Substance Abuse & Brain Injury

1. Substance Abuse & Brain Injury Cheryl Ann Kennedy, M D Associate Professor Rutgers New Jersey Medical School Department of Psychiatry Newark, New Jersey May 2014

2. Scope of the Problem • Traumatic Brain Injury (TBI) is a leading cause of death & disability among young adults • Over 1.4 million Americans get TBI annually • Almost 250,000 are hospitalized • Substance users are a disproportionate percentage of this group (falls, MVAs, violence) • Number of TBI survivors in US increased A LOT recently because of the WARS ~30% of combat troops receive brain injury

3. Scope of the Problem History of SUD predicts: • Increased disability • Poorer prognosis • Delayed recovery

4. Scope of the Problem Well known that TBI causes: • Pain • Headaches • Cognitive impairments • Motor impairment in some • Increased risk for MOOD disorders • Increased risk for Alzheimer’s Disease

5. Scope of the Problem • Current evidence says that Alcohol and other drug use can CAUSE TBI • Conversely, it is known that TBI can create a situation that increases the risk for subsequent Substance Use Disorders (SUD)

6. Scope of the Problem • Even ‘Mild’ Traumatic Brain Injury can cause subtle impairments in cognitive, executive and decision making brain functions THAT are poorly recognized at the early stages of treatment • Social adjustment & need for new coping skills often increase RISK for alcohol and other drug use (AOD)

7. Reasons why not use AOD Brain Injury can cause: • BALANCE PROBLEMs • Impulsive speech & behavior • Memory & concentration problems • Increased vulnerability of the brain • Lower seizure threshold • Increased risk for another brain injury

8. Alcohol & Other Drugs • Can worsen any of the problems associated with brain injury • Make it harder for the brain to recover • Cause greater impulsivity in all areas • Increase the risk of falls • Increase the incurring more injury • Lower the seizure threshold • Impair judgment & motor functions

9. Essentials in the Healing Process • Eating High quality food in a well-balanced diet • Reduced exposure to substances that exacerbate impulsivity (AOD) • Avoidance of substances & situations that impair concentration or attention • Protection of the newly sensitized brain from further insults • SCREENING for alcohol or other drug use disorders early in process

10. Essentials in the Healing Process • Observance & evaluation of mood, other disturbance • Early intervention for identified issues • Protection against further injury • Patient, Family & Peer education: MAJOR issue since individual is fundamentally changed and all need to re-learn a lot about his/herself, the environment and limitations that may be necessary

11. Essential: Early Identification • Those who use must have supervised medical detoxification • Those with previous history of use are at highest risk to use again • Those with prior Psychiatric conditions at high risk to use • Those without support of cognitive evaluation and rehabilitation are VERY vulnerable

12. Pre-Morbid Conditions • Among AOD users: Those with TBI started using 5 years earlier on average than those without TBI • A history of TBI is associated with greater psychiatric morbidity • Users have higher risk of heavy drinking post TBI

13. Risk over Time in Recovery • Initial HONEYMOON period while in care or rehab with good monitoring • After longer follow-up researchers have found that the risk for use of AOD use increases as time goes on • Even those without history of prior use develop risk for use over time with TBI • PTSD may be present and it alone confers higher risk for SUD

14. Problems with Diagnosing some Injuries • Injury to the Orbito-Frontal Cortex (OFC) can engender even greater risk of subsequent SUD • OFC contusions & abrasions difficult to detect even with MRI • OFC dysfunction is subtle clinically---no gross signs like speech impairments, disorientation or problems with general memory • OFC disruption often causes increased mood instability & hostility

15. Orbital-Frontal Cortex Injury • Diminished self awareness of socially inappropriate behaviors • Alters perception of self as the actor—distances individual from responsibility for behavior • Sub group of TBI survivors may be at greater risk with this damage to processing, executive function and judgment

16. PAIN!!! • Common post TBI complication • Independent of mood disorders • More common in those with mild TBI and those who sustained injury from a violent event (as opposed to stroke or other intra-cranial insult like surgery) • Chronic pain may strongly increase the risk for SUD (even with prescribed meds)

17. MILD TBI Deficits • Cognition • Attention • Memory & Calculation • Judgment & Insight • Reasoning, that is, logical thinking • Sensory processing (sight, hearing, touch) • Communication, processing deficits

18. MILD TBI Deficits • Communication • Language expression • Word recall • Understanding & comprehension • Social Functioning • Compassion • Interpersonal social awareness

19. MILD TBI Deficits • Mental health: • Depression • Anxiety • Aggression • Irritability • Social inappropriateness • Sleep disturbance • Vertigo/dizziness

20. SEVERE TBI SEQUELAE • Abnormal states of consciousness • Deficits in speech & swallowing • Cranial neuropathies • Paresis/paralysis • Complications of prolonged bed rest • Seizure disorder • Movement disorder • Self image problems

21. Mild versus Severe Can be more severe if: • Period of loss of consciousness= longer is higher risk • Loss of memory for events immediately prior to or after the accident • Alteration of mental state at time of accident (dazed, confused, disoriented)

22. Mild versus Severe Focal neurological deficits may or may not be transient. Better prognosis if: • Post-traumatic amnesia not greater than 24 hours • After 30 minutes, an initial Glasgow score of 13-15 (higher =better; 3=deep unconsc.) • Loss of consciousness about 30 minutes or less

23. How to Help Objective: PREVENT further complications!! • Early intervention & identification of SUD • Find empathetic and knowledgeable provider • Many Neurologists and Psychiatrists not necessarily knowledgeable in ID and treatment of SUD, particularly in context of TBI: REQUIRES SPECIALIZED SKILLS AND EVALUTION

24. EVALUATION EVALUATOR MUST: • Determine how well individual reads and writes • Can individual comprehend both written & oral communication • Determine unique communication style of person • Develop effective communication techniques

25. EVALUATION EVALUATOR MUST: • Understand person’s capacity for learning new material • Understand strengths and weakness • Always build on strengths TAKE 5 VILLAGES!!!! Maybe more….

26. Substance Abuse Provider: • Modify written material for conciseness so it is to the point • Use concrete examples • Use visual aids or be able to present ideas in a variety of ways • Encourage individual to take notes or otherwise develop aides memoir

27. Substance Abuse Provider: • Encourage use of calendars, planners,easy reference • MAKE A SCHEDULE: those with difficulty thinking do much better with a structured environment---even if it is activities that don’t seem to lend themselves to a schedule, like bedtime, meals, going to the gym: SCHEDULE EVERYTHING

28. Substance Abuse Provider: • Give homework assignments (write down) • If in group, give advantage of individual attention as well • Provide assistance and more time to complete tasks • Family, friends, other service providers can reinforce goals and be ‘provider-extenders’

29. Providers & Others • Patience is a virtue!! (easy for others to say!) • Do NOT take anything for granted,especially that success in one area will translate to other areas, or that new learning can easily translate across the board

30. Providers & Others • Do NOT ASS-U-ME non-compliance arises from lack of motivation or resistence • Confrontation shuts down thinking & engenders rigidity; roll with resistence • Do just ‘discharge’ for non-compliance or give up if RELAPSE • Think: How many diabetics or cardiac patients get discharged for ‘non-complicance?’ • RELAPSE is a sign of SUD, just like chest pain is a sign of cardiac problem or blood sugar, etc.

31. MAKE IT STICK!! • REPEAT • REVIEW • REHEARSE • REVISE • REPEAT • REVIEW • REHEARSE…

32. Teaching, training, learning • Give direct feedback • Let someone knowthatbehaviorisunacceptable: do not ASS-U-ME individualisaware of thatand deliberatelychoosing to do it • Straightforwardfeedbackwhen & wherebehaviors ARE appropriate • Redirecttangentialorexcessive speech (usepre-arrangedsignals for groups)

33. SUMMARY MAIN POINTS • Alcohol & other drug use disorder common with TBI • Universal screening for SUD • Early intervention • Combine rehab techniques with SUD treatment techniques (AA, NA, MAT,etc,) • Education for all • Linkage with community based programs

34. Providers & Others • Primary care physicians, specialists • Specialty organizations: NJ Psychiatric Association; NJ Society of Addicton Medicine • Local drug and alcohol rehab programs • Your own resilience, patience and LOVE • If a parent, your own experience…

35. RESOURCES • http://www.nj.gov/humanservices/das/home/ • NJ DIVISION of Mental Health and Addiction Services (DMHAS)

36. Case Discussion & Consultation • Your cases • Your problems • Your lives…

37. THANK YOU! • PLEASE COMPLETE YOUR EVALUATIONS • Cheryl Ann Kennedy MD • Current President of NJSAM • Board Member, Integrity Inc <kennedy@njms.rutgers.edu>