ALCOHOL AND BRAIN INJURY

1. ALCOHOL AND BRAIN INJURY A DOUBLE TROUBLE? Steve Shears Headway UK

2. Aims • To consider the issue of traumatic brain injury and alcohol abuse. • To explore developments and research into TBI rehabilitation that integrates substance misuse into the treatment programme.

3. Scale of the problem? • WHO (2004) – worldwide 76.3 million people have diagnosable alcohol disorder. Half of the deaths alcohol plays a part in are from unintentional mishaps/accidents. • Some researchers suggest that substance/alcohol misuse is a significant problem for some people prior to brain injury (Delmonico et al 1998, Sander et al 1997) • Corrigan (2005) cited the findings of the Centre for Substance Abuse Treatment (1998) that substance abuse is more prevalent in people with disabilities. • Miller (1995) claimed that treatment for alcohol addiction was not well integrated into brain injury rehab.

4. Times they are a changing? • My literature review (Sept 05) of the treatment for alcohol problems within brain injury rehabilitation indicated it was still not widely integrated into the rehabilitation setting. • This is despite alcohol and other substance abuse being a problem for a significant amount of TBI survivors and the effects of alcohol and TBI on the brain being worse than either factor alone (Buguley 1997 – ERP Studies)

5. Risk Factors Alcohol Use After ABI(Source BIUSA) • Alcohol and other drugs interfere with new connections between neurons. • It can exacerbate post-brain injury balance problems and lead to falls (and further brain injuries) • Brain injury sometimes leads to people saying the first thing that comes to mind. Alcohol tends to have this effect anyway so increases the possibility of social/relationship problems. • Brain injury causes cognitive problems like concentration difficulties and alcohol and other drugs make this worse. • The brain is more sensitive to alcohol and other drugs following brain injury.

6. Brain injury – a window of opportunity? • Brain injury as a turning point for alcohol and substance misuse (Bombardier et al 2002) study concluded that there was a readiness to change in most at risk drinkers and the brain injury rehabilitation setting was a good place to assess/intervene. • Bombardier et al (1997) sample of 50 – according to their RCQ scores 84% were in ‘contemplation’ or ‘action’ phases of readiness to change.

7. Substance misuse and brain injury – Ohio Valley, USA

8. Integrated programmes. • Interesting work going on at Ohio Valley centre for brain injury prevention and rehabilitation in substance abuse treatment and brain injury. • This includes information and self-help literature for TBI survivors about substance use and brain injury. Researchers from Ohio Valley also wrote the BIUSA information booklet about this subject. • www.ohiovalley.org

9. Ohio Valley –Users Manual for the Brain Ohio Valley Centre presents a Users Manual For Faster. . .More Reliable Operation of a Brain after Injury

10. Part of the manual www.ohiovalley.org The human brain is often com pared to a computer, full of bits of information, able to make swift, steady connections. Just like a computer, the brain has many programs like the ones that allow us to move, think and make decisions.

11. Part of the manual (II) www.ohiovalley.org The effects of alcohol and other drugs are different for people after a brain injury. This User’s Manual presents facts about how alcohol and other drugs affect people with brain injuries. These facts – like software – are ready to be installed. But you’re the operator.If you have had a brain injury, take time to study this manual. Read. Think. Decide. We hope after you’ve done that, you will install new alcohol/other drug software – a new set of facts, attitudes and beliefs – in your brain.

12. Part of the manual (III)

13. The neuroscience of dependence. Mesolimbic Dopamine System

14. Neuroscience of dependence • Summary • Ethanol increases the firing rate of the ventral tegemental area (VTA) dopamine neurons and release of dopamine in the nucleus accumbens (Nac) –part of the mesolimbic dopamine system. Explains reinforcing effect of alcohol. • It increases the inhibitory action of the GABA-A neurotransmitter receptors and decreases the excitatory effects of the glutamate receptors. This explains the sedative effect of alcohol and the memory impairments during intoxication.

15. Treatments for Alcohol Dependence • Chemical treatments – anti-abuse medications –makes the person sick when they try to drink alcohol (Disulfiram). • Chemical treatments – Acamprosate – restores the normal functioning of the glutaminergic neurons, which become hyper-excited during alcohol abuse. Naltrexone – helps prevent relapse. • Psychosocial interventions – counselling, cognitive behavioural therapy, motivational interviewing (MET), 12 Step programmes (Alcoholics Anonymous). • Project MATCH.

16. Research into motivation for keeping in substance treatment following TBI • Corrigan et al (2005) • Trial of 4 different approaches to motivation to complete substance abuse treatment for people who had survived TBI. • Attentional control, MET Interview, Barrier Reduction and Financial Incentive. • Most successful approaches in terms of signing up tp programme and completion of programme was financial incentive, followed by barrier reduction. • Implications for substance/TBI rehabilitation.

17. Stages of Change – DiClemente and Prochaska • Pre-contemplation • Contemplation • Action

18. Readiness to Change Questionnaire (RCQ) • My thoughts about alcohol and me (Circle the statements that you feel you agree with) • 1. I don’t think I drink too much. • 2. I am trying to drink less than I used to. • 3. I enjoy drinking, but sometimes I drink too much. • 4. Sometimes I think I should cut down on my drinking. • 5. It’s a waste of time thinking about my drinking. • 6. I have just recently changed my drinking habits. • 7. Anyone can talk about wanting to do something about drinking, but I am actually doing something about it. • 8. I am at a stage where I should think about drinking less alcohol. • 9. My drinking is a problem sometimes. • 10. There is no need for me to think about changing my drinking. • 11. I am actually changing my drinking habits now. • 12. Drinking less alcohol would be pointless for me.

19. Appendix - Definitions • DSM-IV Definition of substance abuse. • ‘A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period. • 1) Tolerance to the substance. • 2) Withdrawal • 3) Substance is taken in larger amounts or over a longer period of time than was intended. • 4) Persistent desire or unsuccessful efforts to cut down or control substance use.

20. Appendix - Definitions – Continued…… • 5) A lot of time is spent trying to obtain the substance. • 6) Important social, recreational and occupational activities are given up or reduced because of substance use. • 7) The substance use is continued despite a knowledge that the substance is causing or making worse a psychological or physical problem.

21. References • Corrigan JD, Bogner J, Lamb-Hart G, Heinemann AW, Moore D (2005) Increasing substance abuse compliance for persons with traumatic brain injury. Psychology of Addictive Behaviours 2005, Vol 19, No 2, 131-139. • DSM-IV (1994) The Diagnostic and Statistical Manual of Mental Disorders. The American Psychiatric Association. • Neuroscience of Psychoactive Substance Use and Dependence. (2004) World Health Organisation (WHO) • Readiness to Change Manual (1993&2000) Heather and Rollnick.

22. More References • Bombardier CH, Ehde D, Kilmer J. (1997) Readiness to change alcohol drinking habits after traumatic brain injury. Arch Phy Med Rehab.June;78(6):592-6. • Bombardier CH, Rimmele CT, Zintel H. (2002) The magnitude and correlates of alcohol and drug use before traumatic brain injury. Arch of Phy Med Rehab. Dec;83(12):1765-73.

23. Units of Alcohol