substance abuse and traumatic brain injury john d. corrigan, phd professor department of physical...

Substance Abuse and Traumatic Brain Injury

John D. Corrigan, PhD

ProfessorDepartment of Physical Medicine

and RehabilitationThe Ohio State University

DirectorOhio Valley Center for Brain Injury

Prevention and Rehabilitation

Addiction changes the pleasure pathways

The “Fingerprint” of TBI

Frontal areas of the brain, including the frontal lobes, are the most likely to be injured as a result of TBI, regardless

the point of impact to the head.

Overlay of 100 consecutive CT scans of patients with closed head

injuries (Bigler, 1984)

Areas of contusion in 40 consecutive cases of closed head injury

(Courville, 1950)

Executive Functions of the Brain

• Comprised of the abilities humans have to self-regulate

• Mediated by systems highly dependent on the frontal lobes

• Demonstrate a developmental hierarchy

• Are highly oriented toward future social implications

The “A-B-C’s” of Self-Regulation

•Affective modulation

•Behavioral planning

•Cognitive resource allocation

The “A-B-C’s” of Self-Regulation

•Affective modulation

•Behavioral planning•Cognitive resource allocation

Delay Discounting:

the value of immediate vs. delayed rewards

from McClure et al (2004). Science 306, 503-507.

Regions of greater activation when considering immediate rewards

Overlay of 100 consecutive CT scans of patients with closed head

injuries (Bigler, 1984)

Areas of contusion in 40 consecutive cases of closed head injury

(Courville, 1950)

Co-occurrence of Substance Abuse and TBI

Co-occurrence of Substance Abuse and TBI

Does TBI Cause Substance Abuse?

–or–Does Substance Abuse Cause

TBI?

Binge Drinking 1 Yearafter Hospitalization for TBI

[Horner, et al, 2005 (South Carolina Follow-up Study)]

52%

70%

22%

14%

26%

16%

0%

20%

40%

60%

none 1 or 2 3 or more

# binging occasions last 30 days

TBI (SCTBIFR)

Gen'l Pop (BRFSS)

% Rehabilitation Patients with Prior Histories of Abuse

43%

54%58%

29%34%

39%

48%

58%61%

0%

10%

20%

30%

40%

50%

60%

70%

Alcohol OtherDrugs

Either

TBI ModelSystems

Ohio StateUniversity

University ofWashington

Intoxication and Occurrence of TBI(Savola, Niemela & Hillbom, 2005)

1.24 1.64

3.20

9.23

0.00

2.00

4.00

6.00

8.00

10.00

12.00

.01-.999 .10-.149 .15-.199 ³ .20

Blood Alcohol Content

Odds Ratio for Having a TBI

% Clients in Substance Abuse Treatment with Histories of TBI

53%

38%

58%63%

48%

0%

10%

20%

30%

40%

50%

60%

70% Alterman & Tarter

Hillbom & Holm

Malloy, et al.

Gordon, et al.(upstate NY)

Gordon, et al.(NYC)

% Clients in Substance Abuse Treatment with Histories of TBI

23%

53% 50%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Adolescent resid.tx

Adult resid., IOP

Prisoners in TC

Dual dx tx program

TBI and at least ER Treatment

0

1000

2000

3000

4000

5000

6000

7000

8000

0-4 5-9 10-14 15-19 20-24 25-34 35-44

Rate

s p

er

10

0,0

00

U.S. Females

Female SUD

U.S. MalesMale SUD

TBI and at least ER Treatment

0

1000

2000

3000

4000

5000

6000

7000

8000

0-4 5-9 10-14 15-19 20-24 25-34 35-44

Rate

s p

er

10

0,0

00

U.S. Females

Female SUD

U.S. MalesMale SUD

Event Related Evoked Potentials[from Baguley, et al., 1997]

0

2

4

6

8

10

12

14

16

Controls Alcohol TBI TBI+Alcohol

P300 Amplitude

Ventricle to Brain Ratio[from Bigler, et al., 1996 and Barker, et al., 1999]

0

0.5

1

1.5

2

2.5

3

3.5

4

Response to Substance Abuse Treatment

Cognitive Impairment in the Match Study(Bates et al. 2006)

Symptoms past 12 months of Clients Admitted for Substance Abuse Treatment in Kentucky (N=7,932)

0 10 20 30 40 50 60 70 80

Serious anxiety

Serious depression

Rx for m.h. px's

Violent behavior

Suicidal thoughts

Attempted suicide

Hallucinations

No TBI

1 TBI/loc

>1 TBI/loc

TBI among participants in IDDT(Corrigan & Deutschle, 2008)

• SAMHSA funded Targeted Capacity Expansion grant

• Collaborative program in 2 rural counties

• 51 program participants (50 included in analyses)

• in active treatment in one of the collaborating agencies

• previous diagnoses of both a psychiatric and substance use disorder

24.11

14.43

20.14

28.5

13.06

4.36

7.69

1.79

4.97

1.07

0

10

20

30

Days

Alcohol Cannabis Cocaine Analgesics Meth/Amphet

Average Substance Usage 6 Months Prior to IDDT Involvement

TBI (N=36)

Non-TBI (N=14)

12.28

15.29

0

5

10

15

20A

ge

1

Age of First Drug Use

TBI(N=36)

No-TBI(N=14)

Psychiatric DX on Axis I

8

0

33

2528

8

1916

21

14

50

7

14

7

0

14

0

20

40

60

Schizophrenia

Psychotic NOS

BipolarSchizoaffective

Major Depression

Dementia/Med.Induced Dx

Panic Disorder

Other

Perc

enta

ge

TBI Non-TBI

Diagnosis on Axis II

511 8.3

75

100

0000

20

40

60

80

100

Antisocial

Borderline

Personality, NOS

None

Perc

enta

ge TBI Non-TBI

Hospital Days

1.65

0.26

3.12

1.81

0

0.5

1

1.5

2

2.5

3

3.5

Pre-Involve Act-Involve

Day

s pe

r Mon

th

TBI (N=36) Non-TBI (N=14)

Emergency Service Utilization

0.39

0.17

0.68

0.24

0

0.2

0.4

0.6

0.8

1

Pre-Involve Act-Involve

Mon

thly

Con

tact

s

TBI (N=36) Non-TBI (N=14)

Jail Days

4.9

1.29

9.03

0.310

1

2

3

4

5

6

7

8

9

10

Pre-Involve Act-Involve

Day

s pe

r Mon

th

TBI (N=36) Non-TBI (N=14)

CSP Contacts

13.4

8.878.212

8.37

0

2

4

6

8

10

12

14

16

Pre-Involve Act-Involve

Con

tact

s p

er M

onth

TBI (N=36) No-TBI (N=14)

44.4

14.3

33.335.7

16.7

35.7

5.6

14.3

0

10

20

30

40

50

Perc

en

tag

e

Deterioratedunstable

Stable w/ sufficientsupport

Stable w/ little/nosupport

Not enough info

Current Functioning

TBI

NonTBI

9

13

11

0

4

8

12

16

1

Age at First TBI0 - 12 (N=9)

13 - 18 (N=13)

>18 N=11)

Current Functioning by Age at First Injury

55.6

11.1

22.2

11.1

33.3

50

8.3 8.3

27.3

36.4

27.3

9.1

14.3

35.7 35.7

14.3

0

10

20

30

40

50

60

Deteriorated unstable Stable W/ sufficientsupport

Stable w/ little/no support not enough info

Perc

enta

ge

0 - 12

13 - 18

>18

Non-tbi

Accommodating TBI in Substance Abuse Treatment

Two Consistent Clinical Observations:

• In substance abuse treatment there is a greater disconnect between TBI clients’ intentions and their behavior.

• Clients with TBI are more likely to prematurely discontinue treatment, often after being characterized as non-compliant.

Persons with TBI face additional challenges seeking substance abuse treatment

• It is easy to see behavior as intentionally disruptive, particularly when there are no visible signs of disability:– Frontal lobe damage affects regulation of thoughts, feelings

and behavior--promoting disinhibition.– Social “rules” may not be observed and interpersonal cues

may not be perceived, creating consternation for fellow clients and staff.

Persons with TBI’s face additional challenges…(cont’d)

• Cognitive impairments may affect a person’s communication or learning style, making participation in didactic training and group interventions more difficult.

• Misinterpretation of cognitive problems as resistance to treatment undermines treatment relationships.

Suggestions for Treatment Providers

1. Determine a person’s unique communication and learning styles.

2. Assist the individual to compensate for a unique learning style.

3. Provide direct feedback regarding inappropriate behaviors.

4. Be cautious when making inferences about motivation based on observed behaviors.

A Model for Systems Response to Substance Abuse Treatment for

Persons with TBI

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I Quadrant II

Quadrant III Quadrant IV

4 Quadrant Model of Services

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Quadrant II

Rehabilitation Programs & Services

Quadrant III

Substance Abuse System

Quadrant IV

Specialized TBI & Substance Abuse Services

4 Quadrant Model: Place of Service Provision

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Screening & Brief Interventions

Quadrant II

Rehabilitation Programs & Services

Education, Screening, Brief Interventions &

Linkage

Quadrant III

Substance Abuse System

Screening, Accommodation &

Linkage

Quadrant IV

Specialized TBI & Substance Abuse Services

Integrated Programming

4 Quadrant Model: Types of Services

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Screening & Brief Interventions

Quadrant II

Rehabilitation Programs & Services

Education, Screening, Brief Interventions &

Linkage

Quadrant III

Substance Abuse System

Screening, Accommodation &

Linkage

Quadrant IV

Specialized TBI & Substance Abuse Services

Integrated Programming

4 Quadrant Model of Services

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Screening & Brief Interventions

Quadrant II

Rehabilitation Programs & Services

Education, Screening Brief Interventions &

Linkage

Quadrant III

Substance Abuse System

Screening, Accommodation &

Linkage

Quadrant IV

Specialized TBI & Substance Abuse Services

Integrated Programming

4 Quadrant Model of Services

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Screening & Brief Interventions

Quadrant II

Rehabilitation Programs & Services

Education, Screening, Brief Interventions &

Linkage

Quadrant III

Substance Abuse System

Screening, Accommodation &

Linkage

Quadrant IV

Specialized TBI & Substance Abuse Services

Integrated Programming

4 Quadrant Model of Services

Traumatic Brain Injury

Su b

s ta n

ce U

s e D

i so r

d er

Low Severity

High Severity

High Severity

Quadrant I

Acute Medical Settings and Primary Care

Screening & Brief Interventions

Quadrant II

Rehabilitation Programs & Services

Education, Screening, Brief Interventions &

Linkage

Quadrant III

Substance Abuse System

Screening, Accommodation &

Linkage

Quadrant IV

Specialized TBI & Substance Abuse Services

Integrated Programming

4 Quadrant Model: Types of Services

For Additional Information

Website:

www.SynapShots.org

e-mail:

corrigan.1@osu.edu