4 Questions. What Substance Abuse Professionals Need to Know About TBI? John D. Corrigan, PhD. 1.What is a traumatic brain injury or TBI?

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1 What Substance Abuse Professionals Need to Know About TBI? John D. Corrigan, PhD Professor Department of Physical Medicine and Rehabilitation Director Ohio Brain Injury Program 4 Questions 1. What is a traumatic brain injury or TBI? 2. Why would TBI be associated with substance abuse? 3. How does TBI affect substance abuse treatment? 4. How can you determine if a person has had a TBI? 1.What is a traumatic brain injury or TBI? TBI occurs when an external force causes an alteration in consciousness Effects can be temporary or permanent Range from mild to severe A concussion is a mild TBI There are additional effects from repeat injury What Substance Abuse Professionals Need to Know page 1

2 Continuum of TBI Severity Mild TBI (concussion) Any LOC Moderate LOC 30 TBI minutes Severe TBI LOC > 24 hours Least severe X X X Most severe Dazed, confused, gap in memory Loss of Consciousness (LOC) Coma ODH estimates for annual rates of TBI in Ohio* 2,259 Deaths More than 100,000 TBIs receive medical attention each year in Ohio 7,003 Hospitalizations 99,135 Emergency Department Visits??? Receiving Other Medical Care or No Care * Ohio Hospital Discharge Data 2011 Unanswered questions about the cumulative effects of impacts to the head Number, spacing or strength? Type of injury (high velocity, blast)? Present even without symptoms (the sub-concussive injury)? Uses up reserves, triggers a pathological process or both? Are some people at more risk than others (genetic, epigenetic)? What Substance Abuse Professionals Need to Know page 2

3 Groups Who May Have Multiple Mild TBI s Military personnel, particularly those with combat deployment in OEF/OIF Athletes, particularly boxers, football players & hockey players Victims of intimate partner violence and childhood physical abuse People who misuse and abuse substances People who are homeless 2. Why would TBI be associated with substance use disorders? Intoxication causes TBIs Early life TBIs predispose to substance abuse Natural History of TBI to Age 25 from the Christchurch Birth Cohort (McKinlay et al., 2008) By age 25: Those hospitalized with 1st TBI before age 6, 3 times more likely to have a diagnosis of either alcohol or drug dependence Those hospitalized with 1st TBI 16-21, 3 times more likely to be diagnosed with drug dependence TBI highly associated with likelihood of arrest What Substance Abuse Professionals Need to Know page 3

4 Age at Injury Among Persons Receiving Substance Abuse Treatment Services Corrigan, Bogner & Holloman (2012) More serious injuries or younger age at 1st injury associated with slower speed of information processing and greater cognitive complaints. Addictions more severe for those 1st injured before age 11. Uniqueness of early childhood TBI observed for persons with substance use disorders replicated in a sample of prisoners. Correlates of Lifetime TBI among Adolescents (Ilie et al., JHTR 2014) Behaviors reported by 9th-12 th graders in Ontario Canada (N=6,288) No TBI* Lifetime TBI* Odds** (95% CI) Tobacco use daily 3.9% 9.2% 2.48 (1.45, 4.25) Alcohol use 63.7% 77.0% 2.01 (1.52, 2.67) Alcohol binging 26.4% 39.3% 1.87 (1.49, 2.35) Cannabis use 25.2% 39.5% 2.00 (1.60, 2.50) LSD use 1.1% 3.0% 2.56 (1.45, 4.52) Cocaine 1.9% 4.6% 2.49 ( ) Ecstasy 3.3% 8.7% 2.82 ( ) Methamphetamine/crystal meth 0.8% 2.9% 3.77 ( ) * TBI if 5 minutes loss of consciousness or overnight hospital stay ** Odds ratio adjusted for grade and sex 2. Why would TBI be associated with substance use disorders? Intoxication causes TBIs Early life TBIs predispose to substance abuse Structural damage from TBI changes behavioral control What Substance Abuse Professionals Need to Know page 4

5 John D. Corrigan, PhD! The brain is set into motion along multiple axial planes Interior Skull Surface Bony ridges Injury from contact with skull Areas of contusion in (Courville, 1950) Loss of gray matter one year post-injury (Bigler, 2007) What Substance Abuse Professionals Need to Know page 5

6 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 Simplified Brain Behavior Relationships Frontal Lobes Initiation Problem solving Judgment Inhibition of impulse Planning/anticipation Self-monitoring Motor planning Personality/emotions Awareness of self Organization Concentration Mental flexibility Speaking Frontal Lobe Temporal Lobe Parietal Lobe Occipital Lobe Cerebellum What Substance Abuse Professionals Need to Know page 6

7 3. How does TBI affect substance abuse treatment? TBI is common among people in substance abuse treatment There are unique challenges for this client population There are unique clinical considerations for treatment planning Substance Abuse Treatment Clients Who Have Had a TBI with Loss of Consciousness Two Consistent Clinical Observations: Compared to others in SUD treatment there is an even 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. What Substance Abuse Professionals Need to Know page 7

8 Reasons for negative effect on outcome due to TBI: 1. Neurobehavioral consequences undermine ability to participate conventionally in treatment People with TBI face additional challenges seeking substance abuse treatment It s easy to see behavior as intentionally disruptive, particularly when there are no visible signs of disability: Frontal lobe damage affects regulation of thoughts, feelings & behavior promoting disinhibition. Social rules may not be observed and interpersonal cues not perceived, creating consternation for fellow clients and staff. People with TBI 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 neurological problems as resistance to treatment undermines treatment relationships. What Substance Abuse Professionals Need to Know page 8

9 Cognitive Impairment in the Match Study (Bates et al. 2006) Reasons for negative effect on outcome due to TBI: 1. Neurobehavioral consequences undermine ability to participate conventionally in treatment 2. Greater co-occurring psychiatric disorders for those with TBI 27 substance abuse treatment facilities in New York (Sacks et al, 2009) No History of TBI History of TBI Age at first use 16.9 yo 15.2 yo > 2 prior SUD treatments 41.7% 50.4% Current mental illness 17.5% 29.4% Hospitalized for mental illness 11.4% 19.6% What Substance Abuse Professionals Need to Know page 9

10 Symptoms past 12 months of Clients Admitted for Substance Abuse Treatment in Kentucky (N=7,932) Dually diagnosed SUD and Severe Mental Illness [N=295] (McHugo et al., 2016) 80% at least 1 TBI; 61% at least 1 TBI with LOC; 24% at least 1 mod/sev TBI Extent of TBI history associated with worse alcohol use, worse psychiatric symptomolgy, more arrests, greater homelessness TBI history assoicated with greater likelihood of PTSD and antisocial and borderline personality disorders. Earlier age at 1 st TBI with LOC associated with presence of psychotic spectrum disorders Reasons for negative effect on outcome due to TBI: 1. Neurobehavioral consequences undermine ability to participate conventionally in treatment 2. Greater co-occurring psychiatric disorders for those with TBI 3. Less ability to sustain improvements without external structure What Substance Abuse Professionals Need to Know page 10

11 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 Hospital Days Days per Month Pre-Involve 0.26 Act-Involve TBI (N=36) Non-TBI (N=14) Emergency Service Utilization 1 Monthly Contacts Pre-Involve Act-Involve TBI (N=36) Non-TBI (N=14) What Substance Abuse Professionals Need to Know page 11

12 Jail Days Days per Month Pre-Involve Act-Involve TBI (N=36) Non-TBI (N=14) Staff Prognosis for Success in Treatment Prognosis TBI Non-TBI Percentage Will Not Succeed/Will Need Intensive Support Success w/ Regular Support Success w/ Minimal or No Support Not Enough Info Sessions per Month Psychiatric Appointments Pre-Involve Act-Involve 1 Group Therapy TBI (N=36) No-TBI (N=14) Individual Counseling Sessions 1.25 Sessions per Month Sessions per Month Pre-Involve TBI (N=36) Act-Involve No-TBI (N=14) 0 Pre-Involve TBI (N=36) Act-Involve No-TBI (N=14) What Substance Abuse Professionals Need to Know page 12

13 CSP Contacts Contacts per Month Pre-Involve Act-Involve TBI (N=36) No-TBI (N=14) Recommendations for SUD Treatment Providers SUD treatment planning needs to incorporate: Accommodations for neurobehavioral deficits Co-morbid interactions (e.g., depression, anxiety, pain) Formal and/or informal supports needed during and after treatment completion Every SUD treatment provider should know whether the person you are working with has had a TBI. What Substance Abuse Professionals Need to Know page 13

14 4. How can you determine if a client has had a TBI? Capture from medical encounters medical treatment often may not be sought lifetime records not available mild TBI often missed in Emergency Departments Biomarkers imaging, neuropsych assessment specific but not sensitive proteomics very acute only and sensitive but not specific Retrospective self-report cannot self-diagnose Gold Standard not aware of injury ( telescoping, poor memory, too young) Selected Methods of Eliciting Self-report TBI-TAC identified 20 different tools being used DVBIC Brief TBI Screen (BTBIS; Schwab et al.) TBI Questionnaire (TBIQ; Diamond et al.) Brain Injury Screening Questionnaire (BISQ; Gordon et al.) OSU TBI Identification Method (OSU TBI-ID; Corrigan & Bogner) Boston Assessment of Traumatic Brain Injury Lifetime (BAT-L; Fortier et al.) Selected Methods of Eliciting Self-report TBI-TAC identified 20 different tools being used DVBIC Brief TBI Screen (BTBIS; Schwab et al.) TBI Questionnaire (TBIQ; Diamond et al.) Brain Injury Screening Questionnaire (BISQ; Gordon et al.) OSU TBI Identification Method (OSU TBI-ID; Corrigan & Bogner) Boston Assessment of Traumatic Brain Injury Lifetime (BAT-L; Fortier et al.) What Substance Abuse Professionals Need to Know page 14

15 John D. Corrigan, PhD! OSU TBI Identification Method Structured interview designed to elicit lifetime history of TBI. Avoids misunderstanding about what a TBI is by eliciting injuries, then determining if altered consciousness occurred. Provides more information than simple yes/no Training at: What Substance Abuse Professionals Need to Know page 15

16 John D. Corrigan, PhD! What Substance Abuse Professionals Need to Know page 16

17 Neurocogni+ve Func+ons Attention Initiation Processing Memory Executive Function Impulsivity Planning & Organization Mental Flexibility Self- Awareness 49 Problem = Processing The time it takes to think through and understand new information or concepts can be affected when a person has had a TBI. This does not mean they cannot understand they may just need more time to understand. What to Look For Is PROCESSING a problem? Only picks up a portion of instructions or conversations Has difficulty keeping up with a conversation May tire easily May appear to zone out May appear passive or unmotivated Is sometimes referred to as lazy 51 What Substance Abuse Professionals Need to Know page 17

18 Accommodating Problems with Processing Keep it Simple It s easy for someone with processing problems to get lost in a conversation. Simplify information and provide one idea or task at a time Check In Frequently check for understanding by asking the person to repeat back instructions or ideas Slow it Down Make sure to provide sufficient time for the person to process and respond. Count silently to yourself after asking a question to allow extra time for the person to process the question What Substance Abuse Professionals Need to Know About TBI? 1. What TBI is 2. That TBI is common in their clients 3. That when TBI & SUD co-occur there are unique clinical manifestations and, thus, unique treatment needs 4. How to screen for TBI and accommodate executive function deficits THANK YOU What Substance Abuse Professionals Need to Know page 18