In the past decade, alcohol screening and early intervention in clinical settings have received increasing attention from substance use and public health researchers. This holds important implications for trauma centers. Research shows that serious injuries and trauma-related fatalities resulting from suicide, fire, firearms, stabbings, falls, drowning, domestic violence, and motor vehicle crashes (driver, passenger, and pedestrian) can be directly linked to alcohol misuse.1 Such research has prompted the National Highway Traffic and Safety Administration to set a high priority on decreasing alcohol-related motor vehicle crash injuries.2 Currently, motor vehicle crashes are the leading cause of death up to age 49, with alcohol involved in many of these deaths. The median blood alcohol concentration (BAC) of drivers in fatal crashes is 0.16 mg/dL. Approximately 33 to 37% of all motor vehicle crashes involve drug- or alcohol-impaired drivers. Moreover, it is now recognized that most alcohol-impaired injured patients are binge drinkers, not alcoholics.
Binge drinking is generally defined as the consumption of five or more alcoholic beverages on any given occasion.3 Because this level of drinking usually results in acute intoxication, which impairs judgment and motor skills, binge drinking is strongly associated with alcohol-impaired driving and resultant alcohol-related deaths.4 In a recent review of binge drinking among adults in the United States, Naimi et al.5 found that this behavior is on the rise, increasing from 6.3 to 7.4 episodes per person each year, with the most frequent incidence found among adults aged 18 to 25 years. Overall, 47% of all binge-drinking episodes occur among those who are not heavy drinkers; further, 73% of all binge drinkers can be classified as moderate drinkers. Fourteen percent of all binge drinkers admit to driving while impaired by alcohol compared, compared with only 1% of non-binge drinkers. Clearly, binge drinking is closely associated with alcohol-impaired driving and substantially increases the risk of motor vehicle crashes.6 This study, in combination with results of other studies, has led to evidence-based recommendations that focus on curbing the effects of binge drinking to reduce deaths from alcohol-impaired driving.7
Trauma centers are uniquely positioned to address the problem of alcohol-impaired driving because many alcohol-impaired patients are admitted after motor vehicle crashes. As increasing evidence continues to demonstrate the efficacy of motivational interventions in reducing alcohol consumption among hazardous drinkers, trauma centers are being recognized as ideal sites to implement alcohol screening, intervention, and referral programs. Despite this opportunity, most trauma centers do not offer such services.1 On May 28–30, 2003, the Centers for Disease Control and Prevention National Center for Injury Prevention and Control sponsored a national conference in Arlington, Va, entitled ‘Alcohol Problems among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism.' During plenary discussions, conference participants identified effective clinical methods for reducing the adverse impact of alcohol and other drug use on trauma patients and addressed related substance-use policy issues that affect trauma centers. Although those in other fields and disciplines may perceive barriers to implementing alcohol screening and intervention programs in trauma centers differently, this article discusses real and mythical barriers to implementing such programs from the trauma surgeon's perspective.
SCREENING AND INTERVENTION PROGRAMS
To successfully implement an alcohol screening and intervention program, trauma centers must first identify injured persons who have substance-use problems and then provide treatment to prevent future high-risk behaviors and injury. There are four essential elements of such a program: 1) identifying injured patients with high-risk alcohol and drug behavior; 2) providing interventions that reliably reduce the incidence of that behavior; 3) following-up to sustain behavior change; and 4) demonstrating that behavior change improves patient outcomes and benefits society.
Realistic barriers to intervention programs include defining the target population, encouraging the target population to accept treatment, providing effective treatment, collecting follow-up data to show that sustained treatment affects overall outcomes, obtaining program resources, and increasing the priority of these programs in trauma centers. These barriers can be further categorized as invalid assumptions, inadequate or variable definitions, patient barriers, operational barriers, practitioner barriers, leadership barriers, and resource barriers.
The idea that trauma centers can participate effectively in alcohol prevention programs is based on the assumptions that high-risk substance use can be defined, identified, and treated. Many trauma surgeons are skeptical that these assumptions are valid. Part of the problem stems from false assumptions that the target population comprises hard-core alcoholics, rather than moderate drinkers who participate in binge drinking. Research must carefully define the target population so that trauma surgeons can identify appropriate candidates for intervention.
Inadequate or Variable Definitions
Patients, health care workers, insurers, alcohol and drug researchers, and trauma center directors may not agree on the definition of high-risk alcohol use or drug use. There are various levels of substance use, ranging from hard-core dependence to complete abstinence. However, most alcohol and drug users lie between these extremes. For example, those who consume alcohol fall into the following five categories: 1) underage drinkers; 2) drinkers who exercise moderation; 3) hazardous drinkers who engage in activities while drinking that place them at risk; 4) harmful drinkers who have experienced alcohol-related adverse events (sometimes repeatedly); and 5) drinkers with various comorbid conditions that affect their response to alcohol.
Which group should be identified as the target population for a trauma center intervention? Inadequate or variable definitions of hazardous drinking make it difficult to answer this question. For example, multiple studies offer several definitions of hazardous drinking. Which definition provides a suitable threshold?
* More than 14 drinks per week for men and 7 drinks per week for women?8
* More than 3 drinks per day for men and 2 for women at least once within the previous 30 days?9
* Regular drinking of more than 162 g (6 oz) of absolute alcohol per week for men and 82 g for women?10
* Drinking to intoxication, which is more than 1.05 g/kg of absolute alcohol for men and 0.90 g/kg for women?11
The difficulty in applying these definitions is illustrated in a study by Gijbers et al.12 Only one third of screened intoxicated drivers who registered a BAC of 0.15 or higher were thought to have an alcohol-related disorder. It is difficult to reconcile this conclusion with the definition of a hazardous drinker as one who drinks three drinks on any given occasion. How can 67% of those with a BAC more than 0.15 not have an alcohol problem? Although this extreme example may be outdated by today's standards, it points out the need for realistic and practical definitions of hazardous drinking that can be applied to the trauma center population. Recent examples of the variable definitions used in research studies to define a drink and levels of drinking behavior were reviewed by Dufour.13 Their research demonstrates the difficulty of generalizing the results from one study to different populations.
The apparent lack of a universally accepted definition of the target population is a major barrier to implementing alcohol screening and intervention programs in trauma centers. The most logical target population in a trauma center would include patients who are injured while participating in hazardous alcohol use or drug-related behavior. Routine BAC testing and urine toxicology screens for illicit drugs can easily identify this population. Although intoxicated patients are often seen in trauma centers, severely dependent drinkers make up a minority (albeit, a highly memorable minority) of admissions. These dependent drinkers are often repeat patients, who typically have a history of failed therapy and who are unlikely to respond well to brief interventions.14 A more realistic target population comprises at-risk drinkers, defined as nondependent drinkers, who occasionally drink to intoxication and participate in dangerous behavior, such as driving under the influence of alcohol.15 At-risk drinking refers to a level of alcohol consumption or pattern of drinking that, if it persists, increases the risk of harm to the drinker. Specific limits for nonhazardous drinking should identify the frequency (number of drinking occasions per week) and intensity (number of standard drinks per occasion) of drinking that are not likely to result in harm to the individual. Such limits have not been agreed upon by experts. However, once consensus on these limits is reached, the goal of any intervention should be moderate drinking below the specific evidenced-based threshold. Unfortunately, research has been unable to establish a threshold for the general population below which there is no alcohol-related harm. Therefore, most guidelines and recommendations cannot really be considered evidence based. A consensus among experts, however, would help build credibility for any given set of recommendations. The National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health has set guidelines for determining the levels of consumption at which drinkers are at increased risk to develop alcohol-related problems.16 For men, the level is no more than an average of two drinks per day or no more than four drinks per occasion. For women, it is no more than an average of one drink per day or no more than three drinks per occasion.
Another guideline published by the U.S. Department of Health and Human Services and U.S. Department of Agriculture defines moderation as no more than one drink per day for women and no more than two drinks per day for men.17
Most patients in trauma centers do not believe they have a drinking problem, but they do understand the consequences of a diagnosis of substance abuse or dependency. Therefore, they are unlikely to admit to having a substance use problem or to accept an intervention if diagnosis or treatment will lead to legal or economic difficulties. Federal regulations protecting confidentiality of drug- and alcohol-abuse information in medical records apply only to specialized programs in which the primary function is to provide treatment or referral for an a1cohol- or drug-related diagnosis.18 Consequently, trauma center screening and intervention programs must be carefully designed to protect patient confidentiality.
All trauma center patients who have sustained an injury associated with a positive BAC or toxicology screen should be considered candidates for an intervention. The ideal candidates are patients, who as a direct result of their injury, actively seek assistance with changing their pattern of consumption. Through intervention, trauma center staff can increase the patient's awareness of the negative consequences of their alcohol use and increase the likelihood that the patient will take action to change behavior.
If screening and intervention programs are to be effective in trauma centers, they must be designed to screen virtually all patients in the target population and provide effective treatment to those who screen positive. Dunn et al.19 demonstrate the difficulty of achieving this goal. In their study, 397 patients who did not participate in an intervention program were selected for screening and follow-up. Only 101 of the 397 patients could be captured by the study for the following reasons: 54 patients could not speak English, 37 patients were too severely injured to participate, 76 patients were discharged before consent could be obtained, 55 patients were unavailable because they were in the operating room or radiology, 19 patients were incarcerated, 29 patients declined to participate, and 10 patients consented but were discharged before they could be interviewed. Furthermore, of the 101 patients who could be interviewed, 37 were BAC-positive, 27 admitted drinking three or more drinks at least four times in the previous month, 16 screened as moderately dependent on alcohol, and 5 screened as severely dependent on alcohol. At the end of 1 year, 12 patients admitted to drug or alcohol problems, and 6 patients received some type of treatment. This study demonstrates that it is possible to target many patients for intervention. However, without some kind of intervention, the study shows that patients do not readily admit to having a drug or alcohol problem, and few seek treatment. Trauma centers are inherently busy places. Patients are frequently unavailable for screening or an intervention because treatment of their injuries takes precedence. After treatment and discharge, outpatient follow-up is usually performed by individual specialists, primary care physicians, or health care workers within a health maintenance organization. Screening and intervention programs will not be effective unless these programs are considered an integral part of trauma care.
A study by Peters et al.20 illustrates the potential barriers trauma surgeons may encounter when implementing alcohol- and drug-screening intervention programs. Nurses who worked in a British hospital were trained to screen all patients admitted to the emergency room, to offer feedback, and to administer an alcohol intervention to screen positive patients. An interim analysis revealed that only 20% of the 4,663 patients eligible for the study were appropriately screened. Of the screened patients, 19% were hazardous drinkers. Only 41% of the patients with a positive screen for hazardous drinking received feedback and were offered an intervention. Furthermore, only 12% of patients who were provided feedback and offered an intervention accepted it. In the final analysis, only 13 (0.3%) of the 4,663 patients were entered into the treatment trial; consequently, the study was aborted. When asked why the success rate was so poor, the nurses suggested several factors: lack of resources, lack of time, inadequate training, poor morale, lack of patient acceptance, and no perceived benefit of the intervention.21
Committed leadership is essential to the success of screening and intervention programs in trauma centers. Screeners and interventionists must believe in the program's effectiveness. The program must also be presented in such a way that it is acceptable to most patients, and interventionists must have adequate training, presented in a standardized format, so that all trauma centers are using similar methodology. Additionally, interventionists must have sufficient time to conduct screening and intervention on all patients. Obviously each trauma center must have the resources to hire and train a sufficient number of interventionists.
Recent studies by Schermer et al.22 show that many of these barriers can be overcome. One study employed dedicated research assistants who screened 114 of the 163 at risk patients (70%) using the short Alcohol Use Disorders Identification Test. Fifty-one patients (45%) screened positive for problematic alcohol use. Only 1% refused screening. Of the 49 patients who were not screened, 14 did not speak English, 19 had injuries precluding interaction, and 16 were missed for a variety of other reasons. When patients were asked if the screening was acceptable to them, 94% agreed that someone from the trauma team should talk with patients about alcohol. A subsequent study conducted by Schermer et al.23 in several large trauma centers demonstrates that a short screening tool and intervention are acceptable to patients and can be effective. However, resources for the screening and intervention were provided by a grant. Refinements of screening techniques may help patients and practitioners overcome the barriers previously mentioned.
Public safety programs come at a price. Implementing screening and intervention programs in trauma centers will require well-trained screeners and interventionists who are available 7 days a week, with a staffing ratio that allows them to see all patients admitted to the trauma service. Follow-up programs must be available to patients, specifically to those with severe dependence problems. Many intoxicated patients who sustain only mild injuries are observed in the emergency department (ED) until they sober up and are discharged without being admitted to the trauma service. If the intent is to screen this population, screeners and interventionists must be available 24 hours a day. Also, researchers must have accessible long-term outcomes data to ensure that the intervention is successful. Otherwise, improvements above the modestly successful results that are to be anticipated will not occur. All of this must be accomplished with little to no reimbursement from third-party payers. In fact, some insurance companies have clauses in their policies that allow denial of alcohol-related injury claims. Finally, in an era of diminishing financial resources for health care, all programs must compete at the ‘value added' level for scarce health care dollars.
The Los Angeles Trauma System has 13 trauma centers that collectively admit about 15,000 adult patients each year. Approximately, 15% of the adult patient population screen BAC positive (9–27% across the various trauma centers), and treatment costs exceed $50 million dollars a year. If insurance companies refuse to pay for alcohol-related treatment, the loss of revenue will be catastrophic to the trauma-care system. This possibility creates an almost insurmountable barrier to implementing screening and intervention programs. Consider a 2003 article in the Los Angeles Times that disclosed a $75 million deficit in the health care budget for one of its county's health care programs, including the trauma-care system.24 Currently, there are likely no new dollars for the system because the state has its own budgetary problems. Options to close the budget gap include shutting down the county rehabilitation hospital, closing 100 beds at the largest county trauma center, or cutting public safety programs.
In the current economic environment, new screening and intervention programs in trauma centers for patients misusing substances will be included only if they add significant value to health care. This comes at a time when it is becoming more difficult to maintain a trauma center system capable of managing acute patient injuries.
What justification is there for establishing alcohol and drug intervention programs in trauma centers? Fleming et al.25 analyzed the cost-to-benefit ratio of screening and brief intervention of problem drinkers in a primary care setting. The intervention group showed a significant decrease in alcohol consumption and use of ED and hospital services. Further, there was a slight downward trend in crime and motor vehicle crashes. The estimated cost of the intervention program was $80,210 for 382 patients, or $205 per patient. Patient health care was estimated to be $195,448 less in the intervention group ($629 per patient) than for patients who did not participate in an intervention. The total cost benefit of the intervention was $423,519 ($1,151 per patient). After comparing the average cost of $205 for the intervention to the estimated cost benefit of $1,151, the net cost benefit was $947 per patient. The benefit-to-cost ratio was 5.6:1. All patients in this study belonged to a managed care organization that paid for screening and intervention ($166 per patient). The cost benefit to the managed care organization for decreasing health care costs was $523 per patient, producing a benefit-to-cost ratio of 3.2:1.
These data would be viewed differently from the trauma center perspective. Unlike a managed care organization, the trauma center would bear the intervention costs, but would not see the economic benefit from decreased use of health care. Trauma centers are interested in treatments that benefit their patients, but somebody has to bear the expense. In reality, trauma center costs for screening and intervention are not reimbursed, so there is no economic incentive for the trauma center to perform these services. To overcome this significant barrier, those who benefit most (i.e., society and insurance companies) should provide the resources to implement alcohol and drug screening and intervention programs in trauma centers. Such a program has been funded and instituted in San Diego County and may serve as a model for the future dissemination of screening and intervention programs to other trauma centers.26 Unfortunately, county funding for this program has recently been withdrawn. However, the program is continuing with federal funding and is developing other sources of public and private financing (personal communication).
PUBLIC HEALTH APPROACH TO INTERVENTIONS
Given the operational problems inherent in the care of the injured trauma patient, what types of interventions are appropriate for a trauma center? Brief motivational interviews? Referral programs? Intensive counseling programs? Inpatient rehabilitation? Long-term outpatient rehabilitation programs? Although many of these programs are effective, brief motivational interviews are the most realistic method of intervention for a trauma center.
Is there sufficient evidence to support allocating additional resources and personnel to conduct brief intervention? Do interventions reduce high-risk alcohol-related behavior? Some researchers believe that empirical support for brief interventions does not need further conceptual verification and recommend moving beyond clinical trials to national dissemination with the focus on successfully adapting proven intervention techniques to ED and trauma center settings.27 Moreover, these researchers advocate the use of a public health approach, which addresses the full spectrum of problem severity in the target population.
To apply the public health approach to screening and intervention programs, four conditions must be met: 1) there must be a reliable screening method to identify patients with the target condition; 2) the natural history and risk factors of the condition must be understood, and the population at risk should be defined; 3) the screening method must be valid, cost-effective, easy to administer, and acceptable to both providers and the target population; and 4) the target population should be managed with the appropriate treatment.28 Much progress has been made to meet the first three conditions, but skepticism remains regarding appropriate treatment for patients who misuse alcohol and drugs.
Studies on Intervention Programs
Few studies have actually tested an alcohol interventional program in trauma centers. One study of an emergency surgical ward by Forsberg et al.29 is often referenced to support the efficacy of brief motivational interventions. Of 563 patients admitted to an emergency surgical ward who were screened, 186 (32%) were found to have alcohol problems. The 186 patients were randomized either to a 30-minute intervention or to extended counseling; 165 patients met the high-risk criteria of an average weekly consumption of absolute alcohol (> 162 g) or drinking to intoxication (1.05 g/kg). There were no significant differences in the success rates of brief intervention and extended counseling; consequently, the outcome data for the two groups were combined. The study demonstrates that brief interventions can potentially reduce alcohol consumption among patients at least as well as more costly counseling. Modest effects were noticed at the end of 12 months: average daily use of alcohol decreased from a baseline of 1.14 g/kg (4.1 ounces of absolute alcohol for a 100-kg man) to 0.99 g/kg (3.5 ounces of absolute alcohol for a 100-kg man); the peak alcohol consumption decreased from 2.3 g/kg (8 ounces of absolute alcohol for a 100-kg man) at baseline to 2.0 g/kg (7.0 ounces for a 100-kg man); and weekly consumption decreased from 133 to 106 g.
Statistically, these interventions have significantly reduced alcohol consumption for over 1 year among patients in an emergency surgical ward. However, the clinical relevance of these reductions in high-risk drinking is questionable. When patients were interviewed at 6- and 12-months after the intervention and were asked whether their alcohol consumption was more, the same, or less than the baseline, 16% of the patients said they were consuming less than they did before the intervention; however, 32% reported an increase in alcohol consumption. Forty-six percent of patients claimed to have more sober days than before the intervention, but 47% admitted to having fewer sober days than before the intervention. Furthermore, 71% of patients claimed to have fewer episodes of intoxication than they did before the intervention, which may be a relevant finding. At the 6- and 12- month follow-up, 15% of at-risk patients no longer met the at-risk criteria. Of the patients who initially did not meet at-risk criteria, it is not known how many patients met at-risk criteria at 6- and 12-months. Although this study demonstrates that brief interventions can decrease alcohol consumption among some patients over a 12-month period, the results do not convincingly demonstrate a clinically important reduction in alcohol consumption or a reduction in alcohol consumption less than hazardous drinking levels.
Another study cited to substantiate the importance of screening and intervention in an ED setting is that by Runge.30 In that study, 2,787 ED patients were screened for alcohol problems using the TWEAK, a mnemonic for the screening tool that identifies potential alcohol problems. Three hundred ninety patients (14%) screened positive for high-risk use. A randomized controlled trial placed 195 patients in the intervention group and the remainder in a control group. Fifty-four patients in the intervention group (28%) agreed to further evaluation, and 27 patients (14%) actually received follow-up by alcohol treatment professionals, the outcome of which is not reported. Although this study shows that 14% of patients who screened positive were successfully identified and were referred for treatment, only 27 of 2,787 patients screened (1%) actually obtained treatment. Restated, only 27 of 390 high-risk patients (7%) received treatment. These accomplishments are rather minimal given the effort required to screen 2,787 patients. This study demonstrates a very low patient acceptance rate for treatment referral and a lack of outcome data on patients that accept referral. Perhaps early brief motivational interventions administered in trauma centers would have a better chance for success. Furthermore, determining intervention outcomes once patients have left the trauma center is essential to evaluation of these programs, and the lack of this information presents a significant barrier.
Opinions on the eventual success of alcohol treatment programs vary considerably. Recent randomized trials show that a decrease in alcohol consumption can be expected in both control and treatment groups.31 Randomized trials of untreated patients demonstrate an average abstinence rate of 21% at follow-up and a mean decrease in alcohol consumption from 37 to 31 drinks per week (a 14% decrease). However, the mean consumption remains considerably larger than the hazardous drinking level. In contrast, the outcome of patients treated in randomized trials demonstrates an abstinence rate of 35% at follow-up, with a decrease in mean alcohol consumption to 18 drinks per week, which is a reduction in consumption of 50%, but the mean alcohol consumption still remains more than the hazardous drinking level at 14 drinks per week.30 More relevant, yet not reported in these studies, is the proportion of drinkers who decrease less than the hazardous level.
Gentilello et al.15 performed one of the few alcohol intervention studies of trauma center patients. They screened 2,524 patients in a Level I trauma center with 1,153 patients (46%) screening positive for high-risk alcohol use; 366 patients were randomized to an intervention group, and 396 were randomized to a control group. At the end of 1 year, alcohol consumption decreased in the intervention group by 22 drinks per week compared with the control group's decrease of 7 drinks per week. Unfortunately, neither the baseline nor the level of alcohol consumption at the end of 1 year was reported in this study, so it is difficult to determine whether either group decreased alcohol consumption to less than the threshold for hazardous drinking. Moreover, it is not clear that the proportion of drinkers drinking at hazardous levels decreased. The study also revealed that 10% of the control patients and 5% of the intervention patients at the 1-year follow-up had sustained a repeat injury requiring treatment in a trauma center ED or hospital. There was a 47% reduction in injuries requiring ED admission at 1 year and a 48% reduction in injuries requiring hospital admission during 3 years. In the 3-year follow-up, 5% of control patients and 3% of intervention patients had sustained an injury that resulted in readmission to a hospital. Therefore, the study showed a decrease in injury recidivism in the intervention group, but the absolute level of trauma recidivism was small, and the difference between the groups was not statistically significant. This study clearly demonstrates that a brief alcohol intervention decreases alcohol consumption at 1 year among trauma center patients who screen positive for hazardous drinking. However, the data are not present to demonstrate whether the decrease was below the hazardous drinking level or whether there was a significant reduction in the proportion of patients drinking less than the hazardous level.
Several studies conducted in the primary care setting demonstrate that problem drinkers benefit from brief intervention. Fleming et al.32 performed a prospective randomized trial of a brief intervention among 382 control patients and 392 intervention patients. Follow-up at 1 year showed a significant decrease in alcohol consumption. The percentage of patients in the intervention group who drank excessively in the previous 7 days decreased from 48% (160 patients) at baseline to 18% (60 patients) at 1-year follow-up. The proportion of intervention patients who engaged in binge-drinking episodes in the previous 30 days decreased from 288 patients (85%) at baseline to 188 patients (56%). For men in the intervention group, the mean number of drinks in the previous 7 days decreased significantly from 22 at baseline to 14 at the 1-year follow-up compared with 22 at baseline and 17 at the 1-year follow-up among men in the control group. The mean number of binge-drinking episodes among men in the previous 30 days decreased significantly from 6.1 at baseline to 3.4 in the intervention group and 5.4 to 4.5 in the control group. The study demonstrates that the intervention decreased alcohol consumption to a mean level under the hazardous drinking cutoff and decreased binge-drinking episodes by 50%. It also shows the intervention group as having fewer alcohol-related motor vehicle crashes. There were 25 crashes in the intervention group compared with 37 in the control group. Additionally, there were 46 traffic violations in the intervention group; 52 traffic violations in the control group; and 7 citations for driving under the influence in the intervention group compared with 6 citations in the control group. Within the intervention group, this study demonstrates an overall significant decrease in hazardous drinking, with a trend toward decreased alcohol-related motor vehicle crashes. It must be acknowledged, however, that this study was performed in a primary care setting where physicians typically develop long-term relationships with their patients. The trauma center is a much different environment. No study of this quality has been performed in trauma center settings.
Dinh-Zarr et al.33 reviewed all randomized trials that measured the effect of alcohol interventions on problem drinking and injury risk. Nineteen trials measured injury outcomes. Although results varied, the study does show a strong correlation between interventions and potential reduction in the incidence of alcohol-related injuries and the behaviors leading to these injuries. Admittedly, the authors acknowledge a lack of current data from which to draw firm conclusions.
Data supporting the efficacy of screening and brief intervention methods in trauma centers are only moderately convincing. With few exceptions, most results are modest at best and not sustained.33,34 Despite reported results, one can argue that intervention clearly reduces alcohol consumption among high-risk drinkers. At a minimum, this represents a starting point for learning how to improve the efficacy of interventions. Advocates of the public health approach argue that the benefits of interventions are similar to those gained in treatment programs for diabetes and hypertension. In these programs, antihypertension medications and insulin have made significant improvements in controlling patient disease, despite the noncompliant behavior of many patients. McLellan et al.35 make a compelling argument that alcohol and drug dependence and the respective treatment options follow similar courses as other chronic illnesses (such as type 2 diabetes mellitus, hypertension, and asthma).
Although trauma center physicians have higher priorities than to provide alcohol and drug interventions, they need to support the process. Trauma social workers and case managers have proven themselves effective as interventionists in some trauma centers and are obvious candidates for administering screening and intervention programs. In a national survey conducted by Nathens et al.,36 trauma center directors were asked what they considered to be the top 10 research priorities for trauma centers. The priorities listed included traumatic brain injury, resuscitation from shock, spinal cord injury, multiple organ failure, deep venous thrombosis and pulmonary embolism, nutrition, and extremity injuries. Although alcohol problems ranked well below these conditions at number 10, these problems were acknowledged to be a higher priority than some traditional issues, e.g., tracheotomy and resuscitation in the field with hypertonic saline. In addition, 50% of trauma center directors ranked alcohol intervention programs as being ‘very important.' Only 6 of the top 16 items were deemed ‘very important' by 50% or more of trauma center directors. Although patient injuries clearly remain the trauma surgeon's top priority, there is still much to be learned about how to effectively treat patients with alcohol-related injuries.
However, the trauma social worker sees patients who, in addition to suffering injury, have just undergone great crises, jeopardizing their futures, their families, and their jobs. The trauma social worker's main priority is to build up patients, their families, and their social environment so that patients are able to return to productive and meaningful lives. Within that context, substance misuse is a high priority, and the trauma social worker should be willing to try any new intervention that could decrease the negative consequences of substance misuse.
Social work services in trauma centers need adequate staffing. Trauma social workers need patient follow-up opportunities, patient acceptance, adequate treatment resources, and standardized and proven protocols. Most important, they need to be assured of patient confidentiality. Patients who are labeled substance abusers face many potential consequences, including loss of insurance coverage to treat injuries, future insurability, loss of employment, loss of their driver's license, and legal problems (if their BAC or toxicology results are reported to the police). Reporting patients to the authorities because they are injured or have caused an injury because of hazardous alcohol use is contrary to the trauma social worker's mission and goals.
There are many barriers to implementing interventions for substance problems in trauma centers. Although the condition has been defined to the satisfaction of some specialties, the trauma surgeon can benefit from a clearer understanding of the three classifications of problem drinkers (hazardous, harmful, and dependent) and the goals of intervention. Intervention goals are variable and must be clearly defined to identify a realistic target population that can be effectively treated with a brief, inexpensive intervention. Anticipated results of screening and treatment programs are modest and must be improved upon. Appropriate resources must be allocated to implement these programs but not at the expense of other high-priority acute care and rehabilitation efforts. Follow-up outcome data must be acquired and incorporated into any intervention program to ensure continued improvement in program efficacy and to help patients maintain changed behaviors. Only then will the benefits of such programs be known and continued improvements become reality. Barriers to intervention can be overcome and resources can be found to introduce these important screening and intervention programs into the nation's trauma centers.
1. Gentilello LM, Donovan DM, Dunn CW, Rivara FP. Alcohol interventions in trauma centers current practice and future directions. JAMA.
2. Runge W. Screening and intervention for alcohol problems in the emergency department: ideal versus reality. In: Hungerford DW, Pollock DA, eds. Alcohol Problems Among Emergency Department Patients: Proceedings of a Research Conference on Identification and Intervention.
Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2002.
3. Wechsler H, Austin SB. Binge drinking: the 5-4 measure. J Stud Alcohol.
4. Centers for Disease Control (CDC). Alcohol-related mortality and years of potential life lost-United States, 1987. MMWR Morb Mortal Wkly Rep.
5. Naimi TS, Brewer RD, Mokdad A, Denny C, Seurdula MK, Marks IS. Binge drinking among US adults. JAMA.
6. Liu S, Siegel PZ, Brewer RD, Mokdad AH, Sleet DA, Serdula M. Prevalence of alcohol impaired driving. JAMA.
7. Centers for Disease Control and Prevention. Motor vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol impaired driving. MMWR Morb Mortal Wkly Rep.
8. US Department of Health and Human Services and US Department of Agriculture (USDA). Nutrition and Your Health: Dietary Guidelines for Americans.
4th ed. Washington, DC: US Department of Agriculture; 1995. Home and Garden Bulletin 232.
9. McLellan AT, Kushner H, Metzger D, et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat.
10. Ashley MJ, Ferrence R, Room R, Rankin J, Single E. Moderate drinking and health: report of an international symposium. CMAJ.
11. Babor TF, Grant M. Project on Identification and Management of Alcohol-Related Problems: Report on Phase II—A Randomized Clinical Trial of Brief Intervention in Primary Health Care.
Vol 5. Geneva, Switzerland: World Health Organization;1992.
12. Gijbers A, Raymond A, Whelan G. Does blood alcohol level of 0.15 or more identify accurately problem drinkers in a drunk-driver population? Med J Aust.
13. Dufour MC. What is moderate drinking? Alcohol Res Health.
14. Gentillelo LM, Rivera FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risks of injury recurrence. Ann Surg.
15. Babor TF. Avoiding the horrid and beastly sin of drunkenness: does discussion make a difference? J Consult Clin Psychol.
16. National Institute on Alcohol Abuse and Alcoholism. The Physician's Guide to Helping Patients with Alcohol Problems.
Washington, DC: US Department of Health and Human Services; 1995. NIH publications 95-3769.
17. US Department of Health and Human Services. Healthy People 2010.
Vol I. 2nd ed. Washington, DC: US Government Printing Office; 2000.
18. Li G. Comment on detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff [editorial]. J Trauma.
19. Dunn C, Zatzick D, Russo J, et al. Hazardous drinking by trauma patients during the year after injury. J Trauma.
20. Peters J, Brooke C, McCabe C, Short N. Problems encountered with opportunistic screening for alcohol-related problems in patients attending an accident and emergency department. Addiction.
21. Brooker C, Peters J, McCabe C, Short N. The views of nurses to the conduct of a randomized controlled trial of problem drinkers in an accident and emergency department. Int J Nurs Stud.
22. Schermer CR, Bloomfield LA, Lu SW, Demarest OR. Trauma patient willingness to participate in alcohol screening and intervention. J Trauma.
23. Schermer CR. Feasibility of alcohol screening and brief intervention. J Trauma.
24. Fox S. Options are few in health dilemma. Los Angeles Times.
May 24, 2003; California metro section: 1.
25. Fleming MR, Mundt MP, French MT, Manuel LB, Stauffacher EA, Barry KL. Benefit cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care.
26. Community Health Improvement Partners-Substance Abuse Work Team. Best Practices and Cost Benefit of Substance Abuse Prevention in Health Care Settings: A White Paper.
San Diego, CA: Community Health Improvement Partners; 2000.
27. Gentilello LM. Implementing preventive interventions in emergency medicine: strategic considerations. In: Hungerford DW, Pollock DA, eds. Alcohol Problems Among Emergency Department Patients: Proceedings of a Research Conference on Identification and Intervention.
Atlanta, Ga: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2002.
28. Morrison AS. Screening in Chronic Disease.
2nd ed. New York, NY: Oxford University Press; 1992.
29. Forsberg L, Ekman S, Halldin J, Roennberg S. Brief interventions for risk consumption of alcohol at an emergency surgical ward. Addict Behav.
30. Runge J, Garrison H, Hall W, Waller A, Shen G. Identification and referral of impaired drivers through emergency department protocols [report online]. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration. February 2002. Report No.: DOT HS 809412. Available at: http://www.nhtsa.dot.gov/people/injury/research/Idemergency/index.htm#Contents
. Accessed February 1, 2005.
31. Moyer A, Finney JW. Outcomes of untreated individuals involved in randomized trials of alcohol treatment. J Subst Abuse Treat.
32. Fleming MR, Mundt MP, French MT, Manuel LB, Stauffacher EA, Barry KL. Benefit cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care.
33. Dinh-Zarr T, Diguiseppi C, Heitman E, Roberts I. Preventing injuries through interventions for problem drinking: a systematic review of randomized controlled trials. Alcohol Alcohol.
34. Poikolainen K. A nice try that fails: the Swedish Council on Technology Assessment in Health Care (SBU) evaluation of the effect of treatment of alcohol and drug problems—the epidemiologists view. Alcohol Alcohol.
35. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA.
36. Nathens AB, Rivara FP, Jurkovich GJ, Maier RV, Johansen JM, Thompson DC. Management of injured patients: identification of research topics for systematic review using the Delphi Technique. J Trauma.
© 2005 Lippincott Williams & Wilkins, Inc.