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Treating Substance Use Disordersin Brain Injury SurvivorsPresented by:Christine (Brenton) Boucher LPC, LADC, CBISJanuary 27, 2016

Treating Substance Use Disordersin Brain Injury SurvivorsPresented by:Christine (Brenton) Boucher LPC, LADC, CBISJanuary 27, 2016

Thomas Durham, PhDDirector of TrainingNAADAC, the Association for Addiction Professionalswww.naadac.orgtdurham@naadac.org

Produced ByNAADAC, the Association for Addiction Professionalswww.naadac.org/webinars

www.naadac.org/webinars

www.naadac.org/braininjurysurvivors

Cost to Watch:FreeCE HoursAvailable:1.5 CEsCE Certificate forNAADACMembers:FreeCE Certificate forNon-members: 20CE CertificateTo obtain a CE Certificate for the time you spentwatching this webinar:1.Watch this entire webinar.2.Pass the online CE quiz, which is posted atwww.naadac.org/braininjurysurvivors3.If applicable, submit payment for CE certificateor join NAADAC.4.A CE certificate will be emailed to you within 21days of submitting the quiz.

Using GoToWebinar – (Live Participants Only) Control Panel Asking Questions Audio (phone preferred) Polling Questions

Webinar PresenterChristine (Brenton) Boucher, LPC, LADC, CBIS(860) 965-2443cccschristine@gmail.comCultivating Change Counseling Services, LLCTolland, CTYour

Webinar Learning Objectives12Understand basicfunctions of the brainand how these arealtered during braininjuryUnderstand howsubstance usedisorders impact braininjury recovery3Learn ways to modifyaddiction treatment for braininjury survivors

The Merging of Two FieldsLimited education and understanding across fieldsBrain injury survivors are twice as likely to have abused alcohol/substance prior totheir injury and up to 20% of survivors will develop a substance use disorder afterinjuryHigher drop out rates in treatment after a TBI due to ineffective methods, lack ofunderstanding around TBI, premature discharge due to “non-compliance”, etc.Availability of treatment programs that address both substance abuse and braininjury are lackingIn order for treatment to be effective after brain injury, methods need to bemodified. This is not yet universally understood or accepted.We know the who and the what, but what about the how?

“Substance abuse is a risk factor for having atraumatic brain injury and traumatic brain injury is arisk factor for developing a substance abuseproblem.”– John Corrigan, PhD

Polling Question #1

Anatomy of the Brain

Prefrontal CortexSocial cognitionMoral cognitionInhibitionControlGoal-settingDelayed gratificationThe prefrontal cortex is the part of the brain often damaged byboth chronic substance abuse and brain injury

Frontal LobeProblem solving ation

Limbic SystemAmygdala – “fight or flight”response, emotions,emotional memoriesHippocampus – memoryfunction, highlysusceptible to loss ofoxygen

So What Happens inBrain Injury?

Brain Injury Defined – TBI vs. ABITraumatic Brain Injury(65% annually)Cause of InjuryMVA“an insult to the brain, not of adegenerative or congenital nature butcaused by an external physical force, thatmay produce a diminished or altered stateof consciousness, which results in animpairment of cognitive abilities and/orphysical functioning. It can also result inthe disturbance of behavioral or emotionalfunctioning. These impairments may beeither temporary or permanent and causepartial or total functional disability orpsychosocial maladjustment” - her

Brain Injury Defined – TBI vs. ABIAcquired Brain Injury(35% annually)“an injury to the brain that hasoccurred after birth and is nothereditary, congenital, ordegenerative. The injury commonlyresults in a change in neuronalactivity, which affects the physicalintegrity, the metabolic activity, or thefunctional ability of the cell. The termdoes not refer to the brain injuriesinduced by birth trauma.” - BIAACause of InjuryStroke7%6%Tumor87%Other,includingTBI

“ A Silent Epidemic”(‘looking good, but feeling strange’)Approx. 5.3 million people in the United States living with a disability due to braininjuryApprox. 1.4 million new brain injuries sustained every year in the United States1.1 million require a visit to the emergency room235,000 require hospitalization50,000 are fatal – of these almost 32% are due to MVA relatedinjuriesInjury is 1.5 times more likely in men than women, at any ageRisk of a second injury is 3x greater and risk of a third injury is 8x greaterThe estimated cost per year to society is 76.5 billion.

Types of InjuriesPrimary – original insult or injurySecondary – swelling, bruising, bleeding,or lack of oxygen resulting from theprimary insultOpen – brain has been exposed, skullhas been penetratedClosed – brain has been harmed, butskull remains intactFocal – damage to the brain remains inone primary locationDiffuse – connections throughout thebrain are stretched and/or broken dueto shaking, tearing, or stretchingthrough rotationCoup-Contrecoup – brain bounces backand forth or side to side upon impact

Measurement of InjuryInpatientGlascow Coma ScaleLoss of ConsciousnessPost-traumatic AmnesiaOther factors, tests, etc.MildModerateSevereOutpatientAcute RehabLong-term rehabResidentialEtc.

Signs, Symptoms, and EffectsPhysicalHeadachesDizzinessFatigueVisual impairmentBalance problemsSeizuresMotor impairmentsReduced mobilityMuscle stiffnessWeaknessCognitiveMemory lossPoor concentrationPoor attentionPoor judgmentPoor decision makingDisorientationLanguage difficultiesLack of awarenessConfabulationSlowed thought processSlowed speechConcrete thinkingEmotionalDepressionAnxietyMood swingsFlattened emotionIrritabilityAgitationInappropriate behaviorsIncreased frustrationIsolationLack of motivationImpulsivenessEgocentrism

The ‘Cycle of ustration

And What AboutSubstance UseDisorders?

Some Perspective40% - 60% of people with a substance use disorder have also had a previous traumatic brain injurythe cost of alcohol/substance abuse to our society is over 700 billion per yearHealth CareOverallTobacco 130 billion 295 billionAlcohol 25 billion 224 billionIllicit Drugs 11 billion 193 billion2008 National Survey on Drug Use and Health23.1 million people (ages 12 ) were in need of addiction-specific treatment20.8 million people did not receive treatment2.3 million people did receive treatment (10%)WHY?

Of that 20.8 million, 95.2% never soughttreatmentMost common reasons- won’t help- stigma attached to being an addict- no one else cares- would rather not live any longer- hope it will go away on its on- fear of being cut off from supply- fear of giving up their “high”- denial and control

3.7% felt they needed treatment, but stilldid not seek itTreatment Needed, Not Sought11.812.9Not Ready38.8No Insurance/CostPossible Effect on Job12.3Not Sure Where32.1Possible Negative Opinion

And 1.1% felt that needed treatment, sought itout, but still did not receive itTreatment Needed, Sought, but NotObtained7.4 7.7Cost/No insuranceNot Ready8.327.48.2No transportation29.38.110.5Self-treated13Unsure whereWrong timingLack of tx availability

Data Obtained by The National Institute on DrugAbuse and The CDCDEATHS DUE TO ineBenzodiazepinesOpioidsIn all drug categories, men had a higher rate of overdose.Prescriptions

The Brain On Drugsdisrupted communication between different areas of the brainchanges in chemical structurenegative effect on one’s ability to have good impulse controlpoor decision makingmemory loss, mood swings

The Cycle of AddictionSober/HighwearsoffGuilt/Shamearound aviorsCravingsPoor High

Typical Components of Treatment forSubstance Use Disorders(and why they may not work for TBI)MedicationsStages of ChangeCBT, Motivational InterviewingMotivational Incentives / Contingency ManagementAbstinence Model vs. Harm Reduction ModelSelf Help / 12 Step GroupsInpatient / Residential SettingsGoals of treatmentReduce or eliminate useIdentify triggers to cravingsDesensitize client to their cravingsRebuild social network / Repair relationships

But what happens whenthey collide?

Polling Question #2

Some More Perspective.In adolescents and adults:20% of those hospitalized were intoxicated at the time of injury30% of those requiring rehab were intoxicated at the time of injury50% of those treated in acute rehab had a prior history of alcohol abuse35% of those treated in acute rehab had a prior history of substanceabuse60% of those treated in inpatient rehab had a history of a substance usedisorder44-66% of TBI survivors report alcohol abuse issues compared to 24% of non-TBIsurvivors21-37% of TBI survivors report use of illegal drugs compared to 15% of non-TBIsurvivors

Effects of Continued Useslower recoveryincreased damage to the brainincreased behavioral issuescontinued impact to cognitive functioningmore powerful effects from alcohol/drugsseizuresincreased depression, anxiety, etc.risk of additional head injuries

Additional Barriers to Treatmentscreening for brain injury is not doneghostinganosognosiahoneymoon period – 2-5 yearsmisdiagnosisnon-compliant or resistanttreatment may be unavailable or require an inpatient settingadditional transportation/financial concerns

“Ghosting”remembering who you were prior to your injury and striving to return to that lifecan be considered an identity disordercan create hostility with providers as client attempts to receive feedbackconsistent with their viewed selfALWAYS take this into consideration when treatment planning

Anosognosialack of awareness around physical or cognitive deficitsspecifically damage to the right parietal, right frontal areas of the braindoesn’t necessarily pertain to all deficitscan improve over timehow?do not use failure as a way to teachdo not point out deficitsutilize compensatory strategiesmain a supportive relationship

So how do we providetreatment?

Polling Question #3

What Doesn’t WorkClient attends an intake assessment. They mention they were in a car accident last year andhave felt different ever since. To cope with this, they have started drinking alcohol daily andoccasionally using cocaine. You complete your assessment and suggest they meet with apsychiatrist and attend a group therapy for people actively abusing alcohol/substances. Theyagree to try out your recommendations. Later that week they meet with a psychiatrist andstart group therapy weekly. The medications start making the client fatigued. Group consistsof sharing past use history, watching an educational film on addiction, and discussing triggers.Homework is assigned and at the second group homework is reviewed and the second part ofthe film is viewed. The client never did the assignment and appears lost when watching thefilm. The client misses group three and four so you call to check in. They apologize andrequest to meet with you individually to discuss some concerns. You’re unable toaccommodate this due to a high caseload and busy schedule so the client agrees to attendthe next group. The client again does not show up, so you discharge them due to treatmentnon-compliance and figure they are resistant to treatment or not ready to change.What went wrong?

A Community Based Model Suggested by JohnCorrigan, PhD and Colleaguescombination of education, intensive casemanagement, and inter-professionalconsultationsignificant differences in outcome foundwhen comparing untreated clients,premature discharge, and completionof treatment goalsmedian length of stay in order for client tobe discharged successfully was 2years

Early Intervention andScreening Tools“honeymoon periods” are common immediately after a brain injury due toincreased treatment and supervision – but treatment is still important!TBI Screening Form- HELPSMontreal Cognitive Assessment – MoCANeuropsychological Assessment

Additional Treatment Goalsnot necessarily changed, but possibly refocusedengagement – how?“success” is redefinedbuilding awareness around brain injury and resulting changes (insight)increasing independencemodifying behavior if neededde-escalation techniquesboundary settingsocialization