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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000174904.24315.e5
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Controlling Alcohol Problems among Hospitalized Trauma Patients

Maier, Ronald V. MD, FACS

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From the University of Washington Harborview Medical Center, Seattle, Washington.

Submitted for publication March 25, 2005.

Accepted for publication April 20, 2005.

This article was written for the proceedings from a conference entitled Alcohol Problems among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism, in Arlington, Virginia, May 28–30, 2003. It does not reflect the official policy/opinions of the participating agencies, the U.S. Department of Health and Human Services, or the Centers for Disease Control and Prevention, and does not constitute an endorsement of the authors or their programs by the Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services, or the federal government, and none should be inferred.

Address for reprints: Ronald V. Maier, MD, FACS, Box 359796 Harborview Medical Center, 325 9th Avenue Seattle, WA 98104-2499; email: ronmaier@u.washington.edu.

Alcohol intoxication is the leading risk factor for injury. It is a well-established fact that alcohol consumption contributes to unintentional and intentional injury and to mortality overall.

This relationship, documented since ancient Egypt, has only become more defined and ingrained in modern society. It has been demonstrated that most of the U.S. population frequently consumes alcohol. In fact, a 1996 national survey revealed that approximately one half the populace had used alcohol within the previous 30 days and that two thirds of those over 12 years of age reported annual use of alcohol.1

Alcohol’s effect on individual reaction times and judgment leads to the major cause of alcohol-induced injury–motor vehicle crashes. In older adults, alcohol is frequently a factor in unintentional injury such as pedestrian and fall-related injuries. Furthermore, intentional injury brought on by the dissociative, antisocial, and disruptive behaviors induced by alcohol and drug abuse have been associated with intentional injury from homicide and suicide.2 In approximately one third of intentional interpersonal injuries involving strangers, alcohol is a key factor; the percentage rises to two thirds in episodes where individuals suffer injury at the hands of an intimate partner. Of individuals currently incarcerated, nearly 40% used alcohol at the time the crime was committed.3

Alcohol and illicit drug consumption is now the third leading preventable cause of death in the United States, accounting for approximately 100,000 deaths annually.3,4 In addition to alcohol’s direct lethal effects, it often contributes to comorbidities that can lead to significant morbidity or early mortality. The statistics are even more alarming for our youth—alcohol and drug use are associated with their leading causes of death (i.e., unintentional and intentional injury resulting from motor vehicle crashes, suicide, and homicide).5–7

Of more than 20 million adults requiring emergency department care for injuries in the year 2000,8 it is estimated that 27% would screen positive for alcohol use disorders or intoxication.9 Of more than 150,000 trauma-related deaths per year, nearly one half the unintentional trauma—two thirds of overall mortality—is attributable to motor vehicle crashes. Thus, consider these dismal statistics. For more than 20 years, alcohol has been consistently linked in 40% to 50% of deaths resulting from motor vehicle crashes; 20% to 70% of deaths caused by occupational and domestic incidents, fires, and drowning; and approximately 50% to 60% of deaths attributable to intentional injuries. In addition to these depressing statistics, commonly abused drugs such as marijuana and cocaine have been implicated in 18% of motor vehicle crash-related fatalities.

To combat America’s injury epidemic, trauma care systems have steadily improved over the past 30 years; such improvements include the development of highly successful Level I and Level II trauma centers throughout the United States. However, these improvements in care have not reduced the incidence of trauma-related deaths that occur at the scene (approximately 50%). These numbers will change only when prevention efforts are increased.

Despite significant overall improvement in trauma care—including documented increases in survival rates and decreases in long-term morbidity—trauma professionals have devoted little effort to preventing a major cause of severe injury and repeat injury: the misuse of alcohol and drugs. Harborview Medical Center, a Level I regional trauma center for the northwestern United States (an area encompassing four states and one fourth of America’s landmass), has had a long standing interest in breaking this lethal chain of events. In association with Harborview’s Injury Prevention Center and federal research funding, it has investigated various components of the alcohol-induced injury epidemic and has tested the validity of proposals for intervention and prevention. On the basis of these intervention trials and those conducted elsewhere, brief alcohol (and, to a lesser extent, drug abuse) counseling sessions have reduced recidivism by 50% and have significantly reduced the number of binge drinking episodes and drinks consumed per week.12,13

These interventions have also reduced health care costs. Gentilello and colleagues recently documented that for each dollar spent on alcohol screening and intervention, $3.81 is saved in overall health care costs.9 Every high-level trauma center has an ethical obligation to develop an injury outreach program that emphasizes the prevention of alcohol- and drug-related recidivism.

Whatever the underlying causes of injury, both the trauma community and the public should be involved in injury prevention. For example, the health care worker can use “teachable moments” during the hospital visit to help the patient link drinking or drug use to negative consequences and, perhaps, the reason for the current hospitalization. Those involved in trauma care who are exposed daily to the devastation of injury must use their clinical experiences and their research data to educate the public, their strongest ally, and legislative leaders to deal with this epidemic. The public’s response may include calling for legislative approaches to restrict access to alcohol and drugs, particularly among underage persons, and to curb alcohol- and drug-impaired driving. It will take a united effort by government and nongovernment agencies and the public to successfully fight the injury epidemic.14 These proceedings describe the successes we have had thus far and consider the challenges and hurdles that lie ahead. We can use this information to impress on ourselves and our institutions the priority of this battle against wasted life. We can also use this information as a reminder that effective strategies already exist. These proceedings are a “must read” for those on the front lines who daily confront injury caused by alcohol and drug abuse.

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REFERENCES

1. Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMSA). National Household Survey on Drug Abuse: Main Findings, 1996 Rockville, MD: Department of Health and Human Services; 1998. Publication 98-3200.

2. Macdonald S, Cherpitel CJ, Borges G, Desouza A, Giesbrecht N, Stockwell T. The criteria for causation of alcohol in violent injuries based on emergency room data from six countries. Addict Behav. 2005;30:103–113.

3. National Institute on Alcohol Abuse and Alcoholism. Alcohol, violence, and aggression. Alcohol Alert. 1997;38:1–4.

4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238–1245.

5. National Institute on Alcohol Abuse and Alcoholism. Drinking and driving. Alcohol Alert. 1996;31:1–4.

6. Office of the Inspector General, US Department of Health and Human Services. Report to the Surgeon General, Youth and Alcohol: Dangerous and Deadly Consequences. Washington, DC: US Department of Health and Human Services; 1992.

7. White HR. Longitudinal perspective on alcohol use and aggression during adolescence. In: Galanter M, ed. Recent Developments in Alcoholism. Vol 13. New York: Plenum Press; 1997.

8. National Center for Injury Prevention and Control. WISQARSTM (Web-based Injury Statistics Query and Reporting System). Centers for Disease Control & Prevention. Available at: http://www.cdc.gov/ncipc/wisqars/wisqars/. Accessed March 1, 2005.

9. Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005;241:541–550.

10. Terhune KW, Ippolito CA, Hendricks DL, et al. The incidence and role of drugs in fatally injured drivers. Washington, DC: National Highway Traffic Safety Administration (NHTSA), Traffic Tech; 1992. Report DOT HS 808 065.
11. Rivara FP, Koepsell TD, Jurkovich GJ, Gurney JG, Soderberg R. The effects of alcohol abuse on readmission for trauma. JAMA. 1993;270:1962–1964.

12. Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230:473–483.

13. Dunn C, Zatzick D, Russo J, et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712.

14. Gentilello LM, Donovan DM, Dunn CW, Rivara FP. Alcohol interventions in trauma centers: current practice and future directions. JAMA. 1995;274:1043–1048.

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© 2005 Lippincott Williams & Wilkins, Inc.

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