Howard Jackson - substance abuse abi

24/09/2012

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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.

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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

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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.



1 Engagement

2 Detoxification


life-style)


substituting)



2. DETOX

Higher risk of epilepsy/death

Increased risk of delerium tremens

Idiosyncratic response to medication

Increased behavioural problems with withdrawal

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1 Engagement

2 Detoxification

3 Establishing Operations (an alternative

‘substance-free’ life-style)


substituting)



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



1 Engagement

2 Detoxification


life-style)

4 Addressing Functional Value of Substance

Abuse (and substituting)



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)

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1 Engagement

2 Detoxification


life-style)


substituting)



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)


Substance Abuse after ABI 1 Engagement

2 Detoxification


life-style)


substituting)


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

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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

Health & Medicine

Howard Jackson - substance abuse abi