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By Diane Sussman
April 24, 2000
Photo: Eyewire

Americans spend about $3 billion a year treating alcohol-related injuries, an amount that could be substantially reduced with $46 worth of intervention.

"Our studies show that 30 minutes of alcohol screening in the emergency room with a trained psychologist had a 47 percent reduction in injuries over the next year," said Larry Gentillelo, MD, assistant professor of surgery at the University of Washington in Seattle.

The study, published in the October 1999 issue of Annals of Surgery, is right in line with others showing that such brief interventions get problem drinkers to cut back. "There is a good bit of research on the value of brief intervention or screenings in the healthcare setting," said Ann Bradley, spokeswoman for the National Institute of Alcoholism and Alcohol Abuse. NIAAA research shows that 10 to 30 percent of early alcoholics reduce their drinking after a serious session with a health professional.

Half of trauma patients

Trauma center personnel are all too familiar with the link between alcohol and accidents, which run the gamut from drunken teen-age drivers to tippling retirees who lose control of their power tools. Indeed, being drunk is the single biggest indicator for trauma, and half of all trauma patients are under the influence of alcohol. Furthermore, such incidents are not generally one-time-only, post-party events. When patients are screened for alcoholism, as many as 44 percent test positive.

"The data seems to show that the more severely injured they are, the more likely they are to have an alcohol-use problem," said Carl Soderstrom, MD, professor of surgery at the University of Maryland in Baltimore.

Given the high number of inebriated patients, trauma centers would seem to be the ideal place to intervene, offering a rare moment when patients are starkly aware of the consequences of their drinking and in a better frame of mind to listen. "It seems like the opportune time for intervention," Soderstrom said. "It’s when we’re bleeding and in pain that we’re most likely to want to change, not a week or two later when we’re starting to forget."

But the reality is that trauma patients are not being screened routinely for alcohol use—far from it. Only 62 percent of hospitals routinely test for alcoholism and only one state, Connecticut, requires it.

A two-year study at the Mayo Clinic found that among 298 car crash patients whose blood-alcohol level exceeded the legal limit, only 78 had further examinations for signs of alcohol dependency or abuse. Of these, 69 showed evidence of alcoholism.

Payment fears

The accumulating evidence is prompting healthcare officials and workers to call for routine screening of trauma and emergency room patients. "Any screening for alcohol is a good idea, even if it’s just a 15-minute CAGE test," said Janet Lassman, RN, volunteer coordinator for EN CARE, the injury prevention arm of the Emergency Nurses Association. "It’s something nurses should be doing, even for patients who don’t need it. Having the conversation never hurts."

Despite evidence of the value of screening, most trauma and ER staff aren’t taking that step because they fear reprisals from insurance companies. According to a survey in the January issue of Journal of Trauma, 38 states have insurance laws that prohibit payment for injuries sustained in cases of alcohol impairment.

"Unfortunately, concerns about the implications of screening for alcohol abuse appear to be based on the firm legal reality that exists in most states," said Frederick Rivera, MD, director of the Harborview Injury Prevention and Research Center in Seattle and principal investigator in the study. "In these states, an insurance carrier can deny a claim for coverage of injures sustained under the influence of alcohol just as the carrier can deny coverage for self-inflicted wounds after a suicide attempt."

But just because an insurance carrier has the legal right to deny coverage doesn’t mean that is the practice, said Laura Diamond, spokeswoman for the American Association of Health Plans, a professional organization for HMOs. "Our lawyers said they don’t know of any of these instances and that we would just pay it," she said.

But, as Lassman observes, "it’s not just about insurance payments.

"It’s more than that," she said. "There are ethics involved and concerns about confidentiality. And we’re not the police."

Underlying cause

Soderstrom added, "When you ask most trauma doctors why they don’t screen, many say they have insurance concerns, but most say they don’t test because it doesn’t lend a lot to the treatment.

"And they have a point. But that doesn’t mean it’s not a good idea to test." At the same time, he said that ignoring problematic drinking or early alcoholism in car crash patients is akin to "stitching up a patient whose blood pressure is 200/100 and not treating him for hypertension."

Gentillelo said, "To treat people for their injuries and send them out the door without treating the underlying disease of alcoholism is completely backward. With any disease, you look for the underlying cause.

"If the leading factor in injury is alcohol, you treat it."