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
Normative
Pre-injury
60
Post-injury
N=87
50
40
30
20
10
0
Abstainer
Infrequent/Light
Moderate/Heavy
Kreutzer et al., 1990
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; nondirective
• 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
Gender
Male
Race
White
Black
Hispanic
Education
<12 years
Unemployed
Texas
Ohio
72%
76%
19%
32%
43%
79%
12%
3%
47%
28%
12%
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
90
80
70
60
50
40
30
20
10
0
BAL
TOX
LAB
CAGE
DAST
Alcohol Illicit
Use
Drug Use
Follow-Up AEQ-III Scores
By Group
Intervention
Control
25
20
15
10
5
0
Global Positive
Cognitive & Physical
Impairment
Readiness to Change Scores
by Group
Intervention
Control
14
12
10
8
6
4
2
0
Precontemplation
Contemplation
Action
Follow-Up Alcohol Use By Group
Intervention
Control
4
3.5
3
2.5
2
1.5
1
0.5
0
Days drank
How many drinks
Five or more
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