Abstract

    Objectives: The link between alcohol, substance abuse and major trauma is well established. This study is the first to assess the prevalence of alcohol and drug intoxication in major trauma admissions to two hospitals in Lebanon.

   Subjects and Methods: A cohort of sixty-three injured patients were enrolled in this study. Testing for serum alcohol and urine drugs of abuse was performed for these patients who were sequentially selected depending upon defined criteria.

   Results: Thirty percent (19/63) of the patients tested had positive toxicology results. Twenty five percent (16/63) were positive for alcohol and 21% (13/63) were positive for drugs of abuse, out of which 61.5% (8/13) were positive for tetrahydrocannabinol (THC, a marijuana metabolite) and 38% (5/13) were positive for benzodiazepines. All THC positive patients were also positive for alcohol. Sixteen percent (10/63) of the patients were concurrently positive for alcohol and substance abuse. Car crashes were the cause of trauma in 75% (47/63) of the cases. Patients positive for benzodiazepines were involved in more severe accidents. Conclusions: Screening for drugs of abuse is recommended for all trauma patients, particularly for those with evident alcohol abuse.

   Key Words: Trauma, Toxicology, Alcohol, Drugs of Abuse, Lebanon

Introduction

     Alcohol and substance abuse are major contributing factors in adult trauma all over the world. This is often compounded by poor decision-making and multiple risk taking behaviors (1,2). While alcohol is involved in most traffic fatalities (2), drugs intoxication has also been linked to other injuries as well: 40-60% of serious head injuries, 30-60% of fatal burns, 50-60% of hypothermia fatalities, up to 40% of fatal falls, up to 50% of drownings, and over 50% of homicides experienced by adults involve one or more individuals who are intoxicated (3).

    Lebanon is a Middle Eastern Country with an area of 10400 km2 and estimated population of 3,505,794. Sixty four percent of the population is aged between 15-64 years, among which the male:female ratio is 0.9 (4). Lebanon has been known for its production of hashish for many years. Up to the beginning of the Lebanon war in 1975, legislation was passed to limit the production of drugs (5). However, a dramatic increase in the production(6), abuse and trafficking of drugs was witnessed during the Lebanon war (5) that ended in 1990. Estimates on drug addiction during the war period revealed that 100,000 persons were taking drugs in Lebanon (7). Heroin was the most widely abused product, often in combination with hashish and cocaine (8). A clear link between the war situation and use of drugs was revealed by the study conducted in 1993 by the United Nations Drug Control Program (UNDCP) (9). Data collected in 1994,and later in 2000, showed a drop in drug users in institutions dealing with drug abuse (10) and University students (6), simultaneously.

     Taking into consideration the high number of deaths due to traffic accidents in Lebanon (313 deaths and 3586 injuries in 2326 car crashes for the year 2000)(11), it becomes important to investigate the correlation between trauma, alcohol and drug abuse in the country; especially as previous studies were mostly limited to psychiatric patients and University students (6,10,12).

    This prospective observational study was undertaken in order to investigate the prevalence of alcohol and illicit drugs in major trauma admissions to two Lebanese Hospitals located in the cities of Beirut and Byblos. Accordingly, trauma protocols can be modified in Lebanese hospitals to better manage these cases and introduce intervention procedures to minimize their impact on the population.

Subjects and Methods

     Subjects and Methods The project was reviewed and accepted by the Institutional Review Board of the American University of Beirut - Faculty of Medicine and Notre Dame Maritime Hospital in Byblos. Informed consents were obtained from patients before enrollment in the study. The selection criteria used in this study was that outlined in the triage decision scheme that is recommended by the American College of Surgeons (13). The inclusion criteria were:

     Glasgow Coma Scale <14, systolic blood pressure <90, respiratory rate <10 or >29, revised trauma score <11, all penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee, flail chest, combination trauma with burns, two or more proximal long-bone fractures, pelvic fractures, limb paralysis, amputation proximal to wrist and ankle, ejection from the automobile, death in the same passenger compartment, extrication time >20 minutes, falls >20 feet, rollover, high-speed auto crash, auto-pedestrian /auto-bicycle injury with significant (>5mph) impact, pedestrian thrown or run over, and motorcycle crash (>20mph) or with separation of rider from bike. All patients with preexisting clinical conditions were excluded so that their condition or treatment will not be the causative reason for the trauma. Subjects anonymity was maintained by the use of special numbers. This study was carried out from January 2000 to March 2001. During this period 2739 patients were admitted to the two hospitals. Only 80 patients met the inclusion criteria. Consents were provided for 63 patients. Two out of the 17 patients who did not consent had a traumatic brain injury and were intubated, four were in coma, six were missed due to unavailability of study staff, and the remaining five refused to consent. Samples were taken systematically from all patients who fit the time, space, and inclusion criteria defined for the study and not upon suspicion of abuse. Blood for alcohol, in simple tube, and urine for drugs of abuse screen, were obtained upon arrival of trauma patients in the Emergency Department of each institution.

     Alcohol was analyzed in serum by enzymatic method on Vitros 250 (Johnson & Johnson Clinical Diagnostics, Rochester, NY, U.S.A.). The method has a reportable range between 10 - 300 mg/dl. The precision was 4.1% and 4.0% at mean concentrations of 87.7 and 217.5 mg/dl, respectively. Triage Drugs of Abuse PANEL PLUS TCA (Biosite Diagnostics, San Diego, CA, U.S.A.) was used for the qualitative determination of the presence of the major metabolites of drugs of abuse in urine. The cut off levels of these screening tests were those recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA)(14). These cut-off concentrations are: 25 ng/ml for phencyclidine, 300 ng/ml for benzodiazepines (BZD), 300 ng/ml for cocaine (benzoylecgonine), 1000 ng/ml for amphetamines, 50 ng/ml for tetrahydrocannabinol (11-nor-(9-THC-9-carboxylic acid) (THC), 300 ng/ml for opiates (morphine), 300 ng/ml for barbiturates, and 1000 ng/ml for tricyclic antidepressants (TCA). The data collected included age, sex, day of the accident, time of the day, trauma mechanism, length of hospital stay, blood alcohol and urine toxicology results, and radiology results. A radiology result was considered positive when any bone fracture was evident by X-ray or an anatomic lesion due to the accident was detected by computed tomography (CT) scan.

Statistical Analysis

    Statistical Analysis Statistical analysis was performed using Stata version 6.0. Odds ratio and comparison of proportions were used to investigate the relationship between different categorical data (such as mechanism of trauma and toxicology results). The t-test was used to check differences between numerical data. Logistic regression was used to investigate the relationships between multiple categorical variables. A p-value of 0.05 or less was considered statistically significant.

Results

    Results As described under methods, the 63 patients enrolled in the study had to fit the trauma selection criteria set forth in the beginning of the study. Male predominance was evident with a sex ratio of 6:1 (54:9). The median age was 30 years (mean was 34 years) with a range of 16-75 years. When investigating the time of admission to emergency units, it was evident that admissions were distributed through out the 24 hour period; equally through all days of the week, with 22% between 4pm-8pm and 25% between 8pm-12pm. Average length of stay was 2.5 hours in the emergency unit and 3 days in the Hospital for those admitted. Four of the study patients died in the hospital. As for trauma mechanisms: car crashes were the cause in 47 patients (75%), falls from heights above 20 feet were the cause in 8 patients (13%), motor cycle crashes in 3 patients (5%), in addition to other minor causes (Table 1)

All 63 patients had a blood alcohol level measurement and 62 were screened for drug use. Positive results were obtained for 19 patients (30%). Sixteen patients (25%) were positive for alcohol and 13 (21%) were positive for drugs of abuse. Ten of these patients (16%) were positive for both simultaneously (Figure 1). Median alcohol result were 100 mg/dl (Figure 2).

 

Figure 2 :Box plot showing distribution of alcohol results

Toxicology screening was positive for THC, benzodiazepines, opiates, amphetamines, and TCA and the mechanism of trauma was car crash in 92% (12/13) of the cases (Table 2). All (8/8) THC positive and 60% (3/5) of benzodiazepine positive patients were also positive for alcohol and were all involved in car crashes (Table 2).

THC positive patients also had higher mean alcohol of 104 ±40 mg/dl versus 74 ± 27 mg/dl for drug negative patients (p=0.08, t-test). None of the THC positive patients had positive radiology results. However, 60% of benzodiazepine positive cases had positive radiology findings (p=0.01, comparison of two proportions), thus suggesting that benzodiazepines abuse results in more severe accidents than THC and alcohol abuse. In trying to identify possible risk factors for drug intoxication in trauma patients and to limit screening to a more targeted population, statistically significant risk factors determined from our data were: younger age, Saturday accidents, alcohol, and admission time between 12pm - 4am. Drug intoxicated patients had a mean age of 28.6 years versus 36.1 years for negative patients (p=0.039, t-test). Saturday accidents, alcohol, and admission time between 12pm - 4am were individually correlated to drugs of abuse (p<0.001, comparison of two proportions). The risk of drug abuse was independent of sex, radiology findings, length of stay in Emergency unit and Hospital, and mechanism of accident. When logistic multivariate regression analysis was performed on the four predictors of drug abuse among our trauma patients, alcohol was the only statistically significant predictor (p=0.013) (Table 3).

Although the frequency of admissions due to accidents increased in the period between 4pm and 12pm with a similar trend in the severity as indexed by positive radiology findings, the frequency of severity, however, was the highest after midnight (Figure 3). The percentage of drunk and/or drugged patients peaked between 12pm and 4am following a unimodal distribution, as reflected in Figure 3.
 

Discussion

     The aim of this study was to investigate the prevalence of alcohol and drugs of abuse in major trauma admissions, and to narrow the indication for drug screening to a more targeted population. We found a prevalence of 30% ± 10% of alcohol and/or drugs of abuse, which are comparable to reported rates of 30-45% in the United States (3). This high prevalence justifies screening major trauma admissions for alcohol and drugs. However, if screening were to be restricted to a more targeted population, it should be done for younger patients (below 30 years), who are admitted to the Emergency units on a Saturday, or after midnight, and particularly when positive for alcohol. In a multivariate analysis, alcohol was found to be the only predictor of drug abuse. Consequently, for cost containment, it would be possible to screen for drugs the alcohol- positive trauma patients (25% of trauma victims) (Figure1).

     For those with unknown alcoholemia, testing for alcohol should be performed first and then drug screening is suggested if the former is positive. This approach will identify 76% of drug users (Figure 1), if screening for all is not possible. In a previous study by Parran et al. (3), it was indicated that major trauma combined with laboratory evidence of intoxication at the time of admission is virtually synonymous with a diagnosis of chemical dependence. Therefore, toxicology testing on admission is ethically sound and is not significantly different from obtaining other routine laboratory tests for the clinical management of the patients. In addition, a positive blood alcohol concentration in injured patients after a road crash increases the chance that the final diagnosis will include more injuries than initially documented. Therefore, more careful monitoring is needed in alcohol-positive trauma patients independent of clinical status, injury severity, and overt symptoms of alcohol intoxication (15). It is also better for interventions to occur after an alcohol-positive motor vehicle crash while the patient is still hospitalized which provides a better opportunity to decrease drinking (16,17).

    In our study, 25% of those severely injured patients were positive for alcohol and fit the above mentioned literature. But, when we look at the most severe cases among our study group, subjects who were positive for benzodiazepines were associated with more severe accidents as determined by radiology findings, where as alcohol and THC positive patients were not. Published literature shows differing conclusions regarding these relationships. In France it was determined, in a case controlled study, that a casual role exists for opiates, alcohol, cannabinoids (and a combination of the last two compounds) in car crashes (18). Nevertheless, a similar Australian study revealed a significant relationship between alcohol, benzodiazepines and responsibility for the car crash, but this relation was not significant for cannabinoids and stimulants (19).

    Our data confirms the world wide differential prevalence of substance abuse in males when compared to females (4:1) (2). A ratio of 8-10:1 was reported for Lebanon in 1993 (12). Previous studies conducted after the war in the early 1990s revealed that heroin was the most widely abused drug in Lebanon. However, marijuana dominated in this study and this could be due to more stringent governmental policies against illicit drugs in recent years. Nowadays, the access to heroin is limited; however, hashish or marijuana is still accessible to the population. The growing of hashish is widely spread in some areas of the country, but the government is seriously exerting all efforts to destroy all the cultivated areas (20). The absolute association between THC and alcohol revealed in our study could be indicative of a social activity, especially as it is mostly occurring on Saturday nights. However, this observation requires further investigation. In conclusion, alcohol and drug abuse are highly prevalent, and measures to contain their use are needed. These can include immediate administration of alcohol breath test by traffic police, restriction of access to benzodiazepines, and combating of hashish. Screening for drugs of abuse is recommended for all trauma admissions, and particularly for those with evident alcohol abuse. Studies on a larger scale, covering all districts of the country, are recommended to better identify trends and help setup appropriate intervention procedures.

Acknowledgements: The authors would like to acknowledge Dr. Nizam Peerwani, Chief Medical Examiner, Tarrant County, Texas, for his support and review of the manuscript. The authors also would like to thank Colonel Charbel Mattar for his assistance in contacting patients and collection of data regarding the accidents.

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