Alcohol Consumption After Severe Burn: A Prospective Study

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Alcohol consumption after severe burn: A prospective study J. Sveen PhD, OsterC. Öster RN, PhD

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S0033-3182(14)00094-2 http://dx.doi.org/10.1016/j.psym.2014.05.019 PSYM477

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Psychosomatics

Received date: 1 April 2014 Revised date: 14 May 2014 Accepted date: 15 May 2014 Cite this article as: J. Sveen PhD, OsterC. Öster RN, PhD, Alcohol consumption after severe burn: A prospective study, Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.05.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Revision May 14 2014 TITLE: ALCOHOL CONSUMPTION AFTER SEVERE BURN: A PROSPECTIVE STUDY

AUTHORS: J. Sveen1 PhD, C. Öster1 RN, PhD

AFFILIATION: 1Department of Neuroscience Psychiatry, Uppsala University, Uppsala University Hospital Burn Center SE-751 85 Uppsala, Sweden. E-MAIL: Josefin Sveen: [email protected], Caisa Öster: [email protected]

ADDRESS FOR CORRESPONDENCE: Caisa Öster, Department of Neuroscience Psychiatry, Uppsala University, University Hospital, SE-751 85 Uppsala, Sweden. Facsimile +46-18-510656, Telephone (office) +46-18-6115243

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Abstract Background: The number of patients with alcohol-related burns admitted to burn units has increased. It has been reported previously that alcohol-related burns are an indicator of alcohol dependence, but there are few studies addressing alcohol use several years after burn injury. Objective: To investigate alcohol consumption 2 to 7 years after burn injury and examine possible contributing factors. Methods: Consecutive adult burn patients (n=67) were included during hospitalization and an interview was performed at 2 to 7 (mean=4.6) years postburn. Data assessed at baseline were injury characteristics, sociodemographic variables, coping, and psychiatric disorders. At follow-up, the Alcohol Use Disorders Identification Test (AUDIT) was used to identify at-risk drinking. Results: Twenty-two percent of the burns were alcohol-related; however, this was not associated with at-risk drinking at follow-up. Seventeen (25%) of the former burn patients were identified as having an at-risk drinking pattern at follow-up. One item in the Coping with Burns Questionnaire (CBQ) used in acute care, I use alcohol, tobacco or other drugs to be able to handle my problems, was the only factor found to predict at-risk drinking several years after injury. Conclusion: There were more at-risk drinkers in this burn population as compared to the general population. The results indicate that an avoidant coping pattern including the use of alcohol to handle problems can be considered a potentially modifiable factor.

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INTRODUCTION A severe burn is a life-threatening state that challenges all of the main integrating systems in the body, and it is associated with long and painful in-hospital treatment. Recovery after burn appears to be less dependent on the severity of the burn and more dependent on pre- and postinjury factors such as pre-existing comorbidities, coping skills and psychological health.1, 2 A high frequency of alcohol-related burns is well documented3-5, and the rate appears to be rising as alcohol consumption increases globally.5 Furthermore, studies have shown that individuals intoxicated with alcohol at the time of injury have a higher risk of infection and mortality compared to burn victims who are not intoxicated.3, 6-9 For example, it was reported in a meta-analysis that approximately 40% of those who die from burn injury are intoxicated at the time of injury.3 It is common for those with alcohol-related burns to have an underlying alcohol use disorder. For instance, Holmes et al.5 found that 54% of those with an alcohol-related burn had underlying alcohol dependence. Palmu et al.10 reported a 35.5% lifetime prevalence of alcohol dependence and an 11.2% prevalence of alcohol abuse in burn patients, and during acute care the rates were 28% and 3.7%, respectively. However, these rates had decreased to 14.1% and 0%, respectively, six months post injury.10 In a sample partly overlapping the sample in the present study, Dyster-Aas et al.11 reported that 32% of the burn patients had a lifetime alcohol use disorder. Moreover, Smitten et al.12 reported that 8% of the burn patients had a postburn, new onset, alcohol use disorder that developed mainly in the period immediately following the burn. In adolescents who have been burned during childhood, alcohol dependence has been identified in 8% several years thereafter13

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and Meyer et al.14 reported a lifetime prevalence rate of 8%. In addition, it has been reported that over 33% were at-risk drinkers at the time of injury, even though alcohol dependence was identified in only 11.6% of burn patients.15 Nevertheless, being an at-risk drinker is a risk factor for later alcohol dependence.16 There are no studies to date describing post-injury alcohol consumption among adult burn patients several years after injury. Thus the aim of the present study was to investigate alcohol consumption 2 to 7 years after burn injury and to explore possible contributing factors.

METHODS Participants and procedures This is part of a prospective longitudinal study concerning physical and psychological outcome after burn trauma conducted at the Uppsala Burn Center, one of two national burn centers in Sweden. Consecutive burn patients admitted to the Burn Center between March 2000 and March 2007 were included if they were 1) 18 years of age or older, 2) Swedish speaking, 3) without documented learning disabilities or dementia, and 4) had ≥ 5% of Total Body Surface Area (TBSA) burned or a length of stay at the Burn Center (LOS) of more than one day. Of the 112 patients who fulfilled the inclusion criteria, six were missed due to administrative reasons and 17 patients declined participation, leaving 89 participants (79%). Assessments were conducted during the initial treatment for the burn. In addition, patients were contacted at 2 to 7 years after the burn and visited for followup interviews. At the time of follow-up, four patients had died, two had emigrated and one had stopped participating earlier during data collection. Of the remaining 82

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patients, five were impossible to locate, nine declined participation and one was excluded for other reasons, leaving 67 out of the 112 previous patients (60%) for the final assessment. In comparison with those 67 former patients, the 22 dropouts from the follow-up were less likely to have been working or studying at the time of the burn (χ²:3.9; P = 0.04). The study was performed according to the Helsinki Declaration and was approved by the Uppsala University Ethics Committee.

Measurements and assessments Sociodemographic and burn-related variables Data extracted from the medical records included sex, age at injury, cause of injury, injury severity, whether the burn was alcohol-related, living alone or co-habiting, years of education, and work status at injury. Data registered at follow-up were time since injury, length of sick-leave due to burn injury, and work status.

Alcohol use at follow-up The AUDIT (Alcohol Use Disorders Identification Test)17 was used to assess hazardous and harmful use of alcohol 2 to 7 years after burn. The AUDIT was originally designed as a screening tool for primary care settings but has also been used in trauma interventions18 and for screening in burn care.15 The 10-item selfreport questionnaire covers the domains of alcohol consumption, drinking behavior and alcohol-related problems. Each question is scored on a scale from 0 to 4 points, for a maximum total score of 40. A higher score is an indicator of hazardous or harmful use or dependence. Hazardous use is a term for a drinking pattern that increases the risk of harmful consequences for the user. A common categorization based on WHO guidelines is used in this study, with recommendations for a lower

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cut-off score for females.16 Thus, hazardous or risky use is defined as 6 points or more for females and 8 points or more for males, and the term at-risk drinking will be used in this study to identify participants with these scores.

Psychiatric disorders The Structured Clinical Interviews for DSM-IV Axis I Disorders (SCID-I)19 and Axis II Disorders (SCID-II)20 were used to assess for psychiatric disorders. The interviews were conducted by three trained interviewers who were not a part of the regular staff at the Burn Center and were therefore not involved in treatment decisions. Fourteen SCID-I interviews were independently rated for interrater reliability. Complete interrater agreement on diagnoses was obtained (kappa=1). The SCID-I and SCID-II interviews were carried out during hospital care as soon as the patient’s medical condition allowed, and after informed consent had been given. As a routine, patients were screened using the Mini Mental State Examination.21 In this study we use “Lifetime” prevalence (any time in life before and including the time of burn), and “During acute care” prevalence, the proportion of the sample that met criteria for a diagnosis at the time of the interview. A substance use disorder was judged to be present during acute care if symptoms were present at the time of injury.

Alcohol use as a coping strategy As it is well known that some people consume alcohol as a coping response to stress (Hasking 2008), one item in the Coping with Burns Questionnaire (CBQ)22 was included in the explorative analysis: I use alcohol, tobacco or other drugs to be able to handle my problems (item 16 in the CBQ). The CBQ was administered during hospital care and the participants' answers were categorized as 1=yes or 0=no.

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Data analysis Differences between groups were assessed with Student’s t test or with the χ2 test for categorical data, and Fisher's exact test was used when appropriate. In an explorative attempt to establish predictive models, logistic regressions were performed with “Atrisk drinking at follow-up” as the dependent variable. The possible predictor variables are those reported in Table 1. The predictor variables were examined with Student’s t test and χ2 analysis and those having a P value ≤ 0.20 were included in subsequent forward conditional logistic regressions. Due to skewed distributions, TBSA, TBSA-full thickness burn (TBSA-FT) and LOS were logarithmically transformed. The relative risks were estimated by odds ratios (ORs) with 95% confidence intervals (CIs). All analyses were performed with the statistical package IBM SPSS 21.0.

RESULTS Participants during acute care The 67 participants (52 men and 15 women) included in the follow-up study on average 4.5 years (SD: 1.9) after burn had a mean age at injury of 42.6 years (SD: 14.8), 56 (84%) were working or studying at the time of injury, 31 (46%) lived in one-person households and 20 (30%) had no more than nine years of compulsory education. Fire was the most common cause of injury (n=62), followed by electrical (n=4) and chemical burns (n=2). One third were work injuries (n=20) and 6 (9%) were intentional injuries. Injury severity assessed as mean TBSA burned was 25.4% (SD: 20.4), mean TBSA-FT (full-thickness) was 10.8% (SD: 14.8) and mean LOS was 27 days (SD 34). Of the 67 participants, 20 (30%) had a previous alcohol use

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disorder any time in life before the burn, and 11 (16%) had this disorder assessed while in acute care. Fifteen (22%) participants were assessed as having alcoholrelated injuries, and of those, 10 (67%) had a current alcohol use disorder.

At-risk drinking at time of follow-up Of the 67 participants, four (6%) were non-drinkers and 63 (94%) were drinkers. Seventeen participants had scores on the AUDIT indicating at-risk drinking. The atrisk drinkers had a mean AUDIT score of 10.4 (SD: 3.2, range 6-18) and the not atrisk drinkers had a mean score of 3.3 (SD: 1.7, range 1-7). All of the at-risk drinkers binge drank at least monthly, whereas only two (4%) of the not at-risk drinkers did so. Two (11.8%) of the at-risk drinkers drank daily or almost daily, and four (23.5%) drank 2-3 times a week. Of the not at-risk drinkers, none drank daily and 6 (13%) drank 2-3 times a week. The at-risk drinking group was compared with the not at-risk drinking group regarding possible predictive factors (Table 1). The same prevalence of psychiatric disorders was found in both groups (using P ≤ 0.05), including any alcohol use disorder lifetime and any alcohol use disorder assessed in acute care, while more participants in the later at-risk drinking group had alcohol-related burns, but this was not statistically significant. The at-risk drinking group had less severe injuries and fewer days in hospital but the differences were not statistically significant. The only significant difference found was the proportion of positive answers to item 16 in the CBQ: I use alcohol, tobacco or other drugs to be able to handle my problems. At follow-up, no statistical differences were identified between the group of at-risk drinkers and the group of not at-risk drinkers.

Predictors for at-risk drinking at follow-up 8

Statistical comparisons showed that low education level, alcohol-related burn, a personality disorder, a positive answer to item 16 in the CBQ and less burn severity measured as TBSA were related to at-risk drinking using P ≤ 0.20 as a cut-off (Table 1). In the multiple regressions only TBSA and a positive answer to item 16 in the CBQ remained (Table 2).

DISCUSSION To our knowledge, this is the first prospective investigation of alcohol use several years after severe burn injury. The lifetime prevalence of an alcohol use disorder prior to the burn was 30% in the present study, which is lower than previously reported (47%) in a Finnish study.23 Twenty-two per cent of the individuals were under the influence of alcohol at the time of the burn injury, and of those 67% had an alcohol use disorder any time in life before and including the time of the burn. A recent study by Holmes et al.5 reported that 20% of burn injuries were alcohol-related and that 54% of those individuals had an underlying alcohol dependence. At the long-term follow-up 25.4% were at-risk drinkers according to their AUDIT scores, which is a much higher percentage than identified with the AUDIT in a Swedish population (12.7% for women and 14.4% for men).24 Of the 63 participants who drank, 29.2% binge drank at least monthly and all of the at-risk drinkers binge drank, whereas only 4% of the not at-risk drinkers did so. A study by Albright et al.15 reported that among burn patients admitted to a burn service, 33.3 % were at-risk drinkers and 28.9 % binge drank at least monthly. A recent study25 on medical-surgical ICU patients reported a much lower rate of at-risk drinkers; 3.8% were at-risk drinkers three months after hospitalization and 7.5% at 12 months.

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Moreover, it was found that probable acute stress disorder and previous unhealthy alcohol use were associated with increased alcohol use after ICU admission. When comparing the at-risk drinkers with the not at-risk drinkers at follow-up, no significant differences were found regarding sick-leave due to burn injury or current work situation. Albright et al.15 found that even though one third of the at-risk drinkers did not have health insurance, they were no more likely to be unemployed than the not at-risk drinkers. This indicates that they have experienced only minor consequences of their drinking, which is consistent with our results. Besides the ongoing adverse effects of alcohol use and an increased risk for repeated injury26, 27 and for adding to the burden of psychiatric symptoms following injury28, being an atrisk drinker is a risk factor for later alcohol dependence.16 It is important to identify and support those who are at-risk drinkers, as it is easier to decrease or cease drinking if the individual is not yet dependent on alcohol, and admission to an intensive care unit can serve as a “teachable moment”.29 For example, brief interventions in trauma care have been shown to modify drinking pattern in early at-risk drinkers.30, 31 In an explorative attempt to find predictive factors for at-risk drinking, a regression analysis was conducted; however, the only factor that was significant in the final model was using alcohol, tobacco or other drugs as a coping strategy. The use of alcohol to handle emotions is part of an avoidant coping style that is thought to be maladaptive. Avoidant coping has previously been associated with worse health outcome after burn injury.32 Furthermore, avoidant coping is related to an increase in alcohol consumption, thereby causing alcohol-related problems.33 Coping-skills training is a component in cognitive behavioral programs directed at alcohol use problems.33 Cognitive behavioral strategies as well as brief interventions are included in a stepped collaborative care model developed and

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implemented by Zatzick and colleagues in US trauma centers. The model encompasses training and organizational development of alcohol-screening and interventions 34 and has proved to reduce alcohol abuse and dependence during the year after injury compared to usual care for control patients.35, 36 A recent study identified a high prevalence of substance abuse comorbidities in trauma patients and high-lighted the importance of treatment of comorbidities that can have an impact on the effectiveness of interventions targeting alcohol disorders.37 The prospective approach, the population-based consecutive inclusion, and the long follow-up time are important strengths of this study, as well as the low attrition rate even several years postburn. Due to the small sample size, and subsequently the small numbers in some cells in the regression analysis, the regression analysis can be seen as a tentative attempt to discern the role of variables contributing to the outcome, and thus the conclusions reached are only preliminary. The study needs to be replicated in a larger cohort of burn patients and preferably with an assessment of atrisk drinking over time. In conclusion, in this first investigation of alcohol consumption several years after severe burn injury, we found that 25% of the former burn patients were at-risk drinkers, which is much higher than in the general population. Identification and information are not exclusively intended for those with alcohol abuse, dependence or alcohol-related clinical signs, but can be of value for those using an avoidant coping pattern including the use of alcohol and drugs to handle problems.

CONFLICT OF INTEREST AND SOURCES OF FUNDING:

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There are no conflicts of interest to declare. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. This research was supported by the Swedish Research Council and the Swedish Council for Working Life and Social Research.

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Table 1. A comparison of possible risk factors in at-risk drinkers and not at-risk drinkers 2 to 7 years after burn Not at-risk drinkers

At-risk drinkers

n=46

n=17

P value*

35/11 19 (41)

14/3 9 (53)

0.595 0.409

41.7 (13.2)

41.1 (14.0)

0.888

Education level low

11 (24)

7 (41)

0.190

Working at injury

42 (91)

14 (82)

0.316

Alcohol-related burn

9 (20)

6 (36)

0.193

Work injury

14 (30)

5 (29)

0.937

Any psychiatric disorder lifetime

27 (59)

10 (59)

0.993

Any alcohol use disorder lifetime

14 (30)

6 (35)

0.713

Any alcohol use disorder

7 (14)

4 (24)

0.360

Any personality disorder

9 (20)

6 (35)

0.193

Positive answer to CBQ item baselineb

13 (31)

11 (69)

0.009

TBSA (Total body surface area burned (%)

29.3 (21.9)

18.4 (14.7)

0.094

TBSA : full thickness

12.5 (16.9)

7.5 (8.6)

0.607

Length of hospital stay

31 (39)

19 (11)

0.454

4.7 (1.9)

4.2 (2.1)

0.286

17.7(21.6)

13.4 (12.4)

0.491

28 (61)

10 (59)

0.883

Male/Female Living alone Age at injury (years) a

At follow-up Time since burn (years) Sick-leave due to burn injury (months) Working at follow-up

All values are means (± SD) or n (%) * Results from Chi Square test, Independent samples t-test and Fisher’s exact test a) No more than nine years of compulsory education b) I use alcohol, tobacco or other drugs to be able to handle my problems (item 16 in the CBQ) Bold figures denote variables used in the logistic regression analyses

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Table 2. Logistic Regression Analysis with at-risk drinking at follow-up as the dependent variable. Independent variables Variables not in the model Alcohol-related burn Low education level1 Any Personality disorder Variables in the model Total Body Surface Area Burned2 Positive answer to CBQ item at baseline3

Odds ratio 0.48 1.38

1

95% CI p value 0.2–1.0 0.051 1.4–18.9 0.015 Nagelkerke’s R Square =0.25

No more than compulsory school Mean values were log-transformed before analyses 3 I use alcohol, tobacco or other drugs to be able to handle my problems (item 16 in the CBQ) 2

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