2. Substance Abuse and Traumatic Brain Injury John D. Corrigan, PhD Professor Department of Physical Medicine and Rehabilitation The Ohio State University Director Ohio Valley Center for Brain Injury Prevention and Rehabilitation

3. Addiction changes the pleasure pathways

4. The “Fingerprint” of TBI Frontal areas of the brain, including the frontal lobes, are the most likely to be injured as a result of TBI, regardless the point of impact to the head.

5. Overlay of 100 consecutive CT scans of patients with closed head injuries (Bigler, 1984) Areas of contusion in 40 consecutive cases of closed head injury (Courville, 1950)

6. Executive Functions of the Brain Comprised of the abilities humans have to self-regulate Mediated by systems highly dependent on the frontal lobes Demonstrate a developmental hierarchy Are highly oriented toward future social implications

7. The “A-B-C’s” of Self-Regulation Affective modulation Behavioral planning Cognitive resource allocation

8. The “A-B-C’s” of Self-Regulation Affective modulation Behavioral planning Cognitive resource allocation

9. Delay Discounting: the value of immediate vs. delayed rewards

10. from McClure et al (2004). Science 306, 503-507. Regions of greater activation when considering immediate rewards

11. Overlay of 100 consecutive CT scans of patients with closed head injuries (Bigler, 1984) Areas of contusion in 40 consecutive cases of closed head injury (Courville, 1950)

12. Co-occurrence of Substance Abuse and TBI

13. Co-occurrence of Substance Abuse and TBI Does TBI Cause Substance Abuse? –or– Does Substance Abuse Cause TBI?

14. Binge Drinking 1 Year after Hospitalization for TBI [Horner, et al, 2005 (South Carolina Follow-up Study)]

15. % Rehabilitation Patients with Prior Histories of Abuse

16. Intoxication and Occurrence of TBI (Savola, Niemela & Hillbom, 2005)

17. % Clients in Substance Abuse Treatment with Histories of TBI

21. Event Related Evoked Potentials [from Baguley, et al., 1997]

22. Ventricle to Brain Ratio [from Bigler, et al., 1996 and Barker, et al., 1999]

23. Response to Substance Abuse Treatment

24. Cognitive Impairment in the Match Study (Bates et al. 2006)

25. Symptoms past 12 months of Clients Admitted for Substance Abuse Treatment in Kentucky (N=7,932)

26. TBI among participants in IDDT (Corrigan & Deutschle, 2008) SAMHSA funded Targeted Capacity Expansion grant Collaborative program in 2 rural counties 51 program participants (50 included in analyses) in active treatment in one of the collaborating agencies previous diagnoses of both a psychiatric and substance use disorder

38. Accommodating TBI in Substance Abuse Treatment

39. Two Consistent Clinical Observations: In substance abuse treatment there is a greater disconnect between TBI clients’ intentions and their behavior. Clients with TBI are more likely to prematurely discontinue treatment, often after being characterized as non-compliant.

40. Persons with TBI face additional challenges seeking substance abuse treatment It is easy to see behavior as intentionally disruptive, particularly when there are no visible signs of disability: –Frontal lobe damage affects regulation of thoughts, feelings and behavior--promoting disinhibition. –Social “rules” may not be observed and interpersonal cues may not be perceived, creating consternation for fellow clients and staff.

41. Persons with TBI’s face additional challenges…(cont’d) Cognitive impairments may affect a person’s communication or learning style, making participation in didactic training and group interventions more difficult. Misinterpretation of cognitive problems as resistance to treatment undermines treatment relationships.

42. Suggestions for Treatment Providers 1.Determine a person’s unique communication and learning styles. 2.Assist the individual to compensate for a unique learning style. 3.Provide direct feedback regarding inappropriate behaviors. 4.Be cautious when making inferences about motivation based on observed behaviors.

43. A Model for Systems Response to Substance Abuse Treatment for Persons with TBI

44. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant IQuadrant II Quadrant IIIQuadrant IV 4 Quadrant Model of Services

45. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Quadrant II Rehabilitation Programs & Services Quadrant III Substance Abuse System Quadrant IV Specialized TBI & Substance Abuse Services 4 Quadrant Model: Place of Service Provision

46. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model: Types of Services

47. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

48. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

49. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model of Services

50. Traumatic Brain Injury Substance Use Disorder Low Severity High Severity Quadrant I Acute Medical Settings and Primary Care Screening & Brief Interventions Quadrant II Rehabilitation Programs & Services Education, Screening, Brief Interventions & Linkage Quadrant III Substance Abuse System Screening, Accommodation & Linkage Quadrant IV Specialized TBI & Substance Abuse Services Integrated Programming 4 Quadrant Model: Types of Services

51. For Additional Information Website: www.SynapShots.org e-mail: corrigan.1@osu.edu