185
The Natural History of Drinking and Alcohol-Related
Problems After Traumatic Brain Injury
Charles H. Bombardier, PhD, Nancy R. Temkin, PhD, Joan Machamer, MA, Sureyya S. Dikmen, PhD
ABSTRACT. Bombardier CH, Temkin NR, Machamer J,
Dikmen SS. The natural history of drinking and alcohol-related
problems after traumatic brain injury. Arch Phys Med Rehabil
2003;84:185-91.
Objective: To describe changes in drinking from before
traumatic brain injury (TBI) to 1 year after TBI.
Design: Inception cohort with 1-year follow-up.
Setting: Level I trauma center.
Participants: Adults (N⫽197) hospitalized with a broad
range of head injury severity.
Interventions: Not applicable.
Main Outcome Measures: Alcohol consumption and alco-
hol-related problems.
Results: Drinking and alcohol-related problems decreased
substantially from preinjury to 1 year after TBI. However,
about one quarter of the sample reported heavy drinking,
significant problems, or both during the first year after TBI.
Preinjury alcohol use and problems were highly predictive of
heavy use and problems after TBI.
Conclusion: Although drinking and alcohol-related prob-
lems decreased after TBI, there appears to be an ongoing need
for prevention and intervention efforts. Screening for preinjury
alcohol problems can be used to identify the vast majority of
persons who will develop alcohol-related problems within 1
year after injury.
Key Words: Alcoholism; Brain injuries; Natural history;
Rehabilitation.
© 2003 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
UCH HAS BEEN WRITTEN about the prevalence of
M alcohol-related problems before traumatic brain injury
(TBI). Considerable evidence exists that persons with TBI are
frequently intoxicated at the time of injury, that they frequently
have a history of more chronic alcohol problems than the
general population, and that a history of alcohol problems may
From the Departments of Rehabilitation Medicine (Bombardier, Machamer, Dik-
men), of Neurological Surgery (Temkin, Dikmen), and of Biostatistics (Temkin),
University of Washington School of Medicine, Seattle, WA.
Supported by the Agency for Healthcare Research and Quality (grant no.
HS05304), the National Institute of Neurological Disorders and Stroke, National
Institutes of Health (grant no. NS19643), the National Center for Injury Prevention
and Control and the Disabilities Prevention Program, National Center for Environ-
mental Health (grant no. R49/CCR011714), and the National Institute on Disability
and Rehabilitation Research (grant no. H133A980023).
The contents of this article are solely the responsibility of the authors and do not
necessarily represent the official views of the granting agencies.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Correspondence to Charles Bombardier, PhD, Dept of Rehabilitation Medicine,
Box 359740, Harborview Medical Ctr, 325 9th Ave, Seattle, WA 98104, e-mail:
chb@u.washington.edu. Reprints are not available.
0003-9993/03/8402-6943$35.00/0
doi:10.1053/apmr.2003.50002
influence neuropsychologic and functional outcomes after
TBI.1 However, less has been written about alcohol use after
TBI and even less about change in drinking from before to after
TBI.
The question of change in drinking behavior is particularly
salient because clinicians are being asked to undertake univer-
sal screening for preinjury alcohol problems when people are
hospitalized for traumatic injury, including TBI.2-4 Screening
soon after injury assumes that preinjury alcohol problems are
predictive of postinjury drinking. Yet, as will be discussed
later, this assumption lacks verification.
There are some reasons to question the assumption that past
drinking behavior is a good predictor of future drinking behav-
ior. For example, some evidence suggests that drinking prob-
lems may not continue after TBI.5 It has also been reported6
that a significant percentage (20%) of persons who were drink-
ing heavily after TBI reported a history of only light drinking
or abstinence before TBI. The epidemiologic literature on
alcoholism in the general population has shown that consider-
able spontaneous change occurs in problem drinking from year
to year.7 Moreover, changes in the course of alcoholism are
usually not attributable to treatment.8 Ultimately, if preinjury
drinking is a good predictor of postinjury drinking, then efforts
to identify the individuals who had preinjury problems and to
conduct secondary prevention may be quite useful. If, however,
preinjury drinking is not that predictive of postinjury drinking,
then secondary prevention efforts would be of less value and
other intervention models should be developed.
Kreutzer et al9 were among the first to describe a tendency
toward reduced drinking after TBI. They recruited 87 brain
injury clinic outpatients an average of 48 months postinjury.
According to their retrospective data, the number of moderate
to heavy drinkers seemed to decline by two thirds from before
to after TBI. The number of persons with self-identified alcohol
problems declined by one third after TBI. Twenty-five percent
of the subject sample was reportedly abstinent preinjury,
whereas 72% were abstinent postinjury. Twenty-seven percent
drank alcohol both pre- and post-TBI. Only 1.2% began drink-
ing, and 4.8% reported developing drinking problems for the
first time after TBI.
Another study10 analyzed data from 73 people followed
longitudinally (1–3y after TBI) and 322 persons with cross-
sectional data from the Traumatic Brain Injury Model Systems
database. Of all persons with TBI, 55% to 56% were abstinent
from alcohol 1 to 3 years after TBI. Consumption varied but
tended to increase over years 1 to 3. Moderate to heavy
drinking was reported by 22% to 29% of the sample 1 to 3
years after TBI. Of persons who were moderate to heavy
drinkers at 1 year postinjury, 56% to 69% continued moderate
to heavy drinking at 2 to 3 years post-TBI. That study sug-
gested moderate stability in drinking after TBI but did not
include data on preinjury alcohol use. Therefore, the change in
drinking from preinjury to postinjury could not be evaluated.
Dikmen et al11 described drinking and alcohol problems
before and after TBI in a large consecutive sample of hospi-
talized patients. In that sample, 45% endorsed 2 or more
Arch Phys Med Rehabil Vol 84, February 2003
186 DRINKING AND TRAUMATIC BRAIN INJURY, Bombardier
alcohol-related problems on the (preinjury) lifetime version of
the Short Michigan Alcoholism Screening Test (SMAST). In
contrast, about 25% reported experiencing 2 or more alcohol-
related problems during both the year before and the year after
TBI. In terms of alcohol consumption, about 40% reported
drinking none or less than 1 drink weekly before injury,
whereas over 60% reported drinking none or less than 1 drink
weekly 1 year after injury. Predictors of greater decreases in
drinking after TBI were more severe TBI (as defined by initial
Glasgow Coma Scale [GCS] score) and higher blood alcohol
level (BAL) at the time of injury. Although the study described
secular changes in drinking, it did not address the relation
between preinjury and postinjury drinking or problems.
A study by Hibbard et al5 provided data on the relation
between substance abuse before and after TBI. The investiga-
tors conducted structured clinical interviews to examine rates
of pre- and postinjury psychiatric disorders in a community-
residing sample of 100 persons who were an average of 7 years
post-TBI. Based on retrospective reports, 40% of the sample
was diagnosed as having had a substance disorder before injury
according to the criteria of the Diagnostic and Statistical Man-
ual of Mental Disorders, 4th edition.12 In contrast, 28% of the
sample met criteria for having had a substance abuse disorder
since TBI. Interestingly, 80% of those judged to have had a
preinjury substance abuse disorder did not have a substance
abuse disorder any time after injury, and 71% of those with a
substance abuse disorder after injury were not judged to have
had such a diagnosis any time before TBI. This study suggests
the possibility that TBI frequently triggers substance abuse and
associated problems in previously unaffected persons. It also
suggests that TBI results in recovery from substance abuse
problems for many of those who had preinjury problems in this
area.
In the present study, we hoped to add to the existing litera-
ture by examining the course of drinking and alcohol-related
problems longitudinally as a function of preinjury drinking and
alcohol problems. To accomplish this, we analyzed the same
drinking data reported on by Dikmen et al.11 We predicted that
persons with greater preinjury alcohol use and more lifetime
alcohol-related problems would be at higher risk of heavy
drinking and alcohol problems after TBI, compared with those
who were not heavy or problem drinkers before TBI. Similarly,
we predicted that heavy alcohol use or alcohol-related prob-
lems after TBI would be rare among persons who did not drink
heavily or have significant problems before TBI.
METHODS
Procedures
The study was reviewed and approved by the institutional
review board of the University of Washington. Subjects who
met study inclusion criteria were approached by research per-
sonnel and informed about the purpose of the project, proce-
dures involved, and the voluntary nature of study participation.
Participants were recruited within days of injury and evaluated
initially at 1 month after TBI. Follow-up assessments were
performed at 1 year after TBI. At each time point, trained
examiners conducted structured interviews to obtain pertinent
data from subjects. The procedures used and data obtained
were part of a larger study of neuropsychologic and psycho-
social recovery after TBI.13
Subjects
Subjects were drawn from consecutively admitted patients
with acute TBI hospitalized at Harborview Medical Center, a
Arch Phys Med Rehabil Vol 84, February 2003
level I trauma center in Seattle, WA. Patient selection criteria
included (1) loss of consciousness of any duration, posttrau-
matic amnesia lasting at least 1 hour, or other objective evi-
dence of brain trauma; (2) survival of at least 1 month postin-
jury; (3) age 15 years or older at the time of their injury; (4)
speaking English well enough to complete the assessments; and
(5) willingness to participate in a longitudinal outcome study.
There was no upper age limit. Preexisting conditions were not
a cause for exclusion in this study.
Of the 285 patients who met our inclusion criteria, 197
(69%) participated in the initial assessment phase of the study
at 1 month postinjury. The modal reasons for not participating
in the initial evaluation were refusal to participate (n⫽30) or
our inability to schedule assessments (n⫽38). The main anal-
yses were based on 174 cases (88%) of the initial inception
cohort with complete 1-year follow-up data. Subjects ranged in
age from 15 to 85 years (mean, 30y) and averaged 12 years of
education. The sample was 73% male.
Measures
Alcohol consumption: quantity and frequency. Subjects’
alcohol consumption was measured in terms of quantity and
frequency by asking the number of alcoholic beverages con-
sumed at a typical sitting and the number of sittings in a typical
week. At the time of the initial evaluation, subjects were asked
about their alcohol consumption before injury. At the 1-year
evaluation, subjects were asked about their alcohol consump-
tion since their injury. Drinks were not differentiated into beer,
wine, or distilled liquor, because the purpose of the inquiry was
only to obtain an approximate self-report of drinking behavior.
Quantity responses were coded as (1) “none or less than 1 drink
per sitting,” (2) “1–2 drinks per sitting,” (3) “3– 4 drinks per
sitting,” (4) “5– 6 drinks per sitting,” (5) “7–9 drinks per
sitting,” and (6) “10 or more drinks per sitting.” Frequency was
coded as (1) “none or less than 1 time per week,” (2) “1–2
times per week,” (3) “3– 4 times per week,” (4) “5– 6 times per
week,” (5) “7–9 times per week,” and (6) “10 or more times per
week.”
Alcohol consumption was summarized by combining quan-
tity and frequency responses into 4 drinking categories: absti-
nent, light, moderate, and heavy drinking (table 1). These
categories were constructed to be roughly equivalent to the
classic quantity-frequency index created by Cahalan et al in
1969.14 Drinking 5 or more drinks per occasion was considered
heavy drinking regardless of drinking frequency. This defini-
tion was based on evidence that drinking 5 or more drinks per
occasion is considered excessive and is associated with risk of
adverse health outcomes such as traumatic injury.15 We defined
drinking as little as 1 to 2 drinks per occasion 7 to 9 times per
week as heavy drinking because 7 drinks per week corresponds
to the 80th percentile for Americans generally and the 70th
percentile for American men.
Lifetime alcohol-related problems. The SMAST16 is a 13-
item list of common signs and symptoms of alcoholism. In it,
subjects indicate whether they have ever experienced each
symptom of problem drinking before their injury and since the
injury. Examples of items include: Does any member of your
family (wife, husband, parents) ever worry or complain about
your drinking? Have you ever gotten into trouble at work
because of drinking? Item scores are equally weighted and
summed to form a total score. The SMAST is used because it
is brief and has demonstrated reliability and validity in several
 DRINKING AND TRAUMATIC BRAIN INJURY, Bombardier 187

Table 1: Definitions of Abstinent, Light, Moderate, and Heavy Drinking Categories

Quantity of Alcohol Consumed per Drinking Occasion

None or 1–2 3–4 5–6 7–9 10⫹
⬍1 Drink Drinks Drinks Drinks Drinks Drinks

Frequency of alcohol consumption

Do not drink or drink ⬍1/wk Abstinent Light Moderate Heavy Heavy Heavy
1–2 times/wk Abstinent Light Moderate Heavy Heavy Heavy
3–4 times/wk Abstinent Moderate Moderate Heavy Heavy Heavy
5–6 times/wk Abstinent Moderate Heavy Heavy Heavy Heavy
7–9 times/wk Abstinent Heavy Heavy Heavy Heavy Heavy
10⫹ times/wk Abstinent Heavy Heavy Heavy Heavy Heavy

populations.2 We used the traditional cutoff of 3 or more to
indicate a clinically significant history of alcohol problems.16
RESULTS
Alcohol Consumption Before and After TBI
Table 2 summarizes the data on drinking categories before
and 1 year after TBI. Comparing pre- to postinjury drinking
categories reveals a clear trend toward decreased drinking in
most categories. The modal drinker preinjury, representing
40.8% of the sample, was in the heavy drinking category. That
is, they drank at least 1 to 2 drinks 7 to 9 times per week or at
least 5 to 6 drinks per occasion regardless of drinking fre-
quency. One year after TBI, the modal person (35.6%) report-
edly abstained from alcohol. The number of abstainers in-
creased by 158% (from 24 to 62), whereas the number of heavy
drinkers decreased by 59% (71 to 29). Generally, less change
in drinking was observed among persons who drank in the light
and moderate drinking categories before injury.
In contrast, very few individuals changed toward greater
alcohol use from pre- to postinjury. Only 1 of 24 persons (4%)
who were abstainers before their TBI became moderate or
heavy drinkers by 1 year after TBI. Eight of 37 light drinkers
(22%) became moderate to heavy drinkers after TBI.
Taken together, the data document mostly healthy changes
in drinking habits from pre- to postinjury. As we would hope,
many of the most significant changes in drinking are among
those at higher levels of consumption before TBI. On the other
hand, the data document substantial ongoing drinking within
the first year after TBI, a period when alcohol use is believed
to interfere potentially with neurologic recovery.17 There is
little evidence in these data to suggest that TBI triggers in-
creased drinking among persons who did not drink before their
injury.
Alcohol Problems Before and After TBI
Next we examined the relation between pre- and postinjury
alcohol-related problems (fig 1). Before TBI, 113 (63.5%) of
all subjects reported a normal range of alcohol-related prob-
lems (ie, scored ⱕ2 on the SMAST). Among this group, only
4 (3.5%) developed significant alcohol-related problems by 1
year after TBI.
Of the 65 (36.5%) who scored in the “alcoholic” range (ⱖ3)
on the SMAST before injury, 25 (38.5%) reported a continu-
ation of significant alcohol-related problems during the year
after their injury. The remaining 40 (61.5%) no longer scored
in the alcoholic range on the SMAST, suggesting that their
alcohol problems were in full or partial remission. If we use
zero alcohol-related problems on the SMAST as the criterion
for remission, 30.8% of those with significant preinjury alcohol
problems were in remission throughout the first year post-TBI.
The chances of reporting significant alcohol-related prob-
lems (SMAST score ⱖ3) 1 year after injury is related to the
magnitude of preinjury alcohol-related problems (see fig 1). As
this figure implies, the presence or absence of preinjury alcohol
problems is highly predictive of postinjury alcohol problems
(␹21⫽36.9, P⬍.001). In fact, the relative risk that a person with
a history of alcohol problems will continue to have significant
alcohol problems after TBI is 10.9 times greater than the
probability that a person without preinjury alcohol problems
will develop significant alcohol problems.
Changes in Alcohol Use and Problems
Single measures of outcome— consumption or problems, for
example— have been criticized for leading to divergent or even
contradictory conclusions about outcome.18 Alternatively,
composite measures can summarize diverse alcohol-related
behaviors in a way that one hopes clarifies global outcomes.
Progress has been made recently in the area of describing and

Table 2: Preinjury Versus Postinjury Alcohol Consumption

Quantity-Frequency Category 1 Year Post-TBI

Pre-TBI Abstainer Light Moderate Heavy Totals
Quantity-Frequency Category n (%) n (%) n (%) n (%) N (%)

Abstainer 16 (9.2) 7 (4.0) 1 (0.6) 0 24 (13.8)

Light 16 (9.2) 13 (7.5) 7 (4.0) 1 (0.6) 37 (21.3)
Moderate 11 (6.3) 7 (4.0) 15 (8.6) 9 (5.2) 42 (24.1)
Heavy 19 (10.9) 13 (7.5) 20 (11.5) 19 (10.9) 71 (40.8)
Totals 62 (35.6) 40 (23.0) 43 (24.7) 29 (16.7) 174

NOTE. See table 1 for definitions of drinking categories.

Arch Phys Med Rehabil Vol 84, February 2003

188 DRINKING AND TRAUMATIC BRAIN INJURY, Bombardier
Fig 1. Percentage of subjects with significant alcohol problems
after TBI as a function of preinjury alcohol problem severity. Signif-
icant alcohol problems is defined as SMAST score of >3 at 1 year
post-TBI.
empirically validating a composite measure of alcohol-related
outcomes.19 These authors operationalized 4 clinically relevant
outcome categories: (1) abstinent, (2) moderate drinking with-
out problems, (3) heavy drinking or problems, and (4) heavy
drinking and problems. This model was adapted to describe
drinking and alcohol problems together for the present sample.
Abstinence and heavy drinking were defined as before, based
on quantity and frequency data. Light and moderate drinking
were combined under the category of moderate drinking. Hav-
ing a significant drinking problem was defined as obtaining a
score of 3 or more on the SMAST within the year before
assessment.
Our data corresponding to these composite categories are in
table 3. The most frequent outcome before and after TBI from
this perspective was abstinence or “normal” drinking, that is,
light to moderate drinking and no significant problems. Normal
drinking or abstinence increased from 49% preinjury to 74% at
follow-up. In contrast, the frequency of heavy drinking and
problems declined by over two thirds, whereas the frequency of
heavy drinking or problems declined by 32%. Of those in the
heavy drinking and/or problem categories before injury
(n⫽89), 39 (44%) remained in 1 of those 2 categories 1 year
after TBI. Almost 26% of the sample reported heavy drinking
and/or significant alcohol-related problems at 1 year postinjury.
Another way of summarizing the data is that 18 (10%) of the
sample were in a worse drinking category after TBI, whereas
64 (37%) were unchanged and 92 (53%) moved into a better
drinking category. No persons who were abstinent and without
recent alcohol problems before injury developed either heavy
drinking or problems by 1 year postinjury. Of the normal
drinkers, only 6 (10%) developed heavy drinking or significant
alcohol problems or both, whereas 23 (37%) became abstinent.
Table 3: Composite Alcohol Outcome Categories Before and 1 Year After TBI
Abstinent, Normal Drinking,
No Problems No Problems
Pre-TBI Outcome Category n (%) n (%)
Abstinent, no problems 15 (8.6) 7 (4.0)
Normal drinking, no problems 23 (13.2) 34 (19.5)
Heavy drinking or problems 9 (5.2) 25 (14.4)
Heavy drinking and problems 9 (5.2) 7 (4.0)
Totals 56 (32.2) 73 (42.0)
Arch Phys Med Rehabil Vol 84, February 2003
Seventy-two percent of those with heavy drinking or problems
before TBI were abstinent or drinking without significant prob-
lems at follow-up. Eighty-three percent of persons with heavy
drinking and problems were in a better composite drinking
category: heavy drinking or problems, 45%; normal drinking
without problems, 17%; or were abstinent, 21% at 1 year after
TBI.
DISCUSSION
Our primary research question had to do with the course of
alcohol use and problems after TBI. These data lead us to make
3 major conclusions on this point. First, drinking and alcohol-
related problems decreased considerably from preinjury to 1
year postinjury. Abstinence rates increased from 14% to 36%.
The proportion of persons who did not report significant alco-
hol-related problems increased from 64% to 84%. The percent-
age that was both abstinent and reported no significant alcohol
problems increased from 13% to 32%. Depending on the
criteria used, rates of remission from significant alcohol prob-
lems ranged from 30.8% (based on SMAST scores) to 56%
(based on the composite measure).
These data must be interpreted in the context of remission
rates among community-residing “alcoholics” in the United
States. Large-scale prevalence studies show that among men
between the ages of 18 and 29 years, the lifetime prevalence of
alcoholism is 28%, the 1-year prevalence of alcoholism is 18%,
and 36% of lifetime alcoholics are in remission during a given
year.7 That is, they have a lifetime history of significant alcohol
problems but do not report any symptoms of alcoholism during
the year before the survey. These data imply that the natural
history of alcoholism in the general population is episodic and
recurrent rather than chronic and progressive. Therefore, the
changes in drinking and alcohol problems observed among
persons with TBI are not unique but may reflect a naturally
occurring waxing and waning of this condition found in the
general population.
It is difficult to determine whether remission rates are greater
in the year after TBI than the base rate of remission expected
among young men generally. Although this is an interesting
theoretical question, a more pragmatic question is, What fac-
tors may promote abstinence or moderation in drinking in the
general population with alcohol problems as well as among
those recovering from TBI? Considerable research has been
done on factors that lead to spontaneous remission in persons
with alcohol problems. Not surprisingly, health problems fre-
quently precede spontaneous reductions in alcohol use,20 and
people who are employed or married are more likely to make
enduring changes in alcohol use after trauma.21
There are few data on predictors of reduced drinking among
persons with TBI. Prior research has indicated that greater
depth of coma (lower GCS) predicted less drinking at 1-year
Outcome Category 1 Year Post-TBI
Heavy Drinking Heavy Drinking
or Problems and Problems Totals
n (%) n (%) N (%)
0 0 22 (12.6)
5 (2.9) 1 (0.6) 63 (36.2)
8 (4.6) 5 (2.9) 47 (27.0)
19 (10.9) 7 (4.0) 42 (24.1)
32 (18.4) 13 (7.5) 174
 DRINKING AND TRAUMATIC BRAIN INJURY, Bombardier
follow-up.11 Therefore, factors such as closer supervision and
less access to alcohol may account for some of the observed
decrease in alcohol use and problems. Higher BAL on hospital
admission also predicted greater decreases in alcohol use from
preinjury to 1 year postinjury.11 Because BAL and alcohol
consumption tend to correlate positively, the BAL’s predictive
power may reflect that persons with high BAL drink more
before injury and thus have more room to decrease. On the
other hand, higher BAL also has a positive correlation with
self-reported readiness to change alcohol use after TBI.22 Peo-
ple with alcohol-related TBI may reduce their consumption
because of increased awareness of the negative consequences
of drinking, spontaneous self-change efforts, and seeking help
from substance abuse treatment programs. The reason for the
tendency to decrease drinking after TBI merits further study to
potentially extend or build on this natural recovery process.
The second main conclusion is that 1 year after TBI, a subset
of survivors are characterized by heavy drinking and alcohol-
related problems. On the composite measure, about one quarter
of the sample reported heavy drinking, significant alcohol
problems, or both within 1 year after TBI. Although it is
difficult to compare across different studies, this finding is
consistent with the 22% to 29% of moderate to heavy drinkers
1 to 3 years post-TBI found by Kreutzer et al10 as well as the
28% of persons meeting criteria for substance abuse or depen-
dence reported by Hibbard et al.5
The third conclusion is that preinjury alcohol use and prob-
lems are highly predictive of heavy use and alcohol problems
after TBI. In the present study, only 7% of those who were
abstinent or who reported normal drinking before their injury
began moderate or heavy drinking or developed significant
alcohol problems in the year after their TBI. Persons who
reported a history of significant alcohol-related problems on the
SMAST were about 10 times more likely to have significant
alcohol problems at 1 year postinjury compared with those who
scored in the normal range on the SMAST. These results are
consistent with previous research that has found that few peo-
ple develop alcohol use problems for the first time after TBI.9
These results also support the use of universal alcohol screen-
ing measures to identify persons at risk for heavy alcohol use
and alcohol problems after TBI.
Clinical Implications
Other implications about relapse and secondary prevention
efforts can also be drawn from these data. At 1 month after
TBI, drinking is significantly lower than before injury and 1
year after injury.11 It also appears that the majority of cases that
relapse into problem drinking do so within the first year postin-
jury because the overall rates of heavy drinking found at 1 year
postinjury are closely comparable to the proportion of heavy
drinking found at 2, 3, and 7 years after TBI.9-11 Similarly,
beyond 1 year postinjury the overall rates of persons with
significant alcohol problems remain fairly steady.10
Therefore, the first year postinjury, when the majority of
relapses occur, may be a critical time to conduct secondary
prevention programs. The window of opportunity seems to be
soon after injury, perhaps within the first month when drinking
is at the lowest point.11 Because high-risk persons can be
identified, we recommend that relapse prevention efforts focus
on these individuals before they resume drinking. We hypoth-
esize that preventing relapse into heavy drinking during this
period can alter the longer-term course of drinking in this
population. If at-risk persons can be motivated to abstain, learn
alternative coping strategies, and obtain social support not to
189
drink during this first year after TBI, perhaps they can cope
with TBI without resorting to alcohol abuse.
Effective secondary prevention programs may require sev-
eral stages. During acute rehabilitation, at-risk persons can be
identified, and strategies can be used to educate and motivate
such persons to abstain from alcohol and to seek appropriate
help during their first year after TBI.23 During postacute reha-
bilitation at-risk persons could be referred to learn specific
relapse prevention strategies24 or could receive prearranged
booster sessions to shore up motivation to remain abstinent
before relapse occurs. It may also be useful to engage inter-
ested persons in self-help programs such as Alcoholics Anon-
ymous (AA). Whatever secondary prevention program is
planned, drinking should be monitored routinely among at-risk
persons to identify relapse as early as possible.
Those who relapse could be referred for a more thorough
assessment, brief interventions, or treatment. Brief motiva-
tional interventions can be repeated at that point with the goal
of having the person reconsider the personal costs and benefits
of drinking in light of their overall recovery and rehabilitation
goals. Referrals can be made to combined brain injury and
substance abuse treatment programs where they are available.6
When specialized treatment programs are not available, clini-
cians should not hesitate to refer patients to traditional treat-
ment programs or AA because some evidence suggests that
obtaining any kind of help is associated with greater reductions
in drinking at 1 year after injury.11 Finally, for persons unable
or unwilling to engage in substance abuse programs, there is an
empirically validated treatment that intervenes exclusively
through the family or concerned others in the person’s life.
Controlled research has shown that community reinforcement
therapy with concerned others is better than other approaches at
significantly improving the chances that the target person will
enter treatment and reduce alcohol use before treatment.25
Other benefits of this therapy approach include reduced emo-
tional distress in the concerned other.
Some rehabilitation programs may not wish to identify high-
risk persons. In such cases, relapse prevention strategies may
be woven, explicitly or implicitly, into generic psychosocial
treatments for TBI survivors. Core relapse prevention strate-
gies such as learning to identify and to cope differently with
stressful situations, emotional distress, interpersonal conflict,
and boredom is relevant to persons recovering from TBI
whether or not they are at risk for returning to alcohol abuse.
An advantage of this approach is that persons recovering from
TBI who are at-risk drinkers report little interest in formal
alcohol treatment or AA.26 Such persons may be more willing
to participate in generic outpatient treatment that includes
strategies relevant to relapse prevention than in programs iden-
tified as dealing with substance abuse.
Limitations and Future Directions
The present study’s primary data are limited to relatively
brief self-report measures of alcohol use and alcohol-related
problems. Our confidence in these self-report data would be
strengthened by having collateral information from others or
objective data as a validity check. On the other hand, it is
reasonable to consider self-reported alcohol-related data to be
as reliable and valid as self-report data on other behaviors.
Sander et al27 found a high degree of agreement, typically
greater than 90%, between self- and collateral reports of alco-
hol use among persons with TBI. More general reviews of this
issue in the substance abuse literature conclude that persons
with alcohol problems generally provide reliable and valid
reports if interviewed in clinical settings, when they are alcohol
Arch Phys Med Rehabil Vol 84, February 2003
190 DRINKING AND TRAUMATIC BRAIN INJURY, Bombardier
free, and when they are given reassurances of confidentiality.
Each of these conditions was met in the present study.
At least 2 factors limit the representativeness of the sample
and may have led to inaccurate estimates of the magnitude of
alcohol abuse and of return to drinking. First, approximately
30% of eligible patients were not able to be assessed. The
major reasons for not gathering data on these persons were the
patient’s refusal to participate at the outset of the study, our
inability to contact the subject and inability to schedule and
conduct the initial evaluation, and the patient having a brain
injury so severe that the he/she could not adequately partici-
pate. If alcohol abuse is overrepresented in such subjects, our
results would underestimate alcohol problems. Next, 89 (45%)
of the sample consisted of persons with more severe TBI who
also participated in a seizure prevention study and were told by
a study nurse that they should not drink alcohol. This may have
had a moderating effect on drinking. The extent to which this
advice may have influenced drinking is unknown and cannot be
disentangled from the confounding variable of brain injury
severity.
The results are also limited by the absence of formal diag-
nostic measures of alcohol abuse or dependence. Although we
used well-accepted brief measures of alcohol use and alcohol-
related problems, these data are not comprehensive enough to
permit us to make alcohol-related diagnoses. The advantages of
using diagnostic measures in future research would include
being able to compare rates of diagnoses with large epidemi-
ologic studies such as the National Health Interview Survey.28
Data on the proportion of persons meeting criteria for alcohol
abuse versus alcohol dependence would also probably inform
prevention and treatment planning. If, as we would assume,
persons with alcohol dependence are in the minority, that
would provide further support for the use of brief interventions
in this population. It would also be interesting to determine
whether rates of spontaneous recovery or time to first relapse
varied as a function of diagnosis.
Another limiter is that the data describe drinking outcomes
only at 1 year post-TBI. Longitudinal data from representative
samples are needed over shorter and longer time periods to
better describe the course and consequences of alcohol use and
problems after TBI. Major unanswered questions about the
course of alcohol use after TBI include more carefully describ-
ing the timing of relapse within the first year. In the general
alcoholism treatment literature, the majority of relapses occur
within the first 3 to 6 months after treatment.29 This may also
represent the period of highest relapse after TBI. More precise
information on the timing of relapse might help focus the time
during which ongoing prevention efforts are needed. On the
other hand, longer-term studies could more fully address the
possibility that there is an ongoing trend toward increased
alcohol consumption beyond 1 year after TBI.10
An important question left unanswered is what are the trig-
gers for relapse after TBI: the study of risk factors for relapse
and, subsequently, factors for relapse prevention has contrib-
uted significantly to the treatment of substance abuse problems
more generally.24 Relapse after TBI may be linked to unique
factors such as posttraumatic headache, distressing cognitive
impairment, inability to work, large amounts of unstructured
time, boredom, and permissive societal attitudes toward sub-
stance abuse in persons with disabilities. Knowledge of com-
mon relapse triggers in this population could help guide relapse
prevention and treatment efforts.
Finally, more research is needed on persons who seem to
recover from their alcohol problems after TBI. How long does
this period of recovery last? What factors predict who will
Arch Phys Med Rehabil Vol 84, February 2003
recover and who will relapse? What role does treatment play
versus “natural recovery”? Spontaneous recovery from alcohol
problems must be taken into account when planning treatment
studies. Secondary prevention studies must include adequate
controls and must show that treatment provides greater im-
provement than the spontaneous improvement directly attrib-
utable to TBI.
CONCLUSION
The natural history of drinking 1 year after TBI seems to
involve 3 patterns. The largest proportion of people who drank
heavily or had alcohol problems before injury enter a period of
moderation or remission after TBI. Almost half of those with a
history of heavy drinking and/or significant problems resume a
pattern of drinking heavily and/or have significant alcohol-
related problems after TBI. A small percentage of people
without preinjury alcohol problems begin drinking heavily or
develop problems in the wake of TBI. Overall, about one
quarter of persons with TBI report heavy drinking and/or
problems 1 year after TBI. Simple screening measures can be
used to identify persons at high risk for having alcohol prob-
lems after TBI. Research is needed to better understand remis-
sion and relapse processes. Improved understanding of these
processes may be used to develop ways to promote natural
recovery and prevent relapse.
Acknowledgments: We thank Dennis Donovan for his help de-
signing the alcohol-related assessment for this project.
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