Treating Clients with Traumatic Brain Injury Substance Abuse and Mental Health Services Administration Page 1 of 6

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  Is there a "best treatment" for a person to avoid using alcohol and drugs after a brain injury, or does it just depend on the individual?

   

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• Avoiding Substance Abuse After Brain Injury?
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  I run a substance abuse support group and I suspect one of the members in the group may have experienced a brain injury at one time. His behavior is often inappropriate and he has trouble remembering what’s been said or following along with the conversation. I’m afraid to ask him directly because he gets angry easily. Any suggestions?

   

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• Recognizing TBI in Substance Abuse Support Groups
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  Jan Brown talks about her experience with substance abuse following traumatic brain injury. Transcript of this video.
  
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  Transcript of this video. "For veterans and non-veterans with TBI, the only amount of drugs and alcohol that is safe is none." Produced by Victoria Tilney McDonough and Brian King.
• Concern About My Brother With a TBI Drinking
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  My brother was in a car crash about eight months ago and had a brain injury. He was driving drunk and had a history of alcohol and drug abuse. The problem now is he’s in a lot of pain and I don’t know whether it’s my place to tell his doctor that he has a drug problem. What should I do?

   

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• Coming Clean About Drugs with Your Doctor

Traumatic brain injury (TBI) is a frequent but under-recognized condition co-occurring with substance use disorder (SUD). TBI can cause a wide range of cognitive and behavioral consequences that interfere with a client’s ability to adhere to substance abuse treatment.

Some clients with TBI enter substance abuse treatment with their injury diagnosed, while others may enter with an undiagnosed TBI that has lingering effects. Treatment counselors also may not recognize clients who have been affected by TBI because its effects overlap with those of SUD and other co-occurring conditions such as depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD).

Substance abuse treatment counselors need to be aware that TBI may be a health condition affecting their clients. Through observation and questioning, counselors can try to identify clients whose functioning is affected by TBI and who may require special strategies in their treatment for SUD. Counselors also can incorporate these important facts into relapse prevention messages for all clients: that substance abuse increases the likelihood of a first or recurrent TBI and that TBI compounds the brain function problems caused by substance abuse.

What Is TBI?

TBI is a disruption of normal brain function that occurs when the skull is struck, suddenly thrust out of position, penetrated, or struck by blast pressure waves. Common causes of TBI include: ^1,2

• Falls from a height or on the same level.
• Motor vehicle crashes, which may include collision of the head against a windshield or steering wheel or whiplash (the brain striking the skull, scraping against its base, or twisting).
• An object hitting the head, such as a bullet, flying debris, or a falling object.
• The head colliding with an object (e.g., a wall) or with another person (e.g., in a contact sport).
• Assaults causing either blunt or penetrating trauma.
• Explosions in which an intense wave of pressure passes through the skull.

The initial trauma tears, shears, or destroys brain tissue. These effects may cause a second injury cascade in the brain including internal bleeding, edema (swelling), oxygen deprivation, and neurochemical responses leading to cell death. A TBI can affect a single, specific region of the brain (a focal injury), neural cells and tissues distributed throughout the brain (a diffuse injury), or both.

How Common Is TBI?

Each year, an estimated average of 1.7 million TBIs occur in the United States. Of those sustaining these injuries, 52,000 die, 275,000 are hospitalized, and 1.365 million — nearly 80 percent — are treated and released from emergency departments. Potentially hundreds of thousands more individuals sustain TBI each year but are not included in the data sets used to form these estimates because they do not seek medical treatment or because they are treated in physicians’ offices, urgent care clinics, or Federal, military, or Veterans Affairs hospitals.³

In every age group, TBI rates are higher for males than for females. Among the age groups that have the highest proportions of TBI are adolescents ages 15–19 and adults ages 75 and older.³ Sports-related TBIs alone are estimated at between 1.6 million and 3.8 million each year.⁴ For service members in Iraq or Afghanistan, the main TBI risk is from an improvised explosive device (IED) such as a roadside bomb. Helmets and body armor provide some protection against penetrating head injury and, to a lesser extent, head-impact events. However, the brain remains vulnerable to the effects of blast waves from IEDs. Gunshot wounds as well as combat- or training-related falls and motor vehicle crashes are other causes of service-related TBI. It is estimated that some 320,000 of the 1.64 million service members deployed to Iraq and Afghanistan through October 2007 may have incurred TBI.⁵

What Are the Links Between SUD and TBI?

Epidemiological surveys have established that acute intoxication or SUD dramatically increases risk of TBI and impairs TBI recovery. The data are described below.

History of substance abuse is a risk factor for TBI.
Among patients hospitalized for TBI, between one-third and four-fifths have histories of substance misuse, with alcohol being the most commonly reported misused substance.^6,7,8

Alcohol use at time of injury is a common occurrence with TBI.
Approximately three-quarters of all patients with TBI have measurable amounts of alcohol in their blood when admitted to the hospital,⁸ and one-third to one-half of them are intoxicated at the time of injury.^6,7

Prior TBI is common among individuals in substance abuse treatment.
In a review of five studies of people in substance abuse treatment, estimates for prior TBI ranged from 38 percent to 63 percent.⁹ In another study of 7,784 adults in State-funded substance abuse treatment programs, almost one-third of persons assessed at intake reported a history of one or more head injuries for which they lost consciousness or were hospitalized at least 1 night.¹⁰

Substance abuse is linked to worse outcomes from TBI.
Brain imaging studies and neuropsychological testing indicate that SUD and TBI compound the negative effects each has on brain structure and function.9 A substance abuse history is associated with worse outcomes from TBI including greater likelihood of mortality, complications, and poorer hospital or emergency department discharge status,6 as well as ongoing disability and nonproductivity a year or more after brain injury.11

Substance abuse is linked to recurrent TBI.
TBI related to alcohol use increases the risk of subsequent TBI, often alcohol-related; this risk extends for several years after the first injury.¹²

It is not yet known whether a TBI itself increases risk of SUD in persons otherwise not at psychological or psychiatric risk of addiction at the time of injury. Some evidence suggests that TBI, especially to frontal cortex regions, may induce deficits in executive function (cognitive processes affecting mental control and self-regulation) that confer risk for SUD generally.¹³

Is TBI Diagnosed?

TBI is initially diagnosed as mild, moderate, or severe, based on the individual’s condition at the time of injury. About 75 percent of all TBIs are mild.¹⁴ Concussion is often used as a synonym for mild TBI, especially in reference to sports injuries.

Center for Substance Abuse Treatment. (2010). Treating Clients With Traumatic Brain Injury. Substance Abuse Treatment Advisory, Volume 9, Issue 2. www.samhsa.gov.

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