Acute alcohol consumption has been identified as a risk factor for traumatic injuries and can worsen outcomes for many patients. Some investigations have shown that up to 50% of all trauma patients have alcohol detected in their bloodstream when they are admitted to the hospital, and many of these individuals will present again to the same institution with a new injury within 1 year. “Many traumatic injuries are secondary events to patients being intoxicated from drinking alcohol,” says Mark Mitchell, DO, FACOEP-D, FACEP. “Considering the interaction between alcohol and trauma, screening and interventions for at-risk drinking behavior are an important public health issue.”
Recent studies have shown that some trauma centers in the United States have benefited from developing brief substance abuse intervention programs. “When patients are hospitalized with traumatic injuries, this represents a potential opportunity for psychosocial interventions like substance abuse screening,” says Dr. Mitchell. Research suggests that most patients are willing to participate in a brief intervention and some studies have linked these interventions to a significant reduction in hospital admissions for traumatic injuries. In some cases, the positive effects have lasted for several years after the brief intervention was initiated.
Experts have developed several reference guides to help hospitals implement brief screening and intervention programs, but these tools are usually selected based on the needs of a particular institution. “Many hospitals use blood alcohol levels to determine at-risk drinking in trauma patients,” says Dr. Mitchell. The Alcohol Use Disorders Identification Test (AUDIT) is another screening method that offers a cheap and easy alternative to using only blood alcohol levels. AUDIT was originally intended for use in primary care, but its value in the ED and trauma unit has been validated by recent studies.
Few direct comparisons have been made between AUDIT and results from blood alcohol level tests in trauma patients. To address this issue, researchers from the Loyola University Medical Center published a study in the Journal of the American Osteopathic Association that compared these approaches. “They wanted to see if AUDIT provided more insights into problematic drinking behavior than simply looking at blood alcohol levels,” Dr. Mitchell says.
In the study, investigators retrospectively reviewed records for all trauma patients aged 18 and older who were admitted to a level I trauma center over the course of about 1 year. Patients were included in the study if they had undergone both blood alcohol level testing and AUDIT on admission. A blood alcohol level higher than 0 g/dL and an AUDIT score equal to or above 8 (out of a possible 40) were considered positive for at-risk drinking.
Results of the study showed that patients who were admitted for trauma were predominantly male and were, on average, about 40 years old. Of patients with records containing data on both blood alcohol levels and AUDIT scores, more than 40% had a positive blood alcohol level while 35% had a positive AUDIT score. About 24% met criteria from the National Institute on Alcohol Abuse and Alcoholism for at-risk drinking behavior.
The sensitivity and specificity of having a positive AUDIT score identify at-risk drinking were 83% and 81%, respectively. These results compared favorably to that of the sensitivity and specificity of having a positive blood alcohol level identify at-risk drinking, which registered at 61% and 62%, respectively. Increasing blood alcohol levels and AUDIT scores were linked to a significantly higher odds ratio (OR) of engaging in at-risk drinking. However, a more robust correlation was seen with the OR for increasing AUDIT scores (Figure).
“The findings suggest that traditional screening for at-risk drinking in trauma settings using blood alcohol levels alone may not be the best,” says Dr. Mitchell. “Doing so only offers a snapshot of patients’ recent drinking behaviors, but these test results can be influenced by a variety of other factors.” Some of these factors include the volume of alcohol consumed, time since ingestion, how an individual’s body absorbs alcohol, and consumption of a meal with alcohol. All of these factors can make it difficult to correlate acute blood alcohol levels with at-risk drinking.
Consider the Overall Goal
If the goal is to screen for and prevent recidivism, Dr. Mitchell says clinicians need to use tools like AUDIT in addition to blood alcohol levels to get a better grasp of problematic drinking behaviors. “Although routine testing for blood alcohol levels may have a role when managing trauma cases, this test should not be viewed as routine for determining at-risk drinking,” he says. “AUDIT uses an osteopathic, whole-person approach to preventing future trauma and is a relatively brief and easy test to administer and adds little time or costs to implement. After using AUDIT, patients should be directed to a brief intervention to reduce trauma recidivism when indicated.”
Readings & Resources (click to view)
Plackett TP, Ton-That HH, Mueller J, Grimley KM, Kovacs EJ, Esposito TJ. Screening for at-risk drinking behavior in trauma patients. J Am Osteopath Assoc. 2015;115:376-382. Available at: http://jaoa.org/article.aspx?articleid=2300621.
Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005;241:541-550.
D’Onofrio G, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med. 2002;9:627-638.
Hadjizacharia P, O’Keeffe T, Plurad DS, et al. Alcohol exposure and outcomes in trauma patients. Eur J Trauma Emerg Surg. 2011;37:169-175.