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RESEARCH

Screening and Brief Intervention for Alcohol
Problems In the Emergency Department

Gail DíOnofrio MS, MD, Associate Professor, Section of Emergency Medicine, 
Yale University School of Medicine; Linda C. Degutis, DrPH, 
Assistant Professor, Yale University School of Medicine;
David A. Fiellin, MD, Assistant Professor, 
Yale University School of Medicine;
Michael V. Pantalon, PhD, Assistant Professor, 
Yale University School of Medicine

The social and personal costs of alcohol use and abuse

Alcohol is the most commonly used drug in the U.S.1 and a leading cause of morbidity and mortality.2 Its use is associated with 100,000 deaths each year, and with an annual economic cost of approximately $100 billion.2 Alcohol is a major risk factor for virtually all categories of injury.3 It has been demonstrated that alcohol is a factor in 60-70% of homicides, 40% of suicides, 38% of fatal motor vehicle crashes (MVC), 60% of fatal burn injuries, 60% of drownings, and 40% of fatal falls.4,5,6,7,8 Nearly 50% of severely injured trauma patients are injured while under the influence of alcohol.9 Alcohol is a risk factor in a variety of diseases including hypertension, stroke, diabetes, liver and other gastrointestinal diseases as well as breast and esophageal cancer.10

Hazardous and harmful drinkers are prevalent 
in the ED population and at risk for injury and illness

Recent emphasis has been placed on the detection and treatment of hazardous and harmful drinkers. Hazardous drinking is defined as a quantity or pattern of use that places someone at risk for adverse health events, while harmful drinking is defined as use that results in adverse events, such as physical or psychological harm.11 The NIAAA defines this entire group as "at-risk," for injury or illness.12 Compared to dependent drinkers, which represent 5% of the population, this at-risk group comprises 20% of the U.S. population.13

Emergency physicians routinely care for patients with the adverse health effects of hazardous and harmful drinking. There are an estimated 90-100 million ED visits each year, and between 10-46% of these visits are known to be associated with alcohol.14,15 Cherpitel screened all patients presenting to an ED, and found that 17% were positive for harmful drinking.16 Problem drinkers average almost twice as many injury-related events per year as non-problem drinkers and four times as many hospitalizations for injury.17 In addition, it has been shown that rates of heavy drinkers and alcohol-related problems among both injured and non-injured ED patients are higher than in the general population.18

An ED visit is often a missed opportunity for detection 
of and intervention with alcohol problems

Many patients routinely visit the ED for medical care. OíBrien, et al, found a higher likelihood of self-reported alcohol and drug use among patients who identified the ED as their regular source of care.19 A single alcohol-related ED visit has been shown to be an important predictor of continued problem drinking, alcohol-impaired driving, and possible premature death.20 In addition, hazardous and harmful drinkers who present to the ED have been found to have a higher rate of ED utilization than patients who do not have alcohol problems.21 A study conducted by Dr. Degutis documented that injured patients with alcohol problems had a repeat ED visit rate that was significantly higher than that of injured patients who screened negative for alcohol problems. Unfortunately, despite high rates of heavy drinking among both injured and non-injured ED patients, routine screening and brief interventions (BI) are rarely performed in the ED. Because of this, an important opportunity to address alcohol-related problems is missed.22

The failure of ED staff to detect, intervene, and refer patients for counseling is well documented.5,24 Reasons cited for lack of recognition and referral include inadequate time, insufficient education, and lack of resources. Emergency physicians are often faced with a busy ED, conflicting demands and ever-increasing responsibilities. Therefore screening and intervention strategies must be brief and effective. However, evidence suggests that acute sub-critical injury may be an important motivator to reduce drinking, and thus the time of the ED visit may be a valuable teachable moment.23 The identification and initiation of treatment for individuals who are drinking at hazardous or harmful levels would be beneficial in broadening the base of alcohol treatment.14

Governmental agencies have become aware of the importance of screening for alcohol-related problems in ED patients. This is evidenced by the recent passage of Public Act 98-201 in the State of Connecticut.24 This Act mandates substance abuse screening for injured patients who are treated in EDs in all hospitals in the state. In addition, it directs that there be a development of standards for continuing education training.

Evidence exists supporting the efficacy of brief intervention

Patients with less severe alcohol use problems (such as hazardous and harmful drinking) are more likely to respond to treatment than dependent drinkers.25,26,27,28 Brief interventions (BI) have been demonstrated to be effective, as described below. BI are short, 5-15 minute counseling sessions, often utilizing motivational enhancement techniques, designed to assist the person in confronting the negative consequences of his or her alcohol consumption. The interaction is patient-centered and intervention strategies are based on the patientís readiness to change. The practitioner helps the patient to resolve ambivalence about change with discussion of pros and cons of drinking behavior. Feedback is given respectfully in the form of useful information. Patients are empowered to begin the process of developing solutions for themselves. The principles of brief motivational interviewing developed by Miller and Rollnick are encapsulated in the FRAMES acronym. (Feed-back: review problems experienced because of alcohol; Responsibility: changing alcohol use is the patientís responsibility; Advice: advise to cut down or abstain; Menu: provide options for changing behavior; Empathy: use an empathetic approach; and Self-efficacy: encourage optimism that one is capable of changing behavior.29

Studies of BI to date have been performed in a variety of inpatient and outpatient settings. Bien and colleagues reported efficacy of BI in 7 out of 8 randomized clinical trials (RCTs) performed in a health care setting.30 These studies demonstrated that BI is more effective than no counseling and often as effective as more extensive treatment. They conclude that BI is one of the most supported and cost-effective intervention modalities for alcohol problems. In addition, a recent meta-analysis of eight RCTs found that heavy drinkers who received a BI were almost twice as likely to decrease and moderate their drinking compared with those who received no intervention (pooled odds ratio of 1.95, CI 1.66-2.30).31

Several studies have demonstrated that BI is effective in decreasing consumption in hazardous drinkers. Wallace studied 909 "excessive drinkers" identified in 47 British general practices.32 He found a significant reduction in the number of drinks per week for men (18 vs. 8) and women (12 vs. 6), who were given "simple advice" as compared to "no advice." A World Health Organization study evaluated the effect of BI with more than 1500 "heavy drinkers" in 12 countries with different cultural orientations and social circumstances.33 Simple advice, 20 minutes of brief counseling, and extended counseling interventions were compared to a control group who received a health survey only. While all groups reduced their drinking, the intervention groups (simple advice and brief counseling) had significantly greater reductions in alcohol consumption than the control group. Five minutes of simple advice was as effective as brief counseling and extended counseling (up to three follow-up sessions). Male drinkers receiving five minutes of brief advice reduced their typical alcohol consumption by 21% and those exposed to brief counseling reduced consumption by 27%, while there was only a 7% reduction among controls. Fleming, et al, conducted a randomized controlled clinical trial involving 64 Wisconsin primary care physicians and 723 patients with problem drinking, defined as more than 14 drinks per week for men, and more than 11 drinks per week for women.34 The intervention consisted of two 15-minute counseling sessions with a reinforcement follow-up phone call. At the 12-month follow-up sessions there were significant reductions in 7 day alcohol use (from 19.1 to 11.5 drinks per week), in mean number of episodes of binge drinking over 30 days (from 5.7 to 3.1), and a decrease in hospitalizations among men. Recently, Marlatt, et al, demonstrated that high-risk college student drinkers who received a brief intervention in their freshman year showed significant reductions in both drinking rates and harmful consequences in comparison with students in a no-treatment control group.35 Gentilello recently studied hospitalized trauma patients who screened and/or tested positively for a continuum of alcohol problems. He reported decreases in alcohol consumption in the intervention group who received a BI compared to a control group (p<.03), which was most apparent in patients with mild to moderate problems (p<.01). In a 3 year follow-up period, there was a 47% reduction in injuries requiring an ED visit, and a 48% reduction in injuries requiring hospital admission.36

Brief Intervention in the ED

E. Bernstein and J. Bernstein successfully applied brief intervention for patients with alcohol problems in the ED.37 Their program, Project ASSERT, funded by the Center for Substance Abuse Treatment (CSAT), utilized trained outreach workers to screen 7,118 ED patients and found alcohol and drug problems in 41%. As part of the project, Dr. Edward Bernstein, working with Dr. Stephen Rollnick, developed an approach to BI entitled the Brief Negotiation Interview (BNI), which incorporates motivational techniques, and can be accomplished in less than 10 minutes. The results of the project indicate that there is potential for success with the use of the BI in the ED. Among the 245 enrollees, primarily dependent drinkers, for whom there was follow-up at 90 days, there was a 56% reduction in alcohol use and a 64% reduction in binge drinking. Over 50% reported follow-up with the treatment referral.

Monty et al, studied the use of a brief motivational interview (MI) to reduce alcohol-related consequences and alcohol use among adolescents (aged 18-19 years) in an ED following an alcohol-related event.38 Follow-up assessments showed that patients who received the MI had a significantly lower incidence of drinking and driving, traffic violations, alcohol-related problems (p <.05), and alcohol-related injuries (p <.01) than those who received usual care. However, the ability to generalize the results of this study may be limited because all interventions were performed by trained social workers hired for the project.

Longabaugh and colleagues at Brown University recently have completed a trial with injured, hazardous drinkers in the ED setting.39 Patients were randomized to standard care, immediate BI and immediate BI followed by a comprehensive intervention session subsequent to the ED visit. The results of this study have not been published. However, the ability to generalize the results may be limited as all interventions also were performed by trained social workers. While this project will contribute information about the value of using the BI in the ED, it does not address its effectiveness with non-injured patients, or the effectiveness of interventions performed by ED practitioners.

Best Practice Standards: 
What Has Research Revealed? Part I

Carl A. Soderstrom, MD, Professor of Surgery, R. Adams Cowley Shock Trauma,
University of Maryland Medical Center

Substance Use Problems Among Emergency Department 
and Trauma Center Patients

Substantial numbers of injured patients who require emergency department or trauma center care have evidence of substance use problems or diagnoses as demonstrated by either positive admission toxicology test results and/or diagnosed substance use disorders. Among injured patients treated in emergency departments 15-25% test positive for pre-injury alcohol use, while 25-55% of trauma center patients are alcohol positive.1-5 While almost one-in-six vehicular crash victims treated in emergency departments are alcohol positive, a third or more (30-35%) of crash victims admitted to trauma centers test positive for alcohol.3,6,7,8

In contrast to alcohol, there is much less data for non-alcohol drug use prior to injury. Studies involving large cohorts of injured patients treated in trauma centers reveal that about 40-45% test positive for other drugs.5,9,10 While 35-45% of vehicular crash victims are drug positive at the time of admission, 50-65% of violence victims tests positive for other drugs of abuse.5,7,10

Recent reports have documented the prevalence of psychoactive substance use disorders among injured patients. While approximately 15-20% of injured patients treated in emergency departments have an alcohol use diagnosis, 25-45% of injured patients treated in trauma centers have such a diagnosis.2,3,5,6 The majority of these diagnoses are for that of dependence, rather than for the less severe diagnosis of abuse. An emergency department study of injured vehicular crash occupants using standard criteria revealed that 23% had a diagnosis of either alcohol abuse (AA) or dependence (AD) (AA/AD were not differentiated), while a trauma center study demonstrated that 17% of crash victims were alcohol-dependent at the time of injury.6,8 The prevalence of alcohol dependence was two and one-half times higher among male drivers compared with female drivers, being 10% vs. 25%.8 The highest prevalence of alcohol dependence was found among struck pedestrians, being 48% overall, and 52% among injured male pedestrians.8 Compared to alcohol, there are few data relative to other drug diagnoses among injured patients. A trauma center study found that 18% of patients had a diagnosis of current drug dependence, and that the prevalence of current drug dependence was over three times higher among violence victims compared with unintentional injury victims, being 36% and 10% respectively.5

Obstacles to Identifying Injured Patients At Risk of Substance Use Problems

While significant numbers of injured patients have diagnosable substance abuse problems, there are obstacles, which preclude identification of patients at risk of those problems. A number of these problems, such as negative/ambivalent feelings about intoxicated and/or injured patients, the thought that alcohol and drug testing is "clinically not important", skepticism about the efficacy of substance abuse treatment, and a general lack of knowledge about screening techniques are all amenable to education.11-15

Another barrier to identification of substance abusing patients is the relatively low testing rates for alcohol and other drugs. A 1994 survey of 278 Level I and II trauma centers documented that admission alcohol and other drug testing was routinely conducted at only 64% and 40% of centers respectively.14 These low testing rates took place despite American College of Surgeonsí Committee on Trauma (COT) guidelines that characterized such testing as an "essential" characteristic of Level I and II centers. While more recent data are not available, one would suspect that fewer centers are now testing since the COT eliminated alcohol and other drug testing in the 1999 iteration of the Resources for Optimal Care of the Injured Patient.16

While reasons for the change in the COT guidelines for testing were not given, it may well be because of the lack of previous evidence concerning the efficacy of intervention for problem drinking trauma patients and fears of, or actual denial of payment by third party payors for the treatment of injuries for patients testing alcohol positive at the time of injury. Relative to the first reason, studies have begun to appear that demonstrate that brief intervention techniques can reduce problem drinking and consequences of problem drinking among injured patients treated in emergency department and trauma center settings.17,18 Relative to the second reason, a recent report by Rivara and colleagues documented that both policies and statutes do allow for denial of payment.19 However, they indicated that "this option (denial of payment) seems to be enforced rarely by most companies." In addition, they offered practical solutions for the removal of alcohol testing as a barrier to identifying injured patients at risk of substance use problems.

Identifying Injured Patients with Substance Use Problems

To treat substance use problems, methods to identify patients at risk of such problems are needed. In the past decade, a number of studies have assessed the effectiveness of laboratory tests and questionnaire screening techniques.

The simplest laboratory test to identify patients with an alcohol use diagnosis (abuse or dependence) is a blood alcohol concentration (BAC) determination. Studies indicate that 55-75% of injured patients who are BAC+ at the time of admission have an alcohol abuse or dependence diagnosis. These same studies indicate that 11-45% of BAC- patients also will have an alcohol use diagnosis.3,5,6

Biologic markers were used for decades to screen for alcoholism in the general population. However, recent reports indicate that these markers are not sufficiently sensitive and specific to be used either in the general population or among injured patients to identify those at risk of alcohol problems.20,21 Indeed, studies of large populations of trauma center patients with alcohol use diagnoses documented that less than 30% had elevated levels of biologic markers consistent with those diagnoses.3,22

Screening questionnaires which take a minute or two to administer have been shown to be useful in identifying injured patients with alcohol use problems both in emergency department and trauma center settings.2,23 Examples of useful questionnaire screening tests are the four-question CAGE (this mnemonic is derived from questions about the need to "cut down on your drinking," being "annoyed" by people "criticizing your drinking," "have felt bad or guilty about your drinking," and ever having "a drink first thing in the morning (eye-opener) to steady your nerves or get rid of a hangover") and the ten-question Alcohol Use Disorders Identification Test (AUDIT).2,23 The sensitivity and specificity of these two instruments in detecting alcohol dependence in injured patients have been documented to be as follows: CAGE, sensitivity - .84, specificity - .87-.90; AUDIT, sensitivity - .75-.91, specificity - .73-.85.2,23 In addition to standardized screening questionnaires, recent National Institute of Alcohol Abuse and Alcoholism quantity and frequency of drinking screening criteria for the general population have been found to be of value in identifying trauma center patients with alcohol use problems.24,25

Recommendations

  1. Substance abuse education should be incorporated into professional schooling and post-graduate educational activities of all clinicians involved in the care of the injured.
  2. All injured patients should be tested for pre-injury use of alcohol and other drugs.
  3. All injured patients should be screened for substance use disorders using questionnaires. Screened positive patients should be evaluated for such disorders by substance abuse clinicians.
  4. Treatment/intervention should be provided to patients with substance use disorders.

Best Practice Standards:
What Has Research Revealed? Part II

Larry M. Gentilello, MD, Associate Professor of Surgery, 
Harborview Medical Center,
University of Washington School of Medicine

Alcohol Interventions in Trauma Centers as a Means 
of Reducing Injury Recurrence

Regional trauma centers were developed 30 years ago when studies demonstrated that 40 percent of deaths due to injuries in the United States could have been prevented if the patient had been treated in a facility with special expertise in treating injuries.1 Since the development of regional trauma systems, preventable mortality has now been reduced to less than 2-3%; therefore, future decreases in trauma mortality are not likely to occur as a result of improvements in the delivery of care. Nearly half of all trauma deaths occur at the scene, and also are not responsive to improvements in care. Future significant decreases in the death rate for injuries therefore depend on progress in injury prevention.

By far, the most common underlying causes of injuries in the United States are alcohol abuse and dependence.2,3 Typically, trauma centers treat the injury, but ignore the underlying alcohol problem. Studies demonstrate that problem drinking patients are two and one-half times more likely to be readmitted to a trauma center due to injury recurrence than patients without an alcohol problem.4 Alcohol problems play such a significant role in trauma that efforts to reduce the risk of injuries or their recurrence are unlikely to be successful if it remains untreated.

Over the past decade, studies have demonstrated that patients with mild to moderate alcohol problems who receive brief, motivational interventions are nearly twice as likely to have long term moderation of their drinking compared to controls, and this is generally accompanied by a reduction in hospitalization and health care costs. To date, there have been over a dozen randomized trials of brief alcohol interventions, as well as 32 controlled studies enrolling over 6,000 patients that support these findings.5,6,7

An injury requiring hospitalization creates a crisis that provides a unique opportunity to intervene and to motivate patients to alter their drinking behavior. This makes trauma centers ideal sites to implement an alcohol screening, intervention, and referral program. We hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption, and decrease the rate of trauma recidivism. A prospective, randomized clinical trial was conducted to determine whether incorporation of a comprehensive program of screening and intervention in a trauma center would reduce future alcohol-related injuries and other alcohol-related morbidities.8

The screening and intervention program was intended to serve as a model for the appropriate care of the alcohol abusing patient by being consistent with the time, financial and staffing constraints found in busy urban trauma centers. Screening consisted of incorporating a blood alcohol concentration (BAC) and a liver function test (gamma glutamyl transpeptidase) into routine admission labs. During a subsequent hospital stay, the 13-question Short Michigan Alcoholism Screening Test (SMAST) was administered. The intervention consisted of a 30-minute motivational interview with the patient prior to trauma center discharge, followed by a letter sent at 30 days that summarized the intervention. A detailed description of the screening and intervention methods employed, along with the method of their implementation in a trauma center, have been described elsewhere.2,9

Screening was performed on 2,524 patients over a two-year period. Only 33 patients refused the SMAST. Screening was positive in 1,153 screened patients (46%). A total of 366 patients were randomized to the intervention group, and 396 were randomized to the control condition. Screening and demographic characteristics of intervention and control patients were similar.

Objective follow-up was obtained by searching Harborview Medical Center Emergency Department Records at one-year post discharge to detect return to the ED for treatment of a new injury. A computerized database of all hospital admissions in Washington State was also reviewed up to three years post discharge to detect hospital readmission for treatment of an injury anywhere in the state. This provided nearly 100% follow-up for the primary study outcome, excluding only those who moved out of state. Interviews with the patient and a collaborative person were also conducted at six and twelve months to re-assess drinking behavior. There was a 47% reduction in new injuries requiring either treatment in the HMC emergency department or readmission to the HMC trauma service in the intervention group compared to controls (HR 0.53, 95% CI 0.26-1.07, p = 0.07), as shown in Figure 1.

Figure 1. Risk of repeat injury requiring treatment in the 
Harborview Medical Center (HMC) Emergency Department 
or admission to the HMC trauma center at one-year follow-up.

Figure 1. Risk of repeat injury requiring treatment in the Harborview Medical
Center (HMC) Emergency Department or admission to the HMC trauma center at one-year
follow-up.

There was a similar reduction (48%) in inpatient hospital readmissions for trauma in intervention group patients with up to three years follow-up, as determined by analysis of the statewide hospital discharge database (HR 0.52, 95% CI = 0.21-1.29, Figure 2).

Figure 2. Risk of injury resulting in 
hospital readmission anywhere in Washington State. 
Follow-up duration was up to three years.

Figure 2. Risk of injury resulting in hospital readmission anywhere in Washington State. 
 Follow-up duration was up to three years.

The reduction in trauma recidivism was accompanied by a significant reduction in alcohol intake in intervention group patients compared to controls. At 12 month follow-up, the intervention group decreased its weekly alcohol consumption by 21.8 + 3.7 standard drinks per week, compared to a 6.7 + 5.8 drinks per week decrease in controls (p = 0.03).

This study demonstrates that reducing hazardous drinking and trauma recidivism in trauma patients is feasible and effective. One out of eight hospital beds in the United States is occupied by an injured patient.10 Since nearly half of these patients are injured while under the influence of alcohol, interventions coupled with trauma center admission have the potential to have a marked impact on public health.

Reasons Why Trauma Surgeons Fail to Screen for Alcohol Problems

If recommendations to integrate alcohol screening and counseling into trauma care are to be implemented, a better understanding of the reasons why trauma surgeons are currently failing to do so is required. We hypothesized an association between current screening and counseling practices, and the trauma surgeonís knowledge, attitude, and perceived role responsibility towards alcohol problems.

We conducted a random survey (n=241) of members of the American Association for the Surgery of Trauma, the leading academic trauma organization in the United States.11 Eighty-three percent of respondents stated they had no prior training in screening or diagnosing patients with alcohol problems. Another indicator of the lack of knowledge of screening for alcoholism was that 76.4% of trauma surgeons were unfamiliar with the most common clinically used alcohol screening instrument, the CAGE questionnaire. Over 13% of trauma surgeons were not familiar with the term "BAC." (Table 1).

Table 1. 
Trauma surgeonís awareness of alcohol screening methods.
Screening InstrumentUsefulNot
Useful
Not
Familiar
With
BAC81.1%5.6%13.3%
SMAST16.1%3.4%80.5%
CAGE21.3%2.3%76.4%
AUDIT7.5%4.0%88.5%
TWEAK3.5%2.3%94.2%

Only 18.7% of respondents reported routinely screening all trauma patients. This group was referred to as "screeners." More than half (54.0%), reported screening 25% or less of all trauma patients, and this group was referred to as "non-screeners." In order to determine the predictors of screening, we compared the responses of screeners and non-screeners.

The most common reason cited by non-screeners for failure to screen was "too busy" (46.6%), although screening can easily be accomplished by incorporating an admission BAC into admission lab draws, and administration of the CAGE or SMAST is not time consuming. In contrast, only 28.2% of screeners reported being "too busy" to screen (p=0.04). The survey specifically asked trauma surgeons who they believed should be responsible for screening. The attending was felt to have major responsibility for screening by 54.5% of screeners, compared to 25.5% of non-screeners (p=0.001).

Logistic regression was used to examine predictors of screening while controlling for other factors (Table 2). Belief that the attending has major responsibility for screening, confidence in the ability to diagnose alcohol problems, and confidence in the ability to personally counsel patients were the three significant predictors of alcohol screening. Each factor roughly doubled the likelihood of screening for alcohol abuse. No other factors were significant predictors of screening in the multivariate model.

Table 2. 
Independent predictors of screening for alcohol use problems.
VariableAdjusted
Odds Ratio
95% CI
Belief that attending has major responsibility for screening  2.35  1.38 Ė 4.01
Confidence in ability to diagnose alcohol problems  1.96  1.05 Ė 3.67
Confidence in ability to counsel patients  2.27  1.34 Ė 3.85

This survey revealed that the trauma surgeonís knowledge and confidence towards alcohol screening is relatively poor, and these factors are significant predictors of screening behavior. One encouraging finding of this survey was that trauma surgeons appeared to have a belief in their primary role in the identification and treatment of alcohol problems in their patients, as the majority did not believe that screening should only be done by specialists in the field. Trauma surgeons also appeared to be motivated to learn about addressing alcohol problems. Nearly all respondents were willing to devote at least one hour to learn brief intervention techniques if they could be convinced they are effective. Thus, the lack of alcohol screening and counseling appears to be due to cognitive factors, not a lack of motivation or sense of responsibility.

We conclude that there is an urgent need to train trauma surgeons in alcohol-related issues. Surgical residents and established trauma surgeons should receive training on screening, as there was a strong correlation between screening practices and confidence in screening skills. Because surgeons also appear to lack knowledge about the success of alcohol treatment, there is also a compelling need for education regarding the results of brief intervention programs in health care settings.

The Ability of Trauma Center Staff to Identify Patients 
with Acute Intoxication or Chronic Alcohol Problems.

Our survey of trauma center screening practices revealed that 54% of surgeons screen only patients whom they suspect are intoxicated based on clinical suspicion. This group reported an estimated screening rate of less than 25%. Other reports confirm that physicians believe that routine BAC testing is unnecessary because clinical judgment is a reliable means of detecting alcohol intoxication.12

We hypothesized that clinical suspicion fails to identify a significant proportion of patients who are acutely intoxicated; that it is further impaired by injury factors such as shock, injury severity, endotracheal intubation, traumatic brain injury, and neuromuscular blockade; and that it is subject to discriminatory bias due to personal factors such as age, race, gender, income, appearance, and socioeconomic status.13

The study population consisted of individuals 18 years of age and older who were admitted to Harborview Medical Center for treatment of an injury. A routine admission BAC was obtained as part of emergency department evaluation. Prior to obtaining BAC results, treating physicians (trauma surgery attendings and residents) and Emergency Department nursing staff were asked to complete a questionnaire which asked whether they thought the patient had any alcohol in their blood, and whether the patient was acutely intoxicated (BAC >100 mg/dl). This estimation was based on the clinical assessment in the emergency room, including history, physical examination, police, and prehospital personnel reports.

Staff were also asked, based on this same clinical evaluation, to determine whether or not the patient was likely to have a chronic alcohol problem. The questionnaire also asked clinicians several questions regarding their perception of patient characteristics such as appearance and socioeconomic status, including housing, insurance status and income.

The CAGE questionnaire and the SMAST were administered to study patients by trained research staff who were blinded to ED questionnaire and BAC results.

There were 748 eligible patients admitted during the study period. Physicians identified only 77% of patients who were acutely intoxicated, with nursing staff performing only slightly better. Sensitivity was significantly affected by a variety of injury and patient factors. Physicians identified only 60% of intoxicated patients greater than 45 years of age, compared to an 81% detection rate for younger patients. Acute intoxication was missed in only 10% of patients described as disheveled, but was missed in 35% of patients described as well-groomed (p=0.003). Clinical suspicion of intoxication failed to identify 31% of intoxicated patients who were severely injured (ISS >9), 37% of patients in shock (BP <90mmHg), 38% of chemically paralyzed patients, and 33% of patients who were endotracheally intubated.

Specificity of clinical testing was also poor, and was significantly affected by a variety of patient factors. Overall, 26% of patients suspected by physicians of having some amount of alcohol in their blood had a BAC of zero, and 17% thought to be acutely intoxicated had a BAC < 100 mg/dl. Clinical suspicion of patient alcohol use was also significantly biased by a variety of patient characteristics, including age, income, appearance, and insurance status (p value for each factor < 0.001). Nearly one-third of males with no detectable alcohol in their blood were thought to be intoxicated. Males were more than twice as likely as females to be falsely suspected of being intoxicated. Patients without health insurance, those with disheveled clothing or appearance, younger patients, and those with an estimated annual income of less than $20,000 were also significantly more likely to be falsely suspected of being intoxicated than older, insured, well clothed, or high income patients.

Only 47% of patients who screened positive for chronic alcoholism with the SMAST, and 38% of patients with a positive CAGE were considered likely to have an alcohol problem based on physician suspicion. Finally, 25-30% of patients who were thought to be chronic alcoholics by their physicians were found not to have a problem based on subsequent standardized questionnaire administration.

In summary, this study demonstrates that the use of clinical judgment to detect acute alcohol intoxication has poor sensitivity and specificity, and is subject to discriminatory bias. This study also demonstrates that trauma staff fail to identify more than half of the patients with chronic alcohol problems, thus missing an important opportunity to identify patients who may benefit from alcohol interventions.

Measurement of Alcohol Levels 
and Reporting Impaired Drivers

Phillip A. Brewer, MD, FACEP, Assistant Professor, 
Yale University School of Medicine

Introduction: The Injured, Intoxicated Driver in the Emergency Department

Alcohol and Vehicular Trauma

Alcohol-related motor vehicle crashes (MVC) are a major source of mortality in the United States. MVCs involving an alcohol level greater than 0.10mg/dl claimed 12,321 lives in 1999.1 Driving under the influence (DUI) is recognized as a major public health issue, and medical professionals have been encouraged to play a greater role in the prevention of alcohol-related MVCs.2-8

In addition to support for community-based prevention efforts, physicians in many states have a unique opportunity to combat DWI by recognizing and reporting the intoxicated driver taken to the Emergency Department (ED) for evaluation following an MVC.9 Indeed, once an impaired driver arrives in the ED, physician reporting may be the only possibility to effectively intervene, because from that point on other interventions, including DUI prosecution, are unlikely to occur.10-19

Limitations of DUI Prosecution

Several factors decrease the likelihood of detection and prosecution, including increased distance from crash site to hospital, severity of driver injury, lack of prior DUI convictions, and lack of passenger injuries and property damage.16 In one study, only 7% of severely injured drunk drivers were charged with DUI while 33% of drivers with minor injuries were prosecuted. The rate of prosecution based on prior DUI convictions is shown in Table 3.15 The overall prosecution rate was 28%.

 

Table 3. Effect of the number of prior DUI convictions on subsequent DUI prosecution following alcohol-related MVC with driver injury.15
Prior DUI ConvictionsDriversDUI 
Prosecutions (%)
0 112 18 (16)
1 35 20 (56)
2 21 11 (52)
3 12 3 (25)
>3  5 0 (0)

In another study of injured, intoxicated drivers who were responsible for 87 MVCs in which there were five non-driver deaths and 74 non-driver admissions to the hospital for injury, there were only 28 police requests for blood alcohol levels.16

These studies demonstrate the importance of intervention by medical professionals in alcohol-impaired driving. Only a minority of alcohol-impaired drivers in the ED are dealt with by the legal system. Unless impaired drivers are identified and made subject to effective medical interventions, they tend to continue a pattern of endangerment of self and others by driving while intoxicated.

For instance, in a study of 3120 drivers killed in MVCs, 26% of drivers with alcohol levels of .02 or more had a history of DUI arrest, compared with only 3% of drivers with no detectable blood alcohol. Alcohol positive drivers 35 years of age or older were 11.7 times more likely than alcohol negative drivers to have been convicted for DUI.20 The remarkable persistence of DUI behavior was shown by the finding that, even while in treatment, male alcoholics continued to drive while intoxicated an average of 8.6 days per month.21

Need for New Strategies

If the national goal of reducing alcohol-related traffic fatalities from 16,580 in 1994 to no more than 11,000 in 2005 is to be achieved, new strategies to reduce alcohol impaired driving will be necessary.22 Medical professionals can play a major role in this effort, and currently available but underutilized strategies can be implemented. Specifically, screening of injured drivers for alcohol impairment and reporting drivers who screen positive should become a routine part of the emergency care.

The present article, in two parts, first examines how the diagnoses of alcohol intoxication and alcohol impairment can be established in the ED. It then goes on to analyze and compare two types of reporting impaired drivers; specifically, reporting to the police under the DUI/criminal justice model, and reporting to the motor vehicle department (DMV) under the chronic impairment/administrative model.

Part 1: Diagnosis of Acute Alcohol Intoxication 
and Chronic Alcohol Impairment

Screening for Alcohol Impairment

An essential step in the evaluation of a patient relative to alcohol abuse, is a screening exam consisting of questions, which explore the patientís drinking pattern, attitudes about drinking, and possible adverse consequences of alcohol abuse. Several methods, including the CAGE, MAST, and others, are included in Appendix D.6

Verbal screening may be supplemented by blood alcohol determination. The value of obtaining an alcohol level is that it can be used as a measure of alcohol tolerance and dependence. A very high BAC is associated with a high likelihood of chronic impairment and recidivism, with a peak correlation at a BAC of 0.29%.23,24 It may also be helpful in interpreting the results of the screening interview; for instance, when a person who denies excessive drinking has an excessively high BAC.

Diagnosis of Acute/Chronic Alcohol Impairment

This evaluation may lead to one or both of the following diagnoses: acute ethanol intoxication and/or chronic alcohol abuse. Acute intoxication is easily diagnosed on the basis of an elevated BAC. A diagnosis of chronic impairment may be based on the presence of one or more of the following elements:

Note that this information can be derived in the short time span of an emergency department evaluation.

Medical, Ethical, and Legal Considerations of Alcohol Screening

Decision to Test

Alcohol testing of injured persons in the ED may be done by protocol or by choice. The Committee on Trauma of the American College of Surgeons recommended until recently that all trauma patients be tested for intoxicating substances, and this is the policy in some trauma centers. Alcohol testing may be indicated in the evaluation of mental status changes. If, in addition to mental status changes, the patientís behavior is so unruly as to necessitate physical or chemical restraint, documentation of intoxicating levels of alcohol provides justification of the need for protective custody.

Impediments to Testing

In spite of the usefulness of determining the BAC, many centers refrain from alcohol testing. In most states, insurance companies are permitted to withhold payment for treatment of injuries incurred during illegal activity such as DUI, thus creating a conflict of interest between medical indications for testing and financial considerations, which oppose it.28 To the extent that uninsured, injured drinkers have more complications, longer hospital courses, and are more likely not to pay their hospital bills than are uninsured, injured non-drinkers, the possibility of cancellation of coverage for insured, injured drinkers has far-reaching financial implications for the receiving institution.29 Consequently, many if not most hospitals have dropped alcohol testing from the routine lab panel done on trauma patients.

If an alcohol level is treated as technical information, the testimony of an expert (usually the laboratory director) may be required to confirm its accuracy. This means that in the event of a subsequent criminal or civil trial, the laboratory director may be required to testify, thus consuming many hours of non-productive, unreimbursed time. This barrier to testing can be overcome by laws that treat laboratory values in the medical records the same as business records, which must be accepted prima facie as accurate.

Documentation of alcohol levels may create liability for the physician and hospital if discharge and follow-up recommendations are not modified appropriately. The physician may share responsibility for subsequent injury to the patient or to others unless there are clearly documented instructions for follow-up as well as prohibition of dangerous activities such as driving, climbing, etc. (1989 #208)30

Part 2: Reporting Acute and Chronic Alcohol-Impaired Individuals

Thirty-one states (see Table 4) have laws, that allow or require some type of physician reporting of impaired drivers.9 Because reporting alcohol-impaired drivers is a controversial subject, it is imperative to give precise definitions to various types of reporting, as follows:

Table 4. 
Reporting laws in the fifty states
Mandatory
Reporting
Permissive
Reporting
No Reporting
Statute
  • California
  • DelawareA
  • NevadaB  
  • New Jersey
  • Oregon, Pennsylvania
  • Alabama
  • Connecticut
  • Florida
  • Georgia
  • Illinois
  • Iowa
  • Kansas
  • KentuckyB
  • Louisiana
  • Maine
  • Minnesota
  • Montana
  • New Mexico
  • North Carolina
  • North Dakota
  • Oklahoma
  • Rhode Island
  • Texas
  • Utah
  • Virginia
  • Wisconsin
  • Arkansas
  • District of Columbia
  • Hawaii, Idaho
  • Indiana
  • Massachusetts
  • Mississippi
  • Nebraska
  • New Hampshire
  • New York
  • Ohio
  • South Carolina
  • South Dakota
  • Tennessee
  • Vermont
  • Washington
  • West Virginia
  • Wyoming

A CNS conditions only, B Epilepsy only, C Must notify driver first

Definitions of Various Types of Reporting

Mandatory vs. Permissive Reporting
Mandatory Reporting

A legal requirement for a physician to notify an official agency that a certain condition exists. Failure to report may result in administrative or even criminal sanctions against the physician or other health care provider. For example, reporting cases of suspected child abuse is mandatory in all states.

Permissive Reporting

A legally established option to report a condition to an official agency. The decision to report is at the providerís discretion and may be influenced by the will of the individual to be reported (e.g., in most states physicians may report individuals diagnosed with sexually transmitted diseases, but it is not generally a requirement to do so and there are no sanctions for not reporting.)

Police vs. Medical Reporting
Police Reporting (PR)

Reporting acutely intoxicated drivers to law enforcement with the intended result of an investigation leading to a DUI prosecution. A national survey of 1055 emergency physicians showed that a majority strongly agreed with mandatory PR.31

PR is not without certain ethical considerations, however. Some physicians feel that PR makes them agents of the police. It may be argued that it is contrary to the traditions of the doctor-patient relationship for a physician to invoke a process which will result in criminal sanctions against a patient who, in seeking medical care, revealed an illegal condition (DUI). The physician may decide not to report the patient in order to spare him/her the personal turmoil of a criminal prosecution. Conversely, the physician may, in a spirit of retribution, report the patient in order to "punish" him or her. For these reasons and others, the American College of Emergency Medicine has adopted a policy that opposes permissive and mandatory PR.32

Responsive Reporting (RR)

Passage of laws that would specifically allow health care providers to answer an investigating officerís questions concerning possible intoxication of an injured driver would resolve some if not all of the ethical conflict inherent in the PR model. Physicians who do not feel that initiating an investigation is ethical may feel that it is permissible to cooperate with an ongoing investigation, provided the law allows it.

This would reduce some of the barriers that lower the likelihood that police investigation of an MVC will include detection of alcohol intoxication. In particular, an officer investigating a crash site, which is a great distance from the receiving hospital, may have time constraints which prevent him/her from pursuing the investigation all the way to the hospital unless there is probable cause to believe that the driver is intoxicated.15

Medical Reporting (MR)

Notifying the medical qualifications board or equivalent branch of the Department of Motor Vehicles (DMV) that an individual has a chronic condition making it unsafe for him or her to operate a motor vehicle. This results in a medical evaluation of the individual and possible restriction or revocation of driving privileges until the medical condition is corrected.

Unlike PR, MR has no punitive intent. It does not result in criminal prosecution, fines, or incarceration. Nor does it directly alter an individualís driving privileges. It is a report to a medical body, which then becomes responsible for determining the subjectís fitness to drive. It is not limited to chemical impairment in that any condition, such as progressive loss of vision, recurrent hypoglycemic episodes, etc. is reportable.

As a result of the medical boardís action, the individual may be barred from driving until the impairment is corrected, he/she may be restricted to driving in certain conditions which are not affected by the impairment, or there may be no change at all.

Conclusions

Alcohol-impaired driving remains a significant public health problem. Alcohol-related traffic deaths have declined over the past 10 years, but there is still an unacceptably high death rate. The effectiveness of prosecution of offenders is dissipated by a relatively low risk of detection and lengthy legal delays when charged. Alcoholic drivers tend to drive while intoxicated on a regular basis thus creating an ongoing risk to themselves and to the general public. While general enforcement of DUI laws has had a positive effect on lowering the alcohol-related fatality rate, overall risk of apprehension remains low, and effective timely action is even more elusive.

Health care providers can play an important role in further reducing drunk driving by cooperating with police investigations and by engaging in medical reporting of chronic impairment. Responsive reporting, a novel concept which has not yet been written into law, would improve police effectiveness in enforcing DUI laws.

Medical reporting is allowed in many states and is conceptually an established part of medical practice along with other types of reporting. It is non-punitive and may lead the reported individual to seek treatment in order to maintain driving privileges. Further study is needed to establish the long-term effectiveness of MR in reducing DUI-related casualties.

Reporting of any type is controversial. Groups which favor strong punitive action against impaired driving find that medical reporting allows the impaired driver to escape punishment.33 On the other hand, certain medical ethicists opposed to reporting argue that it is a fundamental violation of patient confidentiality. While this may be true, it is also true that various laws allow for or even require that specific exceptions be made in the interest of public health and safety. States which do not have such laws should consider enacting them in order to give their practitioners the opportunity to reduce alcohol impaired driving.