Substance Abuse & Brain Injury

1. Substance Abuse& Brain Injury

2. Brain Injury and Alcohol….A recent analysis of research studies on the relationship between alcohol and brain injury found: • Between 37-51% of individuals hospitalized for TBI were intoxicated at the time of injury & have a history of alcohol misuse • Individuals with a history of pre-injury alcohol use have a more complicated course of recovery and generally poor rehabilitation and social outcomes (Parry-Jones et.al 2006)

3. According to John Corrigan PhD: 5-10% of those with TBI develop substance abuse after their injury

4. 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)

5. Presence of SA-Under the radar immediately following injury • Medical & rehabilitation interventions take precedence • Family and friends provide 24/7 supervision • Physical, cognitive deficits present barriers to alcohol and other substances. • Injured individuals believe they have “seen the light”

6. “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)

7. 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

8. The Honeymoon is Over Australia researchers found similar results in a 2007 study looking at post TBI drug and alcohol use. Alcohol & drug use declined in first year. By two years post injury, only 21.4% of participants reported abstinence and 25.4% were drinking at hazardous levels

9. 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)

10. Impact of TBI in Adolescent Substance Abuse Treatment Programs 2005 study by Corrigan et.al • 189 adolescents receiving residential SA tx were screened for a hx of brain injury • TBI with LOC reported by 23% of residents • 13% reported a moderate or severe TBI

11. TBI related symptoms included: • Headaches • Dizziness • Memory problems • Fatigue • Difficulty controlling temper • Being easily stressed • Having problems with school work

12. The Take Home Message...

13. “Having a TBI with loss of consciousness was significantly associated with being more likely to be dependent on both alcohol and other drugs, to having experienced a drug overdose with loss of consciousness, being in special classes and having a seizure disorder. There were trends toward TBI with loss of consciousness being associated with having a learning disability, having violence-related convictions, and receiving psychiatric outpatient services. Among the later, persons with TBI were more likely to be treated for attention deficit hyperactivity disorder, anger management and conduct disorders.” John Corrigan Ph.D

14. 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)

15. Techniques for change: Recommended for individuals with a history of brain injury • Stages of Change The 5 Stages of Change Prochaska and DiClemente cited by Corrigan 1999 • Motivational Interviewing Based on the work of W. R. Miller, adapted by Corrigan & Colleagues • Successive ApproximationUtilized by the brain injury rehabilitation team at Pathways in Hollywood MD

16. How to Utilize Substance Abuse Education & Intervention with individuals with Brain Injury:Tips for Mental Health Professionals

17. Messages to ShareDrinking After Brain InjuryAdapted 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

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

19. 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)

20. 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)

21. 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? * Negative responses are alcoholic responses • (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?

22. 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)

23. 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?

24. 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

25. Additional Screening Tools-also recommended for individuals with cognitive disorders • 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

26. 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

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

28. 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.

29. 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 or... • My Name is Bill W. a 1989 movie with James Gardner and James Wood • Scene from last season of HBO’s The Wire depicting a 12 step meeting • Ask a consumer in recovery to come and speak to group/individual

30. For Individuals with Severe Brain Injury Provide concrete examples of AA Convert 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)

31. A Letter to Potential AA & NA 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

32. 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

33. 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

34. 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

35. 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

36. 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 • Handout from Ohio Valley Center, Suggestions for Providers Working with Persons with Brain Injury

37. 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”

38. 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

39. What They said….. To stay clean; find the right 12-step program, change “persons, places and things” that trigger use, spirituality…..,

40. …………..Pets”

41. Never underestimate the value the participants place on your opinions and advice • You don’t have to be an Addictions Counselor to speak from your knowledge and expertise regarding the impact of substances on the rehabilitation work you are doing with someone e.g…. • “As your ___________, I need to let you know that drinking will impact your balance and we want to do all we can to minimize the risk of fall” • “As your ____________, I recommend you do not drink alcohol because it will make your articulation, memory and new learning abilities worse”

42. References • 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

43. 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.

44. References • Vungkhanching M., Heinemann AW., Langley MJ., Ridgely M., Kramer KM. (2007) Feasibility of a Skills-based Substance Abuse Prevention Following Traumatic Brain Injury. Journal of Head Trauma Rehabilitation, 22(3):167-76 • Ponsford J., Whelan-Goodinson R., Bahar-Fuchs A. (2007) Alcohol and drug use following traumatic brain injury: a prospective study. Brain Injury Dec;21(13-14): 1385-92P • Parry-Jones BL., Vaughan FL., Miles Cox w. (2006) Traumatic Brain Injury and Substance Misuse: a systematic review of prevalence and outcomes research (1994-2004) Neuropsychological Rehabilitation October;16(5):537-60

45. RESOURCES • Brain Injury Association of America 703-236-6000, www.biausa.org • Brain Injury Association of Maryland 410-448-2924, www.biamd.org • Ohio Valley Center For Brain Injury Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org. Excellent SA TX resource & information • www.headinjury.com. Good resource for memory aides and tips

46. RESOURCES • New York State Office of Alcoholism and Substance Abuse Services www.oasas.state.ny.us/TBI/index.cfm, this is a great site to share with community substance abuse providers who are interested in learning about TBI. • SynapShots website, a joint project of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation and the Charlotte Institute of Rehabilitation www.synapshots.org/index.html. Provides very clear, concrete information on the topic of TBI & Substance Abuse, Cognitive Fatigue and Irritability post injury. Is consumer friendly and appropriate for family members and professionals.

47. RESOURCES • Rethinking Drinking, a interactive website from the National Institutes of Health www.rethinkingdrinking.niaaa.nih.gov/default.asp • Substance Abuse and Mental Health Services Administration (SAMHSA) www.samhsa.gov information and resources on substance abuse & mental health

48. The Michigan Department of Community HealthWeb-Based Brain Injury Training for Professionals www.mitbitraining.org 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”

49. Abraham Lincoln to the Washington Temperance Society, Springfield Illinois 1842 “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”

50. Anastasia Edmonston MS CRCTBI Trainer, Maryland Mental Hygiene Administration410-402-8478anastasia.edmonston@maryland.gov Thank You