24/09/2012 1 Substance Abuse and Acquired Brain Injury Dr Howard F Jackson Consultant Clinical Neuropsychologist Founder and Clinical Director TRU Ltd People who use alcohol or other drugs after they have had a brain injury do not recover as much. Brain injuries cause problems in balance, walking or talking that gets worse when a person uses alcohol or other drugs. People who have had a brain injury often say or do things without thinking first, a problem that is made worse by using alcohol and other drugs. People who abuse alcohol render themselves more likely to encounter undesirable influences, Brain Injury increases the vulnerability to further brain injury as a result of intoxication. Excessive intoxication may cause further brain injury Alcohol and Brain Injury Alcohol and ABI Alcohol use was found to be the main factor in getting into trouble with the law after ABI (Jackson, et al, 1992). There are significant problems with supporting individuals with ABI who are intoxicated. Police will often refuse to keep them until they are sober and return to a unit with potentially vulnerable other residents is often untenable. Alcohol and Brain Injury Brain injuries cause problems with concentration, memory, social judgment, executive functioning, self-control, and emotional stability. Using alcohol or other drugs exacerbates these cognitive impairments. After brain injury, alcohol and other drugs have a more powerful effect. People who have had a brain injury are more likely to have times that they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse in the long-term. After a brain injury, drinking alcohol or using other drugs can increase the likelihood of a seizure. People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury. Alcohol and ABI Services Access to Brain Injury Services are often restricted due to Alcohol Abuse Access to Substance Abuse Service are often restricted due to ABI. Social Influences Within the unadapted home and community, the full impact of various deficits may be experienced for the first time. Rather than deal with the emotional consequences of such awareness (e.g., depression, frustration and boredom) the individual may seek refuge in the bottle, especially if such a pattern existed in the past. In sharp contrast to the rejection experienced in other social situations, members of the drug culture extend a warm and friendly welcome and cognitive and physical limitations are readily accepted.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
24/09/2012
1
Substance Abuse and
Acquired Brain Injury
Dr Howard F Jackson
Consultant Clinical Neuropsychologist
Founder and Clinical Director
TRU Ltd
People who use alcohol or other drugs after they have had a brain injury do
not recover as much.
Brain injuries cause problems in balance, walking or talking that gets worse
when a person uses alcohol or other drugs.
People who have had a brain injury often say or do things without thinking
first, a problem that is made worse by using alcohol and other drugs.
People who abuse alcohol render themselves more likely to encounter
undesirable influences,
Brain Injury increases the vulnerability to further brain injury as a result of
intoxication.
Excessive intoxication may cause further brain injury
Alcohol and Brain Injury
Alcohol and ABI
Alcohol use was found to be the main factor in getting into trouble with the law after ABI (Jackson, et al, 1992).
There are significant problems with supporting individuals with ABI who are intoxicated. Police will often refuse to keep them until they are sober and return to a unit with potentially vulnerable other residents is often untenable.
Alcohol and Brain Injury Brain injuries cause problems with concentration, memory, social
judgment, executive functioning, self-control, and emotional stability. Using alcohol or other drugs exacerbates these cognitive impairments.
After brain injury, alcohol and other drugs have a more powerful effect.
People who have had a brain injury are more likely to have times that they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse in the long-term.
After a brain injury, drinking alcohol or using other drugs can increase the likelihood of a seizure.
People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.
Alcohol and ABI Services
Access to Brain Injury Services are often restricted due to Alcohol Abuse
Access to Substance Abuse Service are often restricted due to ABI.
Social Influences
Within the unadapted home and community, the full impact of various deficits may be experienced for the first time. Rather than deal with the emotional consequences of such awareness (e.g., depression, frustration and boredom) the individual may seek refuge in the bottle, especially if such a pattern existed in the past.
In sharp contrast to the rejection experienced in other social situations, members of the drug culture extend a warm and friendly welcome and cognitive and physical limitations are readily accepted.
24/09/2012
2
Abuse of Other Substances
Antidepressants,
Pain Killers,
Hypnotics
Anticonvulsants
Tobacco
Caffeine
Substance Abuse BLIPS
BLIPS - Brief Limited Induced Psychosis
Cannabis
Alcohol
Amphetamines
Cocaine
LSD, Psilocybin (Magic Mushrooms)
Ecstacy
Steriods?
Incidence
Out of 80 clients at TRU 16 of them present with alcohol abuse as a core problem. Of these 4 had poly-substance abuse.
Two others have core issues of substance abuse involving substances other than alcohol.
Ponsford (2007) found 25.4% drinking at a hazardous level (australian study). Only 9% presented with other drug problems. Main abusers were young men.
Mistaken Identity
Individuals with acquired brain injury are more likely to present as intoxicated (eg slurred, slow speech, incoherence. emotional lability, etc)
Individuals with acquired brain injury are likely to present with psychiatric symptoms (paranoia, delusions, etc), especially under the influence of psychotropic substances – the Case of PD
Different Responses to Alcohol
Aggressive Response - Case of CM
At Risk Response - Case of CH
Passive Response – Case of JC
Pleasant (Slightly embarrassing) response – Case of HJ
A systemic rehabilitation approach
Treatment of Substance
Abuse After ABI
24/09/2012
3
A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance Abuse (and
substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
1. Engagement
Legal Issues (MHA, MCA, Court Order)
Motivational Issues
(Incentives, Insight, Commitment)
Engagement
The Stages of Change Model
STAGE 1: PRE-CONTEMPLATION
STAGE 2: CONTEMPLATION
STAGE 3: PREPARATION
STAGE 4: ACTION
STAGE 5: MAINTENANCE
STAGE 6: LAPSE / RELAPSE
Motivational Interviewing
Short term effect without ongoing MI
Insight or intention does not equate with behaviour (good in theory, bad
in practice)
Slippage in the MI stages (episodic memory impairments)
Difficulty with reaching the contemplative stage due to impaired abstract
thinking
Difficulty with preparation stage due to impairments in ability to plan.
Difficulty with action stage due to initiative and memory problems.
Difficulty with maintenance due to executive dysfunction
Resistance of Conceptual Attributions.
A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance Abuse (and
substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
2. DETOX
Higher risk of epilepsy/death
Increased risk of delerium tremens
Idiosyncratic response to medication
Increased behavioural problems with withdrawal
24/09/2012
4
A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
2 Detoxification
3 Establishing Operations (an alternative
‘substance-free’ life-style)
4 Addressing Functional Value of Substance Abuse (and
substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
3. Establishing Operations
Developing a life-style without substance misuse:-
Sleep/Wake Cycle
Exercise and Healthy Diet
Goal-orientated activity
Pain Management, etc
Self-structuring
A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance
Abuse (and substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
4. (Dys)functional Value of
Alcohol Misuse
Initial function may change over time
If the functional reasons for misusing are not addressed then relapse or unhelpful substitutions are likely.
4. Different Typologies of Alcohol
Abuse – Functional Value
Impulsive Intoxication – Case of RM
Stimulus Bound Drinking – Case of AA
Escalating Drinking - Case of NC
Suggestible Drinking – Case of CH
Encouraged Drinking – Cases of JC & KW
Social Anxiety Drinking – Case of JSS
Addicted Drinking – Cases of KW & BW
Bored Drinking – Case of JE
4. Functional Reasons For
Abusing Other Drugs.
They relieve my pain (cannabis)
They help me sleep (cannabis, hypnotics)
They keep me alert (amphetamines, proplus)
They keep me calm and chilled (cannabis)
They give me confidence (cocaine)
They help me stay in control (cocaine)
24/09/2012
5
A Rehabilitation Programme for
Substance Abuse after ABI
1 Engagement
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance Abuse (and
substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse prevention)
5. False Attributions/Attitudes
I can’t get drunk since my ABI
It improves my social functioning
It calms me down
Being normal is getting drunk/stoned
5. False Attributions/Attitudes
Rational Self Analysis (and other CBT Approaches) – Adapted for ABI
Peer pressure discussion groups (EQUIP)
Education (Direct, Implicit)
A Rehabilitation Programme for
Substance Abuse after ABI 1 Engagement
2 Detoxification
3 Establishing Operations (an alternative ‘substance-free’
life-style)
4 Addressing Functional Value of Substance Abuse (and
substituting)
5 Addressing False Attributions/Attitudes
6 Helping the client take control (Relapse
prevention)
6. Helping the client take control
(Relapse prevention)
1 Establishing and Maintaining Commitments (WRAP).
2 Identifying Triggers and developing risk assessment and management.
3 Coping strategies (Neuropsychological : self-structuring, problem solving, risk evaluation)
4 Systematic and Contingent Exposure and Desensitisation (De-conditioning)
6. Contingent Pathways to Self-
Management
No-alcohol contact – non-alcohol related settings
No alcohol contact – alcohol related settings
Planned/Controlled alcohol contact – alcohol related settings with supervision
Planned Controlled alcohol contact – alcohol related settings without supervision
24/09/2012
6
Substance Abuse and ABI
Knowledge is not the sole answer -
Most interventions for substance abuse involve educational or self-exploration approaches as the primary therapeutic approach.
Most interventions fail to address habitual behaviours directly.
Educate client and family about the risks of clients with Brain Injuries
using substances.
Engage family/social network in actively supporting the client to
address the issue.
Take a history of client’s prior and current use. Be specific — ask,
“What’s the most you’ve used? The least?”
Ask client about his/her family history of Substance Use. Ask what
effect use is having on client’s life (social, family, job, legal).
Gain an understanding of the Model for Change . It may help you move
your client through the stages.
General Guidance
Practical Help
Assess stressors and risk factors that might cause client to begin/maintain using (isolation, boredom, depression, job loss, etc).
Help client find meaningful substance-free activities.
Provide support for behavioural changes before, during and after the Substance Abuse program to build motivation and reinforce new behaviours.
Establish ongoing contact with professionals in Substance Abuse
programs to exchange information and make sure the Substance Abuse program is meeting the client’s needs.
Refer for Specialist ABI substance abuse rehabilitation