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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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