Interventions for Substance Abuse Review and a Model

John D. Corrigan, PhD Intervention for Substance Abuse: Review and a Model John D. Corrigan, PhD Ohio Valley Center for Brain Injury Prevention and Rehabilitation Ohio State University 4 Quadrant Model: Types of Services High Severity Quadrant III Substance Abuse System Quadrant IV Specialized TBI & Substance Abuse Services Substance Use Disorder Screening, Accommodation & Linkage Quadrant I Acute Medical Settings and Primary Care Integrated Programming Quadrant II Rehabilitation Programs & Services Screening & Brief Interventions Education, Screening, Brief Interventions & Linkage Low Severity Traumatic Brain Injury High Severity 4 Quadrant Model of Services High Severity Quadrant III Substance Abuse System Quadrant IV Specialized TBI & Substance Abuse Services Substance Use Disorder Screening, Accommodation & Linkage Quadrant I Acute Medical Settings and Primary Care Integrated Programming Quadrant II Rehabilitation Programs & Services Screening & Brief Interventions Education, Screening, Brief Interventions & Linkage Low Severity Traumatic Brain Injury High Severity 1 John D. Corrigan, PhD Brief Interventions • 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 costeffectiveness 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. Gentilello, Rivara, Donovan, Jurkovich, et al. (1999) • 762 Level 1 trauma patients who screened positive for problem alcohol use • Randomly assigned to Brief Intervention (BI) or standard care • 12 months later those receiving BI : – 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 – BI group had 47% reduction in ER or trauma admissions • 3 years later, BI group had 48% reduction in injuries requiring hospitalization 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 2 John D. Corrigan, PhD 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 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 Re-cap: Quadrant I • Screening and Brief Intervention (SBI) is becoming 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 SBI protocols specifically for persons with TBI. 3 John D. Corrigan, PhD 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. 4 John D. Corrigan, PhD 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 5 John D. Corrigan, PhD Brief Intervention for More Serious TBI Give booklet and introduce videotape Play the videotape Ask: “Do you have any questions?” 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?” 1. 2. 3. 4. BI 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. 6 John D. Corrigan, PhD BI 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. BI 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 selfmotivational statements and support selfefficacy. BI 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. 7