|Year : 2011 | Volume
| Issue : 3 | Page : 350-352
Alcohol and injuries: Emergency department studies in an international perspective
Rajat Ray, Alok Agrawal
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110 029, India
|Date of Web Publication||6-Apr-2011|
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ray R, Agrawal A. Alcohol and injuries: Emergency department studies in an international perspective. Indian J Med Res 2011;133:350-2
Alcohol and injuries: Emergency department studies in an international perspective (World
Health Organization, Geneva) 2010. 286 pages.
Price: CHF 50.00/US$ 50.00
Alcohol consumption and problems arising thereof are major global public health concerns. In addition to the risk of abuse and dependence, alcohol is one of the main contributors to health problems. Accidental injuries are direct medical consequences of alcohol intoxication and it is well accepted that alcohol increases the risk of injuries through cognitive and psychomotor impairment. Alcohol related injuries include unintentional injuries like road traffic accidents, fire and burns, poisoning, pedestrian falls and drowning as well as intentional injuries such as violence against oneself or others. The impact of these injuries affects not only those who are intoxicated at the time of injury occurrence, but also those who fall victim to their behaviour.
The problem of alcohol-related injuries is particularly alarming in developing countries, like India, where intervention for the traumatic injuries is poor due to lack of infrastructure, poor enforcement of laws, and lack of appropriate public health policies. In India, alcohol misuse has a disproportionately high association with traffic accidents and deliberate self-harm, and alcohol consumption has been implicated in over 20 per cent of traumatic brain injuries.
Alcohol-attributable injuries and violence are of growing concern to the World Health Organization. However, to prepare a response to this problem with effective policies and interventions, evaluation of the role of alcohol in causation of injuries and identification of alcohol-attributable fraction of such injuries is required through scientific research. Emergency Department (ED) studies offer one method to undertake such research as alcohol-related injuries are especially evident in hospital emergency rooms (ER) and trauma centres which often are the point of first contact with medical services. The clinical encounters in these settings present a chance for health professionals to get access to such a population. Around the world, a number of ED studies have been undertaken over the last three decades which resulted in strengthening and standardization of methodology of such studies and enhancement in the understanding of alcohol's role in injury causation. However, significant gaps remain in knowledge especially with regards to the population attributable fraction of alcohol related injuries, role of cultural factors, prevention of such injuries and effectiveness of intervention in cases of alcohol-attributable injuries both in the ED and within the community.
This publication by the WHO on alcohol and injuries provides the current state of knowledge of alcohol's association with injuries based on hospital emergency department (ED) studies in several countries. This is the first such book which focuses on alcohol and injuries exclusively in the emergency department setting and presents a synthesis of the latest international studies conducted in high-, low- and middle-income countries, including the WHO Collaborative Study on Alcohol and Injuries and the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP).
The WHO Collaborative Study on Alcohol and Injuries was undertaken between 2001-2002 in ERs in Argentina, Brazil, Belarus, Canada, China, Czech Republic, India, Mexico, Mozambique, New Zealand, South Africa, and Sweden. The study included a probability sample of injured patients admitted within six hours of the event who underwent clinical assessment of intoxication and BAC estimation using a breath analyzer. A total of 5243 patients were recruited into this study. ERCAAP is a meta-analysis of the alcohol and injury relationship which combined and re-analyzed the data from 12 ED studies, all using controls and similar robust methodology.
The current monograph is divided into five sections which cover various aspects of alcohol and injury relationship including studies on epidemiology, research methodology, screening, interventions, and implications of these findings on global and community levels.
Section I is dedicated to the epidemiology of alcohol and injury in ED studies and is divided into four chapters. This section highlights the advantages of ED studies in examining the association of alcohol and injuries and presents the latest approaches. The chapters in this section bring the problem of identification of factors associated with alcohol-related injury to the forefront. Distinction is made between alcohol-related injury and alcohol-attributable injury. The modifying effects of usual consumption patterns on the relationship of acute drinking prior to the event and injury has been emphasized. Research has shown a strong association between acute alcohol intake and injury (relative risk-RR 5) and that risk accumulators (high usual volume and frequent binge drinking) and risky single-occasion drinkers (low usual volume and frequent binge drinking) have the highest risk of injury. Studies also suggest that alcohol shows greater association with increased risk of violence related injuries as compared to non-violence-related injuries and intentional as compared to unintentional injuries (RR 5.2). Moreover, the risk of injuries especially violence-related injuries increases significantly with increase in acute alcohol intake. It has been estimated that, globally, 16.8 per cent of deaths due to unintentional injuries (21.7% for men) and 16.1 per cent of deaths due to intentional injuries (19% for men) can be attributed to alcohol use.
Section II of the book deals with the issues related to ED studies and consists of four chapters and puts particular emphasis on methodological problems and limitations of existing studies, as well as issues regarding the future development of studies in the ED. The problems associated with ED studies particularly the selection of cases and controls, case-crossover design, methods and timing of sample collection for BAC estimation, conceptual issues in emergency room and biases affecting such studies have been identified and discussed. Key elements in the design and execution are provided (Cherpitel model) as a box item and are very useful.
Section III (two chapters) discusses the issues relating to identification of alcohol-related injuries in emergency departments. The chapters in this section discuss the potential of using routine recording of alcohol intake in injured patients by use of optional codes given in ICD-10 (Y-codes). A broad array of monitoring options involving the ED, including the use of "surrogate" measures, objective tests of blood alcohol level, adaptations of routine medical records and the regular sampling of ED attendees for surveys are discussed as means of screening and surveillance.
Section IV (three chapters) focuses upon the wide range of experiences with alcohol screening and brief intervention (SBI) in acute care medical settings. These interventions utilize injury as a "window of opportunity" to reduce drinking. The section reviews studies on the effectiveness and feasibility of implementing brief interventions. It also discusses the challenges of translating research results into routine practices outside the research setting. By and large, it can be concluded that SBI is effective, feasible, and cost-effective in emergency department settings.
Section V is the largest section of the book consisting of six chapters and deals with the application and implications of findings from the ED studies. The first chapter provides the practical experiences of conducting ED studies (WHO collaborative project) in five diverse cultural settings and discusses the implications of the findings. Some important themes that emerge from these descriptions are that alcohol is a significant risk factor in cases presenting in emergency departments; in contrast, alcohol-related problems are not perceived to be a significant health and safety issue; and there is no routine monitoring or screening for alcohol in ER settings.
These studies also identify influence of cultural differences on alcohol-related injuries which may affect the magnitude of the alcohol-injury relationship. 'Dry' cultures, as in India, are known to predispose to deviant, unacceptable and anti-social behaviour related to alcohol use. In such cultures, the dominant drinking expectancies favour drinking to intoxication, and alcohol use is strongly associated with expectations of disinhibition, especially among males, which 'legitimizes' male drunkenness and violence. This section also discusses the implications of emergency room research for community mobilization, prevention and public health implications. ER studies can be used to increase awareness of the damage from alcohol, as an indicator of the range of problems in the community, introduce community-based prevention programmes and monitor the impact of community interventions and policy initiatives.
Finally, the authors examine the ER experience in the contexts of alcohol policies. Policy decisions have a bearing on how ER studies are conducted and, in turn, ER data can influence policy deliberations and decisions and help monitor impact of policy changes.
However, gaps still remain in knowledge about this phenomenon which need to be filled with continued research. There is a need to generate evidence that will facilitate enactment of good alcohol policies. Some other areas requiring attention include information on prevalence and incidence of damage from alcohol, evidence of high-risk drinking situations, and socio-economic conditions that intensify injuries. Further studies are necessary to identify the most appropriate screening tools, target population, personnel to deliver the intervention, appropriate time and place for the same and the measures for their success.
The book is a comprehensive document on association of alcohol use and injury and covers almost all aspects of the relationship between the two and the issues arising thereof. Most of the chapters discuss issues like selection bias during measurement, establishing blood alcohol level at the time injury, generalisability of findings, future development and conclusion. This multi-authored book has been compiled by an international group of editors with extensive experience in the area of alcohol and injuries. This along with the use of robust statistical methods used for collation of data from various studies is the most significant strength of this book. However, the book has some limitations with regard to applicability in developing countries (the majority of the studies reviewed are from western countries) which have limited application to countries with limited trained manpower, poorly developed health systems and scarcity of resources. The use of different measurement units for BAC in different chapters makes it somewhat difficult to compare the findings.
In conclusion, the book is a well written and exhaustive work on one of the most important global public health issues. It is especially relevant to the developing countries like India where the increasing use of alcohol and cultural and infrastructural factors lead to an enhanced risk for alcohol-related injuries. The studies reviewed establish unambiguously the causal association between alcohol and injuries. The book discusses the public policy implications of these findings, identifies gaps in the current knowledge and provides the framework for future research. It can serve a useful purpose as a reference document for any discussion or research in the area of alcohol-related injuries. The book is highly recommended to a wide audience of health professionals, researchers and service providers interested in epidemiology and monitoring of alcohol involvement in injuries and developing effective interventions for reducing alcohol-related injuries.