Management of Substance Abuse after Trauma
I’m Ed Smith, a Sacramento Brain Injury Lawyer. Substance abuse, especially alcohol intoxication, is the underlying cause of almost half of all traumatic injuries in the US. One survey showed that 75 percent of intoxicated patients have a prior history of clinically-significant alcohol related life events and 26 percent admit to significant pre-injury alcohol problems. This means that alcohol abuse disorder is reported to be the most prevalent disease among trauma survivors. Injured problem drinkers are subsequently more likely to be reinjured, re-hospitalized, and to die compared to normal people. Despite the high incidence of substance abuse, it is rarely screened for in rehabilitation units.
Links between alcohol problems and traumatic brain injury/spinal cord injury will be described in terms of the prevalence of these problems together and the effects on outcome. There are persistent stereotypes and myths about substance abuse that may interfere with the implementation of effective screening and intervention programs.
The emphasis is on seeing rehabilitation as a window of opportunity for intervening on these problems. Rehabilitation physicians, psychologists, and others without extensive training in addictions can still play useful roles in preventing a return to substance abuse after rehabilitation.
The Prevalence of Alcohol and Drug Abuse in those with Traumatic Brain Injury and Spinal Cord Injury
The occurrence of pre-injury alcohol abuse and dependence ranges from 16 percent to 66 percent among those with traumatic brain injury, depending on the study. One research study showed that 59 percent of consecutive inpatients with traumatic brain injury were considered to be “at risk” drinkers. About 31 percent of these patients used illicit drugs within a three month period before their injury. Only 27 percent of this group of individuals abstained from alcohol or drugs or used alcohol in a normal fashion before their injury.
Among spinal cord injured patients, about 35 percent to 44 percent of individuals reported a significant history of alcohol problems. Studies on general trauma patients showed that 44 percent of consecutive trauma admissions scored in the “alcoholic range” on a brief screening measure. Another study found that 24 percent of all admissions met the criteria for current alcohol dependence while 18 percent met the criteria for drug dependence.
Toxicology can be assessed on patients at the time of their injury. Among those with traumatic brain injury, the rates of alcohol intoxication were between 36 percent and 51 percent. Twenty four percent tested positive for marijuana, 13 percent tested positive for cocaine, and 9 percent tested positive for amphetamines. A total of 38 percent tested positive for some kind of illicit drug.
Among patients with spinal cord injury, the rates of alcohol intoxication are about 40 percent. Among general trauma patients, 47 percent had a positive blood alcohol test and 36 percent were intoxicated at the time of their injury.
Studies of spinal cord trauma patients and brain trauma patients showed a decline in alcohol consumption immediately after the injury followed by increased drinking during the first and second years post-injury. At one year after the injury, about 25 percent of people with traumatic brain injury reported heavy drinking or alcohol-related problems. Pre-injury alcohol use is highly predictive of use and problems a year after the injury.
Some people begin problem drinking only after their injury. This pattern has been found to be seen in 7 percent of normal drinkers. Alcohol consumption after traumatic brain injury may be somewhat higher than in the general population.
Altogether, the rates of lifetime alcohol abuse or dependence approach 50 percent among those with traumatic brain injury or spinal cord injury, while current dependence is nearly 25 percent. For many people, there is a natural remission in problem drinking shortly after the trauma. It is often due to the changes in health that follow a traumatic injury.
On the other hand, a significant fraction of people with alcohol dependency resume their problem drinking, probably as the person achieves greater independence and has increased access to alcohol. Little is known about what triggers relapse into problem drinking or drug use after injury.
The Effect of Substance Abuse on Outcomes
Studies of the effects of alcohol intoxication on neurological outcomes have mixed results. Some studies have shown that alcohol intoxication at the time of traumatic brain injury is associated with poorer short-term outcomes, including a longer length of coma, longer period of agitation, and greater cognitive impairment after the injury.
The pre-injury pattern of chronic alcohol abuse or dependence is predictive of numerous negative outcomes after traumatic brain injury and spinal cord injury. A history of alcohol abuse is believed to increase the risk of mortality and more severe brain injury following trauma.
A history of alcohol abuse is believed to increase the risk of recurrent traumatic brain injury and is associated with post-traumatic seizures and cerebral atrophy. There is poorer cognitive recovery among those with significant alcohol-related problems. In the best studies, patients with a history of alcohol abuse showed performed more poorly on neuropsychological testing a month and a year after injury. In the same way, pre-injury alcohol abuse predicts poorer integration into the community.
Spinal cord injury patients may be at a higher risk of post-injury medical complications. This may be due to differences in rehab participation or in the rate of functional gain. Those with alcohol problems have been found to spend less time in productive activities in rehabilitation. There is a 36 percent reduction in functional improvement measurements per day when compared to normal drinkers.
The general trauma literature also demonstrates that a history of significant alcohol-related problems result in a greater risk of injury, re-hospitalization, and death after the initial injury. In one study, it was found that 44 percent of drinkers had been reinjured and 20 percent had died due to another trauma, most of the time related to substance abuse.
It is widely believed that even moderate alcohol use after traumatic brain injury might lessen neurological recovery and intensify cognitive impairments. In one study, brain function after traumatic brain injury was worse among those who abused alcohol when compared to those who did not abuse alcohol.
Among those with spinal cord injury living in the community, alcohol abuse is associated with poorer subjective health, higher levels of depression, and more life stress. The same was found to be true of those who smoked marijuana. Interestingly, those who abstained from alcohol after injury have been found to be at an increased risk of getting pressure sores after the injury.
Screening and Assessment
There are several reasons why screening should be done for alcohol use during rehabilitation. Substance abuse is prevalent and influences important outcomes relevant to rehabilitation and yet healthcare providers are notoriously poor at detecting substance abuse problems without the systematic use of screening tools.
One survey or rehab staff indicated that about 22 percent of rehab patients have substance abuse problems. Screening studies, however, suggest that the number is 2-3 times that number. Even in acute trauma care, doctors did not identify 23 percent of acutely intoxicated patients.
Blood alcohol and other toxicology screening can help identify those with substance abuse; however, simple self-report measures tend to be more sensitive and specific for substance use. Self-report screening tools can be in the acute setting, surgical setting, and rehabilitation setting. The purpose of screening is to identify those who need intervention.
There are a number of brief screening techniques that are reliable and valid indicators of significant alcohol-related problems. In one screening tool, called the CAGE questionnaire, patients are asked four questions:
- Have you ever felt you should cut down on your drinking?
- Have you ever felled annoyed by someone criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning?
A score of 2 or more is considered significant for alcohol abuse. There are several other screening tools that have been used in a similar fashion to detect alcohol and drug abuse.
Treatment of Substance Abuse
There are several techniques that can be used to help those suffering from substance abuse. These include the following:
- Giving advice. This is a possible solution for just about any healthcare provider dealing with this at-risk population. Studies have shown that brief physician advice results in significant and lasting decreases in drinking. It takes just a couple of 10-15 minute interactions between the physician and the patient to result in a 40 percent reduction in alcohol consumption among problem drinkers measured a year later. Advice may be more effective when it is given along with self-help guides written for substance abuse and trauma patients.
- Brief Interventions. This can be used in a variety of settings, both as a standalone treatment and as a means of enhancing the effects of subsequent treatments. This involves seeing a therapist after screening for alcohol and drug abuse. These types of interventions can be conducted in a rehab setting, are acceptable to patients, and fit with the needs of a large segment of patients with substance abuse problems in the rehabilitation setting. Rehabilitation psychologists are in a good position to do these kinds of interventions.
- Coping and Social Skills Training. This includes teaching alcoholics social skills like drink refusal skills, giving positive feedback, giving criticism, receiving criticism about substance abuse, learning listening skills, learning conversation skills, developing sober supports, and learning conflict resolution. Coping and social skills training can be adapted for those with traumatic brain injury and is highly recommended for those with significant alcohol dependence.
- Relapse prevention. This is a cognitive behavioral self-management program designed to help people cope with the possibility of relapse. It involves behavioral skills training, cognitive interventions, and lifestyle change. Relapse becomes a natural phase of behavior change that can be anticipated and intervened upon.
Substance abuse is a major underlying cause and disability in trauma patients, especially those with traumatic brain injury and spinal cord injury. While rehabilitation programs report improved attention to substance abuse, more can be done. Only about 67 percent of surveyed programs offered universal screening, while 53 percent offered substance abuse education to their patients. About 69 percent provide easy access to substance abuse counselors.
The key to providing better care is to improve access to effective treatment. Rehabilitation programs can do a lot to promote access to treatment through systematic screening and by bringing valid treatment approaches into the acute and post-acute care rehab settings in which people with traumatic injuries are usually seen.
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