Traumatology

Penetrating trauma: Relationships to recreational drug and alcohol use

a b s t r a c t

Introduction: The incidence of alcohol and recreational drug use is increasing. The impact on penetrating trauma is unknown. This study was undertaken to identify the incidence of alcohol and recreational drug use prior to penetrating trauma, and to identify ISS and outcomes among patients with penetrating trauma.

Methods: In this retrospective study, eligible subjects included trauma patients age 18 and older, with major trauma (admitted or evaluated by the Trauma Team) from 2017 to 2021. A chart review was conducted to iden- tify data including mechanism of injury, ISS, alcohol level, toxicologic testing, length of stay, and final disposition. Results: Among 1270 adult subjects with penetrating trauma during 2017 through 2020, the majority were male (N = 1071; 84%), and African American (N = 679; 54.3%) or White (N = 537; 42.9%). Mechanisms of injury in- cluded gunshot wound (GSW) (N = 973; 76.6%) or Stab wound (N = 297; 23.4%). Injury severity score (ISS) ranged from 1 to 75. Among 426 subjects (33.5%) tested for recreational drugs, 395 (93%) were positive for at least one substance. The most common recreational drugs identified included marijuana (N = 280; 65.7%), ben- zodiazepine ((N = 131;30.8%), alcohol ((N = 248; 25.3%), opiate ((N = 116; 27.2%), cocaine (N = 87; 20.4%), and amphetamine ((N = 84; 19.7%). Subjects with an ISS of 9 to 15 had higher odds of testing positive for opiates compared to subjects with an ISS of 1 to 3 (OR 2.3). Most patients were ultimately discharged home ((N = 912;71.8%) and a minority expired (N = 142; 11.2%).

Conclusions: Positive screens for alcohol and recreational drugs were common among penetrating trauma pa- tients in this setting. The most common identified recreational drugs included marijuana, benzodiazepine, opi- ates, alcohol, cocaine, and amphetamine.

(C) 2021

  1. Introduction

Trauma is one of the leading causes of death in the United States, ac- counting for over 700,000 hospitalizations in 2018 [1,2]. Trauma can re- sult from a wide variety of Motor vehicle collisions, machinery accidents, falls, natural disasters, and many other physical injuries that can occur anywhere in the home, work, or outdoors [3]. Penetrating trauma is often related to violence, especially in regions with increased illicit drug activity such as inner cities [4].

The incidence and impact of drug and alcohol use among trauma pa- tients has been reported in various studies [5-11]. A recent study by McGraw et al. estimated that 39% of patients admitted to level I trauma centers in 2020 were alcohol positive (blood alcohol concentration

>=10 mg/dL), and the rate of drug positive patients was estimated to be

* Corresponding author at: Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, 2555 University Blvd, Dayton, OH, United States of America.

E-mail address: [email protected] (C.A. Marco).

52% [12]. An elevated blood alcohol level (BAL) is associated with vari- ous mechanisms of injury such as falls, cycling accidents, motor vehicle crashes, head trauma, and assaults [13]. Previous research has shown that the risk of severe or fatal injuries increases in a dose-dependent fashion, increasing over twenty-fold (OR = 20.2) when an individual’s BAL is greater than 0.08 g/dL [14]. a 2004 study determined that there is a high rate of alcohol and illicit drug use in men who die from pene- trating trauma [15].

In many cases, differences exist between drug intoxication type and mechanism of injury [16]. For example, a 5-year study in California showed that patients using methamphetamine are more likely to be in- jured in a blunt force manner, such as a motor vehicle collision , while cocaine users are more likely to be involved in violent injuries such as assaults, gunshots, and stabbings [17]. Other work has showed similar findings regarding methamphetamine and blunt force trauma [18]. It is important to note though that some studies have found a strong association between stimulants (cocaine, but also methamphet- amine) and violent injuries and penetrating trauma with odds rations of

https://doi.org/10.1016/j.ajem.2021.11.035

0735-6757/(C) 2021

2.9 and 3.3, respectively, as opposed to blunt trauma [19]. This area of study continues to evolve as new testing and new recreational drugs are synthetically created and available. More work needs to be done to attempt to ascertain the incidence of PEnetrating trauma patients who are positive for alcohol as well as various categories of recreational drugs prior to the occurrence of their trauma.

This study was undertaken to identify the incidence of alcohol and recreational drug use among patients with penetrating trauma. A sec- ondary objective was to identify ISS outcomes among patients with penetrating trauma.

  1. Methods

This is a retrospective data study conducted at Miami Valley Hospi- tal, a Level 1 Trauma Center in Dayton, Ohio. The study was approved by the Wright State University Institutional Review Board. Eligible sub- jects included adult subjects (age >= 18) with penetrating trauma during 2017 through 2020. Data were collected from our institution’s Trauma Registry. Data were extracted using a query of the Trauma Registry for 2017 through 2020. Data collected included: age, gender, race, ISS, cause of trauma, final disposition, results of urine toxicologic screen and blood alcohol levels, including the presence of amphetamine, co- caine, opiate, benzodiazepine, barbiturates, marijuana, and alcohol.

    1. Data analysis

Data are presented as frequency counts and percentages, or medians and interquartile ranges [25th percentile, 75th percentile]. Univariate associations between a positive Drug test and subjeCT characteristics and outcomes were explored using Chi-square tests for categorical fac- tors and Mann Whitney Wilcoxon tests for continuous factors. Univari- ate logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals. The odds ratio is the increase in odds of testing positive for each category of the factor compared to the reference cate- gory. For continuous factors, the OR is the increase in the odds of testing positive per 1 unit increase in the factor. CIs that do not encompass the value 1 are considered significant. Data were analyzed with SAS v9.4.

  1. Results

Among 1270 adult subjects with penetrating trauma during 2017 through 2020, the majority were male (N = 1071; 84%), and African American (N = 679;54.3%) or White (N = 537;42.9%) (Table 1). Mecha- nisms of injury included gunshot wound (GSW) (N = 973; 76.6%) or stab wound (N = 297; 23.4%). Injury severity score (ISS) ranged from 1 to 75. Among 426 subjects (33.5%) tested for recreational drugs, 92.7% tested positive for at least one drug. The most common recreational drugs identified included marijuana (N = 280;65.7%), benzodiazepine ((N = 131;30.8%), alcohol ((N = 248;25.3%), opiate ((N = 116;27.2%), cocaine (N = 87;20.4%), and amphetamine ((N = 84;19.7%) (Fig. 1). Most pa- tients were ultimately discharged home ((N = 912;71.8%) and a minority expired (N = 142;11.2%).

Drug screen data were available for 426 of the 1270 subjects (33.5% of the sample). ETOH data was available for 981 subjects (77.2% of the sample). Availability of data from a drug screen data was associated (p < 0.001) with higher ISS, longer LOS, and higher disposition to “other” (Table 1).

The odds of testing positive for drugs was 4.8 (95% CI: 1.4, 17.1) times greater for subjects with an ISS of 16 or more compared to sub- jects with an ISS of 1-3. However, the odds of testing positive for drugs decreased with age (OR 0.97 per 1 year increase in age, CI: 0.94, 0.99). All of the 23 deaths had a positive drug test. Sex, race, and length of stay were not associated with positive drug tests (Table 2).

Univariate analysis tested associations between positive drug tests and subject characteristics and outcomes. African American subjects were less likely to test positive for amphetamine compared to White subjects (OR: 0.1). The median age was significantly higher in subjects who tested positive for amphetamine (34 years) compared to the me- dian age of subjects who tested negative (29 years). (Supplement: Table 3).

African American subjects were less likely to test positive for cocaine compared to White subjects (OR: 0.5). The median age was significantly higher in subjects who tested positive for cocaine (34 years) compared to the median age of subjects who tested negative for cocaine (29 years, OR 1.03 is the increase in odds per 1 year increase in age). (Supplement: Table 4).

Table 1

Characteristics of subjects overall and stratified by drug testing

All subjects

Subjects without a drug test

Subjects with a drug test

P-value

No. subjects

Age, median years [IQR]

1270

No. with data 1268

31 [24, 41]

844

31 [24, 42]

426

30 [25, 40]

0.45

ISS, median score [IQR]

1269

5 [1, 14]

5 [1,13]

9 [1, 14]

<0.001

LOS, median days [IQR]

1262

1 [1, 4]

1 [0,3]

2 [1, 6]

<0.001

Sex, n (%)

Female

1269

198 (15.6)

127 (15.1)

71 (16.7)

0.46

Male

Race, n (%)

1251

1071 (84.4)

716 (84.9)

355 (83.3)

Overall p = 0.38

White

537 (42.9)

345 (41.6)

192 (45.6)

(ref)

African American

679 (54.3)

462 (55.7)

217 (51.5)

0.16

Other

ISS groups, n (%)

1-3

1269

35 (2.8)

480 (37.8)

23 (2.8)

361 (42.8)

12 (2.9)

119 (27.9)

0.86

Overall p < 0.001 (ref)

4-8

197 (15.5)

126 (15.0)

71 (16.7)

0.003

9-15

294 (23.2)

161 (19.1)

133 (31.2)

<0.001

16 or more

298 (23.5)

195 (23.1)

103 (24.2)

0.004

Mechanism, n (%)

Gunshot

1270

973 (76.6)

654 (77.5)

319 (74.9)

0.30

Stab

Final disposition, n (%)

1270

297 (23.4)

190 (22.5)

107 (25.1)

Overall p < 0.001

Home or home with professional services

912 (71.8)

617 (73.1)

295 (69.3)

(ref)

Coroner

142 (11.2)

119 (14.1)

23 (5.4)

<0.001

Other

216 (17.0)

108 (12.8)

108 (25.4)

<0.001

Data are presented as median [IQR interquartile range 25th, 75th percentile] or frequency count (% of all subjects in the column). P-value compares subjects without a drug test to subjects with a drug test using Mann Whitney Wilcoxon or Chi-square test.

barbiturates amphetamine

cocaine

ETOH >= 80

opiate benzodiazepine

marijuana

1.6

19.7

20.4

25.3

27.2

30.8

0 10 20 30 40 50 60

65.7

70

% of subjects with positive test

Fig. 1. Prevalence of positive drug test(s) or ETOH >=80.

Subjects with an ISS of 9 to 15 had higher odds of testing positive for opiates compared to subjects with an ISS of 1 to 3 (OR 2.3). Subjects who died or were discharged to a ‘other’ location were less likely to test pos- itive for opiates compared to subjects who were discharged home (OR 0.2 and 0.5, respectively). (Supplement: Table 5)

African American subjects were less likely to test positive for benzo- diazepine compared to White subjects (OR 0.5). Subjects with an ISS of 9 to 15, and 16 or greater, were more likely to test positive for benzodi- azepine compared to subjects with an ISS of 1 to 3 (OR 2.5 and 6.2, re- spectively). Subjects who were discharged to a ‘other’ location were more likely to have tested positive for benzodiazepine compared to sub- jects who were discharged home (OR 1.6). Subjects who tested positive for benzodiazepine had longer LOS (OR 1.12 is the increase in odds per 1 day increase in LOS) (Supplement: Table 6).

African American subjects had higher odds of testing positive for marijuana compared to White subjects (OR 3.0). Subjects who tested positive for marijuana where younger than subjects who tested nega- tive (OR 0.93). (Supplement: Table 7).

Nine hundred and seventy-one subjects had ETOH data. Of these, 25.5% had ETOH values of 80 or more. The odds of having a positive ETOH test were 1.6 (CI: 1.2, 2.1) times greater for African Americans compared to White subjects. The odds of a positive ETOH increased with age (OR 1.01 per 1 year increase in age, CI: 1.00, 1.02). Sex, ISS,

disposition, and LOS were not associated with positive ETOH. (Supple- ment: Table 8).

  1. Discussion

The relationship between drug and alcohol use with trauma is im- portant to understand the prevalence and impact on treatment and out- comes. In our sample of trauma patients, 33.5% who were tested had positive drug screens with the most detected drugs being marijuana, benzodiazepines, and opiates.

Prognosis may be determined using the Injury Severity Score (ISS), an internationally recognized anatomical scoring system [20]. However, results of ISS as it relates to Pre-injury use of various substances varies in literature. Studies by Hsieh et al. (2013) and McKee et al. (2016) showed that trauma patients with alcohol in their system were more likely to have increased ISS [21,22]. Valdez et al. found that certain mechanisms of injury, such as bicycle collisions, concussions, and soft tissue injuries, had higher ISS with higher blood alcohol levels com- pared to others [23]. Conversely, studies performed by Fuller (1995) and Lee et al. (2020) found that there was no significant difference in ISS between trauma patients with or without alcohol intoxication [24,25]. A study by Oliveira et al. (2019) demonstrated that the use of cocaine is associated with higher ISS values, while Fujii and McCague (2019) showed that ISS was not significantly different for cocaine posi- tive patients [26,27]. Some studies have demonstrated a greater likeli- hood of higher ISS values for trauma patients with marijuana or amphetamine in their system, and others have found that no differences in ISS exist between those having positive or negative toxicology screens for marijuana, opiates, amphetamines, benzodiazepines, or co- caine [25,28]. Our results are consistent with those of a previous study by Cordovilla-Guardia et al., which found a relationship between de- pressants and higher ISS specifically only in instances when the depres- sants were present in combination with alcohol [29].

geographic location affects the prevalence of illicit drugs [30]. For example, the two most prevalent substances in trauma patients in Jo- hannesburg were alcohol and marijuana [31]. In a trauma setting in an ED in Brazil, cannabis, benzodiazepines and cocaine were the most fre- quently used substances [32] while among trauma patients in Australia, meth/amphetamines were the most common substance [33]. In rural midwestern environments, particularly the central plains, there is

Table 2

Factors associated with positive drug tests or alcohol

UDS+

UDS-

Odds ratio for UDS+ (CI)

ETOH+

ETOH-

Odds ratio for ETOH+ (CI)

No. subjects

395

31

248

733

Sex – n (%) Female

66 (93.0)

5 (7.0)

Ref

31 (20.5)

120 (79.5)

Ref

Male

329 (92.7)

26 (7.3)

1.0 (0.4, 2.6)

217 (26.2)

612 (73.8)

1.4 (0.9, 2.1)

Race – n (%)

White

177 (92.2)

15 (7.8)

Ref

89 (21.1)

332 (78.9)

Ref

African American

204 (94.0)

13 (6.0)

1.3 (0.6, 2.9)

155 (29.9)

364 (70.1)

1.6 (1.2, 2.1)

Other

9 (75.0)

3 (25.0)

0.3 (0.1, 1.0)

3 (11.5)

23 (88.5)

0.5 (0.1, 1.7)

ISS – n (%) 1-3

104 (87.4)

15 (12.6)

Ref

86 (25.5)

251 (74.5)

Ref

4-8

67 (94.4)

4 (5.6)

2.4 (0.8, 7.6)

40 (25.3)

118 (74.7)

1.0 (0.6, 1.5)

9-15

124 (93.2)

9 (6.8)

2.0 (0.8, 4.7)

61 (24.0)

193 (76.0)

0.9 (0.6, 1.3)

16 or more

100 (97.1)

3 (2.9)

4.8 (1.4,17.1)

61 (26.3)

171 (73.7)

1.0 (0.7, 1.5)

Disposition – n (%) Home

270 (91.5)

25 (8.5)

Ref

191 (26.8)

521 (73.2)

Ref

Coroner

23 (100)

0 (0)

Not calculable

17 (22.7)

58 (77.3)

0.8 (0.5, 1.4)

Other

102 (94.4)

6 (5.6)

1.6 (0.6, 3.9)

40 (20.6)

154 (79.4)

0.7 (0.5, 1.0)

Age – median years [IQR]

29 [24,38]

38 [30,49]

0.97 (0.94, 0.99)

33 [26,44]

30 [24,40]

1.01 (1.00, 1.02)

LOS – median days [IQR]

3 [1, 6]

2 [1, 5]

1.05 (0.97, 1.14)

2 [1, 5]

2 [1, 5]

1.00 (0.98, 1.02)

UDS+ means the subject tested positive for one or more of the following drugs: amphetamine, cocaine, opiate, benzodiazepine, barbiturate, marijuana. UDS- means the subject tested negative for all of these drugs.

ETOH+ is ETOH >=80; ETOH- is ETOH <80.

increased heroin and methamphetamine use, when compared to other regions throughout the US. Additionally, in urban settings, there is eas- ier access to drugs through interpersonal connections and increased supply [34].

There is a concerning relationship between violence and substance abuse. In a level one trauma setting in California in 2004 penetrating trauma was more likely to be associated with drug and alcohol use than blunt trauma and 42.7% of Trauma deaths had a positive drug screen [35]. Madan et al. showed that gunshot wounds in adolescents are independently associated with positive drug screens and that 72% of gunshot wound victims had some evidence of substance abuse [36]. Another study found that among homicide victims in 9 states, alcohol (37.5%) and marijuana (31.0%) were frequently identified [37]. Fujii et al. found that higher rates of major trauma and longer hospital stays were associated with positive amphetamines and marijuana screens [38]. The results of this retrospective study revealed higher use of marijuana and ETOH use among African American participants when compared to Non-Hispanic Whites. To investigate whether this finding is statistically significant or coincidental, additional research was done on this topic. Current research shows that overall substance use (including the substances covered in this paper) has increased in the United States across all ethnic and racial groups, especially in groups of low socioeconomic status [39]. In fact, households with a total house- hold income of less than $20,000 per year have a greater perceived risk of regular cannabis use than households with an income of greater than

$75,000 per year [40]. Additionally, regarding regular cannabis use, a significant narrowing of the gender gap has been reported. Women are now using cannabis more often than in previous years when men have been the primary consumers; this finding points to stronger social and environmental influences [41]. While these factors support the no- table increases in substance use, race was not easily defined. In one study, researchers found a perceived increase in risk of cannabis use among non-white races and ethnicities [42], but no other data supporting the findings of this current paper were noted. Because of the inconclusive literature, it is difficult to definitively say that race plays a role in the use of marijuana and ETOH.

    1. Limitations

As a retrospective chart review, results are dependent on data avail- ability and accuracy. Missing toxicology screen data may introduce a bias in the results. Despite the missing data, the results are compelling and should be considered when treating patients with penetrating trauma. These results from a single institution may not be generalizable to other settings.

  1. Conclusions

Positive screens for alcohol and recreational drugs were common among penetrating trauma patients in this setting. The most common identified recreational drugs included marijuana, benzodiazepine, opi- ates, alcohol, cocaine, and amphetamine.

Declaration of Competing Interest

The authors have no conflicts of interest to disclose.

Acknowledgements

The authors wish to thank Nancy Buderer, MS, for her assistance with statistical analysis.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.11.035.

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