Vinland’s Associate Director Duane Reynolds was featured in the latest issue of The Carlat Report, a monthly publication for all things in addiction medicine. He discussed substance abuse treatment for individuals with traumatic brain injuries in the publication’s Expert Q & A feature. The article is reprinted here with permission.
CATR: How common is traumatic brain injury (TBI) in patients with addiction?
Mr. Reynolds: In the state of Minnesota, where licensed treatment programs are required to submit data to a large registry, 2.6% of clients in 2012 had a traumatic brain injury. That number is probably on the low side. In Kentucky, where there is also mandatory reporting, 32% of clients had a history of TBI when they were specifically assessed using the Brain Injury Screening Questionnaire (Walker R et al, J Head Trauma Rehabil 2007;22(6):360–367). An older review of six studies found that between 38% and 63% of clients seeking substance abuse treatment reported a history of brain injury (Corrigan JD et al, J Head Trauma Rehabil 1995;10(3):29–46). The bottom line is that it’s pretty common.
CATR: And what are the causes of TBI?
Mr. Reynolds: According to the Centers for Disease Control and Prevention, there were 2.5 million emergency department visits, hospitalizations or deaths related to TBIs in 2010 (http://1.usa.gov/VIjVoX). The top cause—about 41% of cases—was falling. Unintentional blunt trauma accounted for 16% of cases, followed by motor vehicle accidents (14%). Another 11% of TBIs were due to assault.
CATR: Does addiction come before TBI or after?
Mr. Reynolds: It’s well established that addiction is a risk factor for TBI and a lot of people are intoxicated at the time of their injury. There is also emerging evidence that causality cuts the other way—that TBI may increase the risk for developing later addiction (Bjork JM & Grant SJ, J Neurotrauma 2009;26(7):1077–1082). Some of this may be due to acquired problems with executive function, but part of it may also be the desirable effects of the substances themselves. This is especially true for methamphetamine or other types of drugs that give people with TBI the perception of being more alert and more in control.
CATR: Does TBI change the trajectory of substance use?
Mr. Reynolds: Studies have found that substance use decreases, often substantially, following TBI (Graham DP & Cardon AL, Ann NY Acad Sci 2008;1141:148–162). For those who continue to use substances, alcohol and other sedatives typically have a greater effect on a person who has cognitive impairment. They will be less likely to think clearly. Addiction can also get in the way of a person’s recovery from their brain injury. When a person gets discharged from the hospital, they need to be able to engage in cognitive and vocational rehabilitation. All of that is often lost because of drinking and other drug use.
CATR: How do cognitive problems impact patients during addiction treatment?
Mr. Reynolds: Clients with TBI do not do well in a standard treatment program where they are sitting in group sessions that last an hour and a half to two hours. They can’t sit still and concentrate for that long. Cognitively they are unable to track or follow the discussion. They get overloaded and fatigued easily. These clients may have aphasias or other reading difficulties, so the usual techniques like lectures and written treatment plans and assignments don’t do a lot of good. Clients often are embarrassed by their disabilities, too. The more you cognitively try to push them, the more their wheels spin. They eventually say, “I can’t do this anymore,” and they leave treatment.
CATR: How do people with TBI do after completing addiction treatment?
Mr. Reynolds: Although this hasn’t been extensively studied, there are some data from specialized centers. For example, in one investigation, 75% of clients were judged to have a positive substance use outcome at one year (Bogner JA et al, J Head Trauma Rehabil 1997;12(5):57–71). When you slice that number, 50% had varying periods of abstinence and the remaining 25% had reduced their substance use. Here at Vinland, we perform follow-up at six months where we call clients and ask them “Are you sober?” or “Have you reduced your substance use?” About 50% to 60% report that they are abstinent and another 20% to 25% say they have moderated their use.
CATR: What can a standard treatment program do to enhance the experience of patients with TBIs?
Mr. Reynolds: They can conduct shorter group therapy sessions of no more than 45 minutes, use simple treatment assignments, and provide more one-to-one therapy. There should not be a lot of distractions in group rooms and other care delivery areas. Sometimes symptoms of head injury are interpreted by clinicians as resistance to treatment. Frontal lobe disruption can impede planning, implementing plans and goals, and problem solving, which are characteristics of a motivated client.
CATR: What else?
Mr. Reynolds: As I mentioned, clients with TBI often don’t find the group experience to be very beneficial because they become easily confused or flustered, and when two or three people start talking, they just zone out. So there should be more individual therapy with the client. Another thing is to keep assignments and concepts simple. Ask closed-ended questions. Sometimes a person with a head injury just can’t put two and two together and come up with an abstract four. They need very concrete questions and answers. And you often have to fill in the blanks—they struggle to deduce things from what you are telling them. And often there are memory issues. We give people planners and teach them to write down their daily tasks and appointments.
CATR: So individualizing treatment is critical.
Mr. Reynolds: Correct. For example, we had a client with alexia who couldn’t recognize words anymore. The counselor would be writing on a board or showing clients how to do something, but he just couldn’t get it. Fortunately, his receptive language ability to spoken voice was preserved. So, with that client, I sat next to him in groups and told him what we were talking about and sort of translated. This is just a concrete example of a general principle. There are usually ways around problems—it just takes more work. You have to slow it down, spend more time with the person, and give highly individualized care.
CATR: You mentioned that there can be problems with group therapy, which is traditionally the cornerstone of treatment. Should we be doing it at all?
Mr. Reynolds: Yes, but with modifications. We have small groups of perhaps six to 10 people, which is smaller in size than normal groups. And our sessions are only 45 minutes in length, which, again, is shorter than normal groups. We also have breaks between groups for clients to decompress, whereas traditional treatment schedules are pretty full.
CATR: How about the actual content of groups?
Mr. Reynolds: Our approach is grounded in Illness Management and Recovery, an evidence-based approach that has been popularized by the Substance Abuse and Mental Health Services Administration (http://1.usa.gov/1wje1eL). The content is simple and there is often a lot of repetition. For instance, a session may focus on medications. Clients will have a list of their medications and how often to take them. We will discuss medication minders—labeled with the days and times for taking medications—as a way of helping clients become more competent in self-management. Another session might focus on symptom recognition. And so on. At the end of each session, we ask clients to verbalize or write down what they learned. Hopefully, they can identify one concrete thing to add to their toolbox.
CATR: Are there other things that you think our readers should know about treating addiction in people with TBI?
Mr. Reynolds: A client was asked what he thought about his TBI and he said, “You know, they tell me that my TBI is mild, but it’s not mild to me.” That illustrates how this can be a hidden disability. You often can’t tell by looking at a client that they have trouble with numbers, sequencing things, or other cognitive difficulties. And they may be too ashamed to tell you. So it’s important to maintain a high index of suspicion for TBI and assess clients for cognitive problems if you sense something is going on.
CATR: Thank you, Mr. Reynolds.