Relationships between Substance Use/Abuse and TBI

Substance use/abuse increases risk of TBI

• Substance use/abuse increases risk-taking behaviors that are associated with sustaining a TBI (e.g., drinking and driving, riding with an intoxicated driver, violence).
• Alcohol is involved in approximately one-half of violence-related injuries.
• Substance abuse increases probability of being involved in a motor vehicle accident.
• Substance use/abuse increases probability of sustaining a TBI due to a fall.
• Individuals who are intoxicated at the time of the TBI are at increased risk for repeat trauma in subsequent years.

Substance use/abuse may affect course/consequences of TBI

• Intoxication at the time of injury may mask a TBI due to similar symptoms (e.g., unsteady gait, confusion), delaying appropriate diagnosis and treatment.
• Individuals with a history of substance abuse/dependence experience brain changes (e.g., cortical atrophy), which can be compounded by a TBI (see Neurological Events Following Head Trauma).

• Intoxication at the time of TBI is associated with need for more intense treatment following TBI.

• Pre-injury substance abuse is a strong predictor of post-TBI disability and non-productivity.
• Persons with no history of pre-injury substance abuse are > 8x as likely to be employed following TBI.

There is no safe amount of alcohol consumption following TBI,

particularly in the first several years of recovery following the injury.

Substance Abuse and TBI Recovery

• Substance use/abuse may complicate issues of TBI recovery by:
• Lowering seizure threshold
• Increasing risk for additional TBIs
• Contributing to brain damage
• After TBI, alcohol and other drugs may have a more powerful effect

• The following TBI-related symptoms may hinder treatment for substance abuse:
• Cognitive limitations
• Increased irritability or emotional distress
• Problems with inhibition
• Treatment of pain with medications

• Negative consequences of ongoing substance use/abuse following TBI include:
• Interference with the natural healing process of the brain
• Increased risk for seizures
• Exacerbations of TBI-related physical and psychological symptoms (e.g., balance difficulties, depression)
• Magnifications of TBI-related cognitive difficulties (e.g., judgment, decision-making)
• Heightened risk for suicide attempts, particularly when depression is also present
• Increased risk for legal difficulties/criminal misconduct
• Difficulties distinguishing whether cognitive difficulties (e.g., problems with memory) are due to TBI or substance abuse
• Increased risk for future TBIs

Individuals often stop using substances after a TBI. However, in some cases, TBI-related difficulties (e.g., impulsivity, diminished judgment) increase the likelihood that a person may initiate or resume substance abuse.

• Risk factors for substance abuse following TBI include:
• Pre-TBI substance abuse
• Post-TBI depression
• Male gender
• Younger age
• Unmarried
• Having Medicaid or no health insurance

Treatments for Substance Use/Abuse

Evaluation, Intervention, and Support are critical for addressing substance use issues in persons with TBI.

CAGE Questionnaire* to evaluate for problematic drinking

(Ewing, J.A., Detecting Alcoholism. The CAGE Questionnaire. JAMA 1984; 252: 1907)

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning (eye-opener) to stop your nerves or get rid of a hangover?

*Two or more “yes” responses suggests a possible alcohol use problem that should be further evaluated by a health care professional.

Interventions for Problematic Substance Use

• Motivational interventions
• Talking therapy interventions designed to enhance a person’s readiness to change target behaviors (e.g., substance abuse).
• Cognitive behavioral interventions
• Therapy that operates by helping the person replace maladaptive thoughts (e.g., “I can only enjoy myself when I’m abusing substances.”) with more functional thoughts (e.g., “I can enjoy myself when not drinking and engaged in other activities – watching movies, spending time with friends, etc.)

• Addressing environmental factors

• In conjunction with interventions directed at changing the behaviors/thoughts of the person abusing substances, therapy must also focus on identifying and addressing social-environmental factors that may be barriers to changing substance use patterns (e.g., substance abuse among family members, peers)

• Therapeutic Community Programs
• These programs offer 24 hour supervision and treatment. They rely on the development of a community (those participating in treatment) that promotes self-evaluation and reflection.

• Medications
• Some medications discourage alcohol use by decreasing cravings.
• Some medications, by treating depression/anxiety, enable persons with TBI to participate in other alcohol treatments.

• Community Support Agencies

• Individual and group therapy offered by community agencies (e.g., Alcoholics Anonymous) can be helpful.

Any use of alcohol or drugs is not recommended for individuals with TBI.

Resources for Substance Use/Abuse

National Organizations

• National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov)
• National Institute on Drug Abuse (http://www.nida.nih.gov/nidahome.html)
• Substance Abuse and Mental Health Services Administration (www.samhsa.gov)

TBI and Substance Abuse

• Ohio Valley Center for Brain Injury Prevention and Rehabilitation (http://www.ohiovalley.org/abuse/index.html)
• Brain Injury Association of America, publications on TBI and substance abuse: At www.biausa.org, search using keywords "substance abuse")
• Substance Use Brain Injury Bridging Project (http://www.subi.ca/)