Psychoactive Substance Dependence

Among Trauma Center Patients

Carl A. Soderstrom, MD; Patricia C. Dischinger, PhD; Gordon S. Smith, MD, MPH; David R. McDuff, MD;
J. Richard Hebel, PhD; David A. Gorelick, MD, PhD

Introduction.\p=m-\Thepractice of assessing only trauma patients with elevated asurvey of 154 trauma centers treating
blood alcohol concentrations (BACs) or positive drug screens for psychoactive approximately 125 000 patients in 1984,
substance use disorders (PSUDs) was evaluated. clinicians were asked to estimate in what
Methods.\p=m-\Twenty-fourBAC-negative (BAC) (BAC, 0) and 21 BAC-positive percentage of cases alcohol played a role
in their patients' being injured. Two
(BAC+) (BAC, \m=ge\22mmol/L or 100 mg/dL; mean, 41 mmol/L; range, 24.3 to thirds of respondents estimated that al¬
79 mmol/L) adult trauma patients were evaluated for alcoholism and other PSUDs cohol was a factor in more than half of
using the Structured Clinical Interview (SCI) from the Diagnostic and Statistical the cases.16
Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Approximately half Approximately 10% of American
were vehicular crash victims and 78% were men. adults have problems with alcohol abuse
Results.\p=m-\Atotal of 64 PSUDs were diagnosed in 31 (68.9%) of the 45 patients; or alcohol dependence during their
all but one was for dependence (vs abuse). Of the BAC+ patients, 14 (66.7%) met lifetimes.1·17 Although trauma has been
DSM-III-R criteria for alcohol dependence, 11 (78.6%) of whom also had other characterized as a "symptom of alco¬
PSUDs not related to alcohol. Two other BAC+ patients had nonalcohol PSUDs. holism,"18 little is known about the
Of the BAC- patients, 11 (45.8%) had alcohol dependence, six (54.5%) of whom prevalence of alcoholism and other
also had nonalcohol PSUDs. Another four BAC- patients had nonalcohol PSUDs. psychoactive substance use disorders
(PSUDs) among trauma patients.19 In a
Overall, 76.2% of the BAC+ patients and 62.5% of the BAC patients had a diag- study of more than 27 000 trauma pa¬
nosis of psychoactive substance dependence.
Conclusion.\p=m-\Allpatients admitted to trauma centers should be assessed for
tients, only 3.0% had hospital discharge
diagnoses of alcohol or other drug
alcoholism and other PSUDs. abuse problems.20
(JAMA. 1992;267:2756-2759) According to criteria delineated in the
Diagnostic and Statistical Manual of
Mental Disorders, Revised Third Edi¬
ALCOHOL use has been linked to all 1982 to 1988, alcohol was estimated to tion {DSM-III-R),21 substance use dis¬
types of injury,1-10 particularly injury sus¬ be factor in 53% of almost 360000
a orders are classified as dependence or
tained in vehicular crashes.11,12 From highway deaths.13 In 1987, alcohol-re¬ abuse. Dependence is characterized by
lated crashes accounted for 57% of the loss of control over substance use. Use
This article is one of a number of articles on violence years of potential life lost owing to road¬ continues despite adverse consequences
that will appear in upcoming issues of The Journal.
The reader is referred to the June 10, 1992, issue, way trauma.13 During that year, trauma regardless of whether physiologic evi¬
which will be dedicated to studies of violence. accounted for 80% of the more than 1.5 dence (development of tolerance and oc¬
From the Department of Surgery, R Adams Cowley million years of potential life lost owing currence of withdrawal syndromes) is
Shock Trauma Center, Maryland Institute for Emer- to alcohol-related causes.14 These fig¬ manifest. The life-styles of dependent
gency Medical Services Systems, Baltimore (Dr Sod- ures are probably low estimates because individuals revolve "around obtaining,
erstrom); the Charles McC. Mathias National Study
Center for Trauma and Emergency Medical Systems, deaths owing to alcohol-related trauma using, and recuperating from" alcohol.21
Baltimore, Md (Dr Dischinger); the Injury Prevention are underreported.15 Abuse is a residual diagnosis given to
Center, The Johns Hopkins School of Hygiene and those who suffer adverse consequences
Public Health, Baltimore, Md (Dr Smith); the Depart-
Alcohol use plays a major role in the
ments of Psychiatry (Drs McDuff and Gorelick) and causation of injuries serious enough to from substance use but do not meet cri¬
Epidemiology and Preventive Medicine (Dr Hebel), require treatment at trauma centers. teria for dependence.
University of Maryland School of Medicine, Baltimore; Data from six regional trauma centers Screening and structured interview
and the National Institute on Drug Abuse, Bethesda,
Md (Dr Gorelick). in the United States, involving 4063 instruments have been used to study
Reprint requests to Department of Surgery, Mary- trauma patients, indicate that 40.2% of the prevalence of alcoholism among gen¬
land Institute for Emergency Medical Services Sys-
those patients had a positive blood al¬ eral medical populations. The results of
tems, 22 S Greene St, Baltimore, MD 21201-1595 (Dr
Soderstrom). cohol concentration on admission.510 In nine recent studies, which are summa-

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Table 1.—Assessment of Prevalence of Alcoholism Among Nontrauma Patients Using Screening and utes, depending on patients' responses.
Structured Interview Techniques Interviews were conducted in private
Prevalence of by a nurse clinician experienced in ad¬
Population Interview Instrument Alcoholism, ministration of the entire SCI, who was
Studies, Year Studied to Detect Alcoholism* _ No. (%)
blinded to blood alcohol concentration
Screening (Questionnaire) test results. Patients initially admitted
Solomon et al,27 1980 Emergency AAS 508 91 (17.9) to critical care units were interviewed
department patients when they were transferred to step-
Sherin et al,28 1982 Hospitalized MAST 396 56(14.1) down units.
medical/surgical All patients admitted to our trauma
patients
Redmond et al,301987 Emergency Hilton 50 (39.6)
center from April through July 1990 di¬
department patients rectly from the scene of injury were
Cyr and Wartman,221988 Medical MAST 47 (20.3) potential study candidates. We used the
outpatients following patient exclusion criteria: age
Moore et al,24 1989 Hospitalized CAGE 394(19.7) less than 21 years; head injury (thus
medical/surgical S MAST
patients excluding patients possibly unable to be
Yersin et al,25 1989 Hospitalized MAST 268 55 (20.5) interviewed reliably); and being deemed
medical patients inappropriate for study by one's attend¬
Structured (In-Depth) ing physicians. The first 12 eligible pa¬
Medical
tients in four categories were asked to
Coulehanetal,261987 DIS 294 42(14.3)
outpatients participate: (1) those injured in a vehic¬
Hoffman et al,231989 Hospitalized SUDDS 108 25(23.1) ular crash, with a blood alcohol concen¬
medical/surgical tration of 0 (BAC"); (2) those injured in
patients a vehicular crash, with a blood alcohol
Buchsbaum et al,231991 Medical DIS 821 294 (35.8)t concentration of 22 mmol/L or more
outpatients
(BAC+) (a BAC of 22 mmol/L is equiv¬
*AAS Indicates Alcohol Abuse Scale; MAST, Michigan Alcoholism Screening Test; Hilton, the Hilton Question¬ alent to a BAC of 100 mg/dL, a level
naire; CAGE, acronym derived from four interview questions; SMAST, Short Michigan Alcoholism Screening Test;
DIS, Diagnostic Interview Schedule; and SUDDS, Substance Use Disorder Diagnostic Schedule. consistent with the charge of drunk driv¬
tAlcohollsrn prevalence by CAGE in this study equals 31.8%. ing in more than 40 states); (3) those
injured as the result of nonvehicular
rized in Table 1, indicate an overall prev¬ diagnostic interview to ascertain the trauma, with BAC" status; and (4) those
alence rate of 22.2% among 4755 pa¬ prevalence of PSUDs among patients injured as the result of nonvehicular
tients (range, 14.1% to 39.6%).22"30 with both positive blood alcohol concen¬ trauma, with BAC+ status. It was de¬
Standardized diagnostic assessments trations and negative blood alcohol con¬ termined that sample sizes of approxi¬
for alcoholism have rarely been applied centrations admitted to a level I trauma mately 24 BAC+ and 24 BAC" patients
to trauma patients. In a small study, 56 center. would allow the estimation of the prev¬
patients admitted to a trauma center MATERIALS AND METHODS
alence of alcohol dependence to within
were examined using a structured di¬ 20 percentage points, with a 95% con¬
agnostic interview (the Diagnostic In¬ This study was conducted at the R fidence interval (CI) in each of these
terview Schedule).31 Eighteen (32.1%) Adams Cowley Shock Trauma Center,32 subgroups. Odds ratios (ORs) for con¬
were diagnosed as having psychoactive the level I regional trauma center33 serv¬ tingency tables were calculated and CIs
substance abuse or dependence. That ing the most populated area of Mary¬ were determined using the Cornfield
study of inner-city trauma patients, land. Most patients treated at the cen¬ method.36 Probability values were de¬
which is not representative of most ter are injured in rural and suburban termined by using 2 tests; P<.05 was
trauma populations, is the only published settings in the counties surrounding Bal¬ considered significant. The study design
report in which a structured diagnostic timore. In fiscal year 1990, almost 3000 was approved by both the Human Vol¬
evaluation for alcoholism and other trauma victims were admitted to the unteers Research Committee, Univer¬
PSUDs was made. Blood alcohol con¬ center: approximately 75% were admit¬ sity of Maryland at Baltimore, and the
centrations, other toxicologie informa¬ ted from the scene of injury, approxi¬ research committee ofthe Shock Trauma
tion, and biologic markers were not re¬ mately 85% were the victims of unin¬ Center.
ported. tentional trauma, and the majority were
Even at trauma centers where toxi¬ injured in vehicular crashes. On admis¬ RESULTS
cology screening is routine and substance sion, a blood alcohol concentration de¬
abuse clinicians are employed, only pa¬ termination is made routinely for clin¬ Demographics
tients with an elevated blood alcohol con¬ ical management, not legal, purposes. Of 48 patients approached for inter¬
centration and/or a positive toxicology Owing to rapid prehospital response and view, 45 (93.8%) gave written consent to
screen for other drugs of abuse are eval¬ the use of helicopters for transport, the participate. (One refused on the advice
uated for a PSUD. This practice implic¬ interval from injury to admission is usu¬ of an attorney, one because of a lan¬
itly assumes that only patients admit¬ ally less than 1 hour. Hence, the blood guage barrier, and one gave no reason.
ted to trauma centers with positive tox¬ alcohol concentration approximates that No patient was deemed inappropriate
icology screens for alcohol or other drugs at the time of injury. for interview by his or her attending
are likely to have a PSUD. Further, it The instrument used to diagnose physician.) Of the 45 patients, 21 (46.7%)
allows such diagnoses to remain unde¬ PSUDs was the Psychoactive Substance were BAC+ (mean, 41 mmol/L [188 mg/
tected in the significant number of Use Disorders section of the Structured dL]; range, 24 to 79 mmol/L [112 to 364
trauma patients admitted without lab¬ Clinical Interview (SCI) from the DSM- mg/dL]) and 24 (53.3%) were BAC' (Ta¬
oratory evidence of alcohol and/or drug III-R, a validated diagnostic interview ble 2). Eleven (52.4%) of the BAC+ pa¬
use proximal to the time of injury. We widely used in psychiatric research.1,34,35 tients and 11 (45.8%) of the BAC" pa¬
present a pilot study using a structured Interviews lasted from 15 to 45 min- tients were victims of vehicular trauma.

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Table 2.—Prevalence of Psychoactive Substance Dependence Among 45 Trauma Patients*

Alcohol Other
Drug Other Drug Lifetime Prevalence
Dependence, Dependence With Dependence Without of Any Psychoactive
Total Alcohol Dependence Alcohol Dependence Substance Dependence
Admitting Total No. I-1
BAC Statust of Patients No. C/P No. C/P No. C/P No. C/P
BAC* 21 14 13/1 4/7 § 1/1 til 16 14/2tt
BAC 24 5/6 1/5*1 2/2 # 15 7/8tt 62.5
Total 45 25 18/7 17 6/12 3/3 31 21/1 Ott 68.9

*Met psychoactive substance use dependence criteria based on the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (see text). BAC indicates
blood alcohol concentration; C/P, current/past. (Past equals no evidence of dependence for 6 months prior to injury.)
tBAC* indicates »22 mmol/L (2IOO mg/dL) of alcohol; BAC-, 0 concentration of alcohol.
^Dependence on marijuana, cocaine, or other psychoactive substances. Some of these patients had more than one dependency.
§Seven patients were addicted to marijuana, six to cocaine, and four to other substances.
||One patient was addicted to marijuana, two to cocaine, and one to other substances.
TJTwo patients were addicted to marijuana, two to cocaine, and five to other substances.
#Two patients were addicted to marijuana, two to cocaine, and four to other substances.
**One patient with diagnosis of alcohol abuse.
ttFor patients who had both a current and a past dependence, only current status is reflected in these figures.

In both groups, 78% of the patients were
men (BAC-, 79.2%; BAC+, 76.2%). The
mean age was 30.4 years in the BAC+
group and 42.3 years in the BAC~ group
(P<.007; two-tailed t test). However,
four patients in the BAC~ group were
65 years or older. If those four are ex¬
cluded, there is no significant difference
in the mean age of the AC~ (35.2 years)
and BAC+ (30.4 years) groups.
Prevalence of Alcohol and Other
Drug Use Disorders
Results of the PSUD/SCI interview
are presented in Table 2. Thirty-one
(68.9%) of the 45 patients had a lifetime
diagnosis of one or more PSUDs. All but
one of the 64 diagnoses were for depen¬
dence. There was no significant differ¬
ence in lifetime PSUD prevalence be¬
tween BAC- (62.5%) and BAC+ (76.2%)
patients or between vehicular (63.9%)
and nonvehicular (69.6%) accident vic¬
tims. Lifetime dependence on substances
other than alcohol was more likely in pa¬
tients with lifetime alcohol dependence
(17 [68.0%] of 25) compared with other pa¬
tients (six [30.0%] of 20) (P<.01; OR, 4.96;
95% CI for OR, 1.18 to 22.05. Lifetime
prevalence of alcohol dependence also did
not differ significantly between BAC+
(66.7%) and BAC" (45.8%) patients
(P<0.2; OR, 2.36; 95% CI, 0.60 to 9.56).
Twenty-one (46.7%) of the 45 patients
had a current (6 months prior to injury)
PSUD, with greater prevalence in the
BAC+ patients (66.7%) than in the BAC"
patients (29.2%) (P<.01; OR, 4.86; 95%
CI, 1.17 to 2.37). Looking at current al¬
cohol dependence alone, those who were
BAC+ had a significantly greater prev¬
alence (61.9%) than those who were
BAC- (20.8%) (P<.01; OR, 6.18; 95%
CI, 1.40 to 29.06).
A BAC+ status was not a clinically
useful predictor of the presence or ab¬
sence of current alcohol dependence. The
predictive value of BAC+ for current
alcoholism was 61.9%. Conversely, the
predictive value for BAC- status for no
alcoholism was 79.2%.
COMMENT
This study is the first to use stan¬
dardized diagnostic criteria to examine
the prevalence of PSUDs in relation to
BACs among patients admitted to a
trauma center. Almost four fifths of
BAC+ patients had a lifetime PSUD. In
addition, almost two thirds of the BAC"
patients had a lifetime history of depen¬
dence on a psychoactive substance (pre¬
dominantly alcohol). This finding high¬
lights the importance of carefully as¬
sessing all trauma patients for PSUDs.
Thus, the standard practice of relying
solely on an elevated BAC status to iden¬
tify patients with such diagnoses is in¬
adequate. In this study, it would have
missed almost 30% of those with cur¬
rent psychoactive substance depen¬
dence.
The overall 68.9% lifetime prevalence
of PSUDs diagnosed in this study is over
two times higher than that found in the
study by Silverman and colleagues
(32.1%).31 Their study, which also em¬
ployed DSM-III-R criteria, involved a
population of predominantly inner-city
assault victims. In contrast, approxi¬
mately half of the patients in the cur¬
rent study were injured in vehicular
crashes, and most of the remaining pa¬
tients were victims of unintentional
trauma. This population is more repre¬
sentative of the profile of patients ad¬
mitted to most trauma centers in the
United States. The incidence of current
alcohol or other drug abuse and/or de¬
pendence disorders documented in the
current study is over 15 times higher
than that reported by MacKenzie and
associates.20 Their study, which involved
recorded discharge diagnoses in a large
cohort of patients treated in trauma cen¬
ters, indicates that current clinical prac¬
tices substantially underdiagnose
PSUDs.
The 42.2% incidence of current alco¬
hol abuse and/or dependence in this
study's trauma population was almost
two times higher than that among pa-
tients using other health services (Ta¬
ble l),22-27 as assessed by both screening
and structured interview methods. In
addition, it is nine times higher than the
estimated 6-month prevalence of such
problems in the general population as
assessed by structured interviews.17 The
57.8% incidence of lifetime alcohol abuse
and/or dependence is almost 4 Va times
higher than the lifetime prevalence of
such diagnoses among the general pop¬
ulation.17
In a 5-year follow-up study of 263
trauma patients admitted to a trauma
center in Detroit, Mich, Sims and col¬
leagues37 noted that 44% sustained two
or more subsequent injury episodes re¬
quiring hospitalization. Alcohol abuse,
ascertained by review ofmedical records,
BACs, and death certificates, was iden¬
tified in 67% of those patients sustain¬
ing recurrent injury. Concerning the
large economic burden of alcohol-related
trauma, Enoch Gordis, MD, director of
the National Institute on Alcohol Abuse
and Alcoholism in Bethesda, Md, re¬
cently stated,19 "Perhaps if patients at
risk for alcohol-related problems were
identified before repeated traumas or
health problems occur, these costs might
be reduced." The study design at our
shock trauma center did not allow for
evaluation of outcome with respect to
referral for treatment of substance use
problems. However, a small, yet signif¬
icant, study of 17 trauma patients by
Gentilello and colleagues3* demonstrated
that those identified as alcoholics are
receptive to treatment. Obviously, the
prerequisite to treating PSUDs is iden¬
tification of patients with such problems.
This study clearly demonstrates that
both BAC+ and BAC" patients admit¬
ted to trauma centers should be assessed
for PSUDs.
Research for this study was supported by funds
contributed by Greek Leaders Against Drunk
Driving and by Towson State University, Towson,
Md (1989-1990).
Dr Smith is supported by First Award
R29AA07700 from the National Institute on Aleo-

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hol Abuse and Alcoholism, Bethesda, Md.
The authors appreciate the assistance of Linda
J. Kesselring, Maryland Institute for Emergency
Medical Services Systems Editorial/Publications
Office, in the preparation of the manuscript.
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