Rates of pre-injury substance abuse in those who have sustained a TBI are high. Substance use disorders and TBI are most common in young males and substance intoxication is a leading contributor to accident-related injury. Studies differ in the criteria used to determine if an individual has an issue with addiction, dependence, or abuse. Studies that only include subjects with a positive Blood Alcohol Concentration (BAC) at time of admission will report an inflated incidence compared to patient reported substance use disorders. Additionally, prevalence rates are variable between populations. Rates of pre-injury alcohol abuse in Australian and North American populations have been recorded at 20-40%, whereas rates in Finland are reported at 8%, which likely reflects cultural differences in alcohol consumption.
Among those who sustain their injury in a motor vehicle collision, which is one of the leading causes of TBI, almost half were found to be intoxicated. Studies suggest that alcohol and substance abuse decline within the first year of injury, but those who returned to drinking two years post injury are likely to consume more than before the injury. In fact, individuals who abused alcohol pre-injury were ten times more likely to demonstrate problematic alcohol use post injury. Individuals who drink excessively and have large negative consequences associated with their drinking are more likely to report alcohol as the cause of their TBI and are more likely to report pre-injury substance abuse. Moreover, the correlation between mood disorders and substance abuse has also been shown to be quite strong both before and after injury.
The specific challenges that substance use disorders raise in the context of TBI require rehabilitation professionals to be particularly aware and vigilant with respect to potential interactions and impacts in the clinical assessment and intervention processes. Rehabilitation programs should have established protocols and processes to manage potential behavior issues in the rehabilitation unit. TBI rehabilitation programs should have designated and specifically trained professionals to oversee the rehabilitation objectives targeting substance use management or have access to outside specialized resources when required.
It is important to have appropriate treatment providers obtain comprehensive training in Motivational Interviewing and related substance use intervention strategies.
Indicators exemples
The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially
Effect of Intoxication on Initial Assessments
Several issues have been raised about assessing the severity of injury, particularly with the use of the GCS. It has been suggested that the GCS is unreliable when used to establish functioning level at time of injury for those who have been drinking and/or using other substances (Jagger et al., 1984). Some studies have reported a negative correlation between GCS score and BAC among individuals admitted to hospital post TBI (Alexander et al., 2004; Berry et al., 2010; O'Phelan et al., 2008; Schutte & Hanks, 2010; Shahin et al., 2010); a positive correlation has been noted between BAC and Injury Severity Scale score (Salim et al., 2009a; Salim et al., 2009b). Andelic and colleagues (2010) noted that patients diagnosed with a less severe TBI more frequently reported substance use at the time of injury, while those diagnosed with a more severe injury frequently report pre-injury substance abuse. Of note, other studies did not find a correlation between the two variables (Kelly et al., 1997; Sperry et al., 2006; Stuke et al., 2007). To date, there is conflicting evidence regarding the effects of alcohol on injury severity. Further, Ponsford and colleagues (2007) found that participants with TBI had similar levels of drug and alcohol use in comparison with controls. Alcohol and drug use declined within the first year post-injury; however, it increased two years post-injury.
Effect of Intoxication on Mortality
The protective role of elevated levels of serum ethanol levels and TBI is a controversial topic. It has been suggested that alcohol acts as a neuroprotective agent and plays a role in survival post injury (Berry et al., 2010). Several studies reported lower mortality rates among individuals who were intoxicated at time of injury than those who were not intoxicated (Berry et al., 2010; O'Phelan et al., 2008; Salim et al., 2009a; Salim et al., 2009b; Tien et al., 2006). A retrospective study reported that BAC was higher for survivors than non-survivors of TBI (Salim et al., 2009a), while a prospective study found that low to moderate BAC was associated with lower risk of mortality in those who had sustained a severe TBI (Tien et al., 2006). While these studies primarily focus on alcohol intoxication, their findings can also apply to illicit drug intoxication at time of injury (O'Phelan et al., 2008; Salim et al., 2009b). Overall, further research needs to be conducted to conclusively determine the effects of alcohol and other substances on survival following TBI.
Effect of Intoxication and Substance Abuse on Recovery
Recovery following TBI will likely be negatively impacted if individuals continue to abuse alcohol or other substances. Many of these individuals have been found to spend more time in rehabilitation programs due to accentuated deficits of sensory, motor, cognitive, and communication functions (Wehman et al., 2000). As well, continued abuse of alcohol and other substances increases the risk of developing medical complications (Salim et al., 2009a). Involvement in rehabilitation deters or prevents individuals from using various substances, as patients are monitored rather closely (Bjork & Grant, 2009). However, once patients are discharged from inpatient rehabilitation, no monitoring exists and patients may return to their previous behaviours as a coping strategy. Addictions to alcohol and other substance may lead to a failure to survive independently in the community (Burke et al., 1988).
During acute recovery, high BAC was found to be predictive of poorer performance on a variety of neuropsychological measures, including orientation, concentration, reasoning, and memory (Bombardier & Thurber, 1998; Kelly et al., 1997; Tate et al., 1999; Wilde et al., 2004). Wilde and colleagues (2004) also noted that high BAC was associated with increased brain atrophy post injury. In terms of long-term recovery, the impact of BAC and substance abuse is unclear. One study reported that acute BAC was not associated with outcome on the Glasgow Outcome Scale up to one year post injury (Alexander et al., 2004). Another study found that acute BAC was correlated with Functional Independence Measure (FIM) score upon admission to rehabilitation, but not with FIM at discharge or one year post injury (Schutte & Hanks, 2010). The authors also reported that acute BAC was not predictive of long-term cognitive outcomes as well (Schutte & Hanks, 2010). Comparatively, a smaller study found that many cognitive measures were negatively impacted by hazardous drinking both before and after injury (Ponsford et al., 2013). Vickery and colleagues (2008) demonstrated that acute BAC and a history of hazardous drinking were associated with outcome on the Disability Rating Scale (DRS) but not the FIM. Interestingly, while high acute BAC was associated with lower score on the DRS, a history of hazardous drinking was associated with a higher score (Vickery et al., 2008).
Substance Abuse Treatment Post TBI
Several programs have been proposed and developed in order to reduce substance abuse in the TBI population. In a systematic review, Corrigan and colleagues (2010) identified 28 studies of screening and/or interventions for substance abuse, but noted that most research specifically excluded participants with severe TBI. The authors suggested that researchers and clinicians should address barriers to routine use of screening and interventions, as well as develop systematic accommodations for individuals with neurobehavioural impairments post injury.
Corrigan and Bogner (2007) conducted a randomized clinical trial to compare two treatment methods (providing a financial incentive and reducing logistical barriers) to improve substance abuse treatment for individuals with TBI. Providing a financial incentive early during substance abuse treatment improve attendance.
Bogner and colleagues (2021) conducted a randomized controlled trial to compare the effects of an adapted Screening, Education, and Brief Intervention (Adapted SBI) for alcohol misuse following traumatic brain injury (TBI) to a Screening and Education with Attention Control (SEA) condition. A nonsignificant difference was found for adherence to abstinence between both treatment conditions, with more participants in the Adapted SBI group remaining abstinent. Those who did resume drinking in the Adapted SBI condition consumed significantly more drinks at 3 months (p=.03). There were no significant group differences for binge use, drug use or the number of facts recalled about the negative effects of substance misuse. While alcohol misuse generally declines postinjury, many individuals resume alcohol use one year after discharge. Adapted SBI may slow the resumption of alcohol use.
REFERENCES
Alexander, S., Kerr, M. E., Yonas, H., & Marion, D. W. (2004). The effects of admission alcohol level on cerebral blood flow and outcomes after severe traumatic Brain Injury. Journal of Neurotrauma, 21(5), 575-583.
Andelic, N., Jerstad, T., Sigurdardottir, S., Schanke, A. K., Sandvik, L., & Roe, C. (2010). Effects of acute substance use and pre-injury substance abuse on traumatic Brain Injury severity in adults admitted to a trauma centre. Journal of Trauma Management Outcomes, 4, 6.
Berry, C., Salim, A., Alban, R., Mirocha, J., Margulies, D. R., & Ley, E. J. (2010). Serum ethanol levels in patients with moderate to severe traumatic Brain Injury influence outcomes: A surprising finding. American Surgeon, 76(10), 1067-1070.
Bjork, J. M., & Grant, S. J. (2009). Does traumatic Brain Injury increase risk for substance abuse? Journal of Neurotrauma, 26(7), 1077-1082.
Bogner, J., Corrigan, J. D., Peng, J., Kane, C., & Coxe, K. (2021). Comparative effectiveness of a brief intervention for alcohol misuse following traumatic brain injury: A randomized controlled trial. Rehabilitation Psychology, 66(4), 345.
Bombardier, C. H., & Thurber, C. A. (1998). Blood alcohol level and early cognitive status after traumatic Brain Injury. Brain Injury, 12(9), 725-734.
Borgen I. M., Kleffelgård I., Hauger S. L., Forslund M. V., Søberg H. L., Andelic N., Sveen U., Winter L., Løvstad M., Røe C. (2022). Patient-reported problem areas in chronic traumatic brain injury. Journal of Head Trauma Rehabilitation, 37(5), 336-45.
Burke, W. H., Wesolowski, M. D., & Lane, I. (1988). A positive approach to the treatment of aggressive Brain Injuryured clients. International Journal of Rehabilitation Research, 11(3), 235-241.
Corrigan, J. D., Bogner, J., Lamb-Hart, G., Heinemann, A. W., & Moore, D. (2005). Increasing substance abuse treatment compliance for persons with traumatic brain injury. Psychology of Addictive Behaviors, 19(2), 131.
Corrigan, J. D., & Bogner, J. (2007). Interventions to promote retention in substance abuse treatment. Brain Injury, 21(4), 343-356.
Corrigan, J. D., Bogner, J., Hungerford, D. W., & Schomer, K. (2010). Screening and brief intervention for substance misuse among patients with traumatic Brain Injury. J Trauma, 69(3), 722-726.
Jagger, J., Fife, D., Vernberg, K., & Jane, J. A. (1984). Effect of alcohol intoxication on the diagnosis and apparent severity of Brain Injury. Neurosurgery, 15(3), 303-306.
Kelly, M. P., Johnson, C. T., Knoller, N., Drubach, D. A., & Winslow, M. M. (1997). Substance abuse, traumatic Brain Injury and neuropsychological outcome. Brain Injury, 11(6), 391-402.
Kelly, M. P., Johnson, C. T., Knoller, N., Drubach, D. A., & Winslow, M. M. (1997). Substance abuse, traumatic Brain Injury and neuropsychological outcome. Brain Injury, 11(6), 391-402.
O'Phelan, K., McArthur, D. L., Chang, C. W. J., Green, D., & Hovda, D. A. (2008). The impact of substance abuse on mortality in patients with severe traumatic Brain Injury. Journal of Trauma - Injury, Infection and Critical Care, 65(3), 674-677.
Ponsford, J., Whelan-Goodinson, R., & Bahar-Fuchs, A. (2007). Alcohol and drug use following traumatic brain injury: a prospective study. Brain injury, 21(13-14), 1385-1392.
Ponsford, J., Tweedly, L., & Taffe, J. (2013). The relationship between alcohol and cognitive functioning following traumatic Brain Injury. J Clin Exp Neuropsychol, 35(1), 103-112.
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Salim, A., Teixeira, P., Ley, E. J., Dubose, J., Inaba, K., & Margulies, D. R. (2009b). Serum ethanol levels: Predictor of survival after severe traumatic Brain Injury. Journal of Trauma - Injury, Infection and Critical Care, 67(4), 697-703.
Schutte, C., & Hanks, R. (2010). Impact of the presence of alcohol at the time of injury on acute and one- year cognitive and functional recovery after traumatic Brain Injury. International Journal of Neuroscience, 120(8), 551-556.
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All individuals with traumatic brain injury should be provided with appropriate education regarding substance use after brain injury. A screening tool appropriate for the treatment setting should be used along the care continuum. A qualified professional should assess those who screen positive for harmful impacts of substance use. Systematic screening, education and discussion of the harms of substance use after brain injury should be conducted, with referral as required.
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Last Updated November 2023
Health and community care providers should be provided with a basic understanding of substance use and current medical and psychosocial intervention strategies. Further, education and training on drug and alcohol misuse after traumatic brain injury, its sequelae, and treatment programs should be provided.
(Adapted from NZGG 2006, 14.3, p. 170)
Last Updated November 2023
Management for co-occurring substance use disorders and brain injury should be concurrent (not sequential) with appropriate consultation with pain management and addiction services. Substance-use-related goals and interventions should be integrated into the traumatic brain injury rehabilitation plans. Substance use should not be an exclusionary criterion. Providers are encouraged to take it into consideration, not see it as a barrier to care. If substance use is found to be interfering with brain injury rehabilitation, every effort should be made to address the problematic substance use before dismissing the individual from care.
Individuals with opioid use disorder may experience hypersensitivity to pain and appear to be drug-seeking. Care should be taken to ensure pain is appropriately managed, ideally in consultation with addiction and pain management specialists. Intervention should be attempted with individuals who come to treatment intoxicated before determining it to be a barrier to care.
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Last Updated November 2023
Healthcare professionals should consider using treatment incentives (i.e., rewards designed to meet early treatment milestones) and barrier reduction (i.e., reminder call) methods to assist individuals with both traumatic brain injury and substance use disorder to effectively engage in intervention.
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Last Updated November 2023
Prevention of substance use disorders after traumatic brain injury should be undertaken through education and information. Materials should be provided to all individuals with traumatic brain injury and their families in written and verbal formats with prevention messages tailored to individuals who have recently sustained a TBI in a timely manner, ideally beginning just after post-traumatic confusion has cleared and continued across the continuum of care. Motivational interviewing, a collaborative, goal-oriented communication style designed to assist individuals in exploring and resolving ambivalence to increase the motivation for change, can also be considered for use.
NOTE: Prevention of substance use disorders aims to reduce the impact of a disease or injury (or an exposure) that has already occurred by detecting and treating disease as soon as possible to halt/slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems.
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Last Updated November 2023