A DOUBLE TROUBLE

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ALCOHOL AND BRAIN INJURY

• A DOUBLE TROUBLE?
• Steve Shears
• Headway UK

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Aims

• To consider the issue of traumatic brain injury
  and alcohol abuse.
• To explore developments and research into TBI
  rehabilitation that integrates substance misuse
  into the treatment programme.

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Scale of the problem?

• WHO (2004) worldwide 76.3 million people have
  diagnosable alcohol disorder. Half of the deaths
  alcohol plays a part in are from unintentional
  mishaps/accidents.
• Some researchers suggest that substance/alcohol
  misuse is a significant problem for some people
  prior to brain injury (Delmonico et al 1998,
  Sander et al 1997)
• Corrigan (2005) cited the findings of the Centre
  for Substance Abuse Treatment (1998) that
  substance abuse is more prevalent in people with
  disabilities.
• Miller (1995) claimed that treatment for alcohol
  addiction was not well integrated into brain
  injury rehab.

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Times they are a changing?

• My literature review (Sept 05) of the treatment
  for alcohol problems within brain injury
  rehabilitation indicated it was still not widely
  integrated into the rehabilitation setting.
• This is despite alcohol and other substance abuse
  being a problem for a significant amount of TBI
  survivors and the effects of alcohol and TBI on
  the brain being worse than either factor alone
  (Buguley 1997 ERP Studies)

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Risk Factors Alcohol Use After ABI(Source BIUSA)

• Alcohol and other drugs interfere with new
  connections between neurons.
• It can exacerbate post-brain injury balance
  problems and lead to falls (and further brain
  injuries)
• Brain injury sometimes leads to people saying the
  first thing that comes to mind. Alcohol tends to
  have this effect anyway so increases the
  possibility of social/relationship problems.
• Brain injury causes cognitive problems like
  concentration difficulties and alcohol and other
  drugs make this worse.
• The brain is more sensitive to alcohol and other
  drugs following brain injury.

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Brain injury a window of opportunity?

• Brain injury as a turning point for alcohol and
  substance misuse (Bombardier et al 2002) study
  concluded that there was a readiness to change in
  most at risk drinkers and the brain injury
  rehabilitation setting was a good place to
  assess/intervene.
• Bombardier et al (1997) sample of 50 according
  to their RCQ scores 84 were in contemplation
  or action phases of readiness to change.

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Substance misuse and brain injury Ohio Valley,
USA
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Integrated programmes.

• Interesting work going on at Ohio Valley centre
  for brain injury prevention and rehabilitation in
  substance abuse treatment and brain injury.
• This includes information and self-help
  literature for TBI survivors about substance use
  and brain injury. Researchers from Ohio Valley
  also wrote the BIUSA information booklet about
  this subject.
• www.ohiovalley.org

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Ohio Valley Users Manual for the Brain
Ohio Valley Centre presents a Users Manual For
Faster. . .More Reliable Operation of a Brain
after Injury
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Part of the manual www.ohiovalley.org
The human brain is often com pared to a computer,
full of bits of information, able to make swift,
steady connections. Just like a computer, the
brain has many programs like the ones that allow
us to move, think and make decisions.
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Part of the manual (II) www.ohiovalley.org
The effects of alcohol and other drugs are
different for people after a brain injury. This
Users Manual presents facts about how alcohol
and other drugs affect people with brain
injuries. These facts like software are ready
to be installed. But youre the operator.If you
have had a brain injury, take time to study this
manual. Read. Think. Decide. We hope after youve
done that, you will install new alcohol/other
drug software a new set of facts, attitudes and
beliefs in your brain.
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Part of the manual (III)
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The neuroscience of dependence. Mesolimbic
Dopamine System
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Neuroscience of dependence

• Summary
• Ethanol increases the firing rate of the ventral
  tegemental area (VTA) dopamine neurons and
  release of dopamine in the nucleus accumbens
  (Nac) part of the mesolimbic dopamine system.
  Explains reinforcing effect of alcohol.
• It increases the inhibitory action of the GABA-A
  neurotransmitter receptors and decreases the
  excitatory effects of the glutamate receptors.
  This explains the sedative effect of alcohol and
  the memory impairments during intoxication.

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Treatments for Alcohol Dependence

• Chemical treatments anti-abuse medications
  makes the person sick when they try to drink
  alcohol (Disulfiram).
• Chemical treatments Acamprosate restores the
  normal functioning of the glutaminergic neurons,
  which become hyper-excited during alcohol abuse.
  Naltrexone helps prevent relapse.
• Psychosocial interventions counselling,
  cognitive behavioural therapy, motivational
  interviewing (MET), 12 Step programmes
  (Alcoholics Anonymous).
• Project MATCH.

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Research into motivation for keeping in substance
treatment following TBI

• Corrigan et al (2005)
• Trial of 4 different approaches to motivation to
  complete substance abuse treatment for people who
  had survived TBI.
• Attentional control, MET Interview, Barrier
  Reduction and Financial Incentive.
• Most successful approaches in terms of signing up
  tp programme and completion of programme was
  financial incentive, followed by barrier
  reduction.
• Implications for substance/TBI rehabilitation.

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Stages of Change DiClemente and Prochaska

• Pre-contemplation
• Contemplation
• Action

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Readiness to Change Questionnaire (RCQ)

• My thoughts about alcohol and me (Circle the
  statements that you feel you agree with)
• 1. I dont think I drink too much.
• 2. I am trying to drink less than I used to.
• 3. I enjoy drinking, but sometimes I drink too
  much.
• 4. Sometimes I think I should cut down on my
  drinking.
• 5. Its a waste of time thinking about my
  drinking.
• 6. I have just recently changed my drinking
  habits.
• 7. Anyone can talk about wanting to do something
  about drinking, but I am actually doing
  something about it.
• 8. I am at a stage where I should think about
  drinking less alcohol.
• 9. My drinking is a problem sometimes.
• 10. There is no need for me to think about
  changing my drinking.
• 11. I am actually changing my drinking habits
  now.
• 12. Drinking less alcohol would be pointless for
  me.

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Appendix - Definitions

• DSM-IV Definition of substance abuse.
• A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same 12
  month period.
• 1) Tolerance to the substance.
• 2) Withdrawal
• 3) Substance is taken in larger amounts or over a
  longer period of time than was intended.
• 4) Persistent desire or unsuccessful efforts to
  cut down or control substance use.

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Appendix - Definitions Continued

• 5) A lot of time is spent trying to obtain the
  substance.
• 6) Important social, recreational and
  occupational activities are given up or reduced
  because of substance use.
• 7) The substance use is continued despite a
  knowledge that the substance is causing or making
  worse a psychological or physical problem.

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References

• Corrigan JD, Bogner J, Lamb-Hart G, Heinemann AW,
  Moore D (2005) Increasing substance abuse
  compliance for persons with traumatic brain
  injury. Psychology of Addictive Behaviours 2005,
  Vol 19, No 2, 131-139.
• DSM-IV (1994) The Diagnostic and Statistical
  Manual of Mental Disorders. The American
  Psychiatric Association.
• Neuroscience of Psychoactive Substance Use and
  Dependence. (2004) World Health Organisation
  (WHO)
• Readiness to Change Manual (19932000) Heather
  and Rollnick.

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More References

• Bombardier CH, Ehde D, Kilmer J. (1997) Readiness
  to change alcohol drinking habits after traumatic
  brain injury. Arch Phy Med Rehab.June78(6)592-6.
  
• Bombardier CH, Rimmele CT, Zintel H. (2002) The
  magnitude and correlates of alcohol and drug use
  before traumatic brain injury. Arch of Phy Med
  Rehab. Dec83(12)1765-73.

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Units of Alcohol