Substance Abuse and Brain Injury

1
Substance Abuse and Brain Injury

• Anastasia Edmonston MS CRC
• TBI Projects Director
• Maryland Mental Hygiene Administration

2
The Elephant In the RoomBrain Injury and
Substance Abuse
3
Overview

• Overview of TBI-Screening for TBI
• Briefly Facts and Figures-What is The Problem?
• Lessons Learned-What brain injury professionals
  have and havent done to address the Brain
  Injury/ Substance Abuse Connection

4
Overview

• Utilities for Community Professionals-Ohio Valley
  Model
• Substance Abuse Screening tools
• Modifying Substance Abuse treatment and
  intervention strategies for individuals with
  brain injuries

5
Definitions How brain injury may be defined in
the Medical Record

• Acquired Brain Injury is an insult to the brain
  that has occurred after birth, for example TBI,
  stroke, near suffocation, infections in the
  brain, anoxia
• Diffuse Axonal Injury the tearing and shearing of
  microscopic brain cells
• Traumatic Brain Injury is an insult to the brain
  caused by an external physical force

6
Incidence of TBI CDC 2004

• In the United States, at least
• 1.6 million sustain a TBI each year

7
Incidence of TBI .Of those 1.6 million.. CDC
2004

• 51,000 die
• 290,000 are hospitalized and
• 1,224,000 million are treated an released from an
  emergency department

8
Annual Incidence of TBI with DisabilityAN
ESTIMATED 124,000 American civilians

• Cited by Jean Langlois ScD,MPH NASHIA Conference
  2007
• Preliminary findings as analyzed by Selassie, et.
  al

9
Service Members returning with TBIRevised
Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09
MSNBC.com 3.4.09

• Pentagon estimates up to 360,000 Iraq and
  Afghanistan vets may have suffered brain injuries
• Of the 360,000 are 45,000 to 90,000 whose (more
  severe) symptoms persist require specialized
  care

10
Service Members returning with TBIRevised
Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09
MSNBC.com 3.4.09

• These numbers are based upon Military
  health-screenings that show 10 to 20 of
  returning troops have suffered at least a mild
  concussion
• Among them 3-5 with persistent (concussive)
  symptoms that require specialists, e.g.
  ophthalmologists to deal with vision problems

11
Service Members returning with TBIRevised
Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09
MSNBC.com 3.4.09

• The estimate represents 20 of the 1.8 million
  troops who have served in Iraq and Afghanistan
• According to Lt. Col. Lynne Md. Lowe of the Army
  surgeon generals office, the Army spent 242
  million in 2008 for staff, facilities, and
  programs to serve brain injured troops

12
Polytrauma a unique constellation of injuries
Archives of Phys Med Rehab 1/08
Friedemann-Sanchez G. et al

• Amputations
• Craniectomies
• Burns
• Traumatic Brain Injury
• Vision problems are being report with greater
  frequency, according to the Blinded Veterans
  Association 75 of those with TBI have visual
  complaints

13
Causes of TBI CDC 2006
14
The Scope of the ProblemCenters for Disease
Control 2004

• Approximately 475,000 TBIs occur among children
  ages 0-14
• ED visits account for more than 90 of the TBIs
  in this age group
• The two age groups at highest risk of traumatic
  brain injury are ages 0-4 and 15-19

15
About 3.17 Million Americans live with the
consequences of traumatic brain injury(that we
know of-those who are counted)Centers for
Disease Control (2008)
16
MD TBI Project 2006-2009Consumer Profile (182
consumers, recipients of community based resource
coordination services)

• Men (_at_56 of consumers)
• On average 9 years post injury
• Mental Health issues 42
• Drug and Alcohol use and abuse 28.
• Homelessness/danger of homelessness 6
• 86 unemployed
• _at_15 of consumers have had some kind of forensic
  involvement

17
There are many we dont count

• 425,000 treated by MDs in office visits
• 90,000 treated in other outpatient settings
• Untold numbers who fall, are assaulted, play,
  sports etc.
• 360,000 service members returning from Iraq
  Afghanistan reporting a probable TBI20 who
  have served
  Langlois et. al., Rand Corporation, 2008, cited
  by Wayne Gordon Ph.D, Webcast, Maternal and Child
  Health Bureau 5.22.08 at www.mchcom.com

18
Reframed, the numbers nauseate. In America
alone, so many people become permanently disabled
from a brain injury that each decade they could
fill a city the size of Detroit...
19
.Seven of these cities are filled already. A
third of their citizens are under fourteen years
of age.From Head Cases, Stories of Brain
Injury and its AftermathMichael Paul Mason2008
published by Farrar, Straus and Giroux
20
The Scope of the Problem

• Distribution of Severity
• Mild injuries 80Loss of consciousness lt30
  min. Post traumatic amnesia lt 1 hour
• Moderate 10 - 13Loss of consciousness 30
  min.-24 hrs. Post traumatic amnesia 1-24 hrs
• Severe 7 - 10 Loss of consciousness gt 24
  hours. Post traumatic amnesia gt24 hrs

21
The Importance of Post Traumatic Amnesia

• PTA is the period of time after injury when a
  person is unable to lay down new memoriesfor
  example

22
That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NYT 3/10/08

• All he remembers from the collision with
  Anderson is the aftermath, being helped off the
  field by two people, although he said he did not
  know who they were until he saw a photograph
  later Ben Shpigel NYT reporter

23
What happens in a TBI?

• Mechanism Acceleration/Deceleration
• Differential movement of partially tethered brain
  within the skull
• Results in
• Bruising of the brain surface
• against rough areas of the skull
• Stretching and twisting of nerve axons

24
Skull Anatomy
The skull is a rounded layer of bone designed to
protect the brain from penetrating injuries.
The base of the skull is rough, with many bony
protuberances. These ridges can result in injury
to the temporal and frontal lobes of the brain
during rapid acceleration.
Dr. Mary Pepping
25
Primary Injuries

• Coup-Contra Coup

26
Primary Injuries

• Diffuse Axonal Injuries

Rotational forces on the brain cause the
stretching, snapping and shearing of axons
27
The Developing Brain

• Childrens brains do not reach their adult weight
  of 3 pounds until they are 12 years old
• The brain, and most importantly the brains
  frontal lobe region does not reach its full
  cognitive maturity till individuals reach their
  mid twenties.
• The frontal lobe is very vulnerable to injury

28
Take Home Message

• Kids Grow Into Their Brain Injuries
• G. Gioia Ph.D
• Childrens National Medical Center

29
Other potential Neurotoxins that may impact the
brain

• Exposure to lead paint
• Regarding exposure to alcohol in utero, according
  to Dr. Jacobson of Wayne State University We
  found more serious cognitive impairment in
  relation to alcohol than cocaine or other drugs,
  including marijuana and smoking From Fetal
  Brains Suffer Badly From Effects of Alcohol NYT
  11.4.03

30
This is important to keep in mind because..

• The Adult you are serving in your program may
  have suffered a brain injury as a child

31
Concussion and Multiple Concussion can lead to...

• Elevated rates of depression (most common mental
  health diagnosis after brain injury)
• alcohol and drug abuse

32
Concussion and Multiple Concussion can lead to...

• elevated rates of panic disorder, obsessive
  compulsive disorder
• These are among the findings a 2000
  epidemiological study by Silver that found of
  5000 individuals interviewed, 7.2 had
  experienced a blow to the head followed by loss
  of consciousness or period of confusion

33
Take Home Message

• Unidentified traumatic brain injury is an
  unrecognized major source of social and
  vocational failureWayne Gordon, Ph.Dquoted in
  the Wall Street Journal 1.29.08

34
Possible Changes

• Physical Motor skills, vision, speech, fatigue,
  seizures, hearing, etc
• Cognitive Memory, concentration, executive
  skills, receptive expressive language, impulse
  control, and the ability to multitask and think
  flexibly
• Behavioral and Personality depression, emotional
  discontrol, reduced frustration tolerance,
  substance abuse

35
Lack of Awareness

• A common and difficult to remediate hallmark of a
  brain injury

36
Recommendation All Human Service Providers
Screen Consumers for a History of Brain Injury

• Why Screen?
• What other TBI Screening efforts have found

37
Impact of TBI in Adolescent 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

38
TBI related symptoms included

• Headaches
• Dizziness
• Memory problems
• Fatigue
• Difficulty controlling temper
• Being easily stressed
• Having problems with school work

39
The Take Home Message...

• 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...

40
The Take Home Message...

• .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

41
Brain Injury in the Correctional
Setting-Nationally CDC website 2008

• According to jail and prison studies,25-87 of
  inmates report having experienced a TBI-this
  compared with 8.5 of the general population
• Prisoners with a history of TBI may also
  experience mental health disorders (including
  severe depression, anxiety, substance abuse)

42
Brain Injury in the Correctional
Setting-Nationally CDC website 2008

• Woman inmates who are convicted of a violent
  crime are more likely to have sustained a
  pre-crime TBI or some other form of physical
  abuse
• Women with substance abuse disorders have an
  increased risk for TBI compared with women in the
  general population

43
In Maryland- Screening Results from the MD TBI
Post Demo II Project-2005

• Summary of TBI Incidence Among all Screened at 7
  public mental health agencies in Frederick and
  Anne Arundel counties
• N190
• 39 no reported history of TBI (78)
• 58.94 of individuals with a history of TBI
  (112)
• 35.78 of individuals with a history of a single
  incidence of TBI (68)
• 23 of individuals with a history of 2 or more
  TBIs (44)

44
Details- Anne Arundel County Detention Center 2005

• N41
• Single TBI 16
• 2 or more incidents of TBI 14
• No history of TBI 11
• 73 screened reported a history of TBI

45
Washington County Detention Center 2008

• N25 (16 male, 9 female)
• 22 reported possible TBI(s)
• Single TBI10
• 2 or more incidents of TBI 12
• No History of TBI 3
• 88 screened reported a history of TBI

46
Brain Injury ViolenceDomestic Violence

• Greater than 90 of all injuries secondary to
  domestic violence occur to the head, neck or face
  region (Monahan OLeary 1999) Adapted from The
  Alabama Department of Rehabilitation Services DV
  Training
• Corrigan et.al., (2003) found that of 167
  individuals treated for domestic violence related
  health issues, 30 experienced a loss of
  consciousness on at least one occasion, 67
  reported residual problems that were potentially
  TBI related
• Valera and Berenbaum, (2003) assessed 99 battered
  women. Of these, 57 had brain injured related
  symptomatology

47
Homelessness Brain InjuryA little studied
population, however..

• A University of Miami study found that 80 of 60
  homeless individuals had high incidence of
  neuropsychological impairment
• Researchers in Milwaukee found possible cognitive
  impairment in 80 of 90 homeless men evaluated.
• Dr. LaVecchia of the MA Statewide Head Injury
  Program reported in 2006 that of 140 homeless
  individuals evaluated, 83.6 of males and 16.4
  of females had an acquired brain injury
• Other studies in the UK and Australia show
  similar rates of brain injury among homeless
  individuals

48
Homelessness 10.7.08 Canadian Medical
JournalHwang et.al

• 904 homeless individuals surveyed
• Addiction Severity Index used
• TBI Screened, gt30 minutes moderate/severe
• Physical mental health assessed

49
Findings

• Hx of moderate-severe TBI associated w/ increased
  likelihood of seizures
• Mental Health problems
• Drug problems
• Poorer physical health status

50
Findings

• Lifetime Prevalence of TBI-53, more common among
  men than women surveyed
• Rates 5 or more times greater than the 8.5
  lifetime prevalence in general population and
  consistent w/ prison studies

51
Briefly Facts and Figures-What is The Problem?
52
Alcohol Use TBI-IncidenceAnalysis of the
Literature (Corrigan 1995)

• Alcohol, the drug of choice-Corrigan and his
  colleagues report that for 70 of the
  individuals they work with who use substances,
  alcohol is the preferred substance
• Intoxication at time of injury-7 studies looked
  at incidence of intoxication (BAL equal or
  exceeding 100mg.dL)at time of injury.
  Intoxication ranged from 36 to 50
• History of Substance Abuse-Findings suggest that
  for adolescents and adults in rehabilitation
  following a TBI, as much as 60 of this
  population have histories of alcohol use or
  dependence.

53
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)

54
TBI Alcohol? Impact on Recovery, Studies
Suggest..

• Kreutzer et al (1995) examined the alcohol use
  patterns, arrest histories, behavioral
  characteristics and psychiatric treatment
  histories of 327 individuals with TBI. Increases
  in abstinence rates were noted. However in
  relation to the uninjured population, analysis
  revealed high incidence of heavy drinking, pre-
  and post-injury among those with a history of
  arrest. History of arrest also associated with a
  greater likelihood of aggressive behaviors.

55
Lessons Learned-What brain injury professionals
have and havent done to address the Brain
Injury/ Substance Abuse Connection
56
Lessons Learned

• Honeymoon effect-first year post TBI
• Subsequent Substance Use and Abuse among
  individuals with a history of brain injury
• Feedback from Individuals with TBI in Recovery

57
Collectively Lulled to Inaction by the
Honeymoon Effect
58
Bombardier reports (1997) that in comparison
with a separate medical patient sample,
individuals with a recent TBI were more motivated
to change their alcohol use. Motivational
Interviewing was utilized and of 50 post TBI
patients, 84 fell into the contemplation or
action phases. Greater willingness to change was
noted in those with alcohol involved injuries and
higher daily consumption pre-injury
59
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)

60
Honeymoon Factors

• Individual in an inpatient and/or highly
  structured outpatient setting resulting in
  detoxification
• Physical and cognitive disabilities make access
  to substances difficult
• Families are instructed to provide supervision
  due to physical needs and judgement concerns
• Individual is remorseful over past use, related
  behavior, blames self for accident and vows to
  change

61
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

62
Subsequent Substance Use/Abuse Among Individuals
with a History of Brain Injury-Characteristics

• 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)

63
Subsequent Substance Use/Abuse Among Individuals
with a History of Brain Injury

• 5-10 of those with TBI develop substance abuse
  problems after their injury (NASHIA Webcast 2001)
• A person with a preinjury history of two drinks
  a day would not have had a reason to seek
  alcohol-related treatment before his or her
  accident. But once that same person becomes
  brain-injured, the continuation of that drinking
  pattern has the potential to cause major
  problems Robert Karol, Ph.D.

64
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)

65
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

66
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

67
What They said..

• To stay clean find the right 12-step program,
  change persons, places and things that trigger
  use, spirituality, pets.

68
Techniques for change Recommended for use with
individuals with a history of brain injury
69

• Stages of Change, Prochaska and DiClemente
  cited by Corrigan 1999 Motivational
  Interviewing Based on the work of W. R. Miller ,
  adapted by Corrigan Successive
  ApproximationUtilized by Pathways Inc. Debra
  Fulton Clark

70
How to Utilize Substance Abuse Education
Intervention with individuals with Brain
InjuryTips for Human Service Professionals
71
The Big Picture

• Brain storm with group ( or individual)
• What do you know about substance abuse, the brain
  and brain injury?
• What do you want to know about substance abuse,
  the brain and brain injury?
• Have a quiz on hand to engage interest
• (building motivation to change, moving from
  Precontemplation to Contemplation)

72
Sample Brain Injury and Substance Abuse quiz
questions- (verbally or pen/paper)

• In 1998, the cost of alcohol abuse in the United
  States was estimated to be 184.6 billion True
  or False
• If there are alcoholics in your family tree, you
  are at risk for alcohol abuse, even if you were
  adopted and raised by nondrinkers. True or False
  Gold 2005

73
Sample Quiz Continued...

• Addiction is a) brain disease b) a moral failing
• Alcohol use after brain injury may increase the
  risk of seizures. True or False
• 5-10 of people with brain injury develop
  substance abuse problems after their injury. True
  or False

74
Discussion Based on the Quiz

• Review the correct answers
• Ask for other thoughts, knowledge and experiences
  regarding substance abuse
• Provide group with Messages to Share
  information sheet
• Discuss the Messages to Share

75
Messages to ShareDrinking After Brain Injury
Adapted from Bogner and Lamb-HartOhio Valley
Center

• People who use alcohol or drugs after TBI dont
  recover as fast as those who dont
• 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

76
Messages to ShareDrinking After Brain Injury
Adapted from Bogner and Lamb-HartOhio Valley
Center

• 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

77
Suggestions

• The Quiz and Messages to Share can be done
  with a group or with one or two individuals
• Any one of the messages can be explored in depth,
  with the facilitator sharing the research on a
  specific message or messages
• The group can digress at any time to a discussion
  of the brains functioning and anatomy-relate
  that information to impact of SA

78
Screening Tools

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

79
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)

80
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)
• CAGEs 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)

81
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?

82
BMAST (Selzer et.al)

• (2) Have you ever had delirium tremens (DTs),
  severe shaking, heard voices, seen things that
  werent 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?

Negative responses are alcoholic responses
83
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)

84
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?

85
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-materials available in
  several languages including Spanish
• 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

86
Additional Screening Tools

• 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

87
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

88
Implementing Interventions

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

89
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.

90
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 a 1988 movie with Kathy Baker,
  Morgan Freeman and Michael Keaton, My Name is
  Bill W. a 1989 movie with James Gardner and James
  Wood

91
For Individuals with Brain Injury Provide
concrete examples of AA

• Show scenes of AA/NA meetings from HBOs The
  Wire, the character Bubbles takes steps towards
  sobriety
• Ask a consumer in recovery to come and speak to a
  group

92
For Individuals with Brain Injury Provide
concrete examples of AA

• Covert 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, in Alternative Therapies in the Treatment
  of Brain Injury and Neurobehavioral Disorders, A
  practical guide, published by The Haworth Press)

93
If feasible, encourage attendance at the Humanim
AA meeting for individuals with BI
94
(No Transcript)
95
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
• Review common cognitive and emotional sequela of
  TBI
• Make compensatory strategies suggestions, e.g.
  poor memory can be supported by journals and
  datebooks

96
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

97
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

98
Additional Tips 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

99
Additional Tips 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 individuals 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

100
Additional Tips 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

101
Strategies to Compensate for Brain Injury Related
Cognitive Barriers
Adapted from the Ohio Valley Center for Brain
Injury Prevention and Rehabilitation 1998
102
Try to determine persons unique learning style

• Ask how well she writes, evaluate via samples
• Ask about observe attention span in busy versus
  quiet environments
• If unable to speak or speak clearly, inquire as
  to alternate methods, e.g. writing, gesturing
• Evaluate comprehension of written and spoken
  language

103
Help Compensate for Unique Learning Style

• Modify written material to make it concise
• Paraphrase concepts, be concrete
• Encourage of note taking for future review
• Enlist support system to reinforce messages

104
Help Compensate for Unique Learning Style

• Dont assume carryover or generalization of
  material, especially novel information
• Repeat, review, rehearse, review, rehearse.

105
Provide direct feedback regarding inappropriate
behaviors

• Let person know a behavior is inappropriate, do
  not assume he knows and is choosing to do so
  anyway
• Provide straightforward feedback
• Redirect tangential or excessive speech,
  including a predetermined method of signals for
  use in groups

106
Be cautious concluding that an underlying
emotional state is the basis of an observed
behavior

• Do not presume that an underlying emotional state
  is the basis of an observed behavior
• Be aware that unawareness of deficits can arise
  as a result of specific damage to the brain and
  may not always be due to denial

107
Be cautious concluding that an underlying
emotional state is the basis of an observed
behavior

• Confrontation shuts down thinking and elicits
  rigidity roll with resistance (principles of
  Motivational Interviewing are highly recommended)
• Do not just discharge for noncompliance follow
  up and find out why someone has not showed up or
  otherwise not followed through

108
Brain Injury Rehabilitation Providers and
Professionals...
109
Never underestimate the value your patients place
on your opinions and advice

• You dont 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 the patient, for
  example.
• As your PT, 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 speech therapist, I recommend you do not
  drink alcohol because it will make your
  articulation, memory and new learning abilities
  worse

110
Brain Injury Providers and Professionals..

• Outreach to substance abuse providers and
  professionals in your geographic area
• Share your knowledge about how to support
  individuals with brain injury related cognitive,
  behavioral and physical challenges
• Create an ad hoc team for those individuals
  with a dual diagnosis of brain injury and
  substance abuse

111
Substance Abuse Providers and Professionals...
112
Understanding how to support individuals with a
history of brain injury can make a huge impact on
treatment participation and successful recovery

• Integrate the suggested strategies across the
  board
• Strategies can assist those not only with a
  history of brain injury, but individuals with a
  developmental disability, alcohol related
  cognitive impairment in addition to those who are
  anxious and depressed

113
Substance Abuse Providers and Professionals..

• Outreach to brain injury providers and
  professionals in your geographic area
• Share your knowledge on substance abuse,
  addiction and treatment.
• Create an ad hoc team for those individuals
  with a dual diagnosis of brain injury and
  substance abuse

114
Where Do We Go From Here?Look to the Innovators

• John Corrigan Ph.D.-currently conducting a study
  on the efficacy of the Dartmouth Evidence Based
  Practice Supported Employment Model with
  individuals with brain injury and co-occurring
  conditions-results should greatly benefit the
  field
• Ken Minkoff MD Christine Cline MD.- their model
  for treating individuals with co-occurring
  psychiatric and substance abuse disorders might
  have application for individuals with co-
  occurring brain injury and substance abuse

115
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-Abraham
Lincoln to the Washington Temperance Society,
Springfield Illinois 1842
116
References

• Alcohol, Alcohol Abuse and Alcohol Dependence CME
  Resource training course, Mark S. Gold, MD
  www.netce.com/course.asp?Course651
• 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 Feb84(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

117
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.
• Slide 18 adapted from Dr. Mary Pepping of the
  University of Idahos presentation The Human
  Brain Anatomy,Functions, and Injury

118
Resources

• University of Kentucky, on line training for
  professionals, Substance Abuse, Mental Illness
  and Brain Injury, A Guide for Making
  Accommodations for Treatment cdar.uky.edu/TBI/wel
  come.html
• Ed Ross of the ICD in NYC, conducting ongoing
  trainings across the state to mental health and
  substance abuse professionals regarding brain
  injury. For more information contact
  eross_at_icdnyc.org.

119
Resources

• The Ohio Valley Center for Brain Injury
  Prevention and Rehabilitation continues to
  conduct research and training regarding brain
  injury, substance abuse and building capacity
  within the community to work with individuals
  with brain injury. www.ohiovalley.org
• Pathways Inc., Brain Injury Recovery Services,
  Hollywood Maryland, contact Debbie Fulton Clark
  for details regarding how substance abuse
  treatment can be integrated into a brain injury
  community re-entry program. dfulton_at_pathwaysinc.or
  g.
• Kenneth Minkoff, MD. Www.kenminkoff.com.
  Regarding co-occurring substance abuse and
  psychiatric illness

120
Staff Training Opportunities

• The Michigan Department of Community
  HealthWeb-Based Brain Injury Training for
  Professionals 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
• The New York State Office of Alcoholism
  Substance Abuse Services-OASAS www.oasas.state.ny.
  us/tbi/index.cfm

121
Websites of Interest

• www.ohiovalley.org, The Ohio Valley Center for
  Brain Injury Prevention and Rehabilitation.
  Specific information and fact sheets on substance
  abuse and brain injury
• casaa.umn.edu/intro.asp, Center on Alcoholism,
  Substance Abuse, and Addictions at the University
  of New Mexico. Visitors can email staff and
  faculty who specialize in different aspects of
  substance abuse treatment.

122
Websites of Interest

• Lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub,
  Alcohol Drug Abuse Institute at the University
  of Washington in Seattle. Visitors can download
  assessment instruments and guides for use.
• NEW!!!!! Rethinking Drinking from the National
  Institutes of Health. This is an interactive
  website that aims to educate individuals about
  alcohol use and abuse. It provides screening
  tools and change plans, supports and resources.
  www.rethinkingdrinking.niaaa.nih.gov.

123
A Product of the Maryland TBI Partnership
Implementation Project, a collaborative effort
between the Maryland Mental Hygiene
Administration, the Mental Health Management
Agency of Frederick County and the Howard County
Mental Health Authority2006-2009
124
Acknowledgement..

• Thank you to John Corrigan Ph.D and colleagues at
  the The Ohio Valley Center for Brain Injury
  Prevention and Rehabilitation for their support
  of the Maryland Traumatic Brain Injury Projects.

125
Anastasia Edmonston 410-402-8478aedmonston_at_dhmh.
state.md.usSupport is provided in part by
project H21MC06759 from the Maternal and Child
Health Bureau (title V, Social Security Act),
Health Resources and Services Administration,
Department of Health and Human ServiceThank you!