Alcohol and Violence in the Emergency

Room: A Regional Report from the

WHO Collaborative Study on Alcohol
and Injuries


Guilherme Borges
1,2,
Ricardo Orozco
2,
Mariana Cremonte
3,
Neliana Buzi Figlie
4,
Cheryl Cherpitel
5
,
Vladimir Poznyak
6,


1.Universidad Autnoma Metropolitana, Mexico City, Mexico
2.Instituto Nacional de Psiquiatra, Mexico City, Mexico
3. National University, Mar del Plata, Argentina
4.UNIAD - UNIFESP2, Sao Paulo, Brazil
5. Alcohol Research Group, Public Health Institute, Berkeley CA, USA
6. Department of Mental Health and Substance Dependence, WHO, Geneva, Switzerland


This study was supported by a National Alcohol Research Center grant AA 05595-12 from the U.S. National Institute on Alcohol Abuse and
Alcoholism, the World Health Organization (Geneva), the National Institute of Psychiatry (4275P) (Mexico), and the Consejo Nacional de
Ciencia y Tecnologa (CONACyT) (39607-H)
http://www.who.int/substance_abuse/activities/injuries/en/

1st Pan American Conference on Alcohol Policies, 28-30 November 2005, Brasilia, Brazil
INTRODUCTION (I)
Alcohol consumption has been found to be a
major risk factor for both intentional and
unintentional injuries in the emergency
department (ED) setting.
Most studies have not tried to differentiate the
risk of injury associated with the long-term
(usual) alcohol consumption from the risk of
short, acute and intermittent alcohol use.
This difference may be crucial in targeting at
risk population.


INTRODUCTION (II)
The case-crossover design provides
estimates of intermittent alcohol use over
and above the base line risk associated
with long-term alcohol consumption.
The case-crossover seems also especially
appropriate to study differences in risk
across mode of injury (violence Vs non-
violence).


INTRODUCTION (III)
We used a case-crossover analysis to
study the risk across mode of non-fatal
injury, using a large WHO multicenter
study of injured patients, collected in
2001-2002.

METHODS (I)
Sample
Adult patients, 18 years and older, admitted to the
emergency department and reporting an injury was
drawn from ED admission forms from the WHO
Collaborative Study on Alcohol and Injuries, 2001-
2002.

We selected here those in Argentina, Brazil and
Mexico. Canada was first included but since only 4
respondents were classified with a violence-related
injury, it is not considered further.



METHODS (II)
Mode of injury was categorized as unintentional injury
(non-violence), intentional self-inflicted and
intentional by someone else (violence related injury).

Face-to-face interview-questionnaire of about 25
minutes in length were administered.

The control information for each case of injury is
provided by the patient himself based on his past
exposure experience.



The case-crossover design provides estimates for
the effect of intermittent alcohol use over and
above the base line risk associated with long-
term alcohol consumption.

1.http://www.pitt.edu/~super1/lecture/lec0821/001.htm

2.Maclure M, Mittleman MA. Should we use a case-crossover design? Annu Rev
Public Health. 2000; 21:193-221.

METHODS (IV)
Use of alcohol for each patient during the six
hours period prior to the injury was compared
with alcohol use during the same time period
for the same day in the previous week for the
pair matched strategy.

Place of injury: Where were you when you
had your injury/accident? Vs Think about the
time you had your accident (today) and
remember the same time a week ago. Where
were you a week ago?
METHODS (V)
Conditional logistic regression was used to
calculate the matched-pair odds ratio (OR)
and 95% confidence intervals (CI)
(discordant pairs).

RESULTS (I)
The total sample included 447 patients in
Argentina (A), 489 in Brazil (B) and 455
in Mexico (M), for a total of 1391.
Prevalence of violence was 13.5%
(A=12.5%, B=10.2%, M=18.0%).

About 46% of violence-related cases used
alcohol (Vs 11.5 Non-Violence), 80%
were males (Vs 63%), and 66% under 30
years (Vs 44%).
RESULTS (II)
OR CI (95%) OR CI (95%)
Argentina* 13.0 (2.4 - 69.5) 3.8 (1.9 - 7.5)
Brazil 12.0 (1.6 - 92.3) 5.2 (2.2 - 12.4)
Mexico 18.0 (4.3 - 74.8) 4.0 (1.8 - 8.7)
TOTAL 15.0 (5.8 - 39.1) 4.2 (2.7 - 6.5)
* Data weighted
Violence No Violence
TABLE 2. WHO-ER Alcohol use six hours prior and one week prior
to the injury.
Matched Pair analyzes by violence related injury.
RESULTS (III)
Al cohol use si x hours pri or and one week pri or t o t he i nj ury
0 . 0
5 . 0
1 0 . 0
1 5 . 0
2 0 . 0
2 5 . 0
1 - 3 4 +
N umbe r of dr i nk s
OR
Vi ol ence
No Vi ol ence
10.2
20.2
3.9
4.5
RESULTS (IV)
Street Drink place
Yes No OR Yes No OR
Previous week Previous week
Yes 12 3 26.1 Yes 2 2 3.8
No 78 95 No 6 178
Street Drink place
Yes No OR Yes No OR
Previous week Previous week
Yes 71 21 18.6 Yes 0 18 0.3
No 392 719 No 5 1181
Table 4a. Violence related injury and place of injury
Accident day
Accident day
Accident day
Accident day
Violence
No violence
Violence Alcohol prior OR CI (95%) OR CI (95%)
No No 15.7 (10 - 24.6) 0.2 (0.0 - 0.9)
No Yes 76.3(10.6 - 548.5) 0.4 (0.1 - 1.4)
Yes No 38.3 (5.3 - 278.7) NA
Yes Yes 20.0 (4.8 - 82.9) 3.8 (0.7 - 21.2)
Street/highway Bar/drink place
Table 4b. Violence related injury, alcohol and place of injury
RESULTS (V)
DISCUSSION (I)
In this sample of non-fatal injured
patients attending 3 EDs across the
region, we found that the risk of a
violent related-injury increased with
drinking [ (15.0- (5.8-39.1) ].

Patients with unintentional injury had a
lower OR [ (4.2- (2.7-6.5) ].

DISCUSSION (II)
If subjects decided to drink, increasing
amounts may have pronounced consequences
in their risk of triggering an injury, specially
a violence-related injury.

Changes from place of injury (street and
drinking place) was also more associated with
a violent related-injury than with an
unintentional injury.
Changing in places and alcohol use may
nevertheless increase more the risk of an
unintentional injury.

DISCUSSION (III)
This study is limited to non-fatal cases of injury
that comes to EDs facilities and although the study
design provides a representative sample of patients
from this facility, patients may not be
representative of other ED facilities in the city or
the country that participated.

DISCUSSION (IV)
As is common with other emergency department
studies, cases also cannot be assumed to be
representative of those with injuries who do not
seek medical attention.
All analyses reported here are based on the
patients self-reported alcohol consumption for
differing time frames, and it is possible that
patients were more likely to better recall their
consumption immediately prior to an injury event
than for any previous period.
http://www.who.int/substance_abuse/activities/injuries/en/