Serious Trauma and Substance Abuse
August 1, 1997 4 minutes read
Serious Trauma and Substance Abuse
ABSTRACT & COMMENTARY
Synopsis: Seriously injured trauma patients are at high risk of having current alcoholism or other psychoactive substance use disorder (PSUD). Trauma centers should screen patients for PSUDs and be prepared to refer them for appropriate evaluation and treatment.
Source: Soderstrom CA, et al. JAMA 1997;277: 1769-1774.
Several studies have shown that victims of trauma are themselves likely to have psychoactive substance use disorders (PSUDs) such as alcoholism. However, such studies have mainly been retrospective in design, hampered by small sample sizes, or highly selective in the patient populations included. In this study, Soderstrom and colleagues at the Shock Trauma Center at the University of Maryland have largely overcome these and other limitations of previous investigations of substance abuse in trauma patients.
During a 27-month period, Soderstrom et al studied English-speaking adult victims of serious trauma who were admitted to their institution directly from the field, remained in the hospital at least two days, and could participate in a standardized, structured interview. Those who were initially intubated or otherwise unable to participate were followed until they met these criteria. Blood-alcohol concentration was measured in every patient, and urine toxicology screens (e.g., for amphetamines, cocaine, marijuana, opiates, and phencyclidine) were performed in about two-thirds of the patients.
Of the 1118 interviewed patients, 70% had suffered unintentional trauma, such as motor vehicle accidents or falls, and 30% were victims of intentional trauma, which included gunshot wounds, stabbings, and assaults. There were 1382 men (72%) and 527 women (28%); 44% were nonwhite, nearly all of them Black. Mean Injury Severity Score was 16, with levels exceeding 15 considered by most authorities to indicate serious injury.
A blood-alcohol level of at least 10 mg/dL was present in 37% of men and 21% of women. Positive tests for opiates, cocaine, and marijuana were each present in 10-15% of patients, while phencyclidine and amphetamines were found in 1% or less. Of all patients, 54% met criteria for at least one PSUD, either currently or in the past, and 88% of these PSUDs were classified as dependence. One of four trauma patients (24%) was alcohol dependent, and one in five (18%) was drug-dependent at the time of injury. Current alcohol-dependence rates were not associated with race; rates of dependence on other drugs were higher among nonwhites and in victims whose trauma was classified as intentional injury.
The PSUD rates found in the trauma patients in this study far exceed those found in the general population; for example, alcohol dependence has been estimated to be present in 7% of U.S. residents aged 15 to 54 during any given year. In addition, because the dependence-to-abuse ratios for each substance category substantially exceeded those reported for the population at large, the data suggest that trauma center patients manifest more severe forms of addiction than most individuals with PSUDs.
Based on the findings of their study, Soderstrom et al make the following recommendations:
1. All trauma patients should be considered to be at high risk for a substance abuse disorder.
2. Victims of serious trauma should be tested for alcohol and other drugs of abuse.
3. Alcohol and drug screening questionnaires should be administered as supplements to blood alcohol and urine toxicology screening.
4. Patients whose tests for any of these are positive should be referred for formal evaluation and treatment of PSUDs.
COMMENT BY DAVID J. PIERSON, MD
This study confirms the findings of others that victims of serious trauma comprise a high-risk group for PSUDs. In a similar study of 2422 trauma patients admitted to Harborview Medical Center in Seattle, 44% tested positive for alcoholism using a somewhat different technique than that of Soderstrom et al (Rivara FP, et al. Arch Surg 1993;128:907-913). In the Seattle study, alcohol abuse was more common among men than among women, in persons 21-59 years of age, and in victims of assault, as compared to those suffering unintentional trauma.
This study and others demonstrate that testing positive for alcohol at the time of injury is an unreliable predictor of alcohol dependence. In the present study, its sensitivity was 52%, and its specificity was 83%. Among currently alcohol-dependent patients, 41% tested negative for alcohol on admission, illustrating the importance of questionnaire screening in addition to blood-alcohol testing in this high-risk population.
Clinicians who regularly participate in the care of trauma patients know only too well the impact of alcohol and drugs on this area of critical care. The findings of this study emphasize not only the high prevalence of PSUDs in this patient population, but also the opportunity presented by serious trauma for the identification and referral for treatment of individuals affected by these disorders.
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