- Email: [email protected]
The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks
ARTICLE IN PRESS International Emergency Nursing ■■ (2016) ■■–■■
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
The association between alcohol, medicinal drug use and posttraumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks Stig Tore Bogstrand RN, PhD (Head of Research/ Associate professor) a,b,*, Laila Skogstad RN, PhD (Post. Doc. /Associate Professor) c,d, Øivind Ekeberg (Senior Advisor/ Professor emeritus) e,f a
Domain for Forensic Sciences, Norwegian Institute of Public Health, PO Box 4404, Nydalen, Oslo N-0403, Norway Lovisenberg University College, Lovisenberggt. 15b, Oslo 0456, Norway c Department of Acute Medicine, Oslo University Hospital, PO Box 4956, Nydalen, Oslo 0424, Norway d Paramedic Sciences, Oslo and Akershus University College, PO Box 4, ST. Olavs Plass, Oslo 0130, Norway e Division of Mental Health and Addiction, Oslo University Hospital, PO Box 4956, Nydalen, Oslo 0424, Norway f Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway b
A R T I C L E
I N F O
Article history: Received 18 November 2015 Received in revised form 4 March 2016 Accepted 20 March 2016 Keywords: Alcohol Psychoactive medicinal drugs Post-traumatic stress Rescue workers Terror attack Trauma Exposure
A B S T R A C T
Background: The aim of this study was to assess whether the use of alcohol and medicinal drugs among rescue workers as a consequence of the 22 July terrorist attack was associated with post-traumatic stress symptoms, and explore if there were differences between affiliated and unaffiliated rescue workers. Methods: Ten months after the bombing in the Oslo government district and the shooting at the youth camp on Utøya Island, a cross-sectional study of 1790 rescue and healthcare workers was conducted. The questionnaire included information on medicinal drug and alcohol use, experiences during rescue work and PTSS. Results: Few rescue workers reported alcohol (6.8% n = 119) or medicinal drug (5.5% n = 95) use as a consequence of participation in the 22 July terror attacks. Alcohol and medicinal drug use was associated with an elevated level of PTSS among the rescue workers who reported to use medicinal drugs (11.1 95% CI: 5.7–21.8) or alcohol (10.0 95% CI: 5.2–19.0) as a consequence of the terror attacks. Conclusion: The study found a low level of post-traumatic stress symptoms (PTSS) and alcohol and medicinal drug use among the rescue workers after the terror attacks in Norway on 22 July 2011. There was a strong association between both medicinal drug and alcohol use and elevated PTSS. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction On 22 July 2011, a car bomb was detonated in the Oslo government district inflicting heavy structural damage. Eight people were killed and many were injured. A few hours later, shooting were reported from Utøya Island, about 40 kilometres north-west of Oslo, where the Norwegian Labour Party were holding a youth camp. In the second attack, 69 adolescents or young adults were killed, and many were injured (Gaarder et al., 2012; Sollid et al., 2012). Survivors from the two attacks were either transported to centres for victims and next of kin, outpatient emergency services, or admitted to hospitals. The healthcare treatment and the psychosocial
* Corresponding author. Division of Forensic Medicine and Drug Abuse Research, Norwegian Institute of Public Health, PO Box 4404, Nydalen, Oslo N-0403, Norway. Tel.: +47 21 07 78 22; fax: +47 22 35 36 05. E-mail address: [email protected] (S.T. Bogstrand).
follow-up for both the survivors and their next of kin lasted for several weeks. Professional rescue workers from the police, the fire service, volunteers affiliated to different organizations who are trained to assist in various rescue operations and healthcare departments were involved in the wake of the attacks. Unaffiliated rescue workers who happened to be close to the terror site contributed substantially to the rescue work in the early stages before the police and other professional rescue workers arrived at Utøya Island. Professional rescue workers have reported higher prevalence rates of post-traumatic stress symptoms (PTSS) than the general population (Berger et al., 2012). Rescue work at major disasters where many people are injured or dead may lead to PTSS afterwards for the rescue workers involved. Using alcohol to cope with such symptoms has been reported in other studies (North et al., 2002; Stewart et al., 2004). A study of Swiss voluntary rescue workers who had worked at an airline crash site reported associations between frequency and severity of PTSS and coping-motivated drinking (Stewart
http://dx.doi.org/10.1016/j.ienj.2016.03.003 1755-599X/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
2
et al., 2004). Post-disaster alcohol use disorders and drinking to cope seem to be associated with indicators of poor functioning among rescue workers (North et al., 2002). Few studies have investigated the use of medicinal drugs among rescue workers involved in traumatic rescue operations. But a study of exposure to the South East Asia tsunami disaster in 2004 reported associations between increased use of medicinal drugs and PTSD symptoms (Vetter et al., 2008). After the terror attracts in Norway 2011, a study was conducted among all the rescue workers involved. Some results of this study have been presented in two papers, and report low prevalence of PTSS among the rescue workers involved (Gjerland et al., 2015; Skogstad et al., 2015). However, it seems like the unaffiliated rescue workers have higher rates of PTSS (Gjerland et al., 2015). Most previous studies on alcohol use after traumatic events have focused on professional rescue workers. The coping strategies of unaffiliated rescue workers compared to professional rescue workers might be different, and a comparison of alcohol and medicinal drug use as a coping strategy between these groups seems to be missing in the current literature. The aim of this study was to assess whether the use of alcohol and medicinal drugs among rescue workers as a consequence of the 22 July terrorist attack was associated with post-traumatic stress symptoms, and explore if there were differences between affiliated and unaffiliated rescue workers. 2. Materials and methods 2.1. Study design and setting The study was cross-sectional, anonymous and questionnaire based. It was conducted between March and June 2012, approximately eight to 11 months after the terror attacks (mean 10 months). Respondents were all personnel involved in the rescue and healthcare service of victims and their relatives after the bombing in the Oslo government district and the shooting at the youth camp on Utøya Island on 22 July 2011. The rescue workers were involved from between one day to several weeks. Professional and unaffiliated rescue workers who contributed to the rescue operations and the treatment of survivors and their next of kin between 22 July and 5 August 2011 were invited to participate in the study. The reporting of this study conforms to the STROBE statement (von Elm et al., 2014). The present paper is part of a larger study examining the consequences for the rescue workers of the 2011 terrorist attacks (Gjerland et al., 2015; Skogstad et al., 2015). 2.2. Participants Six disciplines of rescue workers were included: 1) police officers; 2) firefighters; 3) trained and affiliated volunteers: i.e. the Norwegian Civil Defence and the National Guard, and volunteer organizations: i.e. Norwegian Search and Rescue Dogs and Norwegian People’s Aid; 4) general healthcare providers (physicians, nurses/ nurse assistants, paramedics, other personnel working in hospital; 5) psychosocial healthcare providers (psychiatrists, psychologists, counsellors [priests, other employees of the church and imams], social workers and nurses; and 6) unaffiliated rescue workers: i.e. civilians who just happened to be at the campsite close to Utøya Island. The distribution of the questionnaires was done in different ways. For the professional groups, a leader within each unit was appointed to distribute the questionnaires to personnel involved in the rescue work. The completed questionnaires were returned anonymously into a sealed box, which was returned to the study group. Some questionnaires were, however, distributed by mail when this was more convenient. The municipality of Hole provided names and addresses for the unaffiliated volunteers, and the questionnaire was
sent to them by mail with return envelopes. For all groups, a reminder was sent after approximately 1 month. 2.3. Variables Demographic variables were gender, age (<30, 30–49 or >50), and if the respondent had an organizational affiliation. The PTSD Checklist (PCL) was used to assess symptoms of post-traumatic stress disorder (PTSD). It is widely used and was first presented by Frank Weathers and colleagues in 1993 (Weathers et al.). The 17-item questionnaire (range 17–85) includes symptoms (in the last month) needed for a formal PTSD diagnosis according to the Diagnostic Statistical Manual of Mental Disorders (DSM IV) (Weathers et al.). The items are scored on a 5-point Likert scale (1 = not at all to 5 = extremely). There are three versions of PCL: M (military), C (civilian) and S (specific). In this study, the specific version was used because it asks about symptoms after an identified “stressful experience.” The results of the 17 items were summarized, and then divided into three categories where a score above 50 points may indicate PTSD, and a score above 35 may indicate clinical problems. The PCL-S has been validated in a sample of Norwegian survivors from the South East Asia tsunami disaster in 2004 (Hem et al., 2012). The rescue workers were exposed to different kinds of threats: ongoing shooting at Utøya Island and fear of collapsing buildings in the city centre, in addition to fear of subsequent terror attacks towards, e.g. hospitals. Place of work was therefore of special interest and thus registered in the following categories: sites of terror, hospital or outpatient emergency clinic, centre for victims, and next of kin and other (patrolling, office, etc.). Experience of peritraumatic threats was measured by three questions: Have you experienced: 1) fear of explosion/shooting, 2) fear of being injured, 3) other risks/uncertainty? The response alternatives were: a) no, not experienced, b) yes, not/a little stressful, c) yes, moderately stressful, d) yes, very stressful. The answers were dichotomized: have not/ have experienced such fear. One question measured concern for relatives/friends that might be present at the terror sites during the attacks. The answers were dichotomized: have not/have been concerned for relatives. Seven items measured if the rescue worker had witnessed situations or impressions that were considered to be stressful. The Norwegian Centre for Violence and Traumatic Stress Studies developed and used these items after the South East Asia tsunami disaster in 2004 (Thoresen et al., 2009). Questions were as follows: Did you experience: disaster victims searching for next of kin, disaster victims in despair, disaster victims with major physical injuries, dead bodies, body parts, or physical contact with dead bodies, and strong smells or other sensory perceptions? The items were collapsed into one dichotomy variable. The variable was positive if the rescue worker reported any witnessing of the experiences described above. Alcohol and medicinal drug use was measured by seven questions, three questions addressed the use of alcohol: Have you as a consequence of the terror attacks used alcohol 1) to calm down, 2) to be in a better mood, and 3) to sleep? The response alternatives for each question were: a) ‘no’, b) ‘in the first week’, and c) ‘for more than one week’. The three questions were collapsed into one dichotomy variable where the answer ‘no’ was coded as negative and any alcohol use was coded as positive. In order to assess the use of medicinal drugs, four questions were used: Have you as a consequence of the terror attacks used one or more of the following medicinal drugs: 1) sleep medicine, 2) medication to calm down, 3) medication for depression, 4) other medication? The response alternatives for each type of medicinal drug were: a) ‘no’, b) ‘a few times’, c) ‘weekly’, or d) ‘daily’. The four questions were collapsed into one dichotomy variable where the answer ‘no’ was coded as negative, and ‘a few times’, ‘weekly’ or ‘daily’ were coded as positive.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
Table 2 Alcohol or medicinal drug use as a consequence of the terror attacks.
Table 1 Characteristics of the sample (n = 1790). Variable Age group
Gender Peri-traumatic threat Witnessing PCL score
Place of work
Groups
<30 30–49 ≥50 Women Shooting, injury, hazard Worrying about family/ friends yes 17.0–34.9 (few symptoms) 35.0–49.9 (sub-threshold PTSD) ≥50 (PTSD level) Sites of terror Hospital or outpatient emergency clinic Centre for victims and next of kin Other (patrolling, office, etc.) Unaffiliated rescue workers
3
n (total: 1790)
%
Alcohol use
No
The first week
More than one week
285 1091 403 881 866 559 1318 1705 48 17 533 717 162 362 55
16 61 22 50 49 31 74 96 3 1 30 40 9 20 3
To calm down (n = 1764) To cheer up (n = 1749) To sleep (n = 1749) Any use of alcohol (n = 1766)
94.7% 98.1% 97.4% 93.2%
4.3% 1.3% 1.8% 5.3%
1.0% 0.6% 0.7% 1.5%
Missing variables: Age group, 11; women, 11; PCL score, 20; unorganized, 1; peritraumatic threat, 27; worrying, 32; place of rescue work, 16; and witnessing, 25.
2.4. Statistical methods Bivariate tables and chi-square statistics and binary logistic regression analyses were used to calculate associations between medicinal drug use, alcohol and other variables (OR = odds ratio). PASW 18 (IBM.inc) was used for all statistical analyses and the limit for statistical significance was p < .05. 2.5. Ethics The study was performed anonymously. Due to the anonymous handling of the data, the research project was outside the remit of the Act on Medical and Health Research, and an approval from the Regional Ethics Committee was not required. The study was reviewed and approved by the Oslo University Hospital’s Privacy Protection Supervisor, and performed in accordance with the data storage and confidentiality regulations. An information letter was enclosed with the questionnaire. The return of the questionnaire was assumed to imply informed consent. 3. Results 3.1. Participants and sample description Of the 2922 distributed questionnaires, 1790 were returned, yielding a response rate of 61%. As the study was anonymous, no data on non-respondents were collected. The response rate differed between the groups of rescue workers. Firefighters had the highest response rate (82%, n = 102), then general healthcare providers (68%, n = 858), psychosocial healthcare providers (66% n = 214), the police (51%, n = 253), affiliated volunteers (51%, n = 307), and unaffiliated rescue workers (46% n = 56). Most of the rescue workers were professionals or trained and affiliated volunteers (97% n = 1734). However, 3% (n = 56) were unaffiliated volunteers who contributed to the rescue operation. In the total sample, 50% (n = 881) were women, and 61% (n = 1091) were 30–49 years of age. Peri-traumatic fear of explosion, shooting, fear of getting injured or other fear or insecurity were experienced by 49% (n = 866), while 31% (n = 559) reported to have been worried that their friends or family might be at the terror sites during the attacks (Table 1). A substantial proportion of the participants contributed to the rescue work at the sites of terror (30%, n = 533). Post-traumatic stress level was low, a PCL score above 50 was found in 1% (n = 17) of the participants, and 3% (n = 48) scored above 35 points (Table 1). Among the un-
Medicinal drug use
No
A few times
Weekly
Daily
Sleep medicine (n = 1748) Medication to calm down (n = 1727) Medication for depression (n = 1725) Other medication (n = 1734) Any use of medicinal drugs (n = 1763)
95.9% 99.1% 99.4% 98.2% 94.5%
3.1% 0.8% 0.2% 1.3% 4.0%
0.5% – – 0.1% 0.5%
0.5% 0.1% 0.4% 0.5% 1.0%
affiliated rescue workers, a greater proportion reported PCL scores above 50 (15% n = 8) and 35 (24% n = 13). 3.2. Alcohol and medicinal drug use as a consequence of the terror attacks In all, 6.8% (n = 119) reported alcohol use, and 5.5% (n = 95) reported to use medicinal drugs as a consequence of the terror attacks (Table 2). Alcohol was most frequently used to calm down (5.3% n = 94). Few used alcohol for more than one week after the attacks, 1% (n = 18%) reported having used alcohol to calm down, while 0.7% (n = 13) reported having used alcohol to sleep and 0.6% (n = 11) to be in a better mood. The most prevalent medicinal drug was sleep medicine (4.1% n = 72), most reported to have used sleep medicine a few times (3.1% n = 56), and only a few reported persistent use weekly (0.5% n = 8) or daily (0.5% n = 8). 3.3. Multivariate analysis of medicinal drug and alcohol use In the multivariate analysis, alcohol use was associated with a positive PCL score. A PCL score above 35 gave an OR of 10.0 (95% CI: 5.2–19.0) and a PCL score above 50 an OR of 11.7 (95% CI: 4.2– 32.6) for alcohol use as a consequence of the terror attacks. Other variables associated with alcohol use were peri-traumatic threat (fear of shooting, fear of being injured, or other hazard) (OR: 2.0 95% CI: 1.3–3.0) and worrying about friends and family during the rescue operation (OR: 1.7 95% CI: 1.1–2.6) (Table 3). There was a statistically significant association between medicinal drug use as a consequence of the terror attacks and a PCL score above both 35 and 50. A PCL score above 35 gave an OR of 11.1 (95% CI: 5.7–21.8), and a score above 50 gave an OR of 49.9 (95% CI: 16.4– 151.9). Other variables associated with medicinal drug use were to witness stressful situations or impressions (OR: 2.5 95% CI: 1.2– 5.0), and worrying about friends or family during the rescue operation (OR: 1.9 95% CI: 1.2–3.1) (Table 4). The unaffiliated rescue workers had a higher prevalence of alcohol and medicinal drug use as a consequence of the terror attacks compared to professionals or trained and affiliated volunteers (alcohol: 25.9% n = 14 vs 6.1% n = 105, p < .001; medicinal drugs: 31.5% n = 17 vs 4.6% n = 78, p < .001, respectively). The associations were, however, not significant in multivariate analysis. 4. Discussion Few rescue workers reported alcohol or medicinal drug use as a consequence of participation in the 22 July terror attacks. Alcohol and medicinal drug use was, however, associated with an elevated level of PTSS among the rescue workers who reported to use medicinal drugs or alcohol as a consequence of the terror attacks.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
4
Table 3 Associations between alcohol use as a consequence of the terror attacks and demographic variables, peri-traumatic experiences and PCL scores. Variable Age group
Gender Peri-traumatic threat: shooting, injury, hazard Worrying about family/friends Witnessing PCL score
Place of rescue work
Unaffiliated rescue workers
<30 (ref) 30–49 ≥50 Women Yes Yes Yes 17.0–34.9 (few symptoms) (ref) 35.0–49.9 (sub-threshold) ≥50 (PTSD level) Sites of terror (ref) Hospital or outpatient emergency clinic Centre for victims and next of kin Other (patrolling, office, etc.) Yes
Unaffiliated rescue workers reported to use more alcohol and medicinal drugs compared to professionals or trained and affiliated volunteers. In line with the findings of the current study, an association between PTSS and alcohol use has earlier been described among volunteers involved in rescue work after an airline disaster (Stewart et al., 2004). A study of Red Cross disaster relief workers who responded to the 9/11 attacks gave conflicting results where both increases and decreases in alcohol use were associated with PTSS (Simons et al., 2005). Among the firefighters involved in the rescue work after the Oklahoma bombing, alcohol use as a consequence was reported by a higher proportion compared to the present study (19% vs 6.8%) (North et al., 2002). Medicinal drug use among persons exposed to the South East Asia tsunami disaster in 2004 disaster was associated with PTSS (Vetter et al., 2008). North et al. (North et al., 2002) reported that 10% of the firefighters used medicinal drugs to cope with their feelings after the Oklahoma bombing. A Dutch study has compared the health of police officers involved in an airline disaster to colleagues that had not been involved 8.5 years after the event. The study showed elevated self-initiated drug use among the officers involved in the disaster during the past 12 months (Slottje et al., 2008). A study of drug and alcohol use among Norwegian employees in selected business areas was published in 2015. The study showed that the use of alcohol and illicit drugs are low among healthcare professionals, but the use of medicinal drugs is higher than among the other groups of workers (Edvardsen et al., 2015). We have no data on whether the medicinal drugs, reported to be
Univariate OR (95% CI)
P-value
1.2 (0.7–2.1) 1.2 (0.7–2.3) 1.4 (0.9–2.0) 2.7 (1.8–4.0) 2.0 (1.4–2.9) 1.8 (1.1–3.1)
0.50 0.50 0.09 <0.001 <0.001 0.02
12.4 (6.8–22.9) 13.5 (4.9–37.1)
<0.001 <0.001
0.9 (0.5–1.4) 0.6 (0.3–1.4) 1.3 (0.8–2.1) 5.3 (2.8–10.1)
0.5 0.2 0.4 <0.001
Multivariate OR (95% CI)
P-value
2.0 (1.3–3.0) 1.7 (1.1–2.6)
0.003 0.01
10.0 (5.2–19.0) 11.7 (4.2–32.6)
<0.001 <0.001
taken as a consequence of the terror attacks in this study, were prescribed or self-initiated use. Alcohol and substance use may be part of a coping style that includes ineffective coping strategies such as avoidance (Ouimette et al., 1998). An association between alcohol use and PTSS has been found in several studies of individuals under treatment for substance abuse problems (Berenz and Coffey, 2012; Ouimette et al., 1998). Moreover, there is evidence that abstinence from alcohol and illicit drugs can lead to reduction in PTSS, even without an intervention directed at PTSD (Berenz and Coffey, 2012). Short-term use of prescribed medicinal drugs may be appropriate for rescue workers after major events, but information on the disadvantages of using alcohol and medicinal drugs as a coping style after stressful events should be incorporated in the training and follow-up of rescue workers. The association between engaging in unorganized rescue work and increased alcohol or medicinal drug use was not significant in multivariate analysis. Still it is important that the unaffiliated rescue workers also get a psychological follow-up, in the same manner as the professional rescue workers get their follow-up. These unaffiliated rescue workers may be harder to reach after the rescue work is completed, as rescue work is not their profession, but they will still be in need of follow-up. 4.1. Strengths and limitations The inclusion of several professional groups and the great sample size, as well as the use of validated questionnaires, are the strengths
Table 4 Associations between medicinal drug use as a consequence of the terror attacks and demographic variables, peri-traumatic experiences and PCL scores. Variable Age group
Gender Peri-traumatic threat: shooting, injury, hazard Worrying about family/friends Witnessing PCL score
Place of rescue work
Unaffiliated rescue workers
<30 (ref) 30–49 ≥50 Women Yes Yes Yes 17.0–34.9 (few symptoms) (ref) 35.0–49.9 (sub-threshold) ≥50 (PTSD level) Sites of terror (ref) Hospital or out-patient emergency clinic Centre for victims and next of kin Other (patrolling, office etc.) Yes
Univariate OR (95% CI)
P- value
0.9 (0.5–1.6) 1.0 (0.5–1.9) 1.6 (1.0–2.4) 2.2 (1.4–3.4) 1.9 (1.2–2.9) 3.0 (1.6–6.0)
0.73 0.91 0.04 0.001 0.003 0.001
14.5 (7.7–27.4) 48.4 (16.1–145.6) 0.8 (0.5–1.3) 0.7 (0.3–1.5) 0.7 (0.4–1.3) 9.6 (5.2–17.8)
<0.001 <0.001
Multivariate OR (95% CI)
P- value
1.9 (1.2–3.1) 2.5 (1.2–5.0)
0.005 0.01
11.1 (5.7–21.8) 49.9 (16.4–151.9)
<0.001 <0.001
0.3 0.4 0.3 <0.001
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
of this study. This study has some limitations. Self-reported use of alcohol and medicinal drugs might be subject to underreporting due to the timespan between the rescue operation and the distribution of the questionnaire. We have no data to distinguish between prescription and non-prescription use of medicinal drugs. The variable response rate in the different groups of rescue workers and especially the low response rate among unaffiliated rescue workers are major limitations. The unaffiliated rescue workers were recruited via questionnaires sent by mail with return envelopes, other ways of recruiting these participants might have given better participation. As we have no data on non-participants, it is not possible to assess the direction of any possible bias. 4.2. Conclusion There was a low level of post-traumatic stress symptoms (PTSS) and use of alcohol and medicinal drug as a consequence of the 22 July terrorist attack among the rescue workers involved. A strong association between both the use of alcohol and medicinal drugs as a consequence of the terror attacks and elevated PTSS was observed. Conflict of interest None declared. References Berenz, E.C., Coffey, S.F., 2012. Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current Psychiatry Reports. 14, 469–477. Berger, W., Coutinho, E.S., Figueira, I., Marques-Portella, C., Luz, M.P., Neylan, T.C., et al., 2012. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Social Psychiatry and Psychiatric Epidemiology. 47, 1001–1011. Edvardsen, H.M., Moan, I.S., Christophersen, A.S., Gjerde, H., 2015. Use of alcohol and drugs by employees in selected business areas in Norway: a study using oral fluid testing and questionnaires. Journal of Occupational Medicine and Toxicology (London, England). 10, 46.
5
Gaarder, C., Jorgensen, J., Kolstadbraaten, K.M., Isaksen, K.S., Skattum, J., Rimstad, R., et al., 2012. The twin terrorist attacks in Norway on July 22, 2011: the trauma center response. The Journal of Trauma and Acute Care Surgery 73, 269–275. Gjerland, A., Pedersen, M.J., Ekeberg, O., Skogstad, L., 2015. Sick-leave and help seeking among rescue workers after the terror attacks in Norway, 2011. International Journal of Emergency Medicine. 8, 81. Hem, C., Hussain, A., Wentzel-Larsen, T., Heir, T., 2012. The Norwegian version of the PTSD Checklist (PCL): construct validity in a community sample of 2004 tsunami survivors. Nordic Journal of Psychiatry. 66, 355–359. North, C.S., Tivis, L., McMillen, J.C., Pfefferbaum, B., Cox, J., Spitznagel, E.L., et al., 2002. Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. Journal of Traumatic Stress. 15, 171–175. Ouimette, P.C., Brown, P.J., Najavits, L.M., 1998. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addictive Behaviors. 23, 785–795. Simons, J.S., Gaher, R.M., Jacobs, G.A., Meyer, D., Johnson-Jimenez, E., 2005. Associations between alcohol use and PTSD symptoms among American Red Cross disaster relief workers responding to the 9/11/2001 attacks. The American Journal of Drug and Alcohol Abuse. 31, 285–304. Skogstad, L., Fjetland, A.M., Ekeberg, O., 2015. Exposure and posttraumatic stress symptoms among first responders working in proximity to the terror sites in Norway on July 22, 2011 – a cross-sectional study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 23, 23. Slottje, P., Smidt, N., Twisk, J.W., Huizink, A.C., Witteveen, A.B., van Mechelen, W., et al., 2008. Use of health care and drugs by police officers 8.5 years after the air disaster in Amsterdam. European Journal of Public Health. 18, 92–94. Sollid, S.J., Rimstad, R., Rehn, M., Nakstad, A.R., Tomlinson, A.E., Strand, T., et al., 2012. Oslo government district bombing and Utoya island shooting July 22, 2011: the immediate prehospital emergency medical service response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 20, 3. Stewart, S.H., Mitchell, T.L., Wright, K.D., Loba, P., 2004. The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. Journal of Anxiety Disorders. 18, 51–68. Thoresen, S., Tonnessen, A., Lindgaard, C.V., Andreassen, A.L., Weisaeth, L., 2009. Stressful but rewarding: Norwegian personnel mobilised for the 2004 tsunami disaster. Disasters. 33, 353–368. von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P., et al., 2014. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. International Journal of Surgery. 12, 1495–1499. Vetter, S., Rossegger, A., Rossler, W., Bisson, J.I., Endrass, J., 2008. Exposure to the tsunami disaster, PTSD symptoms and increased substance use – an Internet based survey of male and female residents of Switzerland. BMC Public Health. 8, 92. Weathers, F.W., Lie, B.T., Herman, D.S., Huska, J.A., Keane, T.M., The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility., The Meeting of the Society of Traumatic Stress Studies, San Antonio, Texas.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
The association between alcohol, medicinal drug use and posttraumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks Stig Tore Bogstrand RN, PhD (Head of Research/ Associate professor) a,b,*, Laila Skogstad RN, PhD (Post. Doc. /Associate Professor) c,d, Øivind Ekeberg (Senior Advisor/ Professor emeritus) e,f a
Domain for Forensic Sciences, Norwegian Institute of Public Health, PO Box 4404, Nydalen, Oslo N-0403, Norway Lovisenberg University College, Lovisenberggt. 15b, Oslo 0456, Norway c Department of Acute Medicine, Oslo University Hospital, PO Box 4956, Nydalen, Oslo 0424, Norway d Paramedic Sciences, Oslo and Akershus University College, PO Box 4, ST. Olavs Plass, Oslo 0130, Norway e Division of Mental Health and Addiction, Oslo University Hospital, PO Box 4956, Nydalen, Oslo 0424, Norway f Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway b
A R T I C L E
I N F O
Article history: Received 18 November 2015 Received in revised form 4 March 2016 Accepted 20 March 2016 Keywords: Alcohol Psychoactive medicinal drugs Post-traumatic stress Rescue workers Terror attack Trauma Exposure
A B S T R A C T
Background: The aim of this study was to assess whether the use of alcohol and medicinal drugs among rescue workers as a consequence of the 22 July terrorist attack was associated with post-traumatic stress symptoms, and explore if there were differences between affiliated and unaffiliated rescue workers. Methods: Ten months after the bombing in the Oslo government district and the shooting at the youth camp on Utøya Island, a cross-sectional study of 1790 rescue and healthcare workers was conducted. The questionnaire included information on medicinal drug and alcohol use, experiences during rescue work and PTSS. Results: Few rescue workers reported alcohol (6.8% n = 119) or medicinal drug (5.5% n = 95) use as a consequence of participation in the 22 July terror attacks. Alcohol and medicinal drug use was associated with an elevated level of PTSS among the rescue workers who reported to use medicinal drugs (11.1 95% CI: 5.7–21.8) or alcohol (10.0 95% CI: 5.2–19.0) as a consequence of the terror attacks. Conclusion: The study found a low level of post-traumatic stress symptoms (PTSS) and alcohol and medicinal drug use among the rescue workers after the terror attacks in Norway on 22 July 2011. There was a strong association between both medicinal drug and alcohol use and elevated PTSS. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction On 22 July 2011, a car bomb was detonated in the Oslo government district inflicting heavy structural damage. Eight people were killed and many were injured. A few hours later, shooting were reported from Utøya Island, about 40 kilometres north-west of Oslo, where the Norwegian Labour Party were holding a youth camp. In the second attack, 69 adolescents or young adults were killed, and many were injured (Gaarder et al., 2012; Sollid et al., 2012). Survivors from the two attacks were either transported to centres for victims and next of kin, outpatient emergency services, or admitted to hospitals. The healthcare treatment and the psychosocial
* Corresponding author. Division of Forensic Medicine and Drug Abuse Research, Norwegian Institute of Public Health, PO Box 4404, Nydalen, Oslo N-0403, Norway. Tel.: +47 21 07 78 22; fax: +47 22 35 36 05. E-mail address: [email protected] (S.T. Bogstrand).
follow-up for both the survivors and their next of kin lasted for several weeks. Professional rescue workers from the police, the fire service, volunteers affiliated to different organizations who are trained to assist in various rescue operations and healthcare departments were involved in the wake of the attacks. Unaffiliated rescue workers who happened to be close to the terror site contributed substantially to the rescue work in the early stages before the police and other professional rescue workers arrived at Utøya Island. Professional rescue workers have reported higher prevalence rates of post-traumatic stress symptoms (PTSS) than the general population (Berger et al., 2012). Rescue work at major disasters where many people are injured or dead may lead to PTSS afterwards for the rescue workers involved. Using alcohol to cope with such symptoms has been reported in other studies (North et al., 2002; Stewart et al., 2004). A study of Swiss voluntary rescue workers who had worked at an airline crash site reported associations between frequency and severity of PTSS and coping-motivated drinking (Stewart
http://dx.doi.org/10.1016/j.ienj.2016.03.003 1755-599X/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
2
et al., 2004). Post-disaster alcohol use disorders and drinking to cope seem to be associated with indicators of poor functioning among rescue workers (North et al., 2002). Few studies have investigated the use of medicinal drugs among rescue workers involved in traumatic rescue operations. But a study of exposure to the South East Asia tsunami disaster in 2004 reported associations between increased use of medicinal drugs and PTSD symptoms (Vetter et al., 2008). After the terror attracts in Norway 2011, a study was conducted among all the rescue workers involved. Some results of this study have been presented in two papers, and report low prevalence of PTSS among the rescue workers involved (Gjerland et al., 2015; Skogstad et al., 2015). However, it seems like the unaffiliated rescue workers have higher rates of PTSS (Gjerland et al., 2015). Most previous studies on alcohol use after traumatic events have focused on professional rescue workers. The coping strategies of unaffiliated rescue workers compared to professional rescue workers might be different, and a comparison of alcohol and medicinal drug use as a coping strategy between these groups seems to be missing in the current literature. The aim of this study was to assess whether the use of alcohol and medicinal drugs among rescue workers as a consequence of the 22 July terrorist attack was associated with post-traumatic stress symptoms, and explore if there were differences between affiliated and unaffiliated rescue workers. 2. Materials and methods 2.1. Study design and setting The study was cross-sectional, anonymous and questionnaire based. It was conducted between March and June 2012, approximately eight to 11 months after the terror attacks (mean 10 months). Respondents were all personnel involved in the rescue and healthcare service of victims and their relatives after the bombing in the Oslo government district and the shooting at the youth camp on Utøya Island on 22 July 2011. The rescue workers were involved from between one day to several weeks. Professional and unaffiliated rescue workers who contributed to the rescue operations and the treatment of survivors and their next of kin between 22 July and 5 August 2011 were invited to participate in the study. The reporting of this study conforms to the STROBE statement (von Elm et al., 2014). The present paper is part of a larger study examining the consequences for the rescue workers of the 2011 terrorist attacks (Gjerland et al., 2015; Skogstad et al., 2015). 2.2. Participants Six disciplines of rescue workers were included: 1) police officers; 2) firefighters; 3) trained and affiliated volunteers: i.e. the Norwegian Civil Defence and the National Guard, and volunteer organizations: i.e. Norwegian Search and Rescue Dogs and Norwegian People’s Aid; 4) general healthcare providers (physicians, nurses/ nurse assistants, paramedics, other personnel working in hospital; 5) psychosocial healthcare providers (psychiatrists, psychologists, counsellors [priests, other employees of the church and imams], social workers and nurses; and 6) unaffiliated rescue workers: i.e. civilians who just happened to be at the campsite close to Utøya Island. The distribution of the questionnaires was done in different ways. For the professional groups, a leader within each unit was appointed to distribute the questionnaires to personnel involved in the rescue work. The completed questionnaires were returned anonymously into a sealed box, which was returned to the study group. Some questionnaires were, however, distributed by mail when this was more convenient. The municipality of Hole provided names and addresses for the unaffiliated volunteers, and the questionnaire was
sent to them by mail with return envelopes. For all groups, a reminder was sent after approximately 1 month. 2.3. Variables Demographic variables were gender, age (<30, 30–49 or >50), and if the respondent had an organizational affiliation. The PTSD Checklist (PCL) was used to assess symptoms of post-traumatic stress disorder (PTSD). It is widely used and was first presented by Frank Weathers and colleagues in 1993 (Weathers et al.). The 17-item questionnaire (range 17–85) includes symptoms (in the last month) needed for a formal PTSD diagnosis according to the Diagnostic Statistical Manual of Mental Disorders (DSM IV) (Weathers et al.). The items are scored on a 5-point Likert scale (1 = not at all to 5 = extremely). There are three versions of PCL: M (military), C (civilian) and S (specific). In this study, the specific version was used because it asks about symptoms after an identified “stressful experience.” The results of the 17 items were summarized, and then divided into three categories where a score above 50 points may indicate PTSD, and a score above 35 may indicate clinical problems. The PCL-S has been validated in a sample of Norwegian survivors from the South East Asia tsunami disaster in 2004 (Hem et al., 2012). The rescue workers were exposed to different kinds of threats: ongoing shooting at Utøya Island and fear of collapsing buildings in the city centre, in addition to fear of subsequent terror attacks towards, e.g. hospitals. Place of work was therefore of special interest and thus registered in the following categories: sites of terror, hospital or outpatient emergency clinic, centre for victims, and next of kin and other (patrolling, office, etc.). Experience of peritraumatic threats was measured by three questions: Have you experienced: 1) fear of explosion/shooting, 2) fear of being injured, 3) other risks/uncertainty? The response alternatives were: a) no, not experienced, b) yes, not/a little stressful, c) yes, moderately stressful, d) yes, very stressful. The answers were dichotomized: have not/ have experienced such fear. One question measured concern for relatives/friends that might be present at the terror sites during the attacks. The answers were dichotomized: have not/have been concerned for relatives. Seven items measured if the rescue worker had witnessed situations or impressions that were considered to be stressful. The Norwegian Centre for Violence and Traumatic Stress Studies developed and used these items after the South East Asia tsunami disaster in 2004 (Thoresen et al., 2009). Questions were as follows: Did you experience: disaster victims searching for next of kin, disaster victims in despair, disaster victims with major physical injuries, dead bodies, body parts, or physical contact with dead bodies, and strong smells or other sensory perceptions? The items were collapsed into one dichotomy variable. The variable was positive if the rescue worker reported any witnessing of the experiences described above. Alcohol and medicinal drug use was measured by seven questions, three questions addressed the use of alcohol: Have you as a consequence of the terror attacks used alcohol 1) to calm down, 2) to be in a better mood, and 3) to sleep? The response alternatives for each question were: a) ‘no’, b) ‘in the first week’, and c) ‘for more than one week’. The three questions were collapsed into one dichotomy variable where the answer ‘no’ was coded as negative and any alcohol use was coded as positive. In order to assess the use of medicinal drugs, four questions were used: Have you as a consequence of the terror attacks used one or more of the following medicinal drugs: 1) sleep medicine, 2) medication to calm down, 3) medication for depression, 4) other medication? The response alternatives for each type of medicinal drug were: a) ‘no’, b) ‘a few times’, c) ‘weekly’, or d) ‘daily’. The four questions were collapsed into one dichotomy variable where the answer ‘no’ was coded as negative, and ‘a few times’, ‘weekly’ or ‘daily’ were coded as positive.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
Table 2 Alcohol or medicinal drug use as a consequence of the terror attacks.
Table 1 Characteristics of the sample (n = 1790). Variable Age group
Gender Peri-traumatic threat Witnessing PCL score
Place of work
Groups
<30 30–49 ≥50 Women Shooting, injury, hazard Worrying about family/ friends yes 17.0–34.9 (few symptoms) 35.0–49.9 (sub-threshold PTSD) ≥50 (PTSD level) Sites of terror Hospital or outpatient emergency clinic Centre for victims and next of kin Other (patrolling, office, etc.) Unaffiliated rescue workers
3
n (total: 1790)
%
Alcohol use
No
The first week
More than one week
285 1091 403 881 866 559 1318 1705 48 17 533 717 162 362 55
16 61 22 50 49 31 74 96 3 1 30 40 9 20 3
To calm down (n = 1764) To cheer up (n = 1749) To sleep (n = 1749) Any use of alcohol (n = 1766)
94.7% 98.1% 97.4% 93.2%
4.3% 1.3% 1.8% 5.3%
1.0% 0.6% 0.7% 1.5%
Missing variables: Age group, 11; women, 11; PCL score, 20; unorganized, 1; peritraumatic threat, 27; worrying, 32; place of rescue work, 16; and witnessing, 25.
2.4. Statistical methods Bivariate tables and chi-square statistics and binary logistic regression analyses were used to calculate associations between medicinal drug use, alcohol and other variables (OR = odds ratio). PASW 18 (IBM.inc) was used for all statistical analyses and the limit for statistical significance was p < .05. 2.5. Ethics The study was performed anonymously. Due to the anonymous handling of the data, the research project was outside the remit of the Act on Medical and Health Research, and an approval from the Regional Ethics Committee was not required. The study was reviewed and approved by the Oslo University Hospital’s Privacy Protection Supervisor, and performed in accordance with the data storage and confidentiality regulations. An information letter was enclosed with the questionnaire. The return of the questionnaire was assumed to imply informed consent. 3. Results 3.1. Participants and sample description Of the 2922 distributed questionnaires, 1790 were returned, yielding a response rate of 61%. As the study was anonymous, no data on non-respondents were collected. The response rate differed between the groups of rescue workers. Firefighters had the highest response rate (82%, n = 102), then general healthcare providers (68%, n = 858), psychosocial healthcare providers (66% n = 214), the police (51%, n = 253), affiliated volunteers (51%, n = 307), and unaffiliated rescue workers (46% n = 56). Most of the rescue workers were professionals or trained and affiliated volunteers (97% n = 1734). However, 3% (n = 56) were unaffiliated volunteers who contributed to the rescue operation. In the total sample, 50% (n = 881) were women, and 61% (n = 1091) were 30–49 years of age. Peri-traumatic fear of explosion, shooting, fear of getting injured or other fear or insecurity were experienced by 49% (n = 866), while 31% (n = 559) reported to have been worried that their friends or family might be at the terror sites during the attacks (Table 1). A substantial proportion of the participants contributed to the rescue work at the sites of terror (30%, n = 533). Post-traumatic stress level was low, a PCL score above 50 was found in 1% (n = 17) of the participants, and 3% (n = 48) scored above 35 points (Table 1). Among the un-
Medicinal drug use
No
A few times
Weekly
Daily
Sleep medicine (n = 1748) Medication to calm down (n = 1727) Medication for depression (n = 1725) Other medication (n = 1734) Any use of medicinal drugs (n = 1763)
95.9% 99.1% 99.4% 98.2% 94.5%
3.1% 0.8% 0.2% 1.3% 4.0%
0.5% – – 0.1% 0.5%
0.5% 0.1% 0.4% 0.5% 1.0%
affiliated rescue workers, a greater proportion reported PCL scores above 50 (15% n = 8) and 35 (24% n = 13). 3.2. Alcohol and medicinal drug use as a consequence of the terror attacks In all, 6.8% (n = 119) reported alcohol use, and 5.5% (n = 95) reported to use medicinal drugs as a consequence of the terror attacks (Table 2). Alcohol was most frequently used to calm down (5.3% n = 94). Few used alcohol for more than one week after the attacks, 1% (n = 18%) reported having used alcohol to calm down, while 0.7% (n = 13) reported having used alcohol to sleep and 0.6% (n = 11) to be in a better mood. The most prevalent medicinal drug was sleep medicine (4.1% n = 72), most reported to have used sleep medicine a few times (3.1% n = 56), and only a few reported persistent use weekly (0.5% n = 8) or daily (0.5% n = 8). 3.3. Multivariate analysis of medicinal drug and alcohol use In the multivariate analysis, alcohol use was associated with a positive PCL score. A PCL score above 35 gave an OR of 10.0 (95% CI: 5.2–19.0) and a PCL score above 50 an OR of 11.7 (95% CI: 4.2– 32.6) for alcohol use as a consequence of the terror attacks. Other variables associated with alcohol use were peri-traumatic threat (fear of shooting, fear of being injured, or other hazard) (OR: 2.0 95% CI: 1.3–3.0) and worrying about friends and family during the rescue operation (OR: 1.7 95% CI: 1.1–2.6) (Table 3). There was a statistically significant association between medicinal drug use as a consequence of the terror attacks and a PCL score above both 35 and 50. A PCL score above 35 gave an OR of 11.1 (95% CI: 5.7–21.8), and a score above 50 gave an OR of 49.9 (95% CI: 16.4– 151.9). Other variables associated with medicinal drug use were to witness stressful situations or impressions (OR: 2.5 95% CI: 1.2– 5.0), and worrying about friends or family during the rescue operation (OR: 1.9 95% CI: 1.2–3.1) (Table 4). The unaffiliated rescue workers had a higher prevalence of alcohol and medicinal drug use as a consequence of the terror attacks compared to professionals or trained and affiliated volunteers (alcohol: 25.9% n = 14 vs 6.1% n = 105, p < .001; medicinal drugs: 31.5% n = 17 vs 4.6% n = 78, p < .001, respectively). The associations were, however, not significant in multivariate analysis. 4. Discussion Few rescue workers reported alcohol or medicinal drug use as a consequence of participation in the 22 July terror attacks. Alcohol and medicinal drug use was, however, associated with an elevated level of PTSS among the rescue workers who reported to use medicinal drugs or alcohol as a consequence of the terror attacks.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
4
Table 3 Associations between alcohol use as a consequence of the terror attacks and demographic variables, peri-traumatic experiences and PCL scores. Variable Age group
Gender Peri-traumatic threat: shooting, injury, hazard Worrying about family/friends Witnessing PCL score
Place of rescue work
Unaffiliated rescue workers
<30 (ref) 30–49 ≥50 Women Yes Yes Yes 17.0–34.9 (few symptoms) (ref) 35.0–49.9 (sub-threshold) ≥50 (PTSD level) Sites of terror (ref) Hospital or outpatient emergency clinic Centre for victims and next of kin Other (patrolling, office, etc.) Yes
Unaffiliated rescue workers reported to use more alcohol and medicinal drugs compared to professionals or trained and affiliated volunteers. In line with the findings of the current study, an association between PTSS and alcohol use has earlier been described among volunteers involved in rescue work after an airline disaster (Stewart et al., 2004). A study of Red Cross disaster relief workers who responded to the 9/11 attacks gave conflicting results where both increases and decreases in alcohol use were associated with PTSS (Simons et al., 2005). Among the firefighters involved in the rescue work after the Oklahoma bombing, alcohol use as a consequence was reported by a higher proportion compared to the present study (19% vs 6.8%) (North et al., 2002). Medicinal drug use among persons exposed to the South East Asia tsunami disaster in 2004 disaster was associated with PTSS (Vetter et al., 2008). North et al. (North et al., 2002) reported that 10% of the firefighters used medicinal drugs to cope with their feelings after the Oklahoma bombing. A Dutch study has compared the health of police officers involved in an airline disaster to colleagues that had not been involved 8.5 years after the event. The study showed elevated self-initiated drug use among the officers involved in the disaster during the past 12 months (Slottje et al., 2008). A study of drug and alcohol use among Norwegian employees in selected business areas was published in 2015. The study showed that the use of alcohol and illicit drugs are low among healthcare professionals, but the use of medicinal drugs is higher than among the other groups of workers (Edvardsen et al., 2015). We have no data on whether the medicinal drugs, reported to be
Univariate OR (95% CI)
P-value
1.2 (0.7–2.1) 1.2 (0.7–2.3) 1.4 (0.9–2.0) 2.7 (1.8–4.0) 2.0 (1.4–2.9) 1.8 (1.1–3.1)
0.50 0.50 0.09 <0.001 <0.001 0.02
12.4 (6.8–22.9) 13.5 (4.9–37.1)
<0.001 <0.001
0.9 (0.5–1.4) 0.6 (0.3–1.4) 1.3 (0.8–2.1) 5.3 (2.8–10.1)
0.5 0.2 0.4 <0.001
Multivariate OR (95% CI)
P-value
2.0 (1.3–3.0) 1.7 (1.1–2.6)
0.003 0.01
10.0 (5.2–19.0) 11.7 (4.2–32.6)
<0.001 <0.001
taken as a consequence of the terror attacks in this study, were prescribed or self-initiated use. Alcohol and substance use may be part of a coping style that includes ineffective coping strategies such as avoidance (Ouimette et al., 1998). An association between alcohol use and PTSS has been found in several studies of individuals under treatment for substance abuse problems (Berenz and Coffey, 2012; Ouimette et al., 1998). Moreover, there is evidence that abstinence from alcohol and illicit drugs can lead to reduction in PTSS, even without an intervention directed at PTSD (Berenz and Coffey, 2012). Short-term use of prescribed medicinal drugs may be appropriate for rescue workers after major events, but information on the disadvantages of using alcohol and medicinal drugs as a coping style after stressful events should be incorporated in the training and follow-up of rescue workers. The association between engaging in unorganized rescue work and increased alcohol or medicinal drug use was not significant in multivariate analysis. Still it is important that the unaffiliated rescue workers also get a psychological follow-up, in the same manner as the professional rescue workers get their follow-up. These unaffiliated rescue workers may be harder to reach after the rescue work is completed, as rescue work is not their profession, but they will still be in need of follow-up. 4.1. Strengths and limitations The inclusion of several professional groups and the great sample size, as well as the use of validated questionnaires, are the strengths
Table 4 Associations between medicinal drug use as a consequence of the terror attacks and demographic variables, peri-traumatic experiences and PCL scores. Variable Age group
Gender Peri-traumatic threat: shooting, injury, hazard Worrying about family/friends Witnessing PCL score
Place of rescue work
Unaffiliated rescue workers
<30 (ref) 30–49 ≥50 Women Yes Yes Yes 17.0–34.9 (few symptoms) (ref) 35.0–49.9 (sub-threshold) ≥50 (PTSD level) Sites of terror (ref) Hospital or out-patient emergency clinic Centre for victims and next of kin Other (patrolling, office etc.) Yes
Univariate OR (95% CI)
P- value
0.9 (0.5–1.6) 1.0 (0.5–1.9) 1.6 (1.0–2.4) 2.2 (1.4–3.4) 1.9 (1.2–2.9) 3.0 (1.6–6.0)
0.73 0.91 0.04 0.001 0.003 0.001
14.5 (7.7–27.4) 48.4 (16.1–145.6) 0.8 (0.5–1.3) 0.7 (0.3–1.5) 0.7 (0.4–1.3) 9.6 (5.2–17.8)
<0.001 <0.001
Multivariate OR (95% CI)
P- value
1.9 (1.2–3.1) 2.5 (1.2–5.0)
0.005 0.01
11.1 (5.7–21.8) 49.9 (16.4–151.9)
<0.001 <0.001
0.3 0.4 0.3 <0.001
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003
ARTICLE IN PRESS S.T. Bogstrand et al./International Emergency Nursing ■■ (2016) ■■–■■
of this study. This study has some limitations. Self-reported use of alcohol and medicinal drugs might be subject to underreporting due to the timespan between the rescue operation and the distribution of the questionnaire. We have no data to distinguish between prescription and non-prescription use of medicinal drugs. The variable response rate in the different groups of rescue workers and especially the low response rate among unaffiliated rescue workers are major limitations. The unaffiliated rescue workers were recruited via questionnaires sent by mail with return envelopes, other ways of recruiting these participants might have given better participation. As we have no data on non-participants, it is not possible to assess the direction of any possible bias. 4.2. Conclusion There was a low level of post-traumatic stress symptoms (PTSS) and use of alcohol and medicinal drug as a consequence of the 22 July terrorist attack among the rescue workers involved. A strong association between both the use of alcohol and medicinal drugs as a consequence of the terror attacks and elevated PTSS was observed. Conflict of interest None declared. References Berenz, E.C., Coffey, S.F., 2012. Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current Psychiatry Reports. 14, 469–477. Berger, W., Coutinho, E.S., Figueira, I., Marques-Portella, C., Luz, M.P., Neylan, T.C., et al., 2012. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Social Psychiatry and Psychiatric Epidemiology. 47, 1001–1011. Edvardsen, H.M., Moan, I.S., Christophersen, A.S., Gjerde, H., 2015. Use of alcohol and drugs by employees in selected business areas in Norway: a study using oral fluid testing and questionnaires. Journal of Occupational Medicine and Toxicology (London, England). 10, 46.
5
Gaarder, C., Jorgensen, J., Kolstadbraaten, K.M., Isaksen, K.S., Skattum, J., Rimstad, R., et al., 2012. The twin terrorist attacks in Norway on July 22, 2011: the trauma center response. The Journal of Trauma and Acute Care Surgery 73, 269–275. Gjerland, A., Pedersen, M.J., Ekeberg, O., Skogstad, L., 2015. Sick-leave and help seeking among rescue workers after the terror attacks in Norway, 2011. International Journal of Emergency Medicine. 8, 81. Hem, C., Hussain, A., Wentzel-Larsen, T., Heir, T., 2012. The Norwegian version of the PTSD Checklist (PCL): construct validity in a community sample of 2004 tsunami survivors. Nordic Journal of Psychiatry. 66, 355–359. North, C.S., Tivis, L., McMillen, J.C., Pfefferbaum, B., Cox, J., Spitznagel, E.L., et al., 2002. Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. Journal of Traumatic Stress. 15, 171–175. Ouimette, P.C., Brown, P.J., Najavits, L.M., 1998. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addictive Behaviors. 23, 785–795. Simons, J.S., Gaher, R.M., Jacobs, G.A., Meyer, D., Johnson-Jimenez, E., 2005. Associations between alcohol use and PTSD symptoms among American Red Cross disaster relief workers responding to the 9/11/2001 attacks. The American Journal of Drug and Alcohol Abuse. 31, 285–304. Skogstad, L., Fjetland, A.M., Ekeberg, O., 2015. Exposure and posttraumatic stress symptoms among first responders working in proximity to the terror sites in Norway on July 22, 2011 – a cross-sectional study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 23, 23. Slottje, P., Smidt, N., Twisk, J.W., Huizink, A.C., Witteveen, A.B., van Mechelen, W., et al., 2008. Use of health care and drugs by police officers 8.5 years after the air disaster in Amsterdam. European Journal of Public Health. 18, 92–94. Sollid, S.J., Rimstad, R., Rehn, M., Nakstad, A.R., Tomlinson, A.E., Strand, T., et al., 2012. Oslo government district bombing and Utoya island shooting July 22, 2011: the immediate prehospital emergency medical service response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 20, 3. Stewart, S.H., Mitchell, T.L., Wright, K.D., Loba, P., 2004. The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. Journal of Anxiety Disorders. 18, 51–68. Thoresen, S., Tonnessen, A., Lindgaard, C.V., Andreassen, A.L., Weisaeth, L., 2009. Stressful but rewarding: Norwegian personnel mobilised for the 2004 tsunami disaster. Disasters. 33, 353–368. von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P., et al., 2014. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. International Journal of Surgery. 12, 1495–1499. Vetter, S., Rossegger, A., Rossler, W., Bisson, J.I., Endrass, J., 2008. Exposure to the tsunami disaster, PTSD symptoms and increased substance use – an Internet based survey of male and female residents of Switzerland. BMC Public Health. 8, 92. Weathers, F.W., Lie, B.T., Herman, D.S., Huska, J.A., Keane, T.M., The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility., The Meeting of the Society of Traumatic Stress Studies, San Antonio, Texas.
Please cite this article in press as: Stig Tore Bogstrand, Laila Skogstad, Øivind Ekeberg, The association between alcohol, medicinal drug use and post-traumatic stress symptoms among Norwegian rescue workers after the 22 July twin terror attacks, International Emergency Nursing (2016), doi: 10.1016/j.ienj.2016.03.003