What's New in Critical Illness and Injury Science? The association between initial blood alcohol concentration and polysubstance use may be indicative of a gateway drug effect.

In this issue, Jordan et al.[1] have reported their findings regarding the question as to whether trauma patients with an elevated blood alcohol concentration (BAC) (indicating intoxication at >0.10%) were using other substances of abuse (SOA) at the time of their injury.[23] This is particularly relevant because 40%–60% of all patients seen in trauma centers are under the influence of alcohol.[45] What is additionally concerning is that data from two surveys of US adults (National Epidemiologic Survey on Alcohol and Related Conditions, n = 43,093; and the National Epidemiologic Survey on Alcohol and Related Conditions III, n = 36,309) demonstrate that 12-month alcohol use (11.2%), high-risk drinking (29.9%), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol use disorder (49.4%) have increased for the US populations across nearly all sociodemographic groups.[6] Furthermore, binge drinking in the US (five or more drinks for men and four or more for women, on one occasion) has gone up 6–7-fold over the past decade.[7] Given that other SOA – both with and without concomitant alcohol consumption – have been linked to an increased risk of motor vehicle crashes, it seems reasonable to presume that a significant percentage of all trauma patients intoxicated with alcohol would also be under the influence of other drugs.[8]

The burden of alcohol in the trauma setting is indeed becoming overwhelmed by the affliction of other substance use disorders. The work by Soderstrom et al. demonstrated in a level 1 trauma center that opiate-positive screenings increased by 543% and cocaine-positive screening by 212% during the last decade and a half of the 20th century.[9] Opioid addiction now affects 2.4 million Americans, and one million of these individuals use heroin (21,000 are minors) with a cost to society of $51 billion annually,[10] and the centers for disease control recently reported that the number of drug overdose deaths has risen nationally to more than 70,000 deaths in 2017.[11] Furthermore, the use of prescription opioids is associated motor vehicle crashes, and the prescriptive use of opioids is also associated with culpability.[12] In other words, our national drug problem as it relates to trauma continues to worsen. In fact, even fundamentalist religious countries, such as Iran, are having increasing problems related to fatal motor vehicle crashes and opioids.[13] The current study adds to the understanding of this problem by identifying that a significant proportion of trauma patients with a BAC >0.10% had evidence of polysubstance use (P < 0.001), including a strong association with opioid and cocaine use (in this study, 14.3% were positive for opioids and 4.5% for cocaine but also 9.67% for marijuana and 13.5% for benzodiazepines). Many of the patients had multiple intoxicants, and the proportion of trauma victims using opioids, marijuana, and cocaine was universally greater in the BAC >0.10% group (but not with benzodiazepines). In fact, more than twice as many patients with BAC >0.10% tested positive for the presence of 1–2 additional SOA.

This study makes an important point regarding the consistency of approach to trauma patients in this time of increasing legal and illegal use of SOA in the US. Of the 4451 patients screened in this study, only 1550 (34.8% [1265 with a BAC <0.10% and 285 with a BAC >0.10%]) were screened for alcohol and “other” substances. This is not a criticism of the authors' efforts but a criticism of a system where physicians in local emergency departments react without an evidence-based approach, i.e., operating without protocols. Bunn et al. have concluded, through their work using the state of Kentucky's Fatality Analysis Reporting System, the Collision Report Analysis for Safer Highways, and mortality data from death certificates, that they could identify the majority of positive drug screens in fatal crashes.[14] However, there was a lack of concordance between the reporting sources, and the authors recommended that states with low rates of driver testing for drugs involved in crashes should make such testing mandatory, at least in fatal crashes.

While opiates and cocaine would seem to be of particular interest to the general readership, it may be that marijuana (cannabis) will play a very important future role in accidents and alcohol. The work of Jordan et al. comes at a unique time because new marijuana laws have been enacted in many states since 2012. As of 2018, nines state in the US have legalized marijuana for recreational use, and over half of the states have legalized it for medical uses.[15] In this changing political and social milieu, Steinemann et al. have reported that marijuana positivity has tripled in motor vehicle crashes in Hawaii and the use of seatbelts by those using marijuana was less likely.[15] Furthermore, Sokoya et al. recently reported that since the legalization of marijuana in Colorado, there have been increases in maxillary and skull base fractures in Denver,[16] with an associated growth in the number of hash oil burns, pediatric marijuana exposures, as well as complaints of cyclic vomiting.[1718192021] Dubois et al. support this position, because in their review of 834,328 drivers who were involved in a fatal crashes between 1991 and 2008, they found that a driver with positivity for alcohol and cannabis had greater odds of making an error than a driver who had just one or the other substance (alcohol or cannabis) in their bloodstream.[22] Jordan et al. demonstrated that 10% of their trauma population that was screened tested positive for marijuana.[1] This number rose to 16.5% in those with a BAC >0.10%, thereby highlighting the need for prospective studies, especially in this period of marijuana legalization in order to clinically and socially intervene more effectively. However, there are reports that dispute such assertions.[23]

The importance of these findings has several important ramifications. First, all trauma victims should be screened for alcohol and other substances (not just one category or the “other”), and that protocols should be put into place to facilitate such an action. Second, the screening for polysubstance use is important to the care of such patients, thereby allowing a more targeted approach to interventions in the hospital and posthospital course of treatment. Third, given that over 60% of opioid users leaving traditional rehabilitation programs relapse within 5 weeks,[24] with many of them returning to US roadways, the trauma setting may offer an opportunity for substance use disorder interventions. Prior efforts in emergency department-based interventions have been promising,[25] and future studies may find a higher yield in targeting patients presenting with a BAC >0.10% for substance use disorder-based interventions.

This report has limitations as noted by the authors; the study is small and retrospective and involves only one institution. There were also inconsistencies in the approach by the providers treating patients suspected of alcohol intoxication and/or other drug use. Clearly, the data set used by the authors has some selection bias. Nonetheless, the information presented by Jordan et al. enlightens us as to the challenges facing medical, public health, and political institution in the near and intermediate terms.

It will be important over the next decade to closely observe the use of alcohol and other SOA, especially heroin and other opioids, so that lessons learned in the treatment of addiction can be applied to the burgeoning opioid overdose epidemic. Furthermore, marijuana, because of its increasingly legal and socially acceptable status, may offer the opportunity for unique health interventions and even potentially necessitating changes to laws in order to lower the legal level of alcohol while driving when also using marijuana.[26] We encourage our colleagues to pursue avenues of research, innovative solutions, and vigilance in the care of their trauma patients who use alcohol and other SOA.