REMEMBER when alcohol was routinely prescribed to inpatients with traumatic brain injury (TBI) to help them relax and socialize? (For those who disbelieve, see Rohe and DePompolo1). We have come a long way since then, or have we?

Even in the late 1980s, rehabilitation clinicians had begun to recognize that TBI and substance misuse tend to co-occur and that a dual diagnosis may be associated with poorer outcomes. In 1987, the National Head Injury Foundation (now Brain Injury Association of America) called for a task force to examine the role of substance misuse in the incidence of TBI. The findings of the task force were published in 1990 in a topical issue of the Journal of Head Trauma Rehabilitation.2 At that time, few studies had accumulated, but patterns were beginning to emerge to allow for estimates of incidence and descriptions of the potential impact of substance misuse preceding and following TBI. Treatment models were being proposed, but few had been implemented and none had been tested.

Fast forwarding to 2012, we can now state with relative certainty that one-third to one-half of adults presenting for TBI rehabilitation have a history of substance misuse3-5 and about the same percentage of persons receiving substance use disorder (SUD) treatment have a history of TBI.6-8 We are still debating whether TBI leads to substance misuse, or vice versa, but are beginning to realize that many adults with SUD have sustained multiple TBIs over a lifetime, and the relationship between the 2 disorders may be tightly interwoven from early childhood.9 As suggested by articles in the current issue, the resulting fabric also includes threads of other psychiatric disorders10 and reflects the varied life experiences of persons from different racial/ethnic backgrounds.11 Special populations are being identified who may be at greater risk for substance misuse and/or have different treatment needs, as demonstrated by Adams and colleagues12 in their examination of combat-deployed soldiers.

Despite our progress in understanding the incidence, prevalence, and impact of co-occurring TBI and SUD, we remain uncertain regarding effective treatment methods. As noted by Corrigan and Mysiw,13 the ideal treatment method likely varies by treatment setting, as well as by severity of both SUD and TBI. Within the acute trauma care setting (ie, level I trauma centers), screening and brief intervention are mandated by the American College of Surgeons14 because of their demonstrated efficacy and effectiveness with persons at risk for substance misuse; however, the studies on screening and brief intervention excluded persons with moderate-severe TBI.15 Clinically, we suspect that screening and brief intervention methods will need to be adapted to the cognitive and executive functioning deficits associated with TBI, using booster sessions, multimedia educational approaches, and/or involvement of family and significant others. However, minimal research has been done to identify the most effective accommodations, and as found by Sander et al,16 Tweedly et al,17 and Ponsford et al18 in this issue, results have been equivocal. In their full-group analyses, neither Sander et al16 nor Tweedly et al17 found significant treatment effects for a brief intervention that combined motivational interviewing with multimedia education. However, in subgroup analyses, Sander et al16 and Ponsford et al18 identified some significant covariates (attribution, readiness to change, education, depression) and 1 moderator (severity of injury) that may have heuristic value about intervention development.

Within the TBI rehabilitation setting, it has been recommended that substance misuse be systematically addressed through screening, brief intervention, patient and family education, and referral for ongoing treatment19; however, the effectiveness of specific approaches is largely unknown. For persons with more severe SUD and TBI, a holistic, community-based treatment approach that integrates brain injury rehabilitation and SUD treatment may be most effective.20 However, retention in treatment is the key to better outcomes, and unfortunately treatment compliance is especially challenging for people with cognitive impairments.21 Financial incentives and reduction in barriers to attending appointments improve retention,22 both for people with TBI and for the general population, but despite the demonstrated efficacy, these tools have yet to be systematically included in most SUD treatment programs.

Indeed, while we have made progress in understanding TBI and substance misuse, much work still needs to be done to improve our approaches to intervention. Future research should seek to determine whether brief interventions as currently configured have utility for persons with TBI, whether accommodations can make them more effective, or whether an entirely new approach is needed. The impact of the setting, the severity of the TBI and the SUD, and unique characteristics of special populations should be carefully considered when evaluating the effectiveness of any intervention. We no longer prescribe alcohol to persons with TBI, but we have yet to find the prescription that will optimize outcomes for persons with co-occurring TBI and substance misuse.

-Jennifer Bogner, PhD

Associate Editor

-John D. Corrigan, PhD

Editor-in-Chief

Department of Physical Medicine & Rehabilitation

The Ohio State University

Columbus, OH

REFERENCES