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Journal of Trauma-Injury Infection & Critical Care:
doi: 10.1097/01.ta.0000177993.83688.36
Session 1

Session 1: Impact of Alcohol and other Drug Problems on Trauma Care—Discussion

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Submitted for publication June 8, 2005.

Accepted for publication June 10, 2005.

Discussion

This article was written for the proceedings from a conference called 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 or opinions of the Centers for Disease Control and Prevention (CDC) or the U.S. Department of Health and Human Services (HHS) and does not constitute an endorsement of the individuals or their programs—by CDC, HHS, or the federal government—and none should be inferred.

The editors of the proceedings prepared the following summary of participant comments made during the session.

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Basil Pruitt

We’ll now take questions from the audience. Yes, Dr. Schecter?

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Bill Schecter

First, I feel compelled to represent the ethnic minorities situated in the room. Dr. Trunkey should add WASPS to the list of ethnic minorities involved in the heroin trade. Second, I believe that the doctors who were unwilling to voluntarily report drinking problems have a point. The body politic has to make a decision that reporting is mandatory. Otherwise, you have an unfair situation. My wife, as the TB controller for San Francisco, had the power to force drug treatment and even to imprison patients with active tuberculosis if they didn’t take their medications because of the danger of spread to the general population. In a similar way, alcohol and drug addiction imperils other members of society for the reasons that we have spoken about this morning, but the body politic has to make this a job de jure to the physician, mind you. You can’t have the doctor, who is trying to care for the patient, be in a situation where reporting is based on personal judgment, when this is not a mandatory action de jure. I think it’s a failure of the legislature. Third, with regard to the destruction of the safety net in cities and the relationship of alcoholism and drug use to mental illness, most of the patients that I treat who suffer alcohol- and drug-use injuries are also impoverished, living on the streets. We treat them, and we discharge them to a street corner or to some lousy hotel for five days. Then they’re back out on the street. I think the public-health approach to this problem has to go way beyond this. We have to provide some kind of social structure for the people who can’t make it, who are exposed to both drugs and alcohol by people who are making a profit off of them.

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Donald Trunkey

The voluntary program I initiated did not work. Some surgeons and emergency physicians did not support it because they do not believe treatment works. I agree that reporting has to be a mandated program just like it is for communicable diseases. Although urban rot is a big problem, I do not agree that it is the main cause of alcohol and drug problems. As I tried to point out in that one slide, I think over 75% of people who abuse alcohol and drugs are employed. It’s a far bigger problem than we realize. And, until we do mandatory testing on these people, we won’t realize how serious it really is. I can tell you from working with the people at American Airlines, it’s a problem in their pilots, and it’s a problem in their flight attendants. Physicians—15% of anesthesiologists—abuse drugs. I think it’s a far bigger problem than we’re willing to acknowledge.

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Eugene Moore

The physician has a responsibility to report alcohol problems just like other diseases, not just to help the individual patient, but also to help others who might be harmed. In our city, social programs and programs for mental rehabilitation and for disadvantaged individuals are being dropped daily. This will escalate our problems with drugs and alcohol in our cities.

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Charles Lucas

The “alcohol problem” is a problem of societal acceptance and of profit. Our typical conference behavior is to go out to eat and drink, have good Italian wine, and then who drives everyone back to the hotel? Me, and I’ve had a generous amount of wine. Every surgeon in this room has probably done the same thing. In other countries, this is not permissible, so societal change is needed. Regarding drugs, I don’t think the problem is just a problem of poor people or access to treatment. When drugs are illegal, the real problem is the profit motive. We need to address the profit motive.

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Carl Soderstrom

It is becoming more acceptable for physicians to report individuals who have conditions like epilepsy, multiple sclerosis, or Alzheimer’s to state agencies that regulate the use of motor vehicles. I think we have to change the culture’s thinking about the word reporting. On medical wards or surgical wards, we don’t report somebody to a neurologist. We don’t report somebody to a cardiologist or a pulmonologist. We refer them. And it might be better if we embrace the mindset that when somebody demonstrates severe risk-taking behavior, reporting these individuals is actually “referring them to another agency.”

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Ronald Stewart

Are we talking about referring to law enforcement agencies or to treatment for the drug problem? I think you would have much less of a problem of getting physicians to report if it was for treatment. We don’t refer people to the police. That’s not something that I commonly do. I would refer someone for treatment, but many physicians may have a problem with treating the patient and then referring them to the police.

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Donald Trunkey

First, let me clarify my recommendation. There’s a paradox. I support reporting if the outcome is medical treatment. These patients have a medical disease. Currently, we’re required to report all stab and gunshot wounds to the police. So, there is a difference here.

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Ronald Stewart

I agree that hospitals may report patients to the police, but suspect that most surgeons do not. Reporting criminal behavior is a stumbling block for most surgeons. However, if you’re talking about referring the patient for treatment, you’ll find a lot of physicians who will support that.

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Donald Trunkey

This has not been my experience. There’s still the issue of violating patient trust, civil liberties. At least in the surgical community, we’re marked by a lot of conservative individuals who are concerned with the patient’s right to privacy.

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Ronald Stewart

I don’t believe that trauma surgeons and emergency physicians have bought into this notion that treating alcohol problems is like treating diabetes. People are sent home all the time without referral for treatment. There’s a reluctance to screen; there’s a reluctance to refer people for treatment. Surgeons I know have an underlying cynicism and skepticism about treatment for alcohol and drug problems. How do we go about changing their behavior and their way of looking at this problem?

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Charles Lucas

My simple approach is that if the alcoholic harms only himself, we recommend treatment. When the alcoholic crosses the line by breaking the law, reporting is mandatory.

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Eugene Moore

That’s an excellent point. Bill Schecter has already mentioned that we need societal change in terms of how we deal with many issues— including drug and alcohol. Broad-based education by individuals in this room like Carol Schermer, Larry Gentilello, and Carl Soderstrom has been ongoing for a decade now. Finally, we’re paying attention to them. We need to educate that brief intervention is effective, and we need to teach a motivational approach versus a confrontational approach to drug and alcohol problems. I’ve been part of the problem and so have many of us in trauma surgery. We need a whole different approach, but the way to get there is to educate ourselves about the tools and psychology of this approach. It’s a different approach than we’ve taken in the past decade.

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Anthony Meyer

I agree with Dr. Moore that managing patients who abuse alcohol or drugs is difficult, especially in the ICU where there are difficulties weaning patients from mechanical ventilation, or in extubating patients with altered mental status. The inability of these patients to participate in their own care is significant. There is a much higher incidence of tracheostomy for treatment of these patients than for the patient who does not have a substance-abuse problem. Another issue is HIPAA. Nobody really knows how HIPAA will be enforced. For mandated reporting, HIPAA should not be an obstacle, but it’s not clear how it will affect other types of reporting—prescribed reporting for example. It just depends on how the law is written. The degree of influence we exert on how these laws are written will determine whether any of our measures will be effective. Although patients with substance-use disorders can have a reasonable success rate when they pursue treatment, there are still too few treatment programs and too few patients who pursue treatment.

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Basil Pruitt

How should these laws be written?

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Donald Trunkey

To me, the Centers for Disease Control and Prevention should be the optimal place to report alcoholism and drug abuse because I believe alcoholism and drug addiction are diseases. And the primary reason for reporting should be to get good epidemiologic data. However, Tony has identified a problem we still have to solve—we don’t have enough people interested in treatment.

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Charles Lucas

I think the best thing that we could do, the government could do, to initiate a societal change would be to implement the laws that all drivers under the influence of alcohol go to jail and actually implement those laws so that the designated driver, the taxi systems, would become popular in America, and all of us wouldn’t be doing what all the surgeons in this room do all the time. When you go out to dinner and entertain, you drive under the influence of alcohol.

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Eugene Moore

I disagree with Charlie. We need to work to change the societal habits of alcohol consumption, and we need to divert sharply from punitive measures. Having boys in college, I’ve heard many stories about local police being given full access to college campuses where they raid private parties. Underage college students are caught, sentenced to mandatory community service, and their driver’s licenses are taken away. My boys and their friends tell me this does not have the intended effect. As with sex education, there should be broad-based educational programs in secondary schools and colleges involving the consequences of both drug and alcohol use—particularly alcohol use.

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Susan Nedza

The idea that screening is part of our responsibility I think is growing, and the place that it’s growing is in our academic centers. It’s in the place where we have people like Larry [Gentilello] or some of the other people that are here in the room who continually say, “Yes, you can treat,” and “Yes, people get better.”

Part of the problem is our narrow perspective. We see people who are recidivist generally, who never get better. In Chicago, where I practice, the alcoholics who are brought in every weekend to sleep in the emergency department in the winter are the ones we believe to have drinking problems. We need to expand this beyond the alcoholic, to the binge drinker, to the teenage drinker, to those who fall down the stairs and hurt themselves because they are intoxicated. Our shift has been toward prevention of all alcohol-related injuries, and probably one of the biggest challenges is that 99% of those people go home. They don’t get admitted to the hospital.

There is a lack of training for social workers, staff, and physicians in alcohol interventions. I recommend that the core curriculums in residencies be changed. Training should occur during hospital rounds and should be expanded beyond the idea of calling the police. Half the time, police show up at the end of your shift. Who wants to stay late when you’ve already worked 14 hours? In Illinois, we had a permissive law. No one reported, and this actually had a negative effect. Nobody drew alcohol levels; first of all, because nobody was going to pay for them, and second, they didn’t want to be involved in court and all the other issues. So the reporting issue isn’t “do we or don’t we?”—it’s to whom do we report? If it’s to DMV, there are programs.

With other diseases, we have medicines and treatments. When we screen our patients for drug and alcohol use they say, “Yeah doc, I’ve got a problem. What can I do?” We respond by calling the local program, which can’t enroll them for three months. We get very, very cynical, and stop screening. So as we approach this topic, we have to recognize the total demolition of the outpatient mental health and substance-abuse programs. We could screen all day long, but if we’ve got nowhere to refer people to, physicians will stop screening. It’s AA or nothing.

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Donald Trunkey

I agree with Susan completely. We just don’t have the available treatment programs anymore. I’ve been at Oregon Health Sciences University for almost 17 years, and I’ve never seen a psychiatrist on our ward—not once. If I ask for a psych consult, I usually get a nurse or a psychiatric aide, never a psychiatrist, and as far as I know, we still have an academic department there.

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Paul Cunningham

Our treatment centers are overwhelmed and under funded. We have been able to refer most of our patients who have been the victims of trauma and substance or alcohol use to a counselor. However, the outcome is blunted by the fact that they either have a delayed appointment or are never seen because the system is truly overwhelmed. The dark side of this business—illicit substances sold on the street—is huge. I really didn’t recognize this until we tried to do interventions within a small rural community. Very quickly after beginning those interventions, I was warned that if I didn’t mute my attempts, I could find myself at the bottom of the river. Decriminalization of drugs might be helpful.

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Charles Lucas

In Detroit, we’ve had one really good 17-week in-house program, which has a very low rate of recidivism. The problem has been getting individuals to take 17 weeks out of their lives; it has to be mandated by the court. To really have success, our courts must be involved.

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Peter Rostenberg

I have a much different background. I worked four years at Harlem Hospital Center in New York City, and I’ve been in private practice in internal medicine and addiction medicine for the past 25 years. We have a policy in my hospital where surgeons address positive blood-alcohol results as clinically important data. And they are required either to address that on the chart or get a consult. These are normal everyday surgeons who’ve had the same kind of experiences as many others across the country, in many other community hospitals. They love this policy. It makes sense to them. I think we’ve had situations in the past where physicians have acted as agents of the state. That hasn’t worked out well. Who says the police have better treatment services than anybody else? The recidivists that I see, DWI, go to jail and get no treatment. They come out the way they went in—dangerous.

There are very few clinical situations where somebody with an alcohol problem will be as receptive as someone coming to my office with a sore throat. Injury is one of them, so we should take advantage of the situation. We should always remember that we work for our patients. Let’s start to institute policies and procedures that make every hospital a kind of treatment center for alcohol and drugs. Not places where patients go knowing they’re going to be arrested or reported. Very possibly, they would avoid even coming to the hospital for treatment.

On the other hand, I once reported a guy who had an alcohol withdrawal seizure while taking off in a 747 as the co-pilot. I have also reported a public bus driver who did not want to go into treatment. Still, I just find it very difficult as a physician to see myself as an agent of the state when we have so many other wonderful opportunities to deal with this major problem.

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Michael Sise

Trauma surgeons are held accountable at a level that no other group of physicians is held accountable in the United States. Are we ready to hold ourselves as trauma directors accountable for working upstream on these issues? Should I know not only the number of my patients who are under the influence of drugs and alcohol when they’re injured, but also the rate of binge drinking at San Diego High School? It’s clear that as trauma directors we have one of the strongest voices in the community. As trauma directors, we can pick up the telephone and talk to the Chief of Police, the Mayor, the US Attorney, or just about anyone in the press and they will listen. Very few people in the community can do this. We’re stuck seeing the downstream effects day after day, night after night, which makes us very, very, very prejudiced when it comes to alcohol and drug problems. Yet the evidence is compelling that screening and brief intervention work. So, I guess we have to answer the question as a group: “What are trauma surgeons willing to answer for?”

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Donald Trunkey

I think you’re absolutely right. We are held to a higher level of accountability and credibility than any other practitioner in the medical profession. I think that is as it should be because we’ve been granted a franchise, and accountability was part of the original trauma system plan. I tend to agree with Gene [Moore] that as trauma surgeons we’ve got to get involved. Number one, we can’t practice trauma surgery and not recognize that drugs and alcohol are a terrible problem in our society. Education about drugs and alcohol should be part of our “Think First” and “Safe Kids” programs. We’ve got to reach the very young. Do we have to personally give lectures? No, but each of us are in a position to convince community leaders to support alcohol and drug education in the secondary schools. It’s just part of our civic duty.

I was disappointed to hear that some are no longer testing for alcohol and drug use in the emergency room and ICU. I test primarily to find out what other ravages I’m going to see downstream in that patient’s care. Knowing that the patient is under the influence of cocaine or alcohol influences my treatment. If I don’t start a program of withdrawal support and a patient gets DTs, mortality goes up. What should we do with this information if the primary disease is alcohol or drug abuse—not the injury?

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Charles Lucas

Mike [Sise], as a trauma director, you know that drug and alcohol screens of all seriously injured patients should be done for the reasons Don [Trunkey] just mentioned. Further, your trauma nurse coordinator should be supervising an injury prevention program, which generally addresses the topic of alcohol use at the high school level. This program should be coordinated with your San Diego County system of prevention. So yes, as a trauma director, you are indirectly responsible for all these activities.

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Larry Gentilello

Several speakers mentioned that they did not have a place to send patients who need treatment. We’re getting into what has been called “The Preventive Paradox”—a misconception that the person who is severely alcoholic is the one who needs treatment. It turns out that most of society’s problems that arise from excessive alcohol use do not come out of the alcoholic population. They come out of the population of people who just drink too much, like the case that Gene Moore talked to us about this morning (the group of high-school students who crashed their car after a party). Those teenagers don’t need a 28-day treatment program. Jeff Runge showed the peak age for impaired driving fatalities is 20 to 21 years of age, so these are not people with alcohol dependence. They are problem drinkers, binge drinkers, hazardous drinkers, or maybe alcohol abusers. Therefore, the absence of available treatment beds should not dissuade us, because even the placement criteria for alcohol treatment promulgated by the American Society of Addiction Medicine does not suggest that those people go to a treatment center. The type of interventions appropriate for these individuals are more limited, less intensive, and are totally consistent with the time and the staffing and the financial constraints of your trauma center.

For example, at Harborview, Chris Dunn does brief interventions. Harborview has over 6,000 trauma admissions per year, and he’s the only one who performs interventions. You would never send someone home from your trauma center with a fracture without having a physical therapist check to make sure that they’re not going to stumble with their crutches on their way out the door. Someone who doesn’t earn any more money than a physical therapist can handle the intervention load typical of a very busy urban trauma center—as does Chris. It is only the more severely impaired patient, the chronic alcoholic, and they are only a small minority of patients, who require access to a formal treatment center. We don’t necessarily need more treatment beds; we need more interest.

Gene Moore mentioned that we need to focus on education. But, education alone is often not enough. Despite widespread evidence of their effectiveness, and many attempts to educate care providers, beta-blockers are still not typically provided to patients after myocardial infarction. There have been many educational and professional society meetings on alcohol and injury that have discussed the need for interventions, and yet most centers do not provide them. So my question for the panelists, especially those who have helped in the development of our trauma system is, what can the American College of Surgeons do to enhance implementation? What can surgical professional societies do? What can surgical leadership do? I ask this question because I do not believe that education is enough.

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Eugene Moore

First of all, Larry, I recognize there’s been an abundance of educational opportunities for trauma surgeons; but frankly, after I returned from the stimulating meeting at Jackson Hole with you and Carol [Schermer], I learned that out of six attending trauma surgeons in our trauma center, I was the only one who knew anything about brief intervention. So, I started beating up poor residents, telling them about CAGE and AUDIT. No one in that room of 30 people understood anything I was saying. Now, why is that? I’d suggest that we need to make a better effort at educating our trauma surgeons. As surgeons, we went into our field because we like science. When I go on rounds and start talking about cell signaling and neutrophil activation, I guarantee you every trauma surgeon, every fellow there, is paying attention to me. When I go on rounds and start talking about brief intervention, I can’t get anyone to talk to me. So I think we have to recognize that we, as surgeons, don’t gravitate toward this part of medical practice. We need to impress upon trauma surgeons that our responsibility to our patients does not end with treatment of the injury and getting them out the back door. It’s getting that patient back into society, safe for that individual, safe for society around them. However, we also need to acknowledge the trauma surgeon’s innate lack of interest in this area as a hurdle to overcome.

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Donald Trunkey

My hospital doesn’t have the equivalent of what you have at Harborview, and it’s not going to, quite frankly. We have done a lot of pro-bono work. The hospital paid thousands of dollars every year to operate a poison control center. It was axed July 1st. So, we will no longer have a poison control center in Oregon. Why? Because the state has slashed medical school budgets so heavily that we’re starting to cut out some of these programs. We may have to discontinue “Think First” and “Safe Kids” because the hospital is losing the trauma nurse coordinator who implements these programs. If I were to tell my hospital administrator that I wanted somebody to see every trauma service patient and provide brief interventions, I would be laughed at. I’ve tried to provide interventions, but I’m not doing it well, because only one in 20 patients follow up. I’m frustrated, quite frankly. I try to be a role model for the residents. When they become practicing surgeons, I want them to know how to intervene appropriately. The intervention may be brief, but getting the follow-up is so frustrating, I cannot express it.

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Charles Lucas

Clearly, Gene needs to stay at home and send his young trauma surgeons to Jackson Hole! My partner, Anna Ledgerwood, and myself have a brief intervention on every patient that we see on rounds. If that patient is in the hospital a week, there are two brief interventions. It’s education for the residents and the students; all trauma surgeons should do it.

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Carol Schermer

I want to get back to what Dr. Soderstrom and Dr. Rostenberg said earlier. We need to be wary of placing the physician in the punitive, reporting role. This makes physicians uneasy and can violate some patient trust issues. There are other policy measures to address punitive action for DUI. As we all know, not every injury is related to alcohol. Even if DUI, many patients don’t warrant punitive measures. We need to rely on the people in this room and our addiction specialist colleagues. Whether it’s the surgeons, the addiction specialist, or the social workers, someone needs to provide some sort of treatment, not just resort to punitive measures. One of the main purposes of this meeting is to get all these really smart people together to figure out how to accomplish things like funding Don Trunkey’s Trauma Center or to fund a substance-abuse consultation service.

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Donald Trunkey

I agree that reporting or referral should not be repugnant to physicians. On the other hand, it’s so frustrating at times. Recently, I had a 37-year-old female patient who shot up heroin, and then at 10:30 in the morning hit three kids in a crosswalk at a school. The cops arrived and did not suspect that she was on drugs. They weren’t going to do a blood alcohol test. I had to take the cop aside to say, “She screened positive for heroin,” because the test that I do cannot be used in a court of law. I said, “You better damned well get a damned test.” I was so angry, and it’s inappropriate for a physician to be that angry, but this woman really got to me. Sunday I was on call, when a 2-year-old boy riding his tricycle was run over by a neighbor driving a pickup; the truck had to be lifted off the little boy. When the mother arrived at the hospital, she was on amphetamines. I said to myself, “This kid is a loser. He’s going to lose the rest of his life. He’s got a mother that doesn’t watch over him, doesn’t care for him, and I can’t test the mother.” I was so angry at this woman because she had let her child get injured. I think sometimes we have an obligation to report.

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Gill Cryer

Recently I met with trauma directors, nurse coordinators, and administrators from the 13 trauma centers in Los Angeles. One of the system wide quality improvement protocols that we tried to put in place this year had to do with alcohol testing. It became very clear during the process that the physicians—trauma directors like you on this panel— had no interest in reporting to police or to any state agency. What they did agree to do was to place the BAC level in the trauma registry, a confidential registry that doesn’t name patients so no one can access the patient’s blood alcohol level to be used against him at some later time. The goal was to produce data for epidemiologic studies, to define the problem, and to use with state legislators to say, “Look. We need to do something with these patients.”

Despite agreement to build a confidential registry, only about 50% of the hospitals were in agreement to regularly test the BAC on their patients, for a variety of reasons already discussed. I think we need to address the reasons why trauma surgeons are reluctant to measure BAC, because I believe that we are going to be a lot more successful at developing solutions to alcohol problems in trauma centers if we are ultimately able to create a disease-related registry, like the cancer societies do to develop and track the success of treatment of cancer patients. Define it, figure out strategies to do something about it, and then enlist our social or political partners to help implement some sort of strategic change.

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Eugene Moore

I still think, Gill, one obvious problem is funding. Unless we can take, for example, the tax on alcohol and direct it specifically toward prevention and treatment programs, it’s going to become more difficult in trauma systems and trauma centers throughout the country. We’ve talked about budget cuts today—whether it’s federal, national, local, or at our institutions. The cuts are wide-sweeping, and we literally cannot afford to do any task or make any effort for which there is no compensation. Our administrators constantly look at our daily schedules and figure out second to second what we do; if it’s not compensable, we’re not allowed to do it. If we aren’t supported for research via a grant, we cannot spend time on a grant. That’s a microcosm, but fundamentally that’s what the health system is all about. Somehow, we’ve got to figure out how to put money back into the system so we can use these preventive programs to eventually save money. Right now, that money is not there.

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Donald Trunkey

Gill, I have problems with the trauma registry approach. Substance- and alcohol-abuse are diseases and should be reported—not only to get good epidemiology, but quite frankly, for intervention. I’m very curious to see what happens at CDC with the current reportable diseases. Is it a violation of HIPAA because you’re reporting somebody’s data?

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Charles Lucas

Every patient with serious injury, and you can define it by ISS, should have an alcohol and a drug screen to know what problems to expect, as Don [Trunkey] mentioned earlier. Screening is needed for patient care. What you do with the data afterward is institutional related.

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Ronald Stewart

I agree with Dr. Moore that surgeons are interested in the biology, the operation, and critical care. The psychologist and the psychiatrist are interested in setting up outpatient treatment programs and behavioral interventions. One of the key questions is: How do we set up a collaboration like the one that exists at Harborview? A collaboration between psychologist and surgeon or psychiatrist and surgeon? As Larry [Gentilello] pointed out, we don’t perform physical therapy. There’s a physical therapist who does this. From my own experience and from listening to these discussions, it’s clear we’re going to have to build the collaborations ourselves. Funding may be an issue, but if the American College of Surgeons verification program sets criteria for alcohol screening and treatment programs, we’d follow it. Even if there were philosophical objection, or no expertise, the hospital would provide these programs because they would be required to do so. What if the college set these criteria through the verification program? That could make it happen.

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Donald Trunkey

I’m not sure it would. If you look at McKenzie’s most recent paper in JAMA, very few of the Level I and Level II trauma centers are actually verified by the colleges—only about a fourth are, maybe even less.

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Ronald Stewart

But a fourth would still be a huge change. In my state, it would be everyone.

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Donald Trunkey

I’m not opposed to the college developing these criteria for inclusion in the optimal criteria document. I’m just saying that a lot of hospitals (three-fourths, in fact), don’t go the ACS route.

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Eugene Moore

The ACS route is the wrong direction to go. This would simply reduce the number of centers that want to be verified by the ACS. I think we have to introduce this or inculcate this as a trauma surgeon’s responsibility, as part of our global care. The collaboration issue is very important as you point out. We are not behavioral scientists. Behavioral scientists have to affect what we believe is correct. On the other hand, behavioral scientists don’t have real-time access to patients to exercise these changes. I’d like to draw the analogy to basic science. Recently, NIH has had enormous funding. This will be effective because now translational research is being emphasized. No longer can clinicians work in isolation from basic scientists. We need behavioral scientists working side by side with clinicians to effect the change. How that will happen I don’t know, but conceptually, that’s what needs to be done—research funding needs to tied to this collaboration.

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Charles Lucas

Ron [Stewart’s] idea is excellent. It could be incorporated into the chapter on prevention. The proportion of hospitals verified by ACS is not an impediment because state verification criteria—about 98% to 99%—are almost mirror images of the recommendations developed by the college.

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Herman Diesenhaus

I used to be the Director of Program Services for the State of Colorado, Alcohol and Drug Abuse Division. You’ve talked about reporting and referring. I’d like to introduce a third term: Commitment. Thirty-eight states have a distinct “alcohol commitment statute”. We used to get into the same kind of discussions over civil commitment versus criminal commitment. Drug courts use criminal commitment. When we were running our system in Colorado, there was a statewide coordinator whose job was to work with various emergency rooms and detoxification centers in developing a treatment plan to present to the court. How many of you as trauma surgeons in your state use the alcohol commitment statute? It is a viable vehicle. This statute’s goal was to do exactly what you’re saying. Is it something we should be revisiting as a group? This is another alternative that may or may not be used.

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Donald Trunkey

I don’t think commitment works in Oregon because it’s not mandatory. I have more faith in the drug courts because judges now recognize that the judicial system is broken and that putting people who possess drugs in jail is absolutely insane. They would rather get them into a mandatory treatment program. From the evidence that I’ve seen, mandatory treatment programs are just as effective as voluntary programs.

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Herman Diesenhaus

Right now, the strongest supporters of expanding treatment are the Attorney Generals Association, prosecuting attorneys, and judges. At the next conference, we should bring surgeons, emergency department staff, and judicial people together to look at how we can develop a system to deal with these issues.

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Basil Pruitt

So far, we have focused on reporting and issues of commitment. This afternoon we are going to discuss screening and intervention. Is everyone happy with Dr. Gentilello’s paper? That we can screen and that the predictor of hazardous drinking is any alcohol level on admission? Is this the most sensitive and specific screen we have? And is this acceptable to all of us?

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Eugene Moore

Recently, Carol Schermer and others produced cogent evidence that even though the trauma center is an opportunity to screen patients at risk for alcohol abuse, blood alcohol level is not the most sensitive marker. The most sensitive marker is injury. Everyone who is admitted to a hospital with an injury should undergo brief intervention.

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Basil Pruitt

Is this cost effective? I mean, screening every admission to the trauma service?

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Eugene Moore

We can’t keep imposing costly services on trauma centers and expect them to survive. And I would argue the more we demand services that are not reimbursed, the more likely it is that trauma centers are going to back out of the system, and our trauma system will break.

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Basil Pruitt

But I thought you just said that everyone admitted to a trauma center with an injury should be screened.

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Eugene Moore

There is compelling data that all injured patients should be screened. The fact that a patient is hospitalized for an injury is an indicator that alcohol may be a problem in that patient’s life. Broad-based screening should be done. It is likely that we can capture the patients who are going to be compliant with the program. What we’re now seeing in our centers are impaired drivers—a group with a higher risk for recidivism.

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Basil Pruitt

But even in Eastern Europe, only one-third of young male deaths are alcohol related—the other two-thirds are needlessly screened. Right?

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Eugene Moore

I don’t think mortality should be our only barometer. It’s global disability, as well as deaths, that we’re trying to address today.

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Ronald Stewart

How expensive is this program? How many employees would be needed? One or a half full-time employee?

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Charles Lucas

It doesn’t cost anything, Ron. Dr. Trunkey is paid as a full professor at his university to teach students and residents. In the process, he has brief interventions with his patients. It doesn’t cost a damn thing, and we should all be doing what he does.

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Basil Pruitt

About those interventions. The professor approaches a patient with an assembled throng and says, “How do you feel about getting your sorry ass in this fix from drinking?” Boy, is that a great intervention!

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Charles Lucas

If that isn’t a military approach to intervention, I don’t know what is. Donald [Trunkey] is a very tender, sensitive, loving person, and his patients like it when he grills his students and residents about alcohol and drugs.

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Robert Woolard

At Brown University, we conducted an alcohol intervention program, a randomized controlled trial of over 500 patients. Results showed that brief interventions can reduce injuries followed out to one year. We collected data on other drugs as well, and learned that 47% of the patients we studied were also using marijuana.

I appreciate the vignette from Dr. Moore about friends of his children. When my own children attend parties, marijuana and alcohol are always available—and sometimes other drugs. They hear lots of myths about the use of marijuana. The most common one is that it’s safe to drive after using marijuana, and that most of the data show that marijuana does not affect reflexes. Another myth is that it’s probably not as hazardous to drive after using marijuana as it is to drive after drinking alcohol. But, put the two together and there is an additive effect. We see a lot of patients who, unless we screen, will continue to use marijuana and alcohol in combination. Counseling should address both.

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Susan Nedza

We need to support these proposed changes in practice. There’s little for the hospital to gain if interventions decrease the number of trauma center admissions, but society has much to gain. Therefore, the case for diminishing alcohol-related illnesses has to be initiated in our communities and has to capture some of the data related to the cost of incarceration. Although the criminal justice system is a proponent for intervention treatment via drug courts, that system is also affected by budget cuts. This is one of the groups we need to partner with.

Regarding interventions, we can take a hint from what we’ve done in violence prevention screening, where someone asks the patient specifically whether violence is part of their history. It then becomes a history issue, and that triggers everything. Effective screening can consist of as few as one or two simple questions, and only screen-positive patients will need an intervention.

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Gordon Smith

We should broaden the focus from criteria for trauma center accreditation to the definition of quality care for the hospital. Just as Larry [Gentilello] mentioned, if a physical therapist wasn’t available to advise on the use of and the appropriate height of crutches, this would be viewed as bad medical practice. If the hospital were to close its physical therapy department to save costs, the hospital would probably fail accreditation. Compulsory referral to police is probably not the answer either, because they’re going to be overwhelmed, and they have no treatment services. States often require hospitals to provide prevention services. Would the American Hospital Association or the state require a certain number of full-time employees per a specified number of beds to begin brief intervention programs? I would like to see a discussion on how we could accomplish this.

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Basil Pruitt

Dr. Lucas, would you speak to that as Chair of the Verification Committee?

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Charles Lucas

Interventions could be introduced in the form of a recommendation, and then over a period of time the results of visits by the college would identify the number of institutions who have put such things into place. Any problems with such programs could be fed back to the college and to other participating institutions.

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Donald Trunkey

I support mandatory referral or mandatory reporting because it works. Every November, I go to Sweden and teach a one-week trauma course. Sweden has some of the most draconian alcohol laws in existence—zero tolerance for driving under the influence.

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Basil Pruitt

As someone else has already mentioned, in states with mandatory reporting laws, insurance companies are allowed to deny payment for medical care when alcohol or drug use is involved. Why would we support mandatory reporting? This would be like shooting yourself in the foot.

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Donald Trunkey

Well, wait a minute. I don’t support insurance companies getting off the hook here one iota, nor do I support the police not arresting these people.

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Basil Pruitt

Are we going to change the law so the insurance companies have to pay?

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Donald Trunkey

Dr. Runge showed you this morning the costs to society are absolutely staggering. I would like to see us reduce those costs by half and put that into education or health care.

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Basil Pruitt

But that takes a legislative action, doesn’t it?

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Charles Lucas

The system is so illogical. Thoracic surgeons don’t have to report people who smoke to the insurance company when they’re taking their lungs out for lung cancer. The whole thing is illogical.

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Basil Pruitt

But Charlie, who said life is logical?

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Charles Lucas

We have to point out to them the illogic of it all. We have to give them other parallel examples.

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Basil Pruitt

So then we’re going to mount a legislative campaign to change the laws in 38 states? Is that right, Larry? That’s a perfectly reasonable goal if you think we can achieve that.

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Eugene Moore

The reason that only 25% of Level I centers are verified by the ACS is because in those states they have decided that the ACS criteria are too onerous. That’s why Washington state doesn’t verify by the ACS—because Ron Maier doesn’t believe what the ACS requires is logical. For example, ACS mandates that a trauma surgeon be in an emergency department for every intubated patient. So the more rules you impose that the trauma surgeon doesn’t believe in, the less compliance and the less credibility that document is going to have. Injury prevention programs mandated by the Committee on Trauma (COT) is not the way to go. Trauma surgeons must believe this is part of our responsibility as physicians. Don’t force them, educate them.

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Charles Lucas

The word is “recommend,” Gene. Nobody said mandate. The Verification Review Committee of the COT does not mandate that every trauma surgeon be present whenever there’s an intubation in the emergency department. Without getting into the details of why Washington or other states don’t use the college program, I re-emphasize that 99% of the state’s criteria is the same as the college’s criteria. The college has been the leader in the development of criteria that nearly all states use to verify or designate their trauma centers.

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Donna Johnson

I’m probably the minority in the room. I’m a substance-abuse director for a rural community just north of Atlanta. In addition to outpatient services, for the past 15 or 16 years I’ve directed an emergency receiving facility for individuals with substance abuse and psychiatric disorders. Our success with referrals from hospitals over this period of time has not been very good because the hospitals referred patients who did not meet the admission criteria for our programs. To address this situation, we met with staff in hospitals and began sending counselors to the hospitals for consults, evaluations, and recommendations for placement. We came to realize that the people showing up in trauma centers and hospitals were at high-risk, and we gave them priority status so they could get into our facilities much quicker. So I’ve seen collaboration work. Unfortunately, on July 1, our program will be ending because of funding cuts. I would love to see the trauma world and the treatment world work together and come up with new protocols.

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Donald Trunkey

We’ve covered a lot of issues. I don’t see a lot of solutions. We need to work on identifying solutions during the next two days.

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Basil Pruitt

I want to thank the audience and our speakers for a good discussion. The meeting is now adjourned for lunch.

© 2005 Lippincott Williams & Wilkins, Inc.

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