Jennifer Olson-Madden , Ph.D.

1. Addressing Comorbid TBI and SUDs: Risk Reduction and Prevention Jennifer Olson-Madden, Ph.D.

2. The SUDs and TBI Link • Substance abuse (SA) is more prevalent among persons with disabilities than in the general population (Center for Substance Abuse Treatment, 1998; Corrigan, Bogner, Lamb-Hart, Heinemann, & Moore, 2005) • Individuals with TBI frequently have pre- and post-injury SA problems (Bogner, 2001; Corrigan, 1995, 2001; Felde, Westermeyer, &Thuras, 2006; Kreutzer, Wehman, Harris, Burns, & Young, 1991) • Individuals with SA are at greater risk for sustaining TBIs(Bombardier, Rimmele, & Zintel, 2002; Kolakowsky-Hayner, Gourley, Kreutzer, Marwitz, Cifu & McKinley, 1999) • History of TBI = greater risk for subsequent injury and/or psychosocial and psychiatric problems(Oquendo, Friedman, Grunebaum, Burke, Silver & Mann, 2004; Walker, Cole, Logan, & Corrigan, 2007; Walker, Hiller, Staton, & Leukefeld, 2003)

3. Among OEF/OIF Soldiers TBI = “signature wound” • Significant rates of SUDs among returning military personnel (i.e., 11% acknowledge an alcohol problem) (Milliken, Auchterlonie, & Hoge, 2007)

4. Traumatic Brain Injury and Psychiatric Diagnoses in Veterans Seeking Outpatient Substance Abuse Treatment Jennifer H. Olson-Madden, Ph.D. Lisa A. Brenner, Ph.D., ABPP Jeri Forster Harwood, Ph.D. Chad Emrick, Ph.D. John Corrigan, Ph.D., ABPP Caitlin Thompson, Ph.D. In press, Journal of Head Trauma Rehabilitation

5. OSU TBI-ID Corrigan and Bogner2008 • Injury caused by blow to the head resulting in LOC or altered consciousness • Multiple dimensions of history collected: • Number of injuries • Severity of injuries • Initial and persistent sequelae • Age of injury • Medical treatment sought post injury • Injury as result of blast exposure • LOC or altered consciousness due to intoxication, drug or alcohol use, or asphyxiation are excluded from scoring • Scored via template format

6. 55% (136/247) of Veterans screened positive for potential TBI history on intake 70 were followed up with OSU TBI-ID (Corrigan and Bognar 2008)100% were verified as having lifetime history of TBI

7. Results • Severity: 83% (n=196) mild; 16% (n=37) moderate, 1% (n=3) severe • Mechanism: 28% (n =67) MVA; 24% (n = 56) Assault; 17% (n = 39) “Other” including blast; 15% (n = 36) Fall; 10% (n= 24) Sports; 6% (n= 15) bicycle/pedestrian • 37% injuries involved use of substance(s) prior to or at the time of injury • 54% veterans sustained at least one injury • prior to age 18 236 Total Injuries (mean = 3.4 per Veteran)

8. Results

9. For each additional TBI sustained there was an estimated 9% increase in the number of psychiatric diagnoses assigned (95% CI: 3%-15%)For each additional psychiatric diagnosis assigned, there was an estimated 11% increase in the number of injuries sustained over the lifetime (95% CI: 3%-19%)

10. Then What? • Increased necessity for specialty substance abuse treatment services BUT………. Options to address TBI-related issues within the context of SA treatment are limited! • Appropriate interventions needed because TBI sequelae can present unique challenges and barriers to treating

11. mTBI and SUDs: Risk Reduction and Prevention Overview • FY 2008 D.O.D. CDMRP TBI and Psychological Health Award:“Development of an Intervention for Soldiers and Veterans with Co-Occurring mTBI and SUDs” (PI: Olson-Madden) • Purpose: • Evidence-based strategies and models combined to target mTBI and SUDs (and comorbidities) among Veterans and post-deployment Military personnel • Manualized intervention and educational materials for clinicians • Further funding via D.O.D., state, VA: feasibility testing, clinical trials, implementation

12. Evidence-based Models • Stages of Change Model (Prochaska & DiClemente, 1991) • Normalize position in process of change • Utilize strategies to assist clients moving through stages • Identifying and understanding ambivalence • Resolving ambivalence • Motivational Enhancement/Group-based Motivational Interviewing (Velasquez, Maurer, Crouch, DiClemente, 2001; Fields, 2004) • Express empathy • Support self-efficacy • Roll with Resistance • Develop discrepancy • Relapse Prevention (Marlatt, 1985, 2005) • Cognitive-behavioral approach • Identify and prevent high-risk behaviors and situations • Multi-determined: self-efficacy, outcome expectancies, cravings, motivation, coping, emotional states, and interpersonal factors

13. Additional Resources • Substance Abuse and TBI Toolkit (Ohio Valley Center for Brain Injury Prevention and Rehabilitation) • Provide prevention, intervention, and treatment resources • To facilitate willingness to change behavior • To educate clients on the importance of abstinence post-TBI • Battlemind Training (https://www.battlemind.army.mil/) • Post deployment transition to home • Focus on resilience, reducing stigma

14. Strategies • Perceived risk + perceived self-efficacy = change • Problem solving skills • Health promotion • Early detection • Restoring function or reducing current complications • Alternative options • Identifying values • Psychoeducation

15. OUTCOMES 1) Increased Motivation to Change 2) Risk Reduction 3) Prevention 4) Health and Wellness Promotion

16. Thank You jennifer.olson-madden@va.gov http://www.mirecc.va.gov/visn19/