Binge Drinking and Alcohol Poisoning in the Adolescent Population

Abstract
The most common drug of abuse in adolescence, alcohol, is consumed primarily through binge drinking. The rapid rise in blood alcohol concentrations during binge drinking can cause alcohol intoxication. Treatment of alcohol intoxication and withdrawal in adolescents mimics that in adults. The main goals of treating acute alcohol intoxication are to ensure adequate respiration and to control associated agitation, nausea, and vomiting. The mainstay of therapy for acute alcohol withdrawal is benzodiazepines. Underage drinking, especially early initiation, can cause developmental problems that may continue into adulthood. Pharmacists can optimize the care of adolescents with alcohol poisoning by understanding the management of this prevalent condition.
Introduction
In American teenagers, the most commonly abused drug is alcohol. An underage drinking epidemic is currently present, starting with elementary- and middle-school–aged children 9 to 13 years old and erupting during college. Underage drinking accounts for a significant amount of total alcohol consumption, with almost 20% of the alcohol consumed in the United States being by those under the age of 21 years.[1]
Increased risk-taking behaviors, low levels of harm avoidance, impulsivity, and anxiety may occur in adolescents (those aged 11–18 years). When accompanied with changes in gonadal steroid and stress-related hormone release, these may lead to initiation patterns of alcohol and drug consumption
Epidemiology
When adolescents drink alcohol today, they consume a larger quantity with a clearer goal to “get drunk” versus earlier generations.[2] The ingestion of large amounts of alcohol can lead to acute alcohol intoxication.[3] Often toxicity is prevented because people pass out before they can ingest toxic amounts or vomiting eliminates the toxic contents.[4]
Since 1975, there has been an increase of almost one-third (27%–36%) in the proportion of children who have begun drinking by 8th grade. Further, there is no longer a gender gap for alcohol consumption.[1,5] The results of community survey data revealed that by 8th grade, 51.7% of adolescents have tried alcohol, increasing to 80.3% by 12th grade.[2]
Binge drinking—consuming at least five alcoholic drinks in one episode—is the most common pattern for alcohol consumption in underage drinkers.[1,5] Binge drinking can lead to acute alcohol poisoning, with rapid elevations in blood alcohol concentration (BAC).[5] In 2011, binge drinking occurred in 22.6% of people over the age of 12 years, with a rate of 12.1% in adolescents spe
Physiological Consequences
Throughout adolescence and into adulthood, the brain continues to develop, producing important structural and functional changes as well as cognitive, emotional, and social maturation.[2,7] When the brain is exposed to ethanol during times of brain development, irreversible abnormalities in the function and structure of the brain may occur due to the vulnerability of the central nervous system (CNS) to alcohol’s effects. Memory deficit, abnormalities in brain structure, and poor academic performance also may occur in adolescents who drink alcohol.[2]
Alcohol use by an adolescent may lead to harmful consequences. The three top causes of teen deaths, accidents (traffic fatalities, drownings), suicide, and homicide, often involve alcohol use.[1] Males aged 16 to 20 years who drove with a BAC of 0.08 g/dL were 52 times more likely to die in a single-vehicle crash than male drivers of the same age who were sober.[5] Further, the primary source of adult alcoholism is teen drinking, with a four-fold increased rate of developing alcoholism if alcohol is initiated prior to the age of 15 compared to 21 years.[1]
Acute alcohol ingestion can have other consequences as well. Respiratory depression is the most life-threatening respiratory problem. Aspiration, nausea, vomiting, diarrhea, acute alcoholic hepatitis, and pancreatitis may also occur.
Risk Factors
Childhood psychopathology can predict adolescent alcohol use disorders with conduct disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, and major depressive disorders being the most clinically relevant childhood mental disorders.[2]
Several sociodemographic characteristics may influence adolescent alcohol involvement. Adolescents from single-parent families, lower socioeconomic status, or European American or Hispanic descent have higher levels of alcohol involvement.[2,5] Timing of maturation also influences early alcohol consumption. Compared to girls who mature on time or late, girls who mature early are significantly more advanced with the trajectories of initiating alcohol use and binge drinking. Additionally, adolescents who mature early and are affiliated with older or more deviant peers and those who have increased parent-adolescent conflict have accelerated alcohol involvement.
Symptoms
Symptoms of acute alcohol intoxication include abdominal pain, nausea, vomiting, and, less frequently, jaundice, shivering, and fevers.[3]
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for alcohol withdrawal (Table 1) involve the cessation of alcohol use with at least two qualifying symptoms causing clinically significant impairment in the absence of another causative agent or medical disorder.[8,10,11] Alcohol withdrawal syndrome features may begin to occur within 6 to 48 hours of the last alcoholic beverage and diminish over 24 to 48 hours.[9,10] The initial symptoms of withdrawal include sweating, agitation, tremor, headache, disorientation, difficulty concentrating, irritability, anxiety, nausea, and vomiting. Transient hallucinations may occur in more serious cases. In addition, the first 24 hours of alcohol withdrawal may be accompanied by seizures in up to 25% of cases.[9] It generally takes 2 to 3 days after the cessation of drinking for delirium to develop, which lasts 48 to 72 hours.[10] Known as delirium tremens, this is the most serious and intense alcohol withdrawal syndrome. Severe agitation, persistent hallucinations, disorientation, tremor, and extreme tachycardia, tachypnea, and hypertension may occur as a result of delirium tremens.[9]
The Clinical Institute of Withdrawal Assessment for Alcohol, revised (CIWA-Ar) may be performed to assess for alcohol withdrawal and the need for benzodiazepine therapy.[9,12] It has well-documented validity, reliability, and reproducibility. A high CIWA-Ar score is predictive of seizure or delirium development.
Conclusion
Due to the commonality of alcohol abuse during adolescence, it is important to be familiar with the treatment options to relieve alcohol withdrawal. Pharmacists should be well informed about the management of acute alcohol poisoning in adolescents to facilitate and optimize timely and appropriate patient care.

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