Who Should Be Screened?

Patterns of Drug Use

Many hospitalized trauma patients have used several drugs at the same time. Studies have shown that one-third or more of patients with traumatic injuries who test positive for alcohol have at least one other drug in their systems (Clark and Harchelroad, 1991). The presence of alcohol, therefore, should be a red flag for the presence of other drugs. In persons who test negative for alcohol, combinations of other drugs are frequently found (Brookoff et al., 1993; Soderstrom et al., 1992).

The issue of polydrug use provides further reason for AOD screening of trauma patients. As discussed in the previous chapter, several organ systems can be involved in a single traumatic injury. That fact, coupled with the high incidence of polydrug use, compounds the complexity of treating the trauma patient. The information gained from AOD screening can be an important aid in assessing injury and how it should be treated.

The Case for Universal Screening

As stated at the beginning of this chapter, the TIP consensus panel agreed that all hospitalized trauma patients aged 14 and over should be screened for AOD use and that screening of younger patients should be done if use were suspected. Screening should be performed for purposes of medical and nursing management and for gathering information regarding the need for future AOD intervention. Deciding to screen some patients and not others opens the door for cultural, racial, gender, and age biases.

A simple story illustrates this point. A mother, age 40, and her 18-year-old son were admitted to a hospital trauma center in a midwestern city after an automobile crash. The son, because of his age, was screened for blood alcohol. That test result was negative. The mother, a well-dressed woman, was not screened. Three days later she began showing signs of alcohol withdrawal.

Studies show that it is impossible to tell from a visual examination which patients are intoxicated (Perper et al., 1986; Rutherford, 1977). Sometimes patients are not responsive and do not give the expected behavior cues, and it is difficult even for people experienced in the trauma setting to make accurate judgments. Even a physical examination by a neurologist can fail to identify intoxication. The well-dressed, middle-class, 40-year-old woman was not identified as an alcohol user because of her physical appearance and possibly because of gender stereotypes. Intoxication can be overestimated as well as underestimated. For example, a patient judged to be intoxicated may be exhibiting the effects of oxygen deprivation.

If screening is universal and a part of the trauma center or hospital routine, problems caused by discretionary screening will be avoided. If screening is part of the standard treatment protocol, the patient is implying consent to screening by coming for treatment.

Deciding to screen some patients and not others opens the door for cultural, racial, gender, and age biases.

Blood Alcohol Concentration Determinations

There are a variety of methods for determining alcohol concentrations in the body. In the busy environment of the trauma center or emergency department, the simplest means is to use blood, since drawing blood is already a part of protocols at trauma centers and some hospitals. Other options exist, such as conducting a saliva test or using the Breathalyzer. However, the panel recommends the use of BACs.

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dl) of blood. This figure is converted to a percentage. One hundred mg/dl equals 100 mg percent or 0.1 percent. Thus, a BAC of .1 mg percent is equivalent to a concentration in blood of 100 mg of alcohol per deciliter of blood.

While the level of BACs will vary greatly, most patients admitted to trauma centers have BACs well over the legal limit that defines drunk driving in most States (that is, 100 mg/dl) and well over the amount known to produce impairment (see below). For the 5-year period from July 1988 through December 1993, the average BAC for patients admitted to the University of Maryland's Shock Trauma Center among both men and women 21 to 34 years of age was 180 mg/dl (Soderstrom et al., 1994b). Further analysis of data from all 18,000 patients tested during that period indicated that the mean BAC was 180 mg/dl. Similarly, among nearly 2,300 trauma patients tested at the trauma center at Seattle's Harborview Medical Center over an 18-month period, the mean BAC for those testing positive was 180 mg/dl (Jurkovich et al., 1992). Both of these studies involved Level 1 trauma centers, where the most severely injured patients are transported. These patients are likely to have higher levels of impairment from alcohol. However, such elevated BACs are seen commonly in trauma patients in community hospitals.

The amount of alcohol that defines drunk driving in most States is 100 mg/dl (or .1 percent), which is well above the amount known to produce impairment (about 50 mg/dl).

A level of 100 mg/dl is usually achieved when a person weighing 70 kilograms drinks three to four drinks per hour. A standard drink is defined as 12 ounces of beer, 1 ounce of liquor or distilled spirits, or 4 ounces of wine. However, there is some variability because of individual differences in alcohol metabolism, which varies because of such factors as stomach contents (food ingested), speed of alcohol consumption, gender, age, and body size.

Impairment from alcohol consumption has been shown to occur at the level of 50 mg/dl. In women and elderly persons, impairment may occur at lower levels. Most people demonstrate impaired driving at levels of 50 to 70. The probability that an auto crash will occur begins to rise when the driver's BAC exceeds 40 mg/dl, and rises dramatically when it reaches 100 mg/dl (American Medical Association, Council on Scientific Affairs, 1986). A level of 150 or higher without noticeable intoxication indicates a high degree of tolerance to alcohol.

Many patients with blood alcohol concentrations higher than 200 mg/dl will be found to have a diagnosable alcohol problem upon further screening and assessment. Such patients are likely to have chronic medical problems because of alcohol use— problems that will complicate the course of treatment for their injuries (Gentilello et al., 1993). Levels above 400 mg/dl can be lethal, although this level for lethality varies from person to person.

Alcohol use by trauma patients may be underestimated because BACs are determined after the patient has been transported from the site of the injury. Most persons metabolize alcohol at a rate of 15 to 20 mg per hour. Thus, the longer the time between injury and testing, the lower the BAC. Many patients must be extricated from their vehicles, and many are transported relatively long distances, allowing for metabolism of a significant amount of alcohol. Frequently at the scene of the injury and during transport, patients are given intravenous fluids that dilute the blood and lower BAC results. Vomiting may eliminate alcohol from the stomach before it reaches the blood.

Many patients with blood alcohol concentrations higher than 200 mg/dl will be found to have a diagnosable alcohol problem upon further screening and assessment.

A single elevated blood alcohol level does not provide information about the regularity and severity of alcohol abuse, unless the counts are extremely high. From the screening perspective, the BAC is just one factor that must be taken into consideration when determining the severity of the problem and making an appropriate referral for care.

Urine Drug Screening

As discussed above, trauma patients at Level 1 trauma centers routinely have urine specimens sent for analysis for purposes other than AOD screening. Therefore, in this setting, urine screening for the presence of drugs can be done with a minimal disruption of trauma center activity. At community hospitals where urine specimens may not be routinely analyzed, emergency department physicians must order them. Not all hospitals have the facilities to perform urine drug screens, but outside laboratories can be used.

In the laboratory, a number of different tests are performed to detect the presence of various drugs. Different test procedures have the capability of detecting different drugs. Testing capabilities differ in hospital laboratories, because of the available instrumentation and the training of laboratory personnel.

There is no single set of test procedures that constitutes a standard urine drug screen. The range of the screening test will vary from locale to locale and should be defined within each institution according to its needs and capabilities. Institutions should design screening tests to detect drugs that they believe are important and feasible to look for and prevalent in their geographic areas.

In screening of the general population, particularly workplace screening, marijuana is one of the more commonly found drugs, especially in young people. Use of drugs such as PCP and hallucinogens is generally less common than use of marijuana. The 1993 survey of drug use among high school seniors showed a significant increase in the use of the hallucinogen LSD (Johnson et al., 1994). Standard toxicologic tests do not screen for hallucinogens or inhalants. LSD is detectable in urine by the EMIT test up to 1 day after use (American Bar Association Center on Children and the Law, 1991).

If the urine screening test comes back negative for drugs, this result means that within the detection limitations of the drugs that were looked for, no drugs were found. No single toxicology test can determine that a patient has ingested no drugs at all.

A positive screen for any nonprescribed psychoactive substance should be a strong factor in the attending physician's decision to order an AOD assessment, if the patient consents. It is important to note, however, that positive results are not 100 percent definitive. If a confirmed positive result is required, a second test of a different type must be performed. Positive results of initial toxicologic screens are not confirmed by a laboratory unless a second test is specifically requested. This test is frequently done at an offsite laboratory and is relatively expensive to perform; results may not be returned for days. Therefore, such confirmatory tests are generally of no clinical value. A practitioner receiving unconfirmed positive test results may want to consult with the hospital laboratory about the meaning of the results and what the consequences of acting on these results might be.

There is no single set of test procedures that constitutes a standard urine drug screen. The range of the screening test will vary from locale to locale.

Positive results of urine drug screens may not indicate use or impairment at the time of injury, because metabolites of some drugs remain detectable for days or weeks after use. Cocaine, crack, and amphetamines may be detected in the urine more than 72 hours after use. Commonly used tests for marijuana measure a metabolite that is detectable in urine or blood for weeks after use. However, at least one study has used a more sophisticated test (radioimmunoassay) to determine marijuana use proximate to trauma. That work, a study of 1,023 victims of vehicular and nonvehicular crashes admitted to the University of Maryland's Shock Trauma Center, found that more than one-third (34.7 percent) had used marijuana within 4 hours of the time of injury. (Almost half of those patients also had positive blood alcohol concentrations.) New tests for marijuana are being developed, and there is a possibility that a test will become available on a widespread basis to determine recent use.

Positive results of urine drug screens may not indicate use or impairment at the time of injury because metabolites of some drugs remain detectable for days or weeks after use.

Finally, negative results of laboratory tests for alcohol and other drugs do not definitively indicate that the patient does not have an AOD problem. For example, Rivara and associates (1993a) found that 25 percent of trauma patients who had negative BAC results tested positive for possible alcoholism on the short version of the Michigan Alcohol Screening Test (SMAST), a brief questionnaire described later in this chapter. Similarly, Soderstrom and colleagues (1992) noted that 15 of 24 trauma center patients (63 percent) who tested negative for alcohol at the time of admission had a current or past substance use disorder.

In short, although chemical testing is an invaluable part of AOD screening, one needs to understand the limitations of tests and evaluate results on an individual basis.

Other Chemical Testing

Some laboratory screening tests can be used to determine whether a patient is a chronic user of alcohol. These tests measure injury to liver cells and to the cells that manufacture red blood cells. A liver function test that indicates an elevated level of gamma-glutamyltransferase (GGT) and a complete blood count that indicates that the red blood cells have a greater than normal mean corpuscular volume (MCV) are both evidence of chronic alcohol abuse.

Alcohol Screening Questions

Alcohol screening questions generally focus on the quantity and frequency of alcohol use. Several questions have been recommended, although not enough research has been done on which are the most effective. Examples of questions include

• "How many days per week do you drink?" (frequency)
• "On a day when you drink alcohol, how many drinks do you have?" (quantity)
• "How many times in the last month did you drink more than five drinks at one sitting?" (binge drinking).

Research by Anda and associates (1988) has indicated a high correlation between binge drinking and injury. As discussed below, the context in which the questions are asked and the skills of the screener in asking them are important factors.

Cyr and Wartman (1988) found that asking just two questions in combination enabled them to detect alcoholism in more than 90 percent of a group of 47 alcoholic patients. The questions were, "Have you ever had a drinking problem?" and "When was your last drink?"

To minimize problems of inaccurate self-reporting, it is important to ask about specific amounts of drinking, rather than average amounts; to define a single drink; to inquire about specific amounts of beer, wine, and hard liquor; and to inquire about the frequency, quantity, and occasions of heavier use with separate questions (Cutler et al., 1988; Sobell and Sobell, 1990).

Asking just two questions in combination has been shown to detect alcoholism in more than 90 percent of a sample. The questions are

• "Have you ever had a drinking problem?"
• "When was your last drink?"

Alcohol Screening Tests

CAGE

The CAGE is another widely used questionnaire (Ewing, 1984; Mayfield et al., 1974). It has not been verified in trauma populations, although its sensitivity and specificity have been widely investigated and validated in a variety of populations. Among screening instruments for alcoholism, it is perhaps the shortest, consisting of four questions (see Exhibit 4-2). Two or more affirmative responses indicate with high likelihood that the patient is a problem drinker. Use of the CAGE with elderly populations has suggested that a positive response to one of the four questions is a better cutoff score (Buschbaum et al., 1991).

Box

Exhibit 4-2 CAGE Questionnaire. CAGE Questionnaire
Have you felt the need to C ut down on your drinking? Do you feel (more...)

The CAGE is very brief, and therefore costs to administer are low. Sensitivity of the CAGE is relatively high; it is able to detect alcoholism in 85 percent of alcoholic patients. The specificity of the CAGE is over 90 percent, meaning that it is able to distinguish alcoholics from nonalcoholics in 90 of 100 cases.

A common criticism of the CAGE is that it is not gender sensitive—that is, women who are problem drinkers are less likely than male problem drinkers to screen positive when this instrument is used. One study of more than 1,000 women found that asking simple questions about frequency and quantity of drinking, coupled with a question about binge drinking, was better than the CAGE in detecting alcohol problems among women (Waterson and Murray-Lyon, 1988).

Others have raised the issue that the CAGE identifies only persons who are alcohol dependent. Screening programs that rely only on the CAGE as a screen for alcoholism may not identify persons whose frequency and quantity of drinking (binge drinking) put them at risk of alcoholism.

Finally, the CAGE asks about "lifetime" experiences rather than current drinking problems. A person who no longer drinks may screen positive on the CAGE.

Screening programs that rely only on the CAGE as a screen for alcoholism may not identify persons whose frequency and quantity of drinking (binge drinking) put them at risk for alcoholism.

AUDIT

Another relatively short screening test for alcohol dependence was developed by the World Health Organization (Babor and Grant, 1989). The Alcohol Use Disorder Identification Test (AUDIT) consists of questions that have reliably identified high-risk drinkers in a six-nation study. Based on answers to a 150-item assessment, ten key questions were selected that were highly correlated with hazardous or harmful alcohol consumption. These ten questions are presented in Exhibit 4-3. They include three questions about alcohol use, four about dependence, and three about problems resulting from drinking. The 10-item AUDIT can be given as a self-administered test, or the questions can be read aloud. The AUDIT takes about 2 minutes to administer.

Table

Exhibit 4-3 Alcohol Use Disorder Identification Test (AUDIT).

The responses to the ten questions are each scored from 0 to 4, with a maximum score of 40. Among patients diagnosed as exhibiting hazardous or harmful use of alcohol, 92 percent had an AUDIT score of 8 or more. Using a cutoff score of 8, the AUDIT has a sensitivity of 92 percent and a specificity of 87 percent (Saunders et al., 1993).

Compared with the SMAST, the AUDIT has been found to be better at detecting current alcohol problems. Barry and Fleming (1990) used the AUDIT or CAGE in a sample of 2,500 patients and found that when the first three questions of the AUDIT were modified, it identified 40 percent more patients at risk of problem drinking than the CAGE.

The modified AUDIT questions were

• "How many days per week do you drink?"
• "On a day when you drink alcohol, how many drinks do you have?"
• "How many times in the last month did you drink more than five drinks at one sitting?"

Particular strengths of the AUDIT in regard to screening of trauma patients are that it is designed for use in a primary healthcare setting, it provides early detection of hazardous and harmful drinking, and it is focused on present use rather than lifetime use.

Screening Tests for Other Drug Abuse

CAGE-AID

The CAGE-AID (CAGE Adapted to Include Drugs) modifies the CAGE questions for use in screening for drugs other than alcohol (Exhibit 4-4). Brown and Rounds (1991) tested its usefulness with 124 patients in a community family practice. It was found to have a sensitivity of 79 percent and a specificity of 77 percent. The authors suggested that stigma associated with use of illicit drugs may have limited its sensitivity. Like the CAGE, the CAGE-AID focuses on lifetime use; although individuals who are dependent may screen positive, individuals who are at risk may not.

Box

Exhibit 4-4 CAGE-AID. CAGE-AID

Have you felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? (more...)

SSI

The Simple Screening Instrument (SSI) for AOD Abuse was developed by a consensus panel for the Center for Substance Abuse Treatment(see the TIP 11 in this series entitled Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases). Source instruments for the questions included the MAST, CAGE, DAST, Problem-Oriented Screening Instrument for Teenagers (POSIT), HSS, AUDIT, and the Skinner History of Trauma Scale. It has 16 items and was developed for use by community outreach workers to provide a comprehensive screen for alcohol and other drug abuse. Two versions of the SSI were developed, one for self-administration, and one for use by an interviewer. Although the developers recommend administering the entire instrument, four questions can be used as a short screen.

The SSI also has a clinical observation checklist for signs and symptoms of AOD abuse (for example, needle track marks, tremors, and dilated or constricted pupils). The SSI has not been validated.

Descriptions of the screening instruments described here are presented in Exhibit 4-5.

Table

Exhibit 4-5 Summary of Screening Instruments.

AOD Screening of Special Populations

Certain special populations of hospitalized trauma patients require special considerations in screening. These include patients who are

• Homeless
• Brain injured
• Illiterate
• Non-English speaking
• Adolescents
• Pregnant
• Elderly
• Victims of domestic violence
• Mentally ill
• Hearing-impaired or deaf.

It is unlikely that special needs will be an issue in chemical screening, which depends simply on drawing blood and urine. With questionnaires, such groups as the brain injured, the non-English speaking, adolescents, and patients with mental illness may require screening by personnel who are sensitive to their special needs and trained to address them. Elderly persons may be especially reluctant to discuss substance use problems because of the stigma they associate with such problems.

When to Assess

If positive results of screening are received, the attending physician should consider ordering an AOD assessment, if the patient consents. The timing of the assessment must be tailored to the patient's capability to communicate and participate and the patient's receptivity to the process. Other factors to consider when deciding when to assess include the projected length of hospital stay, ongoing medical procedures, and whether the hospital has an inpatient treatment program. Another factor to consider is "the teachable moment," which was discussed in Chapter 3. AOD assessment as soon as possible after the injury may help the patient to make the connection between AOD use and the injury. A general rule is to conduct an assessment as soon as possible after the need for it has been identified.

An argument for delaying the assessment comes from a study that found that patients were less likely to follow through with recommendations from assessment if it were done early during their hospital stay, when they were primarily concerned with their medical needs (Gentilello et al., 1988). Intervention provided as closely as possible to the time the patient could begin treatment was the most effective.

Early assessment is important for medical reasons to evaluate for the possibility of withdrawal. Another reason to assess as soon as possible is the need to improve pain management for patients who require additional medication. Some institutions have physicians on staff who are addiction specialists; consultation with these physicians may be necessary for patients in whom AOD withdrawal is suspected or anticipated or who require specialized pain management.

Patient Consent

When the treating physician is considering ordering an AOD assessment, he or she should communicate to the patient his or her concern about the possible contribution of alcohol and other drug use as a contributing factor. The physician should encourage the patient to agree to the assessment and participate fully in it. Another approach is to explain to the patient that the policy of the hospital is that patients who have positive laboratory screening tests should discuss their alcohol or other drug use with an AOD specialist.

The manner in which the idea of assessment is introduced to the patient is an important factor in gaining patient consent and participation. In hospitals where AOD screening programs are in place and staff have been trained to recognize and respond to substance abuse, patients may begin to feel early in their stay that discussing their substance abuse problems is possible. In some cases, the attending physician may not feel that he or she has the time or skill to adequately address positive screening results. However, the importance of the relationship between physician and trauma patient should not be underestimated. Expressions of concern about the patient's AOD use, coupled with a nonjudgmental attitude, will generally go a long way toward engaging the patient in the assessment process.

In hospitals where AOD screening programs are in place and staff have been trained to recognize and respond to substance abuse, patients may begin to feel early in their stay that discussing their substance abuse problems is possible.

Where to Assess the Trauma Patient

The assessment must be done confidentially, and the location should be chosen with this in mind. A patient's room is the most likely setting, but using this area may present some problems, particularly if it is not a private room. It may be up to the assessor to put the patient in a wheelchair and take him or her to a private location, such as a vacant office or conference room. The patient may choose to be accompanied by a family member or friend.

Who Performs the AOD Assessment

AOD assessment requires a high level of knowledge and skill. The assessment should be performed by an AOD clinician who possesses good interviewing techniques and who is sensitive to cultural-ethnic and gender issues. Such personnel can include

• Physicians with specialized training
• Nurses with specialized training
• Social workers with addiction training
• AOD counselors
• Physician's assistants with specialized training.

Properly trained AOD clinicians maximize opportunities to motivate patients.

The assessor should have certified training in evaluating and treating persons with substance use disorders. A nonjudgmental, empathic attitude is crucial to the success of this process.

The Assessment Process

Assessment can be approached in a variety of ways by a variety of personnel. Face-to-face AOD assessment is a challenging and often difficult task, in particular because of the denial that nearly always surrounds substance use problems. The assessor should have certified training in evaluating and treating persons with substance use disorders. A nonjudgmental, empathic attitude is crucial to the success of this process. The interviewer must know how to confront traits not seen as frequently in non-substance-abusing populations. These include shame, manipulation, lying, minimization, belligerence, and anger.

The assessor should have a brief initial contact with the patient, introducing him- or herself and explaining why he or she is there. If the patient will be in the hospital for only a day, this first brief encounter may be all that is possible. Such an encounter may be limited to a brief educational intervention or advice about AOD use (see the discussion below of brief interventions). A skilled assessor usually can quickly establish a good rapport with the patient.

Patients may fear participating in the AOD assessment process if they do not understand the purpose of the process or the consequences of their responses. They may fear that the results of the AOD assessment will be obtained by the criminal justice system or that insurance companies will refuse to pay for treatment of injuries resulting from AOD use. Patients may also fear other consequences such as losing their jobs or the custody of their children. AOD assessment may be less threatening to the patient if the assessor assures the patient that the results will be kept in the strictest confidence. Specific measures for maintaining confidentiality can be mentioned, for example, use of consent forms (see Chapter 6). The assessor can state that the goal of the assessment is not to force the patient to accept unwanted or unnecessary treatment but to help the patient make choices that could prevent reinjury.

As discussed above, the initial result of a urine drug screen may be false, and it may be the hospital's policy not to confirm these results because of costs. Therefore, the interviewer must be diplomatic when raising the topic of drug use with the patient. The assessor may want to consult with the laboratory first.

Facilities should examine their own resources and make decisions about how they can best be used. They may also consider looking outside their own walls. A trauma center or hospital treating injured patients may want to establish a linkage with an AOD treatment center to ensure comprehensive AOD assessment. Since it is usually the role of the patient's primary physician to initiate the process of comprehensive AOD assessment, it is important that the physician be knowledgeable about the implications of positive screening results. It is also important that the physician know the hospital and community resources for AOD assessment and treatment so that he or she can make referrals directly.

Since it is usually the role of the patient's primary physician to initiate the process of comprehensive AOD assessment, it is important that the physician be knowledgeable about the implications of positive screening results.

Special Concerns in AOD Assessment Of Trauma Patients

Traumatic injuries can complicate the AOD assessment process in both physical and psychological ways. On the most basic physical level, the patient may be unable to cooperate with the assessor. Intubation, which involves inserting a tube into the patient's trachea, restricts the patient's ability to communicate verbally. Medications may also impair the patient's mental status. Patients may be heavily sedated or lethargic. Traumatic brain injury may result in significant cognitive impairment.

Psychologically, patients will probably be focused on the current crisis—the traumatic injury -- and may be unwilling to shift their focus to talk about the AOD problem. They may also be experiencing sensory overload from the environment of the trauma center or hospital; for example, many people may be going in and out of the room, and the medical equipment in the room may be intimidating or frightening. The support and concern of family, friends, physician, and hospital staff are important elements in gaining the patient's participation.

Trauma patients fall into a wide age range, and age can be a factor influencing the AOD assessment process at both ends of the spectrum. Adolescents, for example, are likely to be unwilling to participate in assessment and resistant to the message that some kind of intervention is necessary. The elderly may be difficult to communicate with because of hearing, cognitive, or other problems. Many elderly people view alcoholism or other drug abuse as shameful and may not be aware that addiction is a treatable disease. Some elderly people may rationalize their AOD abuse by stating that "life is not worth living" without alcohol or another drug. Many elderly persons fear losing their independence and do not realize that continued use threatens the independence that they value so much.

Culturally sensitive assessors are an essential part of a successful assessment process. The skilled assessor will be able to take different approaches with individual patients, as needed. Attention must be given to the special issues involved with special populations, as listed above in the discussion of screening. Factors that should be considered include socioeconomic group, ethnicity, gender, and type of injury.

Patients' families should be brought into the assessment process whenever possible, if the patient consents. Their role is particularly important if the patient's ability to participate is limited. Families may deny or minimize the patient's AOD use. On the other hand, families of patients with AOD problems are often eager to talk about these problems with someone. However, as discussed in the next chapter, efforts must be made to protect the patient's privacy and confidentiality.

Patients' families should be brought into the assessment process whenever possible, if the patient consents.

All of these factors highlight the importance of having a skilled AOD assessor who is flexible enough to adapt to the special circumstances that are involved for the trauma patient.

Assessment Instruments

Specific tools have been formulated to assist in AOD assessments of adolescents and adults. Several assessment instruments for use with adolescents have been reproduced in the TIP Screening and Assessment of Alcohol- and Drug-Abusing Adolescents. The Assessment Severity Index (ASI), which is perhaps the most widely used AOD assessment instrument in adult populations, is reproduced in the TIP 7: Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System. A comprehensive discussion of assessment tools was considered by the panel to be beyond the scope of this TIP, the main focus of which is screening. However, the panel agreed on certain components that should be included in a comprehensive AOD assessment.

Components of the Assessment

The AOD assessment consists of a number of distinct components, and there is a formulation that occurs in piecing together the components to lead to a set of comprehensive, cohesive observations and recommendations. The assessment also takes into account laboratory screening results (such as BAC and urine toxicology tests).

The components of a complete assessment include a medical and psychiatric history, a physical examination, a mental status examination, a history of AOD use, and patterns of use. Assessment of several other life areas, such as family and employment status is also important, but is not described in detail here.

Medical history. The medical history should be focused on the patient's use of alcohol and other drugs. It should include the family medical history, including AOD problems of parents, siblings, aunts, and uncles. The patient's trauma history should also be included. The Skinner Trauma History, presented in Exhibit 4-6, consists of five questions about previous trauma injuries and is a simple way to gather this data. A score of two or more positive responses to the five questions has been shown to indicate a high probability of excessive drinking or alcohol abuse (Skinner et al., 1984). Obtaining the patient's trauma history is important because previous injuries are a primary predictor of future injury. Yet they are often not included in a typical medical history because many people do not view trauma as a disease.

Table

Exhibit 4-6 Skinner Trauma History.

Psychiatric history. The psychiatric history should include the history of AOD use and treatment. AOD use and abuse problems are prevalent in people with psychiatric illnesses, although many psychiatric symptoms abate rapidly with abstinence. Some people use and abuse AODs in an attempt to self-medicate their psychiatric problems. In fact, in some cases, patterns of AOD abuse can improve psychiatric symptoms, but they may also worsen them. Especially in brain-injured patients, symptoms of AOD use can be misdiagnosed as psychiatric disorders.

Another TIP in this series, Screening, Assessment, and Treatment Planning for Patients with Coexisting Mental Illness and AOD Abuse, discusses assessment of this patient population.

Physical examination. The physical exam, to be performed by a physician, is focused on factors associated with AOD use. The physician should look for symptoms of withdrawal and signs of chronic use. Signs of chronic use include a perforated septum (cocaine sniffing), liver damage (alcohol), or track marks (injection drug use). Some elderly persons have long histories of substance use. It is especially important to attend to physical findings in this population, because many elderly persons will deny or minimize use.

Mental status examination. A mental status examination is a key element in AOD assessment and is needed to validate the accuracy of the assessment. This examination considers the patient's mental status in areas such as mood, memory, orientation, and affect. The level of cognition is another area to be evaluated, particularly in patients with traumatic brain injury. Level of cognition is an important factor in the consideration of patients' ability to participate in their treatment. Results of the mental status examination can also contribute to making a diagnosis of withdrawal symptoms.

AOD history of use patterns. Patterns of alcohol and drug use in the patient's past contribute important information that helps lead to a diagnosis of chronic use. Information about these patterns can be obtained from the patient, from family members and significant others, and from physical signs and symptoms.

A single factor that is highly predictive of traumatic injury is quantity/frequency of alcohol and drug use, specifically, binge use of substances. Binge drinking is generally defined as consuming between five and nine drinks at one sitting at least once a week. Excessive use on isolated occasions results in acute neurological impairment, which increases the risk of traumatic injury. An example of a binge drinker is the young drinker who drinks only on weekends, but consumes excessive quantities.

Other areas to assess. Other areas to assess include

• Social history
• Family history
• Environmental components
• Employment history
• Educational history
• Legal status, including involvement with criminal justice system
• Financial status.

Determining an AOD Diagnosis

Positive Findings of Assessment

A positive assessment results in a diagnosable condition of a substance abuse disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (1994). Exhibit 4-7 presents DSM-IV criteria for substance dependence. The diagnosis will determine the severity of the substance use disorder and has to be considered in the context of traumatic injury as well as the biopsychosocial context.

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Exhibit 4-7 DSM-IV Diagnostic Criteria For Substance Dependence. DSM-IV Diagnostic Criteria For Substance Dependence
The DSM-IV defines AOD addiction as "substance dependence," and describes the diagnostic (more...)

Once a condition has been diagnosed, a treatment plan can be developed that takes into account the severity of the patient's substance use disorder, the available treatment resources, and the patient's preferences. The American Society of Addiction Medicine (ASAM) has developed criteria and recommendations for patient placement in various levels and types of treatment (ASAM, 1991). Other criteria for placing patients in treatment have been developed by States and managed-care organizations. Some of those are reviewed in another TIP in this series, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders.

If the assessment reveals that a patient has experienced AOD withdrawal in the past, this information can be used to estimate the severity of current withdrawal signs and symptoms.

Treatment Planning

The discussion below focuses on some issues specific to treatment planning for hospitalized trauma patients. A detailed discussion of treatment planning and treatment is beyond the scope of this TIP. Other TIPs in this series have addressed treatment for special populations including adolescents, pregnant women, offenders, persons with coexisting mental illness and substance abuse, persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and persons with opiate addictions.

A discussion of the effectiveness of brief interventions has been included at the end of this chapter. Some brief intervention strategies may be used in the hospital setting with patients who are recovering from injuries. Such interventions can help keep patients with AOD problems focused on the need for treatment and can motivate and prepare them for entering treatment.

Treatment planning, like assessment, employs a biopsychosocial approach. The entire range of AOD treatment options should be considered for the trauma patient, including inpatient AOD treatment, intensive outpatient treatment, outpatient treatment, residential treatment, family therapy, and so forth. Information pertaining to the patient's medical condition, as it relates to trauma, must be integrated into treatment planning and aftercare planning. Some patients, for example, will be taking prescribed analgesics, and pain management becomes an issue.

As discussed in Chapter 3, AOD abusers may display difficult behaviors. The assessment may document behaviors that can complicate medical, nursing, and psychiatric management of patients. Knowledge of these issues can sometimes help staff anticipate deviations from the normal hospital course.

For many trauma patients, posttrauma care will include ongoing rehabilitation and physical therapy. There may be a long period as an inpatient. Recommendation for AOD abuse treatment may coincide with these other therapies, and the patient's course of treatment will affect the type of AOD treatment that is most appropriate and possible. Continuing care should be anticipated and discussed in the early stages of treatment planning. This care can include participation in self-help groups and regular telephone contact with the counselor.

As discussed in Chapter 3, models are needed for providing effective AOD treatment to patients with cognitive impairments resulting from brain damage and patients with paralysis from spinal cord injuries. Special AA meetings or other support groups may offer help to patients and families.

If the patient is willing, the family should become involved in the treatment as soon as possible. Family issues are frequently pivotal in undertaking AOD abuse treatment. The traumatic injury is often a crisis for the family, as well as for the patient. It is a clear signal that help is needed, and it is an opportunity to get help. Family members are usually adversely affected by the AOD problems of the patient. They may have AOD problems themselves and may have mixed feelings about getting help for the patient. They may feel as helpless as the patient in doing something about the situation. The involvement of an AOD professional in addressing these issues can help them work toward a positive resolution. Contact with the family can be established only with appropriate consents. The process of obtaining these consents is described in Chapter 6 of this TIP.

The Effectiveness of Brief Interventions

Brief, empathic interventions that consist of even a single session can decrease consumption of alcohol and its adverse effects by 20 to 50 percent (Babor and Grant, 1992; Chick et al., 1985; Wallace et al., 1988). Research has found that when programs are implemented to identify problem drinking and drug use, physicians' behaviors change coincident with increased confidence in their own management skills (Wallace et al., 1988; Graham, 1991).

Brief, empathic interventions that consist of even a single session can decrease consumption of alcohol and its adverse effects by 20 to 50 percent.

Specific strategies and supporting research for such brief interventions are described in this section. The focus of research to date has been on reducing alcohol use. Although such interventions may be similarly effective in decreasing use of other drugs, more research is needed.

The earliest healthcare research on brief interventions for problem drinkers occurred in the emergency medical care setting, where personnel were concerned about how to facilitate referrals to AOD treatment (Chafetz, 1961; Chafetz et al., 1962). Without any intervention, investigators found that only 5 percent of those referred to a postdischarge appointment with an AOD specialist kept the appointment. A brief intervention strategy was implemented in which a specially trained counselor met briefly with the patient after emergency care was completed. The counselor discussed and evaluated the patient's drinking. An empathic approach that communicated respect, understanding, and caring was emphasized. Sixty-five percent of patients who received this brief intervention kept the followup appointment. In a replication of the study (Chafetz, 1968; Chafetz et al., 1964), the appointment completion rates were 6 percent for the control group (no intervention) and 78 percent for the group that received the intervention.

A study by Kristenson and associates (1983) in Sweden showed that simple, inexpensive, short-term interventions were effective in motivating patients to change their heavy drinking behaviors. In that study, levels of the liver enzyme gamma-glutamyltransferase (GGT) were measured in 8,859 men ages 46 to 53. Elevated levels were used to select heavy drinkers from this group. These subjects were offered monthly GGT tests and monthly medical check-ins with a nurse (quarterly with a physician). They were encouraged to lower their overall alcohol consumption. These interventions resulted in a significant decrease in the subjects' alcohol consumption and days absent from work because of illness, as well as lower GGT values over a period of 6 years.

A number of other clinical trials have examined the effectiveness of brief advice with problem drinkers. Bien and colleagues identified 10 such studies in healthcare settings in 14 countries (Bien et al., 1993). In Great Britain, the impact of a physician's advice on the reduction of excessive alcohol consumption was demonstrated in a 12-month followup study of 909 heavy drinkers (Wallace et al., 1988). Participants were given general advice on smoking, exercise, and diet. The intervention group was also given information on the potentially harmful effects of their drinking and was provided a weekly diary to record alcohol use. Group members were shown a histogram comparing their weekly alcohol consumption with national norms, given a booklet on sensible drinking, and scheduled for followup visits. Twelve months later, the intervention group showed significant reductions in heavy drinking—in fact, a twofold greater reduction than the control group. There was no substantial change in smoking, exercise frequency, or weight reduction.

A multinational study for the World Health Organization on brief interventions with heavy drinkers had similar findings (Babor and Grant, 1992). This landmark study developed and tested brief-intervention protocols in 10 countries with diverse cultures and healthcare systems. (This project also developed the AUDIT screening test discussed earlier in this chapter and shown in Exhibit 4-3). The intervention protocols tested included simple advice (a 5-minute session on sensible drinking or abstinence), brief counseling (a 15-minute session and a self-help manual), and extended counseling (initial brief counseling and three or more monitoring visits). The findings upheld the positive results of other minimal intervention studies: alcohol consumption was significantly reduced, even in the group that received the briefest intervention.

Common Elements of Effective Brief Interventions

Research in healthcare settings supports the efficacy of using brief interventions for people identified as having addictive behaviors. Several common elements of effective brief interventions have been identified.

Bien and colleagues (1993) observed that many successful brief interventions focused on raising the patient's awareness of the problem and providing advice; they speculated that these approaches addressed critical conditions needed to instigate change. Miller and Sanchez (1993) enumerated six elements, commonly included in brief interventions, that have been shown to be effective. They are summarized by the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, and Self-Efficacy (see Exhibit 4-8).

Box

Exhibit 4-8 FRAMES: Elements of Brief Interventions. FRAMES: Elements of Brief Interventions FEEDBACK of personal risk or impairment. Most successful (more...)

A landmark, multinational study for the World Health Organization on brief interventions with heavy drinkers found that alcohol consumption was significantly reduced, even in the group that received the briefest intervention -- 5 minutes of simple advice.

Client-Centered Interviewing

As discussed in the commentary by Bien and colleagues (1993), current medical training emphasizes technology-based, physician-centered decisionmaking. Excluded from most training are skills in effective listening, negotiating with patients, and dealing with ambivalence. Physicians may learn to blame patients for lack of compliance and for denial, whereas their own interviewing and negotiating styles may greatly influence a patient's compliance and outcome.

The patient's motivation is an important factor in changing behavior. A healthcare professional can encourage motivation with client-centered interviewing that makes the patient an active participant in setting the goals to be achieved. The elements of the interview should be empathic and warm, yet provide objective feedback of the data obtained from screening and assessment. Aggressive confrontation or coercion will not achieve the objective of encouraging the patient to change.

Researchers additionally recommend that the interview incorporate the following elements (Delbanco, 1992; Miller and Rollnick, 1991; Ockene et al., 1988; Rollnick et al., 1992):

• Assessing the patient's readiness for change
• Identifying barriers to recovery
• Identifying patient strengths
• Reinterpreting past experiences in light of current medical consequences
• Negotiating a followup plan
• Providing hope.

Referral

The healthcare professional can refer the patient to appropriate treatment programs or counselors or recommend a self-help group. Studies suggest that such referrals can lead to successful treatment yielding long-term benefits (Elvy et al., 1988). A variety of specific practices increase the likelihood of a successful referral. These practices include the following, in addition to the FRAMES elements outlined above:

• Telephoning for a specific appointment with the patient present
• Following up with an encouraging note or phone call
• Arranging for the patient to be seen without delay.

If an immediate appointment is not available, some evaluation and intervention should be provided immediately, rather than have the client wait until an appointment is available.