September 25, 2025 • 23 mins
In this episode, Lillian Erdahl, MD, FACS, is joined by Jordan Rook, MD, from UCLA, and Lorraine Kelley-Quon, MD, FACS, from Children’s Hospital Los Angeles and Keck School of Medicine of USC. They discuss Drs Rook and Kelley-Quon’s recent article, “Expanding the Public Health Role of Pediatric Trauma Centers: Drug Screening for Adolescent Trauma Patients,” in which the authors found that biochemical drug screening for injured adolescents is decreasing at pediatric trauma centers, despite increasing national adolescent overdose deaths. Given high rates of substance use among injured adolescents, this is a missed opportunity to intervene on problematic substance use and prevent future adolescent overdose deaths.
Disclosure Information: Drs Rook, Kelley-Quon, and Erdahl have nothing to disclose. To earn 0.25 AMA PRA Category 1 Credits™ for this episode of the JACS Operative Word Podcast, click here to register for the course and complete the evaluation. Listeners can earn CME credit for this podcast for up to 2 years after the original air date.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recentlypublished authors about the motivation
behind their latest research
and the clinical implicationsit has for the practicing surgeon.
(00:23):
The opinions expressed in this podcastare those of the participants,
and not necessarilythat of the American College of Surgeons.
Welcome to The Operative Word,
the official podcast at the Journalof the American College of Surgeons.
I'm your co-host, Lillian Erdahl,and today I am joined by
Dr Lorraine Kelley-Quon,and Dr Jordan Rook.
(00:45):
Dr Kelley-Quon is a pediatric surgeonat Children's Hospital of Los Angeles
and associate professor of surgeryat Keck School of Medicine of USC.
And then Dr Rookis a general surgery resident at UCLA.
Thank you both for joining us.
Thank you for having us. Yeah. Thank you.
We're here to talk about your research,“Expanding the public health role
of pediatric trauma centers (01:06):
drug screening for adolescent trauma patients.”
And first, I'll just ask if you have anydisclosure or as relevant to this podcast.
I have no disclosures.
I have no disclosures.
Excellent.
Well, I'm really excitedto talk about this research.
I think it's a really important topic.
You know, how can we look at public healthinterventions that might impact
(01:30):
pediatric health and pediatric death.
So, I was hopingyou would tell us a little bit about,
you know,kind of what brought about this research.
And then we can talk about,
you know, what you've looked atand how we might make changes.
Yeah, of course.
So, this projectwas really a perfect synthesis
of our clinical experiences with ourpublic health researcher backgrounds.
(01:53):
So as clinicians, we noticed thatsome of our injured adolescents
weren'tbeing biochemically screened for drugs.
And we began askingamongst ourselves, why?
Well, when we lookedat the guidance from the American College
of Surgeons, which is the accrediting bodyfor trauma centers, we realized that
we have really robust alcohol use disorderscreening standards for adolescents.
(02:13):
And because it's required by the ACSfor patients 12 and older, we do it.
Screening for drugs,however, is recommended but not required.
And that createsa lot of this variability.
And whether adolescentsand whether trauma centers are going
to do this.
And so then as public health researchers,particularly with Dr Kelley-Quon's
background in investigatingopioid stewardship, we're also very aware
(02:36):
that drug overdose is a massive publichealth problem in the United States.
Since 2020, drug overdosehas risen above childhood cancers
to be the third leading cause of deathfor children and adolescents.
So how do we bring this all together?
Where do trauma centers come in?
Well, the top three causes of deathare firearm injury,
motor vehicle collisions,and then drug overdose.
(02:59):
Understanding that injured adolescents
have high rates of substanceuse disorders, we hypothesize
that trauma centers are a settingwhere we can begin to address
all three of these causes of death,and that brought us to this paper.
So, our goals were twofold.
First,
we wanted to determine if there was a gapin screening practices, essentially,
(03:19):
were pediatric trauma centers keeping upwith national trends in overdose deaths?
Second, we wanted to look at ratesof drug positivity
among screened adolescentsto determine if popular,
if this population really doeshave high rates of substance
use, indicating a need to strengthenscreening practices.
So then, in order to kind of look at this
(03:39):
and it's a it's a sobering statistic,I think, just to hear,
that this is such a,
risk for,you know, adolescents in our country.
You used a population databaseto look at this question, you know,
to look at sort of the screening ratesand what they might mean.
Tell me a little bitabout, the WONDER database or how we go
(04:00):
about the database researchto answer a question like this.
Yeah. So that's great.
I mean, we had two awesomedata sets to do this research.
The the one you mentioned is the CDC,
wide ranging online data for epidemiologicresearch or WONDER database.
It's publicly available,public facing.
You don't need an IAB to access it.
(04:22):
And it gives you mortality data,
for the entire United States by age.
And so that's what we used to look at,overdose deaths.
It's an incredible resource.
And they use ICD-10 cause of death codes,
essentially to allow researchersto look at this.
And then on the other end,to look at screening at trauma centers.
(04:44):
So, CDC data was used at a national levelto look at screening at trauma centers.
We actually used the American Collegeof Surgeons Trauma Quality Improvement
Program dataset,which is a registry of trauma centers
nationally and included a 134pediatric trauma centers.
And once again,an incredibly rich, resource
(05:05):
for this quality improvement-focused workthat we're doing in trauma.
Yeah.
And, just a highlightto all the people who gather this data,
and the institutionsthat support gathering these data
because without, all of those efforts,we can't do this type of research study.
And I think, you both know.
So I don't don't have to tell you, but,
(05:27):
the support of the peoplewho maintain registries,
you know, having somebody who's enteringthose data for your trauma center,
you know, having somebody maintain,
a website
or, you know, a databasewhere all of the information is
housed is really key to us being ableto make improvements in public health.
So how how did,
(05:49):
you then goabout kind of analyzing those data?
What is the result?
What do we knowabout the rates of screening
and where we might make interventionto improve those?
Yeah, absolutely.
So to give a high-level overviewof the methods.
Essentially by using the Trauma QualityImprovement program, the ACS dataset,
we assessed, the outcomes of biochemicaldrug screening and drug positivity.
(06:13):
And then using the CDC data,we took a look at drug overdose deaths.
And this was amongstadolescents ages 12 to 17 years.
That's our population of interest.
Of note for drug screening.
There's two ways that the ACS recommendsthat you can do substance use screening.
There's interview-based screens,essentially validated methods
(06:36):
where you ask the adolescentsthey have use of these substances
and if they have any risky behaviors,and then there's biochemical screens,
which essentially at mosthospitals is a UTOX
or a urine toxicology, TQIPonly collects data on UTOXes.
SoI want to clarify that our data is limited
to biochemical substance use screening.
(06:59):
So then sorry,I was just gonna highlight that that's a,
you know, a weakness, right?
The strength of the TQIP isthat you have such a large, number
to work with, but,you can't always capture,
every piece of information you might wantwhen you're working with a database
someone else is maintaining.
So, yeah,go ahead with their statistics.
Yeah. And absolutely.
And that'll be a future directionin which,
(07:21):
you know, we can discuss in a little bit.
But yeah.
So statistical analysiswas actually quite straightforward.
And perhaps our most important analyses,
are simple chartscomparing the incidence of overdose death
among adolescentsin the US annually to rates of drug
screening among injured adolescentsat pediatric trauma centers.
We also used a similar approachto compare rates of drug positivity
(07:42):
among injured adolescents
with the national incidenceof drug overdose by age.
And those are once againjust simple charts.
And then we used linear and logistic
regression to assess temporal trendsas well as to evaluate
patient characteristics and injurycharacter characteristics that are
independently associated with screeningpositive for particular substances.
(08:02):
So diving into our results,
I, I really think our figures capturethis work really well.
So for a quick summary of this paper,I'd suggest
the listeners just take a lookat our Figure 1 and Figure 2.
Because it really embodies our findings.
But simply stated,rates of biochemical drug
screening for 2017 to 2022 went down
(08:24):
from 23% of adolescents great to 21%of adolescent screened biochemically.
And during the same time, drugoverdose deaths among adolescents
nationally tripled, from 1 deathper 100,000 adolescents
annually to 3 deathsper 100,000 adolescents.
And this discordance is essentiallyour key finding.
(08:44):
Additionally,we found that rates of drug positivity
among those screened was high, with 34% of
12 to 17 yearolds screened positive for any substance,
including 29%,who screened positive for cannabis,
nearly 5%who screened positive for an opioid,
2% who screened positivefor methamphetamine or amphetamines.
(09:06):
And these rates are,
multiple times
higher than we would expectamongst adolescents in the general public.
On our adjusted analyses, ageas expected, was associated
with a steep increase in direct positivityfor all substances.
This correlates with drug overdose deaths,which increased from about
0.3 deaths per 100,000 12 year olds
(09:29):
to all the way up to about five deathsper 100,000 17 year olds.
And,
as you're kind of looking through this,you also looked at injury patterns
as well, right?So was there any association.
And again, this is the sub populationwho was screened.
But was there any associationwith injury type and testing positive,
(09:51):
or anything that you could draw, you know
from that about specific populationsor specific injury patterns?
We should be really focused on?
Yeah.
So regarding injury characteristics,the strongest associations we saw
were primarily assaults or mechanismsthat were due to interpersonal violence.
So, injuries due to assaultwere associated with a greater likelihood
(10:14):
of positivity for benzos, cannabisand methamphetamine,
when compared to adolescentswith unintentional injuries.
And then when we dive a little bit deeperinto that and we look at, the mechanisms,
and not the intent,
we found that, injuriesdue to firearm-related injuries
were also associated with an increasedlikelihood of screening positive
(10:37):
for benzos, cannabis,cocaine, and opioids.
And that's compared to motorvehicle collisions.
So, we see that some of the,these interpersonal-violence
type injuries, those adolescentswho come in with those injuries,
do have a higher likelihoodof screening positive for substance use.
I was,
(10:57):
you know, interested again to look at thatbecause I think,
we can look at sortof the overall approach, which is maybe
should we screen everyone who comesin, right?
Every adolescent who comes in,
or should we screen for specific injuries.
So I think, you know,some of what I wanted to talk to also talk
about also is, you know,what were your conclusions?
How does this, inform us,
(11:19):
in changing policy or our practices
and I think that's a, that's a really,a really great question.
Dr Rook has done a fantastic job
of summarizing our findingsbut some of the most exciting,
some of the most exciting partsof writing this paper
and putting it together was thinking aboutwhat's the next step
and how can ithow can we make things better?
(11:40):
I think the American College of Surgeonshas done such a fantastic job of creating
a framework of how to screenand refer for treatment
for alcohol use disorder.
So, building on that framework
and rolling in, screeningfor overall drug use and referral
for drug use, substance use treatment,I think it's already built in.
(12:02):
And if we expand that framework,I think that would
I think that would really buildon a lot of our results.
Another important thing,
to point out, is the increase
in the presence of fentanylin the general drug supply.
So because of that,there is a lot of interest,
both from the American Academyof Pediatrics,
(12:24):
and other medical organizations,including the American Medical
Association, to increase the availabilityof naloxone or Narcan,
which is a drug overdoseagent that is, intranasal spray.
And it's available over the counter.
So dovetailing efforts to increaseNarcan distribution within that trauma
setting for adolescents who are screeningpositive for substance use,
(12:48):
could also be a really meaningfulintervention is actually something
that we're we're starting here
at, at, Children's Hospital Los Angeles,where I'm practicing,
as you've highlighted before, having gooddata is really how you change.
Change a lot of this.
So TQIP, as we mentioned before,it does monitor biochemical drug screening
(13:09):
that it's not capturing, interview-basedscreening that all of our social workers,
are doing, in the trauma bayand also in the inpatient floor.
So having that be a component of datathat we're tracking
on a national leveland feeding back to hospitals,
I think also could, really move the needlein how to improve practice.
(13:30):
And then finally,you also hinted at this before
this is datagenerated from TQIP and from the CDC.
So ensuring that clinical datasetsin addition to national data sets
that are supported by taxpayer money,continue to be supported, continue
to be available and utilized, reallyis going to ensure that we always have
(13:52):
our finger on the pulseof what children need in terms
of, allocating resources, for trauma caredelivery.
All right.
That's a great point to to just highlight,I think multiple times,
particularlywhen we see that there may be,
questions and insecurity around ongoingfunding of research databases
(14:14):
to lose a databasethat has been maintained for decades
is is something that I worry will leadto much greater
consequences than might be apparenton simply a line item on a budget.
So understanding the rich, datathat are cumulative,
because we can look at these trendsand we can see, you know, the increase,
(14:37):
over 100% in, in deaths
in adolescents from a particular drug
or type of drug abuseshould be alarming to all of us.
And we only see those trendswhen we track the data.
And again, I would your group has gone
the next step to say, well,not only are we alarmed, but
we have an opportunity perhapsto make an improvement in this and,
(15:02):
I think each of our medical interactionsis an opportunity for us
to look at health improvement,not simply to say, you know, okay, we've
we've treated your broken arm or,
you know, we've helped you recoverfrom your stab wound.
But, you know, how can we look at, overallimproving your health or identify
future risks to the healthand particularly of our adolescents?
(15:24):
These interventions can,make a long-term difference
not just to that individual,but to their family and their community.
So,I really appreciate that you're looking
at, you know,how can we improve this statistic?
And, also, I think the interventions,as you mentioned, that our social workers
and our trauma systemsmake can't always be measured in,
(15:45):
statistical numbersbecause that 1 patient you help,
you know,
each 1 patient is really important to usas clinicians and as citizens.
You did talk a little bitabout sort of the
the American College of Surgeonstrauma programs, talk
a little bit more if you will, about sortof how that looks at an individual site,
(16:05):
you know, who captures these dataand how do you find resources?
Do you have an assigned social worker
on your pediatric trauma service,or is this a shared hospital resource?
How do we make this happenat a practical level?
Yeah, that's a great question.
You know, we're very fortunate.
The children's hospital I practice with,we have a very, robust trauma team.
(16:29):
We have a very engaged,team of social workers,
and, clinical data extractors,
to, track this data prospectively,
and continually, evaluatewhether we're meeting,
given metrics, both for the ACS and alsoour own, quality improvement efforts.
But that is somethingthat's variable across the country.
(16:52):
And again, pointsto why it's so important to be able
to track some of these statisticsnationally so we can potentially,
provide resources to teamsthat, need more support.
I think that in, in pediatric and,pediatric surgery,
we talk about not just saving, lives,but saving lifetimes.
(17:13):
And I really feel likethis is one of those spaces where it's
so applicable that that small interactionwith a social worker
sending a young person with substanceuse to referral
and getting them on the right track, itcould just be a key moment in their life.
That may not change.
You know, a population curveon a large level that it may really make
(17:37):
a difference.
In that particularyoung person's life.
So I think sofinding ways to support trauma,
trauma centers,specifically, trauma centers,
caring for children in this space,I really think is going to be
the next generation of how to,
deliver excellent care for injured kids.
And investing in treating substanceuse disorder
(17:59):
also is a long-term investmentfrom our health system.
So I didit's not as specific to your paper,
but I did want to mentionalso the support for mental healthcare,
and the importance of policiesand actions by organizations,
you know, including hospitals,to continue to support having adequate
(18:21):
resources for mental healthcare and substance use disorder treatment.
The first time that we intervenemight not be the time that we,
get someone to bettercoping with their substance use disorder.
They're going to need ongoing support.
You know, from, from health resourcesas well as their community.
(18:41):
Yeah, that's absolutely correct.
And again,I find that's why it's so compelling
because at the end of the day,I think, you know, regardless
of how you approach this problem,we all just want to do the right thing.
And we want to help our patientsand help families and, you know, building
up, mental health support servicesand substance use services for youth.
Is is definitely in that space.
(19:03):
Dr Rook, you mentioned a little bit,earlier sort of next steps.
So where mightyou take this research in the future?
How do we either get,
you know, fill in the gaps of informationand or look at other interventions?
Yeah, absolutely.
So, itthere's there's the work that we're doing,
in terms of improving our data accessand then eventually our, the data we have
(19:26):
and eventually we're also goingto have to turn towards implementation.
And Dr Kelley-Quon hintedat some of that with, these programs
where we screen all adolescentsand those that
screen positive, we're sending homewith counseling and Narcan prescription,
I think, for some other future directions.
I think something of great interest to us
(19:47):
is which centers are high screeningand which centers are low screening.
I think that's really importantthat we start highlighting which centers
are doing really well at this alreadyand which ones are falling behind.
And that's definitely in termsof, using a national data
set, like TQIP something that we're goingto look at next.
(20:08):
And then,
there's the other arms of research,which obviously is policy and advocacy.
ACS has done such a tremendous jobwith alcohol screening as,
Dr Kelley-Quon, brought up.
And so I think as we build upthis body of data, I think
as we move forward in trauma systems,advocating for more robust
(20:28):
screening programs, this is honestly wherewe want to go with this.
Because I dothink we have a really amazing opportunity
to expand the already
critical public health rolethat trauma centers play in US society,
especially for kids,and expand that to, once again,
the third leading cause of deathand I think it was a few episodes
(20:49):
ago, Dr Britt Christmas,mentioning that a trauma the best,
the best, treatment is prevention.
And I think we havea really great opportunity to prevent,
drug overdose, amongst our kids.
Again, I, I liked hearingyou talk about sort of the implementation
science lens, you know,and as I think about looking at both high
(21:10):
screening and low screening centers,I expect that you will learn more about
what are the factors that,you know, play into that, because it's
probably not only participatingin the trauma programs, but it's, again,
do you have the robust resourceswithin your institution,
and that can provide the lenswhere you can recommend
specific interventionsthat might lead to improvement,
(21:33):
across multiple centers.
So,
I look forward to seeing your future workand, you know, hopefully
this episode reaches our listenerswho can consider whether there are things
that can be done in their pediatrictrauma center or their hospital system,
to improve the outcomes of kidsacross the spectrum of trauma.
(21:54):
Thank you. Yeah.
Is there anything else that, you wantedto highlight about this work or,
you know, about your work in populationhealth for pediatrics?
I think it's really important in this work
to constantly go back to basics and see
what's happening, because adolescentsubstance use is always changing.
There will always be new substances,there always be new problems.
(22:17):
And so,we need to be very facile in our ability
to change our approach to track dataand constantly improve better care
by constantly looking at whatthe injured children we'recaring for need.
And I think that's reallyimportant for this question in particular.
But a lot of questions, that arise whencaring for, caring for injured children.
(22:39):
So, thank you to you both for joining ustoday on The Operative Word.
And we look forward to highlightingmore of your work in the future.
Thank you so much for this opportunity. Yeah.
Thank you.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
(23:01):
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Lillian Erdahl,and throughout this series, Dr Tom
Varghese and I will speak with recentlypublished authors about the motivation
behind their latest research
and the clinical implicationsit has for the practicing surgeon.
(00:23):
The opinions expressed in this podcastare those of the participants,
and not necessarilythat of the American College of Surgeons.
Welcome to The Operative Word,
the official podcast at the Journalof the American College of Surgeons.
I'm your co-host, Lillian Erdahl,and today I am joined by
Dr Lorraine Kelley-Quon,and Dr Jordan Rook.
(00:45):
Dr Kelley-Quon is a pediatric surgeonat Children's Hospital of Los Angeles
and associate professor of surgeryat Keck School of Medicine of USC.
And then Dr Rookis a general surgery resident at UCLA.
Thank you both for joining us.
Thank you for having us. Yeah. Thank you.
We're here to talk about your research,“Expanding the public health role
of pediatric trauma centers (01:06):
drug screening for adolescent trauma patients.”
And first, I'll just ask if you have anydisclosure or as relevant to this podcast.
I have no disclosures.
I have no disclosures.
Excellent.
Well, I'm really excitedto talk about this research.
I think it's a really important topic.
You know, how can we look at public healthinterventions that might impact
(01:30):
pediatric health and pediatric death.
So, I was hopingyou would tell us a little bit about,
you know,kind of what brought about this research.
And then we can talk about,
you know, what you've looked atand how we might make changes.
Yeah, of course.
So, this projectwas really a perfect synthesis
of our clinical experiences with ourpublic health researcher backgrounds.
(01:53):
So as clinicians, we noticed thatsome of our injured adolescents
weren'tbeing biochemically screened for drugs.
And we began askingamongst ourselves, why?
Well, when we lookedat the guidance from the American College
of Surgeons, which is the accrediting bodyfor trauma centers, we realized that
we have really robust alcohol use disorderscreening standards for adolescents.
(02:13):
And because it's required by the ACSfor patients 12 and older, we do it.
Screening for drugs,however, is recommended but not required.
And that createsa lot of this variability.
And whether adolescentsand whether trauma centers are going
to do this.
And so then as public health researchers,particularly with Dr Kelley-Quon's
background in investigatingopioid stewardship, we're also very aware
(02:36):
that drug overdose is a massive publichealth problem in the United States.
Since 2020, drug overdosehas risen above childhood cancers
to be the third leading cause of deathfor children and adolescents.
So how do we bring this all together?
Where do trauma centers come in?
Well, the top three causes of deathare firearm injury,
motor vehicle collisions,and then drug overdose.
(02:59):
Understanding that injured adolescents
have high rates of substanceuse disorders, we hypothesize
that trauma centers are a settingwhere we can begin to address
all three of these causes of death,and that brought us to this paper.
So, our goals were twofold.
First,
we wanted to determine if there was a gapin screening practices, essentially,
(03:19):
were pediatric trauma centers keeping upwith national trends in overdose deaths?
Second, we wanted to look at ratesof drug positivity
among screened adolescentsto determine if popular,
if this population really doeshave high rates of substance
use, indicating a need to strengthenscreening practices.
So then, in order to kind of look at this
(03:39):
and it's a it's a sobering statistic,I think, just to hear,
that this is such a,
risk for,you know, adolescents in our country.
You used a population databaseto look at this question, you know,
to look at sort of the screening ratesand what they might mean.
Tell me a little bitabout, the WONDER database or how we go
(04:00):
about the database researchto answer a question like this.
Yeah. So that's great.
I mean, we had two awesomedata sets to do this research.
The the one you mentioned is the CDC,
wide ranging online data for epidemiologicresearch or WONDER database.
It's publicly available,public facing.
You don't need an IAB to access it.
(04:22):
And it gives you mortality data,
for the entire United States by age.
And so that's what we used to look at,overdose deaths.
It's an incredible resource.
And they use ICD-10 cause of death codes,
essentially to allow researchersto look at this.
And then on the other end,to look at screening at trauma centers.
(04:44):
So, CDC data was used at a national levelto look at screening at trauma centers.
We actually used the American Collegeof Surgeons Trauma Quality Improvement
Program dataset,which is a registry of trauma centers
nationally and included a 134pediatric trauma centers.
And once again,an incredibly rich, resource
(05:05):
for this quality improvement-focused workthat we're doing in trauma.
Yeah.
And, just a highlightto all the people who gather this data,
and the institutionsthat support gathering these data
because without, all of those efforts,we can't do this type of research study.
And I think, you both know.
So I don't don't have to tell you, but,
(05:27):
the support of the peoplewho maintain registries,
you know, having somebody who's enteringthose data for your trauma center,
you know, having somebody maintain,
a website
or, you know, a databasewhere all of the information is
housed is really key to us being ableto make improvements in public health.
So how how did,
(05:49):
you then goabout kind of analyzing those data?
What is the result?
What do we knowabout the rates of screening
and where we might make interventionto improve those?
Yeah, absolutely.
So to give a high-level overviewof the methods.
Essentially by using the Trauma QualityImprovement program, the ACS dataset,
we assessed, the outcomes of biochemicaldrug screening and drug positivity.
(06:13):
And then using the CDC data,we took a look at drug overdose deaths.
And this was amongstadolescents ages 12 to 17 years.
That's our population of interest.
Of note for drug screening.
There's two ways that the ACS recommendsthat you can do substance use screening.
There's interview-based screens,essentially validated methods
(06:36):
where you ask the adolescentsthey have use of these substances
and if they have any risky behaviors,and then there's biochemical screens,
which essentially at mosthospitals is a UTOX
or a urine toxicology, TQIPonly collects data on UTOXes.
SoI want to clarify that our data is limited
to biochemical substance use screening.
(06:59):
So then sorry,I was just gonna highlight that that's a,
you know, a weakness, right?
The strength of the TQIP isthat you have such a large, number
to work with, but,you can't always capture,
every piece of information you might wantwhen you're working with a database
someone else is maintaining.
So, yeah,go ahead with their statistics.
Yeah. And absolutely.
And that'll be a future directionin which,
(07:21):
you know, we can discuss in a little bit.
But yeah.
So statistical analysiswas actually quite straightforward.
And perhaps our most important analyses,
are simple chartscomparing the incidence of overdose death
among adolescentsin the US annually to rates of drug
screening among injured adolescentsat pediatric trauma centers.
We also used a similar approachto compare rates of drug positivity
(07:42):
among injured adolescents
with the national incidenceof drug overdose by age.
And those are once againjust simple charts.
And then we used linear and logistic
regression to assess temporal trendsas well as to evaluate
patient characteristics and injurycharacter characteristics that are
independently associated with screeningpositive for particular substances.
(08:02):
So diving into our results,
I, I really think our figures capturethis work really well.
So for a quick summary of this paper,I'd suggest
the listeners just take a lookat our Figure 1 and Figure 2.
Because it really embodies our findings.
But simply stated,rates of biochemical drug
screening for 2017 to 2022 went down
(08:24):
from 23% of adolescents great to 21%of adolescent screened biochemically.
And during the same time, drugoverdose deaths among adolescents
nationally tripled, from 1 deathper 100,000 adolescents
annually to 3 deathsper 100,000 adolescents.
And this discordance is essentiallyour key finding.
(08:44):
Additionally,we found that rates of drug positivity
among those screened was high, with 34% of
12 to 17 yearolds screened positive for any substance,
including 29%,who screened positive for cannabis,
nearly 5%who screened positive for an opioid,
2% who screened positivefor methamphetamine or amphetamines.
(09:06):
And these rates are,
multiple times
higher than we would expectamongst adolescents in the general public.
On our adjusted analyses, ageas expected, was associated
with a steep increase in direct positivityfor all substances.
This correlates with drug overdose deaths,which increased from about
0.3 deaths per 100,000 12 year olds
(09:29):
to all the way up to about five deathsper 100,000 17 year olds.
And,
as you're kind of looking through this,you also looked at injury patterns
as well, right?So was there any association.
And again, this is the sub populationwho was screened.
But was there any associationwith injury type and testing positive,
(09:51):
or anything that you could draw, you know
from that about specific populationsor specific injury patterns?
We should be really focused on?
Yeah.
So regarding injury characteristics,the strongest associations we saw
were primarily assaults or mechanismsthat were due to interpersonal violence.
So, injuries due to assaultwere associated with a greater likelihood
(10:14):
of positivity for benzos, cannabisand methamphetamine,
when compared to adolescentswith unintentional injuries.
And then when we dive a little bit deeperinto that and we look at, the mechanisms,
and not the intent,
we found that, injuriesdue to firearm-related injuries
were also associated with an increasedlikelihood of screening positive
(10:37):
for benzos, cannabis,cocaine, and opioids.
And that's compared to motorvehicle collisions.
So, we see that some of the,these interpersonal-violence
type injuries, those adolescentswho come in with those injuries,
do have a higher likelihoodof screening positive for substance use.
I was,
(10:57):
you know, interested again to look at thatbecause I think,
we can look at sortof the overall approach, which is maybe
should we screen everyone who comesin, right?
Every adolescent who comes in,
or should we screen for specific injuries.
So I think, you know,some of what I wanted to talk to also talk
about also is, you know,what were your conclusions?
How does this, inform us,
(11:19):
in changing policy or our practices
and I think that's a, that's a really,a really great question.
Dr Rook has done a fantastic job
of summarizing our findingsbut some of the most exciting,
some of the most exciting partsof writing this paper
and putting it together was thinking aboutwhat's the next step
and how can ithow can we make things better?
(11:40):
I think the American College of Surgeonshas done such a fantastic job of creating
a framework of how to screenand refer for treatment
for alcohol use disorder.
So, building on that framework
and rolling in, screeningfor overall drug use and referral
for drug use, substance use treatment,I think it's already built in.
(12:02):
And if we expand that framework,I think that would
I think that would really buildon a lot of our results.
Another important thing,
to point out, is the increase
in the presence of fentanylin the general drug supply.
So because of that,there is a lot of interest,
both from the American Academyof Pediatrics,
(12:24):
and other medical organizations,including the American Medical
Association, to increase the availabilityof naloxone or Narcan,
which is a drug overdoseagent that is, intranasal spray.
And it's available over the counter.
So dovetailing efforts to increaseNarcan distribution within that trauma
setting for adolescents who are screeningpositive for substance use,
(12:48):
could also be a really meaningfulintervention is actually something
that we're we're starting here
at, at, Children's Hospital Los Angeles,where I'm practicing,
as you've highlighted before, having gooddata is really how you change.
Change a lot of this.
So TQIP, as we mentioned before,it does monitor biochemical drug screening
(13:09):
that it's not capturing, interview-basedscreening that all of our social workers,
are doing, in the trauma bayand also in the inpatient floor.
So having that be a component of datathat we're tracking
on a national leveland feeding back to hospitals,
I think also could, really move the needlein how to improve practice.
(13:30):
And then finally,you also hinted at this before
this is datagenerated from TQIP and from the CDC.
So ensuring that clinical datasetsin addition to national data sets
that are supported by taxpayer money,continue to be supported, continue
to be available and utilized, reallyis going to ensure that we always have
(13:52):
our finger on the pulseof what children need in terms
of, allocating resources, for trauma caredelivery.
All right.
That's a great point to to just highlight,I think multiple times,
particularlywhen we see that there may be,
questions and insecurity around ongoingfunding of research databases
(14:14):
to lose a databasethat has been maintained for decades
is is something that I worry will leadto much greater
consequences than might be apparenton simply a line item on a budget.
So understanding the rich, datathat are cumulative,
because we can look at these trendsand we can see, you know, the increase,
(14:37):
over 100% in, in deaths
in adolescents from a particular drug
or type of drug abuseshould be alarming to all of us.
And we only see those trendswhen we track the data.
And again, I would your group has gone
the next step to say, well,not only are we alarmed, but
we have an opportunity perhapsto make an improvement in this and,
(15:02):
I think each of our medical interactionsis an opportunity for us
to look at health improvement,not simply to say, you know, okay, we've
we've treated your broken arm or,
you know, we've helped you recoverfrom your stab wound.
But, you know, how can we look at, overallimproving your health or identify
future risks to the healthand particularly of our adolescents?
(15:24):
These interventions can,make a long-term difference
not just to that individual,but to their family and their community.
So,I really appreciate that you're looking
at, you know,how can we improve this statistic?
And, also, I think the interventions,as you mentioned, that our social workers
and our trauma systemsmake can't always be measured in,
(15:45):
statistical numbersbecause that 1 patient you help,
you know,
each 1 patient is really important to usas clinicians and as citizens.
You did talk a little bitabout sort of the
the American College of Surgeonstrauma programs, talk
a little bit more if you will, about sortof how that looks at an individual site,
(16:05):
you know, who captures these dataand how do you find resources?
Do you have an assigned social worker
on your pediatric trauma service,or is this a shared hospital resource?
How do we make this happenat a practical level?
Yeah, that's a great question.
You know, we're very fortunate.
The children's hospital I practice with,we have a very, robust trauma team.
(16:29):
We have a very engaged,team of social workers,
and, clinical data extractors,
to, track this data prospectively,
and continually, evaluatewhether we're meeting,
given metrics, both for the ACS and alsoour own, quality improvement efforts.
But that is somethingthat's variable across the country.
(16:52):
And again, pointsto why it's so important to be able
to track some of these statisticsnationally so we can potentially,
provide resources to teamsthat, need more support.
I think that in, in pediatric and,pediatric surgery,
we talk about not just saving, lives,but saving lifetimes.
(17:13):
And I really feel likethis is one of those spaces where it's
so applicable that that small interactionwith a social worker
sending a young person with substanceuse to referral
and getting them on the right track, itcould just be a key moment in their life.
That may not change.
You know, a population curveon a large level that it may really make
(17:37):
a difference.
In that particularyoung person's life.
So I think sofinding ways to support trauma,
trauma centers,specifically, trauma centers,
caring for children in this space,I really think is going to be
the next generation of how to,
deliver excellent care for injured kids.
And investing in treating substanceuse disorder
(17:59):
also is a long-term investmentfrom our health system.
So I didit's not as specific to your paper,
but I did want to mentionalso the support for mental healthcare,
and the importance of policiesand actions by organizations,
you know, including hospitals,to continue to support having adequate
(18:21):
resources for mental healthcare and substance use disorder treatment.
The first time that we intervenemight not be the time that we,
get someone to bettercoping with their substance use disorder.
They're going to need ongoing support.
You know, from, from health resourcesas well as their community.
(18:41):
Yeah, that's absolutely correct.
And again,I find that's why it's so compelling
because at the end of the day,I think, you know, regardless
of how you approach this problem,we all just want to do the right thing.
And we want to help our patientsand help families and, you know, building
up, mental health support servicesand substance use services for youth.
Is is definitely in that space.
(19:03):
Dr Rook, you mentioned a little bit,earlier sort of next steps.
So where mightyou take this research in the future?
How do we either get,
you know, fill in the gaps of informationand or look at other interventions?
Yeah, absolutely.
So, itthere's there's the work that we're doing,
in terms of improving our data accessand then eventually our, the data we have
(19:26):
and eventually we're also goingto have to turn towards implementation.
And Dr Kelley-Quon hintedat some of that with, these programs
where we screen all adolescentsand those that
screen positive, we're sending homewith counseling and Narcan prescription,
I think, for some other future directions.
I think something of great interest to us
(19:47):
is which centers are high screeningand which centers are low screening.
I think that's really importantthat we start highlighting which centers
are doing really well at this alreadyand which ones are falling behind.
And that's definitely in termsof, using a national data
set, like TQIP something that we're goingto look at next.
(20:08):
And then,
there's the other arms of research,which obviously is policy and advocacy.
ACS has done such a tremendous jobwith alcohol screening as,
Dr Kelley-Quon, brought up.
And so I think as we build upthis body of data, I think
as we move forward in trauma systems,advocating for more robust
(20:28):
screening programs, this is honestly wherewe want to go with this.
Because I dothink we have a really amazing opportunity
to expand the already
critical public health rolethat trauma centers play in US society,
especially for kids,and expand that to, once again,
the third leading cause of deathand I think it was a few episodes
(20:49):
ago, Dr Britt Christmas,mentioning that a trauma the best,
the best, treatment is prevention.
And I think we havea really great opportunity to prevent,
drug overdose, amongst our kids.
Again, I, I liked hearingyou talk about sort of the implementation
science lens, you know,and as I think about looking at both high
(21:10):
screening and low screening centers,I expect that you will learn more about
what are the factors that,you know, play into that, because it's
probably not only participatingin the trauma programs, but it's, again,
do you have the robust resourceswithin your institution,
and that can provide the lenswhere you can recommend
specific interventionsthat might lead to improvement,
(21:33):
across multiple centers.
So,
I look forward to seeing your future workand, you know, hopefully
this episode reaches our listenerswho can consider whether there are things
that can be done in their pediatrictrauma center or their hospital system,
to improve the outcomes of kidsacross the spectrum of trauma.
(21:54):
Thank you. Yeah.
Is there anything else that, you wantedto highlight about this work or,
you know, about your work in populationhealth for pediatrics?
I think it's really important in this work
to constantly go back to basics and see
what's happening, because adolescentsubstance use is always changing.
There will always be new substances,there always be new problems.
(22:17):
And so,we need to be very facile in our ability
to change our approach to track dataand constantly improve better care
by constantly looking at whatthe injured children we'recaring for need.
And I think that's reallyimportant for this question in particular.
But a lot of questions, that arise whencaring for, caring for injured children.
(22:39):
So, thank you to you both for joining ustoday on The Operative Word.
And we look forward to highlightingmore of your work in the future.
Thank you so much for this opportunity. Yeah.
Thank you.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
(23:01):
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
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