Injuries are the single greatest killer of Americans between 1 and 44 years of age and the fifth overall leading killer for all age-groups combined.⁴ As described by Gentilello “alcohol and other drug (AOD) use disorders are the leading risk factors for injury.”⁵ Therefore, it is the importance of the cause-effect relationship between alcohol and injury that has stimulated interest in developing mechanisms to promote a change in behavior to prevent further injury.

Alcohol is a drug. Unlike many other abused drugs, its naturally occurring state is that of a liquid. It is unique because it requires no digestion, is quickly absorbed unchanged into circulation, is water and lipid soluble, and is therefore rapidly transported to and concentrated in the brain and central nervous system (CNS). It has the capacity to shorten the attention span, slow reaction time, interfere with performance of motor tasks and impair reasoning ability. Inebriated drivers often develop impaired perceptions that can lead to speeding, reckless driving, and failure to wear safety belts. This constellation of potentially lethal motor and cognitive consequences has resulted in a public health problem of monumental proportions.⁶

Recent studies have shown that 40% of patients admitted to trauma centers are BAC positive on admission.⁷ In 2005, 85% of those with a positive BAC met the legal definition for intoxication or impairment¹ and studies have shown a mean BAC in those patients as nearly twice the legal limit.⁸,⁹,¹⁰,¹¹ Forty percent of motor vehicle passenger crash deaths involve alcohol and the same 40% figure is reported among pedestrians who die after being struck by a vehicle. Alcohol is also commonly associated with intentional violent injuries.⁵ These alarming statistics illustrate, albeit rather simplistically, the public health importance of this problem.

Excessive alcohol consumption is the third leading cause of preventable death in the United States.¹² In the United States each year, more than half of the estimated 80,000 alcohol attributable deaths are due to intentional and unintentional injuries.⁶ Moreover, in addition to the direct lethal effects, alcohol contributes significantly to trauma-related morbidity, years of productive life lost, and breathtaking costs.⁶,¹³

In the United States in the year 2000, the annual economic burden attributed to alcohol-related crashes was $51 billion.¹⁴ Alcohol intoxication increases treatment costs by complicating the clinical examination and even obscuring signs of injury, which often results in the need for unnecessary additional diagnostic testing. Additionally, intensive resources are sometimes required for alcohol-positive patients who are uncooperative or who have severely altered mental status due to their level of intoxication. Alcohol-positive patients tend to have more severe injuries that require longer lengths of stay.¹⁵ Further, patients with chronic alcohol use who develop alcohol withdrawal syndromes (AWS) during their hospitalizations have been shown to have more prolonged and costly hospitalizations.¹⁶

There is a known high incidence of recurrent injuries in patients who screen positive for alcohol following trauma.¹⁷,¹⁸,¹⁹ One frequently cited study shows that patients who are injured while intoxicated are two-and-a-half times more likely to be readmitted for an injury over a 2-year period than patients who were not intoxicated when injured.¹⁸ The frequency of recidivism in this population has led to the suggestion that it causes an additional fourth peak of mortality beyond the established trimodal distribution of mortality after trauma.²⁰,²¹

Although several studies note the incidence of patients returning again to their centers with traumatic injuries, this underestimates the problem. There are other patients who die from subsequent injuries without being treated. One large study from Baltimore followed up all trauma patients discharged alive for subsequent mortality. Of the 29,354 patients followed up, those who were toxicology positive during their initial trauma center admission were nearly twice as likely to die as a consequence of injury compared to the toxicology-negative group (1.9% vs. 1.0%). Of those who died in the period of follow-up, toxicology-positive patients were more than twice as likely to have died from injury (34.7% vs. 15.4%).¹⁹

Clearly, recidivism is a costly cycle affecting the injured party, the hospital, and society as a whole. The patient’s self-destructive behavior frequently results in the injury or death of themselves and/or others. Therefore, reducing this costly cycle of alcohol-driven injury recidivism will save trauma care facilities and society millions of dollars while helping to reduce alcohol-related morbidity and mortality. Given the high incidence of alcohol-related injuries requiring admission to trauma centers and the high rate of recidivism among problem drinkers, it is imperative that health care providers take advantage of the teachable moment provided by the treatment of a problem drinker following injury.

In January 2006, the American College of Surgeons Committee on Trauma (ACS-COT) added requirements for trauma center verification to include the need for a focused program to identify and provide an intervention for problem alcohol users as part of routine trauma care.¹⁵ Level I centers are now required to establish a program to both screen and provide an intervention, whereas Level II centers will be required to screen patients. The addition of this requirement has evolved over time as leaders in the trauma community have elevated the issue of alcohol and trauma and painstakingly detailed its impact on the incidence, outcome, and cost to trauma centers and to society as a whole.

A large portion of patients who are harmed secondary to alcohol use are not, by standard definition, true alcoholics.¹¹ While dependent use may provide for more potential exposure to traumatic situations over time, the largest segment of the population and the great majority of patients sustaining alcohol-related injuries drink excessively only on occasion and would not be classified as truly dependent drinkers. This is largely the rationale behind a 1990 Institute of Medicine (IOM) report titled Broadening the Base of Treatment for Alcohol Problems.²² This report recommended expansion of the existing focus on patients with severe dependence to include patients with less severe problems who put themselves and others at risk by the nature of their drinking patterns. The report also called on medical specialties outside of those focused on drug addiction to share the responsibility of addressing those with alcohol problems. Given the large number of patients with alcohol problems that the trauma community cares for every day, it seems intuitive that we should become a cornerstone of that base identified in the IOM report. The report also recommended that those with nondependent alcohol problems receive brief on-site counseling, whereas those with true alcohol dependence should be referred for more intensive treatment.

A great deal of experimental effort has been put forth by those in the trauma community to validate SBI as a simple, yet effective approach to the problem. Given that SBI is now a mandated requirement for Level 1 trauma center verification,¹⁵ early workers such as Gentilello and a number of his contemporaries are, at long-last, being acknowledged for their vision and efforts to validate its theoretic underpinnings and encourage its nationwide
implementation based on a substantial body of supportive evidence.²³,²⁴,²⁵,²⁶,²⁷,²⁸,²⁹,³⁰,³¹,³²,³³,³⁴,³⁵,³⁶,³⁷,³⁸,³⁹,⁴⁰,⁴¹,⁴²,⁴³

For example, in 1993 Bien et al. reviewed 32 international brief intervention (BI) trials and concluded that BI was more effective than no counseling and often just as effective as more extensive interventions.⁴⁴ In 1997, Wilk et al. described a dozen randomly controlled BI trials and determined that they were nearly twice as effective as no intervention, demonstrating an odds ratio of 1.9.⁴⁵ In 1999, Gentilello reported that BIs with injured patients reduced the risk of future injuries by 47%.²⁷

In 2001, the Centers for Disease Control and Prevention (CDC) convened a conference focusing on the identification and intervention of alcohol-related problems in patients in the emergency department (ED). Participant contributors included scientists, practitioners, and a variety of additional stakeholders from around the country. They evaluated and assessed the current knowledge about alcohol problems among patients in the ED and the effectiveness of ED-based screening and intervention methods. Eventually, conference organizers produced a list of recommendations to enhance research and clinical practice in hospital EDs and provided impetus and direction for attacking the problem.⁴⁶

One year later, D’Onofrio and Degutis⁴⁷ published their findings from a systematic meta-analysis launched to evaluate the strength of the recommendations for SBI for alcohol-related problems in the ED setting. Their methodology consisted of multiple Medline searches coupled with a comprehensive review of the Cochrane Collaboration Library. They identified and reviewed 27 new articles in addition to 14 primary articles appearing in an earlier US Preventive Services Task Force Report.⁴⁸ Their final SBI meta-analysis consisted of 39 reports. These included 30 randomized controlled and 9 cohort studies, of which 32 demonstrated a positive SBI effect. This led to their published recommendation that SBI be incorporated into clinical practice for alcohol-related problems in hospital EDs. In 2003, Burke et al. confirmed earlier reports by other workers that BIs were effective in reducing alcohol consumption and alcohol-related problems in various settings including hospital EDs.⁴⁹

In 2004, Dinh-Zarr et al. reported another systematic review of the alcohol intervention effectiveness literature focused on problem drinkers.⁵⁰ Their effort represented an important departure because prior SBI evaluations had attempted to measure the effects of the intervention on alcohol consumption, maintenance of abstinence and reduction of ED recidivism. Still other trials attempted to evaluate the effects of interventions on a variety of negative consequences linked directly or indirectly to drinking such as hospitalizations, rehospitalizations, and social or occupational maladjustment. This exhaustive study yielded the following conclusions: (i) interventions for problem drinking are likely to reduce the incidence of injuries and their antecedents, but current data are insufficient to draw firm conclusions, particularly in terms of effects on violent injuries; and, (ii) interventions for problem drinking appear to have beneficial effects on injury risk, but this benefit does not necessarily correlate with the effect of the intervention on abstinence, alcohol consumption, or drinking-related hazardous behavior. Therefore, one may reasonably conclude that a key finding of the Dinh-Zarr et al. review was that the trials they studied reported imprecise effect estimates, and often had methodological weaknesses, underscoring the requirement for further research.

The CDC organized a second conference in May 2003, which focused on trauma surgery and trauma centers titled Alcohol Problems Among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism.⁵¹ Participants in this conference included clinicians and researchers from emergency medicine and trauma surgery, psychiatrists, psychologists, alcohol researchers, epidemiologists, policy advocates, and representatives from federal and state agencies focused on alcohol research and substance treatment efforts.⁵² The result of this two-and-a-half day conference was a list of seven recommendations.⁵² The most immediate impact on trauma centers from this conference was the eventual change in the ACS-COT’s Resources for Optimal Care of the Injured Patient as noted in the preceding text. The Steering Committee for the conference endorsed recommendations to disseminate the evidence in support of SBI to the trauma community, to fund implementation research involving the trauma community, to change insurance regulations to prevent denial of medical expense coverage for those patients found to be intoxicated, and to reimburse trauma center staff for SBI for substance abuse disorders.