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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
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Addiction changes the pleasure pathways
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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.
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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)
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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
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The “A-B-C’s” of Self-Regulation
•Affective modulation
•Behavioral planning
•Cognitive resource allocation
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The “A-B-C’s” of Self-Regulation
•Affective modulation
•Behavioral planning•Cognitive resource allocation
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Delay Discounting:
the value of immediate vs. delayed rewards
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from McClure et al (2004). Science 306, 503-507.
Regions of greater activation when considering immediate rewards
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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)
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Co-occurrence of Substance Abuse and TBI
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Co-occurrence of Substance Abuse and TBI
Does TBI Cause Substance Abuse?
–or–Does Substance Abuse Cause
TBI?
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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)
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% 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
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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
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% 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)
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% 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
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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
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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
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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
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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
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Response to Substance Abuse Treatment
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Cognitive Impairment in the Match Study(Bates et al. 2006)
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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
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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
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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)
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12.28
15.29
0
5
10
15
20A
ge
1
Age of First Drug Use
TBI(N=36)
No-TBI(N=14)
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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
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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
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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)
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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)
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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)
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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)
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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
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9
13
11
0
4
8
12
16
1
Age at First TBI0 - 12 (N=9)
13 - 18 (N=13)
>18 N=11)
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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
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Accommodating TBI in Substance Abuse Treatment
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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.
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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.
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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.
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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.
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A Model for Systems Response to Substance Abuse Treatment for
Persons with TBI
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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
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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
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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
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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
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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
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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
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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