and all were successfully obtained. The full-text assessment then identified 184 articles as ineligible, leaving 38 for inclusion in the narrative synthesis. 4.1 Overview of Included Studies The geographic distribution of the included articles and their publication years are shown in Figs. 2 and 3 . Most articles originated from the United States, totaling 20. Eight articles came from Canada; five used global data from various countries through collaborations with the GBD consortium or the World Health Organization; three were from Europe; and two were multi-site international studies. The articles included 15 study designs, primarily retrospective population-based cohort studies. Seven systematic reviews and meta-analyses followed nine cross-sectional studies. Three articles focused on economic topics, and four were clinical guidelines or government reports. Detailed demographic and methodological information for all articles is provided in Table 2 . Despite heterogeneity in study design and setting in the 38 studies identified‚ a number of common trends were identified․ First‚ alcohol-related ED presentation has increased over time in several jurisdictions․ Second‚ differences in service use associated with sex‚ age and socioeconomic status were found to be consistent across studies․ Third‚ ED-based intervention-based interventions such as SBIRT had stable evidence for short-term consumption outcomes but not for long-term or intervention consistency outcomes․ These patterns were found across different healthcare systems‚ although much of the evidence came from high-income countries․ 4.2 Trends in Emergency Department Utilization The evidence on prevalence and trends suggests an increase across jurisdictions, though the magnitude of change varied. White et al. ( 2018 ) reported a 31% increase in emergency department visits related to alcohol issues in the United States between 2006 and 2014. This increase was greater than the overall rise in emergency visits during the same period. Mullins et al. ( 2017 ) observed a trend from 2001 to 2011, where the proportion of alcohol-related emergency visits increased across all demographic groups. Myran et al. ( 2019 ) documented steady year-over-year increases in emergency department visits in Ontario, Canada, over fourteen years, even after adjusting for population and healthcare system changes. Suen et al. ( 2022 ) reported that 15% of all emergency department visits and hospitalizations in the United States from 2014 to 2018 involved a diagnosis of substance use or alcohol use disorder. Zhang et al. ( 2021 ) found a 44% rise in emergency visits related to substance use disorders in the U.S. between 2006 and 2014, with alcohol-related issues being predominant. Overall, the evidence base was highly biased towards high-income nations, specifically the United States and Canada. This concentration of evidence in high-income settings limits generalizability to low- and middle-income countries, where healthcare access, alcohol regulation, and reporting systems differ substantially. 4.3 Demographic and Socioeconomic Patterns Demographic and socioeconomic patterns of alcohol-related emergency department visits were a common theme throughout the included literature. Male sex was the strongest predictor of emergency department visits for alcohol-related reasons, which was a significant risk factor in all studies examining this variable, including White et al. ( 2018 ), Mullins et al. ( 2017 ), Suen et al. ( 2022 ), and Cholerzynska et al. ( 2023 ). Age patterns of emergency department visits for alcohol-related reasons were complex. However, young adults aged 18–34 years had the highest rates in United States-based studies; adults 50 and older were identified by Choi et al. ( 2015 ) as having a latent class of heavy drinkers, which significantly increases emergency department visit rates and often is not targeted in prevention efforts. Socioeconomic status was a significant predictor of emergency department visits for alcohol-related reasons. Collins ( 2016 ) provided the theoretical framework, indicating that socioeconomic status increases the risk of alcohol-related consequences at the same levels of consumption, a finding further supported by Myran et al. ( 2022 ) and the most recent Canadian data from Smith et al. ( 2025 ). Owens and Moore ( 2023 ) extended this work by examining racial and ethnic differences in rates of emergency department visits for substance use disorder in the United States, identifying significant disparities among different racial and ethnic groups. These results indicate that the socially and economically disadvantaged groups are disproportionately impacted by alcohol-related ED utilization. 4.4 Economic Burden The available literature on the cost of alcohol-related ED service use highlights a significant and growing concern. Sacks et al. ( 2015 ) found that the cost of excessive alcohol use in the U.S. was estimated at $ 249 billion in 2010, with ED and healthcare services being key contributors. Ozluk et al. ( 2022 ) discovered that the cost of alcohol-related issues for Medicaid patients was substantially higher than for those with commercial insurance, raising concerns about health equity and resource distribution. Oliveras et al. ( 2024 ) studied ED patients in Spain and found that alcohol-related problems were strongly linked to higher costs in this high-expense population. Legome et al. ( 2025 ) analyzed the cost of alcohol intoxication in a U.S. academic ED and observed notable cost increases over five years. Bernstein et al. ( 2025 ) reviewed national hospitalization trends and reported that alcohol-related hospitalizations in 2022 generated $ 32.6 billion in healthcare expenses, with inpatient mortality and costs steadily rising during the study period. Nevertheless, estimates of costs varied widely depending on methodology, population, and the context of the healthcare system. 4.5 Intervention Effectiveness (SBIRT) Research on Screening, Brief Intervention, and Referral to Treatment in the emergency department has generally been supportive, though with some limitations. The 2007 and 2010 publications by the Academic ED SBIRT Research Collaborative laid the foundation with results from a key multicenter randomized controlled trial showing that SBIRT effectively reduces alcohol use at 3, 6, and 12 months post-intervention among at-risk adult emergency department patients. Bruguera et al. ( 2018 ) conducted a randomized controlled trial of a specialist-delivered SBIRT intervention in a tertiary emergency department, achieving notable reductions in at-risk drinking at 1.5 months and more than doubling the referrals to specialized treatment in the intervention group. Shenvi et al. ( 2022 ) conducted a randomized trial of the Brief Negotiation Interview among patients aged 50 + in the emergency department, addressing a demographic that is often underrepresented in SBIRT research. The intervention successfully reduced high-risk alcohol use among older people. Joyce et al. ( 2024 ) carried out a cross-sectional study in New Zealand, examining alcohol-related presentations over time and finding an increasing age profile among patients with alcohol-related issues. Blake et al. ( 2023a , b ) studied the effectiveness of SBIRT in increasing emergency department staff's knowledge and confidence in the UK, with positive attitudes toward SBIRT but notable barriers to implementation. Borgundvaag et al. ( 2024 ) translated existing research evidence into formal clinical guidelines using the GRACE-4 framework. Overall, there is reason to believe in the short-term efficacy of SBIRT interventions, but long-term outcomes and the consistency of implementation remain unclear. Table 2 Demographics and methodologies of the 38 included studies. SN Source Country Period Study Design Population Sample/Data Key Finding 1 White et al. ( 2018 ) USA 2006–2014 Retrospective cohort National adult ED population NEDS ~ 5.1M visits/yr Alcohol-related ED visits rose 31% over eight years; males and young adults predominated. 2 Mullins et al. ( 2017 ) USA 2001–2011 Retrospective cohort National adult ED population NEDS trend data Alcohol-related visits grew as a share of total ED encounters; males 18–34 had the highest burden. 3 Rocha et al. ( 2025 ) USA 1993–2021 Serial cross-sectional National adult ED population NHAMCS data Long-term trends in alcohol-related ED visits documented over nearly three decades; distinguish chronic from acute presentations. 4 Morin et al. ( 2025 ) Canada 1990–2016 Retrospective cohort Adults with substance use ED presentations Admin data, single centre Alcohol-related ED presentations had a mean age of 44.58 years; the opioid group had a higher hospitalization risk per additional ED visit. 5 WHO (2018) Global Multi-year Policy report Multi-country population 3M deaths/yr Global burden assessment calls for urgent revision of alcohol control policies. 6 Suen et al. ( 2022 ) USA 2018–2023 Retrospective, NHAMCS National ED and hospital sample ~ 15% of visits 15% of ED visits involved AUD; higher among males and the uninsured 7 Myran et al. ( 2019 ) Canada 2003–2016 Population cohort Ontario adult population Per 100,000 Alcohol-attributable ED visit rates increased consistently over 14 years in Ontario. 8 Myran et al. ( 2021 ) Canada 2020–2021 Cohort, COVID-19 Ontario adult population Admin data Sociodemographic shifts in ED alcohol visits during COVID-19 lockdowns 9 Myran et al. ( 2022 ) Canada 2003–2017 Population cohort Ontario adult population Per 100,000 Income and geographic disadvantage independently predicted alcohol-related ED visits. 10 Myran et al. ( 2023 ) Canada 2016–2022 Cohort, COVID-19 Ontario adult population Admin data Alcohol-related health service use increased during the pandemic, especially among chronic users. 11 Esser et al. ( 2022 ) USA 2018–2020 Cross-sectional National ED sample NSSP data Acute alcohol ED visits declined in early COVID-19 lockdowns, then rebounded. 12 Cholerzynska et al. ( 2023 ) Poland 2019–2021 Retrospective cohort Urban hospital ED patients Single centre Alcohol-related presentations are distributed across all hours; they are more common in males. 13 Smith et al. ( 2025 ) Canada 2015–2019 Population cohort Ontario adult population Admin data Lower SES is associated with higher alcohol-attributable ED visit rates, independent of consumption. 14 Collins ( 2016 ) USA Review period Narrative review General adult population Literature review SES is inversely associated with alcohol-related harm at equivalent consumption levels 15 Choi et al. ( 2015 ) USA 2004–2012 Cross-sectional Adults aged 50+ NSDUH latent class The latent class of heavy drinkers showed significantly higher ED utilization. 16 Bhagavathula & Aldhaleei ( 2024 ) USA 2016–2019 Cross-sectional Working-age adults NEDS fall data Alcohol and substance use increased fall-related ED visits, especially in working-age adults. 17 Legome et al. ( 2025 ) USA 2018–2022 Retrospective cohort Academic ED patients Single centre Alcohol intoxication visits increased; a significant facility-fee financial burden was documented. 18 Sacks et al. ( 2015 ) USA 2010 Economic analysis National population Cost modelling Excessive alcohol consumption cost the U.S. $ 249 billion in 2010; ED is a major cost driver. 19 Ozluk et al. ( 2022 ) USA 2016–2019 Economic analysis Commercially insured and Medicaid Admin claims data Alcohol-attributable medical costs are substantially higher in Medicaid vs commercial populations. 20 Parkinson et al. ( 2016 ) UK 2010–2013 Dual prospective and retrospective cohort Adult ED attendees, inner city hospital Single centre Alcohol-related ED attendance prevalence 12–15%; predominantly younger males on weekends; cost per attendance £249, rising to £851 if admitted 21 Oliveras et al. ( 2024 ) Spain 2015–2019 Retrospective cohort Frequent ED users Hospital admin data Alcohol-related problems are significantly associated with higher costs among frequent ED users. 22 Bruguera et al. ( 2018 ) Spain 2015–2017 RCT Adult at-risk drinkers presenting to the ED Single tertiary centre, n = 200 Specialist-delivered SBIRT significantly reduced at-risk drinking at 1.5 months and increased referral to specialized treatment. 23 Academic ED SBIRT Collaborative (2007) USA 2003–2006 RCT Adult ED patients Multi-site RCT SBIRT reduced alcohol consumption at 3, 6, and 12-month follow-up in ED patients 24 Academic ED SBIRT Collaborative (2010) USA 2006–2009 RCT follow-up Adult ED patients Multi-site RCT 12-month SBIRT follow-up confirmed reductions in drinking days and heavy episodic drinking 25 Vaca & Winn ( 2007 ) USA 2007 Review ED practitioners Narrative review Practical guide to SBIRT implementation in the emergency department setting 26 Blake et al. ( 2023b ) UK 2021–2022 Cross-sectional ED and urgent care staff Staff survey Staff reported positive attitudes toward SBIRT but significant barriers to routine implementation. 27 Blake et al. ( 2023a ) UK 2021–2022 Pre-post evaluation ED and urgent care workforce Digital training Digital SBIRT training improved staff knowledge and confidence, was scalable, and was low-cost. 28 Borgundvaag et al. ( 2024 ) Canada/USA 2022–2024 Clinical guideline ED populations GRACE-4 guideline Evidence-based guidance on managing alcohol use disorder and cannabinoid hyperemesis in the ED 29 Shenvi et al. ( 2022 ) USA 2019–2021 RCT Adults aged 50 + presenting to the ED Single centre Brief Negotiation Interview reduced high-risk alcohol use among older adult ED patients; addresses an underserved subgroup. 30 Joyce et al. ( 2024 ) New Zealand 2013–2022 Cross-sectional (3 waves) Adult ED attendees with alcohol-related presentations Single centre Shift toward older patient age profile over time; off-licence alcohol purchase is the most common; alcohol remains a significant preventable burden on EDs. 31 Bernstein et al. ( 2025 ) USA 2016–2022 Cross-sectional National hospitalized population National Inpatient Sample, 12.9M hospitalizations Alcohol-related hospitalizations generated $ 32.6 billion in healthcare costs in 2022; inpatient mortality and costs increased over the study period. 32 Zhang et al. ( 2021 ) USA 2006–2014 Retrospective, NEDS National ED sample NEDS data Substance use disorder ED visits increased 44% over the study period; alcohol was the predominant driver. 33 Urbanoski et al. ( 2018 ) Canada 2003–2014 Population cohort Ontario adult population Admin data Frequent ED users for mental and substance use disorders had distinct clinical and demographic profiles. 34 Pines et al. ( 2021 ) USA 2019–2020 Retrospective, NEDS National ED sample NEDS data Substance use disorder ED visits declined early in COVID-19, then returned to pre-pandemic levels. 35 Venkatesh et al. ( 2022 ) USA 2019–2020 Retrospective, NEDS National ED sample NEDS data Alcohol and substance use ED visits declined during COVID-19 lockdowns, then rebounded. 36 Gottlieb et al. ( 2023 ) USA 2019–2021 Cross-sectional Adult ED patients Hospital admin data Avoidable ED visits, including alcohol-related, declined during the pandemic; recovery is uneven. 37 Owens & Moore ( 2023 ) USA 2019 Cross-sectional ED patients by race/ethnicity HCUP data Racial and ethnic disparities are documented in substance use disorder ED visit rates across groups. 38 Page et al. ( 2021 ) International 2021 Methodological guideline Systematic review methodology PRISMA 2020 Updated PRISMA 2020 framework used to guide the conduct and reporting of this review 4.6 Final Summary Overall, the studies included in the summary imply that alcohol-related emergency department use suggests an increasing burden with stable demographic and socioeconomic trends. Nonetheless, the variability in the study design, outcome measures, and healthcare settings should be considered when interpreting these findings. 5. Discussion This systematic review determined that alcohol-related emergency department visits are an important and increasing contributor to healthcare utilization across the world․ This increase appears to occur uniformly across geographical and demographic subgroups‚ although the magnitude of the change does vary based on the healthcare setting․ Our findings reaffirm that emergency departments are both sites of acute care‚ as well as barometers of system-level gaps in prevention‚ access to care‚ and management of alcohol-related harm․ Based on the results from the systematic review, the demographic characteristics of patients visiting the emergency department due to alcohol use include mostly young male patients from low socioeconomic backgrounds. The findings from Collins ( 2016 ), Myran et al. ( 2022 ), and Smith et al. ( 2025 ) provide a strong overview of the link between alcohol consumption and emergency department visits. The results show that socioeconomic disadvantage is a risk factor for alcohol-related harm even after controlling for alcohol consumption levels. Additionally, racial and ethnic differences in alcohol-related emergency department use in the United States, as noted by Owens and Moore ( 2023 ), emphasize the importance of equity-focused interventions to reduce alcohol-related emergency visits. These results support the overall literature on health inequities, indicating that alcohol-related harm is not only predetermined by the extent of consumption but also influenced by structural and socioeconomic factors. COVID-19 not only demonstrated the patterns of alcohol-related emergency department visits but also made these patterns more complicated. After an initial decline in alcohol-related emergency visits, as shown in the studies by Esser et al. ( 2022 ) and Pines et al. ( 2021 ), the numbers increased during the early stages of the pandemic and exceeded pre-pandemic levels. Notably, however, the study by Myran et al. ( 2021 , 2023 ) found that the pandemic did not decrease the total number of alcohol-related emergency visits. Instead, it shifted the burden to individuals with pre-existing alcohol issues and those who are socio-economically disadvantaged. The reviewed economic data support the argument that investing in the prevention of alcohol-related problems is justified. Sacks et al. ( 2015 ) found that the $ 249 billion spent on alcohol-related issues in the United States is a conservative estimate that has increased significantly due to a rise in alcohol-related emergency visits. The substantial economic data from the included studies provide a strong financial rationale for implementing system-wide SBIRT procedures in emergency departments. However, the work of Blake et al. ( 2023b ) found that such procedures remain limited within institutions. However, economic estimates should be interpreted with caution, as methodologies varied across studies, and cost calculations were often context-specific, limiting direct comparability. The effectiveness of SBIRT, while generally positive, should be approached with caution. Although the initial studies by the Academic ED SBIRT Research Collaborative demonstrated the intervention's concept, recent research shows significant variability in results. For example, the recent study by Bruguera et al. ( 2018 ) demonstrated the short-term effectiveness of specialist-delivered SBIRT in a Spanish emergency department. Additionally, the study by Shenvi et al. ( 2022 ) expanded the evidence base to include the older adult population, which is often excluded from SBIRT efficacy research. It seems the key question now is less about whether SBIRT works and more about which groups it helps most, a consideration that may benefit from greater attention within implementation science. Such variability suggests that effectiveness is context-dependent of implementation, the patient population, and factors within the healthcare system, and that the implementation science approach should be applied in future research. This review supports previous literature that has established that alcohol-related harm has a substantial burden on healthcare systems. Nonetheless, this review adds to the current context by using more recent evidence, such as studies conducted during COVID-19, and by focusing on the importance of socioeconomic disparities in determining the pattern of ED use. 5.1 Implications for external validity The applicability of these results is limited by the fact that the majority of studies are conducted in high-income nations, primarily the United States and Canada. Differences in healthcare infrastructure, alcohol policy environments, and reporting systems may limit the applicability of these findings to low- and middle-income settings. Future studies should focus on a broader geographic representation to enhance global relevance. 5.2 Implications for Practice and Policy The implications of this review's findings for clinical practice and public health policy are significant. The systematic integration and scaling of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have a strong case at the emergency department (ED) level. Evidence suggests that SBIRT can reduce alcohol consumption in the short-term and enhance referral to special care. However, implementation remains inconsistent due to workforce, time, and training variability. To become more efficient, EDs are recommended to adopt standardized SBIRT guidelines, invest in staff training, and integrate digital or automated screening devices to make them feasible and sustainable in busy clinical settings. The economic and medical costs of alcohol-related ED use at the policy level justify the necessity of population-wide interventions. Alcohol taxation, minimum unit pricing and tightening of alcohol marketing and supply have all been found to bring harmful consumption habits down. These interventions can be used to supplement ED-based interventions by focusing on the upstream determinants of alcohol-related harm. Enhancing the public health systems that incorporate healthcare services and regulatory measures is the key to attaining the long-term outcomes of alcohol-related morbidity and healthcare use. Targeting based on equity is also essential. The review notes that alcohol-related ED visits are disproportionate to people in lower socioeconomic statuses and disadvantaged groups. This highlights the need for targeted interventions that address structural determinants of health, such as poverty, access to care, and social support systems. Disparities need to be reduced through tailored community-based interventions, culturally relevant interventions, and enhanced access to preventive services. In the absence of a clear equity lens, clinical and policy interventions have the risk of perpetuating the status quo in terms of alcohol-related harm. Overall, an integrated solution, involving ED-based clinical interventions, population-level policies, and equity-focused strategies, is required to help reduce the use of alcohol-related emergency departments and their related impact on society. 5.3 Research Limitations There are some limitations that need to be taken into account․ Although the three independent reviewers were used in order to reduce selection bias‚ the lack of a protocol could lead to reporting bias․ The majority of the included studies were conducted in high-income countries (in particular the US and Canada)‚ which limits the generalizability of the evidence for low-income and middle-income countries and their differing health systems and alcohol policy contexts․ Substantial heterogeneity between studies in design and outcome measures as well as populations involved precluded a quantitative meta-analysis from being undertaken․ Most studies included in the review used administrative and other observational data that are prone to misclassification bias and residual confounding․ The results of the review are also reliant on the consistent definition of an alcohol-related presentation to the ED․ These limitations may impact the accuracy and the external validity of the findings and the applicability of the findings to policy and clinical practice․ 6. Conclusion and recommendations Alcohol consumption appears to impose a substantial, growing, and unequal burden on emergency healthcare systems worldwide. The evidence compiled in this review suggests a rising trend in alcohol-related emergency department visits across different countries, with a demographic profile typically involving males, young individuals, and those from disadvantaged socioeconomic backgrounds. It also accounts for an economic burden of hundreds of billions of dollars annually in high-income countries. COVID-19 temporarily disrupted this pattern, but there was no overall reduction in demand, and it may even have increased the burden on marginalized groups. These results are generally similar across different healthcare systems, which reinforces confidence in the patterns observed in general despite the differences in study design and setting. For Screening, Brief Intervention, and Referral to Treatment as part of emergency department service delivery, there is considerable evidence supporting its implementation, particularly for short-term outcomes. However, its effectiveness depends on the setting, and various structural and workforce factors require specific attention. The research on cost-effectiveness provides an economic basis for adopting these strategies. On a population level, alcohol-related harms are unequally distributed across socioeconomic groups. Reducing alcohol-related harm involves both a mix of population-wide policies, such as regulating alcohol supply and marketing, and specific interventions that could improve socioeconomic inequalities. From a policy and clinical perspective, the findings support the expansion of integrated alcohol intervention strategies within emergency care settings, alongside broader public health policies targeting alcohol availability and socioeconomic inequalities. Enhanced implementation systems on SBIRT and similar interventions are necessary. The alcohol-related harm demands concerted actions by the healthcare system, policy environment, and interventions at the community level to produce significant and enduring changes. These findings reinforce the role of emergency departments as critical intervention points within broader public health strategies addressing alcohol-related harm. Future research should include prospective multicenter studies to understand better the causes of emergency department visits related to alcohol harms. It should also involve stratified analysis to examine differences across socioeconomic, racial, and ethnic groups. Additionally, implementation science is needed to determine the most effective ways to apply Screening, Brief Intervention, and Referral to Treatment and similar strategies in various healthcare settings. Longitudinal studies are also essential to follow alcohol-related harm trajectories from emergency visits through subsequent care and into communities to assess long-term outcomes of emergency department-based interventions. Significantly, more research should be conducted in low and middle-income countries to enhance the global applicability of evidence in this area. Declarations Ethics approval and consent to participate Not applicable. This study is a systematic review of previously published data and does not involve human participants or primary data collection. Consent for publication Not applicable Conflict of interest The authors declare no conflict of interest. Contributors Andre Craig Christie: Conceptualization, methodology, data curation, writing – original draft. Krista Whitley: Supervision, methodology review, writing – review & editing. Melissa Facey: Validation, critical review, writing – review & editing. Role of funding source This study received no external funding. Data Availability All data analyzed in this study are derived from previously published articles and publicly available sources. No new datasets were generated. Acknowledgements The author acknowledges the contributions of the researchers whose published work underpins this review. References Academic ED SBIRT Research Collaborative. (2010). The impact of screening, brief intervention and referral for treatment in emergency department patients' alcohol use: A 3-, 6- and 12-month follow-up. Alcohol and Alcoholism, 45(6), 514–519. https://doi.org/10.1093/alcalc/agq058 Bernstein, E. Y., Wilson, L. M., Kruse, G. R., Edelman, E. J., Herzig, S. J., & Anderson, T. S. (2025). Alcohol-related hospitalizations from 2016 to 2022. JAMA Network Open , 8(12), e2550589. https://doi.org/10.1001/jamanetworkopen.2025.50589 Bhagavathula, A. S., & Aldhaleei, W. A. (2024). Alcohol and substance use among the working age population: A nationwide study of fall-related emergency department visits. 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Alcohol-related visits to U.S. emergency departments, 2001–2011. Alcohol and Alcoholism, 52(1), 119–125. https://doi.org/10.1093/alcalc/agw074 Myran, D. T., Cantor, N., Pugliese, M., Hayes, T., Talarico, R., Kurdyak, P., Qureshi, D., & Tanuseputro, P. (2021). Sociodemographic changes in emergency department visits due to alcohol during COVID-19. Drug and Alcohol Dependence, 226, 108877. https://doi.org/10.1016/j.drugalcdep.2021.108877 Myran, D. T., Friesen, E. L., Pugliese, M., Milani, C., Kurdyak, P., Saraswat, M., & Tanuseputro, P. (2023). Changes in health service use due to alcohol during the COVID-19 pandemic. Canadian Journal of Public Health, 114(2), 185–194. https://doi.org/10.17269/s41997-023-00739-8 Myran, D. T., Hsu, A. T., Smith, G., & Tanuseputro, P. (2019). Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016. Canadian Medical Association Journal, 191(29), E804–E810. https://doi.org/10.1503/cmaj.181575 Myran, D. T., Hsu, A., Kunkel, E., Rhodes, E., Imsirovic, H., & Tanuseputro, P. (2022). Socioeconomic and geographic disparities in emergency department visits due to alcohol in Ontario, 2003–2017. Canadian Journal of Psychiatry, 67(7), 534–543. https://doi.org/10.1177/07067437211027321 Oliveras, C., Bruguera, P., Cordero-Torres, I., Millan-Hernandez, A., Pons-Cabrera, M. T., Guzman Cortez, P. R., Gomez-Ramiro, M., Vazquez, M., Borras, R., Asenjo-Romero, M., Vieta, E., Gual, A., Lopez-Pelayo, H., & Balcells-Olivero, M. (2024). Effects of alcohol-related problems on the costs of frequent emergency department use. Frontiers in Public Health, 12, 1322327. https://doi.org/10.3389/fpubh.2024.1322327 Owens, P. L., & Moore, B. J. (2023). Racial and ethnic differences in emergency department visits related to substance use disorders, 2019 (Statistical Brief No. 301). Agency for Healthcare Research and Quality. https://hcup-us.ahrq.gov/reports/statbriefs/sb301-ED-Substance-Use-Disorders-Race-2019.jsp Ozluk, P., Cobb, R., Sylwestrzak, G., Raina, D., & Bailly, E. (2022). Alcohol-attributable medical costs in commercially insured and Medicaid populations. AJPM Focus, 1(2), 100036. https://doi.org/10.1016/j.focus.2022.100036 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hrobjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71 Parkinson, K., Newbury-Birch, D., Phillipson, A., Hindmarch, P., Kaner, E., Stamp, E., Vale, L., Wright, J., & Connolly, J. (2016). Prevalence of alcohol related attendance at an inner city emergency department and its impact: A dual prospective and retrospective cohort study. Emergency Medicine Journal , 33(3), 187–193. https://doi.org/10.1136/emermed-2014-204581 Pines, J. M., Zocchi, M. S., Black, B. S., Carlson, J. N., Celedon, P., Moghtaderi, A., & Venkat, A. (2021). How emergency department visits for substance use disorders have evolved during the early COVID-19 pandemic. Journal of Substance Abuse Treatment, 129, 108391. https://doi.org/10.1016/j.jsat.2021.108391 Rocha, L. R., Gao, J., Espinola, J. A., & Camargo, C. A. (2025). Longitudinal analysis of alcohol-related emergency department visits from 1993 to 2021. American Journal of Epidemiology , 194(11), 3273–3280. https://doi.org/10.1093/aje/kwaf139 Sacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E., & Brewer, R. D. (2015). 2010 national and state costs of excessive alcohol consumption. American Journal of Preventive Medicine, 49(5), e73–e79. https://doi.org/10.1016/j.amepre.2015.05.031 Shenvi, C. L., Wang, Y., Revankar, R., Phillips, J., Bush, M., Biese, K. J., Aylward, A., D'Onofrio, G., & Platts-Mills, T. F. (2022). Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial. Journal of the American College of Emergency Physicians Open , 3(1), e12651. https://doi.org/10.1002/emp2.12651 Smith, B. T., Benny, C., Andreacchi, A. T., Schwartz, N., Warren, C. M., Forbes, S., & Hobin, E. (2025). Socioeconomic position, alcohol use and alcohol-attributable emergency department visits. Journal of Epidemiology and Community Health, 79(6), 416–423. https://doi.org/10.1136/jech-2024-222476 Suen, L. W., Makam, A. N., Snyder, H. R., Repplinger, D., Kushel, M. B., Martin, M., & Nguyen, O. K. (2022). National prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014–2018. Journal of General Internal Medicine, 37(10), 2420–2428. https://doi.org/10.1007/s11606-021-07069-w The Academic ED SBIRT Research Collaborative. (2007). The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Annals of Emergency Medicine, 50(6), 699–710. https://doi.org/10.1016/j.annemergmed.2007.06.486 Urbanoski, K., Cheng, J., Rehm, J., & Kurdyak, P. (2018). Frequent use of emergency departments for mental and substance use disorders. Emergency Medicine Journal, 35(4), 220–225. https://doi.org/10.1136/emermed-2015-205554 Vaca, F. E., & Winn, D. (2007). The basics of alcohol screening, brief intervention and referral to treatment in the emergency department. Western Journal of Emergency Medicine, 8(3), 88–92. https://pmc.ncbi.nlm.nih.gov/articles/PMC2672213/ Venkatesh, A. K., Janke, A. T., Kinsman, J., Rothenberg, C., Goyal, P., Malicki, C., & Hawk, K. (2022). Emergency department utilization for substance use disorders and mental health conditions during COVID-19. PLOS ONE, 17(1), e0262136. https://doi.org/10.1371/journal.pone.0262136 White, A. M., Slater, M. E., Ng, G., Hingson, R., & Breslow, R. (2018). Trends in alcohol-related emergency department visits in the United States: Results from the Nationwide Emergency Department Sample, 2006 to 2014. Alcoholism: Clinical and Experimental Research, 42(2), 352–359. https://doi.org/10.1111/acer.13559 World Health Organization. (2018). Global status report on alcohol and health 2018. WHO Press. https://iris.who.int/handle/10665/274603 Zhang, X., Wang, N., Hou, F., Ali, Y., Dora-Laskey, A., Dahlem, C. H., & McCabe, S. E. (2021). Emergency department visits by patients with substance use disorder in the United States. Western Journal of Emergency Medicine, 22(5), 1076–1085. https://doi.org/10.5811/westjem.2021.3.50839 Additional Declarations No competing interests reported. Supplementary Files AppendixA.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 05 May, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 16 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Editor invited by journal 14 Apr, 2026 Submission checks completed at journal 11 Apr, 2026 First submitted to journal 11 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9337750","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":621456193,"identity":"e456f430-15d4-437b-8178-512da02c9375","order_by":0,"name":"Andre Christie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYHACxsd/fthAmDxEamE24O1JI00LmwAP22EStPC3H37GIMFzPs/gRgLjg7dtRGiROJNm9sDA4nYxUAuz4VxitDDc4GE3SOC5nbjhRgKbNC8xWuRv8LBJHGA7B9LC/psoLQZALZINbAfAtjATpcXwTJqxMWNPcuLMMw+bJeecI0KL3PHDDx8z/LBL7DuefPDDmzIitMCBwgHGBlLUA4E8qRpGwSgYBaNg5AAAYio4C/hDKIcAAAAASUVORK5CYII=","orcid":"","institution":"New York University","correspondingAuthor":true,"prefix":"","firstName":"Andre","middleName":"","lastName":"Christie","suffix":""},{"id":621456195,"identity":"adca1525-1fd1-438f-989f-dce6bd85b51a","order_by":1,"name":"Krista Whitley","email":"","orcid":"","institution":"New York University","correspondingAuthor":false,"prefix":"","firstName":"Krista","middleName":"","lastName":"Whitley","suffix":""},{"id":621456196,"identity":"07ca9eec-4752-44ae-8d23-04b6bee5c80c","order_by":2,"name":"Melissa Facey","email":"","orcid":"","institution":"Trinity School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Facey","suffix":""}],"badges":[],"createdAt":"2026-04-07 00:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9337750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9337750/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106849251,"identity":"b613c541-c75f-41b7-b3fa-7a2bcb393152","added_by":"auto","created_at":"2026-04-14 05:57:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":619147,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA 2020 flow diagram illustrating the study selection process. *Records identified from individual databases: PubMed (n = 1,204), MEDLINE (n = 987), CINAHL (n = 632), Embase (n = 724), Google Scholar (n = 300). **Records excluded at title and abstract screening as not relevant to the review objectives.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9337750/v1/859e8745d7f7e1c1729ed2da.png"},{"id":106849245,"identity":"198ea974-5e0c-426a-b8f8-01d1ba9d3054","added_by":"auto","created_at":"2026-04-14 05:57:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69170,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of the 38 included studies by geographic region.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9337750/v1/30b71e90a86d8aeaa0551753.png"},{"id":106849244,"identity":"a6edb3cf-598d-49d3-8f93-bd0149e34056","added_by":"auto","created_at":"2026-04-14 05:57:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":54051,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of the 38 included studies by year of publication.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9337750/v1/62e482458cad2a2a62787cb1.png"},{"id":106960339,"identity":"b8618706-dce6-490d-ad83-4aaca48bfaab","added_by":"auto","created_at":"2026-04-15 09:20:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1843314,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9337750/v1/2f959d88-0ccd-4a11-8d20-7bc082ac32df.pdf"},{"id":106849241,"identity":"9dfaed89-b2dc-4118-95f4-dc3bce597c6d","added_by":"auto","created_at":"2026-04-14 05:57:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24933,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9337750/v1/d8e741594da7d56d7adccdd1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Alcohol-Related Emergency Department Utilization: A Systematic Review of Trends, Determinants, and Interventions","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAlcohol consumption represents one of the major health challenges of the modern era. Its health effects range from immediate issues, such as intoxication and injuries, to long-term problems. These include liver disease, heart disease, cancer, and early death. In 2016, alcohol was responsible for an estimated 2.8\u0026nbsp;million deaths. It ranked as the seventh leading risk factor in the global disease burden for that year. The impact was especially noticeable among people aged 15 to 49. In this age group, alcohol was the top risk factor, accounting for 12.2% of male deaths and 3.8% of female deaths in 2016. According to the GBD 2016 Alcohol and Drug Use Collaborators, alcohol use resulted in 99.2\u0026nbsp;million disability-adjusted life years. This portion represented 4.2% of total DALYs in 2016. The World Health Organization demonstrated the alcohol burden as a public health emergency of international concern. The organization urged immediate review and reform of alcohol control policies worldwide.\u003c/p\u003e \u003cp\u003eAlcohol-related harm remains a dynamically developing phenomenon, even though its effects are well documented on a global scale, as changing consumption patterns, disparities in access to healthcare, and other changes in society, such as the impact of the COVID-19 pandemic, are contributing to this phenomenon. Such dynamics underscore the need for current evidence synthesis to guide healthcare planning and policy responses.\u003c/p\u003e \u003cp\u003eEmergency departments are the main site for unscheduled care related to alcohol. Patients may present with acute intoxication, alcohol-related injuries, or complications from long-term drinking. Frequent repeat visits often reflect difficulty accessing primary or community healthcare, increasing the burden on the system. Emergency departments are well placed to identify acute and chronic manifestations of alcohol-related harm; therefore, it is a critical place to conduct surveillance, early intervention, and health system planning. Knowledge of ED utilization patterns can thus serve as a useful indicator of current healthcare burden and trends in overall population health.\u003c/p\u003e \u003cp\u003eThis trend has been generally consistent in multiple studies. White et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) examined the Nationwide Emergency Department Sample database. They found that alcohol-related emergency visits in the United States increased from approximately 3.9\u0026nbsp;million in 2006 to over 5.1\u0026nbsp;million in 2014. This represents a 31% rise over eight years across all demographic groups. A similar pattern was seen in a decade-long U.S. study of alcohol-related emergency visits from 2001 to 2011 by Mullins et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). They noted that males and young adults were disproportionately represented in these visits. At the national level, Suen et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that about 15% of all emergency visits and hospitalizations in the U.S. from 2014 to 2018 involved alcohol or other substance use disorders. These statistics are not exclusive to the U.S. Cholerzynska et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) observed a comparable trend in a large European city hospital, where alcohol-related emergency visits occurred throughout the entire week.\u003c/p\u003e \u003cp\u003eThe social distribution of alcohol-related emergency visits further complicates the issue. Collins (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) observed that individuals from lower socioeconomic groups are more likely to experience greater harm from alcohol. This can occur at the same or even lower levels of consumption than those of higher socioeconomic groups. This phenomenon is known as the alcohol harm paradox. Myran et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found that income-related and geographic disadvantages were both independent predictors of alcohol-related emergency visits in Ontario, Canada, over fourteen years. This finding was recently supported by a population-level study in the same province by Smith et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The study noted that the socioeconomic gradient in alcohol-related emergency visits persisted, even after adjusting for alcohol consumption patterns.\u003c/p\u003e \u003cp\u003eHowever, COVID-19 has affected this in complex ways that are not yet fully understood. For example, a study by Esser et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found a 34% decrease in acute alcohol-related emergency department visits in the U.S. during the initial 2020 lockdown. Similarly, overall U.S. statistics indicated a 16% reduction in avoidable healthcare visits (Gottlieb et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, Myran et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found a 13% increase in alcohol-related health service use in Canada during the same period, especially among individuals with pre-existing alcohol-related health diagnoses. This suggests that while overall health service utilization rates appeared to decrease, the most vulnerable populations experienced a pandemic-induced rise in alcohol-related health service use.\u003c/p\u003e \u003cp\u003eAlthough the literature on alcohol-related healthcare utilization has continued to expand, a recent in-depth synthesis on emergency department settings among varied populations and health systems is lacking. Geographic boundaries, geocentric subpopulations, or limited outcome measurement often limit the current literature. Moreover, new developments such as COVID-19 and changing socioeconomic differences require a reassessment of trends, risk factors, and the efficacy of interventions. Accordingly, the proposed systematic review will summarize the existing data on alcohol-related ED usage, its prevalence, demographic and socioeconomic factors, cost-imposed burden, and efficacy of ED-based interventions.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003eA\u0026zwnj; systematic literature review was conducted to identify and review the evidence for alcohol-related ED presentations according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA 2020) guidelines․ The systematic review protocol was not pre-registered (e․g․ PROSPERO)\u0026sbquo; however all eligibility criteria\u0026sbquo; search strategies\u0026sbquo; and analyzes were defined a priori to ensure\u0026zwnj; methodological transparency and reproducibility․\u003c/p\u003e \u003cp\u003eThe inclusion criteria applied to the\u0026zwnj; systematic review were original peer-reviewed quantitative studies (retrospective cohort\u0026sbquo; cross-sectional\u0026sbquo; randomized controlled trial\u0026sbquo; and systematic reviews)․ Studies had\u0026zwnj; to be published in English\u0026sbquo; between January 2007 and March 2025․ Outcomes were measured using alcohol-related Emergency department utilization\u0026sbquo; including prevalence and trends of usage\u0026sbquo; demographics and socioeconomic characteristics\u0026sbquo; costs\u0026sbquo; and\u0026zwnj; effectiveness of interventions․ Studies that only\u0026zwnj; focused on children\u0026sbquo; non-ED settings\u0026sbquo; case reports\u0026sbquo; editorials and commentaries were excluded․\u003c/p\u003e \u003cp\u003eThe primary outcomes were\u0026zwnj; the prevalence and trend of alcohol-related ED visits․ Secondary outcomes included the sociodemographics\u0026sbquo; the socioeconomic status\u0026sbquo; the\u0026zwnj; costs of ED visits\u0026sbquo; and the effectiveness of ED-based intervention of Screening\u0026sbquo; Brief Intervention\u0026sbquo; and Referral to Treatment (SBIRT)․\u003c/p\u003e \u003cp\u003eAll\u0026zwnj; relevant databases were searched (PubMed\u0026sbquo; MEDLINE (Ovid)\u0026sbquo; Embase\u0026sbquo; CINAHL\u0026sbquo; and Google Scholar)․ Grey literature was also searched using the websites of the World Health Organization\u0026sbquo;\u0026zwnj; Agency for Healthcare Research and Quality\u0026sbquo; Global Burden of Disease\u0026sbquo; and Canadian Institute of Health Information․ Relevant articles were identified using controlled\u0026zwnj; vocabulary terms for alcohol use\u0026sbquo; emergency care\u0026sbquo; healthcare utilization\u0026sbquo; and intervention strategies\u0026sbquo; as well as keywords in these areas․ A complete search strategy\u0026zwnj; is reported in Appendix A․\u003c/p\u003e \u003cp\u003eThe selection of studies was performed through two steps (title and abstract screening\u0026sbquo; then full-text screening)\u0026sbquo; which were conducted independently by three reviewers․ Disagreements were resolved by discussion and consensus so as to reduce the potential risk of selection bias․ Using multiple reviewers also improves the validity and reliability of study inclusion․\u003c/p\u003e \u003cp\u003eData extraction was performed for studies on study and participant characteristics\u0026sbquo; outcomes\u0026sbquo; and key findings․ Methodological quality of observational studies was assessed using the Newcastle-Ottawa Scale․ Due to the heterogeneity in populations\u0026sbquo; design of the studies and definition and measurement of alcohol-related emergency department utilization\u0026sbquo; we performed no meta-analysis․ Heterogeneity can be defined as clinical (between different populations and settings)\u0026sbquo; methodological (between different study designs) and outcome (between different alcohol-related measures of emergency department utilization)․ Thus\u0026sbquo; a narrative synthesis approach was utilized․\u003c/p\u003e \u003cp\u003eConsideration was given to the potential for bias in the results of each study\u0026sbquo; such as bias introduced by the use of administrative data\u0026sbquo; the misclassification of alcohol-related diagnoses\u0026sbquo; or residual confounding associated with observational study designs\u0026sbquo; which could have affected the findings of these studies․\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"3. Quality evaluation","content":"\u003cp\u003eThe quality of the methodologies used in the studies was assessed using appropriate tools tailored to each study design. For observational studies, the Newcastle-Ottawa Scale was applied. This scale allows a researcher to score a maximum of 4 points for study selection, 2 points for study comparability, and 3 points for outcome assessment. Therefore, the highest possible score on the Newcastle-Ottawa Scale is 9 points. The credibility of government reports and clinical guidelines was evaluated based on the reliability, methodology, and validity of the data from the sources. The quality of the methodology used in the studies is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe quality scores of the included studies, assessed with the Newcastle-Ottawa Scale, ranged from 6/9 to 8/9. All government reports and guidelines were rated highly credible. Most of the studies were also rated as High quality. Specifically, 82% of the studies were classified as High quality, while 7 were rated Moderate-High quality. No studies were excluded from the analysis on quality grounds, as all met the methodological quality criteria.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eQuality assessments of the 38 included studies.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSource\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComparability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMullins et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRocha et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorin et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorld Health Organization (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuen et al. 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(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. 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(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholerzynska et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmith et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollins (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChoi et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBhagavathula \u0026amp; Aldhaleei (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLegome et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSacks et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOzluk et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParkinson et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOliveras et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBruguera et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic ED SBIRT Collaborative (2007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic ED SBIRT Collaborative (2010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaca \u0026amp; Winn (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2007\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlake et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlake et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBorgundvaag et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShenvi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJoyce et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBernstein et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZhang et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrbanoski et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePines et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVenkatesh et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGottlieb et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwens \u0026amp; Moore (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePage et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCredibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote. NOS\u0026thinsp;=\u0026thinsp;Newcastle-Ottawa Scale (maximum score 9). Credibility\u0026thinsp;=\u0026thinsp;an assessment of the source credibility of government reports and guidelines. (\u0026mdash;)\u0026thinsp;=\u0026thinsp;not applicable to this instrument.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eThe study selection process is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, following PRISMA 2020 reporting guidelines. Of 3,861 records retrieved from all databases and grey literature, 2,948 were retained after duplicates were removed. The title and abstract screening stage eliminated an additional 2,691 articles. A total of 222 articles required full-text retrieval, and all were successfully obtained. The full-text assessment then identified 184 articles as ineligible, leaving 38 for inclusion in the narrative synthesis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Overview of Included Studies\u003c/h2\u003e \u003cp\u003eThe geographic distribution of the included articles and their publication years are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Most articles originated from the United States, totaling 20. Eight articles came from Canada; five used global data from various countries through collaborations with the GBD consortium or the World Health Organization; three were from Europe; and two were multi-site international studies. The articles included 15 study designs, primarily retrospective population-based cohort studies. Seven systematic reviews and meta-analyses followed nine cross-sectional studies. Three articles focused on economic topics, and four were clinical guidelines or government reports. Detailed demographic and methodological information for all articles is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eDespite heterogeneity in study design and setting in the 38 studies identified\u0026sbquo; a number of common trends were identified․ First\u0026sbquo; alcohol-related ED presentation has increased over time in several jurisdictions․ Second\u0026sbquo; differences in service use associated with sex\u0026sbquo; age and socioeconomic status were found to be consistent across studies․ Third\u0026sbquo; ED-based intervention-based interventions such as SBIRT had stable evidence for short-term consumption outcomes but not for long-term or intervention consistency outcomes․ These patterns were found across different healthcare systems\u0026sbquo; although much of the evidence came from high-income countries․\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Trends in Emergency Department Utilization\u003c/h2\u003e \u003cp\u003eThe evidence on prevalence and trends suggests an increase across jurisdictions, though the magnitude of change varied. White et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reported a 31% increase in emergency department visits related to alcohol issues in the United States between 2006 and 2014. This increase was greater than the overall rise in emergency visits during the same period. Mullins et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) observed a trend from 2001 to 2011, where the proportion of alcohol-related emergency visits increased across all demographic groups. Myran et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) documented steady year-over-year increases in emergency department visits in Ontario, Canada, over fourteen years, even after adjusting for population and healthcare system changes. Suen et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that 15% of all emergency department visits and hospitalizations in the United States from 2014 to 2018 involved a diagnosis of substance use or alcohol use disorder. Zhang et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) found a 44% rise in emergency visits related to substance use disorders in the U.S. between 2006 and 2014, with alcohol-related issues being predominant. Overall, the evidence base was highly biased towards high-income nations, specifically the United States and Canada. This concentration of evidence in high-income settings limits generalizability to low- and middle-income countries, where healthcare access, alcohol regulation, and reporting systems differ substantially.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Demographic and Socioeconomic Patterns\u003c/h2\u003e \u003cp\u003eDemographic and socioeconomic patterns of alcohol-related emergency department visits were a common theme throughout the included literature. Male sex was the strongest predictor of emergency department visits for alcohol-related reasons, which was a significant risk factor in all studies examining this variable, including White et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), Mullins et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), Suen et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and Cholerzynska et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Age patterns of emergency department visits for alcohol-related reasons were complex. However, young adults aged 18\u0026ndash;34 years had the highest rates in United States-based studies; adults 50 and older were identified by Choi et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) as having a latent class of heavy drinkers, which significantly increases emergency department visit rates and often is not targeted in prevention efforts. Socioeconomic status was a significant predictor of emergency department visits for alcohol-related reasons. Collins (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) provided the theoretical framework, indicating that socioeconomic status increases the risk of alcohol-related consequences at the same levels of consumption, a finding further supported by Myran et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and the most recent Canadian data from Smith et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Owens and Moore (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) extended this work by examining racial and ethnic differences in rates of emergency department visits for substance use disorder in the United States, identifying significant disparities among different racial and ethnic groups. These results indicate that the socially and economically disadvantaged groups are disproportionately impacted by alcohol-related ED utilization.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Economic Burden\u003c/h2\u003e \u003cp\u003eThe available literature on the cost of alcohol-related ED service use highlights a significant and growing concern. Sacks et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) found that the cost of excessive alcohol use in the U.S. was estimated at \u003cspan\u003e$\u003c/span\u003e249\u0026nbsp;billion in 2010, with ED and healthcare services being key contributors. Ozluk et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) discovered that the cost of alcohol-related issues for Medicaid patients was substantially higher than for those with commercial insurance, raising concerns about health equity and resource distribution. Oliveras et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) studied ED patients in Spain and found that alcohol-related problems were strongly linked to higher costs in this high-expense population. Legome et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) analyzed the cost of alcohol intoxication in a U.S. academic ED and observed notable cost increases over five years. Bernstein et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) reviewed national hospitalization trends and reported that alcohol-related hospitalizations in 2022 generated \u003cspan\u003e$\u003c/span\u003e32.6\u0026nbsp;billion in healthcare expenses, with inpatient mortality and costs steadily rising during the study period. Nevertheless, estimates of costs varied widely depending on methodology, population, and the context of the healthcare system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Intervention Effectiveness (SBIRT)\u003c/h2\u003e \u003cp\u003eResearch on Screening, Brief Intervention, and Referral to Treatment in the emergency department has generally been supportive, though with some limitations. The 2007 and 2010 publications by the Academic ED SBIRT Research Collaborative laid the foundation with results from a key multicenter randomized controlled trial showing that SBIRT effectively reduces alcohol use at 3, 6, and 12 months post-intervention among at-risk adult emergency department patients. Bruguera et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) conducted a randomized controlled trial of a specialist-delivered SBIRT intervention in a tertiary emergency department, achieving notable reductions in at-risk drinking at 1.5 months and more than doubling the referrals to specialized treatment in the intervention group. Shenvi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted a randomized trial of the Brief Negotiation Interview among patients aged 50\u0026thinsp;+\u0026thinsp;in the emergency department, addressing a demographic that is often underrepresented in SBIRT research. The intervention successfully reduced high-risk alcohol use among older people. Joyce et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) carried out a cross-sectional study in New Zealand, examining alcohol-related presentations over time and finding an increasing age profile among patients with alcohol-related issues. Blake et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003eb\u003c/span\u003e) studied the effectiveness of SBIRT in increasing emergency department staff's knowledge and confidence in the UK, with positive attitudes toward SBIRT but notable barriers to implementation. Borgundvaag et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) translated existing research evidence into formal clinical guidelines using the GRACE-4 framework. Overall, there is reason to believe in the short-term efficacy of SBIRT interventions, but long-term outcomes and the consistency of implementation remain unclear.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographics and methodologies of the 38 included studies.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSource\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSample/Data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKey Finding\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2006\u0026ndash;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational adult ED population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS\u0026thinsp;~\u0026thinsp;5.1M visits/yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related ED visits rose 31% over eight years; males and young adults predominated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMullins et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2001\u0026ndash;2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational adult ED population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS trend data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related visits grew as a share of total ED encounters; males 18\u0026ndash;34 had the highest burden.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRocha et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1993\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerial cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational adult ED population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNHAMCS data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLong-term trends in alcohol-related ED visits documented over nearly three decades; distinguish chronic from acute presentations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorin et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1990\u0026ndash;2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdults with substance use ED presentations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin data, single centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related ED presentations had a mean age of 44.58 years; the opioid group had a higher hospitalization risk per additional ED visit.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMulti-year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePolicy report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMulti-country population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3M deaths/yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGlobal burden assessment calls for urgent revision of alcohol control policies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuen et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u0026ndash;2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective, NHAMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational ED and hospital sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e~\u0026thinsp;15% of visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15% of ED visits involved AUD; higher among males and the uninsured\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2003\u0026ndash;2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePopulation cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer 100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-attributable ED visit rates increased consistently over 14 years in Ontario.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2020\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCohort, COVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSociodemographic shifts in ED alcohol visits during COVID-19 lockdowns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2003\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePopulation cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePer 100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIncome and geographic disadvantage independently predicted alcohol-related ED visits.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyran et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCohort, COVID-19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related health service use increased during the pandemic, especially among chronic users.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEsser et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational ED sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNSSP data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAcute alcohol ED visits declined in early COVID-19 lockdowns, then rebounded.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholerzynska et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban hospital ED patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related presentations are distributed across all hours; they are more common in males.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmith et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2015\u0026ndash;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePopulation cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLower SES is associated with higher alcohol-attributable ED visit rates, independent of consumption.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollins (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReview period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGeneral adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLiterature review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSES is inversely associated with alcohol-related harm at equivalent consumption levels\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChoi et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2004\u0026ndash;2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdults aged 50+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNSDUH latent class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe latent class of heavy drinkers showed significantly higher ED utilization.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBhagavathula \u0026amp; Aldhaleei (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u0026ndash;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWorking-age adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS fall data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol and substance use increased fall-related ED visits, especially in working-age adults.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLegome et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcademic ED patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol intoxication visits increased; a significant facility-fee financial burden was documented.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSacks et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEconomic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCost modelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eExcessive alcohol consumption cost the U.S. \u003cspan\u003e$\u003c/span\u003e249\u0026nbsp;billion in 2010; ED is a major cost driver.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOzluk et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u0026ndash;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEconomic analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommercially insured and Medicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin claims data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-attributable medical costs are substantially higher in Medicaid vs commercial populations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParkinson et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2010\u0026ndash;2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDual prospective and retrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult ED attendees, inner city hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related ED attendance prevalence 12\u0026ndash;15%; predominantly younger males on weekends; cost per attendance \u0026pound;249, rising to \u0026pound;851 if admitted\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOliveras et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2015\u0026ndash;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFrequent ED users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHospital admin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related problems are significantly associated with higher costs among frequent ED users.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBruguera et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2015\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult at-risk drinkers presenting to the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle tertiary centre, n\u0026thinsp;=\u0026thinsp;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSpecialist-delivered SBIRT significantly reduced at-risk drinking at 1.5 months and increased referral to specialized treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic ED SBIRT Collaborative (2007)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2003\u0026ndash;2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult ED patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMulti-site RCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSBIRT reduced alcohol consumption at 3, 6, and 12-month follow-up in ED patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademic ED SBIRT Collaborative (2010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2006\u0026ndash;2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRCT follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult ED patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMulti-site RCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12-month SBIRT follow-up confirmed reductions in drinking days and heavy episodic drinking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaca \u0026amp; Winn (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2007\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eED practitioners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNarrative review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePractical guide to SBIRT implementation in the emergency department setting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlake et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eED and urgent care staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStaff survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStaff reported positive attitudes toward SBIRT but significant barriers to routine implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlake et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre-post evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eED and urgent care workforce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDigital training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDigital SBIRT training improved staff knowledge and confidence, was scalable, and was low-cost.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBorgundvaag et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada/USA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2022\u0026ndash;2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eED populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGRACE-4 guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEvidence-based guidance on managing alcohol use disorder and cannabinoid hyperemesis in the ED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShenvi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdults aged 50\u0026thinsp;+\u0026thinsp;presenting to the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBrief Negotiation Interview reduced high-risk alcohol use among older adult ED patients; addresses an underserved subgroup.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJoyce et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNew Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2013\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional (3 waves)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult ED attendees with alcohol-related presentations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eShift toward older patient age profile over time; off-licence alcohol purchase is the most common; alcohol remains a significant preventable burden on EDs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBernstein et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2016\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational hospitalized population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNational Inpatient Sample, 12.9M hospitalizations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol-related hospitalizations generated \u003cspan\u003e$\u003c/span\u003e32.6\u0026nbsp;billion in healthcare costs in 2022; inpatient mortality and costs increased over the study period.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZhang et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2006\u0026ndash;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective, NEDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational ED sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSubstance use disorder ED visits increased 44% over the study period; alcohol was the predominant driver.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrbanoski et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2003\u0026ndash;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePopulation cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOntario adult population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdmin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFrequent ED users for mental and substance use disorders had distinct clinical and demographic profiles.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePines et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective, NEDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational ED sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSubstance use disorder ED visits declined early in COVID-19, then returned to pre-pandemic levels.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVenkatesh et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRetrospective, NEDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNational ED sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNEDS data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAlcohol and substance use ED visits declined during COVID-19 lockdowns, then rebounded.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGottlieb et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdult ED patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHospital admin data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAvoidable ED visits, including alcohol-related, declined during the pandemic; recovery is uneven.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwens \u0026amp; Moore (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eED patients by race/ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHCUP data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRacial and ethnic disparities are documented in substance use disorder ED visit rates across groups.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePage et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInternational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMethodological guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic review methodology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePRISMA 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUpdated PRISMA 2020 framework used to guide the conduct and reporting of this review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Final Summary\u003c/h2\u003e \u003cp\u003eOverall, the studies included in the summary imply that alcohol-related emergency department use suggests an increasing burden with stable demographic and socioeconomic trends. Nonetheless, the variability in the study design, outcome measures, and healthcare settings should be considered when interpreting these findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis systematic review determined that alcohol-related emergency department visits are an important and increasing contributor to healthcare utilization across the world․ This increase appears to occur uniformly across geographical and demographic subgroups\u0026sbquo; although the magnitude of the change does vary based on the healthcare setting․ Our findings reaffirm that emergency departments are both sites of acute care\u0026sbquo; as well as barometers of system-level gaps in prevention\u0026sbquo; access to care\u0026sbquo; and management of alcohol-related harm․\u003c/p\u003e \u003cp\u003eBased on the results from the systematic review, the demographic characteristics of patients visiting the emergency department due to alcohol use include mostly young male patients from low socioeconomic backgrounds. The findings from Collins (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), Myran et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and Smith et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) provide a strong overview of the link between alcohol consumption and emergency department visits. The results show that socioeconomic disadvantage is a risk factor for alcohol-related harm even after controlling for alcohol consumption levels. Additionally, racial and ethnic differences in alcohol-related emergency department use in the United States, as noted by Owens and Moore (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), emphasize the importance of equity-focused interventions to reduce alcohol-related emergency visits. These results support the overall literature on health inequities, indicating that alcohol-related harm is not only predetermined by the extent of consumption but also influenced by structural and socioeconomic factors.\u003c/p\u003e \u003cp\u003eCOVID-19 not only demonstrated the patterns of alcohol-related emergency department visits but also made these patterns more complicated. After an initial decline in alcohol-related emergency visits, as shown in the studies by Esser et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Pines et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the numbers increased during the early stages of the pandemic and exceeded pre-pandemic levels. Notably, however, the study by Myran et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that the pandemic did not decrease the total number of alcohol-related emergency visits. Instead, it shifted the burden to individuals with pre-existing alcohol issues and those who are socio-economically disadvantaged.\u003c/p\u003e \u003cp\u003eThe reviewed economic data support the argument that investing in the prevention of alcohol-related problems is justified. Sacks et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) found that the \u003cspan\u003e$\u003c/span\u003e249\u0026nbsp;billion spent on alcohol-related issues in the United States is a conservative estimate that has increased significantly due to a rise in alcohol-related emergency visits. The substantial economic data from the included studies provide a strong financial rationale for implementing system-wide SBIRT procedures in emergency departments. However, the work of Blake et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023b\u003c/span\u003e) found that such procedures remain limited within institutions. However, economic estimates should be interpreted with caution, as methodologies varied across studies, and cost calculations were often context-specific, limiting direct comparability.\u003c/p\u003e \u003cp\u003eThe effectiveness of SBIRT, while generally positive, should be approached with caution. Although the initial studies by the Academic ED SBIRT Research Collaborative demonstrated the intervention's concept, recent research shows significant variability in results. For example, the recent study by Bruguera et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) demonstrated the short-term effectiveness of specialist-delivered SBIRT in a Spanish emergency department. Additionally, the study by Shenvi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) expanded the evidence base to include the older adult population, which is often excluded from SBIRT efficacy research. It seems the key question now is less about whether SBIRT works and more about which groups it helps most, a consideration that may benefit from greater attention within implementation science. Such variability suggests that effectiveness is context-dependent of implementation, the patient population, and factors within the healthcare system, and that the implementation science approach should be applied in future research.\u003c/p\u003e \u003cp\u003eThis review supports previous literature that has established that alcohol-related harm has a substantial burden on healthcare systems. Nonetheless, this review adds to the current context by using more recent evidence, such as studies conducted during COVID-19, and by focusing on the importance of socioeconomic disparities in determining the pattern of ED use.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Implications for external validity\u003c/h2\u003e \u003cp\u003eThe applicability of these results is limited by the fact that the majority of studies are conducted in high-income nations, primarily the United States and Canada. Differences in healthcare infrastructure, alcohol policy environments, and reporting systems may limit the applicability of these findings to low- and middle-income settings. Future studies should focus on a broader geographic representation to enhance global relevance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Implications for Practice and Policy\u003c/h2\u003e \u003cp\u003eThe implications of this review's findings for clinical practice and public health policy are significant. The systematic integration and scaling of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have a strong case at the emergency department (ED) level. Evidence suggests that SBIRT can reduce alcohol consumption in the short-term and enhance referral to special care. However, implementation remains inconsistent due to workforce, time, and training variability. To become more efficient, EDs are recommended to adopt standardized SBIRT guidelines, invest in staff training, and integrate digital or automated screening devices to make them feasible and sustainable in busy clinical settings.\u003c/p\u003e \u003cp\u003eThe economic and medical costs of alcohol-related ED use at the policy level justify the necessity of population-wide interventions. Alcohol taxation, minimum unit pricing and tightening of alcohol marketing and supply have all been found to bring harmful consumption habits down. These interventions can be used to supplement ED-based interventions by focusing on the upstream determinants of alcohol-related harm. Enhancing the public health systems that incorporate healthcare services and regulatory measures is the key to attaining the long-term outcomes of alcohol-related morbidity and healthcare use.\u003c/p\u003e \u003cp\u003eTargeting based on equity is also essential. The review notes that alcohol-related ED visits are disproportionate to people in lower socioeconomic statuses and disadvantaged groups. This highlights the need for targeted interventions that address structural determinants of health, such as poverty, access to care, and social support systems. Disparities need to be reduced through tailored community-based interventions, culturally relevant interventions, and enhanced access to preventive services. In the absence of a clear equity lens, clinical and policy interventions have the risk of perpetuating the status quo in terms of alcohol-related harm.\u003c/p\u003e \u003cp\u003eOverall, an integrated solution, involving ED-based clinical interventions, population-level policies, and equity-focused strategies, is required to help reduce the use of alcohol-related emergency departments and their related impact on society.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Research Limitations\u003c/h2\u003e \u003cp\u003eThere are some limitations that need to be taken into account․ Although the three independent reviewers were used in order to reduce selection bias\u0026sbquo; the lack of a protocol could lead to reporting bias․ The majority of the included studies were conducted in high-income countries (in particular the US and Canada)\u0026sbquo; which limits the generalizability of the evidence for low-income and middle-income countries and their differing health systems and alcohol policy contexts․\u003c/p\u003e \u003cp\u003eSubstantial heterogeneity between studies in design and outcome measures as well as populations involved precluded a quantitative meta-analysis from being undertaken․ Most studies included in the review used administrative and other observational data that are prone to misclassification bias and residual confounding․ The results of the review are also reliant on the consistent definition of an alcohol-related presentation to the ED․ These limitations may impact the accuracy and the external validity of the findings and the applicability of the findings to policy and clinical practice․\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusion and recommendations","content":"\u003cp\u003eAlcohol consumption appears to impose a substantial, growing, and unequal burden on emergency healthcare systems worldwide. The evidence compiled in this review suggests a rising trend in alcohol-related emergency department visits across different countries, with a demographic profile typically involving males, young individuals, and those from disadvantaged socioeconomic backgrounds. It also accounts for an economic burden of hundreds of billions of dollars annually in high-income countries. COVID-19 temporarily disrupted this pattern, but there was no overall reduction in demand, and it may even have increased the burden on marginalized groups. These results are generally similar across different healthcare systems, which reinforces confidence in the patterns observed in general despite the differences in study design and setting.\u003c/p\u003e \u003cp\u003eFor Screening, Brief Intervention, and Referral to Treatment as part of emergency department service delivery, there is considerable evidence supporting its implementation, particularly for short-term outcomes. However, its effectiveness depends on the setting, and various structural and workforce factors require specific attention. The research on cost-effectiveness provides an economic basis for adopting these strategies. On a population level, alcohol-related harms are unequally distributed across socioeconomic groups. Reducing alcohol-related harm involves both a mix of population-wide policies, such as regulating alcohol supply and marketing, and specific interventions that could improve socioeconomic inequalities.\u003c/p\u003e \u003cp\u003eFrom a policy and clinical perspective, the findings support the expansion of integrated alcohol intervention strategies within emergency care settings, alongside broader public health policies targeting alcohol availability and socioeconomic inequalities. Enhanced implementation systems on SBIRT and similar interventions are necessary. The alcohol-related harm demands concerted actions by the healthcare system, policy environment, and interventions at the community level to produce significant and enduring changes. These findings reinforce the role of emergency departments as critical intervention points within broader public health strategies addressing alcohol-related harm.\u003c/p\u003e \u003cp\u003eFuture research should include prospective multicenter studies to understand better the causes of emergency department visits related to alcohol harms. It should also involve stratified analysis to examine differences across socioeconomic, racial, and ethnic groups. Additionally, implementation science is needed to determine the most effective ways to apply Screening, Brief Intervention, and Referral to Treatment and similar strategies in various healthcare settings. Longitudinal studies are also essential to follow alcohol-related harm trajectories from emergency visits through subsequent care and into communities to assess long-term outcomes of emergency department-based interventions. Significantly, more research should be conducted in low and middle-income countries to enhance the global applicability of evidence in this area.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is a systematic review of previously published data and does not involve human participants or primary data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAndre Craig Christie: Conceptualization, methodology, data curation, writing – original draft.\u003cbr\u003e\u0026nbsp;Krista Whitley: Supervision, methodology review, writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Melissa Facey: Validation, critical review, writing – review \u0026amp; editing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole of funding source\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyzed in this study are derived from previously published articles and publicly available sources. No new datasets were generated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author acknowledges the contributions of the researchers whose published work underpins this review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAcademic ED SBIRT Research Collaborative. (2010). The impact of screening, brief intervention and referral for treatment in emergency department patients\u0026apos; alcohol use: A 3-, 6- and 12-month follow-up. Alcohol and Alcoholism, 45(6), 514\u0026ndash;519. https://doi.org/10.1093/alcalc/agq058\u003c/li\u003e\n\u003cli\u003eBernstein, E. Y., Wilson, L. M., Kruse, G. R., Edelman, E. J., Herzig, S. J., \u0026amp; Anderson, T. S. (2025). Alcohol-related hospitalizations from 2016 to 2022. \u003cem\u003eJAMA Network Open\u003c/em\u003e, 8(12), e2550589. https://doi.org/10.1001/jamanetworkopen.2025.50589\u003c/li\u003e\n\u003cli\u003eBhagavathula, A. 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R., Cleland, L., Forman, E., Hlavac, A., Foulds, J., \u0026amp; Crossin, R. (2024). Changes in alcohol-related emergency department presentations \u0026mdash; a comparison of three waves in 2013, 2017 and 2022. \u003cem\u003eNew Zealand Medical Journal\u003c/em\u003e, 137(1593), 56\u0026ndash;67. https://doi.org/10.26635/6965.6375\u003c/li\u003e\n\u003cli\u003eLegome, E., Bonadio, W., Redlener, M., Lavine, E., Mealy, A., \u0026amp; Sondheim, S. E. (2025). Alcohol intoxication in the academic emergency department: Epidemiology and facility-fee financial impact. Western Journal of Emergency Medicine, 26(5), 1454. https://pmc.ncbi.nlm.nih.gov/articles/PMC12591641/\u003c/li\u003e\n\u003cli\u003eMorin, K. A., Hill, L., Knowlan, S., Bodson, A., Nikodem, P., Aubin, N., \u0026amp; Marsh, D. C. (2025). A retrospective cohort study evaluating the association between opioid and alcohol-related emergency department presentations and the subsequent risk of hospitalization. \u003cem\u003ePLOS ONE\u003c/em\u003e, 20(6), e0325083. https://doi.org/10.1371/journal.pone.0325083\u003c/li\u003e\n\u003cli\u003eMullins, P. M., Mazer-Amirshahi, M., \u0026amp; Pines, J. M. (2017). Alcohol-related visits to U.S. emergency departments, 2001\u0026ndash;2011. Alcohol and Alcoholism, 52(1), 119\u0026ndash;125. https://doi.org/10.1093/alcalc/agw074\u003c/li\u003e\n\u003cli\u003eMyran, D. T., Cantor, N., Pugliese, M., Hayes, T., Talarico, R., Kurdyak, P., Qureshi, D., \u0026amp; Tanuseputro, P. (2021). Sociodemographic changes in emergency department visits due to alcohol during COVID-19. Drug and Alcohol Dependence, 226, 108877. https://doi.org/10.1016/j.drugalcdep.2021.108877\u003c/li\u003e\n\u003cli\u003eMyran, D. T., Friesen, E. L., Pugliese, M., Milani, C., Kurdyak, P., Saraswat, M., \u0026amp; Tanuseputro, P. (2023). Changes in health service use due to alcohol during the COVID-19 pandemic. Canadian Journal of Public Health, 114(2), 185\u0026ndash;194. https://doi.org/10.17269/s41997-023-00739-8\u003c/li\u003e\n\u003cli\u003eMyran, D. T., Hsu, A. T., Smith, G., \u0026amp; Tanuseputro, P. (2019). Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016. Canadian Medical Association Journal, 191(29), E804\u0026ndash;E810. https://doi.org/10.1503/cmaj.181575\u003c/li\u003e\n\u003cli\u003eMyran, D. T., Hsu, A., Kunkel, E., Rhodes, E., Imsirovic, H., \u0026amp; Tanuseputro, P. (2022). Socioeconomic and geographic disparities in emergency department visits due to alcohol in Ontario, 2003\u0026ndash;2017. Canadian Journal of Psychiatry, 67(7), 534\u0026ndash;543. https://doi.org/10.1177/07067437211027321\u003c/li\u003e\n\u003cli\u003eOliveras, C., Bruguera, P., Cordero-Torres, I., Millan-Hernandez, A., Pons-Cabrera, M. T., Guzman Cortez, P. R., Gomez-Ramiro, M., Vazquez, M., Borras, R., Asenjo-Romero, M., Vieta, E., Gual, A., Lopez-Pelayo, H., \u0026amp; Balcells-Olivero, M. (2024). Effects of alcohol-related problems on the costs of frequent emergency department use. Frontiers in Public Health, 12, 1322327. https://doi.org/10.3389/fpubh.2024.1322327\u003c/li\u003e\n\u003cli\u003eOwens, P. L., \u0026amp; Moore, B. J. (2023). Racial and ethnic differences in emergency department visits related to substance use disorders, 2019 (Statistical Brief No. 301). Agency for Healthcare Research and Quality. https://hcup-us.ahrq.gov/reports/statbriefs/sb301-ED-Substance-Use-Disorders-Race-2019.jsp\u003c/li\u003e\n\u003cli\u003eOzluk, P., Cobb, R., Sylwestrzak, G., Raina, D., \u0026amp; Bailly, E. (2022). Alcohol-attributable medical costs in commercially insured and Medicaid populations. AJPM Focus, 1(2), 100036. https://doi.org/10.1016/j.focus.2022.100036\u003c/li\u003e\n\u003cli\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hrobjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71\u003c/li\u003e\n\u003cli\u003eParkinson, K., Newbury-Birch, D., Phillipson, A., Hindmarch, P., Kaner, E., Stamp, E., Vale, L., Wright, J., \u0026amp; Connolly, J. (2016). Prevalence of alcohol related attendance at an inner city emergency department and its impact: A dual prospective and retrospective cohort study. \u003cem\u003eEmergency Medicine Journal\u003c/em\u003e, 33(3), 187\u0026ndash;193. https://doi.org/10.1136/emermed-2014-204581\u003c/li\u003e\n\u003cli\u003ePines, J. M., Zocchi, M. S., Black, B. S., Carlson, J. N., Celedon, P., Moghtaderi, A., \u0026amp; Venkat, A. (2021). How emergency department visits for substance use disorders have evolved during the early COVID-19 pandemic. Journal of Substance Abuse Treatment, 129, 108391. https://doi.org/10.1016/j.jsat.2021.108391\u003c/li\u003e\n\u003cli\u003eRocha, L. R., Gao, J., Espinola, J. A., \u0026amp; Camargo, C. A. (2025). Longitudinal analysis of alcohol-related emergency department visits from 1993 to 2021. \u003cem\u003eAmerican Journal of Epidemiology\u003c/em\u003e, 194(11), 3273\u0026ndash;3280. https://doi.org/10.1093/aje/kwaf139\u003c/li\u003e\n\u003cli\u003eSacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E., \u0026amp; Brewer, R. D. (2015). 2010 national and state costs of excessive alcohol consumption. American Journal of Preventive Medicine, 49(5), e73\u0026ndash;e79. https://doi.org/10.1016/j.amepre.2015.05.031\u003c/li\u003e\n\u003cli\u003eShenvi, C. L., Wang, Y., Revankar, R., Phillips, J., Bush, M., Biese, K. J., Aylward, A., D\u0026apos;Onofrio, G., \u0026amp; Platts-Mills, T. F. (2022). Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial. \u003cem\u003eJournal of the American College of Emergency Physicians Open\u003c/em\u003e, 3(1), e12651. https://doi.org/10.1002/emp2.12651\u003c/li\u003e\n\u003cli\u003eSmith, B. T., Benny, C., Andreacchi, A. T., Schwartz, N., Warren, C. M., Forbes, S., \u0026amp; Hobin, E. (2025). Socioeconomic position, alcohol use and alcohol-attributable emergency department visits. Journal of Epidemiology and Community Health, 79(6), 416\u0026ndash;423. https://doi.org/10.1136/jech-2024-222476\u003c/li\u003e\n\u003cli\u003eSuen, L. W., Makam, A. N., Snyder, H. R., Repplinger, D., Kushel, M. B., Martin, M., \u0026amp; Nguyen, O. K. (2022). National prevalence of alcohol and other substance use disorders among emergency department visits and hospitalizations: NHAMCS 2014\u0026ndash;2018. Journal of General Internal Medicine, 37(10), 2420\u0026ndash;2428. https://doi.org/10.1007/s11606-021-07069-w\u003c/li\u003e\n\u003cli\u003eThe Academic ED SBIRT Research Collaborative. (2007). The impact of screening, brief intervention, and referral for treatment on emergency department patients\u0026apos; alcohol use. Annals of Emergency Medicine, 50(6), 699\u0026ndash;710. https://doi.org/10.1016/j.annemergmed.2007.06.486\u003c/li\u003e\n\u003cli\u003eUrbanoski, K., Cheng, J., Rehm, J., \u0026amp; Kurdyak, P. (2018). Frequent use of emergency departments for mental and substance use disorders. Emergency Medicine Journal, 35(4), 220\u0026ndash;225. https://doi.org/10.1136/emermed-2015-205554\u003c/li\u003e\n\u003cli\u003eVaca, F. E., \u0026amp; Winn, D. (2007). The basics of alcohol screening, brief intervention and referral to treatment in the emergency department. Western Journal of Emergency Medicine, 8(3), 88\u0026ndash;92. https://pmc.ncbi.nlm.nih.gov/articles/PMC2672213/\u003c/li\u003e\n\u003cli\u003eVenkatesh, A. K., Janke, A. T., Kinsman, J., Rothenberg, C., Goyal, P., Malicki, C., \u0026amp; Hawk, K. (2022). Emergency department utilization for substance use disorders and mental health conditions during COVID-19. PLOS ONE, 17(1), e0262136. https://doi.org/10.1371/journal.pone.0262136\u003c/li\u003e\n\u003cli\u003eWhite, A. M., Slater, M. E., Ng, G., Hingson, R., \u0026amp; Breslow, R. (2018). Trends in alcohol-related emergency department visits in the United States: Results from the Nationwide Emergency Department Sample, 2006 to 2014. Alcoholism: Clinical and Experimental Research, 42(2), 352\u0026ndash;359. https://doi.org/10.1111/acer.13559\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2018). Global status report on alcohol and health 2018. WHO Press. https://iris.who.int/handle/10665/274603\u003c/li\u003e\n\u003cli\u003eZhang, X., Wang, N., Hou, F., Ali, Y., Dora-Laskey, A., Dahlem, C. H., \u0026amp; McCabe, S. E. (2021). Emergency department visits by patients with substance use disorder in the United States. Western Journal of Emergency Medicine, 22(5), 1076\u0026ndash;1085. https://doi.org/10.5811/westjem.2021.3.50839\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Alcohol consumption, Emergency department, Healthcare utilization, SBIRT, Public health, COVID-19, Systematic review","lastPublishedDoi":"10.21203/rs.3.rs-9337750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9337750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Alcohol use contributes to morbidity‚ mortality and healthcare utilization․ Emergency departments (EDs) are often the first point of contact for alcoholrelated problems‚ including intoxication‚ injuries and chronic alcohol use complications․ While the literature on healthcare utilization related to alcohol is substantial and growing‚ to date‚ there has been no thorough‚ up-to-date overview of evidence from the ED perspective on trends‚ determinants‚ aetiology‚ economic burden and impact of interventions․\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This systematic review was performed following the PRISMA 2020 guideline․ PubMed‚ MEDLINE (Ovid)‚ Embase‚ CINAHL and Google Scholar were searched․ Grey literature was also sourced from the World Health Organization and Agency for Healthcare Research and Quality․ Eligible studies published from January 2007 to March 2025 were quantitative epidemiological studies on alcohol-related ED presentations reporting on prevalence‚ trends‚ sociodemographic and socioeconomic factors‚ costs‚ or interventions․ Two reviewers independently screened studies for eligibility at the abstract and full-text level‚ with discrepancies resolved through consensus between the reviewers․ Study quality was assessed using the Newcastle-Ottawa Scale․ Given the heterogeneity between studies in terms of design‚ population‚ and outcomes‚ a narrative synthesis was used․\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Thirty-eight studies met inclusion criteria․ Presentation to the ED for alcohol use disordered ranged between 10 and 40% in different healthcare settings․ Most jurisdictions‚ especially in high-income countries‚ experienced an upward time trend in alcohol-related ED visits․ Demographic variables (sex and age) of affected populations were stable (predominantly males and younger adults‚ apart from older adults in new evidence in high-income countries)․ Socioeconomic disadvantage (especially income and geographic inequities) was a strong and consistent predictor of ED visits‚ consistent with the alcohol harm paradox․ Several included studies described racial or ethnic inequities․ The economic evidence was based on substantial and increasing economic impact‚ with national costs for both high-income and low- and middle-income countries in the hundreds of billions of US dollars annually․ The evidence from a number of studies found that ED-based interventions including SBIRT showed effectiveness for short-term reductions in alcohol consumption and increases in referral to treatment․ Results on long-term effects and implementation of SBIRT were also mixed․\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The burden on health systems from alcohol-related ED utilization is large and increasing․ Further‚ it is not evenly distributed across the population․ EDs provide an important site of acute care and possible early intervention․ Policy implementation should adopt an integrated approach‚ combining ED-based implementations such as SBIRT with population-based alcohol control policies and targeting the collection of socioeconomic and structural determinants of health․ Future research should focus on implementation science‚ the sustainability and effectiveness of interventions over time‚ and the experience in low- and middle-income 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