Substance use among persons with traumatic brain injury - IOS Press

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Steven L. West. Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Science and Engineering, Virginia. Commonwealth University ...


NeuroRehabilitation 29 (2011) 1–8 DOI 10.3233/NRE-2011-0671 IOS Press

20th Anniversary Article

Substance use among persons with traumatic brain injury: A review Steven L. West Department of Physical Medicine and Rehabilitation, Center for Rehabilitation Science and Engineering, Virginia Commonwealth University, P.O. Box 3038, Richmond, VA, USA Tel.: +1 804 827 2562; Fax: +1 804 828 0336; E-mail: [email protected]

Abstract. This paper provides a review of the current literature in the area of substance use and traumatic brain injury (TBI). Collectively, these studies demonstrate that substance use and SUD are common in the TBI population both pre- and post-injury, are a frequent causative factor in injury acquisition, complicate the rehabilitation process, and have substantial negative impact on individual health and well being. Further, individuals with a demonstrated SUD and concurrent TBI are likely to be severely limited in their ability to access SUD care due to physical barriers. This literature is reviewed and then considered in terms of its general weaknesses. Finally, a brief outline of future research needs is provided. Keywords: Substance abuse, substance use disorders, brain injury

1. Introduction A growing body of research has developed over the last several decades that demonstrate persons with disabilities (PWDs) use alcohol and other drugs and have rates of substance abuse and dependence (collectively referred to as substance use disorders or SUD) that are considerably greater than that of the general population [1–4]. Note that although much of literature combines “substance use”, “substance abuse” and “substance dependence” into a generic catch-all of “substance abuse”, they refer to distinct behaviors and conditions. Substance use should be considered any use of alcohol or other drugs. Conversely, both “substance abuse” and “substance dependence” are clinical terms with definitions in the DMS-IV which may collectively be termed as “substance use disorders” or “SUD”. In the case of the substance abuse, patients must be identified as experiencing at least one of four domains (recurrent failure to meet responsibilities due to use, recurrent use when physically dangerous, recurrent legal problems related to use, and continued use despite such

problems) within the last year and without experiencing dependence. Substance dependence involves the experience of at least three of the following in the prior year: tolerance, withdrawal, use in durations longer than intended, a desire or inability to cut down, extended time obtaining the substance or using it, using in lieu of other important activities, or continued use despite knowing that such use causes or exacerbates problems. Where appropriate, the review that follows refers specifically to substance use, abuse, or SUD. However, as noted below, much of the literature is limited by a failure to adequately define the presentations in their samples using these standard terms. The terms used in associated with particular studies noted below use the most appropriate terms based on the information in the original works. Further, PWDs incur numerous significant negative consequences as a result of such use, appear in SUD treatment infrequently, and are denied SUD treatment services due to access concerns at alarming rates [1– 8]. Although such facts are generally true across the breadth of disabilities, individuals with neurotrauma

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such as traumatic brain injury (TBI) appear to be the unfortunate vanguard of this larger group. Indeed, a substantial body of literature exists to note that as much as 50% to 60% of persons with TBI have significant issues with alcohol and/or other drugs [5,7–9]. More than one-third to more than three-quarters of these individuals had issues with substances prior to acquiring their disability, and as many as half were intoxicated at the time of injury; facts that speak to the entrenched nature of these issues as well as their role in disability etiology [6,10–14]. At the same time, individuals with TBI and other disabilities are largely absent from the nation’s SUD treatment network and nascent research has developed to suggest that service denials to these groups are common and are linked to physical and programmatic access barriers [1–4]. Importantly, much of the literature has demonstrated that these issues have been known for decades. Yet, the availability of dedicated prevention resources, treatment options, and empirically tested treatment modalities are limited at best. Such issues are known but are not widely reported on by the addictions field or the wider public health community. As with the greater PWD community, the inclusion of persons with TBI in the addictions literature is scant and much of what is detailed in the following review has appeared in the neurotrauma and physical medicine literature. This paper provides an overview of the state of the science on these topics and specifically addresses substance use, abuse, and SUD among persons with TBI within the context of neurorehabilitation. Core information will be broken down into discussion overall rates of use, issues in assessment and diagnosis, impact on health and function, and implications for treatment. Lastly, a critique of the overall literature is provided along with directions for future research. 2. Rates of substance use and SUD among persons with TBI TBI is a leading cause of disability and death, particularly in younger populations, worldwide. In the U.S., TBI is increasingly common with some 1.4 million new cases being incurred annually. Most commonly associated with falls, auto accidents, and violent physical assaults, TBI has gained attention of late in military populations where the most common cause of TBI is blast injuries [15,16]. To date, over 320,000 service members reported a possible TBI from OIF/OEF, and it is estimated that as many as 60% of returning OIF/OEF

war veterans may have sustained a TBI [17,18]. The range of substance use, abuse, and SUD appears to evidence in all of these populations and across all levels of injury severity. A notable body of literature also exists to suggest that in many cases, the use, abuse, and perhaps the addiction to alcohol and other drugs is common in this population before injury and that intoxication at the time of injury is very common. Rates of pre-injury substance use and SUD are typically found to be greater than that of the general population. Between 44% and 79% of individuals with TBI have been described as having a pre-injury history of alcohol abuse, and 21% to 40% evidence a history of illicit drug abuse predating impairment [10,11,13,19, 20]. However, notable variability in these rates have been evidenced and the limited number of studies appearing which clearly define subject samples in terms of injury severity or by standard definitions of substance use and SUD limit the interpretability of these findings. Likewise, many of these reports rely on the confirmation of such use by family members and caregivers of those with TBI. Although such methods can be effective, they do not lend themselves well to traditional methods of verification. Confusing the matter further, each of the reports noting such pre-injury use or SUD assessed for such issues at varying points in time post-injury. As noted above, intoxication at the time of TBI is a common theme present in the literature for at least two decades. Beginning in the early 1980’s, research has generally shown that across levels of injury, alcohol intoxication at the time of TBI is present in numbers approaching half of all cases. Two studies indicate alcohol intoxication at the time of injury is as low as roughly 37% [21,22], while at least four have indicated that number to be about half of all cases [23–26]. A handful of studies have addressed illicit substance use or intoxication at the time of injury, with cocaine, marijuana, and methamphetamines being the most common [27– 32]. Two studies have noted combinations of alcohol and illicit substances present in individuals at the time of injury [33,34]. Uniformity in assessing substance use and in reporting as use, abuse, or SUD is frequently lacking in these reports and is likely a significant factor behind the wide variability seen in these reports. Still, substance use and SUD are clearly indicated as a prime causative factor in TBI acquisition. Studies examining rates of substance use and SUD among samples of persons with TBI have typically shown such rates to be substantial. Hibbard and colleagues found that 28% of individuals with TBI living

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in the community met the criteria substance abuse or dependence [20]. For individuals with a history of substance abuse pre-injury, there appears to be a refractory period after injury before which such individuals generally return to pre-injury levels of use [5,35,36]. Several studies have indicated that a period of abstinence among those individuals with TBI and prior history of alcohol or other drug use is common, followed by a return to pre-injury levels in the short-term post injury [37,38]. This increasing trajectory continues for some both in the near- and long-term [35,39–43]. Overall, reports generally indicate the overall rate of substance abuse in the TBI population to push upwards 50% [5,20,35–43]. Likewise, studies with samples drawn primarily from SUD treatment populations have likewise found large percentages of individuals with various levels of head injury. Walker and colleagues found that in a treatment seeking population of prison inmates, some 68% selfreported a history of a head injury, although the nature and extent of such injuries were not defined [44]. Alterman and Tarted found rates of head injury resulting in unconsciousness to range from 35% to 60% of patients in treatment for alcohol use disorders (with variation dependent on familial history of alcoholism) [45]. Hillbom and associates noted that 41% of men and 22% of women alcoholics had a history of head injury, but, as with the Walker report, no information was available to verify the injury or to detail its nature or severity [46]. In a second study of over 7,000 patients in state-funded SUD treatment in Kentucky, Walker and colleagues found that over 31% had incurred a TBI as defined as a prior self-reported head injury resulting in a loss of consciousness [47].


chiatric interviews, few have been evaluated for their effectiveness with this population [7,8,13,42,62]. Ashman and colleagues provide an examination of the psychometrics of properties of such devices with a TBI population [62]. They compared the findings from the BMAST, CAGE, and SASSI to the gold standard of a structured clinical interview in two small-scale studies of individuals with TBI. The first study consisted of 100 subjects with TBI at least one year post injury and considered the psychometrics of the CAGE compared to clinical interview. Results indicated the CAGE to have high specificity but generally low sensitivity resulting in a large number of false positives. The second study considered the psychometrics of the BMAST and SASSI compared to the gold standard of clinical interview in a sample of 223 persons with TBI. Results indicated both to have generally high and similar rates of sensitivity and specificity. No additional information on the psychometric properties of these three devices were provided nor was information about injury severity or, in the case of the second study, information about length of time injury. Ashman and colleagues also assessed the utility of the SASSI [72]. In a sample of 78 subjects in inpatient rehabilitation services, they found the device to have limited accuracy for identification of dependence and moderate accuracy for substance abuse. These findings support the use of these devices as general screening tools, but given the noted shortcomings and the general lack of research in the area, substantial efforts are needed to further determine the appropriateness of these and other devices in common use. 4. Impact

3. Assessment and diagnosis The assessment and diagnosis of substance abuse and dependence among persons with TBI has received scant attention in the literature despite the fact that both can share similar impact on cognitive functioning, mood states, and disinhibition. Further, both TBI and SUD are independently associated with a variety mental health and psychiatric issues. Although a number of a number of varying methods have been used to identify substance use and SUD among persons with TBI including quantify-frequency indices, scales such as the Brief Michigan Alcoholism Screening Test (BMAST), the Substance Abuse Subtle Screening Inventory (SASSI), and the CAGE, and structured psy-

The outcomes associated with substance use, abuse, and dependence by those having incurred a TBI are also considerable. Alcohol use and intoxication at the time of injury are associated with increased injury severity and concomitant complications acutely post-injury [14, 27,28,48–50]. As with other groups of substance users, persons with TBI who use and who have SUD are prone to increased risks for a variety of medical problems such as cirrhosis; esophageal, liver, and other cancers; and a variety of other use-induced conditions [7,19– 21]. Alcohol use alone is associated with a variety of acute complications for patients with TBI and related trauma during initial inpatient stays including sepsis, pneumonia, and organ failure [51,52]. Further, substance use and SUD have important implications for


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the course and outcomes of both trauma and rehabilitation medicine. Alcohol and other drug use, abuse, and dependence are associated with increased length of inpatient stay, increased severity and duration of patient agitation, lower scores on the Glasgow Coma Scale, increased brain tissue atrophy, poorer performance on a variety of neurocognitive assessments, lower cognitive functioning at discharge, and lower adherence to and participation in post-hospitalization rehabilitation [7, 24,27,28,48–50]. Thus, substance use serves to inhibit rehabilitation outcomes, decrease adjustment to disability and reintegration into the community, and increase the likelihood of a number of serious negative consequences. But as with other aspect of research in this area, the studies reporting these issues are limited in number and scope and many suffer from a failure to describe substance use in a manner consistent with the addictions literature. Substance use, abuse, and dependence also have a direct impact on the course of physical recovery from TBI. For example, chronic alcohol use has been shown to cause brain tissue atrophy notable on computerized tomography (CT) and magnetic resonance imaging (MRI) [53,54]. Such atrophy may in turn complicate existing TBI both in terms of physical impact and subsequent psychosocial sequelae. Four studies have indicated that white matter tissue is more susceptible to the impact of both TBI and alcohol abuse; continued alcohol use and abuse could therefore exacerbate the functional limitations incurred from TBI [55–58]. Rates of a variety of negative outcomes have also been shown to be positively correlated with alcohol and other drug use. When compared with abstaining and low-using peers, individuals with TBI who use alcohol and other drugs present with higher rates of psychiatric comorbidity, higher arrest rates, and are more likely to behave aggressively and to attempt suicide [13,24,28, 59]. Conversely, such individuals are more likely to be unemployed and to require supported employment services [28,60]. Although substance use and SUD are associated with familial disruption, recent research by Kreutzer and colleagues found no association between TBI and subsequent marital or relationship dissolution [61]. However, no attempt was made to discern variations in relationship dissolution based on the presence of substance use or SUD. 5. SUD treatment Numerous studies have clearly demonstrated that successful SUD treatment reduces secondary illness

prevalence, lowers associated mortality rates, and greatly reduces overall healthcare costs [63–65]. Likewise, successful treatment is associated with reductions in crime and associated crime-related expenses. Over the last decade, research has indicated that a cumulative savings return (based on such factors as reduced healthcare costs, public assistance, and criminality) of between $6 and $7 are evidenced for every $1 spent on treatment [66,67]. Despite this, the presence of persons with TBI in the nation’s SUD treatment network is notably low. Although a number of causes for this low representation have been explored, mounting evidence suggests that both physical and programmatic accessibility barriers play a significant role in the problem. Physical barriers, such as stairs and inaccessible restrooms, can inhibit and even prohibit access by many PWDs including persons with TBI, and developing research suggests that such barriers are common in substance abuse treatment centers. In a study of 19 treatment facilities in Wisconsin, Voss and colleagues found numerous barriers that would inhibit PWD access particularly among those individuals with mobility impairments [68]. For example, inaccessible parking, wheelchair-inaccessible bathroom stalls, and doors with inaccessible handles were present in 27- to 53% of the facilities they examined. A national self-report survey of treatment centers found such issues to be commonplace [1]. Inaccessible parking, restrooms, bathing facilities (in residential facilities), and hallways/stairs appear to be present in 20- to 40% of such facilities across the U.S. with variability based on the nature of services provided (i.e., inpatient versus outpatient care). Related studies have found substantial rates of physical barriers in treatment centers outside the U.S. as well [69]. It has also been shown that when barriers to access are present, they result in immediate denials of service to a wide range of PWDs including persons with TBI [2, 3]. Service denials based on physical inaccessibility to individuals with TBI are notable at 42%–68% respectively [2,3]. The denial of services based on physical barriers was largely universal and not related to practice affiliation (private or public) or practice type (outpatient, nonmedical residential, or hospital based). Such findings paint a dire picture for those individuals with TBI who seek out addictions treatment. Aside from other groups of PWDs, such frequent and demonstrative barriers to treatment are unprecedented in the scientific literature. Such research is still in a nascent form, however, and the picture is far from complete. The consistency of the findings suggest their accura-

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cy, but the few studies appearing to date have largely been based on relatively small and, in the case of those studies in the U.S., geographically limited samples. To date, no studies have appeared to fully define the presence of persons with TBI in the nation’s SUD treatment 6. Limitations of current research In a recent review of research on substance use and mental retardation (MR), McGillicuddy [2] noted the literature to be limited by a lack of consistency in defining core constructs. He correctly noted that substance use, abuse, and dependence are not interchangeable terms; yet such notations are frequently used and interpreted as such. He further noted that the literature was limited by the lack of a consistency in MR determination and definition and reasoned that a population as varied as that of persons with MR cannot be fully understood in terms of generalizations across the population. For the most part, such issues are equally present in the literature on TBI and substance use. Over a decade ago, Kolakowsky-Hayner and colleagues noted that many studies appearing on the topic merge alcohol use and illicit substance use into a single category of “substance abuse” [1, p. 572] and suggested that such use compromised the quality of the overall research literature. Such imprecision continues today. Despite calls for uniformity in assessment and reporting and the development of screening tools specifically for TBI populations, there remains great variability in the manner by which subjects are assessed for substance use and SUD and how they are described after assessment (e.g. [62,72]). Few studies appear which clearly define subjects into groups based on accepted diagnostic criteria using the gold standard of structured clinical interviews (e.g. [70]). The distinctions between substance use, misuse, and SUD are critically important for understanding the nature, course, and severity of substance related presentations. Scholars conducting research primarily from a TBI perspective must become voiced in these distinctions and make clear both the terminology they use and the manner by which such determinations have been made. Likewise, studies conducted by scholars whose primary affiliation and expertise are in the substance use arena frequently err when assessing and reporting on the presence of TBI. Many studies rely on the selfreport of patients in SUD care as to the existence of a TBI. Frequently, evidence of the presence of a TBI is


limited to affirmation to such basic questions as “have you ever had a traumatic brain injury?” or “As an adult, have you ever been unconscious as the result of a head injury?” [46,47]. Such a determination is often followed by the failure to classify the degree of injury as mild, moderate, or severe despite the fact that variation in substance use, misuse, and SUD presentation seems to be linked to injury severity. Even in the context of the subjective nature of injury severity identification, such simplistic identification methods lack rigor particularly in light of the large and varied availability of TBI screening and assessment tools and the substantial literature justifying their existence. The issue of consistency of terminology also extends to those studies considering access to SUD care. Each of the studies noting that persons with TBI were denied access to SUD care relied on respondent’s definition of TBI and did not attempt to discern injury severity. Just as scholars whose primary specialty is in TBI must seek to utilize acceptable assessment tools and diagnostic criteria, so too should addictions professionals seek to employ the accepted practices of their rehabilitation and physical medicine counterparts. A large percentage of the literature on TBI and substance use is limited to one of two clinical samples: those seeking neurorehabilitation oriented care and those seeking SUD care. Clinical samples are ideal for understanding the presentations and needs of those seeking care but provide little to no insight into the status of others. The use of the national TBI Model Systems database overcomes these issues somewhat, but still lacks the depth and vigor available from true epidemiologic studies. Although no ready source is available to identify individuals with TBI nationwide, the pursuit of data from a nationally representative sample is warranted for the acquisition of true population statistics. Further, issues of access have also been limited to examinations of barriers solely at the treatment site and on the perceptions and actions of those who provide treatment. Although telling, these perspectives leave many questions unanswered and the dispositions of those seeking care who are denied access are unknown. Do such individuals continue to seek care until they receive it? Do they attain care in alternate venues? What barriers exist community-wide that impact care seeking and acquisition? Such questions demonstrate the need for study of such issues both from an individual perspective and longitudinally. Seeking addictions treatment has been described as a unique timing event and missing that distinct opportunity may in fact lead


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to continued use. Additional research from these two alternate perspectives is necessary to fully understand the problems individuals with TBI face in accessing care and thus to make informed attempts at remediating access barriers. 7. Future directions Despite the limitations noted in the previous section, a body of literature going back at least three decades indicates that individuals with TBI are at substantial risk for substance use and SUD. Important issues and questions remain, however, that must be unequivocally addressed to move the field forward. First, studies are needed that address the true population dynamics of substance abuse after TBI. It would be difficult to access nationally representative samples of persons with TBI, but studies that provide a truly representative epidemiological assessment of substance use and SUD among the TBI are sorely needed. Identification of the actual population rate of use and SUD would allow for a comprehensive understanding of those factors promoting and inhibiting substance use. Such information could then be used to formulate prevention and intervention activities that are based on the actual and not merely the perceived correlates of such use. Such efforts could also clearly delineate variations by injury severity and time since injury that at present seem crucial in terms of their relationship with use, abuse, and addiction. But before such studies could be undertaken, additional work is needed in determining the most appropriate and effective means of determining the presence of substance abuse and dependence in the TBI population. Although foundation work has been conducted in this area, to date no clear standard for easy and accurate assessment is available. The field would do well to undertake efforts to refine or develop such a tool in the near future. Finally, since access to SUD treatment appears to be limited, additional study should first determine if such reportedly high rates of treatment denials are indeed as common as they appear and then work to develop models to insure their eradication. One of the most notable attributes of the research literature in this area is a general lack of scholarly articles exploring best practices with regard to patients with concurrent TBI and SUD. Aside from the few papers noted in this review, there is a dearth of studies in either the neurorehabilitation or SUD literatures that are focused on clinical applications. The limited information available relates largely to screening and assessment.

These studies would seem to indicate that simple, brief, and easy-to-use screening tools may well suited for use directly with persons with TBI; larger more complex protocols offer little in the way of greater accuracy. This is not surprising in a population with neurocognitive deficits. Although limited by a propensity for false positives, such devices appear to be useful tools for clinicians who do not have access to caregivers or family members who may verify rates, correlates, and consequences of substance use and are merely looking for a quick screen from which to build to direct clinical interview. Alternately, several of the above noted studies indicate that use of proxies can be relatively effective means for the potential identification of substance abuse and dependence in this population. No research to date has appeared which provides direct evidence for the use of any particular intervention, counseling, or prevention effort with the TBI population. Beyond such generalizations little in the way of scientific support is available to identify good clinical practice in this area. Although a number of studies and a growing body of literature have developed to provide support for proper diagnosis of substance abuse and dependence in a myriad of other populations, no robust body of knowledge is yet available in this area. One might presume that those professionals engaged in neurorehabilitation are better suited to deal with the issues simply due to the fact that they are versed in and knowledgeable of the general needs of the TBI population. However, such an assumption has not yet been tested in the literature. These short comings point to the pressing need for basic study and eventual clinical trials in this area. The size, unique characteristics, strengths, and needs of this population all warrant an increase in the amount of funding dedicated to research on this topic. Only with the provision of such support may the field begin to determine optimal screening, assessment, intervention, and prevention techniques. References [1] [2] [3]

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