- Email: [email protected]
Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire
JBUR 6014 No. of Pages 3
burns xxx (2019) xxx
xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the editor
Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire article info
abstract
Article history:
Burn survivors who misuse alcohol and/other substances have been associated with poorer
Available online xxx
long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and
Keywords:
emergence of potential substance misuse through examination of CAGE scores may provide
Burn injury
important information about this population. Using data collected from the Burn Model
Substance misuse
System National Database, demographic and clinical characteristics of individuals who
CAGE questionnaire
reported positive CAGE scores (total score of 2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared. © 2019 Published by Elsevier Ltd.
1. Worldwide, alcohol misuse results in about 3.3 million deaths each year and roughly 31 million people suffer from different drug use disorders [1]. Burn survivors are suggested to be at an increased risk for substance misuse following their injury [2,3]. Recent literature suggests poorer outcomes and clinical complications, such as higher rates of graft failure, increased wound infection, and increased mortality, for burn survivors who use alcohol and/or other substances compared to those who do not [4]. The opioid crisis is currently at the forefront of international attention, therefore understanding the prevalence, patterns, and consequences of substance misuse as it relates to burn injury can potentially provide important information to clinicians on how to better screen and care for their patients. The persistence and emergence of substance misuse among adults in the Burn Model System (BMS) National Database were examined. The CAGE questionnaire is a selfreported assessment tool used to screen for potential substance misuse. CAGE is an acronym for the four questionnaire items: Cut down, Annoyed, Guilty, and Eyeopener. The CAGE instrument was originally designed to examine alcoholism but has since been adapted to also screen for other drug misuse [5]. The validity of the CAGE for burn survivor populations is unknown, though previous research has found the CAGE to be sensitive and specific for
other populations [6 8]. Within the BMS National Database, a total of eight CAGE questions screen for potential alcohol and/or drug misuse, respectively. An example of a CAGE alcohol or drug-related item includes, “Have you ever felt you needed to cut down on your [alcohol or drug] use?”. A “Yes” response to any item corresponds to one point with a maximum of four points possible upon completion of the questionnaire. A score suggestive of substance misuse is defined as an overall positive score of 2 on alcohol or drugrelated items. Data were obtained from the BMS National Database from 1997 2018 [9]. Burn survivors aged 18 years or older who completed self-reported CAGE questionnaires at two time points: 1) discharge questionnaire assessing pre-injury substance misuse (hence referred to as “pre-injury”) and 2) follow-up questionnaire at 6, 12, or 24 months post-injury were included. Follow-up CAGE questionnaires assessed potential substance misuse in the past 30 days. CAGE scores and trajectories over time following burn injury were reviewed. Demographic and clinical characteristics were compared for participants who reported positive CAGE scores for either alcohol or drugs and those who reported negative CAGE scores. A total of 466 adult burn survivors were included in the analysis. Approximately 18% of these survivors reported a positive CAGE score for pre-injury substance misuse and over half of those (62.7%) reported positive CAGE scores at a follow-up time point. Of those who reported negative
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016
JBUR 6014 No. of Pages 3
2
burns xxx (2019) xxx
xxx
Table 1 – Demographic and clinical characteristics of the study population. CAGE + Pre-Injurya (n = 83) Age, mean years (SD)c Male Gender, percent (n)c White, Non-Hispanic, percent (n) Burn Size, mean percent (SD) a b c
CAGE - Pre-Injuryb (n = 383)
42 (13.6) 69 (57) 75 (62) 21 (23.1)
48 67 65 18
(15.9) (255) (249) (18.4)
CAGE +: CAGE (Cut Down, Annoyed, Guilty, Eye-opener) questionnaire score of 2. CAGE -: CAGE (Cut Down, Annoyed, Guilty, Eye-opener) questionnaire score of < 2. Statistically significant differences in age and gender were found (p 0.01).
Table 2 – Number of CAGE scores for the study population at discharge and follow-up. CAGE + Pre-Injurya (n = 83) CAGE + at Follow-Upb (n) CAGE - at Follow-Upb (n) a b
52 31
CAGE
Pre-Injurya (n = 383) 34 349
Pre-Injury: CAGE pre-injury data collected at time of discharge. Follow-Up: CAGE post-injury data collected at 6, 12, or 24 months.
pre-injury CAGE scores (82.2%), 8.9% reported a positive CAGE score at a later follow-up post-burn. Individuals reporting positive CAGE scores (alcohol or drug misuse) pre-injury were more likely to be male and were younger than those who reported negative CAGE scores pre-injury (p <0.01). No significant differences in burn size or race were detected between groups. These data indicate that about 1 in 5 burn survivors screened positive for a potential pre-injury substance misuse issue. For a majority of these individuals, positive CAGE scores at later follow-up suggest that substance misuse persists after treatment for the acute burn injury. Additionally, a notable fraction of those individuals without pre-injury substance misuse issues, as assessed by the CAGE at acute burn discharge, screened positively for substance misuse at follow-up during the next several years. (Tables 1 and 2) The CAGE scores gleaned from the BMS National Database reflect the need for routine alcohol and drug misuse screening of burn survivors at long-term follow-up after injury. New studies are needed to understand the extent of substance misuse in this population as this study was limited by a small sample size and partial data set. These data highlight the importance of screening and support of burn survivors for substance misuse, particularly in the first two years following burn injuries. Burn injury- oriented education on the risks and consequences of substance misuse may help improve long-term outcomes.
Conflict of interest The authors, G.G. Grant, L.E. Kazis, and C.M. Ryan declare the following financial interests which may be considered as potential competing interests: MediWound Ltd. The remaining authors have no conflicts of interest to disclose.
Funding The contents of this letter to the editor were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPBU0001). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this letter do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. This study was also partially supported by the Fraser Fund of the Massachusetts General Hospital.
REFERENCES
[1] World Health Organization. Global Health Observatory (GHO) data. 2017 Situation and trends. Screening and brief intervention for substance use in primary Care: data by country. [2] Sveen J, Oster C. Alcohol consumption after severe burn: a prospective study. Psychosomatics 2015;56:390 6. [3] Rehou S, Mason S, MacDonald J, Pinto R, Jeschke MG. The influence of substance misuse on clinical outcomes following burn. Burns 2017;43:1493 8. [4] Klifto KM, Shetty PN, Slavin BR, Gurno CF, Seal SM, Asif M, et al. Impact of nicotine/smoking, alcohol and illicit substance use on outcomes and complications of burn patients requiring hospital admission: systematic review and meta-analysis. Burns 2019, doi:http://dx.doi.org/10.1016/j.burns.2019.08.003 (In Press). [5] Ewing J. Detecting alcoholism: the CAGE questionnaire. J Am Med Assoc 1984;252(14):1905 7. [6] Chen YT, Ibragimov U, Nehl EJ, Zheng T, He N, Wong FY. Validity of the CAGE questionnaire for men who have sex with men (MSM) in China. Drug Alcohol Depend 2016;160:151 6. [7] Dezman ZDW, Gorelick DA, Soderstrom CA. Test characteristics of a drug CAGE questionnaire for the detection
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016
JBUR 6014 No. of Pages 3
burns xxx (2019) xxx
of non-alcohol substance use disorders in trauma patients. Injury Int J Care Injured 2018;49:1538 45. [8] Malet L, Schwan R, Boussieron D, Aubley-Cuvelier B, Llorea PM. Validity of the CAGE questionnaire in hospital. Eur Psychiatry 2015;20:484 9. [9] Goverman J, et al. The national institute on disability, independent living, and rehabilitation research burn model system: twenty years of contributions to clinical service and research. J Burn Care Res 2017;38(1):240 53.
Gabrielle G. Granta,b Audrey E. Wolfec Catherine R. Thorpea Nicole S. Gibrand Gretchen J. Carrougherd Shelley A. Wiechmane Radha Holavanahallif Frederick J. Stoddarda,g,h Robert L. Sheridana,b,h Lewis E. Kazisi Jeffrey C. Schneiderc,h Colleen M. Ryana,b,h,* a
Department of Clinical Research, Shriners Hospitals for Children Boston, Boston, MA, United States b
Department of Surgery, Massachusetts General Hospital, Boston, MA, United States c
3
xxx
d
Department of Surgery, University of Washington, Seattle, WA, United States
e
Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
f
Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX, United States
g
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States h
Harvard Medical School, Boston, MA, United States
i
Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States * Corresponding author at: Massachusetts General Hospital, 55 Fruit Street, Bigelow 1302, Boston, MA, United States. E-mail address: [email protected] (C. Ryan). Available online xxx http://dx.doi.org/10.1016/j.burns.2019.12.016 © 2019 Published by Elsevier Ltd.
Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016
burns xxx (2019) xxx
xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the editor
Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire article info
abstract
Article history:
Burn survivors who misuse alcohol and/other substances have been associated with poorer
Available online xxx
long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and
Keywords:
emergence of potential substance misuse through examination of CAGE scores may provide
Burn injury
important information about this population. Using data collected from the Burn Model
Substance misuse
System National Database, demographic and clinical characteristics of individuals who
CAGE questionnaire
reported positive CAGE scores (total score of 2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared. © 2019 Published by Elsevier Ltd.
1. Worldwide, alcohol misuse results in about 3.3 million deaths each year and roughly 31 million people suffer from different drug use disorders [1]. Burn survivors are suggested to be at an increased risk for substance misuse following their injury [2,3]. Recent literature suggests poorer outcomes and clinical complications, such as higher rates of graft failure, increased wound infection, and increased mortality, for burn survivors who use alcohol and/or other substances compared to those who do not [4]. The opioid crisis is currently at the forefront of international attention, therefore understanding the prevalence, patterns, and consequences of substance misuse as it relates to burn injury can potentially provide important information to clinicians on how to better screen and care for their patients. The persistence and emergence of substance misuse among adults in the Burn Model System (BMS) National Database were examined. The CAGE questionnaire is a selfreported assessment tool used to screen for potential substance misuse. CAGE is an acronym for the four questionnaire items: Cut down, Annoyed, Guilty, and Eyeopener. The CAGE instrument was originally designed to examine alcoholism but has since been adapted to also screen for other drug misuse [5]. The validity of the CAGE for burn survivor populations is unknown, though previous research has found the CAGE to be sensitive and specific for
other populations [6 8]. Within the BMS National Database, a total of eight CAGE questions screen for potential alcohol and/or drug misuse, respectively. An example of a CAGE alcohol or drug-related item includes, “Have you ever felt you needed to cut down on your [alcohol or drug] use?”. A “Yes” response to any item corresponds to one point with a maximum of four points possible upon completion of the questionnaire. A score suggestive of substance misuse is defined as an overall positive score of 2 on alcohol or drugrelated items. Data were obtained from the BMS National Database from 1997 2018 [9]. Burn survivors aged 18 years or older who completed self-reported CAGE questionnaires at two time points: 1) discharge questionnaire assessing pre-injury substance misuse (hence referred to as “pre-injury”) and 2) follow-up questionnaire at 6, 12, or 24 months post-injury were included. Follow-up CAGE questionnaires assessed potential substance misuse in the past 30 days. CAGE scores and trajectories over time following burn injury were reviewed. Demographic and clinical characteristics were compared for participants who reported positive CAGE scores for either alcohol or drugs and those who reported negative CAGE scores. A total of 466 adult burn survivors were included in the analysis. Approximately 18% of these survivors reported a positive CAGE score for pre-injury substance misuse and over half of those (62.7%) reported positive CAGE scores at a follow-up time point. Of those who reported negative
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016
JBUR 6014 No. of Pages 3
2
burns xxx (2019) xxx
xxx
Table 1 – Demographic and clinical characteristics of the study population. CAGE + Pre-Injurya (n = 83) Age, mean years (SD)c Male Gender, percent (n)c White, Non-Hispanic, percent (n) Burn Size, mean percent (SD) a b c
CAGE - Pre-Injuryb (n = 383)
42 (13.6) 69 (57) 75 (62) 21 (23.1)
48 67 65 18
(15.9) (255) (249) (18.4)
CAGE +: CAGE (Cut Down, Annoyed, Guilty, Eye-opener) questionnaire score of 2. CAGE -: CAGE (Cut Down, Annoyed, Guilty, Eye-opener) questionnaire score of < 2. Statistically significant differences in age and gender were found (p 0.01).
Table 2 – Number of CAGE scores for the study population at discharge and follow-up. CAGE + Pre-Injurya (n = 83) CAGE + at Follow-Upb (n) CAGE - at Follow-Upb (n) a b
52 31
CAGE
Pre-Injurya (n = 383) 34 349
Pre-Injury: CAGE pre-injury data collected at time of discharge. Follow-Up: CAGE post-injury data collected at 6, 12, or 24 months.
pre-injury CAGE scores (82.2%), 8.9% reported a positive CAGE score at a later follow-up post-burn. Individuals reporting positive CAGE scores (alcohol or drug misuse) pre-injury were more likely to be male and were younger than those who reported negative CAGE scores pre-injury (p <0.01). No significant differences in burn size or race were detected between groups. These data indicate that about 1 in 5 burn survivors screened positive for a potential pre-injury substance misuse issue. For a majority of these individuals, positive CAGE scores at later follow-up suggest that substance misuse persists after treatment for the acute burn injury. Additionally, a notable fraction of those individuals without pre-injury substance misuse issues, as assessed by the CAGE at acute burn discharge, screened positively for substance misuse at follow-up during the next several years. (Tables 1 and 2) The CAGE scores gleaned from the BMS National Database reflect the need for routine alcohol and drug misuse screening of burn survivors at long-term follow-up after injury. New studies are needed to understand the extent of substance misuse in this population as this study was limited by a small sample size and partial data set. These data highlight the importance of screening and support of burn survivors for substance misuse, particularly in the first two years following burn injuries. Burn injury- oriented education on the risks and consequences of substance misuse may help improve long-term outcomes.
Conflict of interest The authors, G.G. Grant, L.E. Kazis, and C.M. Ryan declare the following financial interests which may be considered as potential competing interests: MediWound Ltd. The remaining authors have no conflicts of interest to disclose.
Funding The contents of this letter to the editor were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPBU0001). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this letter do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. This study was also partially supported by the Fraser Fund of the Massachusetts General Hospital.
REFERENCES
[1] World Health Organization. Global Health Observatory (GHO) data. 2017 Situation and trends. Screening and brief intervention for substance use in primary Care: data by country. [2] Sveen J, Oster C. Alcohol consumption after severe burn: a prospective study. Psychosomatics 2015;56:390 6. [3] Rehou S, Mason S, MacDonald J, Pinto R, Jeschke MG. The influence of substance misuse on clinical outcomes following burn. Burns 2017;43:1493 8. [4] Klifto KM, Shetty PN, Slavin BR, Gurno CF, Seal SM, Asif M, et al. Impact of nicotine/smoking, alcohol and illicit substance use on outcomes and complications of burn patients requiring hospital admission: systematic review and meta-analysis. Burns 2019, doi:http://dx.doi.org/10.1016/j.burns.2019.08.003 (In Press). [5] Ewing J. Detecting alcoholism: the CAGE questionnaire. J Am Med Assoc 1984;252(14):1905 7. [6] Chen YT, Ibragimov U, Nehl EJ, Zheng T, He N, Wong FY. Validity of the CAGE questionnaire for men who have sex with men (MSM) in China. Drug Alcohol Depend 2016;160:151 6. [7] Dezman ZDW, Gorelick DA, Soderstrom CA. Test characteristics of a drug CAGE questionnaire for the detection
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016
JBUR 6014 No. of Pages 3
burns xxx (2019) xxx
of non-alcohol substance use disorders in trauma patients. Injury Int J Care Injured 2018;49:1538 45. [8] Malet L, Schwan R, Boussieron D, Aubley-Cuvelier B, Llorea PM. Validity of the CAGE questionnaire in hospital. Eur Psychiatry 2015;20:484 9. [9] Goverman J, et al. The national institute on disability, independent living, and rehabilitation research burn model system: twenty years of contributions to clinical service and research. J Burn Care Res 2017;38(1):240 53.
Gabrielle G. Granta,b Audrey E. Wolfec Catherine R. Thorpea Nicole S. Gibrand Gretchen J. Carrougherd Shelley A. Wiechmane Radha Holavanahallif Frederick J. Stoddarda,g,h Robert L. Sheridana,b,h Lewis E. Kazisi Jeffrey C. Schneiderc,h Colleen M. Ryana,b,h,* a
Department of Clinical Research, Shriners Hospitals for Children Boston, Boston, MA, United States b
Department of Surgery, Massachusetts General Hospital, Boston, MA, United States c
3
xxx
d
Department of Surgery, University of Washington, Seattle, WA, United States
e
Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
f
Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX, United States
g
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States h
Harvard Medical School, Boston, MA, United States
i
Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States * Corresponding author at: Massachusetts General Hospital, 55 Fruit Street, Bigelow 1302, Boston, MA, United States. E-mail address: [email protected] (C. Ryan). Available online xxx http://dx.doi.org/10.1016/j.burns.2019.12.016 © 2019 Published by Elsevier Ltd.
Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
Please cite this article in press as: G.G. Grant, et al., Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire, Burns (2019), https://doi.org/10.1016/j.burns.2019.12.016