1. 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

2. 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.

3. 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)

4. 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%

5. Pre- and Post-Injury Alcohol Use Among Patients With TBI Kreutzer et al., 1990 N=87

6. 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)

7. 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)

8. 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)

9. 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

10. 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.

11. 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

12. 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

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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?”

21. 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?”

22. 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

23. Demographics By Center TexasOhio Gender Male72%76% Race White19%79% Black32%12% Hispanic43% 3% Education <12 years47%12% Unemployed28%45%

24. Injury Severity by Center TexasOhio ER admit GCS score 11.55 (SD=3.81) 11.15 (SD=4.91) Length of Stay16.88 (SD=25.19) 9.33 (SD=8.72)

25. Proportion of Persons Meeting Problem Substance Use Criteria

26. Follow-Up AEQ-III Scores By Group

27. Readiness to Change Scores by Group

28. Follow-Up Alcohol Use By Group

29. 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