Chapter 42: Alcohol and Drugs

INTRODUCTION

Trauma surgeons are very likely to interact with patients suffering from a wide variety of substance use disorders. It is important that providers are familiar with the various states of intoxication and withdrawal and the management of these states. If not for the traumatic event, this patient population often would not have presented to a hospital and may have little to no interest in recommendations related to treatment of the substance use disorder. This leads to challenges faced by trauma centers that are mandated to identify and address these problems. Just like the nature and extent of traumatic injuries can vary widely, the same is true for the nature and extent of sequelae related to drugs and alcohol. The spectrum can range from a young patient intoxicated and injured during their first use of “bath salts” to the patient involved in an alcohol related motor vehicle collision who develops complications related to alcohol withdrawal after admission.

According to the CDC, unintentional injuries were the fourth leading cause of death in the United States in 2013 (Fig. 42-1).¹ Deaths related to drug overdose exceeded 41,000 in 2012, while the age adjusted drug related death rate rose from 6.1 per 100,000 in 1999 to 13.1 per 100,000 in 2012. During the same period, deaths from opioid related poisoning tripled (Fig. 42-2).² It is estimated that one in three traffic deaths involves a driver who is intoxicated.³ The cost of alcohol related motor vehicle crashes exceeds $80 billion per year, and it is estimated that about 16% of injury related deaths worldwide are related to alcohol use.⁴ As the risk of injury is greater among light drinkers who occasionally drink heavily compared to those who regularly drink heavily, but not episodically, tolerance presumably plays a role.⁵ Of interest, violence related injuries have been found to have a stronger association with alcohol use than unintentional injuries.⁶ In one study, the odds ratio for intentional injury related to drinking was 21.5 compared to 3.37 for unintentional injury.⁷ Hence, drug and alcohol use and abuse are clearly linked to the risk of injury and death. Understanding the pathology of addiction, various types of drugs and potential interventions are critical to an effective trauma center.