Nutritional status of substance abusers with mandible fractures

j Oral Max4oiac Surg 58 153-157 2000

Nutritional Status of Substance Abusers With Mandible Fractures Richard C. Manzcs, Jr, DMD, * Kbomas B. Dodson, DMD, MPH, f Edulard J. Miller, Jr, DMD,f and Vincent J. Perciaccante, DDSJ The purposes of this study were 1) to assess the validity of patient self-report in identifying illegal substance abuse and 2) to identify nutritional deficiencies in substance abusers presenting for treatment of mandible fractures. To address the research purposes, a prospective cohort study was conducted Patients and Methods: of patients presenting for treatment of mandible fractures. A urine drug screen was used to determine the validity of patient self-report of substance abuse. For purposes of assessing nutritional status, 2 categories of substance abusers were identified: illegal and legal (alcohol). The nutritional status was measured using various laboratory markers.

Purpose:

The sample was composed of 93 subjects. Urine drug studies were available for 32 patients. Of the 22 patients who denied illegal drug use, 12 (55%) had a positive drug screen. Of the 10 patients reporting a positive history of illicit drug use, 7 (70%) had a positive urine drug screen (P = .47). A positive correlation was found between alcohol exposure and serum aspartate aminotransferase, mean corpuscular volume, and lactate dehydrogenase. Positive drug screens also were associated with increased serum ferritin levels.

Results:

The results of this study suggest that patient self-report of illicit drug use may be unreliable. The findings also suggest that legal and illegal substance abusers presenting for treatment of mandible fractures have minimal nutritional deficiencies.

Conclusions:

alcohol abuse as a risk factor for the development of fibrous union in mandible fracture patients. Alcohol abusers constituted 63% of the patients who developed fibrous unions. Chronic alcohol exposure may inhibit fracture healing because of abnormal bone metabolism, resulting in hypocalcemia, hypercalciuria, diminished levels of vitamin D metabolites, suppression of osteoblast function, and decreased levels of serum osteocalcin3,+ Based on the results of their study, Haug and Schwimmer recommended that strong consideration be given to treating alcohol abusers with rigid internal fixation. Numerous medical problems have been associated with intravenous drug abuse, including hepatitis, cutaneous infections, malabsorption, and malnourishment.5 The current medical literature fails to support a direct association between intravenous drug abuse and bone healing; however, the associated problems of malnourishment, infection, and malabsorption have been correlated with a higher frequency of nonunion6,’ A review of the literature indicates general agreement that chronic substance abusers are more likely to have complications after treatment of their mandible fractures. The reported increased risk for complications in substance abusers may be multifactorial. They are reported to be noncompliant, may prematurely release maxillomandibular fixation, and fail to

Abusers of illegal substances and alcohol have been reported to be at higher risk for complications after treatment of mandible fractures. A retrospective study of 352 patients with mandible fractures reported postoperative complication rates of 30% for intravenous drug abusers (TVDA), 19% for abusers of nonintravenous drugs, 15.5% for chronic alcohol abusers, and 6.2% for patients not chronically using drugs.’ Therefore, identifying substance abusers preoperatively may aid in formulating appropriate treatment plans. A 1994 study by Haug and Schwimmer’ identified

‘Formerly. Surgery.

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tine. Atlanta.GA; Currently. Private Practice. Athens. GA. tAssociateProfessor. Division of Oral and Maxillofacial Department of Surgery. Emory Universi~ School of Atlanta.

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Amer~con Assoc~ot~on 01 Oral and Mcx~llofac,al

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Address correspondence and reprint requests Prince Avc, Suite 101E. Athens. GA 30606. ir 2000

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154

NUTRITIONAL

follow postoperative dietary and wound care instructions.81’ Malnutrition has also been cited as a factor in postoperative complications among substance abusers, but the data from previous studies were inconclusive. The purpose of this study was to address 2 research questions: 1) is patient self-report of illegal substance abuse reliable, and 2) are abusers of illegal substances and alcohol malnourished?

Patients

and

Methods

STUDY DESIGN/SAMPLE To address the research purpose, a prospective cohort study design composed of a sample of patients presenting to the Emory University School of Medicine oral and maxillofacial surgery service at Grady Memorial Hospital between September 1995 and February 1998 for initial treatment of mandible fractures was used. All adult patients were eligible for inclusion in the study. For study purposes, patients were divided into 2 groups: illegal substance abusers (ISA) and legal (alcohol) substance abusers (ISA). Use of illegal substances was determined by patient history and confirmed through urine drug screens. Legal substance abusers acknowledged ethanol use by history. Alcohol exposure was measured as a continuous variable, drinkyears; for example, someone who drinks 2 drinks per day for 10 years has 20 drink-years of alcohol exposure. The urine samples were tested for the presence of cocaine metabolites, opiates, narcotics, stimulants, and miscellaneous drugs. To assess the validity of patient self-report of illegal substance abuse, the self-report results were compared with the urine sample results. To prevent erroneous classification of patients as substance abusers, treatment records were reviewed and the timing of hospital-administered narcotics and sedatives was compared with timing of the urine drug screens. Nutritional status was measured by various serum markers. The specific laboratory studies used included hemoglobin, mean corpuscular volume, albumin, prealbumin, ferritin, iron, and transferrin. Liver function tests were also evaluated. For descriptive purposes, data were collected on patient age, sex, number of fractures, and cause of the injury. DATA ANALYSIS Descriptive statistics were computed, and the chisquare test was used to assess the relationship between patient self-report and illegal substance use. To assess the relationship between alcohol exposure and markers of nutritional status, Pearson correlation coefficients were calculated. T-tests were used to assess

STATUS

OF SUBSTANCE

ABUSERS

the relationship between illegal substance abuse and markers of nutritional status. Differences and correlations were considered statistically significant when

PS .05. Results Between September 1995 and February 1998, 93 study patients were enrolled. Data regarding illegal substance abuse were available on 32 patients, with 18 patients testing positive on urine drug screens (ISA+) and 14 patients testing negative (ISA-). The mean age for the ISA+ group was 33.3 2 8.0 years, and the mean age for the ISA- group was 28.8 + 8.6 years (P = .13). Males constituted 94.4% of the ISA+ group and 35.7% of the ISA- group (P < .OOl>. Significant differences in fracture cause were noted between the 2 groups (P = .02). Assault was the most common cause for the ISA+ group (72.2%) whereas motor vehicle accident (MVA) was the most common cause for the ISA- group (35.7%). MVA was the second most likely cause for the ISA+ group (16.7%) whereas assaults and falls each accounted for 28.6% of ISA- group cause. Gunshot wounds (GSW) accounted for Il. 1% of ISA+ group cause and 0% of ISA- group cause. Total fracture number per patient was similar in both groups: 1.6 f 0.6 for the ISA+ group, and 1.7 5 1.O for the ISA- group (P = .S). Of the 10 patients reporting a positive history of illegal substance use, 3 had negative urine drug screens. Of the 22 patients denying illegal substance use, 12 (55%) had positive urine drug screens. Selfreport of illegal substance use was not associated with the results of the urine drug screen (P = .47). Values for nutritional markers in illegal substance abusers are listed in Table 1. Positive drug screens were associated with increased serum ferritin levels (P = ,031). A relationship approaching statistical significance was also noted between positive drug screens and increased hemoglobin (P = ,055) and increased serum magnesium (P = .08). Seventy-four patients reported alcohol use (LSA+). and 19 patients denied alcohol use (LSA-). The mean age for the LSA+ group was 34.1 2 8.26 years, whereas the mean age for the LSA- group was 28.2 Z 9.62 years (P = .009>. Male patients accounted for 82.4% of the LSA+ group and 68.4% of the LSAgroup (P = .18). Significant differences were noted in fracture cause between LSA+ and LSA- groups (P = .008). Both groups reported assault as the most common cause (71.6% LSA+, 42.1% LSA-). MVA was the second most frequent cause for both groups (10.8% ISA+, 36.8% LSA-). Gunshot wounds accounted for 81% and 0% of mandible fractures in the LSA+ and LSAgroups, respectively. The total number of fractures

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MANIJS ET AL

volume (MCV) (P = .025), and lactate dehydrogenase (LDH) (P = .05).

Table 1. NUTRITIONAL MEASURES IN ILLEGAL SUBSTANCE ABUSERS (SA) Nutritional Mea.slKe Hemoglobin MCV Albumin Prealbumin Protein Iron Tmnsferrin Ferritin Magnesium Cholesterol LDH ALP AST

+SA 11.0 88.3 4.2 22.7 7.5 45.4 263.6 2-11.2 1.7 161.8 225.5 71.6 42.0

P

-SA

+ 1.9 12.5 + 2.4 + 4.9 89.1 + 4.4 k 0.6 4.0 + 0.9 5 7.1 26.0 t 13.2 + 0.8 7.1 f 1.4 k 24.7 44.8 Z 44.0 5 51.9 248.6 + 72.9 2 193.7 113.4 + 58.4 -)_ 0.2 1.5 k 0.3 + 32.1 152.1 2 11.0 + 87.1 262.7 + 165.5 -c 14.9 72.5 I 31.7 f 42.8 0.7 Z 38.1

Normal Value’

,055 13.5-17.5 .640 80-97 ,310 3.2-5.5 ,110 1040 ,320 6.0-9.2 ,960 59-158 ,530 200-400 ,031 20-300 .080 1.2-2.1 ,470 180-240 ,430 118-242 .920 39-117 ,930 O-37

Abhrcviations: MCV. mean corpuscular volume; LDH. lactate dchydrogrnasc; ALP. alkaline phosphatasc; AST. aspanate trxxamin:w.

‘Normal lahomtoy values as determined Hospital L;lhoratoy Manual 19881999.

by Grady Memorial

was similar for both groups, 1.66 k 0.73 and 1.7-i f 0.73 for LSA+ and LSA-, respectively (P = .70). Data regarding correlations between drink-years exposure and nutritional markers are reported in Table 2. Alcohol exposure was variable (range, 0 to 250 drink-years; mean, 37.4 t 5 1.6 drink-years). Common nutritional markers for protein deficiency (albumin, prealbumin. and transferrin) did not significantly correlate with alcohol exposure (P = .36, .45, and .65, respectively). A positive correlation was found between drink-years exposure and serum aspartate aminotransferase (AST) (P = .OOl), mean corpuscular per patient

Table 2. DRINK-YEARS EXPOSURE CORRELATED WITH NUTRITIONAL MEASURES Correlation Nutritional Hemoglobin Mean corpuscular Albumin Prealbumin Protein Iron Transferrin Ferritin Magnesium Cholesterol LDH ALP AST

Measure volume (MCV)

Coefficient .oo ,244 -.lOl ,088 -.45 .127 ,053 - ,078 ,062 .092 .216 ,064 ,364

P 1.00

,025' .36 .A5 .69 .29 .65 .58 .50 .40 .Oj' .57 ,001’

Abbreviations: MCV. mean corpuscular volume; LDH, lactate dehydrogcnase; ALP. alkaline phosphatase; AST. aspartate transnminase. ‘Statistically significant.

Discussion Demographic data from this study were generally comparable to previous mandible fracture studies in urban settings. with most of the patients being young males (mean age, 32.9 years; 80% male).1,2,1@‘5The most common cause of fracture in the sample was assault (65.6%>, followed by MVA (I6.1%), falls (8.6%), GSW (6.5%), and sports injury (1 .l%). This distribution of fracture causes was also consistent with previous studies.l~1’~‘z~15 Previous studies have identified a significant percentage of mandible fracture patients as abusers of legal and illegal substances.‘,“,‘5 Other studies have found that substance abuse and mandible fractures are closely related in regard to cause and incidence of complications.‘~‘“iX Passeri et all noted that 30% of patients admitting to intravenous drug use developed postoperative complications. They also noted chronic alcohol abuse was associated with a 15.5% complication rate. t Preoperative nutritional status may be an important variable associated with postoperative healing. Low body weight and hypoalbuminemia have been associated with postoperative complications in patients undergoing surgery. 19.?0Reduced serum levels of albumin, prealbumin, and transferrin are commonly used to diagnose protein-caloric malnutrition. They are also signs of decreased metabolic capacity of the liver in patients with alcohol-induced liver injury.“,zz Several previous studies on substance abuse and mandible fractures have relied on patient self-report to identify substance abusers.‘.‘.15 Various methods of objective corroboration have been applied to assess the validity of self-report, including peer reports, comparison of data with official records, and urine drug screens. The validity of patient self-report of drug use through urine drug screens ranges from 25% to 72% of subjects with positive urine drug screens denying current or recent use.‘s,“’ Our results were consistent with previous reports; 55% of the patients who denied drug use had positive urine drug screens. Interestingly, 30% of the patients who reported current drug use had negative urine drug screens. The reasons for this are unclear, but it may relate to timing of the urine drug screens and the patient’s last use of illicit substances. The results of this study suggest that patient self-report of illicit substance abuse is an unreliable screening tool in patients presenting for treatment of mandible fractures. If one believes accurate information regarding illicit drug use is needed, urine or serum drug testing is indicated. Malabsorption and malnourishrnent have been re-

156 portedly associated with illegal substance abuse.? However, in this study, significant correlations between illegal substance abuse and deficient laboratory nutritional markers were not identified. A relationship between increased ferritin and illegal substance use was found (Z’ = .03 l), and a relationship approaching statistical significance was also noted between illegal substance abuse and serum magnesium (P = .OS) and hemoglobin (P = .055). However, given the multiple outcome measures, these associations may be spurious. Alcohol abuse also has been reported to correlate with increased postoperative complication rates after treatment of mandible fractures.‘,’ The reasons for this may be multifactorial and include malnutrition. Chronic alcohol abuse is considered the most common cause of malnutrition in the Western world.“i Early nutritional studies conducted on hospitalized chronic alcoholic patients with liver disease led to the misconception that alcoholics are commonly severely malnourished.‘“,‘- More recent studies involving middleclass alcoholics without major organ disease show only mild to moderate malnutrition.‘x,19 However, a recently published study reported a 62% rate of malnutrition in alcoholics with no evidence of liver ~jupT,‘” This study did not find significant correlations between most nutritional markers and alcohol exposure. The most commonly accepted laboratory markers of nutrition (albumin, prealbumin, and transferrin) were not significantly correlated with alcohol exposure. An inverse correlation between MCV and alcohol exposure has been reported,31 but this study found a positive correlation between MCV and drinkyears (P = ,025). Folate deficiency in alcoholics may manifest as a macrocytic anemia. This study attempted to measure serum folate, but data were not reported because folate laboratory tests were ordered under an incorrect code on several patients. A correlation between increased LDH and alcohol exposure was also noted (P = .05). Consistent with other studies, a positive correlation between AST and drink-years exposure was also found (P = .OO1).“l There are several possible explanations why this study failed to find a relationship between malnutrition and legal and illegal substance abuse. The average age of the patients who used alcohol was 34.1 2 8.26 years. It is possible that this young patient sample may have had an insticient alcohol exposure to show significant nutritional compromise. This is probably a valid argument in light of more recent studies that failed to find nutritional deficiencies among alcohol abusers without liver disease. A second explanation may be the small sample size. This is especially true for the illegal substance abuser group (n = 32). Perhaps with a larger sample size

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more significant results would have been found. Finally, the statistically significant associations may be spurious because of multiple outcome variables, Itests, and correlation coeticients. One should bear in mind that the increased rate of complications among patients using legal and illegal substances is probably multifactorial. Other studies have reported increased complication rates in poorly compliant patients, including alcohol abusers and illegal drug abusers. Adell et al, in a review of 451 mandible fractures, reported that uncooperative alcoholics were likely to have delayed or nonunions.x Eid et al” noted a 30% complication rate among patients with mandible fractures who were intoxicated with alcohol at the time of injury. Marciani et al”’ reported more postoperative complications in noncompliant patients who left the hospital against medical advice, removed themselves from maxillomandibular fixation, and failed follow-up appointments. I” Stone et al, ’ I in 1991, also noted a trend for increased postoperative infections in poorly compliant patients who prematurely released maxillomandibular fixation after open reduction and wire osteosynthesis. ’ I Although malnutrition may play a role, noncompliance among this patient population is also a concern. In future studies, it will be important to compare and contrast the nutritional status of patients with complications to patients without complications.

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