Need for Brief Interventions for Marijuana and ... - Wiley Online Library

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Need for Brief Interventions for Marijuana and Alcohol Use Related to Injuries As Woolard et al. remind us, in this issue of Academic Emergency Medicine,1 few injured patients are routinely screened for alcohol and other drug problems. The finding of increased incidence of injury among problem drinkers who also use marijuana is compelling, and adds to the argument for interventions for substance use in the emergency department (ED), in order to prevent further injury events as well as health problems related to substance use. Marijuana use is widespread, and frequently associated with alcohol use. Woolard et al. found that nearly half, 48.5%, of problem drinkers reported using marijuana in the three months prior to the ED visit and that marijuana users had more hazardous drinking, higher Alcohol Use Disorders Identification Test (AUDIT) scores, and higher risktaking scores than injured patients who did not use marijuana. In addition, more marijuana users also used other illicit drugs. Of particular interest is the finding that readiness-to-change patterns of alcohol consumption were similar between marijuana users and non-users. This indicates that there is an opportunity for providing combined interventions to decrease both alcohol and marijuana consumption. The National Household Survey on Drug Abuse (NHSDA) provides further detail on the incidence of current alcohol and marijuana use. The data in this survey are obtained using a computer-assisted interview strategy of residents of households in all 50 states and the District of Columbia. The yearly survey is administered through the Substance Abuse and Mental Health Services Administration’s Office of Applied Studies.2 This survey provides an overview of current patterns, as well as trends in alcohol and other drug use across the United States. For example, the year 2000 survey found that approximately 47% of their sample of people aged 12 years and over had used alcohol within the month prior to the survey. Of these, 21% reported binge drinking, and 6% reported heavy drinking. The rates of alcohol use increased with age. Drinking and driving occurred most often in 22-year-olds (24%), and males were more likely than females to drink and drive (14% vs. 6%).3 With respect to marijuana use, the 2001 NHSDA estimates that 28,409,000 Americans had used marijuana or hashish in the year prior to the survey, with 15,910,000 reporting use within the prior

month. This translates to 12.6% and 7.1% of the population aged 12 and over. The highest rates of use were among 18-to-25-year-olds, with 31.9% using marijuana or hashish in the prior year, and 18.8% using one of these drugs within the past month.2 Data from the Drug Abuse Warning Network (DAWN), which are abstracted from ED and medical examiner records in 21 metropolitan areas, provide more detailed data about combined alcohol and marijuana use and marijuana use alone for drug-related ED visits. Reports of alcohol-only-related ED visits are not included in DAWN, and therefore it is not possible to determine the specific number of visits in this category. In addition, patients who come to the ED with problems that may not be directly alcohol-related, may not be included in the data, so that a patient who is in the ED for treatment of an injury that occurred in conjunction with alcohol and marijuana use may not appear in the data set.4 Despite this, the estimates provide valuable information about drug-related ED visits, and are useful in exploring potential opportunities for intervention. Drug-related ED episodes occurred at a rate of 252 per 100,000 population in 2002. These episodes increased by 6% from 2000 to 2001. Most mentions of drug use on ED visit records were in a small number of categories, with alcohol in combination with other drugs listed as a factor in 34% of drugrelated ED visits. Marijuana was mentioned in 17%. There was a 15% increase in marijuana mentions from 2000 to 2001. Descriptions of alcohol in combination with other drugs increased by 36% between 1994 and 2001, and this was the most frequent type of report. As with the NHSDA, DAWN describes higher rates of marijuana use in the young adult population (18–25) than in other adult age groups. Alcohol use in combination with other drugs was mentioned less often in this age group than in the 26–34 age group.4 Estimates of reason for ED contact indicate that 2.9% of the visits in the DAWN data set were due to injuries.4 While this appears to be a relatively low proportion of ED visits, it is important to remember that the data in DAWN are only as good as the medical records that they are abstracted from. In other words, if the ED staff did not doc-

ACAD EMERG MED • January 2003, Vol. 10, No. 1 • www.aemj.org

ument alcohol and/or other drug use in the record, the case would not appear in DAWN. Therefore, we can assume that the DAWN estimates are underestimates of the extent of the problem. National data provide a solid foundation for the work that has been done by Woolard and colleagues, in that the trends of increasing marijuana use, and the high incidence of alcohol use in combination with other drugs, argue for the need for ED-based interventions. Woolard et al.’s findings are supported further by work done by Levy et al., in a cohort of orthopaedic trauma patients who were admitted to the orthopaedic service for the treatment of injury.5 Laboratory tests were used to determine the drugs that were used, and confirmed alcohol use in 25% of cases, cocaine in 22%, and marijuana in 21%. In addition, drugs were more commonly used by males, especially those between the ages of 21 and 30 years. It is likely that this is an underestimate of the true frequency of recent use of alcohol and other drugs, as the use of a laboratory test provides only a snapshot of use in proximity to an injury event. Still, the relatively high rate of use in this population of patients with fractures and other orthopaedic injuries again provides evidence for the need for intervention in injured patients. Braun et al. found an association between marijuana use and specific injury events, including motor vehicle crashes and cutting and piercing injuries, as well as falls.6 They also found an association between marijuana use and alcohol use, in that daily drinking was associated with current marijuana use. Other studies, most notably that by Soderstrom et al., have examined marijuana use among patients admitted to the trauma service.7 However, the epidemiology of marijuana use has changed since the time of many of these studies, and there is a need to address the issue as it relates to current patterns of use. Woolard and colleagues suggest that counseling for both alcohol and marijuana use be part of the ED intervention for injured patients who use both alcohol and marijuana. Given the data presented, it is hard to argue against this. The authors present background evidence that brief interventions work in decreasing marijuana consumption, and also demonstrate that patients who use marijuana are amenable to changing consumption patterns. It only makes sense to combine the brief intervention or counseling for alcohol and marijuana use where appropriate. Other strategies that may be used to change the nature of this problem in the ED are broad policy changes that lead to implementation of screening and brief intervention for alcohol and other drug

63 problems. The Connecticut State Legislature was the first in the country to do something along this line. On October 1, 1998, Connecticut Public Act 98201 took effect.8 This law requires that any patient treated for an acute injury be screened for alcohol and other drug problems. In the initial development of this legislation, the task force working on the law recommended that it require screening for any patient who sought injury treatment in an acute care hospital. This was based on both national and state data that demonstrated the prevalence of alcohol and other drug problems in injured patients. For example, a study that took place in the ED of Yale New Haven Hospital found that of patients who came to the ED for treatment of minor injuries, approximately 22% either tested positive for recent alcohol use, screened positive on the CAGE,9 or both.10 Other evidence was documented in the trauma literature.11–15 The Connecticut Law Revision Commission had made the original recommendation for this law in its report on alcohol and other drug legislation in the State of Connecticut.16 The law was developed, was brought to the legislature, underwent public hearings, and was signed by the governor in the first legislative session in which it was introduced. Once it had been enacted, the state’s emergency physicians requested a technical amendment to clarify that the screening requirement did not apply to all patients who presented to the ED for the treatment of injury, but only to those who required evaluation by the trauma team. In the subsequent legislative session, there was a technical revision at the request of emergency physicians who did not want the law to apply to all injured patients presenting to the ED, and requested that it be changed to include only admitted patients and patients requiring activation of the trauma team. The revised statute requires alcohol and other drug screening for all patients of sufficient age who require the activation of a trauma team, who are admitted to an acute care hospital for treatment of injury, or who are transferred from one acute care hospital to another for the treatment of injury. Based on a preliminary review of data from key informant interviews, we have found that some hospitals have implemented broad screening using standardized instruments such as the CAGE, and are using this screening as a basis for referral for further intervention. We are currently reviewing hospital and ED discharge data for Connecticut in order to determine whether there have been more cases of alcohol and other drug problems identified in injured patients since the implementation of the law. In summary, Woolard and his colleagues provide

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data that have significant implications for practice, education, and future research in this area. In combination with evidence from other studies and national surveys, it is clear that the problem of alcohol use, as well as alcohol use combined with marijuana use, is a major problem in injured patients. Much evidence is available to support the implementation and use of brief interventions, and recommendations have been made for the use of brief interventions in the ED.17–19 Despite this, in practice, emergency medicine has only begun to scratch the surface on the topic of brief interventions. Educating emergency physicians in these strategies is effective in changing practice, as demonstrated by D’Onofrio et al.20 While emergency physicians counsel patients who have other chronic diseases or health risks, alcohol and other drug use is often ignored, despite the fact that we know that it makes a significant contribution to the range of health problems that are seen in the ED. The identification of potential or existing problems with alcohol and marijuana provides an opportunity to intervene in order to prevent further health and social problems related to their use— Linda C. Degutis, DrPH (linda. [email protected]), Section of Emergency Medicine, Yale University, New Haven, CT

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Woolard R, Nirenberg TD, Becker B, et al. Marijuana use and prior injury among injured problem drinkers. Acad Emerg Med. 2003; 10:43–51. Substance Abuse and Mental Health Services Administration. 2001 National Household Survey on Drug Abuse. Website: http://www.samhsa.gov/oas/nhsda/ 2k1nhsda/vol1/chapter1.htm#1.1. Accessed September 2002. Substance Abuse and Mental Health Services Administration. 2000 National Household Survey on Drug Abuse. Website: http://www.samsha.gov/oas/2k2/alcNS.htm. Accessed September 2002. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Emergency Department Trends from the Drug Abuse Warning Network, Preliminary Estimates January–June 2001 with Revised Estimates 1994–2000. Website: http://www.samhsa.gov/

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oas/dawn/TrndED/2001/Text/TrndEDtxt.PDF. Accessed September 2002. Levy RS, Herbert CK, Munn BG, Barrack RL. Drug and alcohol use in orthopedic trauma patients: a prospective study. J Orthop Trauma Surg. 1996; 10(3):21–7. Braun BJ, Tekawa IS, Gerberich SG, Sidney S. Marijuana use and medically attended injury events. Ann Emerg Med. 1998; 32:353–60. Soderstrom CA, Trifillis AL, Shankar BS, Clark WE, Cowley RA. Marijuana and alcohol use among 1023 trauma patients: a prospective study. Arch Surg. 1988; 123:733–7. Connecticut General Statutes, P.A. 98-201. An Act Concerning Substance Abuse Emergency Room Screening and Training and Education for Health Care Professionals. 1998. Ewing J. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984; 252:1905–7. Degutis LC. Screening for alcohol problems in emergency department patients with minor injury: results and recommendations for practice and policy. Contemp Drug Probl 1998; 25:463–75. el-Guebaly N, Armstrong SJ, Hodgins DC. Substance abuse and the emergency room: programmatic implications. J Addict Dis. 1998; 17(2):21–40. Cherpitel CJ. Alcohol and injuries: a review of international emergency room studies. Addiction. 1993; 88:923– 37. Cherpitel CJ. Drinking patterns and problems associated with injury status in emergency room admissions. Alcohol Clin Exp Res. 1988; 12:105–10. Grisso JA, Schwarz DF, Hirschinger N, et al. Violent injuries among women in an urban area. N Engl J Med. 1999; 341:1899–905. Rivara FP, Koepsell TD, Jurkovish GJ, Gregory J, Gurney JG, Soderberg R. The effects of alcohol abuse on readmission for trauma. JAMA. 1993; 270: 1962–4. Connecticut Law Revision Commission. The Drug Policy Reports: Part I Drug policy in Connecticut and Strategy Options; Part II Drug Policy in Connecticut. 1997. D’Onofrio G, Degutis LC. Screening and brief intervention for alcohol problems in the emergency department. Acad Emerg Med. 2002; 9:627–38. D’Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 1: improving detection. Acad Emerg Med. 1998; 5:1200–9. D’Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 2: intervention and referral. Acad Emerg Med. 1998; 5: 1210–7. D’Onofrio G, Nadel ES, Degutis LC, et al. Improving emergency medicine residents’ approach to patients with alcohol problems: a controlled educational trial. Ann Emerg Med. 2002; 40:50–62.