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Substance Abuse and Brain Injury

Substance Abuse and Brain Injury. Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration. The Elephant In the Room: Brain Injury and Substance Abuse. Overview. Overview of TBI-Screening for TBI Briefly: Facts and Figures-What is The Problem?

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Substance Abuse and Brain Injury

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  1. Substance Abuse and Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

  2. The ElephantIn the Room:Brain Injury and Substance Abuse

  3. Overview • Overview of TBI-Screening for TBI • Briefly: Facts and Figures-What is The Problem? • Lessons Learned-What brain injury professionals have and haven’t done to address the Brain Injury/ Substance Abuse Connection

  4. Overview • Utilities for Community Professionals-Ohio Valley Model • Substance Abuse Screening tools • Modifying Substance Abuse treatment and intervention strategies for individuals with brain injuries

  5. Definitions: How brain injury may be defined in the Medical Record • Acquired Brain Injury is an insult to the brain that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia • Diffuse Axonal Injury the tearing and shearing of microscopic brain cells • Traumatic Brain Injury is an insult to the brain caused by an external physical force

  6. Incidence of TBICDC 2004 In the United States, at least 1.6 million sustain a TBI each year

  7. Incidence of TBI …….Of those 1.6 million.. CDC 2004 • 51,000 die; • 290,000 are hospitalized; and • 1,224,000 million are treated an released from an emergency department

  8. Annual Incidence of TBI with DisabilityAN ESTIMATED 124,000 American civilians Cited by Jean Langlois ScD,MPH NASHIA Conference 2007 Preliminary findings as analyzed by Selassie, et. al

  9. Service Members returning with TBIRevised Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09 & MSNBC.com 3.4.09 • Pentagon estimates up to 360,000 Iraq and Afghanistan vets may have suffered brain injuries • Of the 360,000 are 45,000 to 90,000 whose (more severe) symptoms persist & require specialized care

  10. Service Members returning with TBIRevised Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09 & MSNBC.com 3.4.09 • These numbers are based upon Military health-screenings that show 10% to 20% of returning troops have suffered at least a mild concussion • Among them 3%-5% with persistent (concussive) symptoms that require specialists, e.g. ophthalmologists to deal with vision problems

  11. Service Members returning with TBIRevised Numbers 3.3.09 Gregg Zoroya, USA Today 3.4.09 & MSNBC.com 3.4.09 • The estimate represents 20% of the 1.8 million troops who have served in Iraq and Afghanistan • According to Lt. Col. Lynne Md. Lowe of the Army surgeon general’s office, the Army spent $242 million in 2008 for staff, facilities, and programs to serve brain injured troops

  12. Polytrauma “a unique constellation of injuries”Archives of Phys Med Rehab 1/08 Friedemann-Sanchez G. et al • Amputations • Craniectomies • Burns • Traumatic Brain Injury • Vision problems are being report with greater frequency, according to the Blinded Veterans Association 75% of those with TBI have visual complaints

  13. Causes of TBICDC 2006

  14. The Scope of the ProblemCenters for Disease Control 2004 • Approximately 475,000 TBIs occur among children ages 0-14 • ED visits account for more than 90% of the TBIs in this age group • The two age groups at highest risk of traumatic brain injury are ages0-4and15-19

  15. About 3.17 Million Americans live with the consequences of traumatic brain injury(that we know of-those who are counted)Centers for Disease Control (2008)

  16. MD TBI Project 2006-2009Consumer Profile (182 consumers, recipients of community based resource coordination services) • Men (@56% of consumers) • On average 9 years post injury • Mental Health issues42% • Drug and Alcohol use and abuse28.% • Homelessness/danger of homelessness 6% • 86% unemployed • @15% of consumers have had some kind of forensic involvement

  17. There are many we don’t count • 425,000 treated by MD’s in office visits • 90,000 treated in other outpatient settings • Untold numbers who fall, are assaulted, play, sports etc. • 360,000 service members returning from Iraq & Afghanistan reporting a “probable” TBI=20% who have servedLangloiset. al., Rand Corporation, 2008, cited by Wayne Gordon Ph.D, Webcast, Maternal and Child Health Bureau 5.22.08 at www.mchcom.com

  18. “Reframed, the numbers nauseate. In America alone, so many people become permanently disabled from a brain injury that each decade they could fill a city the size of Detroit……...

  19. ….Seven of these cities are filled already. A third of their citizens are underfourteen years of age.”From Head Cases, Stories of Brain Injury and its AftermathMichael Paul Mason2008 published by Farrar, Straus and Giroux

  20. The Scope of the Problem • Distribution of Severity: • Mild injuries = 80%Loss of consciousness <30 min. Post traumatic amnesia < 1 hour • Moderate = 10 - 13%Loss of consciousness 30 min.-24 hrs. Post traumatic amnesia 1-24 hrs • Severe = 7 - 10% Loss of consciousness > 24 hours. Post traumatic amnesia >24 hrs

  21. The Importance of Post Traumatic Amnesia PTA is the period of time after injury when a person is unable to lay down new memories…for example

  22. “That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled” Ryan Church, NYT 3/10/08 “All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel NYT reporter

  23. What happens in a TBI? • Mechanism – Acceleration/Deceleration • Differential movement of partially tethered brain within the skull • Results in: • Bruising of the brain surface against rough areas of the skull • Stretching and twisting of nerve axons

  24. Skull Anatomy The skull is a rounded layer of bone designed to protect the brain from penetrating injuries. The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration. Dr. Mary Pepping

  25. Primary Injuries… Coup-Contra Coup

  26. Primary Injuries… Rotational forces on the brain cause the stretching, snapping and shearing of axons Diffuse Axonal Injuries

  27. The Developing Brain • Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old • The brain, and most importantly the brain’sfrontal loberegion does not reach it’s fullcognitive maturity till individuals reach their mid twenties. • The frontal lobe is very vulnerable to injury

  28. Take Home Message Kids “Grow” Into Their Brain Injuries G. Gioia Ph.D Children’s National Medical Center

  29. Other potential Neurotoxins that may impact the brain • Exposure to lead paint • Regarding exposure to alcohol in utero, according to Dr. Jacobson of Wayne State University “We foundmore serious cognitive impairmentin relation toalcohol than cocaine or other drugs, including marijuana and smoking” From “Fetal Brains Suffer Badly From Effects of Alcohol” NYT 11.4.03

  30. This is important to keep in mind because….. The Adult you are serving in your program may have suffered a brain injury as a child

  31. Concussion and Multiple Concussion can lead to... • Elevated rates ofdepression(most commonmental health diagnosis after brain injury) • alcohol and drug abuse

  32. Concussion and Multiple Concussion can lead to... • elevated rates of panic disorder, obsessive compulsive disorder • These are among the findings a 2000 epidemiological study by Silver that found of 5000 individuals interviewed, 7.2% had experienced a blow to the head followed by loss of consciousness or period of confusion

  33. Take Home Message “Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure”Wayne Gordon, Ph.Dquoted in the Wall Street Journal 1.29.08

  34. Possible Changes • Physical: Motor skills, vision, speech, fatigue, seizures, hearing, etc • Cognitive: Memory, concentration, “executive skills”, receptive & expressive language, impulse control, and the ability to multitask and think flexibly • Behavioral and Personality:depression, emotional discontrol, reduced frustration tolerance,substance abuse

  35. Lack of Awareness A common and difficult to remediate hallmark of a brain injury

  36. Recommendation: All Human Service Providers Screen Consumers for a History of Brain Injury Why Screen? What other TBI Screening efforts have found

  37. Impact of TBI in Adolescent Treatment Programs2005 study by Corrigan et.al • 189 adolescents receiving residential SA tx were screened for a hx of brain injury • TBI with LOC reported by 23% of residents • 13% reported a moderate or severe TBI

  38. TBI related symptoms included: • Headaches • Dizziness • Memory problems • Fatigue • Difficulty controlling temper • Being easily stressed • Having problems with school work

  39. The Take Home Message... “Having a TBI with loss of consciousness was significantly associated with being more likely to bedependent on both alcohol and other drugs, to having experienced a drug overdose with loss of consciousness, being in special classes and having a seizure disorder……...

  40. The Take Home Message... …….There were trends toward TBI with loss of consciousness being associated with having a learning disability, having violence-related convictions, and receiving psychiatric outpatientservices. Among the later, persons with TBI were more likely to be treated for attention deficit hyperactivity disorder, anger management and conduct disorders.” John Corrigan Ph.D

  41. Brain Injury in the Correctional Setting-Nationally CDC website 2008 • According to jail and prison studies,25-87% of inmates report having experienced a TBI-this compared with 8.5% of the general population • Prisoners with a history of TBI may also experience mental health disorders (including; severe depression, anxiety, substance abuse)

  42. Brain Injury in the Correctional Setting-Nationally CDC website 2008 • Woman inmates who are convicted of a violent crime are more likely to have sustained a pre-crime TBI or some other form of physical abuse • Women with substance abuse disorders have an increased risk for TBI compared with women in the general population

  43. In Maryland- Screening Results from the MD TBI Post Demo II Project-2005 • Summary of TBI Incidence Among all Screened at 7 public mental health agencies in Frederick and Anne Arundel counties • N=190 • 39% no reported history of TBI (78) • 58.94% of individuals with a history of TBI (112) • 35.78% of individuals with a history of a single incidence of TBI (68) • 23% of individuals with a history of 2 or more TBIs (44)

  44. Details- Anne Arundel County Detention Center 2005 • N=41 • Single TBI= 16 • 2 or more incidents of TBI= 14 • No history of TBI= 11 • 73% screened reported a history of TBI

  45. Washington County Detention Center 2008 • N=25 (16 male, 9 female) • 22 reported possible TBI(s) • Single TBI=10 • 2 or more incidents of TBI= 12 • No History of TBI =3 • 88% screened reported a history of TBI

  46. Brain Injury & ViolenceDomestic Violence • Greater than 90% of all injuries secondary to domestic violence occur to the head, neck or face region (Monahan & O’Leary 1999) Adapted from The Alabama Department of Rehabilitation Services DV Training • Corrigan et.al., (2003) found that of 167 individuals treated for domestic violence related health issues, 30% experienced a loss of consciousness on at least one occasion, 67% reported residual problems that were potentially TBI related • Valera and Berenbaum, (2003) assessed 99 battered women. Of these, 57 had brain injured related symptomatology

  47. Homelessness & Brain InjuryA little studied population, however….. • A University of Miami study found that 80% of 60 homeless individuals had high incidence of neuropsychological impairment • Researchers in Milwaukee found possible cognitive impairment in 80% of 90 homeless men evaluated. • Dr. LaVecchia of the MA Statewide Head Injury Program reported in 2006 that of 140 homeless individuals evaluated, 83.6% of males and 16.4% of females had an acquired brain injury • Other studies in the UK and Australia show similar rates of brain injury among homeless individuals

  48. Homelessness: 10.7.08 Canadian Medical JournalHwang et.al • 904 homeless individuals surveyed • Addiction Severity Index used • TBI Screened, >30 minutes moderate/severe • Physical & mental health assessed

  49. Findings • Hx of moderate-severe TBI associated w/ increased likelihood of seizures • Mental Health problems • Drug problems • Poorer physical health status

  50. Findings • Lifetime Prevalence of TBI-53%, more common among men than women surveyed • Rates 5 or more times greater than the 8.5% lifetime prevalence in general population and consistent w/ prison studies

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