emergency room visits from energy drinks

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The Link Between Energy Drinks and ER Visits

Reaching for an energy drink when you need an early morning spike, an after-lunch boost or an evening lift, can have serious health ramifications. Recent studies have shown a drastic rise in the incidents of ER visits due to the dangerous effects of drinking energy drinks.

“Energy drinks and energy shots can be very dangerous to your health,” said Advance ER physician Dr. Rajesh Rao. “If you choose to drink energy drinks, sooner or later you may be visiting the doctor or the ER.”

What are the facts?

In a prominent study over four years, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) found a ten-fold increase in hospital-related emergency room visits due to energy drink consumption. People aged 18-24 had the highest number of ER visits, followed by those aged 26-39. Almost half of the energy drink abuses had been combined with alcohol, pharmaceuticals or illicit drugs.

Who is at risk?

With colorful packaging and youthful advertising, energy drinks are being targeted to children and teens. The American Academy of Pediatrics does not recommend any beverage containing caffeine for children or adolescents. Further, they have said that “children should not consume” these products.

The World Health Organization (WHO) has also issued a statement to discourage energy drink consumption by children and adolescents. They say that “increased consumption of energy drinks may pose danger to public health, especially among young people.”

What harm can happen from drinking energy drinks?

There are a variety of symptoms caused by drinking energy drinks and energy shots including:

Rapid heartbeat
Heart arrhythmia
Muscle tremors
High blood pressure
Nervousness
Irritability & restlessness
Weight gain
Tooth decay

What’s in energy drinks?

The main appeal of energy drinks is the high amount of caffeine. This gives an immediate energy spike, followed by an energy crash later on. Coupled with enormous amounts of sugar, energy drinks cause an energy crash that is much worse than if the person had not consumed the drink to begin with.

In addition, energy drinks contain ingredients such as ginseng and guarana which, along with the sugar, contribute to similar symptoms as those above and are shown to enhance the effects of caffeine. There are other chemical additives in energy drinks and shots that are not fully understood, as well. To compare caffeine amounts in different beverages that you enjoy, click here.

What’s the alternative to energy drinks?

“I recommend a consistent diet of protein, vegetables and fruits, along with getting plenty of sleep each night, for the best energy possible without artificially adding harmful substances to your system,” said Dr. Rao. “Stay hydrated with fresh water or sparkling water and get plenty of exercise. However, if you follow these guidelines and are still feeling run-down and low on energy, it’s time to have your doctor examine you. There could be an underlying condition, such as anemia, that needs to be addressed.”

Where can I get help?

If you’re suffering symptoms from large caffeine or other substance consumption, come to the nearest Advance ER for prompt emergency treatment. We’re open 24/7 for all your emergent medical conditions. Check out our two convenient locations.

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Caffeine Can Kill: the Dangers of Energy Drinks

ER visits for energy drink-related complications have doubled in the last several years.

Last year, there were more than 20,000 emergency room visits attributable to the ingestion of energy drinks – following a 2011 government report that expressed real concern about the emerging problem posed by energy drinks and shots. Recently, a South Carolina high school student collapsed and died after consuming a very high dose of caffeine in a short time: coffee, soft drinks and an energy drink. The coroner reported that the student died from a caffeine-induced lethal cardiac arrhythmia . Today in the U.S., the energy drink business is a multibillion dollar industry (estimated to reach $61 billion by 2020), and most of these products have been marketed directly to children and adolescents. When these drinks are combined with other drugs and alcohol, the adverse events can become even more severe. Over the last decade, the number of ER visits related to energy drink consumption has more than doubled.

[See: 'Healthy' Foods You Shouldn't Be Eating .]

What Exactly Is in These Energy Drinks and Shots?

Energy drinks are sugary beverages that are loaded with caffeine as well as additives such as vitamins, minerals, taurine, herbal supplements and guarana (a plant extract with a high concentration of caffeine). From a medical standpoint, they have absolutely no nutritional value – they're high in calories due to their sugar content.

Caffeine. It's the primary ingredient in energy drinks; caffeine content typically ranges from 50 to 500 milligrams, compared to 100 milligrams in a regular cup of coffee.

Guarana. This is a plant from Brazil that contains a high concentration of a caffeine-like compound. In fact, 1 gram of guarana is equivalent to 40 milligrams of caffeine.

Sugars. Energy drinks contain anywhere from 21 to 34 grams of sugar per 8 ounces, and this can be sucrose, glucose or high fructose corn syrup – which is known to be associated with obesity. Children and adolescents who consume energy drinks are at high risk for obesity and dental problems. If you drink two energy drinks per day, you could be consuming nearly six times the maximum daily recommended amount of sugar.

Taurine. This is one of the most common amino acids – or building blocks for proteins – in the body. Taurine supports brain development and helps enhance athletic performance. The amount of taurine in energy drinks is much higher than that found in foods such as meat, seafood and milk. There is no evidence to support that higher levels of taurine have any beneficial effect on our bodies.

[See: How to Know if You're Exercising Too Much .]

Ginseng. This energy drink additive is derived from the ginseng root and has been linked to insomnia, high blood pressure and headaches. There is no scientific evidence that ginseng can enhance athletic performance, improve mood or stimulate the immune system, as many energy drink makers claim.

B vitamins. These are important minerals typically obtained in adequate amounts in a normal American diet . There's no evidence that taking larger amounts of these vitamins (unless you have a proven deficiency of some type) can have any impact on your overall health.

It's important to remember that energy drinks are not regulated by the Food and Drug Administration and vary greatly in their composition; there's no standard formula. Unlike pharmaceuticals, the FDA does not require any proof for the safety and efficacy of energy drinks and energy shots. When alcohol is added to these beverages, the risk for negative health effects increases significantly.

What Are the Potential Health Effects of Energy Drinks?

Caffeine has powerful effects on many of our vital organs – particularly the cardiac and nervous systems. After drinking an energy drink , heart rate increases, blood vessels stiffen and your blood may become thicker; all changes that can precipitate a heart attack or stroke in those who are at risk. A recent study suggests that the other ingredients, such as taurine, may significantly increase heart rate and blood pressure, as well as risk for heart rhythm problems independent of caffeine content. These drinks can also cause periods of anxiety, changes in sleep patterns and mood swings – particularly in children and adolescents. Energy drinks have also been associated with serious complications including seizures, stoke and sudden cardiac death.

[See: The 12 Best Diets for Your Heart .]

What Can We Do to Stay Safe?

The World Health Organization has stated that energy drinks "may pose a danger to public health," and the American Academy of Pediatrics has recommended that "children should not consume" these drinks. A growing body of scientific evidence suggests these drinks have no positive benefits and may put consumers at significant risk for health-related side effects. A study from 2014 found that nearly 40 percent of the calls to poison control centers concerning children under the age of 6 were related to energy drinks. It's now clear that under no circumstances should children or adolescents be given access to these beverages. For adults, it's important to consider your risk for heart disease or stroke: If you're predisposed to these conditions, the consumption of an energy drink can precipitate an event. If adults do choose to drink energy drinks, never combine these beverages with alcohol or drugs, as this can potentiate their effects.

From a medical standpoint, energy drinks have no nutritional value and should be avoided. Water is a healthy beverage choice, and one that has been proven time and again to be part of an overall healthy lifestyle.

Tags: food and drink , caffeine , Heart Health

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Energy Drink-Associated Electrophysiological and Ischemic Abnormalities: A Narrative Review

Affiliations.

1 Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA, United States.
2 Department of Pharmacy Practice, Thomas J Long School of Pharmacy, University of the Pacific, Stockton, CA, United States.
3 David Grant USAF Medical Center, Fairfield, CA, United States.
4 Heart and Vascular Institute, UPMC Presbyterian, Pittsburgh, PA, United States.
PMID: 34277730
PMCID: PMC8280314
DOI: 10.3389/fcvm.2021.679105

An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to energy drinks. In this review, we summarized available published literature assessing electrophysiological and ischemic adverse effects associated with energy drink consumption. Overall, 32 case reports and 19 clinical trials are included in this review. Ventricular arrhythmia, supraventricular arrhythmia, and myocardial ischemia were amongst the most commonly reported in case reports with 3 having a fatal outcome. Although serious ischemic changes, arrhythmias, or death were not observed in clinical trials, significant electrophysiological changes, such as PR/PQ interval shortening/prolongation, QT/QTc shortening/prolongation, and ST-T changes, were noted. QT/QTc interval prolongation appears to be the most significant finding in clinical trials, and there appears to be a dose-response relationship between energy drink consumption and QTc prolongation. The exact mechanisms and the particular combination of ingredients behind energy drink-induced cardiac abnormalities require further evaluation. Until more information is available, energy drink use should be considered as part of the differential diagnosis in appropriate patients presenting with electrocardiographic changes. Further, certain patient populations should exercise caution and limit their energy drink consumption.

Keywords: adverse effects; arrhythmia; electrophysiology; energy drinks; ischemia.

Publication types

clock This article was published more than 10 years ago

More than 10 percent of emergency room visits involving energy drinks result in hospitalization

More than 10 percent of emergency room visits by people age 12 or older for problems involving energy drinks are serious enough to result in hospitalization , the federal government warned this week.

The Substance Abuse and Mental Health Services Administration said that 20,783 people visited emergency rooms in 2011 for difficulties involving the high-caffeine drinks, which are heavily marketed to youths and young adults. Eleven percent of them were hospitalized.

The data showed that 12 percent of people who had consumed only the energy drinks were hospitalized, while eight percent of those who had consumed an energy drink in combination with alcohol or drugs needed in-patient care. The total number of emergency room visits involving the beverages doubled between 2007 and 2011.

The flavored drinks -- which include the brands Red Bull, Monster Energy and the smaller 5-Hour Energy shots -- can contain as much as 500 milligrams of caffeine, which is five times as much as a typical cup of coffee and 10 times as much as a 12-ounce cola, according to SAMHSA. Ingesting that amount can cause health problems such as insomnia, racing heartbeat and increased blood pressure, the agency said in a bulletin issued March 13.

Even as their sales have soared, the drinks have been linked to "marijuana use, sexual risk taking, fighting, smoking, drinking and prescription drug misuse" among college students, the agency reported in 2013.

In 2012, the New York Times reported that the Food and Drug Administration had received 13 reports of deaths over the previous four years that cited the possible involvement of 5-Hour Energy and five fatalities that mentioned the possibility of Monster Energy being involved. A year ago, a group of physicians, researchers and public health experts urged the Food and Drug Administration to protect children and teens by restricting the amount of caffeine in energy drinks.

Energy drink companies have said that their products contain about the same amount of caffeine as strongly brewed coffee. Energy drinks and shots are usually sold as dietary supplements or food products, which don’t have caffeine limits. Other ingredients in energy drinks, such as taurine and ginseng, aren’t regulated by the FDA.

Studies have set different limits for the amount of caffeine an adult can safely consume, ranging from 2oo to 400 milligrams a day. More than 200 milligrams can be dangerous for children and adolescents, and the American Academy of Pediatrics advises against giving energy drinks to children.

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Home of Caffeine Scientist, Author, and Speaker GreenEyedGuide

The Trouble with the “Energy Drink Related ER Visits” Stat

So you want to talk about energy drinks sending people to the er....

Hi. I’m Caffeine Scientist GreenEyedGuide. In this post, we’ll breakdown the statistic which gets mentioned all the time in energy drink-related news. It usually goes something like this, “energy drinks send thousands to the ER”, or “energy drink-related ER visits doubled in a 5 year period.”

This statistic does carry meaning, but it’s not the full story. Journalists aren’t experts in the science behind caffeine and energy drinks. But I am. And so, in this post, we’ll take a closer look at the source of this statistic.

First, we’ll look at real headlines.
Second, we’ll look at the source of this stat.
Finally, we’ll put it all together and identify what caffeine lovers can do.

Ready? Let’s Go!

You can read the blog post below or listen to it in podcast form. Just click the button to open the podcast on your platform-of-choice (e.g., Spotify, Apple Podcasts, etc.)

ONE - Where have we seen this stat on energy drink-related ER visits?

This statistic about energy drink-related ER visits is almost always used in articles about energy drinks. Here are a few examples:

Related Reading: Energy Drink Hospitalization Checklist – How to Ask the Right Questions

You might have noticed some of these headlines are years old. In fact, this energy drink-related ER statistic comes from a report that came out nearly a decade ago! Nonetheless, this statistic is still used to this day in news articles about energy drinks.

For example, it’s mentioned again in this article from February 2021:

To summarize, this article, and others like it, use this statistic about energy drink-related ER visits to emphasize energy drinks are dangerous. And they’re not wrong. But there’s more to the story, which brings me to the next point.

TWO - What does the report on energy drink-related ER visits actually say?

Before I start listing my concerns with this statistic, let’s look more closely at where it comes from. Here are the 3 most important things you need to know about that report.

The DAWN Report

This statistic comes from the DAWN Report. Drug Abuse Warning Network. It was a federal study. The link has moved around a bit since the report has been published A DECADE AGO but I’ve found a link where you can read the whole report (only 3,0000 words – 10-minute read, max).

REFERENCE : Mattson, M. E. (2013). Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern. In The CBHSQ Report . (pp. 1–7). Substance Abuse and Mental Health Services Administration (US). https://pubmed.ncbi.nlm.nih.gov/27606410/

The numbers come from national estimates of Emergency Department (ED) visits involving energy drinks from 2005 to 2011. Again, that’s between 2005-2011.

What’s special about those years?

Hold that thought.

The Number of ER Visits

This report found, “The estimated number of ED visits involving energy drinks doubled from around 10,000 visits in 2007 to 20,000 visits in 2011.” Again, that’s an increase from 10-20 thousand.

Twenty THOUSAND sounds like a lot, right?

We’ll get to that.

Notable Details

Roughly 42% of the hospital visits had to do with combinations of energy drinks and alcohol or other drugs.

In other words, almost half of these energy drink-related ER visits had to do with energy drinks and bad decisions.

So let’s dive into what this all means.

four loko is 5 red bulls and 7 shots vodka thus played a role in energy drink related ER visits

THREE - We've got the news and the science. Now let's break that all down.

What's special about 2005-2011.

First of all, let’s talk about those years. From 2007-20011.

Do you know the big event that happened in 2009-2010? Does anyone remember Four Loko? Also known as Black Out In a Can?

That whole fiasco where Four Loko was sending people to the ER with potentially lethal alcohol poisoning all went down in 2009 and Four Loko reformulated in 2010.

Full disclosure, I’m married to a former frat brother, and he told me how his buddies stocked up on Four Loko when they knew it was going to be reformulated. This is the sh*t that gives me nightmares.

For those of you who weren’t there and don’t know, Four Loko was 12% alcohol and 500 mg caffeine, all in one 23 oz can. This is 7 shots of Vodka and 5 Red Bulls! That’s too much alcohol and too much caffeine. Don’t mix your uppers and downers. It is not a good idea.

Four Loko Played a Big Role in Those Energy Drink-Related Hospitalizations

This Four Loko saga all happened right during this critical data collection period of this report! This is a HUGE asterisk that gets completely glanced over when articles casually mention how energy drinks are sending more people to the ER. Furthermore, we’re not done talking about energy drinks and alcohol. But we’ll come back to that…

Is 20,000 energy drink-related ER visits a lot?

Second of all, we need to talk about the number of hospital visits. From 10,000 to 20,000. For context, there are more than 1 million drug-related hospital visits every year. That means, even at the peak, these energy drink-related visits accounted for only 2% of these drug-related hospital visits.

The Role of Alcohol-Energy Drink Combinations

Finally, roughly 42% of those hospital visits had to do with people combining energy drinks and alcohol or other drugs. We’ve already talked about the fiasco that was Four Loko, but that’s just a portion of those visits.

The data suggests that 58% of those energy drink-related visits involved energy drinks only. But which energy drinks? And how much caffeine? And what other ingredients were in these drinks? We will never know because this level of detail is not collected.

Before 2020 and COVID, I approached a few hospitals here in Milwaukee with a pilot study I wanted to do on energy drink-related hospitalizations. And all the nurses I talked to said, “When you come into the ER, we don’t care which energy drink you had. We’re just trying to save your life.”

The Bottom Line

In other words, no one is collecting the details about caffeine content, the energy drink brand, or the other ingredients during these energy drink-related ER visits. As a result, when articles say, “energy drinks double the rate of hospitalizations”, this line doesn’t help anyone make better choices.

If you’re a journalist, stop dropping this statistic. It’s irrelevant, outdated, and out of context.

Instead, here’s what all energy drink articles SHOULD say:

Don’t mix alcohol and energy drinks. This combination played a significant role in the number of energy drink-related hospitalizations.
Know how much caffeine is too much. We can assume that a majority of these energy drink-related hospitalizations had to do with people who had too much caffeine.
Stop assuming all energy drinks are the same. Doing that ignores the role of the other ingredients in energy drinks.

So what can you do, if you love energy drinks? Check out my Energy Drink Report Card. Whether you love the stereotypical energy drinks like Red Bull or the clean energy drinks like Marquis, I’ve got recommendations in there for you. Knowing how much caffeine is too much and knowing the difference between these energy drinks is key to avoiding a trip to the ER.

In conclusion, if you’re someone like a shift-worker, teacher, or first-responder, you probably rely on caffeine to get you through the day. So understanding the science behind claims like the ones in this news article can help you make better decisions. In other words, I want to make sure your caffeine choices are based on facts, not fear.

When Does Coffee Become an Energy Drink?

Science Behind Starbucks Doubleshot

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Review article, energy drink-associated electrophysiological and ischemic abnormalities: a narrative review.

1 Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA, United States
2 Department of Pharmacy Practice, Thomas J Long School of Pharmacy, University of the Pacific, Stockton, CA, United States
3 David Grant USAF Medical Center, Fairfield, CA, United States
4 Heart and Vascular Institute, UPMC Presbyterian, Pittsburgh, PA, United States

Introduction

Energy drinks (ED) are an increasingly utilized niche in the beverage market and are gaining popularity in recent years, especially amongst teenagers and young adults. According to the National Health and Nutrition Examination Surveys, ED consumption has grown substantially amongst adolescents and adults in the United States ( 1 ). A United States Substance Abuse Services and Mental Health Administration (SAMHSA) report revealed patients aged 18 to 39 were most commonly involved in ED-related emergency department visits ( 2 ). Energy drinks are generally available in a variety of sizes ranging from a 60 ml “shot” form, to a larger 710 ml container. They typically contain caffeine in conjunction with presumed energy-enhancing ingredients such as taurine, B vitamins, and herbal extracts. Caffeine content in ED typically vary from 70 to 200 mg per 473 ml serving ( 3 ). Beneficial claims of ED include improvements in alertness, physical endurance, metabolism and concentration. Energy drink-associated emergency department visits have sharply increased in recent years. According to a report by SAMHSA, the number of emergency department visits due to EDs increased from 10,068 to 20,783 between 2007 and 2011 ( 2 ). In a recent study conducted in Air Force personnel, nearly 1% of energy drink users reported needing to see a physician or going to the emergency department because of adverse effects from energy drinks ( 4 ). The Center for Science in the Public Interest reports 34 deaths linked to energy drink consumption ( 5 ). An analysis of poison control data of 5,156 reports suggests cardiac and neurological adverse effects are amongst the most common ( 6 ). It is important to note, however, that the number of adverse events due to ED is likely underestimated in these reports since such reporting is completely voluntary. Accordingly, we reviewed available literature of published case reports and clinical research studies evaluating electrophysiological abnormalities related to ED consumption. This review serves to better inform clinicians of the notable connection between ED and electrocardiogram (ECG) changes. The information may provide additional insight in the differential diagnosis of patients presenting with ECG changes in the emergency department.

A qualitative review was conducted by searching for relevant articles in PubMed, EMBASE, Cochrane database from 2001 to July 1, 2019 along with hand searching references from appropriate articles. Case reports and clinical trials assessing the effects of energy drink on electrophysiological and ischemic abnormalities were included. Studies assessing energy capsule, bar, soda or sports drink were excluded. Due to the sparsity of randomized, placebo-controlled trials and the heterogeneity among these studies, a meta-analysis was not performed.

A total of 32 individual cases (28 case report publications) have been described in the literature regarding ED and cardiac rhythm abnormalities ( Table 1 ) ( 7 – 35 ). Three cases were described in two publications by Mattioli et al. and each case was only counted once as the authors assumed that the two publications were referring to the same patients. The majority of patients were male (84%) with a median age of 25 years (range 13–53). Seventeen cases were from the United States. The most common presentations were chest pain, palpitation, nausea/vomiting, and cardiac arrest. Twenty-two cases involved consumption of ED only, while 10 reported coingestion of an ED with another substance (5 with alcohol, 3 with amphetamine salts, 1 with additional caffeine, and 1 with a caffeinated soda). A total of 3 cases resulted in death, with one of the cases reporting coingestion with 3, 4-methylenedioxymethamphetamine (MDMA). Arrhythmia was reported in 20 cases (9 supraventricular [includes one case of Wolff-Parkinson-White Syndrome], 10 ventricular and 1 being supraventricular and ventricular). Fourteen cases reported ST-segment changes, 1 of which was fatal, 5 were found to have coronary artery occlusion, 2 were diagnosed with spontaneous coronary artery dissection, 1 had a normal repeat exercise treadmill test without ED, 4 revealed normal coronary arteries post coronary angiography, 1 was diagnosed with Brugada syndrome, and 1 was diagnosed with coronary artery vasospasm. QT/QTc prolongation was evident in 4 cases. One case was associated with ventricular tachycardia, 2 were discharge with a diagnosis of Long QT type 1 (LQTS1), and QTc prolongation resolved without intervention in 1 case involving a healthy volunteer. One patient was identified as having reverse Takotsubo cardiomyopathy.

Table 1 . Case reports of energy drinks and related electrophysiological and ischemic abnormalities ( 7 – 35 ).

Table 2 contains a list of all 19 original research articles ( 36 – 54 ). The smallest sample size studied was 1 (this study was designed as a clinical trial but stopped early due to administrative reasons and the emergence of new data), and the largest study included 80 participants. Subjects were generally young healthy volunteers with the exception of the study by Gray et al. which evaluated subjects with long QT syndrome (LQTS). Caffeinated EDs were used in all studies. The volume of EDs or matching control drinks ranged from 60 to 1,000 ml. The shortest total duration of assessment was 30 min, while the longest lasted 24 h. Ten out of the 19 studies were performed in the United States. Thirteen were controlled trials, whereas 6 were non-controlled. Three studies employed a parallel study design, 8 employed crossover, and 1 study used both parallel and crossover design. All trials assessed the effect of ED on QTc interval. In 8 of the 19 studies, ED was associated with statistically significant QTc prolongation compared to at least one comparator group. In contrast, 1 study showed ED-associated QTc shortening. QT interval correction were most commonly calculated using the Bazett's formula (9 out of 19 studies). Of the remaining studies, 3 used both Bazett's and Fridericia formula, and 7 did not specify the formula used for QTc correction. Eighteen of the trials evaluated the effect of ED on heart rate (HR). Of these studies, 5 demonstrated a statistically significant increase in HR with ED in at least one comparison, and 1 found a statistically significant HR decline. ED was associated with more frequent ST-T changes in 1 study, and none of the studies noted any clinically significant arrhythmias.

Table 2 . Clinical trials of energy drinks and related electrophysiological and ischemic abnormalities ( 36 – 54 ).

In our comprehensive review of case reports with a documented electrophysiological abnormality, ventricular arrhythmia, supraventricular arrhythmia, and myocardial ischemia were amongst the most commonly reported. Although serious arrhythmias or death were not observed in clinical trials, a multitude of significant ECG changes (PR/PQ interval shortening/prolongation, QT/QTc shortening/prolongation, ST-T changes) with ED were noted. QTc prolongation was the most common and significant finding in clinical trials. In controlled trials showing a significant prolongation of the QT interval, the average change in QT/QTc was small (6–10 ms) ( 38 , 41 , 50 , 51 ), but this magnitude of change can still be meaningful. The FDA requires thorough QT/QTc evaluation for all new drug entities with a QT/QTc prolongation of at least 5 ms ( 55 ), and results of such evaluation may carry drug labeling significance. As an example, azithromycin bears a warning in its package insert for prolonging the QTc by 5–9 ms with the administration of 500–1,500 mg of oral azithromycin ( 56 ). QT/QTc changes >50 ms or an absolute value >500 ms are generally considered clinically significant in practice ( 55 ), and this degree of QT/QTc prolongation was observed in a few cases and several clinical trials participants ( 14 , 25 , 43 , 45 , 51 ).

Our review identified 3 cases resulting in death, all of which had a documented ventricular arrhythmia prior to the fatal event. Sudden cardiac death in patients under the age of 35 is usually attributed to an underlying cardiac condition but is also frequently idiopathic ( 57 ); however, the temporal relationship between energy drink consumption, ventricular arrhythmia, and fatality is concerning. As noted in prior studies, QT/QTc prolongation can induce early after depolarizations, provoke Torsades de Pointes, or lead to ventricular fibrillation, which can potentially cause sudden cardiac death. As such, QT/QTc prolongation appears to provide a plausible explanation for energy drink-induced ventricular arrhythmias. The relation between QTc and all-cause mortality, cardiac mortality, and sudden cardiac death has also been well-established in population studies ( 58 ). However, it is important to note that QTc prolongation does not always lead to Torsades de Pointes or ventricular arrhythmias, therefore additional markers for arrhythmia risk prediction should also be incorporated in future studies.

Supraventricular arrhythmia and myocardial ischemia were also frequently documented in case reports, but these abnormalities cannot necessarily be explained by the prolongation of the QT/QTc interval. A multitude of risk factors exist for supraventricular arrhythmias such as atrial fibrillation and atrial flutter, including high dose caffeine, alcohol, amphetamine salts, excessive sympathetic stimulation, and stress amongst others. That being the case, coingestion of ED with another substance may explain the supraventricular arrhythmias seen in published cases. Interestingly, of the 10 cases of supraventricular arrhythmia, 6 involved coingestion of a second substance (2 with alcohol, 2 with amphetamine salts, 1 with caffeine, and 1 with a caffeinated soda). In contrast, coingestants were only involved in 2 of the 11 cases of ventricular arrhythmia and 4 of the 14 cases with ST-segment changes.

Consumption of ED has also been linked to myocardial ischemia in multiple case reports ( 8 , 9 , 11 , 16 , 17 , 19 , 24 , 26 , 28 , 30 – 32 , 34 , 35 ). Changes in platelet aggregation post-ED consumption has been suggested by some studies ( 59 ), warranting further exploration of this phenomenon as a pathway leading to coronary thrombosis.

Even though inconsistencies in outcome have been observed in clinical trials due to heterogeneity in study design and small sample size, one interesting trend was observed. There appears to be a dose-related relationship between ED consumption and QTc prolongation. In studies showing significant QTc prolongation with ED, the median volume of ED consumed was >800 ml, compared to <500 ml in studies showing a lack of association. The majority of reported cases also involved consumption of large amounts of ED. Limiting the volume of energy drinks acutely therefore should be encouraged.

Certain patient population may be at particular risk for developing ED-related adverse effects. The majority of the studies included young health volunteers; however, one study had a cohort of overweight or obese students ( 36 ) and another looked at patients with underlying LQTS ( 43 ). While QTc was not changed in the normal weight group, the overweight/obese group demonstrated significantly increased QTc at 60 min post-ED consumption ( p = 0.006) ( 36 ). A meta-analysis conducted by Omran et al. seems to confirm the association between overweight/obesity and QTc prolongation ( 60 ), therefore this population may require further risk assessment. Although a significant change in QTc was not observed in the study conducted in patients with LQTS, 3 out of 24 patients in the study developed QTc increase of at least 50 ms after the ED consumption ( 43 ). Energy drink consumption also unmasked LQTS in 2 of the published cases ( 14 , 25 ). Together, these data suggest that the consumption of ED should be limited in patients with underlying LQTS.

Whether it is an individual component in energy drinks, multiple ingredients, or their combination that may induce ECG abnormalities requires further investigation. Though most energy drinks contain caffeine, caffeine is generally recognized as safe at doses under 400 mg and seems unlikely to be the sole ingredient contributing to rhythm abnormalities in EDs. In a small study of 10 healthy volunteers, no ECG changes were evident 3 h post 400 mg of caffeine ingestion ( 61 ). Based on population studies, moderate caffeine consumption is also thought to be an unlikely cause of arrhythmias ( 62 ). As such, in the study by Fletcher et al. where ED was compared to a matching caffeine-only control, the QTc was 10 ms higher in the ED group when compared to the caffeine group ( 41 ). However, there was not a non-caffeinated-control group which would have allowed for a more ideal comparison. A recent study by Basrai et al. also evaluated the impact of a commercial ED against ingredients commonly included in ED. Comparator groups in the study included placebo, placebo with caffeine, placebo with taurine, placebo with glucuronolactone and placebo with caffeine and taurine ( 38 ). Despite the complex structure of the design, QTc prolongation was observed in the ED group while all other groups either had no change or QTc shortening. Lastly, in a study comparing ED, panax ginseng and a placebo control, panax ginseng did not appear to have an effect on ECG parameters while ED prolonged the QTc interval ( 50 ). It appears likely that the unique combination of ingredients in ED, as opposed to caffeine alone, may be responsible for inducing ED-associated ECG changes in clinical studies. Based on available information, taurine or panax ginseng alone does not appear to drive any ECG effects associated with EDs.

One important consideration in studies investigating the effect of ED and QTc is the formula used for QT interval correction. While Bazett's formula is most commonly used clinically, it has been known to overcorrect at higher heart rates and undercorrect at lower heart rates. Several other correction formulas exist, and some data suggest that the Fridericia and Framingham correction formulas have the best rate correction and significantly improved prediction of 30-day and 1-year mortality compared to the Bazett's correction formula ( 63 ). Most trials included in this review used the Bazett's correction formula, but future studies should consider reporting multiple correction formulas.

The impact of acute vs. chronic consumption also warrants further evaluation. In a number of case reports, subjects had been consuming energy beverages for an extended period of time before presenting with a cardiac abnormality ( 7 , 14 , 17 , 19 , 27 , 28 , 30 , 32 ). Only 2 clinical trials evaluated the effects of chronic (1 week) ED consumption ( 49 , 52 ). However, interpretation of these studies is difficult due to discordant results and study design limitations. With emerging data, multiple organizations started to raise a note of caution with ED consumption. In 2011, the American Academy of Pediatrics, an organization of 60,000 pediatricians recommended against kids and teens from drinking EDs ( 64 ). In 2013, the American Medical Association called for a ban in advertising EDs to children under 18 ( 65 ). Lithuania was the first country to enact a ban against the sale of EDs to minors ( 66 ). Aiming to safeguard the development of EDs in Europe, all European Union member states must now abide to specific provisions for the labeling of EDs under the Code of Practice for the Marketing and Labeling of Energy Drinks. Countries have either adopted specific rules on EDs (Germany, Switzerland) or provided principles for the composition of EDs through corresponding food guidelines (Austria) ( 67 ). Subsequently, the American Beverage Association also developed voluntary guidelines to label EDs for their age appropriateness in 2014 ( 68 ).

To our knowledge, this is the most comprehensive review as other reviews are only driven by case reports or have not captured the totality of available literature ( 69 , 70 ). However, several limitations should be noted when interpreting our findings in this review. It is important to note that the majority of the studies were small, mainly studied in young healthy volunteers, assessed only the acute cardiovascular effects of ED consumptions and with some, lacked a control arm. This review also does not extend to soda type beverages which may also contribute to the total daily caffeine consumed by individuals (e.g., soft drinks typically contain between 20 and 70 mg of caffeine per 12 fluid ounces) ( 71 ).

Conclusions

The preponderance of data suggests a significant correlation between ED and electrophysiological changes. While case reports have noted both ventricular and supraventricular arrhythmias, these were not evident in clinical trials. Large volume ED consumption appears to mildly prolong the QTc interval which may in part explain the mechanism behind some of the ventricular arrhythmias and associated deaths. Coingestion of other substances was seen in the majority cases of supraventricular arrhythmias. ST-segment changes and myocardial ischemia were also frequently noted in case reports. The exact mechanisms and the particular combination of ingredients behind these cardiac abnormalities require further evaluation. Until more information is available, energy drink use should be considered as part of the differential diagnosis in appropriate patients presenting with electrocardiographic changes. Appropriate labeling or warnings for consumers are also worthy of consideration by policy makers.

Author's Note

Energy drinks are an increasingly utilized niche in the beverage market and are gaining popularity in recent years, especially among teenagers and young adults. An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to the consumption of energy drinks. To our knowledge, this is the most comprehensive review assessing electrophysiological and ischemic adverse effects associated with energy drink consumption. Overall, 32 case reports and 19 clinical trials are included in this review, suggesting the need for thorough patient evaluation presenting with electrocardiographic changes. The exact mechanisms and the particular combination of ingredients behind energy drink-induced cardiac abnormalities require further evaluation. Until further information is available, certain patient populations should exercise caution and limit their energy drink consumption.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

The views expressed in this material are solely those of the authors and do not reflect the official policy or position of the US Government, the Department of Defense, the US Air Force, the Marshall B. Ketchum University, or the University of the Pacific.

Conflict of Interest

SS has served as an expert witness in legal cases related to caffeinated energy drinks.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: energy drinks, electrophysiology, arrhythmia, ischemia, adverse effects

Citation: Cao DX, Maiton K, Nasir JM, Estes NAM and Shah SA (2021) Energy Drink-Associated Electrophysiological and Ischemic Abnormalities: A Narrative Review. Front. Cardiovasc. Med. 8:679105. doi: 10.3389/fcvm.2021.679105

Received: 11 March 2021; Accepted: 12 May 2021; Published: 01 July 2021.

Reviewed by:

Copyright © 2021 Cao, Maiton, Nasir, Estes and Shah. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Sachin A. Shah, sshah@pacific.edu ; orcid.org/0000-0001-5850-1113

† These authors have contributed equally to this work

This article is part of the Research Topic

Highlights in General Cardiovascular Medicine: 2021

Watch CBS News

Report Finds Spike In Energy Drink-Related Emergency Room Visits

January 16, 2013 / 8:39 PM EST / CBS New York

NEW YORK (CBSNewYork) -- Energy drinks are the fastest growing segment of the carbonated soft drink market.

Trouble is, most people don't realize that they can be hazardous to their health and the Food and Drug Administration is already investigating the safety of energy drinks after a number of deaths were linked to them, CBS 2's Dr. Max Gomez reported.

The beverages are super popular, especially with young adults.

College junior Allen Abrishame, 20, works late nights at a restaurant, so he uses them to stay awake.

"During the middle of the shift, I'll get tired and knock one down," Abrishame said.

But the drinks are landing more and more people in the emergency room.

"The first question I ask when I see a young person with a rapid heart beat and anxiety is 'Have you taken any energy drinks?'" said Dr. Stephen Meldon, the Vice Chair of the Emergency Services Institute at the Cleveland Clinic.

A report from the Substance Abuse and Mental Health Services Administration said ER visits doubled in the last four years from about 10,000 to more than 20,000.

Doctors said those high doses of caffeine and other additives can cause a number of reactions.

"It's really going to be symptoms of taking a stimulant...so you're going to have nervousness, rapid heart rate, anxiety," Meldon said.

In recent years sales have soared for the top three energy drink companies. -- Red Bull, Monster and Rockstar and marketers main target is young people.

The government report found those same young people, ages 18-25, were the most common age group to need emergency treatment.

"I get really jittery, I get really, really hyper. It makes me want to pace and I just don't feel good, and once the energy drink wears off, I have a really bad headache," said 19-year-old freshman nursing student Victoria Benson.

The American Beverage Association criticized the report, saying many of those who end up in the ER were also consuming alcohol or drugs.

About half of the ER visits were for people who combined energy drinks with alcohol or stimulant drugs like Adderall or Ritali.

CBS 2's Gomez reported that three energy drinks is the equivalent of 15 cups of coffee and said people using them should limit themselves to one every few hours.

Share your thoughts about energy drinks in the comments section below...

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ER Visits Tied to Energy Drinks Double Since 2007

More than 20,000 people went to the er with complaints tied to energy drinks in 2011, a new report shows, by garance burke • published january 16, 2013 • updated on january 16, 2013 at 4:42 pm.

A new government survey suggests the number of people seeking emergency treatment after consuming energy drinks has doubled nationwide during the past four years, the same period in which the supercharged drink industry has surged in popularity in convenience stores, bars and on college campuses. From 2007 to 2011, the government estimates the number of emergency room visits involving the neon-labeled beverages shot up from about 10,000 to more than 20,000. Most of those cases involved teens or young adults, according to a survey of the nation's hospitals released late last week by the Substance Abuse and Mental Health Services Administration. The report doesn't specify which symptoms brought people to the emergency room but calls energy drink consumption a "rising public health problem" that can cause insomnia, nervousness, headache, fast heartbeat and seizures that are severe enough to require emergency care. Several emergency physicians said they had seen a clear uptick in the number of patients suffering from irregular heartbeats, anxiety and heart attacks who said they had recently downed an energy drink. More than half of the patients considered in the survey who wound up in the emergency room told doctors they had downed only energy drinks. In 2011, about 42 percent of the cases involved energy drinks in combination with alcohol or drugs, such as the stimulants Adderall or Ritalin. "A lot of people don't realize the strength of these things. I had someone come in recently who had drunk three energy drinks in an hour, which is the equivalent of 15 cups of coffee," said Howard Mell, an emergency physician in the suburbs of Cleveland, who serves as a spokesman for the American College of Emergency Physicians. "Essentially he gave himself a stress test and thankfully he passed. But if he had a weak heart or suffered from coronary disease and didn't know it, this could have precipitated very bad things." The findings came as concerns over energy drinks have intensified following reports last fall of 18 deaths possibly tied to the drinks — including a 14-year-old Maryland girl who died after drinking two large cans of Monster Energy drinks. Monster does not believe its products were responsible for the death. Two senators are calling for the Food and Drug Administration to investigate safety concerns about energy drinks and their ingredients. The energy drink industry says its drinks are safe and there is no proof linking its products to the adverse reactions. Late last year, the FDA asked the U.S. Health and Human Services to update the figures its substance abuse research arm compiles about emergency room visits tied to energy drinks. The Substance Abuse and Mental Health Services Administration's survey was based on responses it receives from about 230 hospitals each year, a representative sample of about 5 percent of emergency departments nationwide. The agency then uses those responses to estimate the number of energy drink-related emergency department visits nationwide. The more than 20,000 cases estimated for 2011 represent a small portion of the annual 136 million emergency room visits tracked by Centers for Disease Control and Prevention. The FDA said it was considering the findings and pressing for more details as it undertakes a broad review of the safety of energy drinks and related ingredients this spring. "We will examine this additional information ... as a part of our ongoing investigation into potential safety issues surrounding the use of energy-drink products," FDA spokeswoman Shelly Burgess said in a statement. Beverage manufacturers fired back at the survey, saying the statistics were misleading and taken out of context. "This report does not share information about the overall health of those who may have consumed energy drinks, or what symptoms brought them to the ER in the first place," the American Beverage Association said in a statement. "There is no basis by which to understand the overall caffeine intake of any of these individuals — from all sources." Energy drinks remain a small part of the carbonated soft drinks market, representing only 3.3 percent of sales volume, according to the industry tracker Beverage Digest. Even as soda consumption has flagged in recent years, energy drinks sales are growing rapidly. In 2011, sales volume for energy drinks rose by almost 17 percent, with the top three companies — Monster, Red Bull and Rockstar — each logging double-digit gains, Beverage Digest found. The drinks are often marketed at sporting events that are popular among younger people such as surfing and skateboarding. From 2007 to 2011, the most recent year for which data was available, people from 18 to 25 were the most common age group seeking emergency treatment for energy drink-related reactions, the report found. "We were really concerned to find that in four years the number of emergency department visits almost doubled, and these drinks are largely marketed to younger people," said Al Woodward, a senior statistical analyst with the Substance Abuse and Mental Health Services Administration who worked on the report. Emergency physician Steve Sun said he had seen an increase in such cases at the Catholic hospital where he works on the edge of San Francisco's Golden Gate Park. "I saw one young man who had mixed energy drinks with alcohol and we had to admit him to the hospital because he was so dehydrated he had renal failure," Sun said. "Because he was young he did well in the hospital, but if another patient had had underlying coronary artery disease, it could have led to a heart attack."

Federal study: ER visits related to highly caffeinated drinks up tenfold

The American Beverage Association, which represents the drink makers, attacked the federal report.

CHICAGO — Emily Marchant had a can of Red Bull at her elbow as she went over an assignment in a Harper College library carrel. She is a long-standing fan of the beverage, she said, usually drinking one a day when she needs a boost.

But she also knows what it’s like to take it too far. Two years ago, she said, she was a designated driver for pub-hopping friends in England when she absent-mindedly downed four of the drinks. She ended up with a bad case of the shakes that lasted for hours.

“Yeah,” she said, “that didn’t work out so good.”

Marchant, 21, of Lake in the Hills, Ill., recovered, but according to a federal report, some energy drink fans haven’t been so lucky: Emergency room visits involving the beverages have risen tenfold in the U.S. since 2005. While many of the visits were the result of combining energy drinks with alcohol or drugs, 56 percent were due to the consumption of energy drinks alone.

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The report, issued last month by the federal Substance Abuse and Mental Health Services Administration, is the latest piece of criticism directed at the fast-growing, multibillion-dollar energy drink industry. Some researchers and physicians say the beverages, which typically contain copious amounts of caffeine, are unhealthy for young people.

“The kids are coming in with heart palpitations, lightheadedness, dizziness, feeling faint and headaches,” said Dr. Todd Zimmerman, medical director of EmergiKids for the Alexian Brothers Health System. “Then we go through the history, and it turns out they’re drinking up to eight to 12 of these drinks a day.”

The American Beverage Association, which represents the drink makers, attacked the federal report, saying it did not account for the overall health of the people who had supposedly downed energy drinks. It said the cases — 13,114 in 2009, the latest year reported — accounted for a tiny percentage of the nation’s 123 million yearly ER visits.

The association also contended that mainstream energy drinks have half the caffeine of an equivalent-size cup of coffee. Some researchers, though, compare them to soft drinks, which the Centers for Disease Control and Prevention have found to be much more popular than coffee among teens.

A report this year in the journal Pediatrics found that energy drinks have about three times as much caffeine as colas, not including the caffeine contained in additives such as guarana, yerba mate and cocoa. The report concluded that the drinks “may put some children at risk for serious adverse health effects.”

The beverage association says energy drinks are not intended for young consumers, but Zimmerman said the pediatric emergency units at the St. Alexius and Alexian Brothers medical centers in the northwest suburbs see at least two patients a week with symptoms they attribute to the beverages. The drinks, he said, have become a crutch for teens who think they need a jolt.

“I’ve heard lots of different reasons: ‘It gets me up for the game, gives me energy for school, keeps me awake during school hours,”‘ he said. “I’ve seen, relatively recently, adolescents taking them because it will curb their appetites, which is another extremely dangerous thing.”

Art Kubic, a pharmacist at the Illinois Poison Center, said 60 of its 81,000 calls last year were related to energy drinks. He said caffeine overdoses can produce a range of unpleasant symptoms.

“If it’s something where they’re feeling a little sick to their stomach and have thrown up, we’ll say avoid any sources of caffeine, other stimulants, nasal decongestants, then follow up in a couple of hours,” he said. “If those more concerning symptoms develop — palpitations, multiple vomiting, fast heart rate — we’d be more likely to send them (to a hospital).”

Dr. Tom Scaletta, medical director of the emergency department at Naperville, Ill.’s Edward Hospital, said the cases he has seen typically involve teens mixing energy drinks with booze.

“The thought was that they would be able to consume more alcohol because the caffeine push was keeping them awake,” he said. “Then they get into the levels that are more dangerous. … They’re unarousable because of the amount of alcohol they’ve drank.”

The federal study found that 44 percent of the emergency room visits resulted from patients combining energy drinks with alcohol or drugs. Males were more likely to pair the beverages with alcohol or illicit drugs, while females were more likely to drink them with pharmaceuticals.

Psychiatric researchers at Johns Hopkins University have suggested that the government consider greater regulation of energy drinks, saying the beverages’ relatively high levels of caffeine can be troublesome for “youthful and inexperienced” consumers.

Daniel Evatt, a Johns Hopkins researcher who has studied caffeine dependence, said warning labels might be a good idea, especially since energy drink marketing — often with images of skateboarding, BMX racing and other “extreme” sports — seems designed to appeal to young people who might not have a large tolerance for caffeine.

“Caffeine is the most commonly used psychoactive drug in the world,” he said. “Many people do use it without any problems at all. But anytime you’re talking about a drug, that can have problems associated with it.”

— — —

WAKING UP TO CAFFEINE

A few years ago, when Illinois Institute of Art student Alex Smyth was a hard-core competitive video gamer, caffeine was the elixir that fueled his all-night Halo rampages. He chugged a dozen energy drinks a day and never felt any ill effects, he said.

“I love caffeine,” said Smyth, 21, who has since moved on to coffee. “It makes me live.”

He’s far from alone in his affection for the world’s most beloved stimulant: In North America alone, some research has concluded, up to 90 percent of adults say they consume caffeine regularly. Yet for centuries, it has been occasionally attacked as an unhealthy — even immoral — substance.

Consider coffee, a potent caffeine delivery system. According to coffee trader and historian Antony Wild’s book “Coffee: A Dark History,” the beverage was first widely consumed in the 15th century by Yemeni Sufis, mystic adherents of Islam who depended on coffee to stay awake for nighttime rituals.

But by 1511, after the drink had arrived in Mecca, some had become suspicious. Kah’ir Bey, ruler of the city, banned coffee after a long debate about its spiritual purity. The decree, however, didn’t last long: When the coffee-loving Ottoman Empire conquered the region in 1517, Wild writes, two doctors who had supported the ban were chopped in two at the waist.

Coffee criticism, though, continued to surface in the Middle East and eventually Europe, where the drink caught on in the 17th century. In his coffee history, “Uncommon Grounds,” author Mark Pendergrast writes that some Englishwomen in 1674 issued a manifesto blasting “the Excessive use of that Newfangled, Abominable, Heathenish Liquor called Coffee, which … has so (unmanned) our Husbands and Crippled our more kind gallants.”

More challenges came in the 20th century, when caffeine became a crucial part of the nascent soft drink industry. In 1911, the federal government sued Coca-Cola for selling a beverage that contained the supposedly harmful ingredient. Ludy Benjamin, who chronicled the lawsuit for the American Psychological Association, wrote that while the company lost the case, it was not forced to remove caffeine from its product.

The U.S. Food and Drug Administration took another hard look at caffeine in 1980 and initially proposed eliminating it from soft drinks. Soda companies countered that it was a “flavor enhancer” that should be allowed, and the agency eventually agreed.

“If caffeine had not been accepted as a flavor enhancer, but had been regarded as a psychoactive ingredient, soft drinks might have been regulated by the FDA as drugs,” wrote a trio of Johns Hopkins University scholars, summing up the controversy in a 2009 research paper.

In the aftermath, the FDA suggested a caffeine level for soft drinks of 0.02 percent, or 71 mg per 12 fluid ounces, the researchers said. But FDA spokesman Douglas Karas said that amounts to guidance, not a hard rule. Officially speaking, caffeine is “generally recognized as safe,” and so far, the agency has not gone after energy drink makers whose beverages far exceed the 0.02 percent level.

Karas added, though, that the FDA continually monitors scientific research for signs that ingredients might be causing health problems. Asked if the agency was looking into energy drinks, he declined to comment.

“We don’t telegraph our actions or anything like that,” he said.

ER visits after energy drinks double since 2007

A new federal government survey suggests the number of people seeking emergency treatment after consuming energy drinks has doubled nationwide during the past four years, the same period in which the supercharged drinks have surged in popularity in convenience stores, bars and on college campuses.

From 2007 to 2011, the government estimates the number of emergency room visits involving the neon-labeled beverages shot up from about 10,000 to more than 20,000. Most of those cases involved teens or young adults, according to a survey of the nation's hospitals released late last week by the Substance Abuse and Mental Health Services Administration.

The report doesn't specify which symptoms brought people to the emergency room but calls energy drink consumption a "rising public health problem" that can cause insomnia, nervousness, headache, fast heartbeat and seizures that are severe enough to require emergency care.

Several emergency physicians said they had seen a clear uptick in the number of patients suffering from irregular heartbeats, anxiety and heart attacks who said they had recently downed an energy drink.

More than half of the patients considered in the survey who wound up in the emergency room told doctors they had downed only energy drinks. In 2011, about 42 percent of the cases involved energy drinks in combination with alcohol or drugs, such as the stimulants Adderall or Ritalin.

"A lot of people don't realize the strength of these things. I had someone come in recently who had drunk three energy drinks in an hour, which is the equivalent of 15 cups of coffee," said Howard Mell, an emergency physician in the suburbs of Cleveland, who serves as a spokesman for the American College of Emergency Physicians. "Essentially he gave himself a stress test and thankfully he passed. But if he had a weak heart or suffered from coronary disease and didn't know it, this could have precipitated very bad things."

Concerns over energy drinks have intensified following reports last fall of 18 deaths possibly tied to the drinks - including a 14-year-old Maryland girl who died after drinking two large cans of Monster Energy drinks. Monster does not believe its products were responsible for the death.

Two senators are calling for the Food and Drug Administration to investigate safety concerns about energy drinks and their ingredients.

The energy drink industry says its drinks are safe and there is no evidence linking its products to the adverse reactions.

Late last year, the FDA asked the U.S. Health and Human Services Department to update the figures its substance abuse research arm compiles about emergency room visits tied to energy drinks.

The SAMHSA survey was based on responses from about 230 hospitals each year, a representative sample of about 5 percent of emergency departments nationwide. The agency uses those responses to estimate the number of energy drink-related emergency department visits nationwide.

The more than 20,000 cases estimated for 2011 represent a small portion of the annual 136 million emergency room visits tracked by Centers for Disease Control and Prevention.

The FDA said it was considering the findings and pressing for more details as it undertakes a broad review of the safety of energy drinks and related ingredients this spring.

"We will examine this additional information ... as a part of our ongoing investigation into potential safety issues surrounding the use of energy-drink products," FDA spokeswoman Shelly Burgess said in a statement.

Beverage manufacturers fired back at the survey, saying the statistics were misleading and taken out of context.

"This report does not share information about the overall health of those who may have consumed energy drinks, or what symptoms brought them to the ER in the first place," the American Beverage Association said in a statement. "There is no basis by which to understand the overall caffeine intake of any of these individuals - from all sources."

Energy drinks remain a small part of the carbonated soft drinks market, representing only 3.3 percent of sales volume, according to the industry tracker Beverage Digest. Even as soda consumption has flagged in recent years, energy drinks sales are growing rapidly.

In 2011, sales volume for energy drinks rose by almost 17 percent, with the top three companies - Monster, Red Bull and Rockstar - each logging double-digit gains, Beverage Digest found. The drinks are often marketed at sporting events that are popular among younger people such as surfing and skateboarding.

From 2007 to 2011, the most recent year for which data was available, people from 18 to 25 were the most common age group seeking emergency treatment for energy drink-related reactions, the report found.

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The DAWN Report: Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern

This Drug Abuse Warning Network (DAWN) short report is about emergency department visits involving energy drinks (beverages containing caffeine and vitamins/minerals) from 2007 to 2011.

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Major Increase Seen in Emergency Room Visits Involving Energy Drinks

Get the latest news from our field

The number of emergency room visits related to energy drinks jumped from 2005 to 2009, according to a new government report . The Substance Abuse and Mental Health Services Administration (SAMHSA) found more people are combining energy drinks with drugs and alcohol.

According to Reuters , the report found the number of hospital visits linked to energy drinks rose more than tenfold, from 1,128 in 2005, to 13,114 in 2009. SAMHSA said 52 percent of visits made by 18- to 25-year-olds involved combinations of energy drinks with alcohol or other drugs.

The report found 64 percent of hospital visits involving energy drinks were made by males; visits by males were more likely than visits by females to involve a combination of energy drinks and alcohol or illicit drugs. Visits by females were more likely to involve energy drinks combined with pharmaceuticals.

The report notes that energy drinks are flavored beverages that contain high amounts of caffeine. They usually have other additives, such as herbal supplements, vitamins, or guarana, a plant product that contains concentrated caffeine. The high doses of caffeine in the drinks act as a stimulant on the central nervous system and cardiovascular system.

The amount of caffeine in an energy drink can range from 80 to more than 500 milligrams, compared with about 100 milligrams in a five-ounce cup of coffee, or 50 milligrams in a 12-ounce cola, the report states.

“Energy drinks used in excess or in combination with alcohol or drugs can pose a serious health risk,” SAMHSA Administrator Pamela S. Hyde said in a news release , which notes that combining energy drinks with substances of abuse increases the risk of serious, even life-threatening injury, as well as the likelihood that a person will engage in risky behaviors such as driving under the influence.

Mithra Salmassi

Educational Content Editor

December 2011

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How do you help patients who show up in the ER 100 times a year?

Leslie Walker

Dan Gorenstein

The hope was that bringing many other services to people with high needs would stabilize their health problems. While the strategy has succeeded sometimes, it hasn't saved money. Douglas Sacha/Getty Images hide caption

The hope was that bringing many other services to people with high needs would stabilize their health problems. While the strategy has succeeded sometimes, it hasn't saved money.

Larry Moore, of Camden, N.J, defied the odds — he snatched his life back from a spiral of destruction. The question is: how?

For more than two years straight, Moore was sick, homeless and close-to-death drunk — on mouthwash, cologne, anything with alcohol, he says. He landed in the hospital 70 times between the fall of 2014 and the summer of 2017.

"I lived in the emergency room," the 56-year-old remembers. "They knew my name." Things got so bad, Moore would wait for the ER nurses to turn their backs so he could grab their hand sanitizer and drink it in the hospital bathroom.

"That's addiction," he says.

Then, in early 2018, something clicked, and turned Moore around. Today, he's more than five-years sober with his own apartment, and he has only needed the ER a handful of times since 2020. He's active in his church and building new relationships with his family.

Moore largely credits the Camden Coalition , a team of nurses, social workers and care coordinators for his transformation. The nonprofit organization seeks out health care's toughest patients — people whose medical and social problems combine to land them in the ER dozens of times a year — and wraps them in a quilt of medical care and social services. For Moore, that meant getting him medical attention, addiction treatment and — this was key for him — a permanent place to live.

"The Camden Coalition, they came and found me because I was really lost," Moore says. "They saved my life."

For two decades, hospitals, health insurers and state Medicaid programs across the country have yearned for a way to transform the health of people like Moore as reliably as a pill lowers cholesterol or an inhaler clears the lungs. In theory, regularly preventing even a few $10,000-hospital-stays a year for these costly repeat customers could both improve the health of marginalized people and save big dollars.

Larry Moore (left) in 2020 with staff members from the Camden Coalition. The housing and addiction treatment the organization helped him get has been life saving. Dan Gorenstein/Tradeoffs hide caption

Larry Moore (left) in 2020 with staff members from the Camden Coalition. The housing and addiction treatment the organization helped him get has been life saving.

But breaking this expensive cycle — particularly for patients whose lives are complicated by social problems like poverty and homelessness — has proved much harder than many health care leaders had hoped. For example, a pair of influential studies published in 2020 and 2023 found that the Coalition's pioneering approach of marrying medical and social services failed to reduce either ER visits or hospital readmissions . Larry Moore is the outlier, not the rule.

"The idea that someone should go to the emergency room 100 times in a year is a sign of deep, deep system dysfunction," says Jeff Brenner, the primary care physician who founded and led the Camden Coalition from 2002 until 2017. "It should be fixable. We're clearly still struggling."

Yet, Brenner and others on the frontlines of one of health care's toughest, priciest problems say they know a lot more today about what works and what misses the mark. Here are four lessons they've learned:

Lesson 1: Each patient needs a tailored, sustained plan. Not a quick fix

The Camden Coalition originally believed that just a few months of extra medical and social support would be enough to reduce the cycle of expensive hospital readmissions. But a 2020 study published in the New England Journal of Medicine found that patients who got about 90 days of help from the Coalition were just as likely to end up back in the hospital as those who did not.

That's because, frontline organizations now realize, in some cases this wraparound approach takes more time to work than early pioneers expected.

"That 80th ER visit may be the moment at which the person feels like they can finally trust us, and they're ready to engage," says Amy Boutwell, president of Collaborative Healthcare Strategies , a firm that helps health systems reduce hospital readmissions. "We do not give up."

Frontline groups have also learned their services must be more targeted, says Allison Hamblin , who heads the nonprofit Center for Health Care Strategies, which helps state Medicaid agencies implement new programs. Organizations have begun to tailor their playbooks so the person with uncontrolled schizophrenia and the person battling addiction receive different sets of services.

Larry Moore, for example, has done fine with a light touch from the Coalition after they helped him secure stable housing. But other clients, like 41-year-old Arthur Brown, who struggles to stay on top of his Type 1 diabetes, need more sustained support. After several years, Coalition community health worker Dottie Scott still attends doctor's visits with Brown and regularly reminds him to take his medications and eat healthy meals.

Aaron Truchil, the Coalition's senior analytics director, likens this shift in treatment to the evolution of cancer care, when researchers realized that what looked like one disease was actually many and each required an individualized treatment.

"We don't yet have treatments for every segment of patient," Truchil says. "But that's where the work ahead lies."

Lesson 2: Invest more in the social safety net

Another expensive truth that this field has helped highlight: America's social safety net is frayed, at best.

The Coalition's original model hinged on the theory that navigating people to existing resources like primary care clinics and shelters would be enough to improve a person's health and simultaneously drive down health spending.

Over the years, some studies have found this kind of coordination can improve people's access to medical care , but fails to stabilize their lives enough to keep them out of the hospital. One reason: People frequently admitted to the hospital often have profound, urgent needs for an array of social services that outstrip local resources.

As a result of this early work, Hamblin says, state and federal officials — and even private insurers — now see social issues like a lack of housing as health problems, and are stepping in to fix them. Health care giants like insurers UnitedHealthcare and Aetna have committed hundreds of millions of dollars to build affordable housing, and private Medicare plans have boosted social services , too. Meanwhile, some states, including New York and California, are earmarking billions of Medicaid dollars to improve their members' social situations, from removing mold in apartments to delivering meals and paying people's rent .

Researchers caution that the evidence so far on the health returns of more socially focused investments is mixed — further proof, they say, that more studies are needed and there's no single solution that works for every patient.

Some health care experts also still question whether doctors and insurers are best positioned to lead these investments, or if policymakers and the social service sector should drive this work instead.

Lesson 3: Recent boom in new programs demands better coordination

This spike in spending has led to a wave of new organizations clamoring to serve this small but complex population, which Hamblin says can create waste in the system and confusion for patients.

"All of these barriers to entry and handoffs don't work for traumatized people," former Coalition CEO Brenner says. "They're now having to form new, trusting relationships with multiple different groups of people."

Streamlining more services under a single organization's roof is one possible solution. Evidence of that trend can be seen in the nationwide growth of clinics called Certified Community Behavioral Health Clinics, These clinics deliver mental health care, addiction treatment and even some primary care in one place.

Brenner, who now serves as CEO of the Jewish Board, a large New York City-based social service agency with a budget of more than $200 million a year, is embracing this integration trend. He says his agency is building out four of that newer type of behavioral health clinic, and offering clients housing on top of addiction treatment and mental health care.

Other groups, including the Camden Coalition, say simply getting neighboring care providers to talk to one another can make all the difference. Coalition head Kathleen Noonan estimates the organization now spends just 25% of its time on direct service work and the rest on quarterbacking, helping to coordinate and improve what she calls the "local ecosystem" of providers.

Lesson 4: Rethink your definition of success, and keep going

Twenty years ago, the goal of the Camden Coalition was to help their medically complex patients stay out of the E.R. and out of the hospital — provide better health care for less cost. Noonan, who took over from Jeff Brenner as CEO of the Coalition, says they've made progress in providing better care, at least in some cases — and that's a success. Saving money has been tougher.

"We certainly don't have quick dollars to save," Noonan says. "We still believe that there's tons of waste and use of the [E.R.] that could be reduced ... but it's going to take a lot longer."

Still, she and others in her field do see a path forward. As they focus on improving their patients' mental and physical health by developing and delivering the right mix of interventions in "the right dose," they believe the cost savings may ultimately follow, as they did in Larry Moore's case.

The stakes are high. Today, homelessness and addiction combined cost the U.S. health care system north of $20 billion a year, wreaking havoc on millions of Americans. As health care delivery has evolved in the last two decades, the question is no longer whether to address people's social needs, but how best to do that.

This story comes from the health policy podcast Tradeoffs . Dan Gorenstein is Tradeoffs' executive editor, and Leslie Walker is a senior reporter/producer for the show, where a version of this story first appeared. Tradeoffs' weekly newsletter brings more reporting on health care in America to your inbox.

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IMAGES

Energy Drinks Continue to be Linked to Emergency Room Visits
Energy Drinks Blamed For Boost In Emergency Room Visits : The Salt : NPR
The DAWN Report: Update on Emergency Department Visits Involving Energy
Energy Drink Emergency Room Visits Continue to Increase
ER visits tied to energy drinks double, study suggests
The DAWN Report: Update on Emergency Department Visits Involving Energy

COMMENTS

Energy Drink-Associated Electrophysiological and Ischemic Abnormalities: A Narrative Review
Energy drinks are an increasingly utilized niche in the beverage market and are gaining popularity in recent years, especially among teenagers and young adults. An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to the consumption of energy drinks.
Update on Emergency Department Visits Involving Energy Drinks: A
The majority of energy drink-related ED visits involved either adverse reactions 8 or misuse or abuse of drugs 9; other reasons are not presented because they represent less than 5 percent of visits.In each year from 2007 to 2011, visits involving adverse reactions were about twice as commonly reported as visits involving misuse or abuse.
Update on Emergency Department Visits Involving Energy Drinks: A
In each year from 2007 to 2011, there were more patients aged 18 to 39 than patients in other age groups; the largest increase was seen among patients aged 40 or older, for whom visits increased 279% from 1,382 visits in 2007 to 5,233 visits in 2011. In 2011, 58% of energy drink-related ED visits involved energy drinks only; the remaining 42% ...
The Link Between Energy Drinks and ER Visits
In a prominent study over four years, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) found a ten-fold increase in hospital-related emergency room visits due to energy drink consumption. People aged 18-24 had the highest number of ER visits, followed by those aged 26-39. Almost half of the energy drink abuses had ...
Caffeine Can Kill: the Dangers of Energy Drinks
Last year, there were more than 20,000 emergency room visits attributable to the ingestion of energy drinks - following a 2011 government report that expressed real concern about the emerging ...
Update on Emergency Department Visits Involving Energy Drinks: A
Consumption of energy drinks is a public health concern because a growing body of scientific evidence documents harmful health effects of energy drinks, particularly for children, adolescents, and young adults. Methods: National estimates of Emergency Department (ED) visits involving energy drinks were analyzed using data from the 2005 to 2011 ...
Energy drink-related ER visits doubled in 4 years
Energy drink-related ER visits doubled in 4 years. January 16, 2013 / 5:09 PM EST / AP. SAN FRANCISCO A new government survey suggests the number of people seeking emergency treatment after ...
Energy Drink-Associated Electrophysiological and Ischemic ...
An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to energy drinks. In this review, we summarized available published literature assessing electrophysiological and ischemic adverse effects associated with energy drink consumption. Overall, 32 case reports and 19 clinical trials are ...
Impact of High Volume Energy Drink Consumption on Electrocardiographic
Introduction. Energy drinks are a growing industry with a market value predicted to reach $61 billion by 2021. 1 It is estimated that about 30% of teenagers between the ages of 12 through 17 years in the United States consume energy drinks on a regular basis. 2 A study of military personnel found that nearly 45% of deployed service members consumed at least 1 energy drink per day with 14% ...
PDF rug buse arning Network The DAWN Report
1 in 10 Energy Drink-Related Emergency Department Visits Results in Hospitalization. Energy drinks are more popular than ever.1 In addition to containing vitamins and other additives, these flavored beverages may contain up to 5 times more cafeine than a typical cup of cofee.1 High amounts of cafeine can cause health problems such as insomnia ...
More than 10 percent of emergency room visits involving energy drinks
More than 10 percent of emergency room visits by people age 12 or older for problems involving energy drinks are serious enough to result in hospitalization, the federal government warned this week.
The Trouble with the "Energy Drink Related ER Visits" Stat
Notable Details. Roughly 42% of the hospital visits had to do with combinations of energy drinks and alcohol or other drugs. In other words, almost half of these energy drink-related ER visits had to do with energy drinks and bad decisions. So let's dive into what this all means. THREE - We've got the news and the science.
Effects of energy drinks on the cardiovascular system
Along with a growing global market, emergency room visits due to the consumption of energy drinks have increased as well. The Substance Abuse and Mental Health Services Administration revealed that 20783 people visited the emergency department with complaints involving caffeine rich energy drinks in 2011. ... Energy drinks often contain a large ...
More Emergency Visits Linked to Energy Drinks
In 2011, there were 20,783 reported emergency room visits in which an energy drink was cited as the primary cause of or a contributing factor to a health problem, compared with 10,068 in 2007 ...
Frontiers
An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to energy drinks. In this review, we summarized available published literature assessing electrophysiological and ischemic adverse effects associated with energy drink consumption. Overall, 32 case reports and 19 clinical trials are included in this review. Ventricular arrhythmia ...
Energy Drinks Blamed For Boost In Emergency Room Visits
They found that energy drink-related visits rose from 10,068 in 2007 to 20,783 in 2011. That's out of more than 1 million drug-related ER visits, the agency says. Before 2007, energy drink ...
Report Finds Spike In Energy Drink-Related Emergency Room Visits
Report Finds Spike In Energy Drink-Related Emergency Room Visits. January 16, 2013 / 8:39 PM EST / CBS New York. NEW YORK (CBSNewYork) -- Energy drinks are the fastest growing segment of the ...
PDF Update on Emergency Department Visits Involving Energy Drinks: A
exceeded 10,000. The number of ED visits involving energy drinks doubled from 10,068 visits in 2007 to 20,783 visits in 2011. From 2007 to 2011, increases did not always occur annually, but an overall upward trend was evident. The majority of energy drink-related ED visits involved either adverse reactions8 or misuse or abuse of drugs9;
ER Visits Tied to Energy Drinks Double Since 2007
The number of people who visited an emergency room for health concerns tied to energy drinks has doubled from 10,068 in 2007 to more than 20,000 in 2011, according to a new government survey ...
Federal study: ER visits related to highly caffeinated drinks up
Marchant, 21, of Lake in the Hills, Ill., recovered, but according to a federal report, some energy drink fans haven't been so lucky: Emergency room visits involving the beverages have risen ...
ER visits after energy drinks double since 2007
Late last year, the FDA asked the U.S. Health and Human Services Department to update the figures its substance abuse research arm compiles about emergency room visits tied to energy drinks.
The DAWN Report: Update on Emergency Department Visits Involving Energy
This Drug Abuse Warning Network (DAWN) short report is about emergency department visits involving energy drinks (beverages containing caffeine and vitamins/minerals) from 2007 to 2011.
Major Increase Seen in Emergency Room Visits Involving Energy Drinks
The number of emergency room visits related to energy drinks jumped from 2005 to 2009, according to a new government report.The Substance Abuse and Mental Health Services Administration (SAMHSA) found more people are combining energy drinks with drugs and alcohol.
How do you help patients who show up in the ER 100 times a year?
"The idea that someone should go to the emergency room 100 times in a year is a sign of deep, deep system dysfunction," says Jeff Brenner, the primary care physician who founded and led the Camden ...
Energy drinks show 'damaging' effects on young adults, multiple studies
Pasch found in her last study on energy drinks that a lower GPA was associated with energy drink consumption. A total of 844 first-year undergraduates in 2016 participated in this study.