Substance Abuse and Traumatic Brain Injury

Who Is at Risk for Developing a Substance Abuse Problem After TBI?

Many people who incur a traumatic brain injury have a substance abuse problem prior to their injury (see 1.3 elsewhere). As a result, it is not surprising that a number of people after they have had traumatic brain injury also have a substance abuse problem. Adolescents and adults who are hospitalized for traumatic brain injury are much heavier drinkers than their peers who have not incurred a TBI. However, for traumatic brain injury as well as for other injuries, there is often a "honeymoon" after the injury when the amount of drinking stops or reduces (Bombardier, Temkin, Machamer & Dikmen, 2003; Corrigan, Lamb-Hart & Rust, 1995; Kreuzer, Doherty, Harris & Zasler, 1990; Krueutzer, Witol, Sander, Cifu, Marwitz & Delmonico, 1996).

A few studies of persons with traumatic brain injury have found that alcohol use gets worse in the period 2 to 5 years after the injury and that unless something is preventing them, many resume their prior levels of alcohol and other drug use (Corrigan, Rust et al., 1995; Kreutzer, Witol et al., 1996; Kreutzer, Witol et al., 1996; Corrigan, Smith-Knapp et al., 1998). Situations that limit resuming use include having to live in an institutional setting where alcohol and other drugs may be less available, or living under closer supervision of family members who help the individual consume less. Of course, use may reduce or stop if the individual is provided information about the effects of alcohol and other drugs after traumatic brain injury or, for people with actual substance abuse problems, being provided treatment.

In addition to the large number of individuals who had a substance use disorder before their injury and return to those levels after, some studies have indicated that between 10% and 20% of persons with traumatic brain injury develop a substance use problem for the first time after their injury (Corrigan et al., 1995; Kreutzer et al., 1996). Thus, taken together, it is a very high proportion of individuals who have been hospitalized for traumatic brain injury who will be at risk for developing a problem after their injury — either because they had one before or because of the vulnerabilities created by the injury itself.

"Substance abuse is a risk factor for having a traumatic brain injury and traumatic brain injury is a risk factor for developing a substance abuse problem." –John Corrigan

How many people who have traumatic brain injuries are intoxicated at the time of injury? 

At least 20% of adolescents and adults who are hospitalized and at least 30% of those requiring rehabilitation are intoxicated at the time of their injury. It is not surprising that there is a significant link between being intoxicated and incurring a serious injury. Whether because of diminished motor control, blurred vision, poor decision making or greater vulnerability to being victimized, a number of persons incur a traumatic brain injury while they are intoxicated. There is a lot of information available about how susceptible to injury people are when they have blood alcohol levels that exceed the legal limit. There is every indication that other drugs also put people at risk for injury. Three studies that have provided estimates of the number of people intoxicated at the time of their injury are shown below:

In persons hospitalized

• Colorado TBI Surveillance and Follow-up System: 21% BAC .08 (n=2,151 hospital admissions in Colorado 16 years old).

In persons treated in rehabilitation:

• TBI Model Systems: 37% BAC .10 (n=3,893 admissions to Model Systems acute rehab centers).
• OSU Suboptimal Outcomes Study: 25% BAC .10, 12% + drug screen, 32% either (n=356 consecutive admissions for acute rehab).

How common is a history of substance abuse before the injury?

Corrigan (1995) reviewed published literature on persons with TBI who were intoxicated at time of injury and those who had a prior history of substance use disorders, whether or not they were intoxicated. Based on articles reporting these variables, having a prior history of substance abuse was more common than being intoxicated at the time of injury. Additionally, clinicians and researchers who used screening tools during the hospital stays found significantly higher rates than those who relied on later medical record review. This result suggests that more people will be identified if a systematic method of inquiring is used; rather than counting on patients to volunteer information or relying on reports of intoxication at injury.

Since that review, there are several additional sources of data on the frequency of prior substance use disorders in adolescents and adults treated in acute rehabilitation. Results from the following articles are graphed below:

• TBI Model Systems National Database (n=1,262; Corrigan et al., 2003): 43% problem alcohol use or worse, 29% illicit drug use, 48% history of either;
• OSU Suboptimal Outcomes Study (n=356 consecutive admits to acute rehab): 54% alcohol abuse or worse, 34% other drug abuse or worse, 58% history of either;
• University of Washington (n=142 consecutive admits to acute rehab, Bombardier, Rimmele & Zintel, 2003): 58% at-risk alcohol use or worse, 39% recent illicit drug use, 61% history of either.

For adolescents and adults who require inpatient rehabilitation–as many as 60% may have a prior history of substance use disorder.

How common is TBI among persons receiving substance abuse treatment?

While there has not been a definitive, population-based study of how many individuals receiving treatment for substance abuse problems have incurred traumatic brain injuries, a collection of studies in the last 20 years suggests that it may be as high as 50%. The studies are summarized below and their results are graphed in the accompanying figure. The lowest rate observed was 38% of persons in treatment, the highest was 63%. Visual inspection of the graph supports an estimate of 50%, if not more.

Articles included in graph (below)

• Alterman & Tarter (1985) found 53% of a sample of 76 male alcoholics had histories of TBI.
• Hillbom & Holm (1986) found 38% of a sample of 157 alcoholics had a history of TBI with loss of consciousness or hospitalization.
• Malloy, et al. (1990) found 58% of a sample of 60 alcoholics had TBI marked by loss of conscious-ness, hospitalization, or major neurological change.
• Gordon et al. (2002) found 63% of 243 clients screened in 13 publicly funded programs in upstate NY had TBIs; 48% of 404 screened in 12 facilities in NYC.
• At OSU, 119 clients in residential treatment, intensive outpatient or ambulatory detoxification at a publicly funded substance abuse facility:

68% 1 TBI with loc 5 minutes, or required ER visit or hospitalization;
35% 1 TBI with loc 1 hour or requiring hospitalization;
60% 1 TBI with early effects that did not persist at time of interview;
53% 1 TBI with early effects that persisted at time of interview.

How does substance abuse affect a person who has had a traumatic brain injury?

There are multiple reasons why alcohol and other drug use after traumatic brain injury is not recommended. The substance abuse education series "User's Manual for Faster, More Reliable Operation of a Brain after Injury" (Ohio Valley Center, 1994) enumerates eight reasons:

1. People who use alcohol or other drugs after they have a brain injury don’t recover as much
2. Brain injuries cause problems in balance, walking or talking that get worse when a person uses alcohol or other drugs.
3. People who have had a brain injury often say or do things without thinking first, a problem that is made worse by using alcohol and other drugs.
4. Brain injuries cause problems with thinking, like concentration or memory, and using alcohol or other drugs makes these problems worse.
5. After brain injury, alcohol and other drugs have a more powerful effect.
6. People who have had a brain injury are more likely to have times that they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse.
7. After a brain injury, drinking alcohol or using other drugs can cause a seizure.
8. People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.

How is the brain affected?

There is mounting evidence about the adverse effects of alcohol and other drug use after traumatic brain injury. Several studies have observed an association between use and such unwanted outcomes as unemployment, living alone and feeling isolated, criminal activity and lower life satisfaction (Sherer et al., 1999; Corrigan et al., 1997; Kreutzer et al., 1996; Kreutzer et al., 1991; Corrigan et al., 2003). While these studies have observed associations, the causal links or processes have not been fully explained.

There are also studies suggesting an "additive effect" on brain structure and function for substance abuse and traumatic brain injury (Barker et al., 1999; Baguley et al., 1997; Bigler et al., 1996). One example is the study by Ian Baguley and colleagues from Australia (see graph below). Their 1997 study of event-related evoked potentials (an indication of how fast the brain detects new stimuli) showed a clear additive effect of heavy social drinking and traumatic brain injury requiring hospitalization. Those subjects who had either of these conditions were slower responding then people with neither; and those with both were slower still.

Are there treatment approaches that have been proven effective for people with traumatic brain injury?

Clinicians and researchers have repeatedly observed that cognitive and emotional impairments caused by brain injury present unique problems when addressing co-existing substance use disorders (Langley, 1991; Center for Substance Abuse Treatment, 1998; Corrigan, Bogner et al., 1999). While several models of how substance abuse treatment can be adapted to traumatic brain injury rehabilitation were proposed in the past (Blackerby & Baumgartnen, 1990; Langley, 1991), most presumed protracted inpatient or residential treatment that is no longer available to most persons with traumatic brain injury. Bombardier and colleagues have recommended brief interventions based on motivational interviewing techniques for use during acute rehabilitation (Bombardier, Ehde & Kilmer, 1997; Bombardier & Rimmele. 1999). Cox, Heinemann, et al. (2003) found some support for Structured Motivational Counseling in a study using a non-random comparison group.

A community-based model for treatment of substance abuse and traumatic brain injury was proposed by Corrigan and colleagues (Corrigan, Lamb-Hart & Rust, 1995; Bogner, Corrigan, Spafford & Lamb-Hart, 1997; Heinemann, Corrigan & Moore, 2004). The model uses consumer and professional education, intensive case management, and inter-professional consultation to address substance use disorders in adults with traumatic brain injury. Program evaluation data suggest significant differences in outcomes depending on whether discharge occurred before an eligible client could be engaged in treatment (eligible but untreated), after initiation of treatment but before treatment goals were met (premature termination) or upon mutual agreement with staff that goals had been met (treated). The Network’s three programmatic outcomes (abstinence, return to work or school, and subjective well-being) assessed three months post-discharge are shown below. The median length of stay for those discharged successfully is 2 years. As might be expected, drop-out is a significant problem in this model. Retrospective analysis of 1,000 consecutive referrals indicated that 66% of those eligible for treatment either are not engaged initially or drop out prematurely.

How can existing substance abuse services be adapted for people with traumatic brain injury?

There should be a very high priority placed on doing research about the effectiveness of current substance abuse treatments for persons with traumatic brain injury. However, until more is known, current treatments and services need to be adapted to accommodate disability arising from traumatic brain injury. The Ohio Valley Center for Brain Injury Prevention and Rehabilitation have made a number of suggestions for substance abuse treatment providers., shown below.

Suggestions for Substance Abuse Treatment Providers Working with Persons Who Have Limitations in Cognitive Abilities

The substance abuse provider should determine a person’s unique communication and learning styles.

• Ask how well the person reads and writes; or evaluate via samples.
• Evaluate whether the individual is able to comprehend both written and spoken language.
• If someone is not able to speak (or speak easily), inquire as to alternate methods of expression (e.g., writing or gestures).
• Both ask about and observe a person’s attention span; be attuned to whether attention seems to change in busy versus quiet environments.
• Both ask about and observe a person’s capacity for new learning; inquire as to strengths and weaknesses or seek consultation to determine optimum approaches.

The substance abuse provider should assist the individual to compensate for a unique learning style.

• Modify written material to make it concise and to the point.
• Paraphrase concepts, use concrete examples, incorporate visual aids, or otherwise present an idea in more than one way.
• If it helps, allow the individual to take notes or at least write down key points for later review and recall.
• Encourage the use of a calendar or planner; if the treatment program includes a daily schedule, make sure a "pocket version" is kept for easy reference.
• Make sure homework assignments are written down.
• After group sessions, meet individually to review main points.
• Provide assistance with homework or worksheets; allow more time and take into account reading or writing abilities.
• Enlist family, friends or other service providers to reinforce goals.
• Do not take for granted that something learned in one situation will be generalized to another.
• Repeat, review, rehearse, repeat, review, rehearse.

The substance abuse provider should provide direct feedback regarding inappropriate behaviors.

• Let a person know a behavior is inappropriate; do not assume the individual knows and is choosing to do so anyway.
• Provide straightforward feedback about when and where behaviors are appropriate.
• Redirect tangential or excessive speech, including a predetermined method of signals for use in groups.

The substance abuse provider should be cautious when making inferences about motivation based on observed behaviors.

• Do not presume that non-compliance arises from lack of motivation or resistance, check it out.
• 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.
• Confrontation shuts down thinking and elicits rigidity; roll with resistance.
• Do not just discharge for non-compliance; follow-up and find out why someone has no-showed or otherwise not followed through.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

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), 1248-1253.

Bigler, E. D., Blatter, D. D., Johnson, S. C., Anderson, C. V., Russo, A. A., Gale, S. D., Ryser, D. K., MacNamara, S. E., & Bailey, B. J. (1996). Traumatic brain injury, alcohol and quantitative neuroimaging: Preliminary findings. Brain Injury, 10 (3), 197-206.

Bogner, J.A., Corrigan, J.D., Mysiw, W.J., Clinchot, D., & Fugate, L.P. (2001). A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes following traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 82(5), 571-577.

Bogner, J. A., Corrigan, J. D., Spafford, D. E., & Lamb-Hart, G. L. (1997). Integrating substance abuse treatment and vocational rehabilitation following traumatic brain injury. Journal of Head Trauma Rehabilitation, 12 (5), 57-71.

Cahalan, D., & Cisin, I. H. (1968). American drinking practices: Summary of findings from a national probability sample: I. Extent of drinking by population subgroup. Quarterly Journal of Studies on Alcohol, 29, 130-151.

Centers for Disease Control and Prevention. (1998). Behavioral Risk Factor Surveillance System user’s guide. Atlanta, GA: Author.

Center for Substance Abuse Treatment (1998). Substance use disorder treatment for people with physical and cognitive disabilities. Treatment Improvement Protocol (TIP) Series Number 29. Washington, DC: U.S. Government Printing Office.

Corrigan, J. D. (1995). Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 76 (4), 302-309.

Corrigan, J. D., Bogner, J. A., & Lamb-Hart, G. L. (1999). Substance abuse and brain injury. In M. Rosenthal, E. R. Griffith, J. D. Miller & J. Kreutzer (Eds.), Rehabilitation of the adult and child with traumatic brain injury (3rd ed.). Philadelphia, PA: F.A. Davis Co.

Corrigan, J. D., Bogner, J. A. , Mysiw, W.J., Clinchot, D., & Fugate, L. (1997). Systematic bias in outcome studies of persons with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 78 (2), 132-137.

Corrigan, J.D., Lamb-Hart, G.L., & Rust, E. (1995). A program of intervention for substance abuse following traumatic brain injury. Brain Injury, 9, 221-236.

Corrigan, J. D., Rust, E., & Lamb-Hart, G. L. (1995). The nature and extent of substance abuse problems among persons with traumatic brain injuries. Journal of Head Trauma Rehabilitation, 10 (3), 29-45

Corrigan, J. D., Smith-Knapp, K., & Granger, C.V. (1998). Outcomes in the first 5 years after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 79 (3), 298-305.

Dikmen, S., Machamer, J. E., Donovan, D. M., Winn, H. R., & Temkin, N. R. (1995). Alcohol use before and after traumatic head injury. Annals of Emergency Medicine, 26, 167-176.

Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association, 252, 1905-1907.

Jernigan, D. H. (1991). Alcohol and head trauma: Strategies for prevention. Journal of Head Trauma Rehabilitation, 6 (2), 48-59.

Kaplan, C.P., and Corrigan, J.D. (1994). The relationship between cognition and functional independence in adults with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 75, 643-647

Kreutzer, J. S., Witol, A. D., & Marwitz, J. H. (1996). Alcohol and drug use among young persons with traumatic brain injury. Journal of Learning Disabilities, 29 (6), 643-651.

Kreutzer, J. S., Witol, A. D., Sander, A.M., Cifu, D. X., Marwitz, J. H., Delmonico, R. (1996). A prospective longitudinal multicenter analysis of alcohol use patterns among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation, 11 (5), 58-69.

Langley, M. J. (1991). Preventing post-injury alcohol-related problems: A behavioral approach. In B. T. McMahon & L. R. Shaw (Eds.), Work worth doing: Advances in brain injury rehabilitation. Orlando, FL: Paul M. Deutsch Press, Inc.

National Association on Alcohol, Drugs and Disability. (1998). Access limited--Substance abuse services for people with disabilities: A national perspective. San Mateo, CA: Author.

Selassie, Pickelsimer, Tyrell, Gu & Turner (2003)

Silver, Kramer, Greenwald & Weissman (2001)

Substance Abuse and Mental Health Services Administration. (1998). National Household Survey on Drug Abuse: Population estimates 1998. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

U.S. Department of Health and Human Services. (1990). Nutrition and your health: Dietary guidelines for Americans (3d ed.). Washington, DC: U.S. Government Printing Office.

Whiteneck, G., Mellick, D., Brooks, C., Harrison-Felix, C., Noble, K., Sendroy Terrill, M. (2001). Colorado Traumatic Brain Injury and Follow-up System Databook. Craig Hosptial, Englewood CO.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (10th Revision). Geneva: Author.