Alcohol and Drugs
There are over 1,675 trauma centers in the United States. Although there are still gaps in coverage, particularly in rural areas, 82% of the U.S. population has rapid access to a trauma center. And, there is a 25% reduction in mortality after injury with trauma center care compared to treatment at a nontrauma center. The rapid development of trauma centers and systems across the United States is one of the most important developments in the history of surgery.1
Despite this success, injuries are still the fifth leading cause of death. This figure actually understates their impact. Years of Potential Life Lost (YPLL), which subtracts the age a person dies from their life expectancy, is a better measure of burden of disease. When a man in the United States dies from an injury at the age of 20, the YPLL is 58 because the average life expectancy for a man in the United States is 78. If he dies of heart disease at the age of 77, there is only one YPLL.
Heart disease causes five times the number of deaths as injuries, but injuries account for one and one half times as many years of life lost, and more than the amount attributable to all malignant neoplasms.2 Thus, the task of reducing injury-related mortality is far from complete.
In a 12-year longitudinal study that tested the impact of a rigorous emphasis on continuous quality improvements, the center involved was unable to reduce major complications or mortality during the entire study period, despite implementation of numerous protocols.3 The authors concluded that mature trauma centers have already reached the limits of their effectiveness at reducing injury-related deaths. Further reductions in trauma mortality will require new strategies.
The reasons for this were demonstrated in a study that looked at 753 consecutive deaths in a trauma center.4 Over 40% of those who died received cardiopulmonary resuscitation in the field and had nonsurvivable injuries. The leading cause of death was severe traumatic brain injuries. Roughly 90% of patients who died had such severe organ damage and destruction that no current or conceivable future treatments would ever be able to prevent their death.
Late deaths due to multiple organ failure, secondary brain injury, sepsis, and pulmonary emboli accounted for only 6% of deaths. The preventable death rate was 2.6%. Thus, a research breakthrough that prevents all deaths due to complications and eliminates all medical errors would have only a marginal effect on survival rates in trauma centers. The actual reductions would be much less than that. Up to 75% of injury-related deaths occur in the field. Autopsy reports suggest that most field deaths probably occur within minutes of injury before help has a chance to arrive. These patients will not benefit from improvements in care.
The most promising way to reduce trauma mortality is to implement evidence-based injury prevention programs. Numerous studies have documented that misuse of alcohol and other drugs is the leading risk factor for injury, and there are highly effective methods to reduce these problems. In 1990, a report by the Institute of Medicine declared that the scientific basis for implementing routine screening for alcohol problems in medical settings and for providing brief interventions to those who screen positive was well-established and should now be adopted into routine practice.5
There have been over 100 clinical trials, most of them prospective controlled trials enrolling more than one-half million patients, demonstrating the positive effects of interventions. Given the relationship between alcohol and injury, trauma centers are ideal sites for establishing such programs.6 Studies conducted specifically in trauma centers have demonstrated their ability to reduce alcohol intake, injury recidivism, and drunk driving arrests. Such programs are not only cost-effective, but result in cost-savings to the hospital also.7–9
In 2006, the American College of Surgeons Committee on Trauma (COT) added two new requirements for trauma center verification. Level I and Level II centers must have a mechanism in place to identify injured patients who have a drinking problem, and Level I centers must have a mechanism in place to offer an intervention to those who screen positive, as well.
This pioneering COT mandate was the first time in the history of health care in the United States that any regulatory organization required that patients with a substance use problem, or any type of mental health problem, receive necessary counseling.
The purposes of this chapter are as follows: (1) to review the scientific basis for the recommendation for routine provision of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in a trauma center; (2) to provide guidance on optimal screening methods for alcohol and drug use disorders; (3) to review the key elements of a brief intervention; (4) to provide step-by-step guidance on how to establish an evidence-based SBI program in a trauma center, and (5) to review relevant legal, billing, and confidentiality concerns.
MAGNITUDE OF THE PROBLEM
Between 35 and 50% of patients admitted to a trauma center are under the influence of alcohol. The number of drivers using illicit drugs has recently been revealed to be as large, if not larger, than the problem of drunk drivers. In the 2007 roadside survey conducted by the National Highway Traffic Safety Administration, the percentage of weekend nighttime drivers testing positive for alcohol dropped from 36.1% in 1973 to 12.4% in 2007. Drivers with a blood alcohol concentration (BAC) over the legal limit of 0.08 g/dL dropped from 7.5% in 1974 to 2.2% in 2007; however, 16.3% of drivers tested positive for drugs. Of these, 11.3% were positive for illegal drugs, and 1.1% tested positive for a combination of illegal drugs and prescription narcotics or psychoactive medications.10
In 2001, alcohol misuse resulted in 34,833 deaths by causing or exacerbating 70 associated medical disorders such as cirrhosis, hepatitis, oropharyngeal cancers, gastrointestinal disorders, and other chronic diseases. In contrast, there were 40,933 alcohol-related injury deaths, which was more than all deaths due to alcohol-related chronic medical problems. Also, alcohol misuse also caused 788,005 YPPL as a result of all of its associated medical diseases, whereas the YPLL due to alcohol-related injuries alone was nearly four times as high at 3,279,322.
The only medical settings with as high a proportion of patients with substance use problems as trauma centers are inpatient psychiatry units.
It is far more common for these patients to receive treatment for an injury than for any other medical or psychiatric problem. Thus, addressing substance misuse, which particularly overburdens trauma centers, is a natural part of a trauma center’s mission.
NATURE OF THE PROBLEM
Since the beginning of the 20th century, the prevailing belief was that people who use alcohol could be divided into two types. One type was considered social drinkers, even if they drank heavily. The others passed a certain irreversible threshold and became known as “alcoholics.” In the early 1980s, the Diagnostic and Statistics Manual III (DSM III) replaced the word alcoholism with the terms alcohol abuse and alcohol dependence syndrome. Alcohol abuse referred to patients who experienced repeated adverse consequences of their drinking, but displayed no signs of addiction or dependence. Such patients can quit ingesting alcohol on their own if they are sufficiently motivated. Patients with dependence syndrome demonstrate tolerance, withdrawal symptoms, and such loss of control that they are usually, but not always, unable to stop drinking without treatment. This is true despite experiencing repeated, often catastrophic, social, legal, and medical consequences. Alcohol abuse and alcohol dependence are mutually exclusive terms.
This classification system will be replaced in DSM-V, scheduled for publication in 2013, to reflect more recent research about the nature of unhealthy substance use. Alcohol and drug problems are similar to hypertension; that is, their severity can be measured along a continuous scale of problem severity. The severity in any single individual varies over time from no problem, to a mild, moderate, or severe problem, based on a variety of environmental and social stresses that interact with genetic and other factors. The term “alcohol abuse” will be dropped because it is stigmatizing and clinically detrimental.
The Spectrum of Severity
In the United States, approximately 30% of people do not use alcohol. Another 45% use it in a way that poses no risk to their health (Fig. 42-1). The remaining 25% use alcohol in ways that can damage their health in one of the two following ways: (1) acute intoxication that causes an injury (often referred to as binge drinking); or (2) long-term excessive use that results in chronic medical diseases. These two types of problems can together be called “unhealthy alcohol use,” a nonstigmatizing, nonjudgmental term that reflects a physician’s appropriate concern about his or her patient’s health.
FIGURE 42-1 Matching interventions to problem severity for trauma patients who use alcohol or drugs. (Reproduced with permission from Daniel Hungerford, PhD, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention).
The threshold for unhealthy alcohol use is defined as more than four drinks for a male or three drinks for a female on any single drinking occasion. Such intake in average sized individuals would result in a BAC above the legal limit for driving and is associated with a greater than 2-fold risk of being injured due to intoxication. An additional definition is more than 14 drinks per week in a male or more than seven in a female. Even if the drinking episodes are spread out over a week and the person never reaches intoxication, alcohol is toxic to virtually every organ system. Therefore, exceeding these amounts over time will significantly increase the likelihood of developing a chronic alcohol-related medical disease.
In recent years, there has been an unprecedented increase in drug overdoses. Deaths due to drug overdose are included as a form of unintentional injury in the International Classification of Disease Version 9 (ICD-9) codes. For decades, motor vehicle crashes were the leading cause of unintentional injury death, followed by falls. The problem has become so severe that deaths from drug overdoses have surpassed falls and are now the second leading cause of unintentional injury-related death. In 15 states, deaths due to drug overdoses have surpassed motor vehicle crashes and are the leading cause of death due to unintentional injury.
The death rate from drug overdose is now seven times higher than it was at the height of the heroin epidemic in the early 1970s, and three and one half times as high as it was at the height of the crack cocaine epidemic in the 1980s. Illicit “street drugs” are not the primary cause of these fatal drug overdoses. More than half are due to misuse of legal prescription drugs, most often obtained from a physician. The exploding overdose rate closely corresponds to a 6-fold increase in the amount of opiates and benzodiazepines prescribed since 1997 (Fig. 42-2).
FIGURE 42-2 Unintentional drug poisoning death rates, United States, 1970–2004. (Courtesy of Leon J. Paulozzi, MD, MPH, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.)
The appropriate goal of an intervention at the trauma center is to capitalize on the effects of the injury to increase a patient’s motivation to change their pattern of usage of intoxicants and to refer the smaller proportion with chronic dependence to available community treatment resources or support systems. Most patients with unhealthy alcohol use will respond to appropriately and skillfully delivered “brief interventions.” Research has demonstrated that even in dependent patients brief interventions more than double the likelihood that they will follow through on a treatment referral.
Brief interventions, which will be further described below, are time-limited (10–30 minute), focused, nonconfrontational discussions between the patient and doctor or other health care professional. They are designed to raise the patient’s level of awareness of their need for behavioral change and their commitment to pursue it. They have specific elements and can be provided by anyone who is able to speak to patients with unhealthful alcohol use in a nonjudgmental, nonconfrontational manner. They are not, however, adequate as a stand-alone treatment for most patients with dependence.
The largest study to date of Screening, Brief Intervention, and for patients who need it, Referral to Treatment (SBIRT), was a multistate program delivered across six states and several tribal nations.11 It was conducted in trauma centers, primary care clinics, emergency departments, general medical and surgery wards, and college health clinics, and enrolled a diverse population. Screening was administered to all adult patients who presented to the study sites for care, unless they were too severely ill or injured.
There were 459,599 patients screened using standardized questionnaires, making it the largest study of its kind. Nearly one out of four patients who presented for medical care (22.7%) screened positive for unhealthy alcohol or drug use; however, screening results indicated that 15.9% of patients were considered nondependent, and in need of a brief intervention only. An additional 3.2% would benefit from having two to three additional sessions that could be administered during return visits. Only 3.7% of patients, or one out of six patients who screened positive, were considered dependent and in need of formal treatment.
Studies show that the majority of patients with unhealthy alcohol use that results in encounters with the medical system, including studies conducted in trauma centers, are appropriate candidates for a brief intervention.
ALCOHOL DEPENDENCE SYNDROMES
The relatively small percentage of patients with dependence require more than a brief intervention. Although alcohol use begins as a choice, for some patients it has become a disease that they have little control over, and they require medical treatment. Trauma centers are not able to act as treatment centers; however, they should have a list of treatment resources available in the community to provide to patients. Brief interventions have been shown to cause a greater than 2-fold increase in the probability that patients will follow through with a referral.
Whether or not these patients require prophylaxis or treatment for withdrawal syndromes is an important consideration. The goals of prophylaxis and treatment are to minimize the risk of serious complications such as seizures, delirium tremens, and the cardiovascular morbidity that occurs as a result of sympathetic overload. Clinicians should consider treating withdrawal as the first step in a comprehensive plan aimed at referring these patients to treatment.
Withdrawal is characterized by signs and symptoms that are the opposite of the pharmacologic effects of the drug that is the cause of the addiction. The four primary categories of addicting agents are alcohol, sedative-hypnotics (benzodiazepines, barbiturates), opiates, and stimulants. All drugs in each category are associated with similar withdrawal syndromes, but they differ in their intensity, timing of onset, and duration. Symptoms from cessation of short-acting drugs such as alcohol may emerge within 6–24 hours, whereas withdrawal from long-acting benzodiazepines may not emerge for several days. Alcohol and sedative-hypnotic drugs have similar pharmacologic effects and similar withdrawal symptoms. Cessation of stimulant use is characterized by depression and a risk of suicidal behavior.
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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