Effective treatment strategies for individuals with Substance Use Disorder and Brain Injury.

Transcription

1 Annette Pearson MS, LADC, CBIS Mind Matters Conference 2018 Effective treatment strategies for individuals with Substance Use Disorder and Brain Injury. The presentation will discuss how the brain changes with a substance use disorder (SUD) and how brain injury and SUD intersect creating challenges. Our objectives for this session include 1) Increased understanding of the risk factors and role of brain development and function in Substance Use Disorder (SUD) 2) Exploration of how brain chemistry changes with SUD 3) Review of approaches for increasing motivation to examine SUD behavior 4) Discussion of tools/strategies to make interactions, groups and community supports more effective. 1

2 l l l l Alarming Facts 43.5% of individuals having emergency room visits for brain injury were legally intoxicated at the time of their injury Research shows that 1 in 2 individuals with a brain injury have had trouble with substance abuse 10 to 20% of individuals develop problems for the first time AFTER injury. Problems tend to get worse 2 to 5 years after discharge from medical rehabilitation. l 32.0% of individuals with disabilities reported drinking alcohol on their medications. Research shows 44 to 66% of persons with traumatic brain injury have alcohol abuse issues compared to 24% of the general population. 21 to 37% of persons with traumatic brain injury used illegal drugs compared to 15% of the general population. 2

3 Decreased brain development from use Changes in Brain Function From injury Brain Function 3

4 The Frontal Area of the brain, including the frontal lobes and prefrontal cortex, are the parts of the brain that statistically sustain some level of damage regardless of the point of impact to the head. Prefrontal Cortex Mid Brain 4

5 Frontal Lobe Control Prediction of Outcomes and Consequences Attention, Organization, Concentration, Planning, Mental flexibility and working memory Impulse control and decision making Emotional control anger, anxiety, affect, language Inhibition of behaviors appropriateness, sexual Treatment Planning Goals Predict consequences of use short and long term Organize/ plan for craving states, triggers, using people and environments Internalize new information learned in group into life Use pro/con lists to make decisions, relapse prevention, planning Stop and think on: emotions, thinking patterns, language and behaviors. RIGHT SIDE Spatial memory issues, shapes, pictures, faces Decreased awareness of deficits Decreased control over left side movements Altered music and creativity perception, visual memory issues Decreased control over left side of body Loss of big picture Trouble with holistic thought and consequence awareness LEFT SIDE Understanding language (receptive) aphasia Speaking or verbal output (expressive) aphasia Decreased control over right side movements Verbal memory issues, language, reading, word recognition Impaired logic and inflexible thinking Sequencing problems Catastrophic reactions to small stimuli 5

6 Brain development Brain Development The average first age of use is

7 Alcohol use and Memory l Alcohol produces greater cognitive disruptions in adolescents including memory (glutamate) storage, retrieval and neurotransmission within the prefrontal cortex. l 10% decrease in hippocampal size with alcohol dependent adolescents. (Storage of long term memories) Retention Rate % Verbal Non Verbal Type of Memory Alcohol Non Alcohol Winters, K. (2015) Substance use and our Brain 7

8 The Brain Addicted In general, what defines a substance use disorder (SUD) as compared to an acceptable behavior is: 1) The participation in the activity carries adverse or negative consequences. 2) Engaging in Compulsive/Obsessive behavior 3) Behavior is pleasurable and/or rewarding 4) Loss of control over limiting intake tolerance and/or withdrawal The obvious solution is to STOP. Pleasurable Memories l When we do something that is pleasurable, our midbrain sends dopamine to the prefrontal cortex. l Dopamine carries that message that was wonderful l The prefrontal cortex wishes to remember this feeling so it sends glutamate back down to the midbrain and hippocampus for storage of memories. l Glutamine is what lays down memories. 8

9 Glutamate l Dopamine and glutamate work together to create pathways of pleasurable memories. l When these pathways are used over and over again, the memories become very strong and create hyper memories. l Hyper memories often filter out negative experiences focusing on the positive ones and individuals can become obsessed. l With alcohol and drugs, this obsession is called craving. Substance use and Dopamine Dopamine is our star in substance use: l Dopamine is responsible for many of the pleasure reward circuit responses around food, water, sexual activity and nurturing. l Taking drugs or drinking too much alcohol effects. the receptors of dopamine 9

10 The Pleasure Center Increasing Dopamine life s happy chemical Examples of Dopamine l A cheeseburger 125 units of dopamine l An orgasm 250 units of dopamine l Cocaine 500 units of dopamine l Methamphetamine 1025 units of dopamine. 10

11 Dopamine l Over time, this chemical imbalance created by substance abuse, will result in a dampening of production of natural dopamine and increased sensitivity to fake dopamine from chemicals which can permanently damage this system. l Not having the chemical (fake) dopamine will create obsessions, WITHDRAWAL and CRAVINGS. l The brain adapting to the higher than it is supposed to be level of dopamine will result in TOLERANCE as the brain needs more and more for the same response. The way to stop cravings is to NOT give in to them, the will become extinct as the brain resets its natural chemistry. However, this takes TIME STOP, THINK and increase natural dopamine by doing something such as: l Exercise and other stress reducers such as yoga, mindfulness, mediation, hobbies, etc. l Eating certain foods such as bananas, almonds, avocados, peas, dark chocolate l Talking to a positive person, l Laughing 11

12 Motivating individuals to explore their use Ambilivance about change is common Individuals who are contemplative tend to go back and forth about wanting to quit and wanting to use as consequences and motivators of change. 24 hour plan with supports and positive, sober things to do. Sobriety as a daily goal Sign a quit date plan Use a non threatening tool 12

13 A personal workbook that teaches the basics about addiction may be useful/non threatening Can use the SUBI workbook at Have them focus on one thing at a time. Examples: Ø Things that happen to me when I don t drink/use Ø Who will get off my back if I stop using Ø Things that have worked in the past to help them not drink or use. Ø People, places, things, events and feelings that make me want to use Ø Use pro s and con s of both use and non use (cause and effect) to help make the decision concrete C.R.A.F.T. Community Reinforcement and Family Training 13

14 12 step meetings empower and support educated choices about chemicals Challenges with some 12 step meetings l Abstract nature l Traditions/unwritten rules l Isolation l Feeling l misunderstood l Confusion over expectations l Lack of structure in some meeting types 14

15 12 Steps Step 1 We admitted that we were powerless over our addiction, that our lives had become unmanageable Admit that alcohol and drugs are not making your problems better. Admit that if you drink and/or use drugs your life will continue to be out of control. Is Alcohol and drugs making my problems better? 1)Who would you like off your back? Why? 2) Money issues/needs? Why? 3) Family members who want you to quit? Why? 15

16 12 Steps - STEP 2 We came to believe that a power greater than ourselves could restore us to sanity. You start to believe that someone can help you put your life in order. This someone could be God, an AA group, counselor, sponsor, etc. Many individuals will be angry with their higher power after an injury and may be resistant to AA things due to that association I have decided to let others help me make better choices maybe my friend, group or a higher power List people who can help you with sobriety, people who will tell you the truth, no matter what: 16

17 What works TEACH the Basics of what the steps are designed to help individuals understand þ What I am doing is hurting me and others and I need to stop. þ In order to stop, I need help from others. þ In order to get help, I need to get along better with others and take better care of myself. USE the 12 steps for concrete thinkers RESEARCH the meeting beforehand about medications and labels DISCUSS what the meetings and terms mean before going to a meeting PAIR the person up with a peer mentor who can help them get comfortable and understand and WRITE down things the client should remember. HAVE the person attend an open meeting with their mentor first 17

18 Good ideas to support sobriety Use and roles l Individuals risk for problem use increases at the 2 to 5 year point from injury. l Many individuals use chemicals to feel part of the group or to minimize differences. A way to gain peer acceptance and assert independence. l Many individuals use chemicals to avoid loneliness, boredom, depression and isolation. To assist with issues around self control and self monitoring. 18

19 Evaluate Goals and Roles Ø Many individuals primary role prior to the injury was the party guy or the guy with the stuff. The glamour and money from using needs discussion. Ø Encourage reevaluation of what roles and goals are most important now. Ø Review roles and goals they currently have and ones they wish. Ø Discuss goals, both short term and long term. Ø Discuss did my chemical use help or hinder my long term goals? Tools and Strategies 19

20 Tools and Strategies ü Have the person journal daily about successes to build a coping set and build self esteem/worth ü Teach STOP-THINK techniques, reinforce with memory aides, homework and conversations ü Roll with the resistance, confrontation shuts down thinking and creates rigidity ü Discuss what has worked for them in the past and how chemicals are interfering with their goals. Tools and Strategies Use a life calendar to aid in motivation for change, decision making and change by pairing highs and lows across the lifespan with alcohol and drug use, increases, changes and consequences Develop and use memory aides to help the person remember to stay sober. Use the persons interests and learning style to attach new learning to older memories Have concrete examples of desired behavior Failure to generalize to new or different situations review, repeat, write, repeat, post 20

21 More Tools and Strategies Use pictures of things, loved ones, goals, events, etc as motivators, have this listed on the relapse prevention plan and in places they will remember it. Use decision boxes of pro s and con s to both use and non use to help make the decision concrete Remind clients that they have the right NOT to use and list that statement on their memory aides Have the person list individuals by their level of support good, neutral, users J Use note cards to list addresses, telephone numbers, title and what the person is going to the appointment for on the plan Include maps, bus routes, cab information if needed. J List support meetings with telephone numbers on note cards. Put in places that they will remember to use them and not chemicals. J Use a weekly or monthly calendar to write it appointments, meetings, reminders to plot structure, High risk times for use 21

22 Work on a solution together Step 1 gather information about how the person see s the problem and show that we are invested in finding a solution together, build trust and safety. Step 2 Identify the issue and discuss feelings, goals, needs around it Step 3 brainstorm ideas together at solutions and control Step 4 remember to take into consideration strengths, function and challenges Step 5 look at Memory aides Work on a solution together l Step 6 look at learning styles and attaching new memories to older memories l Step 7 put this is writing or in pictures to help cue memory for next time l Step 8 look for memory aides that can address multiple things, cue memory and help with organization and planning. l Step 9 - Clinicians help consumers to develop awareness and optimism so that their motivation for recovery can be internalized 22

23 Remember with Substance Use Disorder: l l l We did not cause it We can not control it We can not cure it l We can help support sobriety. Any questions? for caring about and learning about individuals with brain injury and their struggles with Substance Use Disorder. 23