The Alcohol-Intoxicated Person in Custody: Diagnosis,Differential Diagnosis and Management

Abstract

Individuals who are intoxicated with alcohol (most commonly ethanol) will commonly be detained by police for a wide range of offenses. It is essential that custody staff are trained to recognize individuals with alcohol use disorders and comorbid health conditions and request medical assistance as required. Forensic physicians and other health care professionals should perform a comprehensive assessment to diagnose alcohol intoxication and ensure that the detainee is fit to be detained and interviewed by police. Forensic pathologists should be aware of the appropriate clinical management of alcohol-intoxicated persons in custody when involved in death in custody investigations.

Keywords

Forensic pathology Alcohol Ethanol Alcohol intoxication Alcohol withdrawal Alcohol use disorders Fitness to interview Comorbidity

Introduction

Individuals may be arrested by the police and detained in police custody for a range of offenses that are “alcohol-related”: driving with excess alcohol, driving under the influence (DUI)/while intoxicated (DWI), “drunk and incapable,” and offenses where the individual is under the influence of alcohol at the time of committing an offense, in cases of assault (domestic violence, sexual assaults), robbery, or public order incidents. In this article, “alcohol” refers to ethanol unless otherwise specified.

In the United States, about three million violent crimes occur each year in which the victims perceive that the offender has been drinking at the time of the offense (1). In the 2011/12 Crime Survey in England and Wales, there were 917,000 violent incidents where the victim believed the offender(s) to be under the influence of alcohol, accounting for 47% of violent offenses committed that year—a 3% rise from the previous year of 2010/2011 (2). Alcohol intoxication is common amongst detainees in police custody; one UK study suggested that 73% of people detained at night were considered to be intoxicated (3). The consumption of alcohol, especially at high levels, is a significant risk factor for violence (4).

Forensic physicians (FP) and other healthcare professionals (HCPs) working in the UK are often called to assess detainees apparently under the influence/impaired by alcohol. It is essential that a detailed history and an appropriate physical examination, including mental state examination, are performed in order to diagnose alcohol intoxication and ensure that the detainee is safe to remain in custody (5). The guidance outlined in this article is based on clinical practice in the UK, however the principles of management apply to all alcohol-intoxicated persons recently detained by police. Where onsite health care professionals are not available in custody centers, individuals will need to be transferred to a hospital or other medical facility for assessment and treatment. Forensic pathologists should be aware of the appropriate clinical management of alcohol-intoxicated persons in custody when involved in death in custody investigations.

Alcohol is a major cause of harm to individuals and society (6) and alcohol use is an important risk factor for disease in young people aged 10–24 years (7). A significant amount of health morbidity is present among detainees in police custody and often, police screening does not detect significant health problems (8). It is essential that custody staff are trained to recognize these problems and request medical assistance as required (9). A study in London, UK, found that 25% of detainees were alcohol dependent (10). Another study looking at detainees who refused, or were unable to complete a breath alcohol test showed that they had high rates of traumatic injuries when compared to those who completed the test (22% versus 8%) (11).

Pathophysiology of Alcohol Intoxication

Alcohol is a poison and cannot be stored by the body. It produces both acute and chronic health effects. Alcohol acts as a central nervous system depressant by means of potentiating GABA activity in the brain (GABA is an inhibitory neurotransmitter) (12), with small doses affecting cortical function and larger doses depressing medullary function.

Ingested alcohol is absorbed throughout the gastrointestinal tract by passive diffusion in the stomach and with the rate of absorption maximal in the duodenum (13). A small amount of alcohol in the stomach is metabolized by its enzymes, gastric alcohol dehydrogenase. Peak alcohol concentration is reached 30–60 minutes after drinking although the range can be 20 minutes to three hours. Blood alcohol levels may rise after arrest if the detainee has been drinking immediately before arrest.

Following gastrointestinal absorption, the alcohol is carried via the portal vein to the liver. Some of the alcohol is metabolized there, the remainder being transported throughout the body via the systemic circulation where it is distributed around the body tissues according to their water content. Tissues with higher water content will take up more alcohol. Diffusion continues between the blood and tissues until equilibrium is reached. A large number of factors can influence how alcohol is metabolized ( Table 1 ) (14).

Table 1

Factors Affecting the Metabolism of Alcohol

Sex and weight	Higher peak alcohol levels occur in females and those who have more fat
Duration of drinking	Lower peak levels if alcohol is consumed over a prolonged period
Nature of the drink consumed	Maximum alcohol absorption when concentration of ingested alcohol between 10–20%
Food in the stomach	Eating a meal may reduce peak alcohol level by up to 50%
Genetic variation	Affecting physiological factors such as stomach wall permeability
Drugs	May affect gastric emptying (e.g., chlorpromazine or other central nervous system depressant drugs such as opioids)
Rate of elimination	Rates vary between 10–25 mg/dL of blood per hour with an average of 15–18 mg/dL per hour equivalent to one unit per hour in a 70 kg male. Habituation is the single most important factor affecting the rate of elimination

Elimination of alcohol occurs mainly by metabolism through enzyme activity in the liver (approximately 95%). The remainder, approximately 5%, is eliminated unchanged in breath, sweat and urine – an important factor that allows the estimation of blood alcohol concentration (BAC) from the level in breath. However the presence of alcohol in urine only proves that alcohol is present in the body and cannot reliably indicate the blood level due to the fact that alcohol may have accumulated in the bladder over a prolonged period and urine concentration will depend on the hydration of the individual.

Assessment of the Potentially Intoxicated Detainee

The diagnosis of alcohol intoxication requires that there must have been recent ingestion of alcohol associated with behavioral or psychological changes and the necessary physical signs along with the proviso that there are no medical conditions that may account for the condition (15). The terms “alcohol intoxication” and “drunkenness” are often used interchangeably. However, a distinction between these terms is justified as people may exhibit behavioral changes associated with drunkenness when they believe they have consumed alcohol but actually have not (16).

The amount of alcohol taken in the previous 24 hours as well as the usual amount taken each day should be documented. As polydrug use is common, a specific inquiry should be made about the use of other substances, such as benzodiazepines and opiates, which may complicate the assessment. A medical history, including a psychiatric history, should be obtained. The physical examination involves looking for signs of intoxication ( Table 2 ), dependence, or withdrawal ( Table 3 ). The mental state examination should document the detainee's appearance, behavior, speech, mood and affect, thought content and form, perception, cognition, and insight.

Table 2

Symptoms and Signs of Intoxication

Symptoms and Signs of Intoxication
Disinhibition/labile effect
Sedation
Concentration/attention/memory difficulties
Smell of alcoholic liquor
Slurred speech
Tachycardia
Hypertension
Flushing
Nystagmus
Pupil size - may be normal or dilated
Sluggish pupillary reaction to light
Poor coordination
Romberg's positive
Severe Intoxication/Overdose
Alteration in mental state
Hypoglycemia
Respiratory depression
Central nervous system depression (coma with pinpoint pupils)
Depressed or absent corneal, gag or deep tendon reflexes
Cardiovascular system depression

Table 3

Symptoms and Signs of Withdrawal

Uncomplicated	Complicated
Agitation	Seizures
Mild tremor	Hallucinations
Sweating	Confusion
Fever	Disorientation
Tachycardia	Aggressive behaviors
Hypertension	Delirium tremens

The prevalence of psychiatric comorbidity, mental illness and substance use disorder, is significant. A U.S. survey on drug use and health found 9.2 million adults in the U.S. (4% of the adult population) met the criteria for both a mental illness and substance use disorder in the past year (17). Bradley also highlighted the importance of mental health awareness and learning disabilities to be a key component in police training because of the prevalence of mental illness in the police detainee population (18).

Individuals who have alcohol problems are at an increased risk of self-harm and suicide (19). The National Confidential Inquiry into suicide and homicide by people with mental illness found that the majority of the suicide cases it investigated (58%) were alcohol dependent, 39% were drug dependent and 29% heavily misused both (20). It is essential that a risk assessment is performed as intoxication and withdrawal can increase the risk of self-harm.

Tolerance occurs to alcohol and so the effects are variable; a guide is provided in Table 4 (21). The effects of alcohol are more pronounced when blood alcohol levels are rising during absorption rather than falling during elimination. This is known as the Mellanby effect and is thought to be due to an acute tolerance to alcohol that develops during intoxication.

Table 4

Effects of Rising Blood Alcohol Concentration

Blood Alcohol Concentration (mg/dL)	Stage of influence	Effects
< 50	Sobriety	No obvious effect but subject maybe more talkative with a sense of wellbeing
50–100	Euphoria	Slurred speech, bravado, some loss of concentration and sensory perception
100–150	Excitement	Emotional instability Marked loss of concentration Poor sensory perception
150–200	“Drunkenness”	Disorientation, mental confusion and dizziness Decreased pain sense, impaired balance and slurred speech
200–300	Stupor	General inertia, approaching paralysis Marked lack of response to stimuli Vomiting, incontinence of feces
300–450	Coma	Coma anesthesia Depressed or abolished reflexes
>450	Death	Possible death from respiratory paralysis

It is essential that the FP excludes other conditions ( Table 5 ) that may simulate intoxication, as failure to do so may lead to deaths in police custody. All detainees who appear to be intoxicated should have their vital signs and blood glucose measured. Hypoglycemia may occur due to inhibition of hepatic gluconeogenesis (22). Detainees should be examined for focal neurology and signs of a head injury. Signs of chronic liver disease should also be sought.

Table 5

Differential Diagnosis of Alcohol Intoxication

Differential Diagnosis	Clinical Marker(s)
Other intoxicants/drugs of abuse
Cocaine/amphetamines-type stimulants	Personal history of use
Opiates	Information from police (national computer database)
Prescribed medication: benzodiazepines, antipsychotic medications	Drug possession/drug paraphernalia identified during police search (e.g., citric acid)
	Disproportionate mental stimulation
	Injection marks, excessive sedation
	Medications found/prescriptions, hospital appointment cards
Infections
	History/examination for source of infection
	Pyrexia
	Meningism
Head injury
	History of head injury, particularly at time of arrest
	Visible head injury
	Localising neurological signs
Metabolic causes
Hypoglcemia	Medic Alert bracelets
Hyperglycemia/diabetic ketosis	Blood glucose measurement
Other electrolyte disturbance	Blood glucose measurement/urinalysis for ketouria
Hepatic encephalopathy	Diuretic use, other comorbid conditions (cancer, heart failure etc.)
	Signs of chronic liver disease, ascites
Other
Seizures/post-ictal states	Confusion/disorientation
Acute psychiatric conditions	Abnormal mental state examination
Hypoxia/hypercapnia	Pulse oximetry

All detainees who are not rousable, are hypoglycemic, hypothermic, have localizing neurological signs, or evidence of head injury or have had seizures, should be referred to a hospital urgently. While awaiting hospital transfer, hypoglycemia may be treated with oral glucose such as “Hypo-stop” in the conscious detainee or intramuscular glucagon in the unconscious detainee, followed by immediate oral glucose once consciousness returns. Glucagon may not be effective in a detainee with liver disease. Intravenous dextrose may be given but may be difficult to administer in the custody environment because of poor venous access.

Those who have severe Alcohol Use Disorder (AUD) may be at risk of Wernicke's encephalopathy, a triad of confusion, ataxia, and nystagmus that may be irreversible. Consideration should be given to offering thiamine to detainees at risk (23).

Detainees suffering from simple intoxication with alcohol without significant comorbidity and who are not judged to be a risk of alcohol withdrawal syndrome may be allowed to detoxify or “soberup” while remaining in police detention.

Any decision regarding fitness to be interviewed should be made on a full, functional assessment of an individual rather than a single specific blood alcohol level (24). However, a hand-held breath testing device may be a valuable tool to confirm the alcohol concentration, thus informing any decision. Salivary alcohol measurement devices may also be of use (25).

Acute intoxication is usually transient and so in the initial period of detention detainees must be checked and roused regularly as per the four “R's” to ensure that the blood alcohol level is falling and the detainee is improving ( Table 6 ).

Table 6

Detained Person: Observation List (26)

If any detainee fails to meet any of the following criteria, an appropriate health care professional or ambulance must be called. When assessing the level of rousability consider:
Rousability – can they be awakened? • Go into the cell • Call their name • Shake gently
Response to questions – can they give appropriate answers to questions such as: • What's your name? • Where do you live? • Where do you think you are?
Response to commands – can they respond appropriately to commands such as: • Open your eyes! • Lift one arm, now the other arm!
Remember – take into account the possibility or presence of other illnesses, injury, or mental condition, a person who is drowsy and smells of alcohol may also have the following: • Diabetes • Epilepsy • Head Injury • Drug intoxication or overdose • Stroke

In a review of 58 deaths in police custody over the period 2000–2001 in England and Wales, it was concluded that those with gross alcohol intoxication were not cared for adequately in police custody (27). This was reflected in the failure to implement the FP's instructions regarding the checking and rousing of detainees. If the level of risk is such that increased supervision is needed, the police station is unlikely to be a suitable location for these detainees. Any severely intoxicated detainees, unable to walk and talk, should be transferred to hospital for observation by trained health care professionals and should receive a full assessment.

Alcohol Dependency

Police arrest and detention is often the first presentation of an Alcohol Use Disorder ( Table 7 ). The long-term health effects of persistent alcohol misuse are multitude, including liver cirrhosis, obesity, high blood pressure, coronary heart disease, pancreatitis, and cancers, particularly the liver, mouth, esophagus, pancreas, breast and bowel (29). Arrest and detention therefore offers an opportunity for healthcare professionals to intervene and promote healthy drinking and/or abstinence.

Table 7

Diagnostic and Statistical Manual (DSM) 5 Alcohol Use Disorder (AUD) (28)

1. Alcohol is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.

6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance as defined by either the following:

A need for markedly increased amounts of alcohol to achieve intoxication or desired effects

A markedly diminished effect with continued use of the same amount of alcohol.

11. Withdrawal, as manifested by either of the following:

The characteristic withdrawal syndrome for alcohol

Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

The presence of at least two of these symptoms indicates Alcohol Use Disorder (AUD). The severity of the AUD is defined as:

Mild: The presence of two or three symptoms

Moderate: The presence of four to five symptoms

Severe: The presence of six or more symptoms

Accurate and reliable information about a person's intake of alcohol is difficult, as heavy drinkers tend to underestimate or deliberately lie about their alcohol consumption (30). The use of an alcohol screening questionnaire is essential in identifying alcohol problems including alcohol use disorder. There are a number of tests available: the Alcohol Use Disorders Identification Test (AUDIT) (31) (probably the best screening instrument in this environment) (32), self-report questionnaires – MAST (33,34) and CAGE (35,36), and the Paddington Alcohol Test (PAT) used by accident and emergency departments to identify patients presenting with injuries that may be due to problem drinking (37).

Police custody offers a setting in which there is scope for the early identification of AUD (38). It is possible that such interventions could be administered by healthcare professionals or other custody staff to the detainee prior to release, when the detainee is sober (39), although in a recent study in France, only around 20% of detainees were willing to accept such advice (40).

Recognition and Treatment of Alcohol Withdrawal

Alcohol withdrawal symptoms and signs ( Table 3 ) usually start within six to eight hours after the last alcoholic drink and before the blood alcohol level reaches zero.

It is essential that alcohol withdrawal is recognized and treated promptly in police custody. If unrecognized, there is a significant morbidity and mortality. A long-acting benzodiazepine such as chlordiazepoxide 15–30 mg tid or diazepam 10 mg tid should be used to prevent the complications of withdrawal, such as seizures and delirium tremens. Consideration should be given to prescribing vitamin B compound.

Frequent reassessment by the FP is required. Detainees with significant comorbidity such as liver disease, pregnancy, or a previous history of severe withdrawal symptoms should not undergo detoxification in custody but referred to a hospital.

In hospital settings, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is used to quantify withdrawal symptoms and signs and guide treatment (41,42). The application of this score to a custody setting has not been determined and the score requires repeated evaluations to determine the response to treatment. However, patients with a score of over 15 are at increased risk of seizures and the authors recommend that these detainees are referred to a hospital.

Fitness to Interview

A detainee may be at risk in a police interview if conducting the interview could significantly harm the detainee's physical or mental state or if anything the detainee says in the interview about their involvement or suspected involvement in the offense about which they are being interviewed might be considered unreliable in subsequent court proceedings because of their physical or mental state (43).

In cases of intoxication, a period of observation may be required before the detainee is sober and fit to be interviewed. Treatment for alcohol withdrawal may be required prior to interview. Reassessment may be considered necessary after a period of time to establish fitness. Individuals who have AUD may have comorbid conditions that may need treatment prior to interview and/or certain psychological vulnerabilities or risk factors such as mental disorder or intellectual disability (44).

Individuals with severe alcohol use disorder are at risk of false confessions (45), in particular, coerced-compliant confessions, where suspects are fully aware of not having committed the crime but will confess in an attempt to escape from an intolerable situation, and coerced-internalized false confessions, which may occur when suspects believe that they have committed the crime of which they are accused, perhaps temporarily. Individuals with severe AUD may come to distrust their own memory or have memory impairment either due to acute temporary alcohol intoxication or permanent damage are suggestible to external cues. Those with comorbid severe mental illness are also at risk of this type of confession.

Conclusion

In summary, the key points for the management of the alcohol intoxicated detainee are given in Table 8.

Table 8

Key Points in the Management of the Intoxicated Patient

1.	Is the detainee intoxicated only with alcohol?
2.	Has the detainee suffered any physical harm as a result of intoxication (e.g., hypothermia, trauma including head injury)
3.	Is the detainee currently fit to detain/are there any concurrent physical ailments that requirement treatment?
4.	Is this a presentation of psychiatric illness/is there a risk of self-harm?
5.	Is the detainee at risk of alcohol withdrawal syndrome?
6.	Does the detainee require assistance with/referral for alcohol dependency on release from custody?
7.	Is the detainee fit to be interviewed by the police? Are there any psychological vulnerabilities/risk factors?

Footnotes

The authors, reviewers, editors, and publication staff do not report any relevant conflicts of interest.

References

NCADD [Internet]. New York: National Council on Alcoholism and Drug Dependence Inc; c2014. Alcohol and crime; [cited 2014 Mar 31]. Available from: http://www.ncadd.org/index.php/learn-about-alcohol/alcohol-and-crime.

Institute of Alcohol Studies [Internet]. St Ives (UK): The Institute; c2013. UK alcohol-related crime statistics; [cited 2014 Mar 28]. Available from: http://www.ias.org.uk/Alcohol-knowledge-centre/Crime-and-social-impacts/Factsheets/UK-alcohol-related-crime-statistics.aspx.

Deehan

, Marshall

, Saville

Drunks and disorder: processing intoxicated arrestees in two city-centre custody suites [Internet]. London: Home Office; 2002 [cited 2014 Mar 31]. 64 p. Available from: http://www.ohrn.nhs.uk/resource/Policy/DrunksandDisorder.pdf.

Morgan

, McAtamney

Key issues in alcohol-related violence [Internet]. Canberra: Australian Institute of Criminology; 2009 [cited 2014 Mar 31]. 8 p. Available from: http://www.aic.gov.au/documents/A/8/C/%7bA8CA2B96-4BE6-4B79-A61D-8408081903BA%7drip04_001.pdf.

Royal College of Psychiatrists; Royal College of General Practitioners; Faculty of Forensic and Legal Medicine; College of Emergency Medicine. Substance misuse detainees in police custody. Guidelines for clinical management [Internet]. 4th ed. London: Royal College of Psychiatrists; 2011 [cited 2014 Mar 31]. 66 p. Available from: http://www.rcpsych.ac.uk/files/pdfversion/CR169xx.pdf.

Nutt

D.J.

, King

L.A.

, Phillips

L.D.

; Independent Scientific Committee on Drugs. Drug harms in the UK: a multicriteria decision analysis. Lancet. 2010 Nov 6; 376(9752): 1558–65.

Gore

F.M.

, Bloem

P.J.

, Patton

G.C.

Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet. 2011 Jun 18; 377(9783): 2093–102.

McKinnon

, Grubin

Health screening in police custody. J Forensic Leg Med. 2010 May; 17(4): 209–12.

Bucke

, Teers

, Payne-James

J.J.

, Stark

M.M.

Near misses in police custody: a collaborative study with forensic medical examiners in London [Internet]. London: Independent Police Complaints Commission; 2008 [cited 2014 Mar 31]. Available from: https://www.ipcc.gov.uk/sites/default/files/Documents/research_stats/ipcc_near_miss_report.pdf.

10.

Payne-James

JJ1

, Green

P.G.

, Green

Healthcare issues of detainees in police custody in London, UK. J Forensic Leg Med. 2010 Jan; 17(1): 11–7.

11.

Lepresle

, Mahindhoratep

T.S.

, Chiadmi

Police custody following drink-driving: A prospective study. Drug Alcohol Depend. 2012 Nov 1; 126(1-2): 51–4.

12.

Nutt

D.J.

, Nestor

L.J.

Addiction. Oxford (UK): Oxford University Press; 2013. 144 p.

13.

Norberg

, Jones

A.W.

, Hahn

R.G.

, Gabrielsson

J.L.

Role of variability in explaining ethanol pharmacokinetics: research and forensic applications. Clin Pharmacokinet. 2003; 42(1): 1–31.

14.

Stark

M.M.

Substance Misusers (Drugs and Alcohol) in Custody. In: Stark

M.M.

, Rogers

D.J.

, Norfolk

G.A.

, editors. Good practice guidelines for forensic medical examiners. 2nd ed. Oxford (UK): Metropolitan Police Service. GPG Editors; 2008. Guideline 5.

15.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington (DC): American Psychiatric Association; 2000. 943 p.

16.

Rix

K.J.

‘Alcohol intoxication’ or ‘drunkenness’: is there a difference?

Med Sci Law. 1989 Apr; 29(2): 100–6.

17.

SAMHSA [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration; c2014. Results from the 2010 National Survey on drug use and health: mental health findings; 2012 [cited 2014 Mar 31]. Available from: http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/2k10MHResults.htm#5.1.

18.

The Bradley Report: Executive Summary [Internet]. London: Central Office of Information; 2009 Apr [cited 2014 Mar 31]. 28 p. Available from: http://www.mac-uk.org/wped/wp-content/uploads/2013/03/Dept-of-Health-Bradley-Report-Exec-Summary.pdf.

19.

Canadian Association for Suicide Prevention [Internet]. National suicide prevention strategy for England. Annual report on progress 2008. Leeds (UK): National Mental Health Development Unit; 2009 Jul [cited 2014 Mar 31]. Available from: http://www.suicideprevention.ca/wp-content/uploads/2010/10/England-6th-annual-report-2010.pdf.

20.

Appleby

, Shaw

, Kapur

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: lessons for mental health care in Scotland [Internet]. Manchester (UK): University of Manchester; 2008 Jun [cited 2014 Mar 31]. 160 p. Available from: http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci/reports/scotland_full_report_june_2008.pdf.

21.

Stark

, Norfolk

Clinical forensic medicine. 2nd ed. London: Greenwich Medical Media; c1996. Chapter 9, Substance misuse; p. 163–80.

22.

Siler

S.Q.

, Neese

R.A.

, Christiansen

M.P.

, Hellerstein

M.K.

The inhibition of gluconeogenesis following alcohol in humans. Am J Physiol. 1998 Nov; 275(5 Pt 1): E897–907.

23.

Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications [Internet]. London: National Institute for Health and Clinical Excellence; 2010 Jun [cited 2014 Mar 31]. 15 p. Available from: http://www.nice.org.uk/nicemedia/live/12995/49004/49004.pdf.

24.

Rogers

D.J.

, Stark

M.M.

, Howitt

J.B.

The use of an alcometer in clinical forensic practice. J Clin Forensic Med. 1995 Dec; 2(4): 177–83.

25.

Payne-James

J.J.

, Keys

D.W.

, Jerreat

P.G.

Salivary alcohol measurement: use in clinical forensic medical practice. J Clin Forensic Med. 1995 Mar; 2(1): 41–4.

26.

Police and Criminal Evidence Act 1984 Code C: revised code of practice for the detention, treatment and questioning of persons by police officers. London: The Stationery Office; 2013. Annex H, Detained person: observation list; [cited 2014 Mar 31]; p. 80. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/306657/2013_PACE_Code_C.pdf.

27.

Best

, Kefas

The role of alcohol in police-related deaths: analysis of deaths in custody (category 3) between 2000 and 2001. London: Police Complaints Authority; 2004 [cited 2014 Mar 26]. 32 p. Available from: http://webarchive.nationalarchives.gov.uk/20100908152737/http://ipcc.gov.uk/deathsincustody_alcoholreport.pdf.

28.

Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): American Psychiatric Association; 2013. 991 p.

29.

Alcohol and public health: position statement [Internet]. London: Faculty of Public Health; 2008 May [cited 2014 Mar 31]. 4 p. Available from: http://www.fph.org.uk/uploads/ps_alcohol.pdf.

30.

Midanik

The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addict. 1982 Dec; 77(4): 357–82.

31.

Babor

T.F.

, Ramon de la Fuente

, Saunders

, Grant

Audit, the alcohol use disorders identification test: guidelines for use in primary health care [Internet]. Geneva: World Health Organization; 1992 [cited 2014 Mar 31]. 30 p. Available from: http://whqlibdoc.who.int/hq/1992/WHO_PSA_92.4.pdf.

32.

Raistrick

, Heather

, Godfrey

Review of the effectiveness of treatment for alcohol problems. London: National Treatment Agency for Substance Misuse; 2006 Nov [cited 2014 Mar 31]. 210 p. Available from: http://www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf.

33.

Pokorny

A.D.

, Miller

B.A.

, Kaplan

H B.

The brief MAST: a shortened version of the Michigan alcoholism screening test. Am J Psychiatry. 1972 Sep; 129(3): 342–5.

34.

Hedlund

J.L.

, Vieweg

B.W.

The Michigan alcoholism screening test (MAST): a comprehensive review. J Oper Psychiatry. 1984; 15: 55–65.

35.

Mayfield

, McLeod

, Hall

The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974 Oct; 131(10): 1121–3.

36.

Ewing

J.A.

Detecting alcoholism. The CAGE questionnaire. JAMA. 1984 Oct 12; 252(14): 1905–7.

37.

Public Health England [Internet]. Liverpool: Public Health England; c2009–2014. Paddington Alcohol Test PAT 2011; 2009 Jul 7 [updated 2011 Mar 23; cited 2014 Mar 31]. Available from: http://www.alcohollearningcentre.org.uk/Topics/Browse/Hospitals/EmergencyMedicine/?parent=5168&child=5169.

38.

Deehan

, Stark

M.M.

, Marshall

E.J.

Drunken detainees in police custody: is brief intervention by the forensic medical examiner feasible?

Crim Behav Ment Health. 1998 Sep; 8(3): 214–21.

39.

Best

, Noble

, Stark

M.M.

, Marshall

E.J.

The role of forensic medical examiners and their attitudes on delivering brief alcohol interventions in police custody. Crim Behav Ment Health. 2002; 12(3): 230–5.

40.

Chariot

, Lepresle

, Lefèvre

Alcohol and substance screening and brief intervention for detainees kept in police custody. A feasibility study. Drug Alcohol Depend. 2014 Jan 1; 134: 235–41.

41.

Sullivan

J.T.

, Sykora

, Schneiderman

Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CI WA-Ar). Br J Addict. 1989 Nov; 84(11): 1353–7.

42.

Alcohol and seniors [Internet]. Vancouver (BC): Charmaine Spencer; c2006. Clinical institute withdrawal assessment for alcohol (CIWA-Ar) scale; [cited 2014 Mar 31]. Available from: http://www.agingincanada.ca/CIWA.HTM.

43.

Police and Criminal Evidence Act 1984 Code C: revised code of practice for the detention, treatment and questioning of persons by police officers. London: The Stationery Office; 2013. Annex G, fitness to be interviewed; [cited 2014 Mar 31]; p. 79. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/306657/2013_PACE_Code_C.pdf.

44.

Gudjonsson

G.H.

Psychological vulnerabilities during police interviews. Why are they important?

Leg Criminological Psychol. 2010; 15(2): 161–75.

45.

Gudjonnson

G.H.

The psychology of interrogations and confessions: a handbook. Chichester (UK): Wiley; 2003. Chapter 8, The psychology of false confession: research and theoretical issues; p. 173–216.