Substance abuse disorders are a relatively common occurrence in the traumatic brain injury (TBI) population. Premorbid rates of substance use are around the same or may even exceed those of the general population. Whether it is associated with the mechanism of injury or post injury behavior, clinicians must be astute in managing these conditions.
Epidemiology
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36% to 51% are intoxicated during injury.
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22% to 29% drink hazardously between 1 to 3 years postinjury. Alcohol use peaks 2 years postinjury and stabilizes afterward.
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Alcohol is the most commonly abused substance in TBI.
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37% to 66% of TBI patients abuse alcohol, whereas 10% to 44% abuse illicit drugs.
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Daily cigarette use is prominent in TBI patients.
Risk factors
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Young age
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Male gender
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Unmarried
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Greater TBI severity
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Repetitive injury
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History of substance abuse
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Psychiatric disorders
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Damage to specific neural circuits: prefrontal cortex (PFC), nucleus accumbens, and the ventral tegmental area. These areas are thought to mediate substance abuse behavior.
Definitions
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Unhealthy (or risky) consumption constitutes a substance use disorder (SUD)
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“Risky” drinking:
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15+ drinks/week, 5+ drinks/day for men
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8+ drinks/week, 4+ drinks/day for women
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Abuse (older term from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV])
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Continued use despite imminent consequence
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Behavior centers around acquisition, consumption, and recovery
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DSM-V combines the DSM-IVs categories of substance abuse and substance dependence into a single group called substance use disorder. ,
Screening
The goals of screening individuals are to identify those with histories of substance misuse and to treat accordingly. Screening also helps to identify issues earlier to manage and treat these individuals effectively. All patients should be intermittently screened for substance misuse. Individuals with TBI often have associated cognitive and neurobehavioral impairments that can limit or confound testing results.
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These standardized measures are self-report questionnaires.
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Alcohol abuse and dependence:
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Alcohol Use Disorder Identification Test (AUDIT): Currently recommended for use in TBI research. Most sensitive to low levels of hazardous alcohol use and can detect episodes of binge drinking. Can detect problems drinking earlier than other screening measures.
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Cut-down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire
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Brief Michigan Alcohol Screen Test
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Illicit drug use:
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A screening standard for drug use in TBI has not been recommended.
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Drug Abuse Screening Test (DAST): Most commonly used self-report measure for detecting drug abuse
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Simple Screening Instrument (SSI)
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Effect on recovery/long-term consequences ,
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Increased extent of brain damage (greater brain atrophy, diminished white matter integrity)
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Exacerbation of existing neurological sequela (physical, cognitive, psychological)
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Lowers seizure threshold
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Increased risk of mood/psychiatric impairments, suicide attempts
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Increased risk for additional TBIs
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Impaired vocational outcome
Interventions
There is no cure or definitive treatment for substance abuse disorders. The unique challenges in treating the brain injury population are the cognitive impairments limiting learning and the efficacy of brief interventions/didactic lesson-based strategies. It is important to educate families also on the consequences of substance misuse on TBI recovery and risks of developing a substance use disorder after TBI.
Behavioral interventions
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Cognitive behavioral therapy (CBT)
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Helps patients modify construed thought processes and alter behaviors that may promote substance use
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Mindfulness-based relapse-prevention therapies
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Includes the use of meditation to increase awareness of thoughts, feelings, and the environment to manage drug cravings/use
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Counseling
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Includes 12-step programs such as Alcoholic Anonymous
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Referral to community resources is an integral part of disposition planning in rehabilitation
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The Substance Abuse and Mental Health Services Administration (SAMHSA)’s Behavioral Health Treatment Services Locator is an electronic database of thousands of treatment programs for different addictions, ages, and settings.
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When referring to programs, be cognizant of the patient’s cultural background and socioeconomic status.
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Financial incentives and addressing barriers have resulted in better patient compliance than motivational interviewing.
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A community-based model using intensive case management has been shown to improve outcomes.
Pharmacological management
Pharmacological management of SUD is recommended in moderate to severe cases. These agents reduce alcohol consumption, prevent relapse, and promote abstinence. No one agent has been deemed superior to the others in the TBI population.
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US Food and Drug Administration (FDA)–approved pharmacological interventions exist for the management of alcohol and opiate dependence ( Table 41.1 ).
TABLE 41.1Related posts:
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