Alcohol Problems in Women Admitted to a Level I Trauma Center: A Gender-Based Comparison

1079-6061/00/4801-0108 The Journal of Trauma: Injury, Infection, and Critical Care Copyright © 2000 by Lippincott Williams & Wilkins, Inc.

Vol. 48, No. 1 Printed in the U.S.A.

Alcohol Problems in Women Admitted to a Level I Trauma Center: A Gender-Based Comparison Larry M. Gentilello, MD, Frederick P. Rivara, MD, MPH, Dennis M. Donovan, PhD, Andres Villaveces, MD, MPH, Elizabeth Daranciang, MPH, Christopher W. Dunn, PhD, and Richard R. Ries, MD Background: Male patients constitute such a large proportion of trauma patients that most studies of alcohol problems in trauma patients have been carried out with clinical data largely or totally contributed by male patients. It may be incorrect to assume that the nature of alcoholism in women and men is identical, or that the size of the problem among women is small, eliminating the need to specifically study female patients. The purpose of this study was to perform a gender-based comparison of alcohol problems in trauma patients. Methods: Admitted injured patients underwent routine screening, including a blood alcohol concentration, serum g-glutamyl transpeptidase, and the Short Michigan Alcohol Screening Test. A random sample of screen positive women and men underwent a comprehensive alcohol use and psychosocial assessment, and the results were compared by gender. Results: The screen-positive rate was higher for men, 51% versus 34% ( p < 0.01). However, screen-positive women and men had similar problem severity as reflected by mean blood

alcohol concentration (162 mg/dL vs. 142 mg/dL, p 5 0.16) and Short Michigan Alcohol Screening Test scores (4.6 vs. 5.0, p 5 0.32). The Alcohol Use Disorders Identification Test, NIMHDIS, and Severity of Alcohol Dependence Data form showed that female trauma patients with alcohol problems have the same severity of dependence symptoms as men. However, women were significantly more likely to have liver dysfunction, depression, psychological distress, and recent physical, emotional, or sexual abuse. Conclusion: Alcohol problems are more common in male trauma patients, but women with alcohol problems are just as severely impaired, have at least as many adverse consequences of alcohol use as their male counterparts, and have more evidence of alcohol-related physical and psychological harm. Key Words: Trauma centers, Traumatology, Injuries, Alcohol, Alcoholism, Intervention studies, Treatment outcome, Public health.

B

the problem among women is small, eliminating the need to specifically study female trauma patients. The lower incidence of alcohol problems in female trauma patients may also reflect past, but not future, trends in alcohol use. Women are the fastest growing segment of the alcoholabusing population. Among young women, the incidence of alcohol problems is now virtually identical with that of men. The sharpest increase in motor vehicle crashes in recent years has been in young females with moderately elevated blood alcohol concentrations (BAC), who have a risk of fatal crash that is 21 times higher than that of men with comparable BAC.6,7 Driving while intoxicated arrest rates have decreased sharply for men but have increased by 26% for young women.8 Single vehicle nighttime crash rates, a surrogate indicator of alcohol involvement, have decreased by 20% for young men versus a 29% increase for women in the same age category.8,9 The purpose of this study was to perform a gender-based comparison of alcohol problems in patients admitted to a Level 1 trauma center. Such information is important in determining the range of counseling services necessary for the development of successful trauma center intervention programs.10,11

ecause of the extraordinary prevalence of alcohol problems in trauma patients, the National Institute on Alcohol Abuse and Alcoholism has stated that trauma centers are ideal sites for alcohol screening and intervention programs.1 When questionnaires such as the Michigan Alcohol Screening Test (MAST) are administered to trauma patients, as many as 44% test positive for chronic alcohol abuse.2– 4 This number exceeds the reported rates of alcoholism on medicine (25%), neurology (19%), obstetrics-gynecology (12%), and even inpatient psychiatry services (30%).5 To effectively implement intervention programs in trauma centers, those providing counseling need information on the types and severity of alcohol problems likely to be encountered. Although alcohol problems in trauma patients have previously been characterized, men constitute such a large proportion of trauma patients that most studies have been carried out with clinical samples largely or totally composed of men. It may be incorrect to assume that the nature of alcoholism in women and men is identical, or that the size of

Submitted for publication January 5, 1999. Accepted for publication July 2, 1999. From the University of Washington School of Medicine, Departments of Surgery (L.M.G.), Pediatrics (F.P.R.), Psychiatry (R.R.R.), and the Harborview Injury Prevention and Research Center (L.M.G., F.P.R., A.V., C.W.D., E.D.), and the University of Washington Alcohol and Drug Abuse Institute (D.M.D.), Seattle, Washington. Supported by grant NIH/NIAAA RO1-AAO9045. Address for reprints: Larry M. Gentilello, MD, Harborview Medical Center, Department of Surgery, Box 359796, 325 Ninth Avenue, Seattle, WA 98104; email: [email protected]

PATIENTS AND METHODS The study was conducted at Harborview Medical Center, University of Washington, between April of 1994, and May of 1996, as part of a larger study on alcohol interventions in trauma patients. The study population consisted of patients who were admitted to the trauma center for treatment of an 108

Vol. 48, No. 1

Alcohol Problems in Female Trauma Patients

alcohol dependence.15 The SADD was developed both to assess a number of the key features of the alcohol dependence syndrome and to be sensitive to early signs of dependence. Concurrent drug use and psychosocial problems were assessed by using selected fields of the Addiction Severity Index.16 The Addiction Severity Index assesses symptom severity in six potential problem areas that contribute to substance abuse syndromes: medical, employment/support, alcohol, legal, family/social, and psychiatric. The overall state of problem denial and degree of treatment readiness was assessed by using the 12-item Readiness to Change Questionnaire.17 Screening results and the results of the comprehensive assessment obtained from all enrolled women were compared with similar data obtained from enrolled men. Statistical analysis on continuous dependent variables such as quantity of alcohol intake was assessed by using t tests and the MannWhitney U test. Scores on outcome questionnaires were compared by using t tests and x2 analysis. The study was approved by the Institutional Review Board of the University of Washington School of Medicine.

injury. Patients were excluded if they were less than 18 years of age, were discharged within 24 hours, did not speak English, had a traumatic brain injury that did not resolve by discharge, died during hospitalization, were not residents of Washington state, were homeless, were transferred from another hospital, had severe psychiatric problems, or were discharged to a nursing home. Injured patients underwent routine screening for an alcohol problem with measurement of BAC and serum g-glutamyl transpeptidase (GGT). After resolution of any mental status abnormalities the Short Michigan Alcoholism Screening Test (SMAST) was also administered.12 Screening was considered positive if one of the following five conditions were met: BAC $100 mg/dL; SMAST score $3; BAC of 1 to 99 mg/dL and SMAST score of 1 to 2; BAC of 1 to 99 and GGT above normal; or SMAST score 1 to 2 and GGT above normal. Patients who screened positive were asked for consent to use their medical records and other databases and were informed that some subjects would be randomly chosen to participate in an in-depth psychosocial assessment during which information on alcohol use would be obtained. This assessment included information on alcohol use patterns, alcohol problem severity, level of dependence, and other information that might impact on the extent of services and counseling program needs for trauma patients. A variety of standardized instruments were used to classify the severity of alcohol abuse or dependence. These included the Alcohol Use Disorders Identification Test, a 10-item self-report measure developed specifically by the World Health Organization as a simple screening instrument for early identification of hazardous drinkers in primary care settings.13 It is targeted at early drinking problems rather than alcohol dependency, thus providing an opportunity to be of use with the broad spectrum of drinking problems likely to be encountered in a trauma center. It assesses the three primary drinking-related dimensions recommended by the Institute of Medicine: alcohol consumption (three items), alcohol dependence (three items), and problems caused by alcohol (four items). Diagnostic confirmation of alcohol abuse or dependence was confirmed by administration of the NIMH Diagnostic Interview Schedule (DIS) Form III-R.14 This test was developed to assess alcohol use disorders and their symptoms, and provides severity criteria for each symptom by using questions in a guided decision tree structure. It uses nine criteria such as attempts to cut down, marked tolerance and withdrawal symptoms, greater alcohol use than intended, and failure to maintain social responsibilities while drinking. At least three criteria must be present to make a diagnosis of alcohol dependence. It also allows a determination of the level of alcohol dependence along a continuum of mildmoderate-severe, based on the number of criteria endorsed, and differentiates between alcohol abuse and dependence on the basis of quality, quantity, frequency, and duration of symptoms. The 15-item Short Alcohol Dependence Data (SADD) questionnaire was used as another measure of the level of

RESULTS There were 7,394 trauma patients admitted during the study period. Of these, 3,195 patients were not eligible (43.2%) because they were less than 18 years of age (15%, n 5 1,127), were discharged less than 24 hours after admission (8.7%, n 5 645), were not Washington State residents (3.3%, n 5 242), did not speak English (3%, n 5 219), had a head injury resulting in impairment that did not resolve before discharge (3%, n 5 224), died during hospitalization (2.9%, n 5 214), had a major psychiatric problem (1.8%, n 5 135), were discharged to nursing home (1.2%, n 5 89), were transferred from another hospital (1%, n 5 73), were homeless (0.9%, n 5 63), or had other reasons (2.2%, n 5 164). The number of patients excluded by each criterion was similar by gender. There were 4,134 eligible patients, approximately one fourth of whom were women. A total of 3,235 patients (78%) were screened. The primary reasons for failure to screen the remaining 22% of patients were admission and discharge over the weekend (when the study was not active) before screening with the SMAST could occur, and lack of an admission BAC and GGT obtained at the time of admission, despite protocol. Only 1% of patients refused the SMAST. The screening rate was slightly higher for men (78%) than for women (74%). Comparing screened and nonscreened patients, the primary predictor of screening was Injury Severity Score (ISS) ( p , 0.0001). A total of 77% of patients who were not screened had an ISS #9, whereas 86.6% who were screened had an ISS .9. This finding is consistent with weekend or early discharge being the primary reason for failure to screen. The distribution of ISS scores did not differ by gender ( p 5 0.77). A total of 1,532 patients screened positive (47%). The screen-positive rate was significantly higher for men than for women (51.4% compared with 34.3%, p , 0.001). As noted 109

The Journal of Trauma: Injury, Infection, and Critical Care

January 2000

(1.32%). Because this was a gender comparison study, and the reasons for missed evaluations were similar by gender ( p 5 0.88), the missed evaluations should not result in bias, or would result in off-setting bias. There was no significant difference in age or ISS in the group receiving the in-depth evaluation. The mean admission BAC for women in this subgroup was 162 6 120 mg/dL, compared with 142 6 114 mg/dL in men ( p 5 0.16). Women and men also had similar SMAST scores (4.6 vs. 5.0, p 5 0.32). However, liver dysfunction, as evidenced by an abnormal GGT, was significantly more common in women (39% vs. 25%, p 5 0.01). The Alcohol Use Disorders Identification Test revealed that both genders had similar degrees of alcohol problem severity ( p 5 0.64). However, there were significant gender differences in the pattern of responses. Men drank significantly larger quantities of alcohol. Considering the trend for women to have a higher blood alcohol level, this finding may reflect gender differences in alcohol tolerance rather than differences in problem severity. Men more frequently admitted to morning drinking, whereas women were more likely to feel drinking-related psychological distress. These data are shown in Table 2. The Diagnostic Interview Schedule (DIS) confirmed alcohol dependence in 66% of women and 74% of men. Thirtyfour percent of women and 26% of women with a positive screen did not meet criteria for either alcohol abuse or dependence. However, of the patients who did not admit to symptoms necessary to meet diagnostic criteria for alcohol abuse or alcohol dependence, 13% had an admission BAC $300 mg/dL, and 19% had an admission BAC $200 mg/dL.

TABLE 1. Screening results for all eligible patients

BAC (mg/dL) 0–99 $100 Mean GGT Abnormal Normal Mean SMAST 0–2 (negative) 3–13 (positive) Mean

Men n (%)

Women n (%)

Total n (%)

1823 (68.5) 840 (31.5) 74.5 6 109.6

677 (80.0) 169 (20.0) 48.7 6 95.3

2500 (71.2) 456 (28.8) p 5 0.0001

323 (14.0) 1990 (86.0) 34.8 6 69

147 (19.7) 601 (80.4) 27.9 6 64.9

470 (15.4) 2591 (84.7) p 5 0.001

1832 (70.4) 771 (29.6) 2.1

729 (83.3) 146 (16.7) 1.2

2561 (73.7) 917 (26.4) p 5 0.0001

BAC, blood alcohol concentration; GGT, gamma glutamyl transpeptidase; SMAST, short version of Michigan Alcohol Screening test. All three components of the screening protocol were not completed in all patients.

above, some patients were discharged before receiving the SMAST and may have screened positive by SMAST criteria. Thus, the positive-screen rate is probably a minimal estimate of prevalence. Screening characteristics are shown in Table 1. A total of 847 screen-positive patients (55%) were randomly chosen for the in-depth alcohol evaluation, and it was completed in 552 patients (65%): 95 women and 457 men, a ratio that matched the gender distribution of the screenpositive sample. The primary reasons for the 294 missed evaluations were discharge before the evaluation could be performed in 234 men (32%) and 50 women (32%). Refusal to consent occurred in only 10 men (1.36%) and 2 women

TABLE 2. Responses to the Alcohol Use Disorders Identification Test (AUDIT) by gender (mean 6 SD) Women

Hazardous use 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have six or more drinks on one occasion? Symptoms of dependence 4. How often in the last year have you found that you were unable to stop drinking once you started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Consequences of drinking 9. Have you or someone else been injured as the result of your drinking? 10. Has a relative, friend, doctor or health worker been concerned about your drinking or suggested that you cut down? Total AUDIT score

Men

p Value

2.57 6 1.17 1.54 6 1.44

2.76 6 1.23 1.94 6 1.48

0.11 0.02

1.81 6 1.44

2.12 6 1.43

0.07

1.21 6 1.39

1.14 6 1.45

0.49

1.03 6 1.25

0.89 6 1.21

0.25

0.48 6 1.17

0.69 6 1.30

0.05

1.31 6 1.31

1.04 6 1.26

0.04

0.88 6 1.22

0.88 6 1.11

0.6

0.91 6 1.96

1.87 6 1.87

0.9

2.49 6 1.86

2.22 6 1.86

0.2

15.27 6 10.33

15.57 6 9.79

0.64

Questions were scored on a point system (questions 3–10: never 5 0; , monthly 5 1; monthly 5 2; weekly 5 3; daily or almost 5 4). Points for questions 1 and 2 were based on quantity and frequency of alcohol use.

110

Vol. 48, No. 1

Alcohol Problems in Female Trauma Patients

This finding suggests a need for a multidimensional approach to screening that includes an objective test such as the BAC. Of those who met criteria for an alcohol problem, only 1.1% of women and 1.6% of men were characterized as alcohol abusers, with most showing signs of dependence. However, severe dependence was uncommon in both groups (16.6% of men and 14.9% of women), with most testing in the mild or moderate severity range. Scores on the SADD confirmed that severe alcohol dependence is uncommon in male and female trauma patients (Table 3). Injury and health-related questions derived from the DIS (Table 4) suggest that both men and women with alcohol problems equally engage in behaviors that placed them at risk for alcohol-related injuries and other morbidities. A driving under intoxication citation within 3 years of hospital admission was reported in 25% of women and 23% of men. Alcohol-related traffic crashes during the same period were also similar and were noted in 25% of women and 22% of men. However, women were significantly more likely to have symptoms of psychological distress, including depression, and were more likely to have suffered recent spousal or domestic abuse (Table 5). The Readiness To Change Scale, a measure of the patient’s willingness to take steps to reduce or stop their drinking, has been shown to correlate with likelihood of accepting a treatment referral, and is a strong predictor of alcohol use at 6 month follow-up in patients referred to treatment. Only 16.9% of women and 18.1% of men were still in a precontemplation phase, or state of problem denial (Table 3). Fiftytwo percent of women and 44% of men were ready to take active steps to address their drinking, expressing a desire to stop, and receptivity toward counseling.

TABLE 3. Levels of alcohol dependence by gender, and readiness to change drinking habits and acceptance towards counseling

SADD Low dependence Moderate dependence Severe dependence Readiness to Change Precontemplation Contemplation Action

Women (%)

Men (%)

p Value

62.8 22.3 14.9

61.5 21.9 16.6

0.92

16.8 31.5 51.7

18.3 38.3 43.5

0.35

SADD, Short Alcohol Dependence Data.

TABLE 4. Health and related questions derived from the Diagnostic Inventory Schedule (DIS) that may reflect the risk of future alcohol-related injuries and other morbidity Injury and health related questions

Women (%)

Men (%)

1. Have you ever had trouble driving, been in an accident, or been arrested because of drinking? 2. If yes, have you had trouble driving several times because of your drinking? 3. Have you ever accidentally injured yourself when you had been drinking? 4. If yes, did this happen several times? 5. Have you been high several times from drinking in a situation where it increased your chances of getting hurt? 6. Did drinking ever cause you to have liver disease, stomach disease, or memory problems? 7. If yes, did you continue to drink knowing that drinking caused you to have a health/injury problem?

38.7

54.0

52.8

48.2

51.6

50.2

54.2 22.2

46.0 42.3

25.8

21.6

70.9

66.1

TABLE 5. Psychosocial data of men and women derived from the Addiction Severity Index (ASI), with significant differences noted by gender

Marital status Never married Married/cohabiting Separated/divorced/widowed Psychiatric status 1. Have you had a significant period in the past 30 days in which you experienced: a. Severe depression? b. Trouble controlling violent behavior c. Experienced serious thoughts of suicide d. Attempted suicide e. Been prescribed medication for a psychological or emotional problem 2. How much have you been troubled or bothered by psychological or emotional problems in the past 30 days? a. Not at all b. Slightly c. Moderately d. Considerably e. Extremely 3. Completed by interviewer a. At the time of the interview, is the patient obviously depressed or withdrawn b. How would you rate the patient’s need for psychological treatment Family and social relationships 1. In the past 30 days did any of these people abuse you (family, friends, coworkers) a. Emotionally make you feel bad through harsh words b. Physically (cause you physical harm) 2. In your life did any of these people abuse you sexually (force sexual advances or sexual acts)

111

Women (%)

Men (%)

p Value

33.7 16.3 50

53.9 14.1 32

0.001

28.8 8.9 10.5 3.8 10

19.7 5.7 7.1 1.9 5.2

0.07 0.30 0.30 0.30 0.10

48.1 9.1 10.3 19.5 13.0

60.3 13.1 12.0 8.6 6.0

0.007

11.5 33

4.2 22.9

0.006 0.01

20.5 14.1 32.1

12.1 2.5 5.9

0.05 0.001 0.001

The Journal of Trauma: Injury, Infection, and Critical Care

January 2000

DISCUSSION

stated that efforts to reduce death and disability from injuries must be combined with efforts to reduce alcohol abuse and called for an increase in the use of alcohol interventions in trauma centers.35 One method of doing so is by linkages with currently existing substance abuse treatment programs or self-help groups. Fuller et al. reported on the use of a substance abuse consultation team that was developed to perform interventions with trauma patients who were suspected of having problems with alcohol, other drugs, or both.36 They diagnosed a substance use disorder in 100 consecutive patients who were referred for evaluation. Of these, 78 were referred for treatment, and nearly two thirds (62%) complied with the referral. In another study, which included 364 severely dependent patients, the impact of hospitalization motivated 74% to accept a treatment referral, and at follow-up, 35% reported involvement in some type of substance abuse treatment or 12-step program.37 Linkage between substance abuse specialists and trauma services may be the most appropriate approach for individuals with more severe levels of alcohol dependence. However, the Institute of Medicine has indicated that the responsibility to provide counseling for patients with uncomplicated cases of mild to moderate alcohol abuse or early dependence lies not with alcohol treatment specialists, but with general staff in hospital wards who are trained to provide “brief interventions.”27 Brief interventions have been repeatedly found to be effective in reducing alcohol intake and negative alcohol-related consequences in patients without severe dependence.38–43 Clinical guidelines for their implementation in trauma centers have already been developed.10,11,44–46 In this study, only 14.9% of women and 16.6% of men were found to have severe dependence. Trauma center interventions capitalize on the increased motivation and readiness to change drinking behaviors that seems to accompany injury and trauma.47–51 The goals are twofold: first, to modify drinking behaviors so that alcohol consumption itself is no longer harmful or hazardous, and second, to reduce the likelihood of future trauma. Preliminary results of a number of clinical trials to determine their efficacy in emergency departments and trauma centers demonstrate positive results and seem to be similar to the results found in other hospital settings.44,49,52 In addition to contributing to less harmful drinking and reduced rates of trauma recidivism, they also appear to have the potential for controlling costs under health care reform and for collateral cost offsets.41,53,54 Many patients with alcohol problems are more likely to receive health care from a trauma surgeon than from a primary care practitioner. Trauma center admission thereby imposes a responsibility to identify and evaluate such patients and to refer them to treatment or to provide them with appropriate brief counseling.10,11,46 Trauma has been referred to as the Neglected Disease of Modern Society.55 However, for many patients it is not a disease, but rather, a neglected symptom of an underlying alcohol use disorder. The 34% screen-positive rate demonstrates that female trauma patients are not an exception. Although alcohol problems are less common in women, their lives are as severely disrupted by alcohol and they seem to be even more susceptible to alcoholrelated physical and psychological harm than men.

This study demonstrates that, although alcohol problems are more common in men, female trauma patients with alcohol problems seem to be just as severely impaired and to have experienced as many adverse consequences of alcohol use as their male counterparts. These findings are consistent with other studies demonstrating that women are less likely to have alcohol problems; yet, among heavy drinkers, women equal or surpass men in the number of problems that result from their drinking.18 These include studies demonstrating that female alcoholics have death rates 50 to 100% higher than those of male alcoholics of similar age and that a greater percentage of female alcoholics die from suicides, violence, or alcohol-related incidents.19,20 This study also found that female trauma patients were significantly more likely to have evidence of liver dysfunction. Other studies have also noted that women are more susceptible to the toxic effects of alcohol. Women develop alcoholic cirrhosis after a comparatively shorter period of heavy drinking and at a lower level of daily drinking than men, and proportionally more alcoholic women die from hepatic cirrhosis.21–23 Women are also at greater risk for alcohol-induced brain damage and cardiomyopathy.24 –27 Female trauma patients were also significantly more likely than men to have symptoms of emotional distress or depression and to have experienced physical or sexual abuse. Others have noted a particularly strong relationship between substance abuse and sexual assault in women, with nearly 70% of women in treatment having a history of being sexually abused, compared with 12% of men.28 The frequent presence of depression, physical, and sexual abuse suggests that trauma center intervention programs may need to have sufficient counseling services available to address these issues in women. The high rate of physical assault within the previous 30 days among women is particularly distressing. Studies demonstrate that emergency department physicians rarely recognize domestic violence.29,30 Women with alcohol problems often have male partners with alcohol problems, and male alcohol use is highly associated with spousal abuse. Women may drink to cope with the trauma of being beaten, setting up a spiral of assault and alcohol abuse.31,32 Female trauma patients in this study were also significantly less likely to have social support than males, with 50% being unmarried, divorced, or widowed. Unmarried women are 50% more likely to drink heavily than married women are, and after women without alcohol problems divorce, their drinking often increases.33 Given the high rate of alcoholism among both genders, it is important to consider developing interventions to address these problems. This study suggests that alcohol intervention programs may need to provide additional services to take into account the unique alcohol-related symptoms and stressors found in women. Alcohol interventions in trauma centers have long been advocated but are rarely provided.34 The Department of Health and Human Services, in its recent report to Congress, 112

Vol. 48, No. 1

Alcohol Problems in Female Trauma Patients

REFERENCES 1.

2. 3.

4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16.

17.

18.

19.

20.

National Institutes of Health/National Institute on Alcohol Abuse, and Alcoholism. Eighth Special Report to the US Congress on Alcohol and Health. USDHHS EEI, Alexandria, Va; 1993. Rivara FP, Jurkovich GJ, Gurney JG, et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg. 1993;128:907–912. Jurkovich GJ, Rivara FP, Gurney JG, Seguin D, Fligner CL, Copass M. Effects of alcohol intoxication on the initial assessment of trauma patients. Ann Emerg Med. 1992; 21:704 –708. Soderstrom CA, Smith GS, Dischinger PC, et al. Psychoactive substance use disorders among seriously injured trauma center patients. JAMA. 1997;277:1769 –1774. Moore RD, Bone LR, Geller G, et al. Prevalence, detection, and treatment of alcoholism in hospitalized patients. JAMA. 1989;261:403– 407. Zador PL. Alcohol related relative risk of fatal driver injuries in relation to driver and age and sex. J Stud Alcohol. 1991;52:302–310. Borkenstein RF, Crowther RF, Shumate RP, et al. The Role of the Drinking Driver in Traffic Accidents. Bloomington, Ind: Department of Police Administration; 1964. Popkin CL, Rudisill LC, Waller PF, et al. Female drinking and driving: recent trends in North Carolina. Accid Anal Prev. 1988;20:219 –225. Fell JC. Alcohol involvement rates in fatal crashes: a focus on young drivers and female drivers. Proceedings of the 31st Annual Conference of the American Association for Automotive Medicine, Washington, DC, 1987. Washington, DC: National Center for Statistics and Analysis; 1987. Gentilello LM, Donovan DM, Dunn C, Rivara FP. Alcohol interventions in Level I trauma centers: current practice, future directions. JAMA. 1995;274:1043–1048. Dunn C, Donovan D, Gentilello LM. Practical guidelines for performing alcohol interventions in trauma centers. J Trauma. 1997;42:299 –304. Selzer ML, Vinokur A, Van Rooijen L. A self-administered Short Michigan Alcoholism Screening Test (SMAST). J Stud Alcohol. 1975;36:117–126. Saunders JB, Aasland OF, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT). Addiction. 1993;88:791– 804. Robbins L, Helzer J, Cottler L, et al. NIMH Diagnostic Schedule: Version II Revised (DIS-IIIR). St Louis, Mo: Washington University Press; 1989. Davidson R, Raistrick D. The validity of the Short Alcohol Dependence Data (SADD) questionnaire. Br J Addict. 1986; 81:217–222. McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic instrument for substance abuse patients: the Addiction Severity Index. J Nerv Ment Dis. 1980; 168:26 –33. Rollnick S, Heather N, Gold R, et al. Development of a short Readiness to Change questionnaire for use in brief, opportunistic interventions among excessive drinkers. Br J Addict. 1992;87:743–754. Wilsnack RW, Wilsnack SC, Klassen AD Jr. Women’s drinking and drinking problems: patterns from a 1981 national survey. Am J Public Health. 1984;74:1231– 1238. Hill SY. Biological consequences of alcoholism and alcoholrelated problems among women. In: Special Populations Issues. Washington, DC: National Institute on Alcohol Abuse and Alcoholism; 1982:43–73. Alcohol and Health Monograph No. 4. DHHS Pub. No. (ADM)82–1193.

21. 22. 23. 24.

25. 26. 27. 28.

29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

113

Alcohol Alert. Washington, DC: National Institute on Alcohol Abuse and Alcoholism; October 1990. Publication 10 PH 290. Saunders JB, Davis M, Williams R. Do women develop alcoholic liver disease more readily than men? Br Med J. 1981;282:1140 –1143. Tuyns AJ, Pequignot G. Greater risk of ascitic cirrhosis in females in relation to alcohol consumption. Int J Epidemiol. 1984;13:53–57. Nicholls P, Edwards G, Kyle E. Alcoholics admitted to four hospitals in England: general and cause-specific mortality. Q J Stud Alcohol. 1974;35:841– 855. Freeza M, di Padova C, Possato G, et al. High blood alcohol levels in women. The role of decreased gastric alcohol dehydrogenase activity and first pass metabolism. N Engl J Med. 1990;382:95–99. Urbano-Marquez A, Estruch R, Fernandez-Sola J, et al. The greater risk of alcoholic cardiomyopathy and myopathy in women compared with men. JAMA. 1995;274:149 –156. Fuchs CS, Stampfer MJ, Colditz GA, et al. Alcohol consumption and mortality among women. N Engl J Med. 1995;332:1245–1250. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press; 1990. Substance Abuse and the American Women. Annual Report from the National Center on Addiction and Substance Abuse. Columbia University, New York, NY: CASA Publications; 1996. Fanslow JL, Norton RN, Spinola CG. Indicators of assaultrelated injuries among women presenting to the emergency department. Ann Emerg Med. 1998;32:341–348. Olson L, Anctil C, Fullerton L, et al. Increasing emergency physician recognition of domestic violence. Ann Emerg Med. 1996;27:741–746. Miller BA, Downs WR. The impact of family violence on the use of alcohol by women. Alcohol Health and Research World. 1993;17:137–143. Oriel KA, Fleming MF. Screening men for partner violence in a primary care setting. A new strategy for detecting domestic violence. J Fam Pract. 1998;46:493– 498. Substance Abuse and the American Women. Annual Report from the National Center on Addiction and Substance Abuse. Columbia University; 1996. Danielsson P, Rivara FP, Gentilello LM, Maier RV. Reason why trauma surgeons fail to screen for alcohol problems. Arch Surg. 1999;134:564 –568. US Dept of Health and Human Services. Model Trauma Care Plan. Rockville, Md: US Dept of Health and Human Services; 1992. Fuller MG, Diamond DL, Jordan ML, et al. The role of a substance abuse consultation team in a trauma center. J Stud Alcohol. 1995;56:267–271. Dunn CW, Ries R. Linking substance abuse services with general medical care: integrated, brief interventions with hospitalized patients. Am J Drug Alcohol Abuse. 1997;23:1–13. Samet JH, Rollnick S, Barnes H. Beyond CAGE. A brief clinical approach after detection of substance abuse. Arch Intern Med. 1996;156:2287–2293. Heather N. The public health and brief interventions for excessive alcohol consumption: the British experience. Addict Behav. 1996;21:857– 868. Richmond R, Heather N, Wodak A, et al. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction. 1995;90:119 –132. Barnes HN, Samet JH. Brief interventions with substanceabusing patients. Med Clin North Am. 1997;81:867– 879. Kahan M, Wilson L, Becker L. Effectiveness of physicianbased interventions with problem drinkers: a review. Can

The Journal of Trauma: Injury, Infection, and Critical Care

43.

44. 45. 46.

47. 48.

January 2000

Med Assoc J. 1995;152:851– 859. Israel Y, Hollander O, Sanchez Craig M, et al. Screening for problem drinking and counseling by the primary care physician-nurse team. Alcohol Clin Exp Res. 1996;20:443– 450. Dyehouse JM, Sommers MS. Brief intervention after alcohol-related injuries. Nurs Clin North Am. 1998;33:93– 104. Dyehouse JM, Sommers MS. Brief intervention as an advanced practice strategy for seriously injured victims of multiple trauma. AACN Clin Issues. 1995;6:53– 62. Treatment Improvement Protocol (TIP). In: Rostenberg PO, ed. Alcohol, and Other Drug Screening of Hospitalized Trauma Patients. Rockville, Md: Center for Substance Abuse Treatment, US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration; 1997. Publication BKD164 Gentilello LM, Duggan P, Drummond D, et al. Major injury as a unique opportunity to initiate treatment in the alcoholic. Am J Surg. 1988;156:558 –561. Bombardier CH, Ehde D, Kilmer J. Readiness to change

49. 50. 51. 52. 53. 54. 55.

114

alcohol drinking habits after traumatic brain injury. Arch Phys Med Rehabil. 1997;78:592–596. Bombardier CH, Rimmele CT. Alcohol use and readiness to change after spinal cord injury. Arch Phys Med Rehabil. 1998;79:1110 –5. Minugh PA, Nirenberg TD, Clifford PR, et al. Analysis of alcohol use clusters among subcritically injured emergency department patients. Acad Emerg Med. 1997;4:1059 –1067. Longabaugh R, Minugh PA, Nirenberg TD, et al. Injury as a motivator to reduce drinking. Acad Emerg Med. 1995;2:817– 825. Skinner HA. Spectrum of drinkers and intervention opportunities. Can Med Assoc J. 1990;143:1054 –1059. McCrady BS, Langenbucher JW. Alcohol treatment and health care system reform. Arch Gen Psychiatry. 1996; 53:737–746. Langenbucher J. Rx for health care costs: resolving addictions in the general medical setting. Alcohol Clin Exp Res. 1994;18:1033–1036. Injury in America. A Continuing Public Health Problem. Washington, DC: National Academy Press; 1985.