Substance Abuse and Traumatic Brain Injury
http://www.synapshots.org
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The following are excerpts from the website, “Synapshots”*

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. 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.

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 much alcohol or other drugs is it safe to consume after brain injury?
The answer to this question requires multiple considerations. First, there are many reasons why it is not safe to consume illegal drugs, including their interactions with prescribed drugs or other medical conditions, the potential for being arrested, the proven greater vulnerability to injury or being victimized, and last but not least the potential for additional brain damage from these uncontrolled substances.

Alcohol – because it is a legal substance for adults – presents a more complex question. Our starting point is that certainly no one should consume more alcohol after traumatic brain injury than would be considered safe for an adult who had not. Many people do not realize that for adult men under age 65 it is recommended that no more than two alcoholic drinks should be consumed each day. For men over age 65 and for women, the recommended maximum is one drink per day (reference NIAAA website).

So the question becomes after traumatic brain injury should an individual drink even these amounts? Based on information about how alcohol and traumatic brain injury add together to change brain structure and function, we believe that there is no safe amount. We suspect that especially during the early period of recovery – the first several years when the brain is attempting to spontaneously heal and otherwise accommodate the injury – alcohol can inhibit these natural processes.

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 weak- nesses 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 individu- ally 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 some- thing 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.

Staff of the Ohio Valley Center (OVC) have also developed a number of materials for prevention and treatment of substance abuse for use by primary and secondary consumers (User's Manual and HIV/AIDS and TBI), facility based rehabilitation professionals (Programmer's Guide) and community based professionals (Utilities for Community Professionals).

* Note. From SynapShots Web site by Charlotte Institute of Rehabilitation and the Ohio Valley Center for Brain Injury Prevention and Rehabilitation. Exerpts reprinted with permission of the Ohio Valley Center.

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