The editors of the proceedings prepared the following summary of participant comments made during the session.
Christine Heenan is the president of the Clarendon Group, a strategic communications, policy, and public affairs firm based in Providence, RI. She has been a Senior Policy Analyst on the White House Policy Council and also worked in the Speech Writing Office during the Clinton Administration. Currently, Christine facilitates health care meetings and conferences for academic and medical centers around the country. I have asked her to facilitate this discussion session to help categorize intervention obstacles and strategies that conference participants have identified.
There was compelling data, some of it conflicting data, presented this morning. I’m sure a number of you have questions for our morning panelists, so we will take those questions first. The latter part of the discussion session will be used to catalogue the obstacles and strategies that were raised during the presentations, with the goal of categorizing and prioritizing them later in the day.
Gill [Cryer], I want to clarify a position I took earlier in the conference. Trauma surgeons should report patients with substance-use problems—not to the police—but to the Centers for Disease Control because they are clearly part of the cause of most of the trauma that we see. If these patients are reported to public health people, good epidemiology can be obtained. Then, we can develop strategies to deal with this problem and can define where the research needs to be done.
Trauma surgeons often face ethical dilemmas. Let me give you an example. I get two patients simultaneously. One is a 19-year-old woman who was driving a small sports car, which was t-boned on her side. She has a severe head injury, a left humerus fracture, and a left acetabular fracture. The guy that hit her was driving a pickup. He has a fractured femur, a ruptured spleen, and a lacerated liver. He’s also in shock. I take him immediately to the operating room. A computed tomography scan of the young woman demonstrates a severe traumatic brain injury with massive swelling on her brain, and she is taken to the intensive care unit (ICU). I do a blood alcohol and drug screen on both patients. The young man’s spleen is removed, and he ends up in the ICU, two beds away from the young woman. At this point, he has now had four units of blood and 7 L of Ringer’s lactate solution. So when police confront him later in the afternoon, the BAC and blood toxicology they take are worthless. The results from initial testing show the woman’s test is completely negative. I go out and tell her parents that she’s brain dead, and I recommend withdrawal of life support. How do I handle the information I have on the young man? His blood alcohol is 340, and he has a positive amphetamine level. I have an ethical dilemma—I’m trying to be an advocate for one patient but also trying to protect the privacy of another.
A similar situation occurred in our trauma center. One of our medical students was killed. Our residents were feeling very uncomfortable providing treatment for the perpetrator of the crime, if you will, and they talked to me about it. I told them (and this is what I really believe), ‘You have to separate the legal problems of your patients from your duty to take care of them. As hard as it is for you emotionally, ethically, and from the perspective of being a good doctor—a caring, compassionate doctor—your obligation in my view is to take care of both of those patients as best you can.’ In response to Dr. Trunkey, the BAC that you took is an issue for the legal community to solve. Our obligation is to the patient. The police know the young man was in a wreck, and the police know he was drunk. The system will deal with it as best they can.
On a totally different topic, several of the speakers have described their difficulties with getting reimbursed for screening patients or providing interventions. The recommendations from this conference should address this issue.
Participants have also raised the question of whether specific training or having a certain degree are requirements for reimbursement.
The reimbursement issue will wind up being significant, but I want to get back to a theme that I’m hearing over and over again. I remember having to do surgery on patients with lung cancer and being discouraged when time after time I would find that the disease had already spread to the mediastinal lymph nodes. Even if I did a lobectomy, the likelihood of a cure was remote. Experiences like this made it clear that if we wanted to reduce lung cancer deaths, we needed to begin to focus upstream on smoking prevention. In trauma, we have to begin to focus not only on the broken pelvis of the methamphetamine user who was speeding the wrong way down the highway, but also, similar to the way we now look at lung cancer, begin to focus upstream on prevention. It’s viscerally compelling to think about the drunk driver and who he or she just killed, but I think that we are, as a group of trauma surgeons, in some ways emoting over the things we see every night, which is natural. But, we’ve got to take the next step and begin to work our way upstream.
Just to go back to screening methods. I’m glad to see that biological markers* have been summarily dismissed. There doesn’t seem to be much use for them in this young population. Perhaps the trauma staff could screen with questions as simple as, ‘How many days a week do you drink?,’ ‘Were you drinking today?,’ and ‘Do you drink everyday?’ This might be enough information to just kick it to the next level and let somebody else do the work for the serious screening.
I’m ambivalent about Carl’s [Soderstrom] recommendation. We would be hard pressed to name a screening instrument that’s been better evaluated on more people and in more countries than the AUDIT.† The nice thing about the AUDIT is that it’s a great transition to begin the discussion. The people I have trained found that the screening instrument helped start discussions with patients about their drinking habits. Such discussions are harder to start when the first topic of the discussion is a positive blood alcohol test. Do we know the most appropriate blood alcohol threshold for activating an intervention?
I don’t advocate eliminating screening instruments, but there are conflicting data regarding when and by whom they should be introduced. Research by Marilyn Sommers and Cheryl Cherpitel indicate that a positive blood alcohol test is useful for starting conversations with some patients. A positive blood alcohol or drug test was useful in recruiting patients for my own current study—quantity or frequency information was not that useful.
Using blood alcohol levels to select a group for intervention may lead to better results than casting a wider net.
The screening literature supports complementary conclusions. First, not all patients in the at-risk drinker group are drunk when they come into the trauma center or the emergency department. Therefore, broad screening instruments are required to identify this group. Second, positive blood alcohol and drug screening results can identify another group of patients. The two are additive. What we found was the more we screened, the cheaper it was, and the more we identified a surprising number at risk. Remember, physicians repeatedly under-perform identifying alcohol users. In some studies, as much as 94% of alcohol problems are missed.
To summarize, I think there are two competing perspectives. One, what is the lowest threshold screening method we can use? Is a positive BAC enough, and if so, is that enough to open the door to conversation with minimal imposition? On the other side, who do we miss, and what don’t we pick up by relying only on that one instrument?
I am struck by the apparent lack of linkage between what’s going on in trauma centers and the specialist alcohol drug treatment system and the lack of knowledge on both sides. Both the University of California Los Angeles (UCLA) and the University of New Mexico have extensive alcohol and drug research and services programs. Do links between the programs exist? Have these links helped in overcoming barriers to treatment?
Before you answer these questions, there are two points I want to make. On outcomes for screening, we have just worked with the National Committee for Quality Assurance to develop screening outcome targets for primary care settings. Trauma centers were not involved in that, and trauma centers may need to be involved in this. There’s a group called the Washington Circle that is in the process of developing performance standards for alcohol screening and interventions that can be applied to health care entities such as HMOs, group practices, primary care clinics, and other settings. And because of the good work done by Dan [Hungerford] and Larry [Gentilello], I’m recognizing that this is an entire group that has been left out of that process.
I talk to Bill Miller‡ three to four times a week. He’s my research mentor. Five years ago he did not know the difference between a trauma center and an emergency room, so we’ve both learned a lot. Our connection facilitated referrals of patients to other research programs for dependent drinkers or just for general treatment. However, this started as a collaborative research effort, not as a systematic effort to link the two systems.
My trauma center has links with outpatient drug and alcohol interventions at the hospital. However, it is difficult to get treatment for patients unless funding comes from a research project or a special source. I think part of it is just that we need the impetus. I need the impetus of a meeting like this—talking with both sides to make establishing better linkages a priority on my part.
We’d like to hear any ideas that you might have to help further that dialogue.
Meetings like this help. Alcohol researchers at Brown University are already working with emergency physicians and talking with trauma physicians from Brown during this conference. Gill now knows he can go back and talk to these people. They aren’t mean. What I mean is that it’s difficult to take the first step to interact with somebody when we are not sure if they have any academic interest in what we do.
Trauma surgeons are very sensitive, and we’re very concerned about people being mean to us. [Laughter.]
All of the presentations were excellent and had about the right combination of skepticism and optimism regarding what I consider to be two critical questions. Do we know enough about the types of patients we encounter in trauma centers? Although we know some are just alcohol users, some of the discussions included descriptions of gang members and stab wounds. Psychiatrists use a term, which is very strongly implicated in the development of alcoholism and drug addiction, called ‘antisocial personality.’ Patients with this characteristic are very difficult to manage from a clinical perspective. A large majority of these people are the ones who come in with traumatic injuries. We haven’t even started to look at intervention outcomes for different types of patients. So, there’s a big question about what we know and then other questions about feasibility—how we do screening, how we screen for drugs, whether we use tox screens or self reports—all of these things. Are screening and intervention protocols ready for prime time in terms of what we know? On the other hand, we’ve learned so much from primary care. Most of the emphasis in this field for the past 20 years has been developing procedures that fit into primary care; trauma centers have been ignored. I think if one were to make a case from the perspective of volume and yield, that is, which population is in need of interventions, we could ignore primary care in favor of emergency and, especially, trauma centers. So the question is, if the Robert Wood Johnson Foundation or the federal government were bringing a national initiative to the trauma field, would you be in a position to say we’re ready for prime time?
I believe that antisocial personality disorders are an important concern when thinking about interventions for trauma center patients.
Tony, would you comment on whether trauma centers and the trauma field are ready for prime time?
We are seeing an evolution in that direction. The number of people here, especially some of the leaders in the field who spoke yesterday, are ready to help bring this about. It will take some time for adoption, but I think the momentum is evident.
We’re ready for prime time, but only as a start. The product we currently have is not going to succeed in prime time. What we really need is ongoing data collection and evaluation of treatment and intervention, ongoing evaluation of why it works for one group but not for another, and the difference between these groups. The average Level 2 trauma center out there (a community hospital with no academic interest) is not ready for prime time. However, now is the right time for academic centers to learn more about interventions so that this will become something we can implement with good success for our patients over time.
We haven’t clearly defined what model to plunk into the trauma centers. The model will need to vary from center to center. For example, the proportion of patients we see with personality disorders varies markedly depending on the trauma center. Most of the patients in my center are normal drinkers. Perhaps the proportion of patients with antisocial personality disorders is different in trauma centers in Seattle and San Francisco. We really need to try it on everybody. And then, like Gill [Cryer] said, see who it works on and see who we need to modify it for. Perhaps somebody with a personality disorder or an anger disorder needs additional treatment.
Trauma centers in California are mandated to provide and report about a dozen activities that involve essentially a brief intervention, for example, diabetic education, child passenger restraint education, and domestic violence screening. In San Diego, about 90% of this effort occurs at nonacademic centers. At most hospitals, trauma center volume represents 5 to 10% of the volume coming through the emergency department. Therefore, I think it is better to base screening activities in the emergency department and complement that with a trauma module. This strategy would catch at-risk drinkers better and be more economical than one focused solely on a trauma center.
I’d like to comment on the issue of whether blood alcohol screening and reporting should be mandatory. I recall the controversy in the mid-1980s over whether preoperative HIV screening should be mandatory. And although the analogy does not completely hold up, I think the stigma and some of the negative repercussions, legal and otherwise, between a positive BAC level and a positive HIV test have some similarities. At that time, a major concern was ensuring that HIV-infected patients did not receive a different level and standard of care compared with HIV-negative patients. Trauma surgeons did not need to obtain BACs on many patients because clinical observations were adequate. However, I have been convinced in the last day and a half that knowing the BAC level will help identify patients with drinking problems and that interventions can be helpful. Although I am in favor of mandatory reporting, I am concerned about police access to that information and the potential negative impact on the patient. Therefore, the body politic has to make a decision regarding mandatory reporting. This has to become law. We can’t have individuals in one hospital versus another deciding, ‘Okay, we’re going to do this for everybody’ and another saying, ‘We’re not because we have concerns about confidentiality.’
Bill [Schecter], you have addressed two separate issues here—widespread blood alcohol screening and mandatory reporting.
Before I finish, I want to address a concern Don [Trunkey] voiced about the surgeon’s dilemma—identifying patients who have positive BACs and who may have injured other patients. A military surgeon faces a similar dilemma when caring for captured enemy soldiers who may have killed the surgeon’s own friends. Baron Larrey, the father of military and trauma surgery, held to the principal that once a soldier is injured on the field, he is a suffering human being; we have to have equal standards of treatment for all soldiers. Having served in an urban combat zone for most of my life, I feel that I am a soldier in a certain sense. Whether or not the patient has a positive BAC level and whatever feelings we have, we must take care of everyone in the same way.
How many of you believe universal BAC screening of trauma center patients is important to public health? [Many participants raised their hands.] How many have concerns you need addressed before you would support implementing such screening? [A majority of participants raised their hands.] Let’s talk about these concerns.
Illinois has an onerous law that requires trauma surgeons to testify in court. So my argument is if you’re going to ask for a BAC, you better be damn sure you’re going to use the results. You’re either using it to screen or you’re going to say, ‘I have a cutoff level at which I’m going to speak to patients about it’ or ‘I’m going to use it to treat withdrawal.’ I initiated a survey that indicated surgeons did not use specific blood alcohol levels to prescribe routine benzodiazepines for withdrawal or to automatically refer patients for alcohol treatment. I know there are senior surgeons out there at very prestigious trauma centers who will not allow a BAC to be taken because they want to get paid for what they’re doing. They have found other ways of screening for alcohol problems instead of a BAC.
A trauma visit, because it ensures the patient’s attention, is a unique opportunity to talk with patients. We need to shift the primary focus from physicians to leaders of institutions, with the goal of changing policies—adding an important component of care. What will get leaders’ attention? The financial means to support new policies or requirements, for example by Joint Commission on Accreditation of Healthcare Organizations (JCAHO),§ to implement new policies?
I’m currently working on a project to increase screening for acute pain management, and we have similar questions. We started out with a goal to have patients well treated for pain. However, we ended up deciding to track screening and the tools used for screening. ‘Was the person screened? Yes or no. Was a tool used? Yes or no.’ We have yet to find a specific tool that everyone agrees is perfect for every setting. I feel an appropriate model would be a mandate from a regulatory body to track a similar process measure—simple yes/no process questions that don’t mandate the physician do it, yet still mandate that things get done. This would allow data collection. It’s a start—an incremental beginning.
If you try to jam a JCAHO requirement down the throat of the average trauma director, the first thing they’re going to say is, ‘What’s the evidence?’ Trauma directors will want to know from the data that we are not wasting our breath when we talk to these patients. To get leaders to support these changes, we will have to show that there’s some outcome benefit compared with the effort we put into it. I want a result that is more than just knowing I have talked to a patient.
Compared with what, though? What about diabetics? How successful are any physicians when talking to diabetics; yet, they’re still responsible for doing that?
I don’t take care of many diabetics. The nice thing about a diabetic is that there is a measurement, which shows whether or not the patient is compliant. The problem that we’re dealing with today is much more difficult to measure.
Gill [Cryer], do you mean that we may have to restudy this to prove it to trauma surgeons or that we have to take time to read the literature to see if we agree with the evidence?
We need to do both. There’s no question in my mind that we need to start this process. We need to learn more about it—how it affects our patients and how to maximize the outcomes for our patients. It shouldn’t be that we just decide that everybody’s going to get a talking to. We need to make sure that whatever intervention we put into place will actually work for our respective patient populations.
I was dragged kicking and screaming into this. My conclusion, after close to 5 years now, is that this is a completely different competence. Understanding this is completely different from what we usually do as trauma surgeons.
It seems there is a chicken and egg conundrum here. Some are saying, ‘Let’s just start the process and have a different threshold for what success means. Maybe success is starting the process; worry about outcomes later.’ Others are saying, ‘Before I implement this in my trauma center, before I look for resources or argue for resources, or before I make a decision on this over something else, I want to know if it works.’ How many in the audience need more compelling data about brief interventions before you will act? [A few hands were raised.]
May I clarify what I am advocating? The presentations and discussions at this conference have convinced me that we need to make these resources available to our patients. But I don’t think this is enough. If we’re going to expend resources, we need to learn how to do it better, and I don’t believe we have focused on this. We don’t have to wait on data that proves efficacy before we implement it. We just need to start the process with the idea that we’re going to continue to learn to do it better.
Carol Schermer’s survey has shown that 30% of trauma surgeons are concerned that asking questions about drinking would offend their patients. This reminds me of where we were with domestic violence 10 or 15 years ago. Then, many survivors of domestic violence said that despite multiple trips to the doctor, they were never asked any questions. Lots of folks in recovery say the same thing now. We [Join Together] have a website [alcoholscreening.org] that uses the AUDIT and it also asks two simple questions: ‘How much is too much?’ and ‘Is my drinking harmful to my health?’ Without a lot of promotion, we’ve had 110,000 completed AUDITs in the last 2 years. People want to know the answers to these questions. They’re not going to be offended. People now have different expectations of their health care providers. We should be worried that we will offend our patients if we don’t ask. Asking questions about alcohol consumption should be a part of the standard of care for any number of medical settings. Patients already have these expectations. Health care needs to run a little bit to catch up.
Anara, for those who may not be familiar with Join Together, would you explain what the organization does and the purpose of the website?
Join Together is a project of the Boston University School of Public Health and is funded by the Robert Wood Johnson Foundation. We work with communities around the country to help solve, at the local level, the national public health problems of substance abuse and also gun violence. The website—www.jointogether.org—has been available for many years and provides extensive information using a nonpartisan, science-based approach to tackling these issues.
There is consensus in the literature that interventions are beneficial. However, there are too many variables that current data does not adequately address, like the best way to monitor outcomes, the best person to implement interventions, how to get reimbursed, or the best screening method. My read of the literature is there isn’t any best way to do these four things. I think we know darn well that even if we had data saying, ‘Oh, it ought to be social workers,’ centers will hire whoever wants to do it and someone they trust. Therefore, I suggest we formulate flexible recommendations with a set of components that trauma centers should include if they want to implement a program without prescribing exactly how each component should be implemented.
Chris [Dunn], would you repeat the four areas of concern? This is an important point.
Number one is how do we get reimbursed? This will depend on your credentials, the CPT code, and the state, I bet you. And that gets really complicated. So let’s not get into this too micro. Second, how do we monitor outcomes so that the program is a self-informing mechanism; a type of self-assessment feedback loop? We need to hire someone that keeps a record of patients screened. Third, who should do it? And finally, how should we screen—with BAC or a questionnaire?
It would be great to get brief intervention programs into all trauma centers, but this alone will not be enough. We need to forge better linkages to specialty treatment for patients with severe problems and develop greater community treatment by clinicians and staff in primary care settings to help patients with less severe problems. A study at Harborview supports the need for broader community involvement.∥ That project does not involve a single intervention like the ones we have been discussing. Instead, there is extended interaction with patients by telephone and by occasional visits. The result—fewer patients in the intervention group met criteria for alcohol dependency a year after the initial visit. How do we initiate change in an organization? One way is that someone in authority makes a wise decision and says, ‘Thou shalt implement brief intervention.’ Then there is the harder way to do it—a champion inside the organization advocates change and spends 20 years doing it, like Larry Gentilello has at Harborview. Is there anyone at this conference who, upon your return home, will have the power to buy a copy machine and to immediately hire a half FTE at $25,000 a year? Does anyone have the power to implement this in their trauma center? Or do you have to go to the medical director or the board for funding?
I have the power to implement this, but the key is to convince the leadership that we’re going to be successful.
I want to go back to the issue of BACs and screening. A strong focus on BACs is problematic, because I suspect that the BAC of some heavy drinkers is not high enough to be identified by BACs drawn at the time of their trauma visit. If a BAC only identifies some of the patients that should get treatment, if surgeons do not use it to direct clinical care, and if it creates problems with insurers, then what is the value? I know the BAC may be useful clinically, but the best model, from a public health point of view, would be to use a screening questionnaire.
Are you saying that we shouldn’t use the BAC as the trigger for the screen or that wide implementation of the BAC has enough problems separate from whether or not that’s the trigger?
There is room for discussion about which screening instrument is best. However, I don’t think that the BAC should be used to trigger the intervention.
Interaction at this point of the discussion may seem confusing. However, it is emblematic of the confusion that arises when physicians interact with psychologists and epidemiologists who are more familiar with treatment for substance-use disorders. This conference highlights the need for more cross training and continued interaction among these disciplines.
BAC results from many current studies and data systems are not representative of the total population of trauma patients or are invalid estimates because many patients go directly to the operating room; others may be transported to the trauma center from a distance and may test negative by the time they are admitted.
I hate to put you on the spot Dr. Hoyt, but you are participating in our multicenter study funded by the Robert Wood Johnson Foundation, and as part of the study, you are supposed to measure BAC. How many people are actually having their BAC measured? At other centers, such as Seattle and Baltimore, where they routinely measure BAC, it does not get measured on every patient because patients get transferred to those centers from another hospital a day or two after their injury, and a BAC is sometimes not obtained for other reasons. Do you have data on the percentage of patients you are able to obtain a BAC on as part of your study?
Could I respond to it though? Let me just say that while you may be right about the BAC not being useful, we really don’t know. The only outcome study in trauma patients that has shown quite good results is Dr. Dunn’s and Dr. Gentilello’s, and they used the BAC. That was the trigger to get an intervention. And yesterday that’s what I heard they are still using.
Well, one, Chris [Dunn] gave you those caveats yesterday. Two, they used the short Michigan Alcohol Screening Test (sMAST). And the people in that study who had a low SMAST score and were BAC positive showed no intervention effect. And my argument, and Larry and I disagree on this, is those people weren’t problem drinkers and didn’t need an intervention. So Chris told us yesterday, he uses the BAC now because it’s easy, but I think I can speak for Chris when I say he does not believe that that is the ideal screening instrument.
I would go further than that. All the patients you see should receive a word about alcohol. If they’re not drinking too much, you give them positive reinforcement. Otherwise, you focus on the areas they should be concerned about. This would really enlarge the spectrum of patients who get an intervention.
Before we take the next question, I want to suggest that tomorrow you drill down the role of the BAC in screening. So far, the conversation is sort of like that Vaudevillian line about your uncle who thinks he’s a chicken. Well why don’t you send him to the asylum? We need the eggs. You know that BAC may not be the perfect tool, but it’s the one you’ve got now, and it’s the most widely implemented. So what role the BAC plays seems to be fundamental. Next question.
The emergency department-based study at Brown used three criteria for screening. Patients who met any of the following were considered screen-positive: an AUDIT score of 8 or more, any positive blood alcohol value, or a self-report of drinking. Almost half of the patients had positive results on all three criteria. Therefore, I believe the difficulty is not in finding screen-positive patients but in providing an intervention. It is important to decide which part of the spectrum of alcohol problems you want your program to address. Chronic inebriants are at greater risk than most drinkers. However, the bulk of the accidents and problems we see doesn’t come from chronic inebriants but from at-risk drinkers. And, those patients have enough recidivism that it can be attacked. Regarding research recommendations, although many people are convinced that something should be done, we don’t know what that something is exactly. I would recommend multicenter trials with outcomes that are relevant to trauma surgeons, such as reductions in injury and risky behaviors like driving under the influence. Alcohol researchers are usually interested in different outcomes, such as reduced consumption. Which outcomes would be important to unconvinced trauma surgeons?
Bert, what I’m hearing from you is that you feel trauma surgeons may not be convinced by the alcohol data that already exists. There is very good data out there, even though some studies produced only small amounts of data. Multicenter projects are funding and grants-management nightmares, but I agree that they recruit lots of patients and are a great way to go.
I’d like to see our resources put into projects that will answer those questions, and we ought not to put in an intervention unless we are prepared to measure the things you’re talking about.
Gill, I’ll guarantee you that you spend more time and energy on DVT [deep venous thrombosis] prophylaxis with less evidence than the evidence available on screening and brief intervention. There are about 20 studies I would recommend reading; not all involved trauma patients. Read these studies, and take a hard look at different models available. I think you’ll come up with the motivation to consider hiring that half FTE to do an 8-minute (on average) screening and brief intervention for drugs and alcohol, and you’ll be fairly convinced that it’s as effective as anything else you’re doing in your practice.
There’s no reason to believe that drinkers treated in trauma centers or emergency departments are different from drinkers in general. For this reason, I believe the results of efficacy studies of interventions in treatment-seeking and primary care populations are applicable to populations in trauma centers and emergency departments.
Mike [Sise] has pointed out that efficacy data does exist. So, does this mean you don’t think a research agenda should come out of the recommendations of this meeting?
I am much more concerned about the education agenda. From my own experience and from discussion with colleagues at this conference, I believe that we have to take a hard look at the level of education, understanding and sophistication, and the approach of practitioners in many different venues. Those of us who are hospital-based—critical care, trauma critical care, or nontrauma critical care—do not have anywhere near the competence we need to understand this problem.
I don’t think there’s any question that the evidence supporting intervention programs does exist. The more important question is, “Once initiated, will we maintain interest and expand these programs?” Or, after a couple of years, will they just fade away because we didn’t take the next step and document our success? Efficacy has been demonstrated in relatively focused areas where studies have been done. Can we translate this to wherever trauma care is delivered—not in just a few centers, but in most centers?
I think it is important to note that it may not be legitimate to generalize results from studies in emergency departments to those in trauma centers. By definition, people who wind up in a trauma center are more seriously impaired, and we might be comparing apples and oranges when we group these two clusters of studies.
Regarding an earlier comment by Raul Caetano about screening in the emergency department, finding an injured alcoholic patient who is not drunk has got to be an extremely rare event. I don’t think that happens very often in trauma centers. I have a question for the panel. Paraphrasing Pareto’s law, “A small number of actors are responsible for a disproportionate share of the action.” Should trauma centers go beyond screening and address hardcore alcohol dependence?
The purpose of the broadening the base concept is that more people in the population are hazardous and harmful drinkers rather than what you are terming alcoholics. We prefer to use the term ‘dependent drinkers.’ They represent about 5 to 7% of the general population. However, because at-risk drinkers represent a much larger percentage of the population, they are responsible for the majority of injuries seen in trauma centers.
So, you’re saying Pareto’s law doesn’t hold here?
Right. Epidemiologically, this is quite clear. Dependent drinkers are the least likely to respond to brief interventions and should be referred to specialized treatment. In Project Match, patients seeking treatment and dependent drinkers had four sessions of motivational enhancement therapy and responded as well as patients who received 12 sessions of cognitive behavioral therapy. So, dependent drinkers do respond to shorter treatments, but a single brief intervention probably is not enough. Most of the people you’ll find in your trauma center are hazardous and harmful drinkers, not dependent drinkers. These are the people that are most likely to respond to brief interventions.
I want to address the issues involved in thinking about patients with different levels of alcohol and drug problems. Trauma centers treat patients who are binge drinkers, mild problem drinkers, social drinkers, and patients who have severe, chronic problems. As one of the authors of the Institute of Medicine report Broadening the Base of Treatment for Alcohol Problems,¶ I can say that we actually wanted to call it ‘Broadening the Base and Sharpening the Tip’— to emphasize that the methodologies for working with the hardcore addict, or the person who is severely alcohol dependent, also need to be refined. Two different models are required, but they have common elements. For the person who is the repeater, for the person who is resistant, we advocate the stepped-care approach. Treatment works; denial can be confronted and dealt with; commitment works. The alcohol commitment statute allows you to commit outpatients. There are various systems that can be used to engage the hardcore addict or alcoholic in maintenance activities. These patients suffer from a chronic relapsing disorder, similar to that experienced by diabetics, and they require long-term treatment and maintenance strategies. It is critical that screening protocols differentiate patients who need this type of extended treatment from ones who can benefit from brief interventions in nonspecialty settings. To accomplish this, trauma centers will need adequate relationships with systems and specialists who can assess, treat, and follow up with these hardcore patients. The Veterans Administration and the Department of Defense have just published new practice guidelines that clearly describe this process, step by step.# You don’t have to have motivation to change to engage in a meaningful therapeutic relationship. There are a variety of technologies that can lead to increases in success rates for the hardcore alcoholic and addict.
I want to return to questions about the best screening strategy. We really don’t need to decide between the BAC or the screening questionnaire. The problem with getting only a BAC is that 25% of trauma patients who have a negative BAC when they arrive at the trauma center will have a positive screening questionnaire. Several studies have shown that even if not drunk at the time, the patient in a trauma center is at a higher risk of having an alcohol problem. On the other hand, a large number of patients who have not had a positive screening questionnaire, nevertheless, have a positive BAC. A good example would be the college student who goes out on a particular night, has too much to drink, and thinks it’s okay to drive home. A minor crash occurs. The college student is not going to have a positive AUDIT but should be given information about the risk of driving at certain BAC levels and the number of drinks it takes to get to that level. This will instill an appropriate self-monitoring mechanism, which might prevent future incidents. The BAC and questionnaire-based screening instruments are complementary.
Alcohol treatment researchers are generally interested in outcome measures related to alcohol consumption, but trauma surgeons are interested in different outcome measures. I would recommend that subsequent studies include a health care economist because we, as trauma surgeons, are interested in trauma recidivism— the repeat visits from patients with substance-use disorders that cost hospitals money.
Trauma centers are ideal places to address substance-use problems because of the high prevalence of trauma patients with substance-use disorders, the ‘teachable moment’ that occurs during trauma care, and the fact that trauma centers are highly organized medical settings. For example, if we wanted to broaden the base [of treatment for substance-use disorders] into family medicine here in Washington, DC, there are probably 2,000 family medicine doctors we’d have to convince to do screening and interventions. Trying to get them all to do this would be like trying to transport a wheelbarrow full of frogs across the road. It will never happen. There is only one Level I trauma center in this city. All we have to do is convince that hospital to do it, and we’ll get all the seriously injured trauma patients in Washington, DC to undergo screening and brief intervention.
Substance-abuse researchers do have valuable methodological expertise, but they are more interested in foundational questions about how, why, when, and with whom treatment works than are trauma surgeons. We’re interested in translational studies, operational studies, and how to make this work in a trauma center. Until more trauma surgeons become involved in this type of research, research of interest to us will not get funded, will not be performed, and, if it is done, it will not be published in journals that we read. So, if we really want to broaden the base, funding agencies must restructure grant criteria to encourage collaborative efforts between substance abuse researchers and trauma surgeons.
Certainly National Institutes of Health (NIH) as a whole are moving very strongly toward collaborative efforts. The days of the lone researcher who works by him or herself until midnight in the lab is over. Trauma surgeons can become more competitive for grant funds by developing collaborative relationships with alcohol, drug, or health services researchers who have methodological expertise.
I think we should expand the list of donors we approach for research funding. Foundations run by large employers might be interested in these issues. I have participated in grant review panels at the Agency for Healthcare Research and Quality. This agency supports collaborative grants whose focus is translating research into practice.
What about the legalization of narcotics? This is an issue that should be seriously addressed by this conference. We’ve talked a lot about alcohol use, but what about the drug addicts? Over half of the injured patients admitted to inner-city trauma centers in Detroit have used or are using heroin or cocaine—almost 35 million Americans have used cocaine. I am recommending that narcotics be legalized to reduce profit motive, standardize dose, and eliminate the infectious complications.
How many participants feel that this is an important public health strategy? [About half the room responded favorably.]
Gathering data on the BAC of trauma patients is extremely important for a number of clinical reasons: to assess altered mental status in patients with possible traumatic brain injury, to evaluate the potential for withdrawal, or to evaluate whether a patient is sober enough to drive home. Blood alcohol concentration data can be useful for research and epidemiologic reasons, as well. For example, like results presented yesterday from the shock trauma center in Maryland, my service in San Antonio has shown a decline of BAC levels over a decade. However, I think integrating physicians and the health care system with law enforcement to ensure prosecution is a very bad idea. Our obligation is to the patient. With regard to denial of payment by insurance carriers, as chair of a Texas task force on this issue, I don’t believe it happens that often. When payment is denied, it most likely occurs only in very high-cost cases. Still, this is enough to discourage trauma centers from collecting BAC data. I believe the conference should recommend collection of BAC data. Also, I think a multicenter randomized clinical trial will be required to convince most trauma surgeons and decision makers that brief interventions can work in trauma services.
Raul Caetano and I have just started a study in a trauma center in Dallas, Texas. The study focuses on whether risk factors and the effectiveness of brief interventions vary by ethnic group. It also uses outcomes we feel are important to trauma surgeons in terms of not only injury recidivism, but also risk behaviors like safety belt use, getting into physical fights, using a gun, having a gun, and having been in those sorts of situations. The multidisciplinary project involves trauma surgeons and nurse clinicians, which we hope will increase future support of such efforts. On the issue of protecting screening information in patient records, my understanding is that if screening is done to identify and treat these people for an alcohol problem, then that information is protected. It’s more than just confidential; it’s protected information. Does 42CFR still confer this protection?
It does. However, to protect this information, it is very important that screening results be placed in a separate folder in the medical record. Medical records staff should also be trained to remove that section when the record is circulated. If BACs are used for screening, the results can and should go in that portion of the medical record; BACs collected for clinical reasons should be placed in the regular part of the medical record.
Even though studies have been done in emergency departments, we probably need trauma center studies as well. I think this stems from the fact that we treat very different subpopulations of patients. Social drinkers and dependent drinkers need not only different types of interventions, but also different amounts of follow-up and postintervention supervision. Data from Rhode Island Hospital indicate that 20% of patients who are documented drunk drivers are convicted of driving under the influence (DUI) within the next year and a half. I’m not convinced that a brief intervention is enough to get these people into treatment or off the street. Some may have problems severe enough to warrant commitment. Intervention research needs to account for these types of variations among trauma patients. Legislation might be required. We legislate seat belt use, and in some areas, motorcycle helmets, so why don’t we legislate penalties for this? I’m not necessarily promoting mandatory jail sentences, but we need a way to report these patients and get them into supervised treatment. The trauma surgeon’s responsibility is more than giving patients a card with a psychologist’s name on it or sending somebody else in to talk to them. We should make sure that something is happening to give them negative reinforcement for this behavior. There are many opinion leaders in the room, and all of you should support changes in insurance legislation that discourages checking a patient’s blood alcohol level. I believe reporting BAC levels should be mandatory.
To Dr. Cryer and my colleagues, this is no humbug. Screening and brief intervention are very well defined. There are some key program elements. It doesn’t matter if you do it yourself or a nurse does it or an educator does it or a social worker does it. There is compelling evidence that screening and brief intervention will reduce drinking among 50% of your at-risk patients. It’s also important to identify and refer alcoholics, but the focus of this conference is at-risk drinkers.
I’ve learned a lot at this conference and am very impressed that leaders in both trauma surgery and substance-abuse research have participated. The challenge we face is in working together toward a common goal. I do believe that an important component of this collaboration will be not only initiating this in our trauma centers, but also continuing meaningful research toward improving these programs so that the results become meaningful to the public.
*In contrast to a blood alcohol concentration (BAC) for example, a biological marker is a specific biochemical in the body that has a particular molecular feature that makes it useful for measuring the progress of disease or the effects of treatment, such as mean corpuscular volume or carbohydrate deficient transferrin. Cited Here...
†The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire developed by the World Health Organization as a simple screening instrument for problem drinking. It is sensitive to a broad spectrum of drinking problems, from early abuse to severe dependence. It has been validated in multiple settings including trauma centers and across genders and different cultural groups. The AUDIT questions are reproduced in the Hungerford DW: Interventions in Trauma Centers for Substance Use Disorders: New Insights on an old malady. J Trauma 2005; 59(Suppl): S10–S17. For a detailed overview, see Reinert DF, Allen, JP. The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research. Alcoholism: Clinical and Experimental Research. 2002;26:272–279. Cited Here...
‡William R. Miller is Director of Research at the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico. He is the co-developer with Stephen Rollnick of motivational interviewing theory and coauthor of Motivational Interviewing: Preparing People to Change Addictive Behavior. Cited Here...
§The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) sets the standards by which health care quality is measured in the United States and around the world. It accredits organizations, such as hospitals, based on how well they meet JCAHO standards. Cited Here...
∥Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004;61:498–506. Cited Here...
¶In this landmark report, the Institute of Medicine (IOM) responded to a call from congress to summarize the current state of knowledge about alcohol problems and their treatment. The document called for broadening the base of treatment because the committee concluded that most alcohol-related problems are caused by individuals who cannot be accurately categorized by the diagnostic terms alcohol abuse and alcohol dependence. They deliberately chose the term alcohol problems in preference to alcoholism or alcohol abuse because they wanted a term to represent the complete spectrum of severity. They also realized that alcohol problems could never be adequately addressed by alcohol treatment specialists alone. Instead, they recommended that staff in a variety of community and health care settings should provide screening for alcohol problems and brief, on-site interventions for screen-positive individuals with mild-to-moderate problems and help individuals with severe problems access more intensive treatment. (Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990.) Cited Here...
#The VHA/DoD clinical practice guideline for the management of substance use disorders can be accessed at http://www.guideline.gov/summary/pdf.aspx?doc_id=3169&stat=1&string=. Cited Here...
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