Trauma surgeons are very likely to interact with patients suffering from a wide variety of substance use disorders. It is important that providers are familiar with the various states of intoxication and withdrawal and the management of these states. If not for the traumatic event, this patient population often would not have presented to a hospital and may have little to no interest in recommendations related to treatment of the substance use disorder. This leads to challenges faced by trauma centers that are mandated to identify and address these problems. Just like the nature and extent of traumatic injuries can vary widely, the same is true for the nature and extent of sequelae related to drugs and alcohol. The spectrum can range from a young patient intoxicated and injured during their first use of “bath salts” to the patient involved in an alcohol related motor vehicle collision who develops complications related to alcohol withdrawal after admission.

According to the CDC, unintentional injuries were the fourth leading cause of death in the United States in 2013 (Fig. 42-1).¹ Deaths related to drug overdose exceeded 41,000 in 2012, while the age adjusted drug related death rate rose from 6.1 per 100,000 in 1999 to 13.1 per 100,000 in 2012. During the same period, deaths from opioid related poisoning tripled (Fig. 42-2).² It is estimated that one in three traffic deaths involves a driver who is intoxicated.³ The cost of alcohol related motor vehicle crashes exceeds $80 billion per year, and it is estimated that about 16% of injury related deaths worldwide are related to alcohol use.⁴ As the risk of injury is greater among light drinkers who occasionally drink heavily compared to those who regularly drink heavily, but not episodically, tolerance presumably plays a role.⁵ Of interest, violence related injuries have been found to have a stronger association with alcohol use than unintentional injuries.⁶ In one study, the odds ratio for intentional injury related to drinking was 21.5 compared to 3.37 for unintentional injury.⁷ Hence, drug and alcohol use and abuse are clearly linked to the risk of injury and death. Understanding the pathology of addiction, various types of drugs and potential interventions are critical to an effective trauma center.

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) contains the most widely accepted nomenclature used by clinicians and researchers for the classification of mental disorders. The DSM-V measures substance use disorders along a continuum from mild to severe, and addiction can best be viewed as a chronic disease. The American Society of Addiction Medicine issued a public policy statement on the definition of addiction as follows: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”⁸ Addiction is characterized by an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Because of the short action of ethanol, withdrawal symptoms usually begin within 8 hours after blood alcohol levels decrease, peak at about 72 hours, and are markedly reduced by day 5 through 7 of abstinence. Special attention should be paid to patients with significant blood alcohol levels who do not appear clinically intoxicated as this suggests tolerance which leads to adaptations over time and makes withdrawal more likely to occur. Gathering collateral information regarding regularity of alcohol consumption can be beneficial as the ability to accurately assess the mental status of the trauma patient on admission can be limited. This population is at risk for developing alcohol withdrawal delirium, which can further complicate management and can lead to death if not quickly and effectively addressed, also (Table 42-1).

Despite studies of many different agents, benzodiazepines remain the standard of care for ethanol withdrawal. Some regimens take advantage of the long half-lives of certain benzodiazepines such as diazepam and chlordiazepoxide. Others take advantage of metabolic pathways, such as glucuronidation which occurs with temazepam, oxazepam and lorazepam that can be used in patients with hepatic impairment. There are a variety of approaches for addressing alcohol withdrawal. The common goal is to induce a calm, nonagitated, and autonomically stable state with repeated administration of benzodiazepine. It remains very difficult to accurately assess exactly who is at risk. The CIWA-Ar scale has been utilized to measure and score withdrawal symptoms; however, other causes of delirium can have an impact on the CIWA-Ar scores, limiting approaches based solely on this type of instrument.⁹

It is important to closely assess the response to whatever detoxification protocol is being utilized. Regardless of approach, excessive doses of benzodiazepines can complicate the management of alcohol withdrawal by causing an intoxication delirium. Symptom driven protocols to help manage alcohol withdrawal have gained popularity and appear effective.^10,11 These protocols address the individual’s physiologic symptoms and match these to a sliding amount of benzodiazepine. In this way, patients with lesser symptoms receive lower amounts of benzodiazepines compared to patients with severe withdrawal symptoms. Also, there is evidence that the adjuvant use of α₂-agonists, such as clonidine and dexmedetomidine, may help blunt the sympathetic response during alcohol withdrawal.^12,13

Sedating agents such as propofol and midazolam used perioperatively and in the intensive care unit (ICU) setting may mask symptoms of alcohol withdrawal and impact the timing of its onset. Patients may present with agitation and combativeness upon attempts to wean sedation in these settings, and benzodiazepine sparing approaches may see more use as evidence accumulates. Dexmedetomidine has been used with success in the ICU setting to help achieve sedation and decreased sympathetic tone. Haloperidol and other antipsychotics can also be helpful when managing severe agitation related to alcohol withdrawal delirium and agitation related to other causes of delirium.¹⁴ Withdrawal from sedatives such as benzodiazepines and barbiturates is similar to alcohol withdrawal and can result in delirium, also. Finally, the timing of the onset of sedative withdrawal will change based on the half-life of the sedative being utilized. This can occur whether the sedative medication was being used as prescribed or illicitly. Steps need to be taken to gather information regarding prescribed or illicit use to avoid discontinuation and withdrawal.