Alcohol and drug abuse continues to be an immense problem that impacts on patient health, family relationships, society, crime, and medical resources. The severity of this problem varies between subgroups identified according to certain characteristics such as gender, race, and income. Physical injury often leads to significant changes in self-image, ability to work, social interactions, and daily routine. Each of these factors alone and in various combinations can greatly impact on individual usage of alcohol and other drugs of abuse (AODA). The purpose of this article is to provide an overview of the influence of AODA in physically disabled patients. More specifically, we will review (1) the role of substance abuse in the cause of injury, (2) the average use of AODA in the physical rehabilitation population before and after injury, (3) the effects of AODA on the quality of physical rehabilitation itself, and (4) what is, and can be, done in rehabilitation programs with regard to substance abuse identification, education, and treatment. This literature review will help medical staff have a better understanding of this important problem, and stimulate thought concerning treatment, education, and future directions of investigation.

Many traumatic injuries leading to use of rehabilitation services are related to drug and alcohol use. As shown in Table 1, alcohol-related traumatic injuries accounted for up to 79% of rehabilitation patients. Alcohol usage has been reported to be involved in about 35% of automobile injuries, 55% of motor vehicle deaths, 40% of drownings, and 30% of airplane (noncommercial) crashes (1). Of those that survive injuries, many require rehabilitation services. Approximately 50% of head injury patients from car accidents occur with drivers being legally intoxicated (blood alcohol level equal to or over 100 mg/dl) at the time of injury, with as many as 72% positive for some blood alcohol (2). Other studies have found similar statistics, ranging from 29% to 58% positive blood alcohol levels (BALs) upon arrival at the emergency room (3-5).

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Alcohol has been shown to be involved in over 50% of head injury (HI) patients prior to the time of accident (2,3,5). Other studies have found a preinjury prevalence of alcohol addiction in 25% to 68% of HI patients, and 29% to 58% had positive BALs at time of injury (3-7). In a study of over 400 patients, 57% of the patients with a history of alcohol abuse/dependency were intoxicated at injury, while 31% of those with no history of alcohol abuse were intoxicated at time of physical injury (8). Likewise, a large study at the University of Virginia showed a history of alcohol abuse in 34% of “moderate” and 10% of “minor” HI patients (9). The percent of those with positive BALs was 78% at the time of injury for moderately injured patients, and 53% of those with minor head injury (Table 1) (9). Gender differences may exist. Galbraith et al. (10) reported that 62% of males had positive BALs at the time of head injury, while only 27% of females had positive BALs.

As shown in Table 1, alcohol was related to the cause of spinal cord injury (SCI) in numbers similar to those for HI (11-13). A study of over 100 SCI patients showed that 39% were intoxicated at the time of injury (11). Twenty-nine percent of SCI subjects have reported family history of alcohol problems (12). In other studies, drinking or intoxication appeared to be involved in as low as 17%, or as high as 79%, of SCI (1,14). Of note, however, is that in the study reporting only 17% intoxication, 50% of the SCI patients had been drinking (1).

Studies on cold temperature-related injuries have also shown a high incidence of alcohol-related injury (15,16). For example, 39% of 101 frostbite patients reported that their injury was related to alcohol (15). Similar results were observed in another much smaller cold injury study (16).

Alcohol abuse appears also to enhance readmission for trauma injury (17). Thus, in a recent study of 2,578 trauma patients at a level I regional trauma center, the readmission rate was increased 2.5-fold in those patients who were intoxicated (BAL > 100 mg/dl) at the time of initial treatment (17). The relative readmission risk was increased 2.2 for those with initial positive Short Michigan Alcohol Screening Tests (SMAST) and 3.5 for patients with initial admission elevated alpha-glutamyltransferase (GGT) scores (17).

WHAT IS THE RELATIONSHIP BETWEEN NON-ALCOHOL DRUG ABUSE AND CAUSE OF INJURY IN PATIENTS WITH PHYSICAL DISABILITY?

Currently there is far less data on non-alcohol, drug-related injury in rehabilitation patients than alcohol-related injury (Table 1). In an NHIF study, about 5% of rehabilitation patients listed drugs other than alcohol as a primary drug of choice (3). In a recent study of 89 head injury patients in Maryland, 18% of subjects appeared to have non-alcohol drug-related injuries (and 38% alcohol-related injuries) (18). Preliminary results of an investigation we are conducting indicate about 9% of trauma patients reported drug (non-alcohol) abuse to be directly related to the physical injury (19).