The ASAM Principles of Addiction Medicine 5th Edition

81. Traumatic Injuries Related to Alcohol and Other Drug Use: Epidemiology, Screening, and Prevention

Federico E. Vaca, MD, MPH, FACEP and Gail D'Onofrio, MD, MS

CHAPTER OUTLINE

■  EPIDEMIOLOGY OF ALCOHOL- AND OTHER DRUG-RELATED INJURY

■  EFFECTIVE SCREENING IN INJURED PATIENTS

■  INTERVENTIONS WITH INJURED PATIENTS

■  INCORPORATING SCREENING AND BRIEF INTERVENTION INTO PRACTICE

Alcohol and other drug (AOD) use contributes to a substantial proportion of injury events, including falls, motor vehicle crashes (MVCs), assaults, drownings, homicides, and suicides. Research evidence shows that injured patients who also have alcohol and drug use disorders suffer more frequent and severe complications than other injured patients. These events, in turn, lead to significant morbidity and mortality, with far-reaching implications for the individual, their family, workplace, and society. This chapter discusses the role of AODs in traumatic injury. It also provides information on the effectiveness of screening instruments for injured patients in the emergency department (ED) and inpatient settings. The clinician’s role in identifying AOD disorders in injured patients is discussed, as are the components of brief intervention and referral to treatment.

Though most of the research done to date in an injury context relates to alcohol, the body of literature related to other drugs in the emergency medicine literature continues to grow and will be referenced throughout the chapter. The objective of the chapter is to provide clinicians with the information and tools required to incorporate screening and brief intervention into routine practice. In this manner, the hope is to ultimately reduce both the risk of injury and adverse consequences associated with AOD use in this highly vulnerable group of patients.

EPIDEMIOLOGY OF ALCOHOL- AND OTHER DRUG-RELATED INJURY

Overall Risks

There are risks of alcohol-related injuries across the entire spectrum of drinking from low risk amounts through a severe alcohol use disorder. Nearly 50% of major trauma cases (1) and 22% of minor trauma cases (2) have been found to be alcohol related. The proportion of positive blood alcohol concentrations (BACs) among injured patients presenting to EDs ranges from 6% to 34% (3). Alcohol is a major risk factor for virtually all categories of unintentional and intentional injuries (312). Of the 140,000 to 150,000 deaths that occur in the United States each year as a result of traumatic injuries, a significant proportion is related to use of alcohol or other drugs. Data from the National Mortality Followback Survey and the National Longitudinal Alcohol Epidemiologic Survey show that persons with a drinking history have a significant increased risk of fatal injury from a multitude of mechanisms of injury, including drowning, firearm homicide, suicide, and unintentional poisoning (13). Other data support the relationship between alcohol and fatal injuries. Injury is the leading cause of death in the United States for persons aged 1 to 44 years (14), whereas MVCs are the leading cause of death for persons aged 4 and for those aged 11 through 27 years (15).

Alcohol and Motor Vehicle Fatalities

According to the National Highway Traffic Safety Administration, 31% of motor vehicle fatalities (approximately 9,878 people) were alcohol related in 2011 (16). The annual cost of these alcohol-related MVCs is approximately $51 billion. More than 50% of those who are arrested for driving under the influence (DUI) have an alcohol use disorder, and many require medical care for injuries related to MVCs. Furthermore, an arrest for DUI is an independent indicator of risk of death in a future MVC (12). This indicator has been demonstrated to be valid for all age groups, and the association becomes stronger with increased age at the time of DUI arrest.

Over 50 years ago, Haddon and Bradess (17) documented that alcohol was a factor in about half of single-vehicle crashes. The statistic remains significant today, as nearly one-third of the approximately 33,000 fatal MVCs in the United States each year are related to alcohol use (18). Alcohol has been implicated as a contributing factor in 40% of crashes involving serious injury, 30% of crashes involving minor injury, and 10% to 15% of minor crashes. Furthermore, research shows that postdeployment military personnel may be at greater risk for alcohol-related crash fatality, particularly in late-night to early-morning crash scenarios (19).

Alcohol and Non-Motor Vehicle–Related Injuries

Alcohol is involved in 42% of pedestrian fatalities, 60% of fatal burns (often related to cigarette smoking), and an unknown percentage of work-related injuries and drownings (20,21). Studies of boating fatalities show that 60% of the victims tested positive for alcohol, and 30% had BACs greater than 100 mg% (22). Alcohol and violence are closely linked. Cherpitel (3) found that persons older than 30 years who sustained violence-related injuries were more likely to have a positive alcohol breath test (e.g., Breathalyzer) reading, to report drinking before the event, and to report a significant history of alcohol-related problems as compared with persons who experienced other types of injuries. In a study of adult patients who came to an ED for treatment of minor injuries, 6% had positive saliva alcohol tests (SATs) or blood alcohol tests, 9% were positive on at least one question of the CAGE screening questionnaire, and 6% were positive on both the saliva test and the CAGE (2).

Mannenbach et al. (23) examined the scope of alcohol use in a population of 243 injured adolescents. Using urine tests, they found results positive for alcohol use in 33% of adolescent patients injured in MVCs (including 38% of drivers), 37% of patients who attempted suicide, and 44% of assault victims. In another study of adolescents aged 12 to 20 years, positive SAT results were found in up to 4% of injured patients who arrived at the ED within 6 hours of injury (24). A study comparing drinking problems in injured versus noninjured emergency patients documented that injured patients were more likely to test positive for use of alcohol, to report heavy drinking, to report prior alcohol-related injuries, and to report a history of treatment for alcohol problems than were patients who sought treatment for other disorders (25). This finding was true of patients who were treated in county or community hospital EDs, as well as patients who were treated in hospitals affiliated with health maintenance organizations (25). In another study, daily drinking, binge drinking, and heavy drinking were each associated with increased likelihood of injury as the underlying cause of death (14).

Relationship between Alcohol, Other Drugs, and Injury

Elucidating the specific relationship between alcohol, other drugs, and injuries is difficult for several reasons: (a) Few studies have been conducted at the time of injury; (b) there are few standards for reporting data about AOD use; (c) alcohol and drug use is underreported on death certificates and hospital discharge data; (d) there is bias in the reporting of alcohol-related deaths; and (e) there is insufficient information on exposure to AODs in control populations (10). In a review of 32 studies of the association between alcohol use and injuries or fatalities from fire and burns, Howland and Hingson (10) found that nearly half of those who died in fires had BACs above 0.10 and that alcohol was an important risk factor for fire and burn injuries associated with cigarette smoking. In addition, as with MVCs, studies conducted to determine the role of alcohol in injuries related to boating and swimming have implicated alcohol as a major risk factor for boating fatalities (26).

Work-related injuries, including injuries requiring hospitalization, were found to be more likely in persons who had an average daily intake of five drinks, compared to abstainers, and in those who used psychoactive drugs (11). Finally, onset of alcohol use at ages younger than 21 years was associated with experiencing an alcohol-related injury (27). Studies that have compared alcohol consumption in the general population with that of injured patients in the ED demonstrate a clear association between alcohol consumption and injury (3,2830). One study found that injured patients presenting at the ED were five times more likely to report a higher quantity and frequency of alcohol consumption than were control subjects. In that study, positive screening results and recent alcohol consumption (i.e., <6 hours before hospital admission) were associated with an increased risk of injury resulting in an ED visit (28).

In a nonsystematic review, data derived from studies that have used probability sampling and compared the prevalence of alcohol problems in patients with and without violence-related injuries indicate that patients with violence-related injuries were more likely to have positive breath or BACs than those with nonviolent injuries (30). However, the prevalence of a positive BAC in injured patients varied considerably across the studies, because of both the method of measurement and decisions about a cutoff value for a positive test result (30).

Alcohol, Other Drugs, and Trauma Patients Admitted to the Hospital

Studies of trauma patients examined those patients with more serious injuries and generally excluded patients who had been discharged from the ED to home or patients who were admitted to the hospital for treatment of single-system injuries, such as isolated extremity fractures. Many of the studies were conducted as retrospective reviews of blood alcohol testing and were based on clinical algorithms or subjective decisions by physicians to test, which could lead to selection bias in the samples. In one of the few studies that examined substance use disorders in trauma patients, Soderstrom et al. (31) found that 54% of 1,118 adult trauma patients at one high-volume northeastern US trauma center over 1 year had a lifetime history of a substance use disorder. In addition, 24% had a current diagnosis of alcohol dependence, and 18% had a current diagnosis of dependence on other drugs. Medical examiners’ reports provide insight into the role of alcohol in deaths resulting from traumatic injuries. A meta-analysis of 331 medical examiner studies found that, in 39% of unintentional deaths resulting from injuries, there was evidence of alcohol intoxication (BAC of at least 100 mg/dL) (32). A separate analysis of studies published between 1985 and 1991 implicated alcohol in 35% to 63% of fatal falls and in 13% to 37% of nonfatal falls. In addition, alcohol was identified in 21% to 47% of cases involving drowning fatalities and in 12% to 61% of fatalities from burns (33). In a study of the role of alcohol in bicycle injuries, persons who died were more likely to have had positive BACs (30% vs. 16%) than were those who were injured but did not die (21).

Cocaine Use and Injuries

The role of cocaine use in injuries or fatalities has been studied less frequently than that of alcohol. One study that employed medical examiners’ records found that as many as 25% of those killed in MVCs had used cocaine within the 24 hours preceding the crash and that 10% had used cocaine and alcohol in combination (34). A separate study found that 31% of homicide victims had used cocaine but failed to find an association between having used cocaine and being killed by a firearm (35). The association between cocaine use and risk-taking behavior leading to fatal injury was evaluated in a unique examination of deaths in participants playing Russian roulette (a deadly game of chance where an individual manually spins the cylinder of a handgun that has at least one bullet, places the gun to the head, then pulls the trigger). Illicit drugs or alcohol was detected in 79% of cases of death resulting from Russian roulette and in 61% of control subjects who committed suicide with a handgun (36). An evaluation of 14,842 fatal injuries found evidence of cocaine in 27%. Of these deaths, approximately one-third were the result of drug intoxication, and two-thirds involved traumatic injuries resulting from homicides, suicides, MVCs, and falls (37). Despite these findings, concerns exist that there has been an underestimation of the role of cocaine in injury or fatality based on evidence of underreporting in the federal Drug Abuse Warning Network, which collects data on ED visits and drug-related deaths (38).

Drugs and Motor Vehicle Injury

Based on the National Survey on Drug Use and Health, an estimated 10.6 million people aged 12 or older, or 4.2% of the population in this age group, reported DUI of illicit drugs. The rate for 2010 was highest among young adults aged 18 to 25 (12.7%). Other drug use has been identified as a major hazard to road traffic safety. Marijuana is the most prevalent illegal drug used and known to be associated with a significantly increased risk of being involved in MVCs. The National Highway Traffic Safety Administration’s 2007 Roadside Survey that randomly stopped and enrolled nearly 11,000 drivers across 300 locations in the United States noted drugged driver prevalence to be as high as 11% during the daytime and over 16% for nighttime. For nighttime drivers, marijuana and cocaine were the most commonly detected drugs in drivers (39). Studies of trauma patients injured in MVCs have documented the use of benzodiazepines, cocaine, opiates, and amphetamines (40). An earlier study of drug use with and without concomitant alcohol use among injured drivers found that 14 (6.6%) of 211 injured drivers tested positive for drugs (amphetamines, barbiturates, benzodiazepines, cocaine, cannabis, and opiates) alone, while 12 (5.7%) of 211 tested positive for alcohol and drugs in combination (41).

EFFECTIVE SCREENING IN INJURED PATIENTS

Principles of Screening

Screening involves the identification of disorders in patients without known disease. It is distinct from case finding, in which patients for whom there is a high clinical index of suspicion of a disease undergo assessment to confirm the diagnosis. Screening is indicated in disorders that meet the following criteria: (a) The disorder has significant prevalence and consequences in the population; (b) there are effective and acceptable treatments for the disorder; (c) early treatment is preferable to later treatment; (d) screening instruments with good operating characteristics are available; and (e) screening instruments are easily administered. Screening for substance use disorders in patients with traumatic injuries meets all of these criteria.

As the foregoing criteria indicate, screening instruments should have specific characteristics to allow for their use in clinical situations. First among these characteristics is good accuracy in identifying patients with the disorder among all those who are screened. Screening tests that are applied to large groups of patients, many of whom do not have the disease, perform best when they have high sensitivity (a low rate of false negatives) and adequate specificity (a low rate of false positives). Other desirable features include brevity, utility in diverse demographic and clinical populations, and low cost.

Screening for Unhealthy Alcohol Use in the Emergency Department

Unhealthy alcohol use occurs across a clinical spectrum in the ED from at risk to dependence. When needed, screening and intervention may take place at almost any time during the ED visit. The important consideration is that there be a protocol or routine for screening and intervention that is based on the resources of the ED. The screening can be part of the history taken by the nurse, physician, or other ED staff member who has been trained in screening. Even equipping an ED staff member with a screening health technology tool has been shown to be feasible in the ED setting (42,43). Interventions are targeted to the patient, and the goal may be to motivate the at-risk drinker to reduce their drinking into lower-risk limits or change behaviors for harmful drinkers such as not driving after drinking or may be to motivate the drinker with an alcohol use disorder to accept a referral to specialized treatment. Patients being admitted to the hospital from the ED may receive screening and intervention when their condition permits, which may mean that for some patients the screening and intervention take place after admission.

At-risk drinking generally is defined as drinking over the National Institute on Alcohol Abuse and Alcoholism (NIAAA) limits (men: more than 4 drinks on any single day OR more than 14 drinks per week; women and men over age 65: more than 3 drinks on any single day OR more than 7 drinks per week) (44). This level of alcohol consumption puts patients at risk for future alcohol-related consequences because of the amount they drink or the effect of alcohol on any comorbid medical conditions. Harmful drinkers experience negative consequences that may be medical, social, and/or legal. This includes poor work or school performance; fighting with friends, spouses, parents, etc.; car crashes; or even DUI. Patients on the severe end of the spectrum of alcohol use disorders often experience significant and repeated negative physical and social effects from their alcohol use, including the cardinal signs of tolerance and withdrawal (45). These diagnostic classifications are useful to clinicians because they allow patients to be stratified according to disease severity and are useful in making treatment recommendations. In addition, the classifications affect the choice of a screening tool for use in identifying patients with unhealthy alcohol use in the clinical setting. Studies of screening instruments for unhealthy alcohol use in the ED have historically focused on the CAGE, TWEAK, and AUDIT with an effort to identify the most harmful spectrum of alcohol consumption, including alcohol use disorders, and so provide little empirical evidence to guide screening for at-risk drinking (46,47). However, recent alcohol Screening Brief Intervention and Referral to Treatment (SBIRT) initiatives have focused on at-risk/harmful drinkers. The evidence has supported the use of brief, formal screening questionnaires such as the NIAAA quantity and frequency questions, the AUDIT-C (the first three questions of the AUDIT that covers quantity, frequency, and intensity of drinking), and recently the ASSIST in preference to clinical recognition or laboratory analyses such as the BAC or SAT (46,4852). The AUDIT has been particularly used for research programs. However, it can be difficult for practitioners to use as it is 10 questions and needs to be scored.

The AUDIT-C was shown to have a sensitivity of 97% and a specificity of 65% for harmful or hazardous drinking (53). In contrast, breath alcohol analysis has been shown to have limited utility in screening, with a sensitivity of 20% to 28% and a specificity of 94% to 97% (50,54). Blood alcohol analysis is similarly disappointing: One study found that the presence of alcohol dependence and other psychoactive substance use disorders was similar in trauma center patients with positive BACs (76%) and negative BACs (62%) (32). The proportion of positive BACs was low even among patients arriving after motor vehicle accidents (55).

The operating characteristics of screening instruments for unhealthy alcohol use in emergency settings have been shown to vary with ethnicity, gender, and nature of the alcohol problem (56–59). While national concerted efforts to close alcohol-related health disparity gaps exist, more research that is focused on addressing racial and ethnic differences in alcohol use disorders in ED populations is needed.

Given that nondependent use is responsible for a considerable proportion of alcohol-related injuries, screening approaches such as the AUDIT-C and the NIAAA single-item screeners (How many times in the past year have you had X or more drinks in a day? For men X is 5, and for women X is 4. A response of ≥1 is considered positive) querying consumption remain strongly favored (60).

INTERVENTIONS WITH INJURED PATIENTS

Alcohol- or other drug-related injury provides a unique opportunity for brief intervention. The negative consequences of the injury can create what has been described as a “teachable moment”—a unique opportunity to motivate patients to change their behavior or to encourage them to seek further treatment. Empirical evidence supports the hypothesis that the aversive nature of the injury and perception of the degree of alcohol involvement in an injury event are predictive of patients’ readiness to change. As shown by control groups that are minimally assessed in randomized brief intervention trials, many of these patients may change their alcohol drinking behavior to some extent on their own and without formal brief intervention. In a study in an ED of patients who were injured in MVCs and who had been drinking alcohol, Cherpitel (61) found that more than one-third connected their alcohol use to the injury event. In addition, the ED presents rich opportunities for such interventions, as research shows that a higher proportion of patients in emergency settings than in other settings have unhealthy alcohol use. One study compared patients from the same metropolitan area who went to an ED with those who went to primary care settings and found that the ED patients were one-and-a-half to three times more likely to report heavy drinking, negative consequences of drinking, alcohol dependence, or prior treatment for alcohol-related problems than patients in a primary care clinic (25).

Brief interventions not only can reduce alcohol use but also may reduce the incidence of alcohol-related injuries.

One systematic review of the effectiveness of such interventions in preventing injuries evaluated 19 randomized controlled trials and found that addressing problem drinking was associated with a reduction in suicide attempts, domestic violence, falls, drinking-related injuries, hospitalizations, and deaths (62). In seven trials that compared interventions with a control group, nearly all showed a decrease in injury-related outcomes. The effect size of these decreases ranged from a 27% reduction in drinking-related injuries to a 65% reduction in accidental and violent deaths. Of note, interventions among convicted drunk drivers reduced the number of MVCs and related injuries. However, it is not clear from this literature whether the mechanism of action of the interventions was reduced alcohol consumption or decreased risk taking (62). Another more recent systematic review and meta-analysis showed that brief interventions were associated with half the odds of suffering an alcohol-related injury (63).

Brief interventions involve counseling sessions that require 5 to 45 minutes. Such interventions often incorporate the six elements proposed by Miller and Sanchez (64), which are summarized by the mnemonic FRAMES: feedback, responsibility, advice, menu of options, empathy, and self-efficacy. Other elements that have been shown to support the efficacy of brief interventions include goal setting, follow-up, and timing (65).

While there have been some mixed results in ED SBIRT studies, several have recently shown promising outcomes (42,66,67). The Academic ED SBIRT (screening, brief intervention, and referral to treatment) Research Collaborative (66) group studied patients who drink over the NIAAA lower-risk limits in 14 ED sites nationwide. A quasi-experimental comparison group was used in which control and intervention patients were recruited sequentially at each site. At 3-month follow-up, the brief intervention group reported consuming 3.25 fewer drinks per week than the controls (B = −3.25 95% CI [−5.75, −0.75]). At-risk drinkers appeared to benefit more from the BI than did dependent drinkers.

In more recent randomized controlled studies, results have strengthened the evidence for the efficacy of brief interventions in the ED setting. Neumann (42) used a computer-generated brief intervention for at-risk drinkers who presented with minor injury to a German ED. The intervention group had a significant decrease in alcohol intake at 6 months compared with the control group (35.7% decrease compared with 20.5% decrease in controls; p = 0.006). This significant decrease persisted at 12 months. Longabaugh et al (68) studied injured adolescent and adult ED patients and reported a significant decrease in alcohol consumption in both the intervention and the control conditions. Monti et al. (69) divided 74 patients 18 and 19 years of age in a randomized manner to receive either brief intervention or standard care. At 6-month follow-up, the brief intervention group had a significantly lower incidence of drinking and driving, traffic violations, alcohol-related injuries, and alcohol-related problems, including trouble with parents, school, friends, dates, or the police. Over the same time period, patients in both groups significantly reduced their alcohol consumption from baseline. Longabaugh (68) found similar results in the group that received an intervention and booster 1 month later.

More compelling evidence is offered by D’Onofrio et al. (70) who found that brief interventions performed by emergency practitioners reduced hazardous and harmful drinking in ED patients. This randomized controlled trial study addressed several methodologic limitations in previous negative ED SBIRT studies. Reductions from baseline to 12 months in the mean number of drinks per week were 7.4 (intervention group), 5.5 (intervention and booster phone call at 1 month by a nurse) compared with the 3.3 in the control group (p < 0.045), and 2.8, 2.1, and 1.4, respectively, in the number of monthly bingeing episodes (p = 0.03). The reductions in rates of driving after drinking more than 3 drinks from baseline to 12 months were greater in the intervention group (38% to 29%) than the intervention and booster (39% to 31%) than in the control group (43% to 42%), p = 0.04.

Brief intervention trials for at-risk alcohol use performed in the ED setting have yielded mixed results, and several trials reporting efficacy are presented here. To date, there are considerably less data and research available on ED-based brief interventions for other drugs. However, at least one randomized controlled trial has shown efficacy of brief interventions to reduce marijuana consumption and to promote marijuana abstinence (71). Sponsored by the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN), another randomized controlled trial, the Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), is currently being completed (72).

INCORPORATING SCREENING AND BRIEF INTERVENTION INTO PRACTICE

As discussed earlier, screening instruments vary in terms of their effectiveness, availability, ease of administration, and test characteristics (73). In most settings where injured patients are treated, such as EDs and trauma centers, time is short, and competing priorities make screening and brief intervention a challenge. Therefore, screens that are short and simple and that can be administered by a variety of providers—nurses, physicians, social workers, and health promotion advocates—have a greater chance of being used.

Screening for unhealthy alcohol use in injured patients should detect the entire spectrum of use, including at-risk and harmful drinkers and drinkers with alcohol use disorders. Such detection is important because nondependent drinkers may benefit most from brief intervention and referral to a primary care provider. Brief interventions may include advice only or incorporate some motivational enhancement techniques. For the at-risk drinker or the patient who has sustained an alcohol-related injury but does not have a moderate-to-severe alcohol use disorder, setting goals within safe limits, coupled with a referral to the patient’s primary care physician, may be all that is needed. For the patient with drug use but no moderate to severe disorder, negotiating abstinence or harm reduction, such as no use while driving, with a referral to primary care may be sufficient. For the patient who has a moderate to severe substance use disorder or the clinician who is uncertain as to where a patient fits on the continuum of unhealthy substance use, the brief intervention becomes a negotiation process to seek further assessment or referral to a specialized treatment program (74).

The contents of such a brief intervention are outlined in Table 81-1. Using this information, the authors recommend that each institution develop a program and resource list tailored to the needs of its own community.

TABLE 81-1 BRIEF INTERVENTION FOR INJURED PATIENTS

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