Drugs and trauma center patients: What do we know about involvement of prescription drugs

1. Drugs and trauma center patients: What do we know about involvement of prescription drugs? Gordon Smith M.D., M.P.H. Patricia Dischinger, Ph.D. National Study Center for Trauma & EMS Shock Trauma Center, University of Maryland, Baltimore Exploring the Science and Experience of Testing for Prescription Drugs in the Non-Regulated Workplace Drug Testing Advisory Board (DTAB) August 19� 2008

2. Drugs and injured patientsWhat do we know? Alcohol Much known Shock Trauma a leader in this area Long history research on trauma patients Screening tests leading to brief interventions Case-control studies Dose response relationship with injury risk Illicit and prescription drugs Much less known Some prevalence information but less complete

5. Percentage of Trauma Patients with Unintentional Injuries and Positive Tests for Alcohol & Other Drug Use

6. This training today will be approximately 2 hours and is to provide Post supervisors with information about The company�s Drug and Alcohol Testing Policy. Let me start by telling you a little about The Walsh Group and our experience: Dr. Walsh and I have been involved in drug/alcohol testing and drug free workplace programs for over 23 years each. I am a retired Navy Captain who headed up the U.S. Navy�s program for more than 10 years (1980-1990) when drug testing was cutting its teeth. These programs have stood the test of time and have withstood many challenges including to the Supreme Court� �Nimitz incident�� Judy Slaughter comes from the Maryland Center For Workplace Health and Safety and worked for about six years as the Program Manager for MD Drug Free Workplace Initiative under the Governor�s Drug and Alcohol Abuse Program. Let me emphasize several points about drug and alcohol testing in general� 1. The system is designed to err to the favor of the individual. If there is any doubt in a test result, the system will �throw it out�. 2. The system is a deterrence system and not a detection system. That is to say, that The Post is out to retain it�s workers and use testing to deter them from using drugs/alcohol and reporting to work under the influence of these substances. 3. The Post policy is a �help� or �hammer� policy. It establishes a precedent that offers help (either through a 60 day amnesty period or prior to detection) if an employee seeks help. However, those who do not and challenge the system stand the chance of being detected and terminated from employment.This training today will be approximately 2 hours and is to provide Post supervisors with information about The company�s Drug and Alcohol Testing Policy. Let me start by telling you a little about The Walsh Group and our experience: Dr. Walsh and I have been involved in drug/alcohol testing and drug free workplace programs for over 23 years each. I am a retired Navy Captain who headed up the U.S. Navy�s program for more than 10 years (1980-1990) when drug testing was cutting its teeth. These programs have stood the test of time and have withstood many challenges including to the Supreme Court� �Nimitz incident�� Judy Slaughter comes from the Maryland Center For Workplace Health and Safety and worked for about six years as the Program Manager for MD Drug Free Workplace Initiative under the Governor�s Drug and Alcohol Abuse Program. Let me emphasize several points about drug and alcohol testing in general� 1. The system is designed to err to the favor of the individual. If there is any doubt in a test result, the system will �throw it out�. 2. The system is a deterrence system and not a detection system. That is to say, that The Post is out to retain it�s workers and use testing to deter them from using drugs/alcohol and reporting to work under the influence of these substances. 3. The Post policy is a �help� or �hammer� policy. It establishes a precedent that offers help (either through a 60 day amnesty period or prior to detection) if an employee seeks help. However, those who do not and challenge the system stand the chance of being detected and terminated from employment.

7. Methods Admissions to Shock/Trauma UM � Baltimore Admissions from all over state of MD Only trauma patients Aliquot taken from clinical specimens Point of Collection Test [POCT] THC, Coc, Mamp /MDMA, Opi, BDP Analyzed urine for drugs Blood for Etoh Funding Office of National Drug Control Policy (ONDCP)

8. Drug and Alcohol Use in Injured Drivers 

9. Marijuana Use by Age Group

10. Crash Culpability Among Injured Drivers Using Alcohol, Marijuana or Cocaine Estimate injury risk from drug use To determine culpability (fault), police officers consider all possible evidence and information Driver information Witness information Vehicle condition Environmental conditions, etc. Testing results for alcohol, cocaine and marijuana from confidential Clinical Toxicology Database of trauma patients Determined alcohol use by blood alcohol concentration (BAC, 20 mg/dl or higher) Determined cocaine (COC) or marijuana (MAR) use from urine specimen (+ or -) Did not assess opiate use due to clinical practice of giving opiates for pain management

11. Linkage of multiple data sources

13. Odds of Culpability by Gender andSubstance Use Odds of being culpable for BAC + were significantly high among both genders And 40% higher for women than men

14. Limitations of Current Research Even among the hospitalized population, drug use rates are low, requiring large numbers of cases for analysis For some subgroups (i.e. elderly, etc), the number of positive cases is very small Toxicology samples drawn for the treatment of the patient, not for legal reasons Over 90% of patients are tested for BAC Rate of testing for other drugs is close to 50% Urine used for most drug testing Does not accurately reflect serum levels at time of injury Presence does not mean increased risk

15. -Most based on presence of drugs only - Need to quantify serum levels that impair performance No agreement on concentrations considered impairment -Difficult to estimate risk Case-control vs. culpability -High rate prescription drug use population 18+ years ? 50% take at least 1 drug during previous week ? 7% took 5 or more prescription drugs Source: Kaufman, JAMA 2002 -Opiate use in population 18+ years ? Opiate used regularly (5days/week for 6 weeks) 2%, 3% less frequently Source: Kelly, Pain 2008 Limitations of Current Studies

17. Drugs and injured patientsWhat do we know? Alcohol Much known Dose response relationship with injury risk Screening tests leading to brief interventions Illicit drugs Much Less known Some prevalence information but less complete Most studies use urine rather than blood Causal role in injuries less clear Prescription drugs Even less information known Elderly at risk from sedating medications

18. Recommendations for Trauma Studies - Illicit and prescription drugs Need for comprehensive data on serum levels at time of injury Look for �at risk� serum levels Interaction other drugs, including alcohol Elderly especially susceptible Need for analytical studies to estimate risk Case-control studies Culpability studies Differences between on and off the job injuries

20. Opportunities for Trauma Studies Develop comprehensive testing Serum levels on all admissions Admission blood stored till discharge at STC Medical Examiner bloods collected for all fatalities OCME tests for the following substances: All abusive drugs (marijuana, cocaine, heroin, opiates, hallucinogens, etc.) Most prescription drugs Document drugs given in field by EMS Interviews with patients or proxies Identify work injuries Prescription drug use history Legal and illegal Feasibility of such studies proven Maryland could be a model for country

21. Questions??? Dr. Gordon Smith gssmith@som.umaryland.edu 410-328-3847

23. SLIDES NOT USED FROM HERE ON

24. Drugs tested at Shock trauma 2008

27. Drugs and Motor-Vehicle Fatalities � NHTSA Study 1990-91 1,882 Operators 4 states, 4 counties. Presence of drug tested for -Alcohol 51.5% -Other drugs 17.8% Marijuana 6.7% Cocaine 5.3% Benzodiazepines 2.9% Amphetamine 1.9% All others less 5.0% Source: Terhune et all 1993 DOT-HS-808-065

28. Drugs and Motor-Vehicle Fatalities � West Virginia 2004-2005 drivers data FARS 84-85% tested - Alcohol 32.5% Other drugs 25.8% Opiates 7.9% Benzodiazepines 6.6% Other drugs, similar to NHTSA study Source: CDC MMWR 2006 Dec 8

29. The Office of the Chief Medical Examiner (OCME) in Maryland tests the following cases for substance use: When requested All homicides All drownings Children (suspected suicide) Most MVC � not all passengers, only when suspected The OCME tests for the following substances: All abusive drugs (marijuana, cocaine, heroin, opiates, hallucinogens, etc.) Most prescription drugs

30. Shock Trauma Clinical Toxicology Database Drug Testing Rates Relative to Demographic Factors Alcohol blood p Drugs urine p Sex: Men 98% 62% Women 98% ns 61% ns Age: <21 99% 60% 21-39 99% 64% 40-59 99% 61% >60 98% ns 61% <0.01 Race: White 99% 65% Non-white 99% ns 57% <0.01 Injury: Violent 98% 55% Non-violent 98% ns 64% <0.01

31. Issues Toxicology samples are drawn for the treatment of the patient, not for legal reasons, thus the differential in testing rates for alcohol and drugs Over 90% of patients are tested for BAC, the rate of testing for other drugs is close to 50%

32. Limitations of Current Research Drug dosage levels are not available, only presence or absence No general agreement on plasma drug concentrations considered as evidence of impairment Association between opiates and crash culpability difficult to determine Pre-injury use vs. therapeutically administered opiates in field

33. Culpability To determine culpability (fault), police officers consider all possible evidence and information Driver information Witness information Vehicle condition Environmental conditions, etc. When the police report did not contain a determination of fault, it was made by the study team using the �culpability scale� (Terhune 1982, Perchonok 1978) based on police narratives, citation information and other available data

34. Crash Culpability Among Injured Drivers Using Alcohol, Marijuana or Cocaine Police crash reports include a determination of �at fault� (i.e., culpable) driver made by the investigating officer Analysis of culpability for each drug conducted among drivers who tested negative for other substances of abuse Odds ratios (OR) and 95% confidence intervals (CI) used to report results of percent comparisons and logistic regression models

35. Policy Implications Admission to a trauma center represents an untapped opportunity to initiate prevention measures Prevention of repeat injury episodes in this population may have profound implications with regard to reduction in health care costs nationwide.

36. Study Types Case/Control People injured vs. people not injured Ideal, but population-based data on drug use is not easily obtained Studies of injured patients Trends over time in toxicology findings Crash culpability studies Diagnostic studies of substance abuse among trauma patients Studies of long-term survival among trauma patients with substance abuse Case fatality studies

37. Trends Over Time in Toxicology Findings

38. Crash Culpability Studies

39. What is CODES?(Crash Outcome Data Evaluation System) Combines vehicle crash data with health outcome data to provide more and better information than is available in crash data alone Utilizes probabilistic linkage to match together records from multiple data sources which apply to the same person/event Does not necessarily require identifiers such as name, address, SSN to match records Can be used to compare crash characteristics and driver culpability for those with and without positive toxicology findings for a given drug

40. Linked Crash and Tox Data(comparing crash reports and BAC database)

41. Crash Culpability Among Injured Drivers Using Alcohol, Marijuana or Cocaine N = 5,573 drivers were found via linkage effort of crash reports and hospital records Of n = 2,537 drivers with complete toxicology findings: 74% were deemed culpable 70% were belted 40% tested positive for some combination of BAC, COC or MAR 19% tested positive for BAC alone 7% tested positive for MAR alone 4% tested positive for COC alone

42. Odds of Culpability by Age Group and Substance Use For each age group, alcohol was the primary substance responsible for crash causation. All those in the <21 age group who were BAC + were at fault