Acquired Brain Injury & Substance Misuse

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1 Acquired Brain Injury & Substance Misuse A Need for a Paradigm Shift? Dr Oliver Aldridge MBBCh, DRCOG, MRCGP Certificant of the International Society of Addiction Medicine

2 Challenges Integration of services Sustainable Recovery Shift of focus from end stage disease treatment to prevention The problem of ABI in Addiction Medicine illustrates all of these issues

3 UN Single Convention on Narcotic Drugs 1961 Paragraph 1, Section 38 The Parties shall give special attention to and take all practicable measures for the prevention of abuse of drugs and for the early identification, treatment, education, after-care, rehabilitation and social reintegration of the persons involved and shall coordinate their efforts to these ends

4 Integrated Care Holistic approach incorporating all elements of health People with substance misuse problems may have cooccurring problems Challenge which may define our field for the foreseeable future (Wilson Compton MD: NIDA)

5 Sustainable Recovery Not enough to talk about recovery Treatment must be about more than just "admit, treat, discharge" Need a holistic, integrated approach recognising that recovery is about more than just abstinence.

6 Continuum of use

7 Prodromal States Continuum/spectrum disorders Memory complaint through to Alzheimer's Prodromal syndrome well known in psychosis Sub-syndromal depression linked with increased risk of major depression Can addiction medicine evolve to treat prodromal states?

8 Pyramid of Substance Use SUD DSM IV Harmful Use Low Risk Use/Abstinence

9 Harmful Use Usually present to general medical services Screening not often done because: don't know what to do, think there is no effective treatment, lack of time, don't think it is a medical problem Screening, Brief Intervention & Treatment: shown to be effective Single question screening tools e.g. NIDAMED

10 Acquired Brain Injury (ABI)

11

12 ABI: Common Causes Traumatic Brain Injury (TBI) Infection, Stroke Substance Misuse (eg Alcohol)

13 "Pyramid of ABI" Severe Moderate Subclinical/None

14 "Repairing Shattered Lives" There is growing evidence of links between incurring a TBI and subsequent offending. This indicates a need to reduce injuries and to manage consequences of injury to enable rehabilitation to be at its most effective There is compelling evidence of a very high prevalence rate of TBI in offenders in custody relative to the general population. Moreover, such injury may be linked to earlier and more frequent custodial sentences, and to more violent offending TBI in childhood and young adulthood may be particularly associated with offending behaviour. Earlier and more effective means to assess and manage the consequences of TBI in the offender population, and those at risk of offending, may lead to improved outcomes for affected individuals and for society

15 Incidence of TBI 8.5% of General Population 71% of DTTO audit had experienced at least one episode of traumatic loss of consciousness Majority as teenagers (age range 5-31). Mostly as a result of fighting or assault As a group had had very little, if any, follow up

16 Predisposing factors for TBI Contact sports Domestic violence Adolescent males who drink Falls Fights

17 Consequences of TBI Memory loss Loss of concentration Decreased awareness of own emotions Decreased awareness of others' emotions Poor social judgement Conduct disorder Attention problems Heightened aggression Impulse control disorders

18 Overlap Enormous overlap between traumatic brain injury and substance misuse Difficult to work out direction of causality Possibly expressions of the same underlying issues?

19 ABI in Drug/Alcohol Treatment Services

20 ABI as Barrier to Recovery Cognitive, behavioural, motor deficits may hamper recovery Need to raise awareness amongst staff to ask about history suggestive of TBI Close links with neuro-rehabilitation services needed to discuss possible referrals and treatment pathways/ care plans

21 Incidence/Screening Significant TBI may be fairly common May not be necessary to definitively distinguish between non trauma related ABI and TBI for clinical purposes Simple questions around history of head injuries may be useful Difficult to carry out screening using a standardised instrument due to concomitant drug use/treatment and mental health issues Often generates useful insights independent of TBI issues.

22 Exposure to Trauma Screening may aid recognition of the levels of trauma experienced by people attending drug/alcohol treatment services May impact significantly on recovery independently of direct neurological damage sustained May expose ongoing risk factors

23 Case Study 1 Male in his 30's with poor educational attainment, difficulty in managing his day to day affairs Poly drug use including Heroin, Benzodiazepines. Long offending history. >10 episodes of traumatic loss of consciousness as a child, starting in primary school, resulting from physical abuse Schooling affected - chronic headaches, difficulty coping with academic tasks Mental health affected - scared, disenfranchised

24 Case Study 2 Male in late 20's on DTTO. Long history of poly drug use and offending Survived a near fatal overdose involving prolonged intensive care unit treatment Resultant neurological deficits Had lost contact with neuro-rehabilitation services due to ongoing drug use Care plan has involved a mix of drug treatment and neurorehabilitation

25 General Medical Services Raising Awareness

26 Cause - Effect TBI may be an underlying cause for offending behaviour and for substance misuse Substance misuse may be an underlying cause for TBI Both mechanisms may exist in the same person Both may be a reflection of another factor - deprivation, risk taking etc

27 Raising Awareness Of TBI and its possible sequelae to improve recognition, monitoring and follow up Of harmful drug/alcohol use and of effectiveness of interventions such as Screening, Brief Intervention & Referral to Treatment (SBIRT), rapid screening tools

28 Conclusions

29 Paradigm Shift Away from viewing addiction purely as end stage disease management, towards prevention Away from quick fix recovery to sustainable recovery Away from mental health dominated views of addiction to a more holistic approach

30 Awareness Raising Of ABI in Alcohol/Drug Treatment services Of ABI and harmful Drug/Alcohol use in general services Of interventions that work e.g. SBIRT

31 References Repairing Shattered Lives: Brain Injury and its Implications for Criminal Justice - Prof Huw Williams NIDAMED Screening: nidamed-medical-health-professionals TBI Screening: downloads/pdfs/tbi-screening_v2.pdf

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