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Alcohol, Drugs, and Trauma
A Risky Mix
Definitions:
In the Washington State Trauma Registry (WTR):
• Alcohol use is determined by a blood alcohol test
• The legal limits are:
• Blood alcohol level >= 0.08 g/dl for adults (age 21+)
• Blood alcohol level >= 0.02 g/dl for minors (age <21)
• Drug use is determined by a toxicology report
Why look at blood alcohol or toxicology results of trauma patients?
Changes in the law
• Title 66 RCW Alcohol beverage control law
• Initiative 502
Legalizing marijuana (cannabis)
• Burden of traumatic injuries due to alcohol and/or drug consumption
• Changing laws and regulations regarding the use of alcohol and drugs
Alcohol is a major contributing factor for:
• Fights
• Stabbings
• Motor vehicle related trauma
• Firearms
• Strangulations
0 5 10 15 20 25 30 35 40 45
Machinery
Sports
Animal Caused
Burn
Other
Electrical Shock
Fall
Bicycle
Drowning
Motorcycle
Strangulation/Asphyxiation
Pedestrian vs Vehicle
Firearms
Blunt Instrument
Motor Vehicle
Sharp Instrument (Knife)
Fight/Assault
Percent
The percentage of trauma with blood alcohol levels over legal limits by
mechanism of injury, during 2010-2012
The linked collision-WTR dataset shows that alcohol is one of the major contributing factors for driver and pedestrian
trauma, 2008-2010 (MV occupants are excluded)
Data Source: The linked DOT collision and DOH WTR dataset
0
2
4
6
8
10
12
14
16
18
20
Pe
rce
nt
Contributing Factors
Contributing circumstances for MV drivers and pedestrians, 2008-2010
The selected injury mechanisms below have high percentages of patients who are positive for both alcohol and drugs
30%
19%
14%
14%
12%
11%
7%
8%
11%
8%
5%
5%
5%
4%
7%
3%
12%
16%
10%
12%
18%
9%
28%
8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Assault
Sharp Instrument (Knife)
Motor Vehicle
Blunt Instrument
Firearms
Pedestrian vs Vehicle
Strangulation/Asphyxiation
Motorcycle
Mechanism-Specific Percent
The percentage of alcohol and drug use in WTR for selected mechanisms during 2010-2012
Positive for Alcohol Positive for Both Alcohol and Drug(s) Positive for Drug(s)
42%
24%
35%
29%
31%
43%
53%
19%
Use of alcohol and drugs by the intent of injury (DOH inclusion criteria, excluding transfers-out, 2010-2012)
10%
20%
33%
14%
8%
29%
25%
15%
0 5 10 15 20 25 30 35 40
Unintentional
Suicide
Assault
Uncertain
Intent-Specific Percent of Trauma Volume
The percentage of alcohol and drug use by the intent of injury
Positive for Drugs Positive for Alcohol
The patients tested positive for alcohol sustain more serious injuries than those patients with no positive test results
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
Injury Severity Score (ISS) by alcohol use
No Yes
ISS 0-8 53.3% 50.0%
ISS 9-15 26.4% 23.9%
ISS 16-75 16.0% 25.1%
Injury Severity Score (ISS) by drug use
No Yes
ISS 0-8 45.1% 46.8%
ISS 9-15 22.4% 23.6%
ISS 16-75 31.2% 28.2%
p value = 0.000
Minor
Moderate
Serious
The patients tested positive for alcohol and drugs stay longer in the hospital if they sustain serious injuries than those patients with no
positive test results (DOH inclusion criteria, excluding transfers-out, 2010-2012)
Mean hospital length of stay (days) by alcohol use
No Yes
ISS 0-8 2.5 1.9
ISS 9-15 4.7 4.6
ISS 16-75 8.0 9.8
Mean hospital length of stay (days) by drug use
No Yes
ISS 0-8 2.5 2.3
ISS 9-15 4.7 5.2
ISS 16-75 8.0 9.7
p value = 0.000
Minor
Moderate
Serious
p value = 0.000
Use of alcohol and drugs does not necessarily increase the likelihood of death for all age groups in the trauma registry
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
Case fatality by alcohol use
Not Positive Positive
Age 15-24 2.3% 2.1%
Age 25-34 3.4% 2.2%
Age 35-44 2.9% 1.5%
Age 45-54 2.9% 4.3%
Age 55-64 3.8% 6.0%
Age 65-74 4.8% 5.2%
Age 75-84 6.3% 2.7%
Age 85+ 8.0% 9.5%
Total 3.9% 3.1%
Case fatality by drug use
Not Positive Positive
2.5% 1.8%
2.2% 2.8%
2.1% 3.0%
4.6% 3.1%
6.9% 6.5%
7.1% 10.3%
16.1% 10.1%
19.32% 10.0%
4.8% 3.3%
Patients tested positive for alcohol are more likely to be sent to the ICU from the ED than patients with no positive test results
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
ED disposition to ICU by alcohol use and ISS
No Yes
ISS 0-8 2.5% 7.8%
ISS 9-15 7.4% 18.0%
ISS 16-75 32.8% 46.1%
ED disposition to ICU by drug use and ISS
No Yes
ISS 0-8 9.8% 9.7%
ISS 9-15 21.3% 19.6%
ISS 16-75 51.6% 49.4%
p value = 0.000
Minor
Moderate
Serious
In comparison to the patients who are not positive for alcohol, the patients tested positive for alcohol have shorter ICU stays if they have minor or moderate
injuries, but they have longer stays in the ICU if their injuries are serious (DOH inclusion criteria, excluding transfers-out, 2010-2012)
Mean ICU Length of stay (days) by alcohol use and ISS
No Yes
ISS 0-8 2.2 1.6
ISS 9-15 2.3 1.9
ISS 16-75 4.0 5.3
Mean ICU length of stay (days) by drug use and ISS
No Yes
ISS 0-8 2.1 2.1
ISS 9-15 2.2 2.0
ISS 16-75 4.2 4.3
p values = 0.000
Minor
Moderate
Serious
About 1 in every 2 patients receiving definitive trauma care are screened for blood alcohol levels while only 1 in 4-5 are screened
for toxicology (DOH inclusion criteria, excluding transfers-out)
0
10
20
30
40
50
60
2006 2007 2008 2009 2010 2011 2012
Pe
rce
nt
of
Tra
um
a P
ati
en
ts
Blood Alcohol Content Tested Tox Screen Performed
18% of all traumatic injuries tested positive for alcohol, drugs or both
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
No Alcohol Use Tested Positive
for Alcohol
No Drug Use 49,497 (82.5%) 5,104 (8.5%)
Tested Positive for Drugs 3,727 (6.2%) 1,687 (2.8%)
p value = 0.000
WTR shows males are more likely to test positive for alcohol and drugs than females
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
24% 27%
76% 73%
0
10
20
30
40
50
60
70
80
90
Positive for Alcohol Positive for Drugs
Pe
rce
nt
of
Po
siti
ve
Scr
ee
nin
gs
Female Male
Nearly half of WTR patients with serious injuries (ISS 16+) who test positive for alcohol or drugs are either on Medicaid or self-
pay (DOH inclusion criteria, excluding transfers-out, 2010-2012)
Positive for alcohol
No (Col%) Positive (Col%)
None 3.0 5.3
Medicare 27.4 8.0
Medicaid 13.1 20.2
Labor & Industries 4.7 2.2
HMO 8.4 7.1
Other Insurance 8.6 9.8
Self-Pay 6.7 14.7
Commercial Insurance 15.4 16.3
Health Care Service 8.5 8.8
Other Sponsored 2.5 3.2
Charity Care 1.7 4.5
Positive for drugs
No (Col%) Positive (Col%)
2.3 5.6
14.2 7.7
13.3 23.9
4.7 5.2
8.6 6.1
10.0 7.0
8.7 13.7
20.2 12.9
9.5 7.5
2.8 1.9
2.2 4.3
Trauma patients in their twenties have the highest exposure to alcohol and drugs
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
0
5
10
15
20
25
Age<1 Age1-4 Age5-14 Age15-24 Age25-34 Age35-44 Age45-54 Age55-64 Age65-74 Age75-84 Age85+
Ag
e-S
pe
cifi
c P
erc
en
t o
f T
rau
ma
Vo
lum
e
Positive for Alcohol Positive for Drugs
Cannabis is the most common drug found in the registry followed by cocaine, amphetamines and opiates
(DOH inclusion criteria, excluding transfers-out, based on the first drug reported, 2010-2012)
Data Source: The linked DOT collision and DOH WTR dataset
Opiates 13%
Cocaine 15%
Amphetamines 14%
Cannabis 41%
Barbiturates 3%
Other 11%
Benzodiazepines 3%
Opiates Cocaine Amphetamines
Cannabis Barbituates Other
Benzodiazepines Phencyclidine (PCP) Methadone
Cannabis is the most widely used drug among trauma patients positive for drugs
(DOH inclusion criteria, excluding transfers-out, based on all drugs entered in the registry)
0
10
20
30
40
50
60
2006 2007 2008 2009 2010 2011 2012
Pe
rce
nt
of
To
xic
olo
gy
Scr
ee
ns
Percentage of trauma records with toxicology reports showing cannabis
Positive for Cannabis
0
1
2
3
4
5
6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pe
rce
nt
of
Tra
um
a V
olu
me
The percentage of WTR patients positive for cannabis
Cannabis use in the registry during 2000-2012 DOH inclusion criteria, excluding transfers-out, based on all drugs entered in the registry)
0
2
4
6
8
10
12
14
Ag
e-s
pe
cifi
c P
erc
en
t o
f T
rau
ma
V
olu
me
Positive for Cannabis
WTR shows trauma patients in their teens and twenties have the highest exposure to cannabis
(DOH inclusion criteria, excluding transfers-out, based on all drugs entered in the registry, 2010-2012)
Cannabis use in the registry went up in all age groups (DOH inclusion criteria, excluding transfers-out, based on all drugs entered in
the registry, 2010-2012)
0
2
4
6
8
10
12
14
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Ag
e S
pe
cifi
c P
erc
en
t o
f T
rau
ma
Vo
lum
e
Percent positive for cannabis by age
Age 15-24 Age 25-34 Age 35-44 Age 45-54 Age 55-64
0
1
2
3
4
5
6
7
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Ge
nd
er
Sp
eci
fic
Pe
rce
nt
of
Tra
um
a V
olu
me
Percent positive for cannabis by gender
Male Female
Cannabis use in the registry went up most drastically in males (DOH inclusion criteria, excluding transfers-out, based on all drugs entered in the
registry, 2010-2012)
4.5%
3.8%
3.4%
2.3%
7.0%
6.4%
4.8%
5.3%
4.9%
0 1 2 3 4 5 6 7 8
Central
North
North Central
Northwest
South Central
Southwest
East
West
Washington
Percent of Trauma Volume
Percent positive for cannabis by region
Regional comparison of cannabis-related trauma (DOH inclusion criteria, excluding transfers-out, 2010-2012)
Regional comparisons of alcohol and drug-related trauma
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
0 2 4 6 8 10 12 14 16 18
Central
North
North Central
Northwest
South Central
Southwest
East
West
Region-Specific Percent of Trauma Volume
Positive for Drugs Positive for Alcohol
Regional comparisons of blood alcohol and toxicology screenings
(DOH inclusion criteria, excluding transfers-out, 2010-2012)
0 10 20 30 40 50 60 70 80
Central
North
North Central
Northwest
South Central
Southwest
East
West
Region-Specific Percent of Trauma Volume
Tox Screen Performed Blood Alcohol Content Tested
Age comparisons of blood alcohol and toxicology screenings
(DOH inclusion criteria, excluding transfers-In, 2010-2012)
0 10 20 30 40 50 60 70
Age 85+
Age 75-84
Age 65-74
Age 55-64
Age 45-54
Age 35-44
Age 25-34
Age 15-24
Age 5-14
Age 1-4
Age-Specific Percent of Trauma Volume
Tox Screen Performed Blood Alcohol Content Tested
Comparison of blood alcohol and toxicology screenings by mechanism of injury
(DOH inclusion criteria, excluding transfers-In, 2010-2012)
0 10 20 30 40 50 60 70 80 90
Fall
Animal Caused
Other
Bicycle
Burn
Sports
Electrical Shock
Machinery
Motor Vehicle
Motorcycle
Fight, Beating
Pedestrian
Gushot
Knife
Mechanism-Specific Percent of Trauma Volume
Tox Screen Performed Blood Alcohol Content Tested
Why look at blood alcohol or toxicology results of trauma patients?
• Evidence shows that alcohol and drugs are major contributing factors for MV related trauma, gunshot wounds, assaults, and stabbings.
• About 1 in every 2 patients receiving definitive trauma care are screened for blood alcohol levels while only 1 in 4-5 of them are screened for toxicology in the trauma registry.
• 18% of all traumatic injuries tested positive for either alcohol or drugs or both. About 1/3rd of those in the registry who tested positive for alcohol also tested positive for one or more drugs.
• Cannabis is the most common drug found in the registry followed by cocaine, amphetamines and opiates, and its use is on the rise.
• Trauma patients in their teens and twenties have the highest exposure to both drugs and alcohol. • Men are more likely to be positive for alcohol and drugs than women. Therefore, young males make up the
highest risk group. • Patients who are positive for alcohol tend to sustain more serious injuries than patients with no blood
alcohol. They are also more likely to be admitted to the ICU for more minor injuries. • Some of the regional variation in the percentages of patients who are positive for alcohol, drugs or both
might be due to differences in the screening practices in these regions. • It is also evident that screening practices change based on the mechanism of injury and other patient
demographics.
Thanks [email protected]
