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Objective: Few investigations have comprehensively assessed the scope of impairment of injured adolescents presenting to acute care inpatient settings., Methods: Randomly sampled injured adolescent inpatients and their parents were screened for posttraumatic stress (PTS) and depressive symptoms, preinjury alcohol use, and preinjury trauma. Linear regression was used to assess which clinical, demographic, and injury characteristics were independently associated with increased levels of adolescent PTS and depressive symptoms., Results: Fifty-seven percent [corrected] of adolescent-parent dyads endorsed high levels of PTS or depressive symptoms and/or high preinjury alcohol use. Adolescent female gender, greater levels of preinjury trauma, greater subjective distress at the time of the injury, and greater parental depressive symptoms were independently associated with increased levels of adolescent PTS and depressive symptoms., Conclusions: The adoption of early screening and intervention procedures that broadly consider the scope of impairment of injured adolescents and their family members could enhance the quality of acute care mental health service delivery.

Background: Injured survivors of individual and mass trauma receive their initial evaluation in acute care. Few investigations have comprehensively screened for posttraumatic stress disorder (PTSD) symptoms and related comorbidities across sites., Methods: This investigation included 269 randomly selected injury survivors hospitalized at two level 1 trauma centers. All patients were screened for PTSD, depressive, and peritraumatic dissociative symptoms during their surgical inpatient admission. Prior traumatic life events and alcohol abuse/dependence also were assessed., Results: In this study, 58% of the patients demonstrated high levels of immediate posttraumatic distress or alcohol abuse/dependence. Regression analyses identified greater prior trauma, female gender, nonwhite ethnicity, and site as significant independent predictors for high levels of posttraumatic distress., Conclusions: High levels of posttraumatic distress, recurrent trauma, and alcohol abuse/dependence were present in more than half of acute care inpatients. Early mental health screening and intervention procedures that target both PTSD and alcohol use should be developed for acute care settings.

Context: Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders., Objective: We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse., Design: Randomized effectiveness trial., Participants: We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center., Intervention: Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury., Main Outcome Measures: We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury., Results: Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P =.01) and alcohol abuse/dependence (P =.048). The CC group demonstrated no difference (-0.07%; 95% confidence interval [CI], -4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of -24.2% (95% CI, -19.9% to -28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year., Conclusions: Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Background: Male patients constitute such a large proportion of trauma patients that most studies of alcohol problems in trauma patients have been carried out with clinical data largely or totally contributed by male patients. It may be incorrect to assume that the nature of alcoholism in women and men is identical, or that the size of the problem among women is small, eliminating the need to specifically study female patients. The purpose of this study was to perform a gender-based comparison of alcohol problems in trauma patients., Methods: Admitted injured patients underwent routine screening, including a blood alcohol concentration, serum gamma-glutamyl transpeptidase, and the Short Michigan Alcohol Screening Test. A random sample of screen positive women and men underwent a comprehensive alcohol use and psychosocial assessment, and the results were compared by gender., Results: The screen-positive rate was higher for men, 51% versus 34% (p < 0.01). However, screen-positive women and men had similar problem severity as reflected by mean blood alcohol concentration (162 mg/dL vs. 142 mg/dL, p = 0.16) and Short Michigan Alcohol Screening Test scores (4.6 vs. 5.0, p = 0.32). The Alcohol Use Disorders Identification Test, NIMH-DIS, and Severity of Alcohol Dependence Data form showed that female trauma patients with alcohol problems have the same severity of dependence symptoms as men. However, women were significantly more likely to have liver dysfunction, depression, psychological distress, and recent physical, emotional, or sexual abuse., Conclusion: Alcohol problems are more common in male trauma patients, but women with alcohol problems are just as severely impaired, have at least as many adverse consequences of alcohol use as their male counterparts, and have more evidence of alcohol-related physical and psychological harm.

Background: Impairment caused by alcohol is the leading risk factor for trauma. However, many physicians do not screen for alcohol use because of concerns about confidentiality and denial of insurance coverage. The purpose of this study was to examine objectively the confidentiality issues and insurance statutes affecting alcohol screening in trauma centers., Methods: We conducted a survey of insurance commissioners in all 50 states to determine the prevalence of statutes allowing denial of coverage for injuries sustained while impaired due to alcohol, reviewed state insurance laws, and reviewed federal regulations protecting the confidentiality of alcohol information in patients seeking alcohol treatment., Results: Special federal regulations protecting confidentiality of alcohol screening data depend on how such information is acquired and do not routinely cover trauma patients. Concerns about screening on insurance coverage are valid in 38 states., Conclusion: Segregating information about alcohol use in the medical record and assigning designated chemical dependency counselors to screen all trauma patients would provide confidentiality of alcohol information under current federal regulations, allowing denial of release of such information, except under subpoena.

Background: Trauma patients with acute alcohol intoxication or chronic alcohol dependence are at greater risk for morbidity and mortality. We hypothesized that relying on clinical suspicion to detect acute alcohol intoxication and chronic alcohol dependence in trauma patients is inaccurate, influenced by injury factors, and biased by race, gender, age, and socioeconomic status., Methods: Trauma patients were screened with a blood alcohol concentration and with the Short Michigan Alcohol Screening Test and CAGE questionnaire. Before screening, physicians and emergency department nurses were asked whether the patient was acutely intoxicated (blood alcohol concentration > 100 mg/ dL) or had a chronic alcohol problem. Sensitivity, specificity, positive, and negative predictive values were determined by comparing responses with blood alcohol concentration, Short Michigan Alcohol Screening Test, and CAGE questionnaire results, stratified by injury and demographic factors., Results: Clinical evaluations were obtained on 462 patients. Overall, 23% of acutely intoxicated patients were not identified by physicians. The miss rate increased to one third in severely injured, chemically paralyzed, or intubated patients. Specificity was also poor. Patients with a negative blood alcohol concentration were more likely to be falsely suspected of intoxication if they were either young, male, perceived as disheveled, uninsured, or having a low income (p < 0.05). Staff identified < 50% of patients with a positive Short Michigan Alcohol Screening Test or CAGE, and falsely identified 26% of patients as alcoholic., Conclusions: Formal alcohol screening should be routine because clinical detection of acute alcohol intoxication and dependence is inaccurate. Screening should also be routine to avoid discriminatory bias attributable to patient characteristics.

Context: While acute alcohol and illicit drug use are common in homicide and suicide victims, the role of chronic substance use in violent death is unclear., Objective: To measure the magnitude of risk of violent death in the home associated with alcohol use or chronic abuse and use of illicit drugs., Data Sources: Data obtained from a case-control study of risk factors for homicide and suicide in 3 large metropolitan areas of the United States., Design: Matched case-control study including 388 homicide cases, 438 suicide cases, and equal numbers of controls matched for age, sex, race, neighborhood, and county. Data were analyzed by means of conditional logistic regressions in which other potential risk factors for violent death were also considered. OUTCOME AND EXPOSURE MEASURES: Homicide and suicide victims were identified from medical examiner reports in Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Structured interviews were conducted with proxy respondents close to the decedents to obtain information about alcohol or illicit drug use, and history of alcohol-related hospitalization or trouble at work because of drinking by the subject. Data about alcohol use by others living in the same house as the subject were also obtained., Results: The risks of homicide and suicide associated with alcohol or illicit drug use were elevated, as were the risks of violent death associated with several indicators of chronic alcohol abuse. In addition, nondrinkers living in a home with alcohol users were at increased risk of homicide (odds ratio, 1.7; 95% confidence interval, 0.98-3.0), and non-drug-using individuals residing in homes with illicit drug users were at greatly increased risk of homicide (odds ratio, 11.3; 95% confidence interval, 4.4-28.8)., Conclusions: Alcohol and illicit drug use appear to be associated with an increased risk of violent death. The risk of homicide was increased for non-substance-abusing individuals living in households in which other members abused alcohol or drugs. The concept of the individual at risk of homicide should be broadened to include not only the abuser but also those who may be at risk because of their exposure to others.

Based on a weighted aggregation of three biological alcohol markers (gamma-glutamyltransferase, blood alcohol and mean corpuscular volume), this study presents a screening instrument for alcohol problems in trauma patients. The sex-specific performance of this instrument was explored on 1088 male and 352 female patients, 18 years or older, admitted with blunt or penetrating trauma during a 30-month period to a regional level one trauma center in Seattle, Washington (USA). The sum of the differentially weighted alcohol markers ("WAM"), determined from one blood sample, formed a "score continuum" ranging from 0 to 24. The WAM scores distributed themselves across the trauma population with higher WAM scores being correlated to higher screening instrument scores for alcohol problems. By using two of the best established screening tests for alcohol problems (CAGE and SMAST) to define cut-off points for likely "alcohol abuse/dependence", the WAM score of > or = 7 in males showed 75% sensitivity and 83% specificity, whereas the WAM score of > or = 6 for females displayed 85% sensitivity and 85% specificity. We conclude that a weighted combination of biological alcohol markers (WAM score) is a useful tool for identifying alcohol problems among trauma patients. Representing an alternative or addition to a more extensive interview, it could be used as a routine part of the care of trauma patients.

Nearly half of all trauma beds are occupied by patients who were injured while under the influence of alcohol. Alcoholism plays such a significant role in trauma that efforts to reduce injury recurrence are unlikely to be successful if it remains untreated. An injury requiring hospitalization creates a unique opportunity to intervene and to motivate patients to alter their drinking behavior, thereby making trauma centers ideal sites to implement an alcohol screening, intervention, and referral program. However, despite emphasis on injury control and prevention, little has been done to incorporate alcohol intervention programs into care of the injured patient. Effective means of intervention exist that are consistent with the time, financial, and staffing constraints of trauma centers, and they should be implemented.

Study Objectives: To explore and compare the sex-specific correlation of two standard behavioral screening instruments, the Short Michigan Alcohol Screening Test (SMAST) and the CAGE, with a weighted scale that combines the three most commonly used biological alcohol markers (blood alcohol level, mean corpuscular volume, and gamma-glutamyltransferase level)., Design: A prospective cohort study., Setting: Regional level I trauma center, in Seattle, Washington., Participants: 1980 male and 602 female patients 18 years of age or older, admitted with blunt or penetrating trauma., Main Results: Spearman rank correlations were used to compare the two screening measures with the weighted scale. The CAGE was found to correlate better than the SMAST with the weighted combination. Correlations for both measures were higher in women than in men. Among the individual biological alcohol markers used to construct the weighted scale, blood alcohol level was the marker that displayed the strongest correlation with both the CAGE and the SMAST., Conclusion: We conclude that the CAGE questionnaire showed a higher correlation with a combination of biological alcohol markers than did the SMAST, and that the CAGE may be the questionnaire of choice for identification of alcohol problems in patients seen in trauma centers.

Objective: To determine the effect of admission for trauma with concurrent acute alcohol intoxication or chronic alcohol abuse on the risk of subsequent recurrence of trauma., Design: Prospective cohort study., Setting: Level I regional trauma center., Patients: A total of 2578 patients 18 years or older admitted with blunt or penetrating trauma within 24 hours of injury and surviving to discharge. All patients had a blood alcohol concentration (BAC) test, a gamma-glutamyltransferase (GGT) test, and the short Michigan Alcohol Screening Test (SMAST) performed on admission., Main Outcome Measurement: Readmission to the trauma center for new trauma. Average follow-up was 28 months (range, 16 to 40 months)., Results: The overall rate of readmission for new injuries was 1.3 per 1000 patient-months of follow-up. Patients who were intoxicated on the initial admission (BAC > 22 mmol/L [100 mg/dL]) were 2.5-fold as likely to be readmitted than those not intoxicated (95% confidence limits, 1.6, 3.9). The relative risks for patients with positive SMAST scores and abnormal GGT values were 2.2 (95% confidence limits, 1.4, 3.5) and 3.5 (95% confidence limits, 2.2, 5.5), respectively. The increased risks remained significant for intoxication and abnormal GGT values after adjustment for gender, race, Medicaid status, and mechanism of injury., Conclusion: Alcohol abuse is associated with an increased risk of readmission for new trauma. Trauma patients should be screened for alcohol problems; referral of problem drinkers for appropriate care may decrease their risk of admission for subsequent trauma.

Objective: To determine the effect of acute alcohol intoxication and chronic alcohol abuse on morbidity and mortality from trauma., Design: Prospective cohort study., Patients: Blunt or penetrating trauma patients at least 18 years of age admitted to one trauma center or dying at the injury scene., Main Outcome Measures: Mortality, complications (infection, pneumonia, respiratory failure, or multiple organ failure), and length of hospital stay., Results: Acute intoxication had no effect on risk of dying--at the injury scene, within the first 24 hours of hospitalization, after the first 24 hours, or overall. Acute intoxication also did not increase the risk of complications and was associated with shorter lengths of stay. Patients with both biochemical and behavioral evidence of chronic alcohol abuse had a twofold increased risk of complications, particularly pneumonia and any infection, compared with those with no evidence of chronic alcohol abuse., Conclusions: Chronic, but not acute, alcohol abuse adversely affects outcome from trauma. Attention to the problem of chronic alcohol abuse in trauma patients is necessary, and screening trauma patients for chronic alcohol abuse appears to be warranted.

Young adults, 18-20 years of age, admitted to a trauma center via the emergency department, were studied to determine if they had been drinking prior to their injury event. The prevalence of self-reported chronic alcohol problems was examined using the short Michigan Alcohol Screening Test (SMAST). Of the 319 subjects, 131 (41%) tested positive for alcohol, including about one-half of those with intentional injuries and 38% with unintentional injuries. Approximately 22% had blood alcohol concentrations of 100 mg/dL or more, indicating they were legally intoxicated at the time of their injury. Of study subjects who completed the SMAST, 49% attained scores suggesting potential or probable alcoholism, and 20% had already sought some type of treatment, despite their young age. Health-care practices and policies related to these findings include routine screening of trauma patients for alcohol abuse and integration of chemical dependency intervention services with trauma care.