THE CASE OF MADISON ROBERTS
INSTRUCTOR GUIDE FOR
TABLE OF CONTENTS:
I. OVERVIEW OF THE CASE page 3
II. OVERVIEW OF OBJECTIVES page 3
III. OVERVIEW OF THE TWO SESSIONS page 4
IV. MANAGEMENT OF THE FIRST GROUP SESSION page 5
V. BACKGROUND INFORMATION FOR LEARNING OBJECTIVES pages 6-8
V. MANAGEMENT OF THE SECOND GROUP SESSION page 9
VI. HANDOUTS 1 AND 2 pages 10-11
OVERVIEW OF THE CASE:
During the first session, the students meet Madison Roberts, a 20 year old college student being evaluated
at the Student Health Clinic of her university for an acute illness related to binge alcohol consumption.
She has a history of alcohol consumption beginning in her high school years with a progressive increase in
the frequency and quantity of her drinking during her first three years in college. Her grades have recently
declined and she has stopped participating in several activities that were formerly of considerable interest
to her. Her family appears to be unaware of her drinking habits, but they have grown concerned about her
school performance. The Student Health physician refers her to the university’s counseling center for
further evaluation and treatment of her alcohol use.
OVERVIEW OF THE CASE OBJECTIVES:
A. Students will be able to explain the underlying biological basis of alcohol
dependency and tolerance.
B. Students will be able to describe the current epidemiology of alcohol use
among teenagers and young adults.
C. Students will be able to provide appropriate recommendations for the
evaluation and treatment of alcohol-related disorders. They will be able to
explain the nature and efficacy of various medical interventions for alcohol
abuse and addiction including 12 Step Programs such as Alcoholics
D. Students will be able to describe current public health efforts to address
underage drinking and adolescent substance abuse.
OVERVIEW OF THE TWO CASE SESSIONS:
At the beginning of session one, the group will review Handout 1, the description
of Madison’s symptoms and initial evaluation at the Student Health Service of her
After the initial discussion and listing of learning objectives, the student's should
review Handout 2, the results of her initial physical examination and the summary of the
laboratory testing and further treatment.
Session 2 will be used to complete the discussion of learning objectives from
SESSION 1: MANAGING THE DISCUSSION
1) Students will receive Handouts 1 and 2.
2) Have group assign a "scribe" and initiate discussion of case.
Identify problems, hypotheses, and learning objectives.
1. Opening the discussion:
The first step in dealing with this case should be one of problem identification.
That is, what problems do the students perceive as relevant to the situation.
Suggested lines of inquiry or questions:
A. Can you summarize the primary problems that face Madison at this point?
2. Investigating Case Objectives
Suggested lines of inquiry or questions:
A. Is Madison addicted to alcohol? How would you be able to tell?
B. Is this a common scenario? What is the epidemiology of adolescent and
young adult alcohol use? What health outcomes are affected by this?
C. How can substance abuse in adolescents be detected? What are the warning
signs? What are common substances of abuse among teenagers and young
D. What sort of treatment(s) can be effective for someone like Madison?
E. What public health interventions are effective in reducing underage drinking
or other substance abuse?
Brief Background Information Regarding the Learning Objectives:
1. Alcohol Abuse
The distinction between alcoholism and alcohol abuse is based primarily on the presence
of neuroadaptation in alcoholics. Neuroadaptation is marked by both tolerance (larger quantities
of alcohol required to produce the same effect) and withdrawal syndromes when drinking is
stopped (a variety of physiological and/or psychological symptoms). Alcoholics also have a
strong craving for alcohol and a need to ‘control’ their drinking paired with an inability to do so
for any extended period. Both types of alcohol users suffer serious social, personal, medical, or
economic consequences from their drinking and yet are unable to avoid alcohol use.
Ms. Madison’s pattern of drinking strongly suggests a pattern of alcohol abuse, although
the scenario does not address several important issues that might better distinguish her diagnosis.
For instance, there is no information about withdrawal symptoms nor is there a formal screening
for alcohol abuse and dependence syndromes (such as the CAGE questionnaire). However, she
appears to have suffered some decline in her academic performance, a loss of interest in an
important life activity (soccer), and now a serious health consequence of heavy alcohol use.
2. The Epidemiology of Alcohol Disorders
Approximately 10 percent of the United States population is affected by alcohol abuse or
dependence during their lifetime. Men predominate by a ratio of about 3:1 compared to women
and also tend to have an earlier age of onset.
Alcohol abuse disorders have the highest prevalence in young college-aged men and
women. Many of these individuals have a pre-college pattern of heavy drinking that continues
during their college years. Certain groups, such as members of Greek Social organizations (both
fraternities and sororities) and athletes, have higher rates of abuse than other student groups.
Alcohol abusers have a higher incidence of many serious social problems including assault,
sexual assault, property damage, driving under the influence, and exposure to increased risk of
sexually transmitted infections.
3. Treatment of Alcohol Abuse and Dependence
The first step in the treatment of alcohol abuse and dependence syndromes is accurate
screening and diagnosis. There are a wide array of effective screening instruments that are
summarized in the attached federal clinician guideline from the National Institute on Alcohol
Abuse and Alcoholism.
Although alcohol abusers can technically stop drinking through simple interventions and
‘will-power’ without suffering withdrawal syndromes, few will be successful without more
intensive medical and psychiatric intervention, frequently combined with 12 step programs such
as Alcoholics Anonymous. For those with alcohol dependence, intensive interventions to
manage medical complications of alcoholism and symptoms of withdrawal combined with
cognitive-behavioral interventions, family interventions, and referral to AA offer the best hope
for sustained abstinence, the ultimate goal of therapy. AA has the highest success rate of any
individual intervention if patients are able to sustain their participation in the program (90
meetings in 90 days and assignment of a ‘sponsor’, followed by continued frequent attendance at
meetings). Some medications (disulfuram, naltrexone, and topiramate) may be useful in
maintaining sobriety when combined with other interventions. Although inpatient treatment
programs are still available, in general, they have not been shown to be more effective than
outpatient management and are considerably more costly.
4. Current Efforts to Address Alcohol Abuse Among Adolescents and College Students
Universities have adopted many educational and enforcement policies in efforts to
decrease underage drinking and alcohol abuse on campuses. Unfortunately, most of these
interventions have not been studied to document their effectiveness. A number of educational,
motivational, and self-monitoring or self-assessment programs have been shown to be effective
in reducing alcohol abuse among members of sororities and fraternities, but most of these have
not been applied to general student populations.
The approach to general underage drinking among adolescents has been addressed in a
number of recent federal reports and policy documents (see references). In general, the
approaches to reducing underage drinking fall into two categories; 1) environmental
interventions, and 2) individual-level interventions.
Environmental interventions include raising the price of alcohol, increasing the minimum
drinking age, ‘zero-tolerance’ laws (illegal for someone under 21 to drive after ANY alcohol
use), and increased enforcement of laws against underage drinking. All of these interventions are
effective in reducing underage drinking, but enforcement of laws remains sub-optimal in many
jurisdictions. Individual-level interventions include school and family-based prevention
programs, some of which have shown promising results in research studies.
5. Suggested resources:
Turrisi R, Mallett KA, Mastroleo NR. Heavy Drinking in College Students: Who is At
Risk and What is Being Done About It? The Journal of General Psychology, 133(4):401-
Moore & Jefferson: Handbook of Medical Psychiatry, 2nd Edition, Mosby, Inc. 2004.
SESSION 2: MANAGING THE DISCUSSION
1) Summarize the learning objectives identified at the last session and
agree on an order for addressing them.
2) Appoint a new scribe to keep track of the discussion and new or
unresolved questions that arise.
Madison Roberts is a 20 year old junior at State University. She is being seen at the Student
Health Service’s Emergency Clinic on Monday morning with a complaint of severe abdominal
pain, nausea, and vomiting.
Ms. Roberts presents with a 6 hour history of progressive abdominal pain associated with
nausea and multiple vomiting. She has been unable to hold down any liquids or food during this
time. She reports that she had gone to a fraternity party the night before where she consumed
large quantities of alcoholic punch and beer. She does not remember how much, nor does she
remember any events after about 1 AM this morning. She woke up at about 5 AM with
abdominal pain and vomiting. She has taken no medications. She denies having used any illicit
drugs or over-the-counter medications. She is sexually active in a monogamous heterosexual
relationship. She uses oral contraceptives for birth control, and her partner wears a condom
Since coming to college, she reports regular consumption of alcohol, 2-3 times per week. She
drinks 4-10 drinks each time, usually becoming intoxicated, though rarely forgetting important
events. She started drinking occasionally in high school with a few episodes of heavy drinking,
but she never got in ‘trouble’ for her drinking, and was able to hide it from her parents.
Past Medical History:
She reports no significant medical or psychiatric illness, surgeries, or prior hospitalizations.
She takes only oral contraceptives, which she was prescribed as a high school senior.
She has no know medication allergies.
She is in compliance with university regulations regarding immunization status.
She is a junior business major with a 3.1 average. She was an A student for the first two
semesters at college, but her grades have fallen over the past 3 semesters. She played on the
women’s soccer team freshman and sophomore years, but quit the team this past fall. She has
been dating her current boyfriend for about 12 months. He is also a junior at State University.
EVALUATION AT THE EMERGENCY CLINIC
Ms. Roberts was evaluated at the emergency clinic. Results of her examination and further testing
showed that she was suffering from alcoholic gastritis, an inflammation of the lining of the stomach related
to heavy alcohol use. She was given intravenous fluids for several hours, some anti-nausea medications,
and some antacid medication. Her symptoms slowly improved and she was released from the clinic later in
the day. She was instructed to follow up at the University Student Health clinic within three days and
referred to the University Counseling Center for evaluation and treatment for her drinking behavior.