Brief Intervention for Problem Substance Use in Persons With

Moderate to Severe TBI Angelle M. Sander, Ph.D.

Assistant Professor

Department of Physical Medicine & Rehabilitation

Baylor College of Medicine/

Harris County Hospital District

Project Co-Director

Rehabilitation Research and Training Center

on Community Integration in

Persons With Traumatic Brain Injury

The Institute for Rehabilitation and Research

Grant Support

• Rehabilitation Research and Training Center on Community Integration in Persons With Traumatic Brain Injury – Co-Project Directors: Angelle M. Sander, Ph.D.

& Margaret A. Struchen, Ph.D.– Director of Training: Karen Hart, Ph.D.– Co-Investigator: Sunil Kothari, M.D.

Brief Intervention for Problem Substance Use

• Joint project between The Institute for Rehabilitation and Research (Texas) and Ohio State University

• Principal Investigators– Angelle Sander, Ph.D. (Texas)– John Corrigan, Ph.D. & Jenny Bogner, Ph.D. (Ohio)

• Level I trauma centers– Ben Taub General Hospital (Houston)– Grant Hospital (Columbus)

Pre-Injury Substance Abuse

• Blood alcohol levels at time of injury- 36 to 51% positive

• Structured interviews or questionnaires- 37 to 66% positive for alcohol abuse

• Other drug use- 36 to 37%

Pre- and Post-Injury Alcohol Use Among Patients With TBI

Kreutzer et al., 1990

N=87

Impact of Alcohol Abuse History on Outcome After TBI

• Associated with a reduced rate of good outcome on the Glasgow Outcome Scale (Ruff et al., 1990)

• Associated with emotional and behavioral deterioration at 6 months post-injury (Dunlop et al., 1991)

• Associated with re-injury/subsequent TBI (Kaplan & Corrigan, 1992)

Impact of Alcohol Abuse History on Outcome After TBI

• Associated with impaired event-related potentials indicating cognitive slowing in response to stimulation (Baguley et al., 1997)

• Associated with poor neuropsychological test performance (Brooks et al., 1989; Dikmen et al., 1993)

Impact of Alcohol Abuse History on Outcome After TBI

• Predictive of employment (Sherer et al., 1999; MaMillan et al., 2002)

• Predictive of independent living status (MacMillan et al., 2002)

• Predictive of life satisfaction (Corrigan et al., 2001)

Barriers to Substance Abuse Treatment After TBI

• Cognitive deficits, including impaired memory, judgment, and awareness

• Social environment

• Boredom, inactivity

• Lack of experienced referral sources

• Not ready to change

Transtheoretical Stages of Change Model

(Prochaska et al., 1992)

• Persons with problem behaviors operate at different stages of readiness for change.

• Intervention works best if it is matched with the person’s readiness for change.

Stages of Readiness for Change

• Precontemplation: problems not acknowledged and no change considered

• Contemplation: acknowledges problem, but no commitment to change

• Preparation: sets goals for change; may begin preliminary attempts to change

Stages of Readiness for Change

• Action: makes changes in behavior and in the environment to support changes

• Maintenance: changes established and goal is to prevent relapse

Readiness to Change Alcohol Use After TBI

• Occurrence of trauma may result in a “teachable moment” (general trauma and spinal cord injury)

• The majority of persons with TBI in an inpatient rehab program were in contemplation or action stage (Bombardier et al., 1997).

• Those with higher BALS or higher preinjury alcohol consumption showed greater readiness to change.

Randomized Trial of a Brief Substance Abuse Intervention

• Persons with complicated mild, moderate, and severe TBI admitted to trauma services at one of the 2 participating Level I trauma centers

• Persons who screen positive for history of alcohol and/or drug abuse are randomly assigned to receive brief intervention or hospital standard of care.

Exclusion Criteria • Age <18• Glasgow Coma Scale score >12 upon ER

admission AND no positive CT/MRI findings

• If no GCS available, then loss of consciousness < 20 minutes

• Discharged to an inpatient rehab facility other than those associated with the 2 Level I trauma centers

• Discharged to a nursing home or long-term care facility or to a prison

Screening Criteria for Randomization to Treatment

• Admit blood alcohol level > or = .08• Laboratory tests positive for cannabis,

cocaine, or any other illicit substance• Positive response to at least 2 CAGE

questions• Score of >5 on the Drug Abuse Screening

Test• Alcohol Use Questionnaire: >14 drinks per

week for men; >7 for women; one day per week of 5 or more drinks; any illicit drug use

Brief Intervention • Videotape created by Ohio Valley Center for

Brain Injury Prevention and Rehabilitation (Ohio State University): education regarding the impact of alcohol on functioning after TBI (10 minutes)

• Brief (10-15 minute) motivational interview: encourage discussion of recovery goals and how substance use will help or hinder goals; non-directive

• Delivered when fully oriented, up to one month post-discharge

Follow-Up Measures (3-4 months)

• Alcohol Expectancy Questionnaire-III– 40 Likert items– 8 factors

• Positive expectancies: Global Positive, Social and Physical Pleasure, Social Expressiveness, Sexual Enhancement, Power and Aggression, Tension Reduction

• Negative Expectancies: Cognitive and Physical Impairment, Careless Unconcern

– Global Positive and Cognitive and Physical Impairment used for current study

Follow-Up Measures • Readiness to Change Questionnaire

– 12 Likert items assessing a person’s belief about drinking or drug use and the perceived importance of change

– “Sometimes I think I should cut down on my drinking.”

– Precontemplation, Contemplation, and Action scales

– Currently using 10 items based on Bombardier & Heinemann’s validation study for TBI

Follow-Up Measures

• Alcohol and drug use questions from the TBI Model Systems national dataset– Adapted from questions used in the CDC’s

National Household Survey on Drug Abuse – “During the past month, how many days per

week or month did you drink any alcoholic beverages on the average?”

– “On the days when you drank, about how many drinks did you drink on the average?”

Follow-Up Measures

• Alcohol and drug use questions from the TBI Model Systems national dataset– “…how many times during the past month did

you have five or more drinks on one occasion?”

– “During the past month, have you used illicit or non-prescription drugs?”

Status of Study

• Data collection began August 2004

• 106 persons enrolled and screened for problem history– 73 Texas– 33 Ohio

• 70 met criteria for problem substance use history and randomized to treatment or standard of care– 48 Texas– 22 Ohio

Demographics By Center

Texas Ohio

Gender

Male 72% 76%

Race

White 19% 79%

Black 32% 12%

Hispanic 43% 3%

Education

<12 years 47% 12%

Unemployed 28% 45%

Injury Severity by Center

Texas Ohio

ER admit GCS score

11.55 (SD=3.81)

11.15 (SD=4.91)

Length of Stay 16.88 (SD=25.19)

9.33 (SD=8.72)

Proportion of Persons Meeting Problem Substance Use Criteria

0

10

20

30

40

50

60

70

80

90

BAL TOXLAB

CAGE DAST AlcoholUse

IllicitDrug Use

Follow-Up AEQ-III Scores By Group

Readiness to Change Scores by Group

0

2

4

6

8

10

12

14

Precontemplation Contemplation Action

Intervention Control

Follow-Up Alcohol Use By Group

Acknowledgements

• Allison Clark, M.A. and Dan Graves, Ph.D. for data analyses

• Allison Clark, M.A., Marie Silva, M.S.W. for project coordination

• Jason Ferguson- consumer advisor