Brief Intervention for Substance Abuse after TBI John D. Corrigan, PhD Ohio Valley Center for Brain Injury Prevention and Rehabilitation Ohio State University

Mitchell Rosenthal, PhD

% Rehabilitation Patients with Prior Histories of Abuse

Problem Substance Use Before and After Moderate and Severe TBI

Pre-injury Substance Abuse in Those Lost to Follow-up 1 year Post-injury (Corrigan et al., 1997)

Binge Drinking 1 Year after Hospitalization for TBI [Horner, et al, 2005 (South Carolina Follow-up Study)]

Percentage With Needs Unmet at 1 Year Corrigan, Whiteneck & Mellick (2004)

Percentage with Unmet Needs at 1 Year Pickelsimer et al. (2007)

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant IQuadrant II Quadrant IIIQuadrant IV 4 Quadrant Model of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Quadrant II Rehabilitation Programs & Services Quadrant III Substance Abuse System Quadrant IV Specialized TBI & Substance Abuse Services 4 Quadrant Model: Place of Service Provision

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model: Types of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model: Types of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model: Types of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

Screening & Brief Interventions (SBI) Brief, opportunistic, counseling and referral conducted in a medical context (e.g., physician’s office, Emergency Department, Trauma Program) Clinical trials support both efficacy and cost- effectiveness for less severe alcohol problems Most studied are the WHO model for primary care (currently promoted by CDC and NIAAA) and “FRAMES” developed by Gentilello and colleagues at University of Washington for use in Emergency Departments & Trauma Centers.

GGT decreased in both groups Fewer sick days in intervention group 10 control, 5 inter- vention deaths Efficacy of Screening & Brief Intervention Kristenson H, et al. Alcohol Clin Exp Res 1983;7:203 Hospital Days 5 years post-intervention

RCT, 17 practices, 64 physicians N=774 –Men >14 drinks/wk –Women >11 drinks/wk 93% 12 month follow-up Control: health booklet Intervention: health booklet ” physician discussions and a follow-up nurse phone call In Primary Care: Project TrEAT Fleming MF, Lawton Barry K, et al. JAMA 1997;277:1039

Project TrEAT Results *p<0.001

FRAMES Study Gentilello, Rivara, Donovan, Jurkovich, et al. (1999) 762 Level 1 trauma patients who screened positive for problem alcohol use Randomly assigned to Screening & Brief Intervention (SBI) or standard care 12 months later those receiving SBI : –Reduced alcohol consumption by 21.8 drinks/wk. (vs. 6.7 for the control group) –Reduction most apparent in patients with mild to moderate alcohol use problems –SBI group had 47% reduction in ER or trauma admissions 3 years later, SBI group had 48% reduction in injuries requiring hospitalization

WHO Model of SBI Screening Distinguish among abstainers, low-risk use, at-risk use and substance use disorder Intervention If low risk, advise not to increase If at-risk, advise and assist depending on readiness to change If substance use disorder, advise, refer and/or treat

FRAMES Components Feedback: respectfully give specific information that concerns the patient Responsibility: stress that the patient is responsible for any change Advice: respectfully give advice to the patient Menu: offer the patient choices Empathy: listen and reflect Self-efficacy: reinforce that change is possible and will be beneficial

FRAMES Process Make introduction and attend to patient’s agenda Introduce substance use agenda Assess readiness to change: –If precontemplative, goal is to raise doubt –If contemplative, goal is to increase ambivalence –If ready to take action, goal is to elicit a commitment Utilize FRAMES components Close on good terms

SBI Summary Screening and Brief Intervention (SBI) has become the standard of care Takes advantage of the opportunity created by recently experienced consequences SBI appears effective for reducing use among heavy users and abusers, less so those with dependence Reduced use reduces subsequent injuries Patients with moderate and severe TBI often excluded from research and clinical protocols Need to develop SBI protocols specifically for persons with TBI

SBI for TBI If used acutely, how to address confusion and/or diminished cognitive functioning? How can an interdisciplinary team optimize the impact of SBI? Are there opportunities to use SBI later post- injury: –Case managers? –Vocational rehabilitation counselors? Who should the target audience be?

Substance Use Disorders and Problem Substance Use Substance Dependence (DSM-IV) Substance Abuse (DSM-IV) or High Risk Use (ICD-9 CM) Unhealthy Use (Dietary Guidelines for Americans)

Unhealthy Alcohol Use (Dietary Guidelines for Americans) Any use of illicit drugs, including alcohol by children. Alcohol use for adults –Men ≤ 65 years old--no more than 2 drinks per day >65 years old--no more than 1 drink per day –Women --no more than 1 drink per day Abstain from alcohol when pregnant or considering pregnancy, when taking a medication that interacts with alcohol; if a contraindicated medical condition is present (e.g., ulcer, liver disease), or if alcohol dependent.

–If at risk for heart disease, consider potential benefits and risks of alcohol use: light to moderate drinking is associated with lower rates of coronary heart disease in certain populations (e.g., men over 45, postmenopausal women). –Infrequent or nondrinkers are not advised to begin drinking to reduce the risk of coronary heart disease because vulnerability to alcohol-related problems cannot always be predicted. –Similar protective effects can likely be achieved through proper diet and exercise. Unhealthy Use (Dietary Guidelines for Americans)

Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

A User’s Manual

Eight Educational Messages 1.People who use alcohol or other drugs after they have a brain injury don’t recover as much. 2.Brain injuries cause problems in balance, walking or talking that get worse when a person uses alcohol or other drugs. 3.People who have had a brain injury often say or do things without thinking first, a problem that is made worse by using alcohol and other drugs. 4.Brain injuries cause problems with thinking, like concentration or memory, and using alcohol or other drugs makes these problems worse.

Eight Educational Messages 5.After brain injury, alcohol and other drugs have a more powerful effect. 6.People who have had a brain injury are more likely to have times that they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse. 7.After a brain injury, drinking alcohol or using other drugs can cause a seizure. 8.People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.

Screening and Brief Intervention in Acute Rehabilitation 60 Ss with TBI receiving acute rehab 3 conditions (interventions randomized): –baseline/standard of care –booklet only intervention –booklet + video intervention Information retained, attitudes, and use measured 30 days following discharge

Screening and Brief Intervention (SBI) for More Serious TBI 1.Give booklet and introduce videotape 2.Play the videotape 3.Ask: “Do you have any questions?” 4.Say: “We hope it is clear…we recommend no drinking alcohol or use of illicit drugs.” 5.Ask: “On a scale of 1 to 10…how important is it that you not use alcohol or illicit drugs?”

SBI for More Serious TBI (cont’d) If low importance (1-3) ask: “Which of the reasons for not using made the most sense to you?” Use open-ended questions and reflective listening to explore patient’s views on negative effects of substance use on recovery from TBI.

SBI for More Serious TBI (cont’d) If moderate importance (4-6) ask: “It sounds like you’re not sure about your use. What do you think would be some good reasons for not using?” After reflective listening, summarize and ask “What are some things that would make it hard not to use?” Again, listen and summarize.

SBI for More Serious TBI (cont’d) If high importance (7-10) ask: “It sounds important to you not to use. What do you think would help you accomplish that?” During reflective listening reinforce self- motivational statements and support self- efficacy.

SBI for More Serious TBI (cont’d) For all patients, conclude interview by: Eliciting up to 3 reasons why it would be a good idea not to use substances Re-capping the key, positive motivational issues.

Conclusions SBI may be an important tool for addressing substance use among persons with TBI. Need to determine if and how SBI needs to be adapted for persons with more serious TBI. The field needs consensus about the level of use we should target and the behavior we will recommend. We need to consider both acute and chronic opportunities to use SBI. We need a lot more research.