Traumatic Brain Injury _TBI_ by pengtt

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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-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
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%
                    34%                  Ohio State
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          ³ .20
                     Blood Alcohol Content
  % Clients in Substance Abuse Treatment with
                Histories of TBI

70%                                 Alterman & Tarter
                        63%
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%
50%                                Adult resid., IOP

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
                                 Female SUD
Rates per 100,000




                    5000



                    4000
                                 U.S. Males
                                 Male SUD
                    3000



                    2000



                    1000



                       0

                           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
                                 Female SUD
Rates per 100,000




                    5000



                    4000
                                 U.S. Males
                                 Male SUD
                    3000



                    2000



                    1000



                       0

                           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
              I




                                            I




                                                                 ly
                       ol
            TB




                                          TB
       ls




                                     ls




                                                       se

                                                               Po
                   oh
    tro




                                  tro




                                                  bu
                  lc




                                                             I+
on




                               on




                                                   a
                 A




                                                ly

                                                            TB
C




                              C
               I+




                                           Po
              B
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

      5


      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
                      Sc           Ps          Bip              Sc          Ma           De           Pa           Ot h
                        hiz            ych         ola            hiz           jo r       me            nic           er
                           op             otic         r             oaf             De        ntia          Di s
                                hre            NO                        fe c          pre          /Me          ord
                                   n ia          S                           tive         ssi           d.In        er
                                                                                              on             duc
                                                                                                                 ed
                                                                                                                    Dx
                                       Diagnosis on Axis II                                        100
             100

              80                                                                            75

                            TBI           Non-TBI
Percentage




              60

              40

              20                         11
                   5                                              8.3
                        0                      0                        0
              0
                       An                     Bo                        Pe                             No
                          ti   soc               rd   erl                    rso                          ne
                                   ial                      ine                    nal
                                                                                      it   y, N
                                                                                                  OS
                                     Hospital Days

                 3.5
                              3.12
                  3

                 2.5
Days per Month




                  2
                                                                           1.81
                              1.65
                 1.5

                  1

                 0.5
                                                                           0.26
                  0
                       Pre-Involve                                  Act-Involve

                                      TBI (N=36)   Non-TBI (N=14)
                         Emergency Service Utilization

                    1


                   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
Contacts per Month




                     12
                     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


             30
Percentage




             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


8



4



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 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
            4 Quadrant Model of Services
High
Severity         Quadrant III       Quadrant IV




                  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




                  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,
              Accommodation &                 Integrated
                  Linkage                    Programming


                   Quadrant I                   Quadrant II
                                          Rehabilitation Programs &
             Acute Medical Settings and            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,
                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,
               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 &                 Integrated
                    Linkage                    Programming


                     Quadrant I                   Quadrant II
                                            Rehabilitation Programs &
               Acute Medical Settings and            Services
                     Primary Care
                                                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,
              Accommodation &             Integrated Programming
                  Linkage


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

								
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