Alcohol and Other Drug Screening of Hospitalized Trauma Patients
Treatment Improvement Protocol (TIP) Series: 16

Immediate Effects

Mood altering drugs with addictive potential -- alcohol, sedative-hypnotics, opiates, and cocaine -- act primarily on the brain, either depressing or stimulating it. The resulting impairment increases the likelihood of injury. Impairment produces poor judgment, decreased reaction time, lowered vigilance, and decreased visual acuity. Impairment can also cause a sense of omnipotence and a willingness to engage in risky behaviors.

Acute effects of alcohol and other depressants include lowered blood pressure, depressed consciousness, respiratory depression, and analgesia (insensibility to pain). Sedative-hypnotics, such as benzodiazepines, are frequently prescribed to the elderly, in whom impairment can occur at low doses. In particular, the long-acting benzodiazepines such as diazepam (Valium) have been associated with falls (Ray et al., 1989).

Cocaine and other stimulants trigger the portion of the brain that responds to emergencies, and activates the "fight-or-flight" response. These effects include anxiety, agitation, paranoia, psychosis, and elevated vital signs. Other conditions that may result from use of cocaine and other stimulants include myocardial infarction (heart attack), weak heart muscle (cardiomyopathy), heart arrhythmia, cerebrovascular hemorrhage, seizures, vascular headache, and ischemic bowel (inadequate blood supply to the bowel).

Cocaine and other stimulants cause central nervous system excitation and can impair judgment and perception. The initial primary effect of cocaine after ingestion is relatively brief excitation of the central nervous system. There is generalized muscular hyperactivity. The mood is elevated, and judgment and perception are impaired. Later, there is depression that can last for days. The period of maximum impairment after cocaine ingestion has not been determined.

Other drugs that may complicate diagnosis and treatment of trauma patients include inhalants, hallucinogens (such as lysergic acid diethylamide -- LSD), and phencyclidine (PCP). Hallucinogens cause perceptual and cognitive distortions and can have some stimulant properties. They may cause hypertension, tachycardia (rapid heart rate), and psychosis.

PCP is a drug with complex actions that can cause hallucinogenic, stimulant, depressant, and analgesic effects, depending on the size of the dose and the amount of time lapsed after taking the drug. Acute effects may include hypertension, seizures, violent behavior, and psychosis. Persons who have ingested PCP may be extremely difficult to restrain and may need physical or chemical restraints.

Some medications prescribed by physicians and over-the-counter medications may also present complicating factors for trauma patients, especially in combination with alcohol and other drugs. Many prescribed medications and over-the-counter drugs are marked with warnings not to drive a motor vehicle or operate machinery while using the drug. People attempting suicide often ingest alcohol in combination with prescribed or over-the-counter medications.

Withdrawal

Persons who are dependent on alcohol and other drugs may experience withdrawal syndromes that can also complicate assessment and treatment of the injury. Signs and symptoms of alcohol withdrawal range from mild anxiety to delirium. The signs and symptoms of alcohol withdrawal include

• Tremors
• Anxiety
• Agitation
• Insomnia
• Fever
• Tachycardia (increased heart rate)
• Hypertension
• Diaphoresis (perspiration)
• Hallucinations
• Seizures
• Delirium.

Signs and symptoms of withdrawal from other sedative-hypnotics such as benzodiazepines are similar to those of alcohol. Whereas alcohol withdrawal symptoms are generally of immediate onset and dissipate within 72 hours, the emergence of sedative-hypnotic withdrawal symptoms depends on the drug ingested and how long it remains in the blood stream. (This is called "half-life" -- the time after ingestion when half of the drug has been excreted.) For example, withdrawal signs and symptoms may be apparent soon after cessation of a short-acting drug, such as alprazolam (Xanax), but may be delayed for several days after cessation of a long-acting drug, such as diazepam (Valium), which has a half-life of 80 to 100 hours in the elderly.

Withdrawal from cocaine may result in bradycardia (slowed heart rate) and lowered blood pressure, which are clinically relevant in trauma patients. However, most signs and symptoms of cocaine withdrawal are psychological. Craving, irritability, depression, and loss of interest in one's surroundings characterize cocaine withdrawal.

Opiate-dependent persons experience acute withdrawal symptoms that include anxiety, irritability, restlessness, yawning, elevated vital signs, diarrhea, abdominal cramps and occasional nausea and vomiting, body aches, and bone pain -- especially lower back pain. Withdrawal from heroin, which has a short half-life, begins several hours after ingestion.

Methadone and levo-alpha-acetyl-methadol (LAAM) are long-acting opioid substitutes that are used to treat opiate addiction. Symptoms of withdrawal from opioid substitutes appear a day or so after cessation of use, that is, a day or so after the patient is admitted for traumatic injury. A patient's use of methadone or LAAM can be documented once information about the clinic attended by the patient is obtained. To prevent withdrawal symptoms and/or maximize pain relief, methadone or LAAM can be given to hospitalized patients. Opioid substitutes are not detected in routine urine drug screens, although questioning the patient usually elicits a history of use.

Acute Assessment and Treatment

Continuous assessment of the severity and extent of a person's injury from the time emergency service workers arrive at the scene to the patient's arrival at the emergency department or trauma center is a fundamental aspect of trauma medicine. As described above, AODs have potent effects on the central nervous system, the cardiovascular system, and the respiratory system, among others, that may complicate and lengthen the evaluation of the nature, extent, and severity of the injury. In addition, the direct effects of the ingested substances may increase the severity of the injury. For example, the injured brain is more vulnerable to increased temperatures, lack of oxygen, low blood pressure, and low clotting factors -- all of which result from alcohol intoxication.

Alcohol and other drugs can decrease the respiration rate, exacerbating the effects of a lack of oxygen to organs such as the brain and to other tissues. Patients under the influence of cocaine, hallucinogens, or PCP may require induced chemical paralysis to enable endotracheal intubation, a procedure which permits a patient to breathe. AODs can alter blood pressure and rate and rhythm of the pulse and can increase bleeding, resulting in increased risk of hemorrhagic shock.

Patients with traumatic injuries often present with an altered mental state, ranging from agitation and confusion to coma. The effects of AODs can mimic the symptoms of traumatic brain injury. Signs and symptoms of brain injury include behavior changes, sleepiness, and inappropriate language. Patients with severe head injuries who have a positive blood alcohol concentration (BAC) or have been using other drugs present diagnostic problems. One study found a lower level of consciousness and a longer period of coma among patients with positive BACs, which could not be explained by other factors (Edna, 1982).

Accurate assessment of many injuries depends on whether the patient can feel tenderness or pain in response to the physician's touch. AODs can raise the level of the pain threshold, thus decreasing a person's ability to feel pain. For example, an intoxicated patient with a cervical spine injury may report no tenderness in the neck, and an individual with an internal injury may not feel pain. The evaluation of blunt injury to the abdomen is of particular concern, because it is much harder to evaluate in an intoxicated patient. Alcohol has a synergistic effect with a number of medications used for pain and sedation; these drugs acting together with alcohol can cause decreased blood pressure, slow respiration, or even apnea (temporary cessation of breathing).

Knowledge of a patient's AOD status may influence an anesthesiologist's choice of an anesthetic agent or its dose. Frequent, heavy use of alcohol enhances the ability of the liver to metabolize alcohol and other drugs. Thus, some anesthetics and other medications are cleared more quickly by the liver and the standard dose may give less than the expected effect. Chronic heavy alcohol use may also create a reverse phenomenon: damaged liver tissue may result in a standard dose having a greater and more prolonged effect.

Anesthetic management of cocaine users can also be difficult. Chronic cocaine users sometimes do not respond in typical ways to anesthetics. They may become hypotensive (i.e., exhibit low blood pressure) when given increased amounts. In cases that are not immediately life threatening, a surgeon may decide to postpone an operation for several hours until the effects of an ingested substance have diminished or the risk of withdrawal symptoms has passed and the patient can undergo surgery with fewer chances of complications.

There is no antidote in clinical use that can be administered to the intoxicated trauma patient to reverse or alleviate the effects of alcohol. Knowledge of a patient's BAC can help predict when effects of intoxication will abate, since the rate of alcohol metabolism is fairly consistent at 15 mg/dl per hour. (Persons maximally tolerant to alcohol can metabolize it at a rate of 25 to 30 mg/dl per hour.) Thus, if an injured person's BAC is 100 mg/dl, after 2 hours it will decrease to around 60 to 70 mg/dl.

Diagnostic Tests

Because patients who have ingested alcohol or other drugs are more difficult to assess, emergency department personnel may request additional diagnostic tests to clarify the clinical picture. A recent study of more than 2,200 trauma patients showed that intoxicated patients were significantly more likely than nonintoxicated patients with the same severity of injury to undergo a larger array of diagnostic and therapeutic procedures in the emergency department (Jurkovich et al., 1992). The patients in the study were significantly more likely to require endotracheal intubation. They required more procedures, such as intracranial pressure monitoring, peritoneal lavage, and CT scans (see Appendix B, Glossary of Medical Terms), to diagnose and determine the extent of their injuries. Intoxicated patients were much more likely than nonintoxicated patients to be admitted to the hospital simply for observation.

Subacute Treatment and Rehabilitation

The "Teachable Moment"

In a few hospitals, an AOD treatment specialist is part of the interdisciplinary inpatient team, both in the subacute phase and during rehabilitation. The AOD treatment specialist works with the patient and the family to begin the AOD intervention and to set the stage for later AOD treatment and educates other team members about the addiction process. Some injury rehabilitation programs provide specialized AOD use treatment for patients with physical and cognitive deficits.

There is extensive evidence and wide agreement in the field that traumatic injury creates a "teachable moment" or a unique opportunity in the course of the addiction process (Gentilello et al., 1988; Reyna et al., 1985; Soderstrom and Cowley, 1987). This teachable moment happens when a patient makes a connection in his or her mind that the traumatic injury is a direct result of AOD use. Those who are able to make the connection may be more open to accepting AOD education or treatment, greatly reducing their chances for reinjury and improving their course of recovery from the injury.

As time after injury elapses, many clinicians believe that opportunities diminish for helping patients make the connection between their drinking and the injury. For example, a patient with an AOD use disorder who is told at hospital discharge several weeks after the crash not to drink and drive may be less likely to make the connection -- and therefore less likely to seek AOD treatment -- than a patient who has had even a brief educational intervention early in the inpatient stay.

Discharge and aftercare planning and linkages of services for trauma patients with AOD problems is especially important. Rehabilitation should continue to focus not only on the injury but on AOD use. The hospital or inpatient rehabilitation setting is a controlled environment where patients recovering from traumatic injury are generally prevented from resuming use of alcohol or other drugs. Many patients who leave such a setting are in danger of relapsing, greatly increasing their risk for reinjury and hampering their recovery from the injury. Therefore it is important that AOD treatment specialists on the rehabilitation team work with the patient and family to help the patient continue the AOD recovery process after discharge.

The following case helps illustrate the importance of AOD interventions with these patients.

Case Example

Mr. B, a 25-year-old single male, was brought to the emergency department by his friends after he was severely beaten outside a bar late at night. His BAC was above 200 mg/dl. Exploratory surgery revealed a lacerated liver, which was sutured with no postoperative complications. After 8 days in the hospital, Mr. B. was discharged. Although the treating physician knew about Mr. B's high BAC on admission and about how Mr. B had sustained the injury, no attempt was made with either him or his family to address his possible AOD use problems.

Eight months later, Mr. B lost control of his car and crashed into a wall. He was brought to the same emergency room, where it was found that his BAC was again above 200 mg/dl. He sustained a broken neck in the crash and extensive internal injuries. This time, the surgeon sought a consultation with an AOD specialist, and Mr. B's pattern of AOD abuse and dependence became clear. During his month-long stay in the acute care unit, Mr. B, who had permanently lost the use of his legs, was offered AOD counseling and treatment. Although he refused to participate in AOD treatment, his family was more receptive, and Mr. B's father entered AOD treatment.

After a month in the hospital, Mr. B was discharged from acute care to a physical rehabilitation facility in the same city. The program included an AOD treatment component, and Mr. B, who had become more receptive to intervention since his father's treatment, successfully completed the program. He has maintained sobriety for 2 years, which he reports has helped him cope with his paralysis and reenter the community and the workforce.

It is impossible to say whether an AOD intervention during Mr. B's first hospitalization would have prevented his reinjury and the extensive emotional and financial costs to himself, his family, and society. However, addressing a trauma patient's possible AOD use problems -- a known risk factor for traumatic injury -- increasingly appears to many clinicians to be an important part of good medical practice.

Barriers and Opportunities

Many reasons have been given for not routinely screening for AOD use among hospitalized trauma patients. In two national surveys of trauma centers assessing clinical practices concerning alcohol (Soderstrom and Cowley, 1987; Soderstrom et al., 1994), it was noted that respondents from the centers did not obtain routine BACs because they did not believe that BACs were clinically important. Other clinicians have also advanced this argument, pointing out that acute care of persons with life-threatening injuries often proceeds according to certain fixed protocols, whether or not the patient is intoxicated. However, as discussed above, knowledge of a patient's AOD status can affect decisions in the emergency department, as well as longer term care and treatment planning.

Many medical personnel in trauma centers and hospitals often assume that the majority of intoxicated persons who are injured are social drinkers who have simply drunk too much on an isolated occasion. Significant evidence has accumulated that this is not the case and that injuries resulting from alcohol use are indicative of chronic use or alcoholism (Arnstein-Kerslake and Peck, 1985; Gentilello et al., 1988; Waller, 1967; Waller, 1972).

Other possible explanations for not implementing AOD screening involve physicians' attitudes. As Lowenstein and colleagues noted (1990), several recent surveys have found that only a minority of primary healthcare providers feel successful and competent in treating alcoholic patients. In a survey of more than 1,000 emergency medical specialists, Chang and colleagues (1992) noted interesting responses concerning alcoholism. While physicians indicated that "alcoholism is a treatable disease," they also acknowledged that "alcoholics are difficult to treat." There is a need for more physician education about AOD abuse treatment.

Unfortunately, little attention has been given to the subject, either in medical school or during residency training (Geller et al., 1989). As described more fully in Chapter 4, the American Medical Association has established policy guidelines for primary care physicians in treating substance-abusing patients (American Medical Association, 1979). At a minimum, physicians should be able to assess and diagnose AOD use disorders and to refer patients to appropriate sources of AOD treatment.

Gentilello and colleagues (1988) noted the "pessimism" that pervades members of the medical profession in regard to AOD treatment, which they speculated is related to the fact that physicians are primarily exposed to active alcoholics who "refuse advice regarding sobriety and seem beyond the call of reason." These patients are often hostile, manipulative, or combative, and physicians respond with pessimism, avoidance, ridicule, disdain, and angry helplessness.

However, as Lowenstein and associates have pointed out (1990), pessimism on the part of emergency department physicians is not warranted. Studies in primary care settings have shown that the majority of alcoholic patients welcome offers of help for their AOD problem. In one trauma center, 17 of 19 patients with major injuries and high BACs agreed to immediate admission to an alcohol treatment program (Gentilello et al., 1988).

Emergency department physicians and others who treat hospitalized trauma patients can benefit from further education about the effectiveness of screening and the success of AOD abuse treatment. Referrals to appropriate types and levels of AOD care can greatly improve outcomes for many patients. When healthcare providers encounter patients who have successfully completed AOD treatment as a result of screening programs, more positive attitudes about the "treatability" of many patients may change.

Specialized Treatment Models

Models are lacking for AOD abuse treatment programs for patients recovering from traumatic brain injury. However, there is increasing recognition of the need for integrated programs to provide brain-injured patients with cognitive and physical rehabilitation as well as AOD use treatment. For example, in Rhode Island, there are about 75 to 100 new cases per year of brain-injured patients who need this dual treatment (personal communication, F. Sparadeo, Ph.D., Rhode Island Hospital Department of Psychiatry, 1994). Such programs should address patients' cognitive, motor, and personality deficits. Appropriate and effective ways of providing such treatment should be the subject of future research. A regional approach to treatment that creates facilities for use in several areas of the country may be more cost-efficient and benefit more people than State or local creation of such facilities.

Similarly, no well-defined approaches to AOD treatment exist for patients with spinal cord injuries. A problem in AOD treatment compliance for these patients is the issue of empowerment. When they are forbidden to use AODs, they may perceive that their power to choose is being taken away, which may seem to them a further loss of their already eroded powers. The AOD treatment provider should create a partnership with the patient in which both collaborate to achieve treatment goals. An educational approach that places AOD use treatment within the rehabilitation framework has been suggested (Kraus, 1992).