Brain Injury Treatment And Substance Abuse

The ripple effects of accidents can spread further than most people realize. Traumatic brain injury (TBI), for example, frequently coincides with substance abuse. Sometimes we focus on the obvious — like blunt force trauma to the head from an automobile accident — and miss the addiction following in its wake.

People suffering from both conditions often don’t get help for one or the other. Many, in fact, don’t even know TBI can go hand-in-hand with substance abuse. But parallel treatments can make the puzzle and pain of their lives subside, at least to the extent that they’re able to heal and begin to function in a more normal manner.

Several links have been documented between addiction and traumatic brain injuries. Epidemiological surveys have established that substance use disorder (SUD) or acute intoxication both substantially increases the risk of TBI and makes recovery from it more prolonged.

What is Traumatic Brain Injury?

TBI is a disruption of normal brain function that occurs when the skull is struck, penetrated, suddenly thrust out of position, or struck by blast pressure waves. Some of the common causes of TBI include the following:

  • Crashes of motor vehicles — these may include the head colliding against the vehicle’s windshield or steering wheel or whiplash, which is the brain striking the skull, twisting or scraping against its base
  • Falls — either from a height or a fall on the same level
  • Assaults — causing either penetrating or blunt force trauma
  • Explosions — during which an intense pressure wave passes through the skull (especially common during wartime)
  • Head collisions — smashing into an object (such as a wall), or with another person (as in some form of contact sport, like rugby or football)
  • Hitting and falling objects — examples include bullets and flying debris

During TBI, the initial impact destroys brain tissue by shredding or tearing it. Secondary effects of the injury may cascade in the brain and include edema (swelling), internal bleeding, deprivation of oxygen, and neurochemical responses that lead to cell death. TBI can affect a specific region of the brain (known as a focal injury), or diffuse injury, which is neural cells and tissues distributed throughout the brain, or both.

Nearly two million U.S. injuries each year

As previously mentioned, TBI is much more common than people think. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), every year in the United States, an estimated average of 1.7 million TBIs occur. Among those sustaining TBIs, about 52,000 die, 275,000 need to be hospitalized, and 1.4 million — about 80% — receive treatment and are released from emergency departments.

But the true figure isn’t even comprehended in these estimates. Why? The simple fact is that many people — potentially hundreds of thousands annually — don’t seek medical treatment, or they may get treated in urgent care clinics, doctors’ offices, or in Federal, military or Veterans Affairs hospitals.

Another fact is that males have higher rates of TBI than females, and this holds true across all age groups. Groups with the highest proportions of TBI are adolescents between the ages of 15 and 19 and adults aged 75 and older. The aforementioned sports-related traumatic brain injuries account for between 1.6 and 3.8 million each year.

Service members in Iraq and Afghanistan have the greatest danger of TBIs from an improvised explosive device (IED). Some protection from penetrating head injury is afforded them by helmets and body armor. But helmets and body armor do not protect the brain against the effects of blast waves from IEDs. Other TBIs that are service-related occur from gunshot wounds, motor vehicle crashes, and combat or training-related falls. It is estimated that about 320,000 of the 1.64 million service members deployed to Iraq and Afghanistan through October 2007 may have sustained TBI.

Links between TBI and substance abuse

Several links have been documented between addiction and traumatic brain injuries. Epidemiological surveys have established that substance use disorder (SUD) or acute intoxication both substantially increases the risk of TBI and makes recovery from it more prolonged.

  • History of substance abuse is a risk factor for TBI — Between one-third and four-fifth of patients hospitalized for TBI have histories of misusing substances. The most commonly reported substance of abuse is alcohol.
  • TBI and alcohol use at time of injury is common — When patients with TBI are admitted to the hospital, approximately three-quarters have measurable amounts of alcohol in their blood — and one-third to one-half are intoxicated at the time of injury (that resulted in TBI).
  • Among those in substance abuse treatment, prior TBI is common — Reviews of five studies of people in substance abuse treatment showed estimates of prior TBI ranging from 38 to 63%. In another study of nearly 8,000 patients in state-funded substance abuse treatment programs, almost one-third reported at intake assessment that they had one or more head injuries in the past during which they lost consciousness or spent at least one night in the hospital.
  • Substance abuse is linked with worse outcomes for TBI — Neuropsychological testing and brain imaging studies have indicated that substance abuse and TBI compound the negative effects each has on brain function and structure. A person with a history of substance abuse is likely to have a worse outcome for TBI including a greater likelihood of death, ongoing complications, poorer discharge status from the hospital or emergency department, and ongoing disability and non-productivity for a year or more following brain injury.
  • Substance abuse is also linked to repeat episodes of TBI — When TBI is related to alcohol use, this increases the risk of subsequent TBI, which is often alcohol-related. Furthermore, the risk extends for several years after the first TBI. What researchers do not yet know is whether TBI itself increases the risk of substance abuse in those not otherwise at psychiatric or psychological risk of addiction (at the time they are injured). There is some evidence that suggests that regions of the brain affected by TBI, especially the frontal cortex, may induce deficits in cognitive processes involving self-regulation and mental control that confer a general risk for substance abuse.

How TBI affects substance abuse

One point about patients with TBI is that there’s an association with subsequent reduced consumption or abstinence. This is not surprising, due to the continued monitoring of patients during hospitalization, as well as recommendations from outpatient healthcare providers to refrain from alcohol or drug use. Other factors contributing to reduced substance use include decreased access to alcohol or drugs (perhaps because of physical limitations or scrutiny by caregivers), a decreased tolerance to substances, and decision to make lifestyle changes following injury. Some patients with TBI, however, only temporarily reduce use of substances.

Research finds that a minority begins or resumes drinking in the first year following injury. Those with a prior history of substance abuse before TBI are at higher risk for heavy drinking afterward. Not only alcohol, but the stimulants and painkillers frequently prescribed to treat cognitive disruption and pain from TBI have their own potential for abuse.

What this means for treatment is that providers need to be aware of the following:

  • TBI can serve as a triggering event that causes the patient to reduce consumption or abstain from substance use. In this sense, patients choose to reform their ways and alter their patterns of behavior.
  • The longer the time from the TBI, the more the risk increases for a return to prior abuse patterns.
  • Patients who have a history of substance abuse may need increased continuing care or aftercare and heavier emphasis on relapse prevention.

TBI and substance abuse treatment

Care for these two conditions can and should be concurrent. Physical and mental recovery from TBI takes time. So does recovery from substance abuse. Here are some of the things that patients with TBI and substance abuse can expect to find during treatment.

  • Rehabilitative services — Recovering from TBI means having to re-learn some things, or to become physically stronger to be able to function normally again. Those referred into treatment for TBI may be able to have access to a range of rehabilitative services. These include exercises to help improve memory, problem-solving ability, reading, speech, physical functioning, attention span, instruction in coping and compensating strategies, and skills and vocational retraining.
  • Therapy — TBI treatment may also include medication and therapy to treat symptoms of injury, including pain, seizures, sleeplessness, anxiety and depression. TBI patients with substance abuse, who have cognitive limitations related to TBI, may benefit from a counseling environment with few distractions and frequent rest breaks. Structured instruction, presented in a variety of formats, is the best support for helping patients to acquire adaptive and coping skills. Therapist feedback to the patient should be specific, direct, positive and immediate.

Coordination with other therapists and care providers will be helpful for patients with TBI and substance abuse. Collaborative care teams may include physicians and specialists for physical and neurological rehabilitation, vocational rehabilitation, psychiatric disorders, employment services and family support services.

Patients with TBI need to be encouraged that their brain injury will heal. Most do, over time, and the reassurance that counselors give patients that their head will clear and they’ll be able to function cognitively again helps spur recovery from the effects of TBI.

Education about the importance of refraining from substance use is imperative. Patients need to be educated about the high risk of subsequent TBI if they resume or begin using substances. They also need to be made aware of the fact that a repeat TBI can cause even greater brain damage.

Motivational counseling has also been shown to help patients in recovery from TBI and substance abuse. Such motivational counseling is often an adjunct to other types of therapeutic techniques for the TBI patient with substance abuse.

Support-group participation is highly recommended. There are TBI support groups that are available and substance abuse treatment programs can also form their own in-house TBI support group. Another option is peer mentors for patients affected with TBI.

Finding treatment for substance abuse

Many times following a traumatic brain injury, the individual and his or her family are most concerned with healing the body. But referral to a substance-abuse clinic can also help the patient cope with the knock-on effects.

SAMHSA maintains a Treatment Facility Locator that can serve as a helpful first step. Its includes searchable databases of treatment programs, including residential treatment centers, outpatient treatment programs, and hospital inpatient programs for drug addiction and alcoholism. Listings include programs treating marijuana, cocaine, and heroin addiction, as well as alcohol and drug addiction treatment programs for adolescents and adults.

Referrals can also be obtained through the hospital treating for TBI initially, as well as physicians and other specialists the patient sees following the TBI. Enlisting the help of family or close friends — particularly if the TBI patient is severely debilitated — can speed up the process of finding the appropriate facility to treat patients with substance abuse and TBI.

The outlook is hopeful

What should be of primary importance to anyone interested in treatment for traumatic brain injury and substance abuse is that the outlook is hopeful if the patient enters treatment, commits to it, stays with it, and continues to receive aftercare following a formal treatment program, and participates in self-help support groups on a continuing basis following treatment.

The brain and the body are remarkable in their healing power. While TBI can be mild or moderate or severe, with proper care and attention, the patient can heal. Substance abuse treatment can help the patient with TBI learn how to overcome dependence on substances and cope with crises, emotional turmoil and pain by changing behavior and focusing on healthier goals.

It won’t happen overnight, so expectations that a patient will just wake up tomorrow and be perfectly fine are completely unrealistic. It just doesn’t happen that way. TBI patients will require varying lengths of recovery time. By the same token, those with co-occurring substance abuse will have their own timetable for healing — and it’s different for everyone. There is no one-size-fits-all treatment program that works for every person, whether it’s for TBI or substance abuse.

The goal is to be able to return to a productive and functioning life, one that’s abstinent of substances and allows the individual to be as independent and self-fulfilled as he or she desires.

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