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Outcomes
Substance Abuse
The Cost Effectiveness of Early Intervention for Substance
Abuse
Summary
Between one third and one half of individuals sustaining a traumatic brain
injury are intoxicated at the time of the injury, and almost two-thirds
of adolescents and adults admitted to brain injury rehabilitation programs
have a history of substance abuse. Case management for the treatment of
substance abuse following brain injury has been piloted in several states
based on a model of treatment developed at Ohio State University. While
recent reports suggest that persons two years post-injury increase their
substance use, evaluations of the OSU treatment model suggest that clients
started early post-injury are more likely to drop out of treatment.
The purpose of the current study was to evaluate the cost effectiveness
for persons with traumatic brain injuries of early versus late treatment
of substance abuse using a case management model. Subjects were drawn
from a multi-center study funded by the Center for Disease Control and
Prevention, with treated groups drawn from a program at Ohio State University
and comparison group subjects from the Rehabilitation Institute of Chicago.
The early group was comprised of individuals who initiated treatment within
one year post-injury; the late group began treatment two to five years
post-injury. Outcomes after nine months of treatment were compared between
groups, as well as with a comparison group of subjects with substance
abuse problems, matched for time post-injury, who did not receive case
management. Cost per client (based on staff contact hours) of changes
in substance use, community integration, and subjective well-being were
compared between early and late groups.
The power of the analyses was weakened by the loss of subjects at the
9-month follow-up. As a result, only a few significant differences were
found despite most means being in the hypothesized direction. Additionally,
for the entire study sample including the subsample analyzed here, there
was a tendency for alcohol use to increase from admission to 9 months,
which we speculated may in part be an artifact of subjects' greater comfort
with the program, and thus greater honesty, at follow-up interview.
Because the power of this design appeared to be a limiting factor, we
conducted post hoc comparisons of differences at admission only, those
preserving subjects who were lost to follow-up at the 9-month assessment.
For the 65 treated subjects referred 1 year (n=38) or 2-5 years (n=27)
post-injury, there were significant differences in amount of alcohol consumed
at admission (p<.05; the later group's score was 83% higher than the
early group), as well as the amount of other drugs used (p<.005; the
later group's score was 166% higher than the early group). There were
no significant differences between the community integration and life
satisfaction scores for the two groups at admission.
While this study did not support greater cost effectiveness during the
first 9 months of treatment, there was considerable evidence suggestive
of advantages gained from early for later care. To summarize these findings:
- Clients referred for treatment 2 to 5 years
post-injury were twice as likely to drop out by 9 months.
- There was a trend for those treated later post-injury
to increase reported use from admission to 9 months, while the early
treated group did not change (alcohol) or reduced use (other drugs).
- Post hoc analyses showed that upon admission
the earlier referred group was consuming significantly less alcohol
and other drugs than those referred later.
- There was significant improvement over time in community integration, with a trend for those treated earlier post-injury to improve more than those treated later.
Further studies, with more powerful designs, should be pursued.