Substance Use and Traumatic Brain Injury

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1 Substance Use and Traumatic Brain Injury From: Marc A Gramatges, Psy.D. December 18, Bancroft All rights reserved

2 Learning Objectives This webinar is designed to help you: Describe the prevalence of substance use (SU) and Traumatic Brain Injury (TBI) Explain the clinical interaction of SU and TBI Select appropriate treatment methods for individuals with SU and TBI Use a list of resources for SU and TBI 2013 Bancroft All rights reserved

3 Prevalence of TBI Every year, at least 1.7 million TBIs occur either as an isolated injury or along with other injuries TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States About 75% of TBIs that occur each year are concussions or other forms of mild TBI (CDCP, 2013)

4 Causes of TBI The leading causes of TBI are: Falls (35.2%) Motor vehicle traffic (17.3%) Struck by/against events (16.5%) Assaults (10%) (CDCP, 2013) From:: wmgc9ai13c/s400/eddie-griffin-ferrari-enzo-crash.jpg

5 Self Harm Intentional Sources of TBI: 17.8% of all cases Males Minorities of lower income <50 years of age Twice as likely to occur in conjunction with SU From:: (Wagner, Sasser, Hammond, Wiercisiewski, & Alexander, 2000).

6 SU and TBI For those suffering TBIs: 44 60% of those injured were intoxicated at the time of injury 58% had a history of alcohol abuse or dependence prior to injury 33% used illicit drugs prior to their injury (Hensold, Guercio, Grubbs, Upton, & Faw, 2006)

7 Continuing Use While receiving treatment: 50% will return to abusing alcohol and other drugs post-injury 20% receiving treatment for substance abuse issues after injury did not have a history of substance abuse prior to their injury (Hensold, Guercio, Grubbs, Upton, & Faw, 2006)

8 Clinical Interaction After a TBI, the brain is more sensitive to alcohol and other drugs after an injury There are not as many neurons to absorb the alcohol or other drugs (BIAA, 2013)

9 Healing SU after a TBI may reduce amount of recovery (BIAA, 2013) From:

10 Seizures 5% of people after a brain injury have problems with seizures SU increases the risk of seizures (BIAA, 2013)

11 Future TBIs After a TBI, chance for another is three times greater SU increases those odds (BIAA, 2013)

12 In one study 76 individuals with moderate to severe TBI in a day treatment program 55 individuals (72%) were employed 18 (24%) were students one (1%) did volunteer work two (3%) were unemployed

13 In one study At follow-up, 54 individuals (71%) were employed or attending school. 22 individuals (29%) Only history of substance abuse was associated with poorer outcome Individuals with no history of substance abuse were eight times more likely to be employed at follow-up compared to those with a history of substance abuse. (Sherer, M., Bergloff, P., High, Jr., W., & Nick, 1999)

14 Evidence for Risk Less likely to return to drinking: More severe injuries Longer hospital stays Greater degrees of disability (Kreuzter, et. al. 1996)

15 Evidence for Risk More likely to return to drinking: High Blood Alcohol Content at time of injury Moderate injuries Young adults Prior heavy drinkers (Kreuzter, et. al. 1996)

16 When Comparing SU and TBI Patients with uncomplicated M(ild)TBIs could not be reliably differentiated from patients with substance abuse problems on these measures of concentration, memory and processing speed. (Iverson, Lange, Franzen, 2005) From:

17 Additional Evidence Heavy social drinkers or those who had been hospitalized for a TBI were slower responding during testing Heavy social drinking and TBI have an "additive effect." (Baguley et. al, 1997) From:

18 Screening for SU with TBI CAGE More effective for Post-TBI alcohol use Substance Abuse Subtle Screening Inventory 3 (SASSI-3) More effective for Post-TBI drug use (Ashman, Schwartz, Cantor, Hibbard, & Gordon, 2004)

19 CAGE Assessment for Alcohol Abuse The CAGE is a 4- item, relatively nonconfrontational questionnaire for detection of alcoholism. It takes less then 1 minute to administer, is easy to learn, remember and replicate. Two or more affirmative responses suggest that the client is a problem drinker. (Ewing, 1984)

20 CAGE Assessment for Alcohol Abuse 1. Have you felt the need to Cut down on your drinking? 2. Do you feel Annoyed by people complaining about your drinking? 3. Do you ever feel Guilty about your drinking? 4. Do you ever drink an Eye-opener in the morning to relieve shakes? (Ewing, 1984)

21 SASSI Identifies high probability of engaging in alcohol or drug abuse Identifies individual with abuse who may not acknowledge it Face-valid and subtle items predictive of substance abuse (Ashman, Schwartz, Cantor, Hibbard, & Gordon, 2004)

22 Cognitive Challenges Attention Emotional Functioning Memory and Learning Social Communication Visual Processing Information Processing Executive Functioning Anosognosia

23 Attention Difficulty concentrating Impacts memory At risk during seemingly simple tasks (BIAA, 2009) From:

24 Emotional Functioning Less frustration tolerance Aggression Depression Emotional lability (BIAA, 2009) From: https://encryptedtbn0.gstatic.com/images?q=tbn:and9gcqi43br0o5xihlnzrvhptulevgznlwo3a_0_yirupyp_csue_a

25 Memory and Learning Learning and retaining new information Forgetting critical events Forgetting appointments Forgetting medication (BIAA, 2009)

26 Social Communication May have inappropriate social interactions Difficulty filtering Trouble reading others emotions (BIAA, 2009)

27 Visual Processing Balance Coordination Walking (BIAA, 2013)

28 Information Processing Decrease in processing speed Difficulty processing multiple streams of information

29 Executive Functioning Increase in impulsivity Difficulty planning Trouble completing tasks (BIAA, 2009)

30 Anosognosia Lack of awareness of deficits (BIAA, 2009)

31 Therapeutic Modalities Cognitive Behavioral Therapy Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs. (BIAA, 2013) From: eck.jpg From: Cognitive/cognitivepics/Albert_Ellis_.jpg

32 Therapeutic Modalities Multidimensional Family Therapy Developed for adolescents with drug abuse problems as well as their families addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning. (BIAA, 2013)

33 Therapeutic Modalities Motivational Incentives (Contingency Management) Positive reinforcement to encourage abstinence from drugs. (BIAA, 2013)

34 Therapeutic Modalities Motivational interviewing Capitalizes on the readiness of individuals to change their behavior and enter treatment. Stages of Change Model (BIAA, 2013)

35 Stages of Change Precontemplation: A person sees no problem when there is one Contemplation: Weighing the pros and cons of changing Determination: Deciding to change Action: Making a specific plan for change Maintenance: Sustaining successful change despite urges to use again (BIAA, 2013)

36 D&A Treatment Long-term residential treatment Provides care 24 hours a day, generally in nonhospital settings Planned lengths of stay of between 6 and 12 months (BIAA, 2013)

37 D&A Treatment Short-Term Residential Intensive but relatively brief treatment based on a modified 12-step approach Originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat other types of substance use disorders 3- to 6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as AA. (BIAA, 2013)

38 D&A Treatment Halfway House A home shared by a group of individuals in recovery with set rules to assist with sobriety. Typically based on a 12-step approach (BIAA, 2013)

39 D&A Treatment Outpatient Treatment Varies in the types and intensity of services offered (Intensive and outpatient) (BIAA, 2013)

40 D&A Treatment Alcoholics Anonymous Narcotics Anonymous 12 Steps From:

41 The 12 Steps Step 1 - We admitted we were powerless over our addiction - that our lives had become unmanageable Step 2 - Came to believe that a Power greater than ourselves could restore us to sanity Step 3 - Made a decision to turn our will and our lives over to the care of God as we understood God Step 4 - Made a searching and fearless moral inventory of ourselves Step 5 - Admitted to God, to ourselves and to another human being the exact nature of our wrongs Step 6 - Were entirely ready to have God remove all these defects of character Step 7 - Humbly asked God to remove our shortcomings Step 8 - Made a list of all persons we had harmed, and became willing to make amends to them all Step 9 - Made direct amends to such people wherever possible, except when to do so would injure them or others Step 10 - Continued to take personal inventory and when we were wrong promptly admitted it Step 11 - Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God's will for us and the power to carry that out Step 12 - Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs

42 The First Step Remember anosognosia From:

43 Which Treatment? Most effective in starting treatment: 83% Financial incentive 74% Barrier reduction 45% Motivational interview 45% Attention control (Bogner, Lamb-Hart, Heinemann, & Moore, 2005)

44 Which Treatment? But staying in treatment: 84% Barrier reduction 79% Financial incentive 66% Motivational interview 53% Attention control (Bogner, Lamb-Hart, Heinemann, & Moore, 2005)

45 Barriers When a person with a brain injury seeks help for a substance abuse problem, significant barriers to treatment may be encountered. (BIAA, 2013)

46 Physical Barriers Limited accessibility for individuals with physical disabilities (BIAA, 2013)

47 Medical Barriers Lack of understanding for need of medications (CDCP, 2013)

48 Social Barriers Lack of social understanding of brain injury (BIAA, 2013) From:

49 In an Intensive SU and TBI Program Significant gains in four of the five outcome areas that were measured over about 6 months: Residential status Level of supervision required Awareness Productive involvement No significant vocational gains (need 20+ hours a week) (Hensold, Guercio, Grubbs, Upton, & Faw, 2006)

50 Relapse Alcohol and drug use declined in the first year post-injury Increased by 2 years post-injury SU was similar at 3 years post-injury (Ponsford, Whelan-Goodinson, & Bahar-Fuchs, 2007)

51 Relapse 21.4% reported abstinence from alcohol 25.4% drank at hazardous levels 9% showed a drug problem 24% returned to some drug use Heavy alcohol users post-injury were young, male and heavy drinkers pre-injury (Ponsford, Whelan-Goodinson, & Bahar-Fuchs, 2007)

52 Important to Remember Insight Barrier reduction Maintenance

53 Resources Alcoholics Anonymous Narcotics Anonymous Brain Injury Association of America Centers for Disease Control and Prevention National Institute on Drug Abuse 2013 Bancroft All rights reserved

54 Questions? From:

55 References Ashman, T. A., Schwartz, M. E., Cantor, J. B., Hibbard, M. R., & Gordon, W. A. (2004). Screening for substance abuse in individuals with traumatic brain injury. Brain Injury, 18(2), doi: / Baguley, I. J., Felmingham, K. L., Lahz,S., Gordan, E., Lazzaro, I., & Schotte, D. E. (1997). Alcohol abuse and traumatic brain injury: Effect on event-related potentials. Archives of Physical Medicine and Rehabilitation, 78 (11), Brain Injury Association of America (2009). The essential brain injury guide (4 th ed.). Vienna, VA: Academy of Certified Brain Injury Specialist. Brain Injury Association of America (2013). Retrieved November 12, 2013 from Centers for Disease Control and Prevention (2013). Retrieved November 12, 2013 from Cox, W., Heinemann, A. W., 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), Bancroft All rights reserved

56 References Ewing, JA (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252, Hensold, T. C., Guercio, J. M., Grubbs, E. E., Upton, J. C., & Faw, G. (2006). A personal intervention substance abuse treatment approach: Substance abuse treatment in a least restrictive residential model. Brain Injury, 20(4), doi: / Iverson, G. L., Lange, R. T., & Franzen, M. D. (2005). Effects of mild traumatic brain injury cannot be differentiated from substance abuse. Brain Injury, 19(1), 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), doi: / x Kreuzter, Jeffrey et. al. (1996). A prospective longitudinal multicenter analysis of alcohol use patterns among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation Research, 11(5), National Institute on Drug Abuse (2013). Retrieved November 12, 2013 from / 2013 Bancroft All rights reserved

57 References Ponsford, J., Whelan-Goodinson, R., & Bahar-Fuchs, A. (2007). Alcohol and drug use following traumatic brain injury: A prospective study. Brain Injury, 21(13/14), doi: / Sherer, M., Bergloff, P., High, Jr., W., & Nick, T. G. (1999). Contribution of functional ratings to prediction of longterm employment outcome after traumatic brain injury. Brain Injury, 13, Wagner, A. K.; Sasser, H. C.; Hammond, F. C.; Wiercisiewski, D.; & Alexander, J. (2000). Intentional traumatic brain injury: Epidemiology, risk factors, and associations with injury severity and mortality. The Journal of Trauma Injury, Infection, and Critical Care, (49), Bancroft All rights reserved

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