brief intervention for substance abuse after tbi john d. corrigan, phd ohio valley center for brain...
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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
1949-2007
% Rehabilitation Patients with Prior Histories of Abuse
43%
54%58%
29%34%
39%
48%
58%61%
0%
10%
20%
30%
40%
50%
60%
70%
Alcohol OtherDrugs
Either
TBI ModelSystems
Ohio StateUniversity
University ofWashington
Problem Substance Use Before and After Moderate and Severe TBI
29%28% 27%
14%15%
20%
4% 5%7%
0%
5%
10%
15%
20%
25%
30%
35%
Pre not post Pre and post Post not pre
1 yr post (N=3635)
2 yrs post (N=2656)
5 yrs post (N=972)
Pre-injury Substance Abuse in Those Lost to Follow-up 1 year Post-injury
(Corrigan et al., 1997)
0%
20%
40%
60%
80%
100%
Lost @ 1 Year Found @ 1 Year
Prior Substance Abuse
No Prior Abuse
Binge Drinking 1 Yearafter Hospitalization for TBI
[Horner, et al, 2005 (South Carolina Follow-up Study)]
52%
70%
22%
14%
26%
16%
0%
20%
40%
60%
none 1 or 2 3 or more
# binging occasions last 30 days
TBI (SCTBIFR)
Gen'l Pop (BRFSS)
Percentage With Needs Unmet at 1 Year
12.7%
19.6%
26.9%
29.5%
33.1%
44.2%
55.6%
68.0%
71.0%
73.6%
83.6%
95.9%
78.3%
Personal assistance
Self-care
Traveling in the community
Home making
Coordinating services
Managing money
Managing stress
Participating in recreation
Improving cognition
Controlling temper
Controlling substance use
Improving job skills
Finding work
Corrigan, Whiteneck & Mellick (2004)
Percentage with Unmet Needs at 1 Year
41.2%
49.7%
53.9%
57.8%
61.2%
66.5%
72.0%
89.7%
78.0%
Opportunities to socialize
Personal assistance
Home making
Improving job skills
Information about services
Managing stress
Coordinating services
Controlling substance use
Finding work
Pickelsimer et al. (2007)
Traumatic Brain Injury
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High Severity
High Severity
Quadrant I Quadrant II
Quadrant III Quadrant IV
4 Quadrant Model of Services
Traumatic Brain Injury
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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.
1644
465
198247
482
808
155 16389 133
0
200
400
600
800
1000
1200
1400
1600
1800
Total Psych GI Injury ARDs
Control
Intervention
• 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 + 2 10-15”
physician discussions and a follow-up nurse phone call
In Primary Care: Project TrEATFleming MF, Lawton Barry K, et al. JAMA 1997;277:1039
Control before/after
Intervention before/after
Drinks/7d* 19/16 (-18%) 19/12 (-40%)
Binges/30d* 5/4 (-21%) 6/3 (-46%)
Hosp days* 42/146 (+248%) 93/91 (-1%)
Project TrEAT Results
*p<0.001
FRAMES StudyGentilello, 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
Su b
s ta n
ce U
s e D
i so r
d er
Low Severity
High 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
Abstaining 30 days post-discharge
83%88%
78%83%
0%
20%
40%
60%
80%
100%
Baseline Booklet only Booklet + video All Subjects
Abstaining 30 days post-discharge
83%88%
78%83%
0%
20%
40%
60%
80%
100%
Baseline Booklet only Booklet + video All Subjects
Abstaining and Facts Recalled
85% 83%
64%
78%80%
100% 100%94%
0%
20%
40%
60%
80%
100%
Baseline Booklet only Booklet +video
All Subjects
<3 recalled3 recalled
Abstaining and Facts Recalled
85% 83%
64%
78%80%
100% 100%94%
0%
20%
40%
60%
80%
100%
Baseline Booklet only Booklet +video
All Subjects
<3 recalled3 recalled
Length of PTA and Facts Recalled
19.821.3 20.8 20.6
6.8 6.8
19.5
12.0
0
5
10
15
20
25
30
Baseline Booklet only Booklet + video All Subjects
<3 recalled
3 recalled
Length of PTA and Facts Recalled
19.821.3 20.8 20.6
6.8 6.8
19.5
12.0
0
5
10
15
20
25
30
Baseline Booklet only Booklet + video All Subjects
<3 recalled
3 recalled
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.
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