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Substance Abuse and

Traumatic Brain Injury


John D. Corrigan, PhD
Professor
Department of Physical Medicine
and Rehabilitation
The Ohio State University
Director
Ohio 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.
Areas of contusion in 40 consecutive
cases of closed head injury
(Courville, 1950)

Overlay of 100 consecutive CT


scans of patients with closed head
injuries (Bigler, 1984)
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-Cs of Self-Regulation

Affective modulation
Behavioral planning
Cognitive resource allocation
The A-B-Cs of Self-Regulation

Affective modulation
Behavioral planning
Cognitive resource allocation
Delay Discounting:

the value of immediate vs. delayed


rewards
Regions of greater activation when considering immediate rewards

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


Areas of contusion in 40 consecutive
cases of closed head injury
(Courville, 1950)

Overlay of 100 consecutive CT


scans of patients with closed head
injuries (Bigler, 1984)
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 Year
after Hospitalization for TBI
[Horner, et al, 2005 (South Carolina Follow-up Study)]

70%

60% TBI (SCTBIFR)


52%
Gen'l Pop (BRFSS)
40%

26%
20% 22%
14% 16%

0%
none 1 or 2 3 or more
# binging occasions last 30 days
% Rehabilitation Patients with Prior
Histories of Abuse
70%
61%
60% 58% 58%
54% TBI Model
50% 48% Systems
43%
40% 39%
Ohio State
34%
30% 29% University

20% University of
Washington
10%
0%
Alcohol Other Either
Drugs
Intoxication and Occurrence of TBI
(Savola, Niemela & Hillbom, 2005)
12.00
9.23
10.00
Odds Ratio for Having a TBI
8.00

6.00
3.20
4.00
1.24 1.64
2.00

0.00
.01-.999 .10-.149 .15-.199 .20
Blood Alcohol Content
% Clients in Substance Abuse Treatment with
Histories of TBI

70%
63% Alterman & Tarter
60% 58%
53% Hillbom & Holm
50% 48%

40% 38% Malloy, et al.

30%
Gordon, et al.
20% (upstate NY)
Gordon, et al.
10% (NYC)
0%
% Clients in Substance Abuse Treatment with
Histories of TBI

80%
72%
70%
Adolescent resid.
60% tx
53% 50% Adult resid., IOP
50%
40%
Prisoners in TC
30% 23%
20% Dual dx tx program

10%
0%
TBI and at least ER Treatment
8000

7000

6000 U.S. Females


Rates per 100,000

Female SUD
5000

4000
U.S. Males
Male SUD
3000

2000

1000

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


TBI and at least ER Treatment
8000

7000

6000 U.S. Females


Rates per 100,000

Female SUD
5000

4000
U.S. Males
Male SUD
3000

2000

1000

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


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

P300 Amplitude
16
14
12
10
8
6
4
2
0
Controls Alcohol TBI TBI+Alcohol
Ventricle to Brain Ratio
[from Bigler, et al., 1996 and Barker, et al., 1999]

4
3.5
3
2.5
2
1.5
1
0.5
0
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
No TBI
Suicidal thoughts
1 TBI/loc
Attempted suicide
>1 TBI/loc
Hallucinations
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
Average Substance Usage 6 Months Prior to IDDT Involvement

28.5
30
24.11 TBI (N=36)
Non-TBI (N=14)
20.14
20
Days

14.43
13.06

10 7.69
4.36 4.97
1.79 1.07
0
Alcohol Cannabis Cocaine Analgesics Meth/Amphet
Age of First Drug Use

20 TBI
15.29 (N=36)
15 12.28 No-TBI
(N=14)
Age

10

0
1
Psychiatric DX on Axis I

60
50

TBI Non-TBI
40
33
Percentage

28
25
21
19
20 16
14 14 14
8 7 8 7
0 0
0
Diagnosis on Axis II 100
100

80 75

TBI Non-TBI
Percentage

60

40

20 11
5 8.3
0 0 0
0
Hospital Days

3.5
3.12
3

2.5
Days per Month

2
1.81
1.65
1.5

0.5
0.26
0
Pre-Involve Act-Involve

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


Emergency Service Utilization

0.8
Monthly Contacts

0.68
0.6

0.4 0.39

0.24
0.2 0.17

0
Pre-Involve Act-Involve

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


Jail Days

10
9 9.03
8
7
Days per Month

6
5 4.9
4
3
2
1.29
1
0.31
0
Pre-Involve Act-Involve

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


CSP Contacts

16
14 13.4
12
Contacts per Month

10 8.212
8.87
8 8.37

6
4
2
0
Pre-Involve Act-Involve

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


Current Functioning

50
44.4
TBI

NonTBI
40
35.7 35.7
33.3
P e rc e n ta g e

30

20 16.7
14.3 14.3

10
5.6

0
Deteriorated Stable w/ sufficient Stable w/ little/no Not enough info
unstable support support
Age at First TBI
0 - 12 (N=9)
13 - 18 (N=13)
>18 N=11)
16 13
11
12 9

0
1
Current Functioning by Age at First Injury
60
55.6

50 0 - 12
50
13 - 18
40 >18
36.4 35.7 35.7
33.3 Non-tbi
Percentage

30 27.3 27.3

22.2

20
14.3 14.3
11.1 11.1
9.1
10 8.3 8.3

0
Deteriorated unstable Stable W/ sufficient Stable w/ little/no support not enough info
support
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 TBIs face additional challenges
(contd)

Cognitive impairments may affect a persons


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 persons 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
4 Quadrant Model of Services
High
Severity Quadrant III Quadrant IV

Substance Use Disorder

Quadrant I Quadrant II

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model: Place of Service Provision
High
Severity Quadrant III Quadrant IV
Substance Abuse System Specialized TBI &
Substance Abuse Services
Substance Use Disorder

Quadrant I Quadrant II
Acute Medical Settings and Rehabilitation Programs &
Primary Care Services

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model: Types of Services
High
Severity Quadrant III Quadrant IV
Substance Abuse System Specialized TBI &
Substance Abuse Services
Screening,
Substance Use Disorder
Accommodation & Integrated
Linkage Programming

Quadrant I Quadrant II
Acute Medical Settings and Rehabilitation Programs &
Primary Care Services
Education,
Screening & Brief Screening, Brief
Interventions Interventions &
Linkage

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model of Services
High
Severity Quadrant III Quadrant IV
Substance Abuse System Specialized TBI &
Substance Abuse Services
Screening,
Substance Use Disorder
Accommodation & Integrated
Linkage Programming

Quadrant I
Quadrant II
Acute Medical Settings and Rehabilitation Programs &
Services
Primary Care
Education,
Screening & Brief Screening, Brief
Interventions Interventions &
Linkage

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model of Services
High
Severity Quadrant III Quadrant IV
Substance Abuse System Specialized TBI &
Substance Abuse Services
Screening,
Substance Use Disorder
Accommodation & Integrated
Linkage Programming

Quadrant I Quadrant II
Acute Medical Settings and
Primary Care
Rehabilitation Programs &
Services
Screening & Brief
Interventions Education, Screening
Brief Interventions &
Linkage

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model of Services
High Quadrant III
Severity Quadrant IV
Substance Abuse System
Specialized TBI &
Screening, Substance Abuse Services
Accommodation &
Substance Use Disorder
Integrated
Linkage Programming

Quadrant I Quadrant II
Acute Medical Settings and Rehabilitation Programs &
Primary Care Services
Education,
Screening & Brief Screening, Brief
Interventions Interventions &
Linkage

Low High Severity


Severity Traumatic Brain Injury
4 Quadrant Model: Types of Services
High Quadrant IV
Severity Quadrant III
Substance Abuse System Specialized TBI & Substance
Abuse Services
Screening,
Substance Use Disorder
Accommodation & Integrated Programming
Linkage

Quadrant I Quadrant II
Acute Medical Settings and Rehabilitation Programs &
Primary Care Services
Education,
Screening & Brief Screening, Brief
Interventions Interventions &
Linkage

Low High Severity


Severity Traumatic Brain Injury
For Additional Information

Website:
www.SynapShots.org

e-mail:
corrigan.1@osu.edu