Traumatic Brain Injury and Alcohol Use Disorders

Traumatic Brain Injury Traumatic Brain Injury and Alcohol Use and Alcohol Use

DisordersDisorders

E. Lanier Summerall, MD, MPHE. Lanier Summerall, MD, MPH

Dartmouth Medical SchoolDartmouth Medical School

1© AMSP 2010

Alcohol Abuse and DependenceAlcohol Abuse and Dependence

80% Lifetime use80% Lifetime use

15% Lifetime abuse15% Lifetime abuse

10% Lifetime dependence10% Lifetime dependence

Intoxication, abuse, dependence=alcohol Intoxication, abuse, dependence=alcohol use disorders (AUD’s)use disorders (AUD’s)

2© AMSP 2010

Traumatic Brain Injury in USTraumatic Brain Injury in US 1.4 million total each year1.4 million total each year

50,000 die50,000 die 235,000 hospitalized235,000 hospitalized 1.1 million to ER1.1 million to ER

Mechanisms Mechanisms Falls Falls Motor vehicle accident (MVA)Motor vehicle accident (MVA) Struck by/against objectStruck by/against object Assaults/violenceAssaults/violence

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Traumatic Brain InjuryTraumatic Brain Injury Location-anywhere in brainLocation-anywhere in brain

Visible-bruise, bleeding, tissue deformityVisible-bruise, bleeding, tissue deformity

Invisible-axon damageInvisible-axon damage

Frontal lobe damage= “fingerprint” of TBIFrontal lobe damage= “fingerprint” of TBI

Acceleration/decelerationAcceleration/deceleration

Bony structure of skullBony structure of skull

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TBI EffectsTBI Effects VVision, hearingision, hearing

AAttention/concentrationttention/concentration

LLanguage skillsanguage skills

IInsightnsight

UUnacceptable behaviorsnacceptable behaviors

MMemoryemory

Physical/neurological problemsPhysical/neurological problems

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AUD+TBI=Complex AUD+TBI=Complex RelationshipRelationship

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↑ Risk TBI ↑ Risk AUD ↓ Recovery

AUD +TBI

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This Lecture ReviewsThis Lecture Reviews

Definitions Definitions Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment

8© AMSP 2010

Glasgow Coma ScaleGlasgow Coma Scale

Eye opening (E): 1-4Eye opening (E): 1-4Motor response(M): 1-6Motor response(M): 1-6Verbal response(V): 1-5Verbal response(V): 1-5E+M+V=Total ScoreE+M+V=Total Score3 (Deep coma)-15(wide 3 (Deep coma)-15(wide

awake)awake)9© AMSP 2010

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Traumatic Brain InjuryTraumatic Brain InjuryDefinitionsDefinitions

© AMSP 2010

Definitions Definitions

Legal intox.=0.08% BAL (blood alcohol Legal intox.=0.08% BAL (blood alcohol level)level)

Std. drink-10-12 gmStd. drink-10-12 gm 0.2 gm/dl0.2 gm/dl 12 oz. beer12 oz. beer 5 oz. wine5 oz. wine 1 oz spirits (gin, vodka, whisky)1 oz spirits (gin, vodka, whisky)

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Alcohol Use DisordersAlcohol Use Disorders

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Intoxication

1 +:

-Slurred speech

-Incoordination

-Unsteady gait

-Nystagmus

- Attention, memory

-Stupor, coma

Alcohol abuse

1 + in same 12 mos.:

- Role obligations

-Hazardous use

-Legal problems

-Interpersonal problems

- Dependence

Alcohol dependence

3+ in same 12 mos:

-Tolerance

-Withdrawal

- Amts. or more time

-Desire/inability to

- Other activities

- Consequences

This Lecture ReviewsThis Lecture Reviews

Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment

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Intoxication and TBIIntoxication and TBI

45% TBI hospitalized legally intox.45% TBI hospitalized legally intox.

Intoxication<19 yo ↑ risk:Intoxication<19 yo ↑ risk:

2 X ↑ Driving after 5+ drinks2 X ↑ Driving after 5+ drinks

1.8 X ↑ Riding with drunk driver1.8 X ↑ Riding with drunk driver

2.6 X ↑ Injuries 2.6 X ↑ Injuries

2.5 X ↑ Violent behavior2.5 X ↑ Violent behavior14© AMSP 2010

Intoxication and TBIIntoxication and TBI

Can mask TBI due to sim. signsCan mask TBI due to sim. signs ↑ ↑ Severity of TBISeverity of TBI ↑↑Intensity of treatmentIntensity of treatment

3X ↑ ICU days3X ↑ ICU days 2.5 X ↑ Benzodiazepines2.5 X ↑ Benzodiazepines 2 X ↑ Opioids2 X ↑ Opioids

↓ ↓ Scores cog. tests 1 mo. post-injuryScores cog. tests 1 mo. post-injury15© AMSP 2010

Abuse/dependence before TBIAbuse/dependence before TBI

37% of TBI have prior 37% of TBI have prior abuse/dependenceabuse/dependence

Abuse/dependence ↑ risk TBI 60% in Abuse/dependence ↑ risk TBI 60% in any yearany year

Post-injury unemployment 3X > TBI Post-injury unemployment 3X > TBI alonealone

Life satisfaction < TBI aloneLife satisfaction < TBI alone ↑↑Risk multiple TBI’sRisk multiple TBI’s

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This Lecture ReviewsThis Lecture Reviews

Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment

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AUD’s Post-TBIAUD’s Post-TBI

50% with AUD ↓ alcohol use after 50% with AUD ↓ alcohol use after TBITBI

2 X ↑ abstinence rates after TBI 2 X ↑ abstinence rates after TBI (15%-30%)(15%-30%)

30% of all in AUD treatment have 30% of all in AUD treatment have unreported hx. of TBIunreported hx. of TBI

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AUD’s Post-TBIAUD’s Post-TBI

25 % develop/maintain AUD after TBI25 % develop/maintain AUD after TBI Risk factors:Risk factors:

Pre-TBI AUDPre-TBI AUD Better physical functionBetter physical function MaleMale YoungerYounger Uninsured or on MedicaidUninsured or on Medicaid UnmarriedUnmarried

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AUD’s Post-TBIAUD’s Post-TBI ↓ ↓ Neuron reorganization from alcohol ↓ Neuron reorganization from alcohol ↓

natural healingnatural healing

TBI +AUD may ↑ atrophyTBI +AUD may ↑ atrophy

TBI +AUD death by suicide 4X > TBI aloneTBI +AUD death by suicide 4X > TBI alone

TBI + AUD death by suicide 7X > gen pubTBI + AUD death by suicide 7X > gen pub

↑ ↑ Involvement criminal justice systemInvolvement criminal justice system

Alcohol use ↑ impact of TBI symptomsAlcohol use ↑ impact of TBI symptoms20© AMSP 2010

This Lecture ReviewsThis Lecture Reviews

Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment

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Prevention TBI/AUDPrevention TBI/AUD

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US Public Health SuccessesUS Public Health Successes

MVA’s once #1 cause TBI, now #2MVA’s once #1 cause TBI, now #2

MADD (MADD (MMothers others AAgainst gainst DDrunk runk DDriving) called for tougher lawsriving) called for tougher laws

Mandatory seat belt laws in US Mandatory seat belt laws in US ↓TBI’s 38% ↓TBI’s 38%

Laws↓ BAL to 0.08% ↓ fatalities Laws↓ BAL to 0.08% ↓ fatalities +TBI’s 36%+TBI’s 36%

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Public Health ChallengesPublic Health Challenges

●●Highest rate drunk Highest rate drunk driving=motorcycledriving=motorcycle

●●2X TBI deaths in 2X TBI deaths in states without states without helmet lawhelmet law

●●<50% of states with <50% of states with helmet lawhelmet law

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This Lecture ReviewsThis Lecture Reviews

Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI✔✔ Assessment/ treatmentAssessment/ treatment

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Assessment: Alcohol WithdrawalAssessment: Alcohol Withdrawal

Caution! TBI may mask withdrawalCaution! TBI may mask withdrawal

SymptomsSymptoms

SignsSigns

InterviewInterview

Physical examPhysical exam

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Treatment: Alcohol Withdrawal Treatment: Alcohol Withdrawal

Benzodiazepines=gold standardBenzodiazepines=gold standard

““Start low, go slow”Start low, go slow”

Longer acting benzos preferredLonger acting benzos preferred

Chlordiazepoxide- 25 mg. PO QIDChlordiazepoxide- 25 mg. PO QID

Diazepam -5 mg. PO QIDDiazepam -5 mg. PO QID

Overmedication→resp.depression,comaOvermedication→resp.depression,coma

Undermedication→delirium,seizureUndermedication→delirium,seizure27© AMSP 2010

Early AUD Treatment after TBIEarly AUD Treatment after TBI Motivation to change alcohol use ↑ after Motivation to change alcohol use ↑ after

TBITBI Alcohol dep. pre-TBI=↑ motivationAlcohol dep. pre-TBI=↑ motivation ↑ ↑ BAL at injury ≠ ↑ motivationBAL at injury ≠ ↑ motivation

Motivational interviewing effective Motivational interviewing effective Non-directive interviewNon-directive interview Patient-centered, empatheticPatient-centered, empathetic Elicits behavior changeElicits behavior change Explores/resolves ambivalenceExplores/resolves ambivalence

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Challenges: AUD+ TBIChallenges: AUD+ TBI

No evidence-based algorithm for tx.No evidence-based algorithm for tx. Cognitive barriers:Cognitive barriers:

↓ ↓ Attention, judgment, insight, languageAttention, judgment, insight, language ↓ ↓ Short term memory, behavior controlShort term memory, behavior control

Interpersonal barriersInterpersonal barriers System barriersSystem barriers

High cost of careHigh cost of care Inpt. AUD programs exclude TBIInpt. AUD programs exclude TBI Outpatient tx. may not be enoughOutpatient tx. may not be enough

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Assessment: AUD +TBIAssessment: AUD +TBI

Routine alcohol screening for all TBI Routine alcohol screening for all TBI patientspatients

Multiple assessment modalitiesMultiple assessment modalities

Interview pt. alone re useInterview pt. alone re use

Review records Review records

Interview familyInterview family30© AMSP 2010

Treatment: AUD +TBITreatment: AUD +TBI

External motivators ↑ effect of tx.External motivators ↑ effect of tx.Financial incentivesFinancial incentivesCase mgmt., peer supportCase mgmt., peer support

Modify tx. conditionsModify tx. conditions↑ ↑ Appointment timeAppointment time↓ ↓ Noise, visual distractionsNoise, visual distractionsFrequent breaksFrequent breaks

31© AMSP 2010

Treatment: AUD + TBITreatment: AUD + TBI ConcreteConcrete

Decision making forms (pros/cons)Decision making forms (pros/cons) Break complex tasks into stepsBreak complex tasks into steps

Behavioral focus (not insight oriented)Behavioral focus (not insight oriented) List specific activities to replace List specific activities to replace

drinkingdrinking Pictorial daily schedulePictorial daily schedule Alarm/watch to initiate activitiesAlarm/watch to initiate activities

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Pharmacology: AUD +TBIPharmacology: AUD +TBI

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ALCOHOL

BenzodiazepinesOxazepam (Serax)

Propanolol

SSRI’sFluoxetine (Prozac)

AntiseizureValproic acid (Depakote)

Processing speed

Seizure control

Processing speed

Sedation

Sedation, Resp. depression

ArrhythmiaHeart failure

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Medications to Stop DrinkingMedications to Stop Drinking

Naltrexone (Revia) 50-100 mg./dayNaltrexone (Revia) 50-100 mg./day

Opioid receptor antagonistOpioid receptor antagonist

Reduces cravings, ↑ abstinenceReduces cravings, ↑ abstinence

Acamprosate (Campral) ~ 2g/dayAcamprosate (Campral) ~ 2g/day

↑ ↑ GABA (inhibits), ↓ glutamate (excites)GABA (inhibits), ↓ glutamate (excites)

Reduces cravings, ↑ abstinenceReduces cravings, ↑ abstinence34© AMSP 2010

This Lecture ReviewsThis Lecture Reviews

Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs

post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI✔✔ Assessment/ treatmentAssessment/ treatment✔✔

35© AMSP 2010