Helping Survivors Prevent Opioid Dependence After Injury

1. Helping Survivors Prevent Opioid Dependence After Injury Joseph Mull, MS, LPCC, LCADC

2. Substance Abuse Treatment with ABI -The Need for Long Term Approach • Bombadier, 2003 - 15% of patients with preinjury abstinence or light drinking were consuming moderate or heavy amounts 1 year post injury. • Kreutzer, 1990 - 25% of ABI patients increased their alcohol use 1to 2 years after brain injury. - 25% increased drug use 2 to 3 years after injury.

3. Substance Abuse Treatment and ABI – Inpatient vs Outpatient • “Clinicians and researchers have repeatedly observed that cognitive and emotional impairments caused by brain injury present unique problems when addressing co-existing substance use disorders. While several models of how substance abuse treatment can be adapted to traumatic brain injury rehabilitation were proposed in the past, most presumed protracted inpatient or residential treatment that is no longer available to most persons with traumatic brain injury.” - Ohio Valley Center for Brain Injury Prevention and Rehabilitation

4. Corrigan’s Model • Corrigan and colleagues (Corrigan, Lamb-Hart & Rust, 1995; Bogner, Corrigan, Spafford & Lamb-Hart, 1997; Heinemann, Corrigan & Moore, 2004) developed a community based model for treating substance use disorders in adults with acquired brain injury. The model emphasizes participant, family, and professional education. It also stresses intensive case management and inter-professional consultation. • Success was measured by abstinence, return to work or school, and subjective well-being. These outcomes were assessed three months post discharge. • The median length of stay for those discharged successfully was 2 years. • A retrospective analysis of 1,000 consecutive referrals indicated that 66% of those eligible for treatment never engaged in treatment or dropped out prematurely. • The high rate of treatment drop out highlights the need for strong therapeutic relationships with participants. http://ohiovalley.org/informationeducation/substanceuseinformation/substanceusetreatment/

5. Outcomes of Corrigan’s Model http://ohiovalley.org/informationeducation/substanceuseinformation/substanceusetreatment/

6. Corrigan’s Model – Key Points • Psycho-education intensive - participant, family, caretakers, professionals working with participant, etc. • Case Management is heavily involved throughout. The primary method of intervention is resource and service coordination. • Inter-disciplinary Communication – Physicians, Counselors, PTs, OTs, SLP, Voc. Rehab., etc. • Community Based • Long Term Care

7. Corrigan’s Principles of Integrated Treatment • Goals for SUD and TBI are interwoven – not sequential and not just parallel. • Treatment is holistic-addressing all aspects of lifestyle, not just TBI and substance abuse. • Participant and clinician collaborate to develop a mutually agreed upon treatment plan. • Clinicians help participants develop awareness and hopefulness so that motivation for recovery is internalized. • Different services will be helpful at different points in recovery – staging – which must be incorporated into the overall treatment model. • Treatment is longer-term. • Key staff are cross-trained to work with both TBI and substance use disorders. • Staff are more experienced and have smaller caseloads.

8. Suggestions for Substance Abuse Treatment Providers Working with ABI Population • The substance abuse provider should determine a person’s unique communication and learning styles. • Ask how well the person reads and writes; or evaluate via samples. • Evaluate whether the individual is able to comprehend both written and spoken language. • If someone is not able to speak (or speak easily), inquire as to alternate methods of expression (e.g., writing or gestures). • Both ask about and observe a person’s attention span; be attuned to whether attention seems to change in busy versus quiet environments. • Both ask about and observe a person’s capacity for new learning; inquire as to strengths and weaknesses or seek consultation to determine optimum approaches. The substance abuse provider should assist the individual to compensate for a unique learning style. • Modify written material to make it concise and to the point. • Paraphrase concepts, use concrete examples, incorporate visual aids, or otherwise present an idea in more than one way. • If it helps, allow the individual to take notes or at least write down key points for later review and recall. • Encourage the use of a calendar or planner; if the treatment program includes a daily schedule, make sure a "pocket version" is kept for easy reference. http://ohiovalley.org/informationeducation/substanceuseinformation/substanceusetreatment

9. Suggestions for Substance Abuse Treatment Providers Working with ABI Population • Make sure homework assignments are written down. • After group sessions, meet individually to review main points. • Provide assistance with homework or worksheets; allow more time and take into account reading or writing abilities. • Enlist family, friends or other service providers to reinforce goals. • Do not take for granted that something learned in one situation will be generalized to another. • Repeat, review, rehearse, repeat, review, rehearse. The substance abuse provider should provide direct feedback regarding inappropriate behaviors. • Let a person know a behavior is inappropriate; do not assume the individual knows and is choosing to do so anyway. • Provide straightforward feedback about when and where behaviors are appropriate. • Redirect tangential or excessive speech, including a predetermined method of signals for use in groups. The substance abuse provider should be cautious when making inferences about motivation based on observed behaviors. • Do not presume that non-compliance arises from lack of motivation or resistance, check it out. • Be aware that unawareness of deficits can arise as a result of specific damage to the brain and may not always be due to denial. • Confrontation shuts down thinking and elicits rigidity; roll with resistance. • Do not just discharge for non-compliance; follow-up and find out why someone has no-showed or otherwise not followed through. http://ohiovalley.org/informationeducation/substanceuseinformation/substanceusetreatment

10. Treatment Modalities Substance Abuse Treatment Modalities – CBT, Motivational Interviewing, DBT, Seeking Safety, Behavior Therapy Behavior Therapy Incentives for Clean Drug Screens, Gas Vouchers for Participation in Treatment, Training family/caretakers on how to reinforce functional behaviors for sobriety and create an environment for extinction of drug seeking behaviors. Motivational Interviewing Has been researched as a brief counseling strategy in acute rehab settings. Mixed results as efficacious for treatment engagement. Bombardier and colleagues have recommended brief interventions based on motivational interviewing techniques for use during acute rehabilitation (Bombardier, Ehde & Kilmer, 1997; Bombardier & Rimmele. 1999). Cox, Heinemann, et al. (2003) found some support for Structured Motivational Counseling in a study using a non-random comparison group.

11. Treatment Modalities Cognitive Behavioral Therapy Psychoeducation – risks of use, medication interaction, short and long term consequences, how drugs work, nature of addiction, disease model Skill Building – calendars, replacement behaviors, saying “no”, craving management, stress management, depression management, mindfulness, natural Highs ABCs – Cognitive Processes

12. Natural Highs Physical - Weight Lifting, Running, Exercise, Hiking, Walking, Yoga Relational – Family, Friends, Significant Other, Community Spiritual – Nature, Faith, Religion, Meditation, Prayer, Music Productive/Creative – “Flow”, Work, Music, Art, Projects Learning – Taking a Class, Reading, Lessons, Museums, Tours, New Skills Adventure – Travel, Sight Seeing, New Experiences, “Adrenaline Rushes”, Outdoors Food – Nutrition, Healthy Diet, Spicy Foods, Chocolate

13. Medication Management • Suboxone (Naltrexone + Buprenorphine), Vivitrol (Long Lasting Naltrexone Injection), Methadone • Addresses Self-Medication for Psychological Issues • Addresses Self-Medication for Pain Management • Medication and Interactions with Alcohol, Illicit Drugs • Opioids and Interactions with other Medications • Developing Trust with Med. Management Providers

14. Pain Management • Successful treatment goal is 40-60% reduction in pain • MOVEMENT • Walking • Physical Therapy – Stretches, Exercises • Massage Therapy • Chiropractor • TENS Unit • Weight Lifting • Cardio Exercise • Calisthenics • Yoga, Tai Chi

15. References & Suggested Reading Bogner, J. A., Corrigan, J. D., Spafford, D. E., & Lamb-Hart, G. L. (1997). Integrating substance abuse treatment and vocational rehabilitation following traumatic brain injury. Journal of Head Trauma Rehabilitation, 12 (5), 57-71. Bombardier C.H, Temkin N.R, MachamerJ,Dikmen S.S. (2003) The natural history of drinking and alcohol-related problems after traumatic brain injury. Arch Phys Med Rehabilitation, 84,185–191. Bombardier, C. H., & Rimmele, C. T. (1999). Motivational interviewing to prevent alcohol abuse after traumatic brain injury: A case series. Rehabilitation Psychology, 44(1), 52-67. Bombardier CH, Ehde D, Kilmer J. (1997) Readiness to change alcohol drinking habits after traumatic brain injury. Arch Phys Med Rehabilitation,78, 592–596. Center for Substance Abuse Treatment (1998). Substance use disorder treatment for people with physical and cognitive disabilities. Treatment Improvement Protocol (TIP) Series Number 29. Washington, DC: U.S. Government Printing Office. Center for Substance Abuse Treatment (2006). Counselor’s Treatment Manual: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders: Counselor's Treatment Manual. HHS Publication No. (SMA) 08-4152. Rockville, MD: Substance Abuse and Mental Health Services Administration.

16. References &Suggested Reading Continued Corrigan, J. D., Bogner, J., Lamb-Hart, G., Heinemann, A. W., & Moore, D. (2005). Increasing Substance Abuse Treatment Compliance for Persons With Traumatic Brain Injury. Psychology of Addictive Behaviors, 19(2), 131-139. Corrigan, JD. Lamb-Hart, GL. Rust, E. (1995). A programme of intervention for substance abuse following traumatic brain injury.. Brain Injury, 9 (3), 221-236. Cox, W. M., Heinemann, A. W., Vincent Miranti, S., Schmidt, M., Klinger, E., & Blount, J. (2003). Outcomes of Systematic Motivational Counseling for substance use following traumatic brain injury. Journal of Addictive Diseases, 22 (1), 93-110. Heinemann, A. W., Corrigan, J. D., & Moore, D. (2004). Case Management for Traumatic Brain Injury Survivors With Alcohol Problems. Rehabilitation Psychology, 49(2), 156-166. Kreutzer, J. S. (1990) Community Integration Following Traumatic Brain Injury. Baltimore, MD: Paul H. Brookes Pub Company. Kreutzer, J. S., Witol, A. D., & Marwitz, J. H. (1996) Alcohol and drug use among young persons with traumatic brain injury. Journal of Learning Disabilities, 29 (6), 643-651. Ohio Valley Center for Brain Injury Prevention and Rehabilitation (year unknown) Treatment for Substance Use with TBI. Retrieved from http://ohiovalley.org/informationeducation/substanceuseinformation/substanceusetreatment/