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
