Spinal Cord Injury Update
Alcohol Abuse and SCI
Alcohol is often a factor in traumatic injuries such as SCI, and many persons with SCI have a history of pre-injury alcohol problems, even if they were not intoxicated at the time of injury.[6,7] Many of these return to drinking after their injuries, putting themselves at greater risk for bladder, skin, and other health problems in addition to all the risks faced by nondisabled problem drinkers. One recent study found that, while the overall rate of alcohol use is lower among persons with SCI than in the general population, the rate of alcohol abuse is higher.
The period of hospitalization after SCI can be a critical window of opportunity for interventions aimed at preventing post-injury alcohol abuse. "Trauma does create a crisis, and in crises people are more amenable to change," said Charles H. Bombardier, PhD, an assistant professor in the UW Department of Rehabilitation Medicine and psychologist at Harborview Medical Center.
As they form new goals and expectations about their lives, rehabilitation inpatients are surrounded by a support system made up of health care professionals, whose roles include giving advice on health-related issues, and key friends and family members who are concerned about the patients' welfare. When alcohol has been a factor in the injury, newly injured patients may be particularly ready to consider a change. "They're thinking more about it than an alcoholic who's in the hospital for some other reason," Bombardier said.
Bombardier is investigating the effectiveness of brief interventions during inpatient rehabilitation on alcohol use in persons with SCI. The study, funded by the National Institute of Disability and Rehabilitation Research as part of the Northwest Regional SCI System grant, uses Motivational Enhancement Therapy (MET), a brief form of intervention designed to encourage rapid, internally motivated change in problem drinkers.
Recent studies have indicated that brief interventions can be as effective as longer, more intensive treatment for changing drinking behavior in the majority of abusive drinkers. Once people decide to change their behavior, they often manage to find the resources to make that change on their own. The trick is getting them to make the decision in the first place, Bombardier said.
"Most models of alcohol treatment are based on the idea that people know they have a problem and want help," he said. Unfortunately, this view is often too optimistic. "Basically, you've got very few people who are interested in treatment. What the rest need is a motivational step before they're ready for any kind of treatment."
MET takes only 3 or 4 sessions, including a comprehensive assessment of the client's alcohol use and any related problems. It has been specifically designed to increase the client's awareness of the hazards of drinking, highlight the reasons for change, circumvent resistance to change, and strengthen the client's belief that change is possible.
The MET approach begins with the assumption that the responsibility and capability for change lie within the client, and that the therapist's task is to enhance the client's own motivation for and commitment to change. Key elements include the need to express empathy with the client and avoid argument, which can trigger resistance and denial of the problem. "The critical thing is not to press them," Bombardier said, citing a study in which confrontation by the therapist was associated with higher levels of alcohol use at 1 year.
Stages of Change
A new theoretical model of how people change addictive behaviors features two steps before the determination to take action, which is where traditional treatment begins.
During this stage, the person is not considering making a change in problem behavior.
The person is thinking about making a change.
A decision is made to change.
Making the change.
Sustaining the change.
Failure, start of another cycle.
Alcohol and SCI--Health Effects
The first step in motivating a client toward transformation is to increase his or her awareness of the risks associated with continued alcohol abuse. Specific information about the health effects of alcohol is likely to have more impact than moral arguments, Bombardier said. In addition to the long-term health risks incurred by anyone who drinks heavily (including liver diseases, cardiovascular diseases, a variety of cancers, inflammation of the pancreas and digestive tract lining, diabetes, brain damage, and birth defects if the drinker is pregnant), people with SCI who drink face a number of additional risks:
Injury severity and recovery. A study of the influence of alcohol intake on the course and consequences of SCI found that people who are intoxicated at the time of injury frequently sustain more serious injuries than people who are sober when injured, and their chances of neurological improvement seem to be worse. More than twice as many patients who were sober at injury regained the ability to walk than those who were intoxicated at injury.
Urinary tract. Alcohol increases the amount of urine produced, causing the bladder to fill more quickly and the body to dehydrate. When drinking, a person may pay less attention to bladder care, and may wait too long to empty the bladder. This can stretch and weaken the bladder wall, allowing a back-flow of urine to the kidneys, which over time can lead to infection and kidney damage.
Autonomic Dysreflexia. The most common cause of this dangerous autonomic nervous system reaction is an overfull bladder.
Infections. Alcohol weakens the immune system's ability to fight off infections, putting the drinker with SCI at greater risk for urinary tract and skin infections. The immune system takes 2 months to recover completely from the effects of drinking.
Skin breakdown.Drinking can increase the risk of developing a pressure sore through dehydration or by causing a person to forget to shift position or to fall asleep in the wheelchair. Increased bladder pressure can lead to an involuntary elimination of urine, which can irritate the skin. An involuntary bowel movement can also increase the risk of skin breakdown (alcohol acts as an irritant to the stomach and intestine). Someone who drinks heavily on a regular basis may pay less attention to good nutrition, which is vital for maintaining healthy skin.
Alcohol-drug interactions. Alcohol can interact with prescription medications to produce unexpected results, such as drowsiness, dizziness, weakness, and decreased motor coordination far out of proportion with the amount of alcohol consumed. Alcohol may also intensify or decrease the effectiveness of a medication by changing the way it is processed by the liver. Drugs known to produce unusual effects in combination with alcohol include baclofen and diazepam (often prescribed for spasticity), warfarin (an anti-clotting agent), and several pain medications, anti-inflammatory drugs, and antibiotics (source: Just Say "Know", a booklet written in collaboration by the Lyndhurst Spinal Cord Centre, the Addiction Research Foundation, and the Canadian Paraplegic Association, Ontario, 1995).
Mental health. The abuse of alcohol, both before and after injury, has been found to correlate with suicides among persons with SCI.
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- Young ME, Rintala DH, Rossi CD, et al. Alcohol and marijuana use in a community-based sample of persons with spinal cord injury. Arch Phys Med Rehabil 1995 Jun;76(6):525-32.