Soderstrom, Carl A. MD
From the Medical Advisory Board, Driver Safety Research, Maryland Motor Vehicle Administration
Submitted for publication June 8, 2005.
Accepted for publication June 13, 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, U.S. Department of Health and Human Services (HHS), or Centers for Disease Control and Prevention (CDC), and it does not constitute an endorsement of the authors or their programs—by CDC, HHS, or the federal government—and none should be inferred.
Dr. Soderstrom participated in this as Adjunct Professor of Surgery, University of Maryland School of Medicine (Baltimore) and preparation of this manuscript was supported in part by NIAAA grant 2R01 AA090050-04A2.
Address for reprints: Carl A. Soderstrom, MD, Director, Medical Advisory Board, Driver Safety Research, Maryland Motor Vehicle Administration, 6601 Ritchie Highway NE, Room 47C, Glen Burnie, MD 21062; email: firstname.lastname@example.org
My task is to “set the stage,” so to speak, by briefly outlining the reasons why brief interventions for patients with alcohol and substance abuse problems should be implemented in trauma centers and emergency departments (ED).
Trauma centers and EDs are hectic environments where clinicians must identify and treat life-threatening injuries under difficult time constraints. These environments are the antithesis of office practices where there is much more time for discussion between clinician and patient. In office settings, patients sit comfortably in chairs or on examining tables, face the clinician, and are in little to no distress. Distractions are minimal; there are no persistent intercom pages or beeping monitoring equipment in the background. But despite the distractions and time constraints, both trauma centers and EDs offer great potential for intervention; more so, in fact, than office practices. Although ongoing patient-care activities and concerns still are distractions—activities like additional surgeries and diagnostic procedures, patient-care rounds, wound care, physical therapy, pain management, or visitors who further limit time and access to the patient—the reasons why patients present at either center sets the stage for discussion.
Compared with patients seen in EDs, a larger proportion of trauma center patients have alcohol use problems. Studies show 15% to 25% of ED patients screen positive for pre-injury alcohol use.1–3 In contrast, 25% to more than 50% of trauma center patients screen positive for alcohol.4–7 These results indicate that alcohol abuse is a common element of injury in both treatment settings.
Efforts to establish testing of patients for alcohol and other drugs as clinical protocol began more than 30 years ago when Dr. R. Adams Cowley founded the Shock Trauma Center (STC) at the University of Maryland. Through his leadership, Maryland's Emergency Medical Services (EMS) system was created8 and routine testing began for all patients admitted to the trauma center. Toxicology tests were obtained for clinical reasons—not for legal reasons—to identify patients with substance use problems and to manage pain. With funds from the Maryland Department of Transportation, we created a confidential toxicology database of STC patients. This database is housed and maintained at the National Study Center for Trauma and EMS of the University of Maryland School of Medicine.7
In recent years, more than 6,000 patients have been admitted annually to the Shock Trauma Center; more than 80% of the injuries have occurred in rural, suburban, and urban areas. More than 95% of these patients have been tested for alcohol without any bias toward gender, minority status, or whether they are victims of violence.7 These test results are germane to these proceedings because the center's patient profile is similar to the aggregate adult (≥14 years of age) trauma population in the American College of Surgeon's (ACS) National Trauma Data Bank.9 For example, in fiscal year 2002, 72% of STC patients were men compared with 64% men in the ACS databank; 66% of STC patients were ages 21 to 54 compared with 62% of ACS patients age 20 to 54; 45% of STC patients were vehicular crash occupants compared with 43% of the ACS patients; and 43% versus 16%, respectively, were victims of violence.
Overall, 21% of STC patients tested positive for alcohol, 81% of which had a blood alcohol concentration (BAC) of ≥ 80 mg/dL, which now defines impaired driving in most states. The highest positive BAC test rate of 27% was among those ages 21 to 34, but 11% of patients age 55 or older, and 15% of patients younger than 21 also tested positive for alcohol. Men tested positive at a rate more than twice that of women (25% versus 12%). However, most men (80%) and women (75%) with positive screening results had a BAC ≥ 80 mg/dL. Finally, even though the highest percentages of BAC-positive patients were victims of violence and pedestrians who were struck by vehicles (28% and 25%, respectively), 21% of vehicular crash occupants and 15% of other victims of unintentional injuries were BAC positive (National Study Center for Trauma and EMS, unpublished data, 2003).
The percentage of patients admitted to the STC who test BAC positive has decreased steadily in recent years. In the mid-1980s, more than one-third of patients age 21 and older tested positive. By 2000, less than one-quarter tested BAC positive. Throughout this period, about 10% of patients ages 14 to 17 treated in this adult trauma center tested positive for alcohol.7 The most common answer given by injured patients to, “How much have you had to drink?” was “Two beers.” Hard data suggest otherwise. The mean BAC level for all alcohol-positive or screen-positive age groups of trauma patients exceeds 100 mg/dL (154 mg/dL for men and 142 mg/dL for women). Trauma patients younger than 21 had mean BACs of 111 mg/dL (National Study Center for Trauma and EMS, unpublished data, 2001).
Clark, McCarthy, and Robinson published a seminal editorial in the Annals of Emergency Medicine characterizing “trauma as a symptom of alcoholism.”10 That observation was corroborated in a prevalence study of alcohol use problems among STC patients using standardized criteria.11 Overall, 24% of patients were found to be alcohol dependent at the time of injury. Of this group, 27% to 28% of patients ages 21 to 60 were alcohol dependent; and 13% of the remaining patients (those younger than 21 or older than 60) were alcohol dependent.
A word about semantics is in order. The use of language affects how trauma patients with alcohol-use disorders are regarded. The terms alcoholism and alcoholic historically have pejorative and negative connotations that imply moral deficits. It is better to use the term alcohol dependent, which refers to the more appropriate disease model. However, alcohol dependence represents the most severe end of the spectrum of patients with alcohol-use disorders. Further, it is not uncommon to encounter patients who were intoxicated when they were injured, but who are not dependent. Finally, another important consideration is that among the relatively younger patients admitted to trauma centers,9 many have alcohol-use disorders, but are not alcohol dependent. Nonetheless, their alcohol use frequently results in severe injuries.
Published reports of results where both screening methods and standardized criteria were used to detect alcohol use disorders, reveal that 15% to 20% of injured patients treated in EDs have such disorders,2,3 compared with a much higher prevalence among patients admitted to trauma centers (25%–50%).3,5,11 Because the mean age of trauma center patients is 30 to 35 years, we can assume that patients who screen positive are better candidates for intervention than patients with a longer history of alcohol-related problems. This observation has important treatment implications, because brief intervention techniques are probably less effective for patients with long-standing chronic alcohol dependence.
A study led by Dr. Patricia Dischinger provides compelling data on substance abuse interventions in trauma centers.12 A national search for death certificates for more than 27,000 STC patients found that 1,631 had died 1.5 years to 14.5 years following discharge. Subsequent trauma was the cause of death among 35% of those who had tested positive for alcohol or other drug use at the index trauma admission. This percentage was almost six times higher than the percentage of Americans who died from injury in 1994 (6.4%), the year immediately preceding the end of the study period.
Most data on alcohol dependency force us to answer Dr. David Lewis's question, which he posed at the earlier Centers for Disease Control and Prevention conference on alcohol use problems and injury in emergency room settings: “How can we possibly continue to treat the complications of an underlying disease without addressing the disease?”13 This is what we have been doing for decades. In the past, many have held a common belief that “a drunkard in the gutter is just where he ought to be,”14 or that getting drunk is the result of “enfeeblement of the moral principle.”15 As Dr. Trunkey has stated, alcohol-dependent trauma patients have “a treatable disease.” It is exciting now to be at this place of change.
In the mid-1990s, Dr. Thomas Scalea assumed the position of surgeon-in-chief of Maryland's Shock Trauma Center. He asked clinicians from the center's Substance Abuse Consultation Service if there was reliable evidence available to document whether it was worthwhile to spend time on interventions. Their answer was, “No.” Indeed, at that time there were no hard data relative to trauma patients. However, now that studies among trauma patients show that brief interventions are feasible and can lead to salutary results, it is time to move forward and implement interventions in trauma centers and EDs. This will require coordinated effort among trauma clinicians, health care administrators and health care policy makers.
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Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2002.
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