Role of alcohol and other drugs in trauma

Opiates, benzodiazepines, and stimulants

There has been an epidemic of drug overdose-related deaths in the last decade. Drug overdoses are classified as a form of injury-related death by International Classification of Diseases, 10th Revision codes (codesX40-X44: unintentional deaths, X60-X64: suicides, X85: homicide, Y10-Y14: undetermined). In 2017, there were 70,237 drug overdose deaths in the United States. The age-adjusted rate of drug overdose deaths in 2017 (21.7/100,000 population) was 9.6% higher than the rate in 2016 (19.8/100,000).

The age-adjusted rate of drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol) increased by 45% between 2016 and 2017, from 6.2 to 9.0 per 100,000 respectively.

The 10 drugs most commonly associated with overdose deaths fall into three categories. Opiates (fentanyl, heroin, hydrocodone, methadone and oxycodone), benzodiazepines (alprazolam, and diazepam), stimulants (cocaine and methamphetamine).

For many years, motor vehicle crashes have been the leading causes of injury-related deaths, followed by falls, then by violence. In the last few years, drug overdose has surpassed falls as the second most common cause of unintentional death, and, in 15 states, drug overdoses have surpassed motor vehicle crashes as the leading cause of injury-related death.

Historically, illicit drugs have been the type most frequently associated with overdose. That is no longer the case. The majority of deaths due to overdose are now caused by misuse of legal drugs, predominantly opiates and benzodiazepines. These medications are most often prescribed by physicians and diverted for nonmedical purposes. Currently, the number of annual deaths due to prescription opiates is twice the number of deaths due to cocaine, and over five times the number of deaths due to heroin.

Nearly 450,000 people died from overdoses involving any opioid, including prescription and illicit opioids, from 1999 to 2018.This rise in opioid overdose deaths can be outlined in three distinct waves.

The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semisynthetic opioids and methadone) increasing since at least 1999.The second wave began in 2010, with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl. The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine. Many opioid-involved overdose deaths also include other drugs.

More than 932,000 people have died since 1999 from drug overdose. In 2020, 91,799 drug overdose deaths occurred in the United States. The age-adjusted rate of overdose deaths increased by 31% from 2019 (21.6 per 100,000) to 2020 (28.3 per 100,000).

Opioids—mainly synthetic opioids (other than methadone)—are currently the main driver of drug overdose deaths. 82.3% of opioid-involved overdose deaths involved synthetic opioids. Opioids were involved in 68,630 overdose deaths in 2020 (74.8% of all drug overdose deaths). From 1999 to 2020, more than 263,000 people died in the United States from overdoses involving prescription opioids (drugs such as fentanyl, fentanyl analogs, and tramadol). However, most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl. It is sold through illegal drug markets for its heroin-like effect. It is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects.

Drug overdose deaths involving psychostimulants such as methamphetamine are increasing with and without synthetic opioid involvement. Rates of overdose deaths involving synthetic opioids other than methadone, which includes fentanyl and fentanyl analogs, increased over 56% from 2019 to 2020. The number of overdose deaths involving synthetic opioids in 2020 was more than 18 times the number in 2013. More than 56,000 people died of overdoses involving synthetic opioids in 2020. The latest provisional drug overdose death counts through June 2021 suggest an acceleration of overdose deaths during the COVID-19 pandemic.

Prescription opioids can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer. In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.

More than 191 million opioid prescriptions were dispensed to American patients in 2017—with wide variation across states. There is a wide variation of opioid prescription rates across states. Health care providers in the highest prescribing state, Alabama, wrote almost three times as many of these prescriptions per person as those in the lowest prescribing state, Hawaii. Studies suggest that regional variation in use of prescription opioids cannot be explained by the underlying health status of the population.

The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone (such as OxyContin), and hydrocodone (such as Vicodin).

To reverse this epidemic, we need to improve the way we treat pain. We must prevent abuse, addiction, and overdose before they start.

Marijuana

Marijuana, also known as cannabis, is a psychoactive drug from the Cannabis plant used primarily for medical or recreational purposes. The main psychoactive component of cannabis is tetrahydrocannabinol (THC). Cannabis can be used by smoking or vaporizing, within food, or as an extract.

In 2015, 44% of the people in the United States had tried marijuana, an increase from 38% in 2013 and 33% in 1985. Twelve percent had used it in the past year, and 7.3% had used it in the past month. In 2014, daily marijuana use among U.S. college students had reached its highest level since records began in 1980, rising from 3.5% in 2007 to 5.9% in 2014, and had surpassed daily cigarette use. In the United States, men are over twice as likely to use marijuana as women, and 18- to 29-year-olds are six times more likely to use as those over 65 years old. Marijuana use in the United States is three times above the global average. These numbers continue to increase with its legalization and medical use.

Summing-up, in the past driving while impaired by alcohol was three times more common than driving under the influence of other drugs. However, the National Highway Traffic Safety Administration 2007 National Roadside Survey was the first U.S. national random-stop roadside survey to collect oral fluid or blood samples from drivers for laboratory testing of illegal drugs as well as for alcohol. Of all weekend nighttime drivers sampled who were willing to provide specimens, 12.4% were positive for alcohol; 16.3% were positive for illegal, prescription, or over-the-counter drugs that could possibly cause impairment; and 20.5% were positive for either alcohol or one or more other drugs including marijuana.

Studies have shown that for the past few years more teenagers initiate their drug use with prescription drugs, although marijuana is the classical “gateway drug,” with a 9% to 10% addiction rate. In some states, more teenagers admit to recent use of prescription opiates than admit to recent use of marijuana. Opiates and benzodiazepines diverted for nonmedical purposes are most frequently accessed by teenagers from prescribed drugs kept within their own home or within the home of a friend. The increase in prescription drug overdoses parallels a 10-fold increase in the number of prescriptions for opiate pain relief drugs since the 1990s.

Health care providers involved in trauma care must be familiar with the epidemiology of the drug use epidemic, as nearly every patient treated for injury will have had some exposure to alcohol and other drugs. Correspondingly, those discharged from a hospital will almost always receive a prescription for some type of pain-relieving narcotic medication.