The Prevalence of Alcohol Abuse in
Soldiers with TBI from GWOT and its
Impact on Treatment
Christopher R. Walsh, PA.
Commander, USPHS
MACH TBI Service
CDR Walsh has no relevant financial relationships to disclose
with any entity associated with this presentation.
The opinions and assertions contained in this presentation
are the private views of CDR Walsh and do not necessarily
reflect the official policies or positions of the Department of
Defense or the Department of the Army.
 Describe
the incidence of alcohol use among
soldiers in both TBI and non-TBI patient pops.
 Describe
the difference alcohol use factors into
civilian and military TBI related injuries.
 Become
familiar with common screening
instruments that aid in detecting symptoms of TBI
and substance abuse.
 Identify
common comorbidities associated with TBI
that may factor into increased alcohol use.
 Describe
the challenges that alcohol use presents
in recovery from a traumatic brain injury.
 Alcohol
use complicates recovery from TBI. (Corrigan
and Lamb-hart, 2004).
 Alcohol
use increases after military combat
deployment. (Jacobson et. al, 2008)
is the signature wound of the current conflicts in
Iraq and Afghanistan, accounting for 70% of injuries
seen in theater. (Heltemes et. al, 2011)
 Alcohol
abuse would be more likely in service
members who have sustained a TBI.
Military mTBI
 1.69
million U.S. Military
personnel have been
deployed more than 2.2 million
times to OIF or OEF since the
start of military operations in 2001.
 Head
and neck injuries, including severe brain trauma,
have been reported in 25% of SM who have been
evacuated from Iraq and Afghanistan.
 mTBI, or
concussion, characterized by brief LOC or
altered mental status, as a result of deployment-related
head injuries, particularly those resulting from
proximity to blast explosions may be as high as 18% of
returning SM.
NEJM Hoge et. Al (2008)
+ Characteristics of Millennium Cohort participants, Jacobson et. al,
+ Prevalence of baseline, follow up, and new onset alcohol use,
Jacobson, et. al, 2008.
+ Adjusted odds of alcohol use among Active-Duty Millennium cohort
participants, Jacobson, et. al, 2008.
+ Adjusted odds for alcohol use among Reserve/Guard Millennium
cohort participants, Jacobson, et. al, 2008.
Screening for TBI
 Anyone
exposed to or
involved in a:
 Blast
 Fall
 Vehicle
 Direct impact
 Who
becomes dazed or confused even
momentarily, should be further evaluated
for brain injury. DVBIC CPG
The difference between civilian and military related
TBI injuries
Roughly 1.9 million civilian TBIs per year. (Chanras & Eddy,
2008). 235,000 hospital admissions, 50,000 deaths.
Mechanisms: falls 28%, MVAs 20%, collision with stationary
object 19%, assaults 11%.
Up to 75% of civilian TBIs involve alcohol/drug use.
Military TBIs typically do not have an alcohol component.
Vast majority of military TBIs are blast related.
IED Explosion
TBI Related Disorders
Definition of
Military mTBI
 An
injury to the brain resulting from an external
force and/or acceleration/deceleration
mechanism which causes an alteration in mental
status typically resulting in the temporally related
onset of symptoms such as: headache, nausea,
vomiting, dizziness/balance problems, fatigue,
trouble sleeping/sleep disturbances, drowsiness,
sensitivity to light/noise, blurred vision, difficulty
remembering, and/or difficulty concentrating.
of 30 minutes
 After
30 minutes, and initial
GCS 0f 13-15; and
not greater than 24 hours
( Diffusion Spectrum Imaging tracks the movement of
water molecules as they slide down axons. Red reflects
right to left connections; green front to back and blue
up and down including links to the spinal cord. )
Screening tools that aid
in detecting TBI & SA.
WARCAT (Warrior Administered
Retrospective Casualty Assessment Tool)
PCL-M (PTSD Checklist, Military Version)
PHQ-9 (Patient Health Questionnaire 9 items
DHI (Dizziness Handicap Inventory)
MAST-22 ( Michigan Alcohol Screening Test)
CNS Vital Signs
RBANS (Repeatable Battery for Assessment of
Neuropsych Status
ANAM (Automated Neuropsychological
Assessment Metrics)
+ Warrior Administered Retrospective Casualty Assessment Tool
+ Patient Health Questionnaire
+ Dizziness Handicap Questionnaire
+ Michigan Alcohol Screening Test
Blast Injuries
PRIMARY: Direct exposure
to overpressurization
wave – velocity >/= 300m/sec
(speed of sound of air)
SECONDARY: Impact of blast energized debris
penetrating and non penetrating
TERTIARY: Displacement of the person by the blast and
QUARTERNARY: Inhalation of toxic fumes, smoke,
Common Comorbidities
of TBI and Alcohol Abuse
 Decreased
self-awareness and insight
 Deficits
of memory, attention and concentration
 Change
in Mood and affect
 Insomnia
 Vocational/educational
Psychiatric Comorbidities of TBI
 mTBI
(i.e., concussion) occurring among
soldiers deployed in Iraq is strongly
associated with PTSD and physical health
problems 3 to 4 months after the soldiers
return home.
and depression
are important mediators
the relationship between
mild traumatic brain
injury and physical
health problems.
NEJM Hoge et. Al (2008)
General Lee lies on its side after surviving a
buried IED blast in 2007.
Heltemes, et. al, 2011, found no statistically
significant relationship between TBI and
Alcohol abuse
Implications for treatment of patients who have TBI
and alcohol abuse issues
Intervention and treatment: Insight oriented approaches are the
predominant models, but of questionable utility with TBI.
Modify admission criteria (remove psychoactive medication
Determine unique learning strategies: avoid jargon and
abstractions, keep ideas concrete.
Beware of attention span deficits
Be cautious when inferring patient motivation levels.
Implications (cont’d)
Repeat instructions and strategies
Attend to transportation issues
Enlist the patients social circle to reinforce goals
Increase treatment compliance/attendance with incentives.
Remember that symptoms of TBI and alcohol abuse are similar and it
can be difficult to distinguish which problem is causing which
mTBI in U.S. Soldiers
Returning from Iraq
NEJM 2008; 358:453-63
Charles W. Hoge, M.D., Dennis McGurk, Ph.D., et al.
2525 U.S. Army soldiers 3 to 4 months after return from 1 yr.
124 (4.9%) +LOC; 260 (10.3%) altered mental status.
+ LOC = 43.9% met criteria for PTSD; AMS = 27.3%; other
injuries = 16.2%; no injury = 9.1%
mTBI associated with poor general health, missed workdays,
medical visits, > somatic & PCS compared to SM with other
After adjustment for PTSD & depression, mTBI no longer
associated with poor physical health except headache
Comprehensive Array of Tests
 Effort
and compliance
 Premorbid
 Learning
and memory
 Visuospatial
 Intelligence
 Executive
 Arousal
 Motor
and attention
 Language
 Emotion, behavior
MACH TBI Services
Primary Care Assessment
Case Management
Neurological Evaluation/Treatment
Psychiatric Evaluation/Treatment
Pain Evaluation/Management
Neuropsychological Screening/Evaluation
Individual & Group Psychotherapy
Cognitive Rehabilitation
Balance Assessment/Neurocom
DeLambo, D. et. Al, Traumatic Brain Injury and Substance Abuse:
Implications for Treatment. Conference March,2008.
Corrigan, J. & Lamb-Hart, G. (2004)Substance Abuse after a
traumatic brain injury: Living with brain injury. Vienna, VA: Brain
Injury Association of America.
Heltemes, K. et. al, Alcohol Abuse Disorders Among US Service
Members with Mild Traumatic Brain Injury. Military Medicine, Vol.
176, February, 2011.
Thanks to these resources:
Defense and Veterans
Brain Injury Center
TBI Service 706-5445102/5176