Summary

Up to 4 in 5 adults seeking treatment for substance use disorders (SUDs) have sustained at least one traumatic brain injury (TBI) in their lifetime.^1,2 TBIs are a type of brain injury resulting from an external bump, blow, or jolt to the head or neck, or from an object piercing the skull and entering brain tissue. As a chronic condition, TBIs can lead to cognitive (e.g., memory, information processing) and behavioral challenges (e.g., impulsivity)^3–5 that can diminish a person’s self-efficacy and perceptions of their ability to set and attain goals, potentially leading to premature treatment termination.^6–8 The American Society of Addiction Medicine’s updated criteria state that neurologic impairment, including subtle weaknesses that may be overlooked or misinterpreted by providers, should not be a barrier to treatment.⁹ Challenges resulting from TBI can be subtle and easily missed or misclassified by untrained treatment professionals as treatment ‘non-compliance’ or poor motivation for change.^1,10 Universal screening using evidence-based methods^11,12 is the first step to identifying clients with TBI, and cognitive compensatory strategies (e.g., checklists, task chunking) can help clients overcome challenges.¹³ Yet, these interventions have not been widely adopted or sustained in SUD treatment,^14–16 signifying a gap in the equity and effectiveness of care. 

Our team at The Ohio State University is conducting a trial to investigate the effectiveness of TBI screening and compensatory strategies on client self-efficacy, engagement, and treatment retention, and the effectiveness of implementation strategies on intervention uptake and sustainment. This approach can expedite the pace of research translation by studying both effectiveness and implementation simultaneously. We will train providers to screen clients for TBI and cognitive/behavioral challenges, and to integrate compensatory strategies into treatment. To increase intervention uptake and sustainment, we will use facilitation. Facilitation is a robust, evidence-based implementation strategy that engages leadership, monitors performance, and delivers implementation support to providers.^17–19 

Significance

This is the first NIH-funded trial to specifically respond to the updated 2023 American Society of Addiction Medicine Criteria by addressing cognitive and behavioral challenges resulting from brain injury in SUD treatment. This is significant because the results of our trial have the potential to transform the standard of care in SUD treatment settings by demonstrating impact and outcomes. Subsequently, this approach could improve the equity and effectiveness of care for a majority of clients in treatment for SUDs, which could improve population-level health benefits over time. In addition, our hybrid trial approach can expedite the pace at which this standard of care is used by informing how these interventions can be implemented and sustained in these settings. Our implementation science approach can be used to inform how TBI screening and compensatory strategies can be implemented in other settings where brain injury is also common (e.g., homeless services, domestic violence, criminal legal systems). 

Up until 2025, brain injury was not formally recognized as a chronic condition by the Centers for Medicare and Medicaid Services (CMS),^20,21 meaning that persons with a history of brain injury could not receive the same benefits as people with other chronic health conditions, like diabetes or heart disease. Through this recognition, and by elevating awareness of the nature and impact of brain injury in SUD treatment settings, individuals can finally begin to receive care and benefits they may not have previously received. Further, by identifying brain injury and integrating cognitive compensatory strategies into existing care, these individuals can receive more appropriate treatment that addresses the cognitive and behavioral challenges common following brain injury, which in turn has the potential to improve SUD treatment outcomes by making treatment more cognitively accessible and equitable for clients. 

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Clinical & medical benefits

Enhance mutual trust and improve treatment satisfaction through a client-provider shared decision-selection on compensatory strategies to use during treatment.  potential.

Shared decision-making

Primary beneficiary:

Patients

Integrate evidence-based TBI screening methods and compensatory strategies to improve substance use treatment outcomes.  potential.

Therapeutic procedures

Primary beneficiary:

Patients

Community & public health benefits

Enhance provider awareness about the role and impact of brain injury in SUD treatment.  potential.

Health care quality

Primary beneficiary:

Patients

Train providers to use existing brain injury screening methods and compensatory strategies.  demonstrated.

Health care quality

Primary beneficiary:

Patients

Improve the quality of existing SUD services by accommodating the effects of brain injury in treatment.  potential.

Health care quality

Primary beneficiary:

Communities / Public

Enhance client outcomes through a neurologically informed treatment approach.  potential.

Community health services

Primary beneficiary:

Patients

Develop and disseminate an educational page on the relationship between brain injury and substance use, and a list of compensatory strategies.  demonstrated.

Health education resources

Primary beneficiary:

Service providers

Reduce the burdens associated with chronic injury and substance use through educating clients about brain injury and its relationship to substance misuse and disorder. potential.

Disease prevention & reduction

Primary beneficiary:

Patients

Improve quality of life through cognitive compensatory strategies that clients can apply in their daily lives.  potential.

Life expectancy & quality of life

Primary beneficiary:

Patients

Economic benefits

Reduce costs associated with relapse through specific compensatory strategies for impulse control and emotional functioning.  potential.

Societal & financial cost of illness

Primary beneficiary:

Patients

Reduce the financial burden of chronic injury by addressing the cognitive and behavioral impacts of brain injury.  potential.

Societal & financial cost of illness

Primary beneficiary:

Patients

Policy & legislative benefits

Institute universal laws for brain injury screening and compensatory strategies as a required standard of care practice.  potential.

Legislation

Primary beneficiary:

Policymakers

Incentivize providers to conduct brain injury screening through insurance reimbursement.  potential.

Legislation

Primary beneficiary:

Policymakers

Create organizational policies that require universal brain injury screening and compensatory strategies as a required standard of care practice.  demonstrated.

Policies

Primary beneficiary:

Service providers

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.²² 

Clinical

Identifying lifetime brain injury exposures, cognitive and behavioral challenges, and integrating compensatory strategies into existing SUD treatment aligns with the updated American Society of Addiction Medicine Criteria. Our trial will train providers on these interventions to be responsive to these criteria. Often, clients who know they have a brain injury have a ‘light bulb’ moment, where the challenges they have been facing suddenly make sense. By giving them this knowledge, paired with compensatory strategies, they may believe that success is possible, and the therapeutic relationship with their provider may be improved through a more informed treatment approach. 

Community

If our trial demonstrates improved client self-efficacy, treatment satisfaction, treatment engagement, and treatment retention, then the public health benefits will be in reducing the chronic burden of SUD and brain injury. Our treatment model is simple and scalable, which can reduce barriers to broad scale-up. In addition, our implementation strategies can be used to inform how these interventions can be adopted, scaled, and sustained across other organizations nationally. 

Economic

Identifying and addressing brain injury in substance use treatment has the potential to reduce the psychological and economic costs associated with the injury by giving individuals the skills and strategies they can use to succeed in treatment and in their daily lives. By addressing the cognitive and behavioral effects of the injury, clients treated in SUD settings may have greater self-efficacy and goal attainment, and may be more likely to remain in treatment until goals are achieved. In turn, this can reduce SUD-related healthcare costs and societal costs long-term. Using our implementation approach, this study has the potential to inform broader adoption, reach, and sustainment of these interventions, which could improve treatment equity and reduce economic costs at the population-level over time. 

Policy

The results from this trial can be used to inform organizational policy updates with a focus on equity and inclusion. The results can also be used to advocate for state and national-level legislative changes that require that these interventions be integrated as the new standard of care practice, and that the time used for screening can be billed to insurance. 

Lessons Learned

Our interdisciplinary team of experts in brain injury, implementation science, and substance use treatment has provided a unique lens to the project that addresses the needs of populations with chronic, co-occurring conditions, while also considering broader implementation science questions that can be addressed during the trial. The biostatistics leader on the team has been instrumental in helping to think strategically about study design and procedures that will enable enrollment of up to 900 clients over the study period, hence increasing the statistical power and impact of the trial. In addition, partnering with the National Association of State Head Injury Administrators (NASHIA) has been instrumental by allowing us to use their web-based brain injury screening and data management platform for this trial. Our strong partnership with NASHIA will facilitate our collaborative efforts long-term as we think about and design future studies to optimize the adoption, reach, and sustainment of these interventions across SUD treatment and other contexts where brain injury is common. Furthermore, leadership at the substance use treatment clinic of The Ohio State University Wexner Medical Center has been incredibly supportive, responsive, and eager to partner with us in this trial, which will undoubtedly contribute to its success. Finally, as facilitation is our key implementation strategy, we are grateful to have experts in facilitation serve as the facilitators on this project.