EFFECTS OF ALCOHOL AND DRUGS ON MANAGEMENT AND OUTCOME

The presence of alcohol significantly affects the initial management of trauma patients. Intoxicated patients are more likely to require intubation for airway control, intracranial pressure monitoring for neurological assessment, and more diagnostic tests such as CT scans to evaluate the abdomen.^5,6 Alcohol use may also increase the risk of death from serious injury. One study used data from more than 1 million drivers involved in a crash and controlled for the effects of variables such as safety belt use, vehicle deformation, speed, driver age, weather conditions, and vehicle weight, and found that intoxicated drivers were more than twice as likely to suffer serious injury or death compared with nondrinking drivers in a crash of equal severity.⁷

Patients with a history of chronic alcohol use are more likely to have underlying medical conditions such as cardiomyopathy, liver disease, malnutrition, osteoporosis, and immunosuppression. Acute, in addition to chronic, alcohol use may also affect outcome from trauma. Alcohol causes respiratory depression as well as vasodilatation that limits the ability to compensate for major blood loss. One study measured the amount of hemorrhage required to induce hypotension in dogs, and found that intoxication decreased this volume by one third.⁸ Acute alcohol intoxication has also been shown to be immunosuppressive. One study analyzed infectious complications in patients with penetrating abdominal trauma and hollow viscus injury.⁹ A blood alcohol concentration of 200 mg/dl or more was associated with a 2.6-fold increase in abdominal infectious complications, even after controlling for chronic use.

The effect of other drugs, alone or in combination with alcohol, has not been as rigorously studied. Heroin causes histamine release, which decreases systemic vascular resistance, and may potentiate the effect of blood loss. Cocaine, especially in its free-base form known as “crack,” has the opposite effect, and causes peripheral vasoconstriction, pupillary dilation, tachycardia, and hypertension. These effects may mask or mimic the sequelae of injury.

ALCOHOL AND INJURY RECIDIVISM

Traumatic injury is a recurrent disease, especially in patients with alcohol or drug use disorders.¹⁰ In a 5-year follow-up study of 263 alcohol intoxicated patients admitted to a level I trauma center, the readmission rate was 44%.¹¹ Although the mean age of the group was only 32 years, the injury-related mortality was 20%, with 70% of deaths attributed to continuing alcohol and other drug use. In a larger, more comprehensive study, over 27,000 patients discharged from a trauma center were followed using death certificate searches to detect postdischarge mortality. Patients who screened positive for an alcohol use disorder had a 35% injury-related mortality rate during the study period, which was significantly higher than patients who screened negative.¹²

WITHDRAWAL SYNDROMES: PROPHYLAXIS AND TREATMENT

Withdrawal is characterized by signs and symptoms that are the opposite of the pharmacologic effects of the drug involved. The four primary categories are alcohol, sedative hypnotics, opiates, and stimulants. The goals of prophylaxis and treatment of alcohol withdrawal syndromes are to minimize the risk of complications such as seizures, delirium tremens, and cardiovascular morbidity that occurs as a result of sympathetic overload.

Symptoms from cessation of short-acting drugs like alcohol may emerge within 24–48 hours, while withdrawal from long-acting drugs like chlordiazepoxide or methadone may not emerge for 3–5 days. Alcohol and sedative hypnotics have similar pharmacologic effects. Patients in the intensive care unit often receive benzodiazepines, leading to a delay in manifestations of alcohol withdrawal until after the patient is transferred to the floor. After 4 or 5 days it is no longer clear if symptoms should be attributable to alcohol or to benzodiazepine withdrawal, although treatment is similar.

Two main types of alcohol withdrawal prophylactic regimens exist. The first is symptom-triggered therapy, and the second is fixed-schedule dosing with a taper. Symptom-triggered therapy reduces the amount of medication administered, as many patients develop only mild symptoms that do not require therapy.¹³ Symptoms are measured using a questionnaire such as the Clinical Institute Withdrawal Assessment–Alcohol Revised short form (CIWA–Ar), which measures 10 signs and symptoms of alcohol withdrawal on a 0–7 scale (nausea, tremor, autonomic hyperactivity, anxiety, agitation, tactile, visual and auditory disturbances, headache, and disorientation).¹⁴ Treatment is titrated to maintain a score in the mild (8–10) range. Although the CIWA–Ar has been used in general medical settings, it requires training and experience, must be repeated at regular intervals, and is not feasible in critically injured patients. For these reasons, fixed-scheduled dosing is commonly practiced in most trauma intensive care units.

All currently existing guidelines recommend the use of benzodiazepines as a primary therapy for alcohol withdrawal.¹⁵ Agents with a short to moderate half-life such as lorazepam are often used when frequent neurological assessments are needed, but may require increased overall dosage and more frequent administration in comparison to the longer-acting benzodiazepines such as diazepam and chlorodiazapoxide. Longer-acting drugs are preferred because slow elimination provides an intrinsic tapering effect.

The administration of alcohol for prophylaxis, either intravenously or orally, is no longer considered acceptable. Alcohol may block some of the autonomic effects of withdrawal, but it lowers the seizure threshold, is difficult to titrate, is highly toxic to tissues in the event of extravazation, increases the risk of gastric mucosal bleeding, may increase liver transaminase levels, and may precipitate acute liver failure in critically ill patients with reduced hepatic reserve.

There is a role for adjunctive agents such as beta blockers, clonidine, and neuroleptics, but none of these should be considered as primary therapy, and they should not be started until adequate doses of benzodiazepines have been administered. These agents do not prevent withdrawal syndromes, and may increase the incidence of delirium tremens by selectively reducing autonomic manifestations and agitation, causing delayed recognition of worsening withdrawal.

The principles of preventing and treating sedative-hypnotic withdrawal are similar to those used for alcohol. Management consists of substituting short-acting agents for longer-acting ones, and tapering the dose by 20% per day over 5 days. Cessation of stimulant use such as cocaine or methamphetamine is characterized by symptoms of depression and a substantial risk of suicidal behavior due to depressed cerebral dopamine levels.

Patients with opiate dependence may experience flu-like symptoms as the dose is tapered. Withdrawal from opiates may also be delayed in onset due to appropriate use of analgesics in trauma patients. Opiate withdrawal is highly stressful, but is not usually dangerous, as symptoms are much less severe than those seen with alcohol or benzodiazepine withdrawal. However, attempts to wean addicts on chronic methadone maintenance are inappropriate in an acute care setting. Their dose should be considered as maintenance, and additional opiates provided as needed for pain.

DEFINITION OF ALCOHOL PROBLEMS

Physicians typically identify patients with advanced or late-stage dependence, and ignore or fail to recognize less severe substance use problems. As a result, their primary experience is with patients who are least likely to quit or reduce their drinking. Alcohol problems exist across a broad spectrum of problem severity, from binge drinking to end-stage dependence. Classifying all patients who consume excessive amounts of alcohol as “alcoholic” is neither appropriate nor diagnostically accurate.

Some patients have a drinking problem that can be described as “risky” or “hazardous.” They have not yet had any harm or consequences as a result of their drinking, but their level of consumption places them at high risk. In the United States this has been defined as more than seven drinks per week or more than three drinks on any one occasion for women, or more than 14 drinks per week or more than four on any one occasion for men.

Further along on the severity continuum are patients who meet diagnostic criteria for alcohol abuse. Alcohol abuse is defined as a pattern of repeated consequences involving health, relationships, employment, financial, or legal status that occur as a result of excessive alcohol intake. However, alcohol abusers are not addicted to alcohol. Alcohol dependence (alcoholism) is present in patients who have repeated consequences, but also experience loss of control, craving, and symptoms of withdrawal upon cessation of alcohol intake due to addiction.

The Institute of Medicine has recommended using the phrase “alcohol problems” as a more comprehensive term to describe patients with any type of abnormal drinking pattern.¹⁶ Patients with less severe problems are responsible for the greatest proportion of the societal burden caused by alcohol use. Patients with severe dependence have a disproportionate share of alcohol-related consequences. However, most alcohol-related injuries occur in patients with mild to moderate problems because such patients constitute the greatest proportion of problem drinkers.

RATIONALE FOR BRIEF ALCOHOL INTERVENTIONS IN TRAUMA CENTERS

As a result of their intimate association with and influence on traumatic injury, alcohol use disorders are promising targets for injury prevention programs. Patients with an alcohol problem may not seek treatment for their problem, but they often receive treatment for medical conditions caused by their alcohol use. Injuries are the most common medical condition for which patients with an alcohol use disorder receive medical attention.¹⁷

A recent analysis of 12 randomized brief intervention trials, each of which was limited to one session and consisted of less than 1 hour of motivational counseling, demonstrated that brief interventions were associated with a reduction in hospital admissions, use of emergency department and trauma center resources, and medical costs.^18,19

A randomized, prospective trial of brief interventions in injured adolescents demonstrated significant reductions in drinking and driving, moving violations, alcohol-related problems, and a greater than 50% reduction in alcohol-related injuries.²⁰ In a prospective, randomized trial conducted on adult trauma patients, at 1-year follow-up members of the intervention group decreased their alcohol intake by 22 drinks per week, compared to a two-drink reduction in the conventional care group.²¹ There was a 47% reduction in new injuries requiring treatment in the emergency department, and a 48% reduction in injuries requiring hospital admission in the intervention group patients with up to 3 years follow-up. A recent cost-benefit analysis demonstrated a savings in direct injury-related medical costs of nearly four dollars for every dollar invested on screening and intervention programs conducted in trauma centers.²²

Brief interventions may also be of use in patients with drug use disorders.²³ A recent randomized clinical trial conducted in an inner city teaching hospital compared brief interventions for cocaine and heroine use with standard care. At 6 months follow-up, hair was sampled for radioactive immunoassay to detect drug use. The intervention group had a greater than 50% increase in abstinence rate, and cocaine levels in the hair were reduced by 29% in the intervention group, compared to 4% in controls.

The provision of screening and brief interventions is consistent with the scope, mission, and responsibilities of trauma centers. Trauma centers currently provide a variety of rehabilitative services, including physical and occupational therapy, nutrition services, and speech therapy. Resource allocation and staffing patterns should reflect the fact that the form of rehabilitative therapy most likely to be needed by a trauma patient is alcohol counseling.

Recognizing this, the Committee on Trauma of The American College of Surgeons, in the newest edition of its document on optimal resources for the care of trauma patients, has deemed the ability to screen for alcohol problems and the provision of brief interventions to patients who screen positive an essential service required to attain verification as a level I trauma center.²⁴ This is a major step toward raising the level of awareness of the importance and efficacy of treatment for alcohol use disorders in acute medical settings.

SCREENING FOR ALCOHOL PROBLEMS

Reliance on clinical judgment alone to detect alcohol problems has poor sensitivity and specificity, and is subject to discriminatory bias.²⁵ A study that examined the ability of trauma center staff to detect alcohol use disorders found that physicians and nurses were unable to detect alcohol intoxication in one third of significantly injured patients, and they failed to identify more than half of the patients who screened positive for a chronic alcohol problem. Thus, a formal method of screening using questionnaires and a blood alcohol concentration, and if indicated, a urine toxicology screen, is needed to maximize sensitivity and specificity.

The CAGE questionnaire is a widely used alcohol screening instrument. It takes its name from the four questions of which it is comprised. These questions inquire about the need to “Cut down on your drinking,” being “Annoyed by people criticizing your drinking,” “having felt bad or Guilty about drinking,” and ever having “a drink in the morning (Eye-opener) to steady your nerves or get rid of a hangover.”²⁶ Although widely used, brief, and easy to administer, the CAGE is useful primarily for the detection of severe problems such as dependence, and is relatively insensitive to mild problems, which limits its utility as a screening tool for trauma center use.

The AUDIT, or Alcohol Use Disorders Identification Test, is a 10-question screening instrument developed by the World Health Organization in 1992 as a brief screening tool.²⁷ It is specifically designed to be sensitive to at-risk drinking, as well as alcohol abuse and dependence. It takes approximately 5–10 minutes to administer, has been validated in trauma patients, and is currently the most widely recommended screening tool for use in trauma centers.

GOALS OF BRIEF INTERVENTIONS

Brief interventions typically target patients with hazardous drinking or abuse, rather than more severe disorders such as dependence. However, in the context of a trauma center, where the intervention is provided in an opportunistic manner by individuals who are usually not specialists in counseling, the focus should not be on establishing a specific diagnosis or severity level, but on capitalizing on the effect of the recent injury to increase the patient’s awareness of the need to consider behavioral change. The recommended change would take into account the patient and interventionist’s perception of the nature of the drinking problem, and the type of change that represents a realistic and achievable goal for the patient.

For patients with a mild problem, or a binge drinker, an appropriate goal might be to stay within recommended safe limits of consumption, avoiding certain activities (driving) while using alcohol, learning to pace drinks, and avoiding drinking on an empty stomach. On the other end of the spectrum, for patients with dependence, the recommendation provided may be for the patient to seek more formal treatment within the public or private sector, or change by means of self-help groups such as 12-Step programs.

SUMMARY

Whether alcohol use is considered a comorbidity of trauma, or trauma is considered a comorbidity of alcohol use problems, the impact on society, the health care system, and the patient are significant. Regardless of whether alcohol use problems are considered a medical, behavioral, or legal problem, we know that like injury, there are clinical, educational, economic, and engineering strategies that can be used to control the prevalence and severity of these two entities. An injury requiring hospitalization creates a crisis that provides a unique opportunity to intervene and to motivate patients to alter their drinking behavior. Ignoring this important opportunity afforded to the health care provider represents a dis-service to the patient and society.

Key Points

Alcohol and drug use disorders are the leading risk factor for injury.

Alcohol problems exist across a broad spectrum of problem severity, ranging from occasional binge drinking to chronic dependence.

Optimal detection of alcohol problems requires combined use of a blood alcohol measurement and a screening questionnaire.

Brief alcohol interventions have been shown to significantly reduce subsequent alcohol intake, trauma center readmission, and health care costs.

Brief alcohol interventions are consistent with the time, financial and staffing constraints of a typical busy trauma center.