Post on 17-Dec-2015
Traumatic Brain Injury Traumatic Brain Injury and Alcohol Use and Alcohol Use
DisordersDisorders
E. Lanier Summerall, MD, MPHE. Lanier Summerall, MD, MPH
Dartmouth Medical SchoolDartmouth Medical School
1© AMSP 2010
Alcohol Abuse and DependenceAlcohol Abuse and Dependence
80% Lifetime use80% Lifetime use
15% Lifetime abuse15% Lifetime abuse
10% Lifetime dependence10% Lifetime dependence
Intoxication, abuse, dependence=alcohol Intoxication, abuse, dependence=alcohol use disorders (AUD’s)use disorders (AUD’s)
2© AMSP 2010
Traumatic Brain Injury in USTraumatic Brain Injury in US 1.4 million total each year1.4 million total each year
50,000 die50,000 die 235,000 hospitalized235,000 hospitalized 1.1 million to ER1.1 million to ER
Mechanisms Mechanisms Falls Falls Motor vehicle accident (MVA)Motor vehicle accident (MVA) Struck by/against objectStruck by/against object Assaults/violenceAssaults/violence
3© AMSP 2010
Traumatic Brain InjuryTraumatic Brain Injury Location-anywhere in brainLocation-anywhere in brain
Visible-bruise, bleeding, tissue deformityVisible-bruise, bleeding, tissue deformity
Invisible-axon damageInvisible-axon damage
Frontal lobe damage= “fingerprint” of TBIFrontal lobe damage= “fingerprint” of TBI
Acceleration/decelerationAcceleration/deceleration
Bony structure of skullBony structure of skull
4© AMSP 2010
5© AMSP 2010
TBI EffectsTBI Effects VVision, hearingision, hearing
AAttention/concentrationttention/concentration
LLanguage skillsanguage skills
IInsightnsight
UUnacceptable behaviorsnacceptable behaviors
MMemoryemory
Physical/neurological problemsPhysical/neurological problems
6© AMSP 2010
AUD+TBI=Complex AUD+TBI=Complex RelationshipRelationship
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↑ Risk TBI ↑ Risk AUD ↓ Recovery
AUD +TBI
© AMSP 2010
This Lecture ReviewsThis Lecture Reviews
Definitions Definitions Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment
8© AMSP 2010
Glasgow Coma ScaleGlasgow Coma Scale
Eye opening (E): 1-4Eye opening (E): 1-4Motor response(M): 1-6Motor response(M): 1-6Verbal response(V): 1-5Verbal response(V): 1-5E+M+V=Total ScoreE+M+V=Total Score3 (Deep coma)-15(wide 3 (Deep coma)-15(wide
awake)awake)9© AMSP 2010
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Traumatic Brain InjuryTraumatic Brain InjuryDefinitionsDefinitions
© AMSP 2010
Definitions Definitions
Legal intox.=0.08% BAL (blood alcohol Legal intox.=0.08% BAL (blood alcohol level)level)
Std. drink-10-12 gmStd. drink-10-12 gm 0.2 gm/dl0.2 gm/dl 12 oz. beer12 oz. beer 5 oz. wine5 oz. wine 1 oz spirits (gin, vodka, whisky)1 oz spirits (gin, vodka, whisky)
11© AMSP 2010
Alcohol Use DisordersAlcohol Use Disorders
12© AMSP 2010
Intoxication
1 +:
-Slurred speech
-Incoordination
-Unsteady gait
-Nystagmus
- Attention, memory
-Stupor, coma
Alcohol abuse
1 + in same 12 mos.:
- Role obligations
-Hazardous use
-Legal problems
-Interpersonal problems
- Dependence
Alcohol dependence
3+ in same 12 mos:
-Tolerance
-Withdrawal
- Amts. or more time
-Desire/inability to
- Other activities
- Consequences
This Lecture ReviewsThis Lecture Reviews
Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment
13© AMSP 2010
Intoxication and TBIIntoxication and TBI
45% TBI hospitalized legally intox.45% TBI hospitalized legally intox.
Intoxication<19 yo ↑ risk:Intoxication<19 yo ↑ risk:
2 X ↑ Driving after 5+ drinks2 X ↑ Driving after 5+ drinks
1.8 X ↑ Riding with drunk driver1.8 X ↑ Riding with drunk driver
2.6 X ↑ Injuries 2.6 X ↑ Injuries
2.5 X ↑ Violent behavior2.5 X ↑ Violent behavior14© AMSP 2010
Intoxication and TBIIntoxication and TBI
Can mask TBI due to sim. signsCan mask TBI due to sim. signs ↑ ↑ Severity of TBISeverity of TBI ↑↑Intensity of treatmentIntensity of treatment
3X ↑ ICU days3X ↑ ICU days 2.5 X ↑ Benzodiazepines2.5 X ↑ Benzodiazepines 2 X ↑ Opioids2 X ↑ Opioids
↓ ↓ Scores cog. tests 1 mo. post-injuryScores cog. tests 1 mo. post-injury15© AMSP 2010
Abuse/dependence before TBIAbuse/dependence before TBI
37% of TBI have prior 37% of TBI have prior abuse/dependenceabuse/dependence
Abuse/dependence ↑ risk TBI 60% in Abuse/dependence ↑ risk TBI 60% in any yearany year
Post-injury unemployment 3X > TBI Post-injury unemployment 3X > TBI alonealone
Life satisfaction < TBI aloneLife satisfaction < TBI alone ↑↑Risk multiple TBI’sRisk multiple TBI’s
16© AMSP 2010
This Lecture ReviewsThis Lecture Reviews
Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment
17© AMSP 2010
AUD’s Post-TBIAUD’s Post-TBI
50% with AUD ↓ alcohol use after 50% with AUD ↓ alcohol use after TBITBI
2 X ↑ abstinence rates after TBI 2 X ↑ abstinence rates after TBI (15%-30%)(15%-30%)
30% of all in AUD treatment have 30% of all in AUD treatment have unreported hx. of TBIunreported hx. of TBI
18© AMSP 2010
AUD’s Post-TBIAUD’s Post-TBI
25 % develop/maintain AUD after TBI25 % develop/maintain AUD after TBI Risk factors:Risk factors:
Pre-TBI AUDPre-TBI AUD Better physical functionBetter physical function MaleMale YoungerYounger Uninsured or on MedicaidUninsured or on Medicaid UnmarriedUnmarried
19© AMSP 2010
AUD’s Post-TBIAUD’s Post-TBI ↓ ↓ Neuron reorganization from alcohol ↓ Neuron reorganization from alcohol ↓
natural healingnatural healing
TBI +AUD may ↑ atrophyTBI +AUD may ↑ atrophy
TBI +AUD death by suicide 4X > TBI aloneTBI +AUD death by suicide 4X > TBI alone
TBI + AUD death by suicide 7X > gen pubTBI + AUD death by suicide 7X > gen pub
↑ ↑ Involvement criminal justice systemInvolvement criminal justice system
Alcohol use ↑ impact of TBI symptomsAlcohol use ↑ impact of TBI symptoms20© AMSP 2010
This Lecture ReviewsThis Lecture Reviews
Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI Assessment/ treatmentAssessment/ treatment
21© AMSP 2010
Prevention TBI/AUDPrevention TBI/AUD
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US Public Health SuccessesUS Public Health Successes
MVA’s once #1 cause TBI, now #2MVA’s once #1 cause TBI, now #2
MADD (MADD (MMothers others AAgainst gainst DDrunk runk DDriving) called for tougher lawsriving) called for tougher laws
Mandatory seat belt laws in US Mandatory seat belt laws in US ↓TBI’s 38% ↓TBI’s 38%
Laws↓ BAL to 0.08% ↓ fatalities Laws↓ BAL to 0.08% ↓ fatalities +TBI’s 36%+TBI’s 36%
23© AMSP 2010
Public Health ChallengesPublic Health Challenges
●●Highest rate drunk Highest rate drunk driving=motorcycledriving=motorcycle
●●2X TBI deaths in 2X TBI deaths in states without states without helmet lawhelmet law
●●<50% of states with <50% of states with helmet lawhelmet law
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This Lecture ReviewsThis Lecture Reviews
Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI✔✔ Assessment/ treatmentAssessment/ treatment
25© AMSP 2010
Assessment: Alcohol WithdrawalAssessment: Alcohol Withdrawal
Caution! TBI may mask withdrawalCaution! TBI may mask withdrawal
SymptomsSymptoms
SignsSigns
InterviewInterview
Physical examPhysical exam
26© AMSP 2010
Treatment: Alcohol Withdrawal Treatment: Alcohol Withdrawal
Benzodiazepines=gold standardBenzodiazepines=gold standard
““Start low, go slow”Start low, go slow”
Longer acting benzos preferredLonger acting benzos preferred
Chlordiazepoxide- 25 mg. PO QIDChlordiazepoxide- 25 mg. PO QID
Diazepam -5 mg. PO QIDDiazepam -5 mg. PO QID
Overmedication→resp.depression,comaOvermedication→resp.depression,coma
Undermedication→delirium,seizureUndermedication→delirium,seizure27© AMSP 2010
Early AUD Treatment after TBIEarly AUD Treatment after TBI Motivation to change alcohol use ↑ after Motivation to change alcohol use ↑ after
TBITBI Alcohol dep. pre-TBI=↑ motivationAlcohol dep. pre-TBI=↑ motivation ↑ ↑ BAL at injury ≠ ↑ motivationBAL at injury ≠ ↑ motivation
Motivational interviewing effective Motivational interviewing effective Non-directive interviewNon-directive interview Patient-centered, empatheticPatient-centered, empathetic Elicits behavior changeElicits behavior change Explores/resolves ambivalenceExplores/resolves ambivalence
28© AMSP 2010
Challenges: AUD+ TBIChallenges: AUD+ TBI
No evidence-based algorithm for tx.No evidence-based algorithm for tx. Cognitive barriers:Cognitive barriers:
↓ ↓ Attention, judgment, insight, languageAttention, judgment, insight, language ↓ ↓ Short term memory, behavior controlShort term memory, behavior control
Interpersonal barriersInterpersonal barriers System barriersSystem barriers
High cost of careHigh cost of care Inpt. AUD programs exclude TBIInpt. AUD programs exclude TBI Outpatient tx. may not be enoughOutpatient tx. may not be enough
29© AMSP 2010
Assessment: AUD +TBIAssessment: AUD +TBI
Routine alcohol screening for all TBI Routine alcohol screening for all TBI patientspatients
Multiple assessment modalitiesMultiple assessment modalities
Interview pt. alone re useInterview pt. alone re use
Review records Review records
Interview familyInterview family30© AMSP 2010
Treatment: AUD +TBITreatment: AUD +TBI
External motivators ↑ effect of tx.External motivators ↑ effect of tx.Financial incentivesFinancial incentivesCase mgmt., peer supportCase mgmt., peer support
Modify tx. conditionsModify tx. conditions↑ ↑ Appointment timeAppointment time↓ ↓ Noise, visual distractionsNoise, visual distractionsFrequent breaksFrequent breaks
31© AMSP 2010
Treatment: AUD + TBITreatment: AUD + TBI ConcreteConcrete
Decision making forms (pros/cons)Decision making forms (pros/cons) Break complex tasks into stepsBreak complex tasks into steps
Behavioral focus (not insight oriented)Behavioral focus (not insight oriented) List specific activities to replace List specific activities to replace
drinkingdrinking Pictorial daily schedulePictorial daily schedule Alarm/watch to initiate activitiesAlarm/watch to initiate activities
32© AMSP 2010
Pharmacology: AUD +TBIPharmacology: AUD +TBI
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ALCOHOL
BenzodiazepinesOxazepam (Serax)
Propanolol
SSRI’sFluoxetine (Prozac)
AntiseizureValproic acid (Depakote)
Processing speed
Seizure control
Processing speed
Sedation
Sedation, Resp. depression
ArrhythmiaHeart failure
© AMSP 2010
Medications to Stop DrinkingMedications to Stop Drinking
Naltrexone (Revia) 50-100 mg./dayNaltrexone (Revia) 50-100 mg./day
Opioid receptor antagonistOpioid receptor antagonist
Reduces cravings, ↑ abstinenceReduces cravings, ↑ abstinence
Acamprosate (Campral) ~ 2g/dayAcamprosate (Campral) ~ 2g/day
↑ ↑ GABA (inhibits), ↓ glutamate (excites)GABA (inhibits), ↓ glutamate (excites)
Reduces cravings, ↑ abstinenceReduces cravings, ↑ abstinence34© AMSP 2010
This Lecture ReviewsThis Lecture Reviews
Definitions Definitions ✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
before TBIbefore TBI✔✔ Epidemiology/outcomes for AUDs Epidemiology/outcomes for AUDs
post-TBIpost-TBI✔✔ Prevention AUD +TBIPrevention AUD +TBI✔✔ Assessment/ treatmentAssessment/ treatment✔✔
35© AMSP 2010