Background

The problem: Alcoholism is the most common chronic disease in trauma patients, and one of the most common in primary care practices. It affects 25% to 40% of trauma patients, compared to 2% to 5% for other co-morbidities (Morris et al, 1990). Screening questionnaires such as the Michigan Alcoholism Screening Test (MAST) are positive in as many as 75% of medical trauma patients with a positive blood alcohol test and are even positive in 26% of trauma patients with no detectable blood alcohol on admission (Rivara et al, 1993). In addition, the relationship between alcohol and trauma is not limited to adults. In a study of 319 injured patients aged 18 to 20 years, 22% were legally intoxicated (legal limit at that time was .1 grams/dL) and 49% had a positive MAST score (Rivara et al, 1992). In primary care patients, there is a strong link between alcohol abuse and morbidity/mortality.

Alcoholism results in repeated episodes of trauma, including Driving while Intoxicated (DWI) related crashes. Five-year follow-up of alcoholic trauma patients admitted to a level I trauma center in Detroit revealed an injury recurrence rate of 44% (Sims et al, 1989). A study by our group in Seattle found that patients who were intoxicated or who had a positive MAST score were 2.5 and 2.2 times as likely to be readmitted within the next 1-2 years as were patients without these markers (Rivara et al, 1993).

Unfortunately, routine screening and intervention for alcoholism is not common at trauma centers or in primary care settings. One survey of trauma centers found that 71% did not screen patients for alcohol abuse (Soderstrom, 1987). The most common reason for not including alcohol screening as a routine part of care was that such screening "had little clinical importance." A key reason for failure to refer patients for alcohol treatment is negative attitudes of medical staff regarding chemical dependency treatment effectiveness due to their frequent exposure in medical settings to patients who may have received such treatment but continue to drink. This attitude even carries over into textbooks. The most recent edition of Cecil Textbook of Medicine (Diamond, 1996) states that alcohol problems are rarely identified by primary care physicians before medical or socioeconomic problems arise, and the book does not recommend screening.

Despite pessimism on the part of medical staff about the effectiveness of specialized chemical dependency programs, intervention has been shown in studies to make a substantial difference. In a long term study of 3,729 persons with alcoholism, health care costs after treatment were reduced by 55% from pre-treatment levels, whereas health care costs for a matched control group of untreated drinkers increased by 202% (Holder et al, 1992).

Brief interventions are appropriate both for primary care and for specialty, including trauma center, settings. They may be used in the time frame of an office visit or hospitalization for trauma or other cause, and can be based on information obtained from a systematic screening procedure. To date, reports of 32 randomized trials of brief interventions enrolling 5,718 patients indicate that such interventions are more effective than no counseling and often as effective as more extensive treatment (Bien et al, 1993). According to the U.S. Preventive Services Task Force, "All persons who use alcohol should be informed of the health and risks associated with consumption, and many patients may benefit from referrals to appropriate consultants and community programs specializing in the treatment of alcohol." (USPSTF, 1996).

One recent study of brief intervention by physicians was a randomized trial conducted in 17 community-based primary care centers in Wisconsin involving over 700 patients (Fleming et al, 1997). At 12 month follow-up, there was a significant reduction in 7-day alcohol use, episodes of binge drinking and of excessive drinking. Another randomized controlled study of 762 trauma patients admitted to a level I regional trauma center found that brief interventions resulted in a reduction of alcohol use at 12 months (reduction of 21.8 vs 6.7 standard drinks per week compared to baseline), a 47% reduction in re-injuries requiring trauma center or emergency department (ED) care, and a 23% reduction in DWI citations (Gentilello, 1999).

Since 70% of people in the United States visit their physician at least once every 2 years, brief advice from physicians can have enormous implications for the health care system and a major impact on alcohol use, impaired driving and DWI-related crashes and injuries. A recent editorial concluded: "Dissemination of [alcohol] screening and counseling skills will require efforts from medical schools, residency training programs, and continuing medical education centers (Parish, 1997). "