Several studies show that a high proportion of traumatic brain injury (TBI) survivors have a history of substance abuse prior to their injury, suggesting that substance use increases the risk of injury/brain injury. Studies also show that continued substance use after TBI negatively affects recovery and rehabilitation. Alcohol and drug use can magnify the cognitive, sensory, motor, communication as well as behavior and mood deficits associated with TBI. These in turn can prolong the recovery process and extend the length of the rehabilitation period. The rehabilitation programs and interventions must address these issues early on and put all necessary elements in place to try and limit as much as possible the consumption of drug and alcohol as studies also show an increased risk of returning to substance abuse post rehabilitation. All individuals having sustained a TBI should be screened for substance use as soon as possible. Education interventions aimed at preventing all alcohol and drug use should be provided to the person and his or her family, at several times during the course of rehabilitation. Rehabilitation interventions should be planned to address simultaneously TBI-related impairments and substance use disorders. If relapses occur during rehabilitation, efforts should concentrate on minimizing impacts on the course of therapies. There is evidence to support the use of motivational interviewing and related interventions in addressing substance use. Financial incentives also appear to improve adherence to substance abuse treatments. Interventions must be concurrent with injury related rehabilitation and not developed as a separate plan or intervention process in order to better support positive long term functional integration.

The specific challenges that substance use disorders raise in the context of TBI require rehabilitation professionals to be particularly aware and vigilant with respect to potential interactions and impacts in the clinical assessment and intervention processes. Rehabilitation programs should have established protocols and processes to manage potential behavior issues in the rehabilitation unit. TBI rehabilitation programs should have designated and specifically trained professionals to oversee the rehabilitation objectives targeting substance use management or have access to outside specialized resources when required.

It is important to have appropriate treatment providers obtain comprehensive training in Motivational Interviewing and related substance use intervention strategies.

Indicators exemples

• Proportion of individuals with TBI who were screened for history of substance use, intoxication at time of injury and current substance use.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

• Cut, Annoyed, Guilty, Eye-Opener – Adapted to include Drugs (CAGE-AID)
• Substance Abuse Subtle Screening Inventory (SASSI)
• Alcohol Use Disorders Identification Test (AUDIT)
• AUDIT manual
• Michigan Alcoholism Screening Test (MAST)
• Assessment and Screening of Assistance Needs – Alcohol/Drug (DEBA)
• Substance Abuse and Brain Injury (SUBI) materials
• Screening for drug use in general medical settings – Resource Guide, National Institute on drug abuse
• Management of substance Use Disorders – VA/DoD Clinical Practice Guidelines, 2015
• Guideline for Alcohol and Substance Use Screening, Brief Intervention, Referral to Treatment, Colorado Clinical Guidelines Collaborative (2008)

Patient and Family Resources:

• Alcohol & TBI – Factsheets – TBI Model Systems Knowledge Translation Center
• Traumatisme cranio-cérébral et alcool : un dangereux mélange! (Traumatic Brain Injury and Alcohol: A Dangerous mix!) – CUSM (in French only)
• Le traumatisme craniocérébral et la consommation à risque (Traumatic Brain Injury and high-risk substance use) – HSCM (in French only)

Other Resource:

• Canadian center on Substance Use and Addiction

Several studies have examined interventions for substance use, such as motivational interviewing (Ponsford, L. Tweedly, et al., 2012; Sander et al., 2012; Tweedly et al., 2012). In a study conducted by Corrigan and Bogner (2007), subjects with a diagnosed substance abuse problem were randomly assigned to one of 3 groups. All interventions were administered during a telephone interview. The three interventions groups were: 1) provision of financial incentives to not miss appointments 2) reduction of logistical barriers to attending appointments and, 3) attention control. Results demonstrated that offering a financial incentive was more effective in promoting compliance in attending treatment sessions than either other intervention which aimed to reduce barriers.

Corrigan et al. (2005) compared 3 methods of increasing participation in substance abuse treatment for clients with TBI. Participants (N = 195) were randomly assigned to 4 conditions: (a) motivational interview, (b) reduction of logistical barriers to attendance, (c) financial incentive, and (d) attention control. Four interviewers conducted structured, brief telephone interventions targeting the timeliness of signing an individualized service plan. Participants assigned to the barrier reduction (74%) and financial incentive (83%) groups were more likely to sign within 30 days compared with the motivational interview (45%) and attention control (45%) groups. Similar results were observed for time to signing, perfect attendance at appointments, and premature termination during the following 6 months. Extent of psychiatric symptoms was the only significant covariate.

Corrigan and Bogner (2007) compared two methods of improving retention in substance abuse treatment for persons with TBI in a randomized trial finding again that provision of a financial incentive was highly effective for facilitating early attendance and appeared to promote eventual successful treatment completion. Reduction of logistical barriers did not significantly improve attendance or successful discharge. They concluded that provision of a financial incentive at an early point in substance abuse treatment substantially improves attendance and reduces the likelihood of premature termination. The basis for this effect appears to involve more than enhancement of the therapeutic alliance. Concrete incentives can provide an opportunity for successful rule-governed behaviour that may generalize to other areas of improved impulse control.

There is currently a large variation in the rates of substance abuse reported in the TBI population. The prevalence of pre-injury alcohol abuse was reported between 11.5% and 49% (Andelic et al., 2010; Bombardier, Rimmele, & Zintel, 2002; Kwok, 2013; Ponsford et al., 2007), while illicit drug use was reported to be between 30% and 38% (Bombardier et al., 2002; Kwok, 2013). Post injury, even small amounts of alcohol can result in more significant cognitive impairments as the individual works through the recovery process (Tweedly, Ponsford, & Lee, 2012). Studies suggest that alcohol consumption and substance use decline within the first year of injury (Bombardier, Temkin, Machamer, & Dikmen, 2003; Jorge, 2005; Kelly, Johnson, Knoller, Drubach, & Winslow, 1997; Ponsford et al., 2007), but those who returned to drinking two years post injury were likely to consume more than before the injury, drink excessively, and be dependent on alcohol (Bombardier et al., 2002; Ponsford et al., 2007). It is important that individuals are screened and managed appropriately, as continued use can negatively impact recovery.

Many individuals have been found to spend more time in rehabilitation programs, as alcohol addiction has been found to accentuate sensory motor, cognitive and communication problems post injury (Wehman, Targett, Yasuda, & Brown, 2000). Involvement in rehabilitation deters or prevents individuals from using various substances as patients are monitored rather closely (Bjork & Grant, 2009). However, once patients are discharged from inpatient rehabilitation, no monitoring exists and patients may return to their previous behaviours. Due to this, it is important that management of these issues are concurrent with rehabilitation and integrated into the rehabilitation plans.

REFERENCES
Andelic, N., Jerstad, T., Sigurdardottir, S., Schanke, A.-K., Sandvik, L., & Roe, C. (2010). Effects of acute substance use and pre-injury substance abuse on traumatic brain injury severity in adults admitted to a trauma centre. J Trauma Manag Outcomes, 4, 6-6.

Bjork, J. M., & Grant, S. J. (2009). Does traumatic brain injury increase risk for substance abuse? J Neurotrauma, 26(7), 1077-1082.

Bombardier, C. H., Rimmele, C. T., & Zintel, H. (2002). The magnitude and correlates of alcohol and drug use before traumatic brain injury. Arch Phys Med Rehabil, 83(12), 1765-1773.

Bombardier, C. H., Temkin, N. R., Machamer, J., & Dikmen, S. S. (2003). The natural history of drinking and alcohol-related problems after traumatic brain injury. Arch Phys Med Rehabil, 84(2), 185-191.

Corrigan, J. D., & Bogner, J. (2007). Interventions to promote retention in substance abuse treatment. Brain Inj, 21(4), 343-356.

Corrigan, J. D., Bogner, J., Lamb-Hart, G., Heinemann, A. W., & Moore, D. (2005). Increasing substance abuse treatment compliance for persons with traumatic brain injury. Psychol Addict Behav, 19(2), 131-139.

Corrigan, J. D. (unknown year). Substance Use Disorders Following Traumatic Brain Injury. osuwmcdigital.osu.edu/sitetool/sites/ohiovalleypublic/documents/OSU_Sub_Abuse_Final.pdf

Jorge, R. E. (2005). Neuropsychiatric consequences of traumatic brain injury: a review of recent findings. Curr Opin Psychiatry, 18(3), 289-299.

Kelly, M. P., Johnson, C. T., Knoller, N., Drubach, D. A., & Winslow, M. M. (1997). Substance abuse, traumatic brain injury and neuropsychological outcome. Brain Inj, 11(6), 391-402.

Kwok, C., McIntyre, A., Janzen, S., Sequeira, K., & Teasell, R. (2013). Drug and alcohol abuse among individuals with acquired brain injury. . CJAM, 4(2), 14-19.

Ponsford, J., Tweedly, L., Lee, N., & Taffe, J. (2012). Who responds better? Factors influencing a positive response to brief alcohol interventions for individuals with traumatic brain injury. J Head Trauma Rehabil, 27(5), 342-348.

Ponsford, J., Whelan-Goodinson, R., & Bahar-Fuchs, A. (2007). Alcohol and drug use following traumatic brain injury: a prospective study. Brain Inj, 21(13-14), 1385-1392.

Sander, A. M., Bogner, J., Nick, T. G., Clark, A. N., Corrigan, J. D., & Rozzell, M. (2012). A randomized controlled trial of brief intervention for problem alcohol use in persons with traumatic brain injury. J Head Trauma Rehabil, 27(5), 319-330.

Tweedly, L., Ponsford, J., & Lee, N. (2012). Investigation of the effectiveness of brief interventions to reduce alcohol consumption following traumatic brain injury. J Head Trauma Rehabil, 27(5), 331-341.

Wehman, P., Targett, P., Yasuda, S., & Brown, T. (2000). Return to work for individuals with TBI and a history of substance abuse. NeuroRehabilitation, 15(1), 71-77.