ACCIDENTS AND INJURIES FROM ALCOHOL

Trauma (bodily injury) is a major social and medical problem in both developed and developing countries. Injuries are among the leading cause of death and disability in the world, and affect all populations, regardless of age, sex, income, or geographic region. In 1998 about 5.8 million people died of injuries worldwide, and injuries caused 16 percent of the global burden of disease (Krug, et al, 2000). In developed countries injuries are the leading cause of death between the ages of one and forty, and in the U.S. population it is the fourth leading cause of death (exceeded only by heart disease, stroke, and cancer). Of all deaths from injury in the United States, about 65 percent are classified as unintentional (which excludes deaths from suicide, homicide, and other criminal offenses); of these, about half result from motor vehicle accidents. Trauma also accounts for high rates of morbidity (number of sick to well). In the United States, the rate of serious injury is estimated to be at least three hundred times the death rate.

The first documentation of alcohol's involvement in injury dates to 1500 B.C.E., with an Egyptian papyrus warning that excessive drinking leads to falls and broken bones. The scientific study of alcohol and injuries has been the subject of much investigation throughout the twentieth century. Data from both coroner and emergency room studies indicate that a large proportion of victims of both fatal and nonfatal injuries test positive for blood alcohol—this proportion is greater than one would expect to find in the general population on any given day. The consumption of alcohol (ethanol) has been highly associated with fatalities and serious injuries, but this may be the result of other high-risk behaviors on the part of the drinking accident victim, such as not using seat belts or motorcycle helmets. Studies of alcohol, injury, and risk-taking dispositions in the general population have found risk-taking, impulsivity, and sensation-seeking to be associated with both injury occurrence and alcohol consumption. Those who scored high on risk-taking and sensation-seeking were twice as likely to report an injury for which treatment was obtained during the last year, and were also more likely to report heavier drinking (Cherpitel, 1999). Although alcohol cannot be said to actually cause the accident in most cases, alcohol consumption is thought to contribute to both fatal and nonfatal injury occurrence, primarily because it is known to diminish motor coordination and balance and to impair attention, perception, and judgment with regard to behavior, placing the drinker at a higher risk of accidental injury than the nondrinker. The residual or hangover effects of alcohol consumption may also contribute to injury occurrence.

ESTIMATES OF ALCOHOL'S INVOLVEMENT

In emergency room (ER) studies, such as those conducted by Cherpitel (1988), patients testing positive for alcohol have had levels that ranged from 6 to 32 percent—established either directly or from a breath sample taken at the time of admission to the ER. In a review of ER studies, Cherpitel (1993a) determined that this variation in blood alcohol level (BAL) or blood alcohol concentration (BAC) is due to differences in the time that passed between the injury and arrival in the ER, to individual characteristics of the particular ER populations studied (such as age, sex, and socioeconomic status—all known to be associated with alcohol consumption in the general population) and to the mix of various types of injury in the ER caseload. For example, alcohol has been found to have a higher prevalence in injuries resulting from violence than from any other cause. In studies that have been restricted to weekend evenings, when one would expect a large proportion of the population to be consuming alcohol, the proportion of those testing positive for alcohol at the time of ER admission has been found to be close to 50 percent. In coroner studies, such as those conducted by Haberman and Baden (1978), alcohol-related fatalities were estimated to account for about 43 percent of all unintentional injuries. (However, the distinction between intentional and unintentional injury is not always readily apparent among victims of fatal injuries.) Studies that have compared estimated BAC between fatal and nonfatal injuries in the same geographic locality have found higher rates of positive BACs among fatal injuries (57%) compared to nonfatal injuries (15%) (Cherpitel, 1996). It is well known that many who drink also consume psychoactive drugs so the independent effect of alcohol on both fatal and nonfatal accidents is not possible to ascertain.

TRAUMA RELATED TO MOTOR VEHICLES

Motor vehicle crashes are the leading cause of death from injury—and the greatest single cause of all deaths for those between the ages of one and thirty-four in the United States. It has been estimated that 7 percent of all crashes and 44 percent of fatal crashes involve alcohol use, and alcohol's involvement is greater for drivers in single-vehicle nighttime fatal crashes (U.S. Department of Health and Human Services, 1997). The risk of a fatal crash is estimated to be from three to fifteen times higher for a drunk driver (one with a BAL of at least .10 to 100 milligrams of alcohol for each 100 milliliters of blood—the legal limit in most U.S. states) than for a nondrinking driver, according to Roizen (1982). Alcohol is more frequently present in fatal than in nonfatal crashes. It is estimated that about 25 to 35 percent of those drivers requiring ER care for injuries resulting from such crashes have a BAL of .10 or greater. The number of alcohol-related crashes has declined in recent years, particularly among younger and older drivers, but has increased among women.

Motorcyclists are at a greater risk of death than automobile occupants, and it has been estimated that up to 50 percent of fatally injured motorcyclists have a BAL of at least .10. Pedestrians killed or injured by motor vehicles have also been found more likely to have been drinking than those not involved in such accidents. Estimates of 31 to 44 percent of fatally injured pedestrians were drinking at the time of the accident. According to Giesbrecht et al. (1989), 14 percent of fatal pedestrian accidents involved an intoxicated driver, but 24 percent involved an intoxicated pedestrian.

HOME ACCIDENTS

Among all nonfatal injuries occurring in the home, an estimated 22 to 30 percent involve alcohol, with 10 percent of those injured having a BAL at the legally intoxicated level at the time of the accident. Coroner data suggest that alcohol consumption immediately before a fatal accident occurs more often in deaths from falls and fires than in motor vehicle deaths.

Falls.

Falls are the most common cause of nonfatal injuries in the United States (accounting for over 60%) and the second leading cause of fatal accidents, according to Baker, et al (1992). Alcohol's involvement in fatal falls has been found to range from 21 to 48 percent (with an average of 33%) according to Roizen; for nonfatal falls, alcohol's involvement has been estimated from 17 to 53 percent (with an average of 30%). Alcohol may increase the likelihood of a fall as much as sixty times in those well over the legal limit for intoxication, compared with those having no alcohol exposure.

Fires and Burns.

Fires and burns are the fourth leading cause of accidental death in the United States, according to Baker and co-workers. Alcohol involvement has been estimated in 12 to 83 percent of these fatalities (with a median value of 46%), and between 0 and 50 percent among nonfatal burn injuries (with a median value of 17%). In a review of studies of burn victims, Hingson and Howland (1993) estimated that about 50 percent of burn fatalities were intoxicated and that alcohol exposure is most frequent among victims of fires caused by cigarettes.

RECREATIONAL ACCIDENTS

Drownings.

Drownings rank as the third leading cause of accidental death in the United States. Haberman and Baden (1978) reported that 68 percent of drowning victims had been drinking, but other estimates have ranged from 30 to 54 percent (with an average of 38%) (Hingson and Howland, 1993). Alcohol is consumed in relatively large quantities by many of those involved in water-recreation (especially boating) activities, and studies suggest that those involved in aquatic accidents are more likely to be intoxicated than those not involved in such accidents. In a review of the literature on those who came close to drowning, Roizen (1982) found that about 35 percent had been drinking at the time.

WORK-RELATED ACCIDENTS

Alcohol's involvement in work-related accidents varies greatly by type of industry, but the proportion of those testing positive for blood alcohol following a work-related accident is considerably lower than for other kinds of injuries, particularly in the United States, since drinking on the job is not a widespread or regular activity. Among work-related fatalities, an estimated 15 percent has been found positive for blood alcohol, and a range of 1 to 16 percent has been estimated for nonfatal injuries, according to Giesbrecht et al. (1989).

VIOLENCE-RELATED TRAUMA

Both fatal and nonfatal injuries commonly result from violence, and these injuries are more likely to be alcohol-related than injuries from any other cause, for men and for women, regardless of age. Such injuries are considered intentional and include those nonfatal injuries resulting from assaults and fights, as well as fatal injuries from homicides and suicides. Alcohol is more likely to be involved in fatal injuries from violence than in nonfatal injuries treated in an ER in the same geographic locality, and a positive BAC in nonfatal injuries among ER patients has been found to range from 17 to 70 percent (Cherpitel, 1993b). These figures refer to alcohol involvement among the victims of violence-related events, and little is known about the alcohol involvement of the perpetrator of such events, but the correlation is thought to also be high. ER patients with violence-related injuries are also more likely to be heavier drinkers and to report alcohol-related problems than those with injuries from other causes.

ALCOHOLISM VERSUS UNWISE DRINKING

The available literature on the role of alcoholism as opposed to unwise drinking in injury occurrence suggests that problem drinkers and those diagnosed as alcoholics are at a greater risk of both fatal and nonfatal injuries than those in the general population who may drink prior to an accident. Alcoholics and problem drinkers are significantly more likely to be drinking and to be drinking heavily prior to an accident than others. Haberman and Baden (1978) found among fatalities from all causes that alcoholics and heavy drinkers were more than twice as likely as nonproblem drinkers to have a BAL at the legal limit. Alcoholics have also been found to experience higher rates of both fatal and nonfatal accidents, even when sober. Analysis of national mortality data found that those who died of injury drank more frequently and more heavily than those who died of disease, and that daily drinking, binge drinking (consuming 5 or more drinks per occasion), and heavier drinking (14 or more drinks per week) increased the likelihood of injury as the underlying cause of death (Li et al., 1994).

Data from the general U.S. population found the risk of injury increased with an average of one drink a day for both men and women, regardless of age. The risk of injury also increased with the frequency of consuming five or more drinks a day more often than twice a year (Cherpitel et al., 1995). This suggests that the risk for injury may be increased at relatively low levels of consumption, in which case preventive efforts aimed at more moderate drinkers, who are greater in number, may have a larger impact on the reduction of alcohol-related accidents than efforts focused on heavier drinkers, who are fewer in number.

Chronic alcohol abuse has long-term physiologic and neurological effects that may increase the risk of accidents. Chronic drinking also impairs liver function, which plays an important part in injury recovery. A damaged liver compromises the immune system, predisposing the alcoholic to bacterial infections following injury. The risk of accidental death has been estimated to be from three to sixteen times greater for alcoholics than for nonalcoholics, with the highest risk being death from fires and burns. Haberman and Baden (1978) found that among all fatalities from fires, 34 percent were alcoholics.

(See also: Alcohol ; Driving, Alcohol, and Drugs ; Driving under the Influence ; Industry and Workplace, Drug Use in ; Social Costs of Alcohol and Drug Abuse )

BIBLIOGRAPHY

Baker, S. P., O'Neill, B. & Karpf, R. (1992). The injury fact book. Lexington, MA: Lexington Books.

Cherpitel, C. J. (1999). Substance use, injury, and risk-taking dispositions in the general population. Alcoholism: Clinical and Experimental Research, 23, 121-126.

Cherpitel, C. J. (1996). Alcohol in fatal and nonfatal injuries: A comparison of coroner and emergency room data from the same county. Alcoholism: Clinical and Experimental Research, 20, 338-342.

Cherpitel, C. J., et al. (1995). Alcohol and non-fatal injury in the U.S. general population: A risk function analysis. Accident Analysis and Prevention, 27, 651-661.

Cherpitel, C. J. (1993a). Alcohol and injuries: A review of international emergency room studies. Addiction, 88, 923-937.

Cherpitel, C. J. (1993b). What emergency room studies reveal about alcohol involvement in violence-related injuries. Alcohol Health and Research World, 17, 162-166.

Cherpitel, C. J. (1988). Alcohol consumption and casualties: A comparison of emergency room populations. British Journal of Addiction, 83, 1299-1307.

Giesbrecht, N., et al. (Eds.) (1989). Drinking and casualties: Accidents, poisonings and violence in an international perspective. London: Croom Helm.

Haberman, P. W., & Baden, M. M. (1978). Alcohol, other drugs, and violent death. New York: Oxford University Press.

Hingson, R., & Howland, J. (1993). Alcohol and non traffic unintended injuries. Addiction, 88, 877-883.

Krug, E. G., Sharma, G.K., & Lozano, R. (2000). The global burden of injuries. American Journal of Public Health, 90, 523-526.

Li, G., Smith, G. S., & Baker, S. P. (1994). Drinking behavior in relation to cause of death among US adults. American Journal of Public Health, 84, 1402-1406.

Roizen, J. (1982). Estimating alcohol involvement in serious events. In Alcohol consumption and related problems. DHHS Publication no. ADM 8201190. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services(1997). Ninth Special Report to the U.S. Congress on Alcohol and Health. NIH Publication No. 97-4017.

Cheryl J. Cherpitel