Substance Use and Traumatic Brain Injury
Marc A Gramatges, Psy.D.
December 18, 2013
© 2013 Bancroft | All rights reserved
Learning Objectives
This webinar is designed to help you:
• Describe the prevalence of substance use (SU) and Traumatic
Brain Injury (TBI)
• Explain the clinical interaction of SU and TBI
• Select appropriate treatment methods for individuals with SU
and TBI
• Use a list of resources for SU and TBI
© 2013 Bancroft | All rights reserved
Prevalence of TBI
• Every year, at least 1.7 million TBIs occur either
as an isolated injury or along with other injuries
• TBI is a contributing factor to a third (30.5%) of
all injury-related deaths in the United States
• About 75% of TBIs that occur each year are
concussions or other forms of mild TBI
(CDCP, 2013)
Causes of TBI
The leading causes of TBI are:
• Falls (35.2%)
• Motor vehicle – traffic (17.3%)
• Struck by/against events (16.5%)
• Assaults (10%)
(CDCP, 2013)
Self Harm
Intentional Sources of TBI:
• 17.8% of all cases
• Males
• Minorities of lower income
• <50 years of age
• Twice as likely to occur in conjunction with SU
(Wagner, Sasser, Hammond, Wiercisiewski, & Alexander, 2000).
SU and TBI
For those suffering TBIs:
• 44–60% of those injured were intoxicated at the
time of injury
• 58% had a history of alcohol abuse or dependence
prior to injury
• 33% used illicit drugs prior to their injury
(Hensold, Guercio, Grubbs, Upton, & Faw, 2006)
Continuing Use
While receiving treatment:
• 50% will return to abusing alcohol and other
drugs post-injury
• 20% receiving treatment for substance abuse
issues after injury did not have a history of
substance abuse prior to their injury
(Hensold, Guercio, Grubbs, Upton, & Faw, 2006)
Clinical Interaction
• After a TBI, the brain is
more sensitive to alcohol
and other drugs after an
• There are not as many
neurons to absorb the
alcohol or other drugs
(BIAA, 2013)
• SU after a TBI may reduce amount of
(BIAA, 2013)
• 5% of people after a brain injury have problems
with seizures
• SU increases the risk of seizures
(BIAA, 2013)
Future TBIs
• After a TBI, chance for
another is three times
• SU increases those odds
(BIAA, 2013)
In one study…
76 individuals with moderate to severe TBI in a day
treatment program
• 55 individuals (72%) were employed
• 18 (24%) were students
• one (1%) did volunteer work
• two (3%) were unemployed
In one study…
At follow-up,
• 54 individuals (71%) were employed or attending school.
• 22 individuals (29%)
• Only history of substance abuse was associated with poorer outcome
• Individuals with no history of substance abuse were eight
times more likely to be employed at follow-up compared
to those with a history of substance abuse.
(Sherer, M., Bergloff, P., High, Jr., W., & Nick, 1999)
Evidence for Risk
Less likely to return to drinking:
• More severe injuries
• Longer hospital stays
• Greater degrees of disability
(Kreuzter , et. al. 1996)
Evidence for Risk
More likely to return to drinking:
• High Blood Alcohol Content at time of injury
• Moderate injuries
• Young adults
• Prior heavy drinkers
(Kreuzter , et. al. 1996)
When Comparing SU and TBI
“Patients with uncomplicated
M(ild)TBIs could not be
reliably differentiated from
patients with substance abuse
problems on these measures
of concentration, memory
and processing speed.”
(Iverson, Lange, Franzen, 2005)
Additional Evidence
• Heavy social drinkers or
those who had been
hospitalized for a TBI were
slower responding during
• Heavy social drinking and
TBI have an "additive
(Baguley et. al, 1997)
Screening for SU with TBI
– More effective for Post-TBI alcohol use
• Substance Abuse Subtle Screening Inventory – 3
– More effective for Post-TBI drug use
(Ashman, Schwartz, Cantor, Hibbard, & Gordon, 2004)
CAGE Assessment for Alcohol Abuse
• The CAGE is a 4- item, relatively nonconfrontational questionnaire for detection of
alcoholism. It takes less then 1 minute to
administer, is easy to learn, remember and
• Two or more affirmative responses suggest that
the client is a problem drinker.
(Ewing, 1984)
CAGE Assessment for Alcohol Abuse
• 1. Have you felt the need to Cut down on your
• 2. Do you feel Annoyed by people complaining
about your drinking?
• 3. Do you ever feel Guilty about your drinking?
• 4. Do you ever drink an Eye-opener in the
morning to relieve shakes?
(Ewing, 1984)
• Identifies high probability of engaging in alcohol
or drug abuse
• Identifies individual with abuse who may not
acknowledge it
• Face-valid and subtle items predictive of
substance abuse
(Ashman, Schwartz, Cantor, Hibbard, & Gordon, 2004)
Cognitive Challenges
Emotional Functioning
Memory and Learning
Social Communication
Visual Processing
Information Processing
Executive Functioning
• Difficulty
• Impacts memory
• At risk during
seemingly simple
(BIAA, 2009)
Emotional Functioning
Less frustration tolerance
Emotional lability
(BIAA, 2009)
Memory and Learning
• Learning and retaining new
• Forgetting critical events
• Forgetting appointments
• Forgetting medication
(BIAA, 2009)
Social Communication
• May have inappropriate social interactions
• Difficulty filtering
• Trouble reading others’ emotions
(BIAA, 2009)
Visual Processing
• Balance
• Coordination
• Walking
(BIAA, 2013)
Information Processing
• Decrease in
processing speed
• Difficulty processing
multiple streams of
Executive Functioning
• Increase in
• Difficulty planning
• Trouble completing
(BIAA, 2009)
• Lack of awareness of deficits
(BIAA, 2009)
Therapeutic Modalities
• Seeks to help
patients recognize,
avoid, and cope with
the situations in
which they are most
likely to abuse drugs.
(BIAA, 2013)
Therapeutic Modalities
Multidimensional Family Therapy
• Developed for adolescents with drug abuse
problems—as well as their families—addresses a
range of influences on their drug abuse patterns
and is designed to improve overall family
(BIAA, 2013)
Therapeutic Modalities
Motivational Incentives (Contingency Management)
• Positive reinforcement to encourage abstinence
from drugs.
(BIAA, 2013)
Therapeutic Modalities
Motivational interviewing
• Capitalizes on the readiness of individuals to
change their behavior and enter treatment.
• Stages of Change Model
(BIAA, 2013)
Stages of Change
• Precontemplation: A person sees no problem
when there is one
• Contemplation: Weighing the pros and cons of
• Determination: Deciding to change
• Action: Making a specific plan for change
• Maintenance: Sustaining successful change despite
urges to use again
(BIAA, 2013)
D&A Treatment
Long-term residential treatment
• Provides care 24 hours a day, generally in nonhospital settings
• Planned lengths of stay of between 6 and 12
(BIAA, 2013)
D&A Treatment
Short-Term Residential
• Intensive but relatively brief treatment based on a
modified 12-step approach
• Originally designed to treat alcohol problems, but during
the cocaine epidemic of the mid-1980s, many began to
treat other types of substance use disorders
• 3- to 6-week hospital-based inpatient treatment phase
followed by extended outpatient therapy and participation
in a self-help group, such as AA.
(BIAA, 2013)
D&A Treatment
Halfway House
• A home shared by a group of individuals in
recovery with set rules to assist with sobriety.
• Typically based on a 12-step approach
(BIAA, 2013)
D&A Treatment
Outpatient Treatment
• Varies in the types and
intensity of services
offered (Intensive and
(BIAA, 2013)
D&A Treatment
• Alcoholics Anonymous
• Narcotics Anonymous
• 12 Steps
The 12 Steps
Step 1 - We admitted we were powerless over our addiction - that our lives had become
Step 2 - Came to believe that a Power greater than ourselves could restore us to sanity
Step 3 - Made a decision to turn our will and our lives over to the care of God as we understood
Step 4 - Made a searching and fearless moral inventory of ourselves
Step 5 - Admitted to God, to ourselves and to another human being the exact nature of our wrongs
Step 6 - Were entirely ready to have God remove all these defects of character
Step 7 - Humbly asked God to remove our shortcomings
Step 8 - Made a list of all persons we had harmed, and became willing to make amends to them all
Step 9 - Made direct amends to such people wherever possible, except when to do so would injure
them or others
Step 10 - Continued to take personal inventory and when we were wrong promptly admitted it
Step 11 - Sought through prayer and meditation to improve our conscious contact with God as we
understood God, praying only for knowledge of God's will for us and the power to carry that out
Step 12 - Having had a spiritual awakening as the result of these steps, we tried to carry this message
to other addicts, and to practice these principles in all our affairs
The First Step
• Remember anosognosia…
Which Treatment?
Most effective in starting treatment:
• 83% Financial incentive
• 74% Barrier reduction
• 45% Motivational interview
• 45% Attention control
(Bogner, Lamb-Hart, Heinemann, & Moore, 2005)
Which Treatment?
But staying in treatment:
• 84% Barrier reduction
• 79% Financial incentive
• 66% Motivational interview
• 53% Attention control
(Bogner, Lamb-Hart, Heinemann, & Moore, 2005)
• When a person with a
brain injury seeks help for
a substance abuse
problem, significant
barriers to treatment may
be encountered.
(BIAA, 2013)
Physical Barriers
• Limited accessibility for individuals with physical
(BIAA, 2013)
Medical Barriers
• Lack of understanding for need of medications
(CDCP, 2013)
Social Barriers
• Lack of social understanding of brain injury
(BIAA, 2013)
In an Intensive SU and TBI Program
Significant gains in four of the five outcome areas that were
measured over about 6 months:
• Residential status
• Level of supervision required
• Awareness
• Productive involvement
No significant vocational gains (need 20+ hours a week)
(Hensold, Guercio, Grubbs, Upton, & Faw, 2006)
• Alcohol and drug use declined in the first year
• Increased by 2 years post-injury
• SU was similar at 3 years post-injury
(Ponsford, Whelan-Goodinson, & Bahar-Fuchs, 2007)
21.4% reported abstinence from alcohol
25.4% drank at hazardous levels
9% showed a drug problem
24% returned to some drug use
Heavy alcohol users post-injury were young, male
and heavy drinkers pre-injury
(Ponsford, Whelan-Goodinson, & Bahar-Fuchs, 2007)
Important to Remember
• Insight
• Barrier reduction
• Maintenance
Alcoholics Anonymous
Narcotics Anonymous
Brain Injury Association of America
Centers for Disease Control and Prevention
National Institute on Drug Abuse
© 2013 Bancroft | All rights reserved
Ashman, T. A., Schwartz, M. E., Cantor, J. B., Hibbard, M. R., & Gordon, W. A. (2004).
Screening for substance abuse in individuals with traumatic brain injury. Brain
Injury, 18(2), 191-202. doi:10.1080/0269905031000149506
Baguley, I. J., Felmingham, K. L., Lahz,S., Gordan, E., Lazzaro, I., & Schotte, D. E. (1997).
Alcohol abuse and traumatic brain injury: Effect on event-related potentials.
Archives of Physical Medicine and Rehabilitation, 78 (11), 1248-1253.
Brain Injury Association of America (2009). The essential brain injury guide (4th ed.). Vienna,
VA: Academy of Certified Brain Injury Specialist.
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© 2013 Bancroft | All rights reserved
Ewing, JA (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the
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Hensold, T. C., Guercio, J. M., Grubbs, E. E., Upton, J. C., & Faw, G. (2006). A personal
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a least restrictive residential model. Brain Injury, 20(4), 369-381.
Iverson, G. L., Lange, R. T., & Franzen, M. D. (2005). Effects of mild traumatic brain injury
cannot be differentiated from substance abuse. Brain Injury, 19(1), 15-25.
J. D., Bogner, J., Lamb-Hart, G., Heinemann, A. W., & Moore, D. (2005). Increasing
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Psychology of Addictive Behaviors, 19(2), 131-139. doi:10.1037/0893-164X.19.2.131
Kreuzter, Jeffrey et. al. (1996). A prospective longitudinal multicenter analysis of alcohol use
patterns among persons with traumatic brain injury. Journal of Head Trauma
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National Institute on Drug Abuse (2013). Retrieved November 12, 2013 from /
© 2013 Bancroft | All rights reserved
Ponsford, J., Whelan-Goodinson, R., & Bahar-Fuchs, A. (2007). Alcohol and drug use
following traumatic brain injury: A prospective study. Brain Injury, 21(13/14),
1385-1392. doi:10.1080/02699050701796960
Sherer, M., Bergloff, P., High, Jr., W., & Nick, T. G. (1999). Contribution of functional
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injury. Brain Injury, 13, 973-981
Wagner, A. K.; Sasser, H. C.; Hammond, F. C.; Wiercisiewski, D.; & Alexander, J. (2000).
Intentional traumatic brain injury: Epidemiology, risk factors, and associations
with injury severity and mortality. The Journal of Trauma Injury, Infection, and Critical
Care, (49), 404-410.
© 2013 Bancroft | All rights reserved
Contact Information
Email: [email protected]
© 2013 Bancroft | All rights reserved

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