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