Substance Abuse and Brain Injury

1. Substance Abuse and Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

2. The Elephant In the Room:Brain Injury and Substance Abuse Good morning and thank you so much for inviting me to your conference. I want to thank especially Caroline Feller who first approached me and Pat David for all her assistance with the logistics associated with preparing for today. The analogy of the elephant popped into my head as I was thinking about today's presentation, it is an old and well used phrase we use when referring to something unpleasant that we as individuals, families and sometimes professionals don't want to deal with. To use another well worn clich�, things that make us uncomfortable, overwhelmed or incompetent we would just as soon "sweep under the rug". (clip art didn't have a good graphic for that!) Imagine this guy under your rug, in your living room, he takes up space, gets in your way, you find yourself rearranging the furniture to accommodate him. Lets not even talk about the cost of feeding him and the ensuing mess, and he won't clean up after himself. Doesn't the problem of substance abuse inspire similar contortions? Can't go back to work yet because my son with a newly acquired bran injury may sneak out to party with his friends. Can't schedule therapy in the morning she might have a hang over. A little worried about the interaction of the seizure meds and the beer, if I bring it up to the physician will he get kicked out of his rehabilitation program. Do I mention to the family member who has been a no show at every family event for the past 6 years who turns up at thanksgiving my god you are so thin are you drinking and doing meth again or have a seat and pass the turkey? And this attitude is not restricted to family and caregivers. Professionals can contort with the best of them. Maybe totally ignoring the problem, or making ultimatums such as we will not refer you to vocational rehabilitation till you stop drinking, or worse, next time you show up to program with alcohol on your breath, we will put put your rehabilitation on hold. I consider the trainings we have been doing in Maryland regarding substance abuse and brain injury as my ongoing mea culpa and penance for my own shortcomings when addressing the issues of co-occurring substance abuse and brain injury during the many years I worked in brain injury rehabilitation settings. The old saying "if I knew then what I know now" has never held more true, for me anyway. So again, thank you for giving me the opportunity to speak with you today. Good morning and thank you so much for inviting me to your conference. I want to thank especially Caroline Feller who first approached me and Pat David for all her assistance with the logistics associated with preparing for today. The analogy of the elephant popped into my head as I was thinking about today's presentation, it is an old and well used phrase we use when referring to something unpleasant that we as individuals, families and sometimes professionals don't want to deal with. To use another well worn clich�, things that make us uncomfortable, overwhelmed or incompetent we would just as soon "sweep under the rug". (clip art didn't have a good graphic for that!) Imagine this guy under your rug, in your living room, he takes up space, gets in your way, you find yourself rearranging the furniture to accommodate him. Lets not even talk about the cost of feeding him and the ensuing mess, and he won't clean up after himself. Doesn't the problem of substance abuse inspire similar contortions? Can't go back to work yet because my son with a newly acquired bran injury may sneak out to party with his friends. Can't schedule therapy in the morning she might have a hang over. A little worried about the interaction of the seizure meds and the beer, if I bring it up to the physician will he get kicked out of his rehabilitation program. Do I mention to the family member who has been a no show at every family event for the past 6 years who turns up at thanksgiving my god you are so thin are you drinking and doing meth again or have a seat and pass the turkey? And this attitude is not restricted to family and caregivers. Professionals can contort with the best of them. Maybe totally ignoring the problem, or making ultimatums such as we will not refer you to vocational rehabilitation till you stop drinking, or worse, next time you show up to program with alcohol on your breath, we will put put your rehabilitation on hold. I consider the trainings we have been doing in Maryland regarding substance abuse and brain injury as my ongoing mea culpa and penance for my own shortcomings when addressing the issues of co-occurring substance abuse and brain injury during the many years I worked in brain injury rehabilitation settings. The old saying "if I knew then what I know now" has never held more true, for me anyway. So again, thank you for giving me the opportunity to speak with you today.

3. Overview Briefly: Facts and Figures-What is The Problem? Lessons Learned-What brain injury professionals have and haven�t done to address the Brain Injury/ Substance Abuse Connection Utilities for Community Professionals-Ohio Valley Model Substance Abuse Screening tools Modifying Substance Abuse treatment and intervention strategies for individuals with brain injuries So this is what I am going to cover today, So this is what I am going to cover today,

4. Briefly: Facts and Figures-What is The Problem?

5. Alcohol Use & TBI-IncidenceAnalysis of the Literature (Corrigan 1995) Alcohol, the drug of choice-Corrigan and his colleagues report that for 70% of the individuals they work with who use substances, alcohol is the preferred substance Intoxication at time of injury-7 studies looked at incidence of intoxication (BAL equal or exceeding 100mg.dL)at time of injury. Intoxication ranged from 36% to 50% History of Substance Abuse-Findings suggest that for adolescents and adults in rehabilitation following a TBI, as much as 60% of this population have histories of alcohol use or dependence. Various researchers have found those intoxicated have more need for intubation, pneumonia, respiratory distress, greater neurological impairment upon discharge, longer periods of agitation lower RLA scores, also longer duration from injury to rehab admission and trend towards longer PTA then those without alcohol on board at the time of injury- and this is important to keep in mind, a MD colleague a physician really stresses this when lecturing about BI, PTA period of time where the individual cannot lay down new memories more indicative of if a person lost consciousness especially true when considering the possible functional impact of a so called mild TBI or concussion. Various researchers have found those intoxicated have more need for intubation, pneumonia, respiratory distress, greater neurological impairment upon discharge, longer periods of agitation lower RLA scores, also longer duration from injury to rehab admission and trend towards longer PTA then those without alcohol on board at the time of injury- and this is important to keep in mind, a MD colleague a physician really stresses this when lecturing about BI, PTA period of time where the individual cannot lay down new memories more indicative of if a person lost consciousness especially true when considering the possible functional impact of a so called mild TBI or concussion.

6. TBI & Alcohol? Impact on Recovery, Studies Suggest�.. Alcohol may negatively affect the process of dendrite profusion thus impede ability of the remaining neurons to compensate for the neurons that have been damaged (Corrigan, NASHIA Webcast 2003) Alcohol use after brain injury may increase the risk of seizure post TBI Increased brain atrophy observed in patients with a positive BAL and or history of moderate to heavy pre-injury use (Bigler et al 1996 & Wilde et.al 2004) A Finnish study (2002) looked at 12,058 followed up to age 31 following childhood or adolescence TBI. =increased risk of MH do, SA and with males, more likely to develop mh with criminal behavior. A Finnish study (2002) looked at 12,058 followed up to age 31 following childhood or adolescence TBI. =increased risk of MH do, SA and with males, more likely to develop mh with criminal behavior.

7. TBI & Alcohol? Impact on Recovery, Studies Suggest�.. Kreutzer et al (1995) examined the alcohol use patterns, arrest histories, behavioral characteristics and psychiatric treatment histories of 327 individuals with TBI. Increases in abstinence rates were noted. However in relation to the uninjured population, analysis revealed high incidence of heavy drinking, pre- and post-injury among those with a history of arrest. History of arrest also associated with a greater likelihood of aggressive behaviors. So my point in relating these studies is some of the best and brightest of our colleagues have described, analyzed and quantified the problem, it is just as neuropsychological evaluations quantify problems with memory, processing, and judgement. Now it is up to us to take the research and apply it to our clinical work, hopefully if I am successful in my goal for being here today you will have some tools to use. So my point in relating these studies is some of the best and brightest of our colleagues have described, analyzed and quantified the problem, it is just as neuropsychological evaluations quantify problems with memory, processing, and judgement. Now it is up to us to take the research and apply it to our clinical work, hopefully if I am successful in my goal for being here today you will have some tools to use.

8. Lessons Learned-What brain injury professionals have and haven�t done to address the Brain Injury/ Substance Abuse Connection

9. Lessons Learned Attitudes and misperceptions of rehabilitation staff/Tales from the Field �Honeymoon� effect-first year post TBI Subsequent Substance Use and Abuse among individuals with a history of brain injury Feedback from Individuals with TBI in Recovery

10. Attitudes & Misperceptions � I want to work with plain brain injuries� Clinicians do not feel qualified to address substance abuse, �I�m not a substance abuse counselor� Rehabilitation staff have dated notions regarding when individuals with substance abuse problems are receptive to intervention, �They need to hit rock bottom� (Lamb-Hart 2001) �What White Paper ?� lack of familiarity with the National Head Injury Foundation�s substance abuse task force White Paper The OT who said this was frustrated with the problems, non brain injury related as she saw them, that were interfering with her treatment goals. Our group was essentially a slice of inner city Baltimore life, individuals, African American and white of lower socio economic status, with poor educational and vocational track records who lived in some of the roughest parts of town. Just to give you some idea of what things are like, more then a few of our consumers were registered in the hospital under assumed names, being victims of violence, the police and their families were afraid the perpetrators would come back and finish the job. Regarding point 2- my feeling now, is if substances now, or potentially in the future negatively impact the ability of the individual to benefit from the skilled rehabilitation and talents of the staff and the love and support of his or her family,(and by this definition I mean every person post a brain injury who participates in rehabilitation) we are obligated to address substance use and abuse in some real way. We know from Dr. McCallister at Dartmouth that 40-45% of individual following a moderate to severe brain injury will have little to no awareness of injury imposed deficits. We wouldn't dream of not addressing awareness, without awareness there is not meaningful carryover of strategies and supports . So with roughly 2/3rds of individuals with brain injuries having a hx of substance abuse we should take the same stance, we need to address it some how within our programs. I don't mean every PT, OT and SP therapist has to run out and get their addictions counseling certification. Just start the conversation within your agencies about what you can do within the bounds of your agencies. I will share with you an example of what I mean. Deb Fulton Clark, my partner in training in MD on SA and I did a training for community providers and and state voc rehabilitation professionals. Following that I received an email from a very talented, bachelor's level employment specialist, a very good one from the reputation he has. He said he has always felt very inadequate dealing with SA issues with his consumers, but after getting the information from our training, he brought it up to one of his consumers who was ready to return to work who he knew had a hx of SA. The consumer spoke honestly about his struggles, the risk factors and agreed to attend a AA meeting for individuals with BI. When Hart-Lamb asked a group of PT (60) how many would feel comfortable talking to a PT about SA only 3 or 4 raised their hands. Feel individuals have to hit "rock bottom" a "lost weekend" mentality. Knowledge of Miller's stages of change theory would be helpful (precontemplation, contemplation, preparation, action adn maintenance) according to Lamb Hart most persons seen in acute rehab are in precon or con Don't ask, don't tell, studies have shown that there is reliable self report of use-we should ask and keep on asking Bias based on pt. appearance, age and Socio-demographic factors. Unrecognized in rehab setting Davis et. al in 2001 found that rehab residents under recognized alcohol probs in an inpatient rehab program. Reflects an overconfidence in our own clinical abilities that we intuitively will know when someone has or has had a SA problem, or at risk for substance abuse use or abuse. White paper, the late great David Strauss and colleaguesThe OT who said this was frustrated with the problems, non brain injury related as she saw them, that were interfering with her treatment goals. Our group was essentially a slice of inner city Baltimore life, individuals, African American and white of lower socio economic status, with poor educational and vocational track records who lived in some of the roughest parts of town. Just to give you some idea of what things are like, more then a few of our consumers were registered in the hospital under assumed names, being victims of violence, the police and their families were afraid the perpetrators would come back and finish the job. Regarding point 2- my feeling now, is if substances now, or potentially in the future negatively impact the ability of the individual to benefit from the skilled rehabilitation and talents of the staff and the love and support of his or her family,(and by this definition I mean every person post a brain injury who participates in rehabilitation) we are obligated to address substance use and abuse in some real way. We know from Dr. McCallister at Dartmouth that 40-45% of individual following a moderate to severe brain injury will have little to no awareness of injury imposed deficits. We wouldn't dream of not addressing awareness, without awareness there is not meaningful carryover of strategies and supports . So with roughly 2/3rds of individuals with brain injuries having a hx of substance abuse we should take the same stance, we need to address it some how within our programs. I don't mean every PT, OT and SP therapist has to run out and get their addictions counseling certification. Just start the conversation within your agencies about what you can do within the bounds of your agencies. I will share with you an example of what I mean. Deb Fulton Clark, my partner in training in MD on SA and I did a training for community providers and and state voc rehabilitation professionals. Following that I received an email from a very talented, bachelor's level employment specialist, a very good one from the reputation he has. He said he has always felt very inadequate dealing with SA issues with his consumers, but after getting the information from our training, he brought it up to one of his consumers who was ready to return to work who he knew had a hx of SA. The consumer spoke honestly about his struggles, the risk factors and agreed to attend a AA meeting for individuals with BI. When Hart-Lamb asked a group of PT (60) how many would feel comfortable talking to a PT about SA only 3 or 4 raised their hands. Feel individuals have to hit "rock bottom" a "lost weekend" mentality. Knowledge of Miller's stages of change theory would be helpful (precontemplation, contemplation, preparation, action adn maintenance) according to Lamb Hart most persons seen in acute rehab are in precon or con Don't ask, don't tell, studies have shown that there is reliable self report of use-we should ask and keep on asking Bias based on pt. appearance, age and Socio-demographic factors. Unrecognized in rehab setting Davis et. al in 2001 found that rehab residents under recognized alcohol probs in an inpatient rehab program. Reflects an overconfidence in our own clinical abilities that we intuitively will know when someone has or has had a SA problem, or at risk for substance abuse use or abuse. White paper, the late great David Strauss and colleagues

11. Collectively Lulled to Inaction by the �Honeymoon� Effect Bombardier reports (1997) that in comparison with a separate medical patient sample, individuals with a recent TBI were more motivated to change their alcohol use. Motivational Interviewing was utilized and of 50 post TBI patients, 84% fell into the contemplation or action phases. Greater willingness to change was noted in those with alcohol involved injuries and higher daily consumption pre-injury So many of us have heard the "seen the light" speech by those early on in recovery who had issues with substance abuse and who's use and abuse played a part in their accident. And hearing it may think to ourselves, "whew one less thing we have to worry about and then say to the person.......... That's nice, good for you, here is your PT schedule" Bombardier used Readiness to Change questionnaire, Michigan Alcoholism Screening (father to the BMAST) and alcohol use questions. I will be discussing the BMAST in the breakout, it is one of those screening tools evaluated by brain injury professionals as being very appropriate for use with individuals with a brain injury.So many of us have heard the "seen the light" speech by those early on in recovery who had issues with substance abuse and who's use and abuse played a part in their accident. And hearing it may think to ourselves, "whew one less thing we have to worry about and then say to the person.......... That's nice, good for you, here is your PT schedule" Bombardier used Readiness to Change questionnaire, Michigan Alcoholism Screening (father to the BMAST) and alcohol use questions. I will be discussing the BMAST in the breakout, it is one of those screening tools evaluated by brain injury professionals as being very appropriate for use with individuals with a brain injury.

12. �Honeymoon� Effect In 197 individuals treated at a Level I trauma center, alcohol use diminished in the first year following TBI (Bombardier et.al 2003) This I have seen the light declaration and behavior is referred to by many as the "honeymoon effect"This I have seen the light declaration and behavior is referred to by many as the "honeymoon effect"

13. Honeymoon Factors Individual in an inpatient and/or highly structured outpatient setting resulting in detoxification Physical and cognitive disabilities make access to substances difficult Families are instructed to provide supervision due to physical needs and judgement concerns Individual is remorseful over past use, related behavior, blames self for accident and vows to change But there are other factors in play besides any change in attitude...............But there are other factors in play besides any change in attitude...............

14. The Honeymoon is Over Kreutzer and colleagues (1996)followed the pre-and post-injury patterns of alcohol and illicit drug use of 87 individuals at 8 and 28 months post TBI. Decline in use was noted at first follow-up. Use at second follow-up were similar to pre-injury use As with Jeff, we rehabilitated him to his premorbid statusAs with Jeff, we rehabilitated him to his premorbid status

15. Subsequent Substance Use/Abuse Among Individuals with a History of Brain Injury Male Younger age History of substance abuse prior to injury Diagnosis of depression since TBI fair/moderate mental health better physical functioning (Kreutzer 1996, Horner et.al 2005) Why? Because they can physically get to it, their families have to get back to work, the early days of strictly following the discharge recommendation of supervision 24/7 are over. As we would ruefully say to say to ourselves and to each other, "well, we rehabilitated them back to baseline" Such a fatalistic detachment that doesn't encourage us to take the next step and capitalize on the "honeymoon effect"Why? Because they can physically get to it, their families have to get back to work, the early days of strictly following the discharge recommendation of supervision 24/7 are over. As we would ruefully say to say to ourselves and to each other, "well, we rehabilitated them back to baseline" Such a fatalistic detachment that doesn't encourage us to take the next step and capitalize on the "honeymoon effect"

16. Subsequent Substance Use/Abuse Among Individuals with a History of Brain Injury 10-20% of those with TBI develop substance abuse problems after their injury (NASHIA Webcast 2001) �A person with a preinjury history of two drinks a day would not have had a reason to seek alcohol-related treatment before his or her accident. But once that same person becomes brain-injured, the continuation of that drinking pattern has the potential to cause major problems� Robert Karol, Ph.D. Here we are, more evidence that we need to proplactically address substance abuse as we do, ADL's, prevention of contractures, and medication toxicity.Here we are, more evidence that we need to proplactically address substance abuse as we do, ADL's, prevention of contractures, and medication toxicity.

17. Co-Occurring with Subsequent Use�.. Worse employment outcomes More likely to be living alone & isolated Greater criminal activity Lower subjective well-being or life satisfaction (NASHIA Webcast 2001) Because if we don't..........and we know that a good majority of individuals are young people with potentially years of productivity ahead of them And I should have added higher likelihood of secondary brain injuries. During our last project, we asked mental health providers to screen as many of their consumers as they could among 7 agencies. The mental health providers at a county detention center screened 41 inmates, 73% of them had a history of a TBI, of those, 16 had a single incident, 14 had 2 or more, many had 3 TBI'sBecause if we don't..........and we know that a good majority of individuals are young people with potentially years of productivity ahead of them And I should have added higher likelihood of secondary brain injuries. During our last project, we asked mental health providers to screen as many of their consumers as they could among 7 agencies. The mental health providers at a county detention center screened 41 inmates, 73% of them had a history of a TBI, of those, 16 had a single incident, 14 had 2 or more, many had 3 TBI's

18. Feedback from Individuals in Recovery The researchers at the Research and Training Center on Community Integration of Individuals with Traumatic Brain Injury at Mt. Sinai in New York asked individuals with TBI, what are the factors involved in �kicking the habit� So the folks at Mt. Sinai went to those who know first hand the issue of substance abuse after brain injury. Gathered a focus group together and asked them a simple questionSo the folks at Mt. Sinai went to those who know first hand the issue of substance abuse after brain injury. Gathered a focus group together and asked them a simple question

19. What They said�.. Early treatment for those identified as known substance abusers Pay attention to the covert drug users Challenge of redefining new self and life doubled with TBI sequela and substance abuse issues Hard to know where to find support, with TBI community or substance abuse community I think the first 2 points speak to the notion of addressing SA across the board. Make it part of the program, so it is not stigmatizing to those who do have a problem, and providing support and knowledge for those who may be at risk in the future for use and abuse. I think the first 2 points speak to the notion of addressing SA across the board. Make it part of the program, so it is not stigmatizing to those who do have a problem, and providing support and knowledge for those who may be at risk in the future for use and abuse.

20. What They said�.. To stay clean; find the right 12-step program, change �persons, places and things� that trigger use, spirituality, pets. How many of you have pets? Birds consumer post stroke and suspected alcohol related dementia and the stray cat "RETURN" Carolyn Knapp wrote "Drinking: a love story" and " A Tribe of Two" a writer who describes her own struggle with alcohol and how her relationship with her dog gave her structure and responsibilities that helped her eventually achieve sobriety, bet you can get either of those from the library for the blind on tape for free, good to listen to for some one struggling Dog from central casting, many of you have heard of Claudia Osborn? Dr. Osborn has Micah. along with prompting her to take her meds and pay attention, signals as a "working dog" that her person may need assistance, so no longer does Dr. Osborn, when she wanders into personnel only areas of airports treated with suspicion, but rather approached and asked if she requires any assistance. Further comments by the consumers, Take advantage of mandatory detox ,talk about it and refer to tx following dc Those with less obvious drug or alcohol history and those who received no inpt rehab less likely to be educated re:negative consequences of continued use. This group may continue to "self medicate" and thus at risk of developing SA disorder forging new social bondsHow many of you have pets? Birds consumer post stroke and suspected alcohol related dementia and the stray cat "RETURN" Carolyn Knapp wrote "Drinking: a love story" and " A Tribe of Two" a writer who describes her own struggle with alcohol and how her relationship with her dog gave her structure and responsibilities that helped her eventually achieve sobriety, bet you can get either of those from the library for the blind on tape for free, good to listen to for some one struggling Dog from central casting, many of you have heard of Claudia Osborn? Dr. Osborn has Micah. along with prompting her to take her meds and pay attention, signals as a "working dog" that her person may need assistance, so no longer does Dr. Osborn, when she wanders into personnel only areas of airports treated with suspicion, but rather approached and asked if she requires any assistance. Further comments by the consumers, Take advantage of mandatory detox ,talk about it and refer to tx following dc Those with less obvious drug or alcohol history and those who received no inpt rehab less likely to be educated re:negative consequences of continued use. This group may continue to "self medicate" and thus at risk of developing SA disorder forging new social bonds

21. Stages of Change,Motivational Interviewing & Successive Approximation Techniques for change applications for use with individuals with a history of brain injury

22. The 5 Stages of Change Prochaska and DiClemente cited by Corrigan 1999 Precontemplation-unaware that a problem exists, no plans to change, those around them however may be aware Contemplation-aware, maybe thinking about a behavior change, but no commitment yet. (weighing pros & cons of change) Preparation- intention to change, with no plan or firm goal

23. The 5 Stages of Change Prochaska and DiClemente cited by Corrigan 1999 Action-Make changes and alter environment in order to modify addictive behavior Maintenance-consolidate the gains, avoid relapse

24. Motivational InterviewingBased on the work of W. R. Miller Phase I-Build Motivation to Change Phase II-Consolidate Commitment to Change Phase III-Monitor and Encourage Progress

25. Phase I-Build Motivation to Change Adapted from Corrigan et. al 1998 Educate about substance abuse and it�s impact on recovery. Build discrepancy in personally held beliefs about use Provide structured feedback of assessment instruments (listen w/ empathy, reflect consumer statements) Question regarding personal feelings, ideas, concerns and plans, work with their personal agenda

26. Phase I-Build Motivation to Change cont. Adapted from Corrigan et. al 1998 Affirm, maintain an atmosphere in which the consumer is encouraged to initiate actions and responses that are appropriate Handling resistance with reflections and shifts of focus-recognize resistance is hallmark of Precontemplation. (confrontation, combativeness not recommended)

27. Phase II-Consolidate Commitment to Change Adapted from Corrigan et. al 1998 Create a balance sheet- positive and negative reasons to change (visual strategy for memory reinforcement) Offer a menu of plan alternative with the consumer Summarize progress Ask for commitment Involve significant others

28. Phase II-Consolidate Commitment to Change Cont.Adapted from Corrigan et. al 1998 Emphasize abstinence, but don�t demand as the only alternative (successive approximation) Handle resistance w/reflection, reframing and/or review Stage I strategies Develop a change plan worksheet (be creative, use consumer�s interests/strengths)

29. Phase III- Monitor & Encourage Progress (for those in Action stage) Adapted from Corrigan et. al 1998  Review progress and motivation Address relapses/slips as opportunities to learn and recommit Develop new change plan worksheet as needed

30. Successive Approximation Debra Fulton Clark Pathways, Hollywood MD Small changes can lead to lasting success Don�t demand total abstinence, although always keeping in mind this is the goal E.g. cutting back from a six pack a night to 3 beers, continually negotiating for greater reduction in consumption

31. All the Right Ingredients-Pathways Inc. Hollywood MD Neuropsychological Assessments Psychiatric Evaluations Group Counseling Individualized Counseling and & Therapy Substance Abuse Counseling and Education Career Assessment, Skills Training,Job Placement and Coaching Long Term Follow-Up, etc.

32. The Results:Pathways Inc. Hollywood MD: N=52FY 2005 The goal of the Pathways program is for each consumer to be placed in some type of skills training or employment setting 4-6 months after completing the program

33. The Results:Pathways Inc. Hollywood MD84% of consumers met all of their IRP goals within 3 months of discharge 43% were competitively employed 29% enrolled in some type of advance technical training 28% were involved in job seeking/placement services 16% of consumers met all goals but choose not to enter job market 100% applying for SSDI afraid of losing benefits 100% under the age of 22 100% still residing at home 100% not attending anytype of post secondary institution 100% had parental caretakers opposed to employment16% of consumers met all goals but choose not to enter job market 100% applying for SSDI afraid of losing benefits 100% under the age of 22 100% still residing at home 100% not attending anytype of post secondary institution 100% had parental caretakers opposed to employment

34. Pathways approached is grounded in�. The Principles of Change Theory, Motivational Interviewing and Successive Approximation

35. How to Utilize Substance Abuse Education & Intervention with individuals with Brain Injury:Tips for Human Service Professionals

36. The �Big� Picture Brain storm with group ( or individual) What do you know about substance abuse, the brain and brain injury? What do you want to know about substance abuse, the brain and brain injury? Have a �quiz � on hand to engage interest (building motivation to change, moving from Precontemplation to Contemplation)

37. Sample Brain Injury and Substance Abuse quiz questions- (verbally or pen/paper) In 1998, the cost of alcohol abuse in the United States was estimated to be $184.6 billion True or False If there are alcoholics in your family tree, you are at risk for alcohol abuse, even if you were adopted and raised by nondrinkers. True or False Gold 2005

38. Sample Quiz Continued... Addiction is a) brain disease b) a moral failing Alcohol use after brain injury may increase the risk of seizures. True or False 10%-20% of people with brain injury develop substance abuse problems after their injury. True or False

39. Discussion Based on the �Quiz� Review the correct answers Ask for other thoughts, knowledge and experiences regarding substance abuse Provide group with �Messages to Share� information sheet Discuss the �Messages to Share�

40. Messages to ShareDrinking After Brain Injury Adapted from Bogner and Lamb-HartOhio Valley Center People who use alcohol or drugs after TBI don�t recover as fast as those who don�t Any injury related problems in balance, walking or talking can be made worse by using drugs or alcohol People who have had a brain injury often say or do things without thinking first, a problem made worse by using alcohol or drugs Brain injuries cause problems with thinking, like concentration or memory, and alcohol makes these worse After a brain injury, alcohol and other drugs have a more powerful effect People who have had a brain injury are more likely to have times when they feel sad or depressed and drinking or doing drugs can make these problems worse After a brain injury, drinking alcohol or taking drugs can increase the risk of seizure People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury

41. Suggestions The �Quiz� and �Messages to Share� can be done with a group or with one or two individuals Any one of the messages can be explored in depth, with the facilitator sharing the research on a specific message or messages The group can digress at any time to a discussion of the brain�s functioning and anatomy-relate that information to impact of SA

42. Screening Tools CAGE Questionnaire Brief Michigan Alcoholism Screening Test (BMAST) AUDIT

43. CAGE (Ewing 1984) Have you ever felt you should Cut down in your drinking? Have you ever felt Annoyed by someone criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye opener)

44. CAGE Researchers at Mt. Sinai found the specificity of the CAGE for alcohol abuse both pre-and post-TBI to be high, 96% & 86%, respectively. (2004) CAGE is very ease to administer & sensitive with TBI population (Fuller et al 1994) CAGE�s brevity allows for easy integration into intake interviews Limitation of CAGE- lacks consumption questions needed to determine individuals with current versus lifetime of alcohol-related problems (Bombardier & Davis)

45. BMAST (Selzer et.al) (2) Do you feel you are a normal drinker? * (2) Do friends or relatives think you are a normal drinker?* (5) Have you ever attended a meeting of Alcoholics Anonymous? (2) Have you ever lost friends or boy/girlfriends because of drinking? (6) Have you ever neglected your obligations, your family or your work for two or more days in a row because you were drinking? (2) Have you ever had delirium tremens (DTs), severe shaking, heard voices, seen things that weren�t there after heavy drinking? (5) Have you ever gone to anyone for help because of your drinking? (5) Have you ever been in a hospital because of drinking? (2) Have you ever been arrested for drunk driving or driving after drinking?

46. BMAST BMAST is very ease to administer & sensitive with TBI population (Fuller et al 1994) BMAST is nearly as sensitive as the complete MAST, using a cutoff of three or more among individuals with TBI Simple true-false format Sensitive to less severe alcohol problems Well researched Limitations-long, some questions may be difficult to understand, and some questions may be offensive. (e.g., �are you a normal drinker?�) (Bombardier & Davis 2001)

47. Alcohol Use Disorders Identification Test (AUDIT) (World Health Organization) 3 items on alcohol consumption, e.g How often do you have a drink containing alcohol? 4 items on alcohol-related life problems, e.g., How often during the last year have you failed to do what was normally expected from you because of drinking? 3 items on alcohol dependence symptoms e.g., How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

48. AUDIT Pros & Cons  (Bombardier & Davis 2001) Takes 2-3 minutes to administer, 1 minute to score Identifies alcohol abuse, not just dependence Sensitivity of the AUDIT is above 90% Developed multi-nationally Can be used to provide specific feedback regarding risk Limitations-length, not used widely with individuals with TBI at this time, but is recommended by the authors

49. Additional Screening Tools Substance Abuse Subtle Screening Inventory-3, Useful for screening for alcohol abuse and the face valid drug sub-scale may be useful for screening for drug abuse in individuals with TBI. (Ashman et. al. 2004) Addiction Severity Index-R (very long) Quantity-Frequency-Variability Index,Well researched self-report questionnaire. Quantitative measure of alcohol use

50. How to Use Screenings(Depending on your agency, consumers, how your program is organized) At intake to program services Individually as part of initial assessment early on in program As part of a group activity As part of ongoing individual counseling/therapy sessions To be repeated as part of discharge preparations

51. Implementing Interventions Accessing and Making Accessible 12-Step Programs in the Community Suggestions for rehabilitation providers and other human service professionals

52. AA 12-Steps, Modifiedfor Individuals with TBI (Peterson 1988) We admitted we were powerless over alcohol; that our lives had become unmanageable Came to believe that a Power greater than ourselves could restore us to sanity Admit that if you drink or use drugs your life will be out of control. Admit that the use of alcohol and drugs after having a brain injury will make your life unmanageable You start to believe that someone can help you put your life in order. This someone could be God, an AA group, counselor, sponsor, etc.

53. For Individuals with Brain Injury Provide concrete examples of AA Share AA literature, big book, the story of Bill W Show a movie or TV depiction of an AA movie e.g. Clean and Sober a 1988 movie with Kathy Baker, Morgan Freeman and Michael Keaton, My Name is Bill W. a 1989 movie with James Gardner and James Wood

54. For Individuals with Brain Injury Provide concrete examples of AA Show scenes of AA/NA meetings from HBO�s The Wire, the character �Bubbles� takes steps towards sobriety (may have to wait till Season V comes out on DVD) Ask a consumer in recovery to come and speak to a group

55. For Individuals with Brain Injury Provide concrete examples of AA Covert the 12 steps into pictures, can be a group activity or individual activity-good for individuals with impaired language skills/concrete thinkers (Reynolds and Murrey 2006)

56. If feasible, encourage attendance at the Humanim AA meeting for individuals with BI

58. A Letter to Potential AA & HA Sponsor (McHenry & members of the Task Force on Chemical Dependency, NHIF 1988) Intended as an educational introduction to a potential sponsor Reviews common cognitive and emotional sequela of TBI Makes compensatory strategies suggestions, e.g. poor memory can be supported by journals and datebooks

59. Suggestions to Personalize Letter Shorten it by focusing on the issues pertinent to the individual Prepare the letter with the individual, include their input in terms of which strategies and supports work for them

60. Suggestions to Personalize Letter�.. If appropriate, obtain releases so the sponsor can contact the mental health/substance abuse professional Provide updated information regarding local and state TBI information and referral resources

61. Suggested Strategies for Rehabilitation Providers and other Human Service Professionals Working with Individuals with TBI Review if available any neuropsychological or neuropsychiatric records Attend 12-Step meetings with a �buddy� or staff member, review meeting highlights �90 meetings in 90 days� may be too stimulating or fatiguing after a TBI, balance so benefits of structure, social group can be gained If the individual plans to share at a meeting, have them jot down before hand what they want to say on an index card

62. Suggested Strategies for Rehabilitation Providers and other Human Service Professionals Working with Individuals with TBI Avoid approaches that are confrontational (Sparadeo, NASHIA Webcast 2003) Insight oriented treatment approaches may not work for individual�s whose thinking is very concrete after a brain injury Offer �The Big Book� and other books with a recovery or inspirational theme on tape �Where the body goes, the mind follows�, �One day at a time� etc. powerful & easy to recall reinforcing messages

63. Suggested Strategies for Rehabilitation Providers and other Human Service Professionals Working with Individuals with TBI Use �Change Plan� & �Staying Clean, Staying Sober� Worksheets Prepare for slip ups-�Emergency Plan�& �Personal Emergency Plan: Lapse� Judicious use of drug testing

64. MD�s Lead Agency for TBI: The Mental Hygiene Administration:Laying the Groundwork Substance Abuse recognized as a co-occurring issue for individuals served through the public mental health system, including consumers of the TBI Medicaid waiver Substance Abuse recognized as a co-occurring issue for individuals with brain injury for those served within the public health system as well as those outside of any formal service delivery system So what are we doing in MD, baby steps, but overall moving forward.So what are we doing in MD, baby steps, but overall moving forward.

65. Where Do We Go From Here?Look to the Innovators John Corrigan Ph.D.-currently conducting a study on the efficacy of the Dartmouth Evidence Based Practice Supported Employment Model with individuals with brain injury and co-occurring conditions-results should greatly benefit the field Ken Minkoff MD & Christine Cline MD.- their model for treating individuals with co-occurring psychiatric and substance abuse disorders might have application for individuals with co- occurring brain injury and substance abuse Minkoff and Cline refer to a Comprehensive, Continuous, Integrated System of Care Model for individuals with psychiatric disorders and a co-occurring substance do. Here are a few of their Model's 8 principals that I think can be applied when thinking about brain injury and substance abuse Dual diagnosis is an expectation, not an exception (given the high rate, and poor outcome when not treated appropriately) Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting When psychiatric and substance abuse disorders coexist, both disorders should be considered primary, and integrated dual(or multiple) primary diagnosis-specific treatment is recommended. There is more and I refer you to his website www.kenminkoff.com His website has him coming to Brown County, Green Bay Wisconsin on July 30th of this year, might want to check him out. Minkoff and Cline refer to a Comprehensive, Continuous, Integrated System of Care Model for individuals with psychiatric disorders and a co-occurring substance do. Here are a few of their Model's 8 principals that I think can be applied when thinking about brain injury and substance abuse Dual diagnosis is an expectation, not an exception (given the high rate, and poor outcome when not treated appropriately) Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting When psychiatric and substance abuse disorders coexist, both disorders should be considered primary, and integrated dual(or multiple) primary diagnosis-specific treatment is recommended. There is more and I refer you to his website www.kenminkoff.com His website has him coming to Brown County, Green Bay Wisconsin on July 30th of this year, might want to check him out.

66. �In my judgement such of us who have never fallen victims (to alcoholism) have been spared more by the absence of appetite than from any mental or moral superiority over those who have�-Abraham Lincoln to the Washington Temperance Society, Springfield Illinois 1842

67. References Alcohol, Alcohol Abuse and Alcohol Dependence CME Resource training course, Mark S. Gold, MD www.netce.com/course.asp?Course=651 Corrigan JD. (1995). Substance Abuse as a Mediating Factor in Outcome from Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation Vol. 76, April: 302-309 Bombardier, CH., Temkin, NR., Machamer, J., Dikmen SS.(2003), The Natural History of Drinking and Alcohol-Related Problems After Traumatic Brain Injury Archives of Physical Medicine and Rehabilitation Feb;84(2):185-91. Bombardier C., Davis, C. (2001). Screening for Alcohol Problems Among Persons with TBI. Brain Injury Source. Fall 16-19. Corrigan J., et. al (1998) Utilities for Community Professionals. Ohio Valley Center for Brain Injury Prevention and Rehabilitation

68. References Bombardier C., Davis, C. (2001). Screening for Alcohol Problems Among Persons with TBI. Brain Injury Source. Fall 16-19. Corrigan J., et. al (1998) Utilities for Community Professionals. Ohio Valley Center for Brain Injury Prevention and Rehabilitation Murrey, J. Gregory (2006). Alternate Therapies in the Treatment of Brain and Neurobehavioral Disorders, A practical guide.Published by The Haworth Press Inc.

69. Resources University of Kentucky, on line training for professionals, �Substance Abuse, Mental Illness and Brain Injury, A Guide for Making Accommodations for Treatment� cdar.uky.edu/TBI/welcome.html Ed Ross of the ICD in NYC, conducting ongoing trainings across the state to mental health and substance abuse professionals regarding brain injury. For more information contact eross@icdnyc.org. Alaska�s lead agency, the Alaska Department of Health and Social Services has made utilization of the Alaska TBI Screening mandatory for any agency that receives funding from the agency to utilize the screening . The screening addresses substance abuse as well as brain injury related issues .

70. Resources The Ohio Valley Center for Brain Injury Prevention and Rehabilitation continues to conduct research and training regarding brain injury, substance abuse and building capacity within the community to work with individuals with brain injury. www.ohiovalley.org Pathways Inc., Brain Injury Recovery Services, Hollywood Maryland, contact Debbie Fulton Clark for details regarding how substance abuse treatment can be integrated into a brain injury community re-entry program. dfulton@pathwaysinc.org. Kenneth Minkoff, MD. Www.kenminkoff.com. Regarding co-occurring substance abuse and psychiatric illness

71. Staff Training Opportunities The Michigan Department of Community HealthWeb-Based Brain Injury Training for Professionals This free training consists of 4 module that take an estimated 30 minutes each to complete. The purpose of the training is twofold, to �ensure service providers understand the range of outcomes� following brain injury and to �improve the ability of service providers to identify and deliver appropriate services for persons with TBI�

72. Websites of Interest www.ohiovalley.org, The Ohio Valley Center for Brain Injury Prevention and Rehabilitation. Specific information and fact sheets on substance abuse and brain injury casaa.umn.edu/intro.asp, Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico. Visitors can email staff and faculty who specialize in different aspects of substance abuse treatment. Lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub, Alcohol & Drug Abuse Institute at the University of Washington in Seattle. Visitors can download assessment instruments and guides for use.

73. Anastasia Edmonston 410-402-8478aedmonston@dhmh.state.md.usSupport is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human ServiceThank you!