Substance Abuse and Traumatic Brain Injury
Traumatic Brain Injury (TBI) is damage to the brain resulting from a jolt, blow or another head injury.
A concussion is by far the most common form of TBI.
A concussion occurs when the brain smashes into the skull at high impact. Concussions are accompanied by a momentary loss of consciousness and may result in long-term cognitive disorders.
All brain injuries can be categorised as TBIs.
The risk of a Traumatic Brain Disorder when intoxicated
Many people who sustain a TBI did so under the influence of alcohol or drugs. When you are drunk or under the influence of drugs, your sense of balance is impaired. And you are also more likely to engage in behaviour that could result in physical injury to your head or elsewhere on your body.
Drinking alcohol or using drugs is a significant risk factor for brain injuries, especially among adolescents and young adults.
In fact, intoxication is the most common cause of brain injury. Studies  show of the adults who get hospitalised for brain injury treatment, 20 per cent of them were under the influence of drugs or alcohol at the time of the injury. We hope you agree this is an alarming statistic.
We can deduce from this that ‘being under the influence’ of either drugs or alcohol is, therefore, the most common cause of TBI.
Those most likely to develop substance use disorder (SUD) after a TBI
For those dependent upon drugs and alcohol before a TBI, studies show many of these people will sadly resume substance-use even after a TBI has been inflicted. This is especially the case when institutional and close family care is not provided.
Experiencing a TBI is also a major risk factor for developing substance misuse disorders even for those who were not addicted to anything before the injury was inflicted.
Studies show that about 10-20 per cent of TBI patients develop a SUD for the first time after suffering from a TBI (Corrigan et al., 1995).
TBI is, therefore, a risk factor for later substance abuse or dependence.
The risk of developing SUD after brain injury is unusually high if the TBI occurs before the age of 5 or at age 16-25. The possible explanation for this is the brain is still growing during these ages. Any interruption of the formation of connections in the brain may lead to a vulnerability to abuse drugs and alcohol.
For most TBI survivors, it was their drinking or drug use that resulted in the injury in the first place. Whilst for others, a TBI makes them highly susceptible to substance misuse and dependency.
Substance abuse after suffering from a TBI
Studies conducted on people with a TBI show that many of them resume their alcoholic ways 2-5 years after the injury. But before that, there’s often a “honeymoon” period when the drinking stops or reduces (Lamb-Hart & Rust, 1995).
What leads to this reduction in alcohol usage has to do with the institutionalised setting they’ll be recovering the brain injuries from.
During this time, TBI patients tend to live under close family supervision and care where it’s not possible to drink alcohol or use drugs.
But when this close level of supervision and care is reduced, the person tends to resume his or her alcohol or drug use.
The Science behind it all
Studies  suggest that TBI increases the risk for SUD by disrupting the neurocircuitry in charge of Incentive-motivation. For example, rats which were treated to TBI inducing substances showed low dopamine levels after electrical stimulation.
In humans, it is the same too as SPECT imaging shows reduced dopamine and dopamine transporting agents in TBI patients.
Another study reported that rats subjected to controlled TBI were less reluctant to seek novelty.
This study confirms what we have seen in human TBI patients already: decreased motivation. Another study reported that TBI in mice resulted in memory loss, passive avoidance deficits and even depression.
Other shreds of evidence suggesting TBI disrupts neurocircuitry responsible for reward and motivation include the fact that some TBI patients fail to predict the reward for specific outcomes.
The patients if treated to dopaminergic components, show improved cognition (Arciniegas and Silver, 2006).
Because of the abnormal functioning of the Incentive-Motivation circuitry, many TBI patients turn to drugs and alcohol. These provide a temporary “feel good” but leads to debilitating cravings in the long-run.
TBI patients have also developed an increased preference for short-term rewards as opposed to long-delayed rewards.
According to Dixon et al., 2005, this aversion to delayed-gratification results in poor choices as the person cannot mentally invoke potential long-term consequences of drug use.
Effects of Substance Abuse after TBI
TBI does not only make one susceptible to alcohol and drugs, but it also makes the substances more harmful. The reason is that the brain is delicate after brain injuries and its ability to assist the body deal with large amounts of drugs in the system is impaired.
Substance abuse after brain injury is, therefore, not recommended because it could lead to the following effects:
1. General effects
General effects include low tolerance for drugs and alcohol. Especially among teens, the consequences of TBI is that they can feel the drugs and alcohol effects more quickly. Just small amounts can mess up their cognitive and motor functioning.
Alcohol and drugs also react badly with prescription medications. And since it’s obvious that medication is going to be prescribed after brain injury treatment, mixing these with drugs and alcohol could have fatal consequences such as seizures.
Drugs and alcohol also result in depression, loss of confidence and feelings of loneliness. These are also common effects of brain injuries and therefore bingeing on drugs won’t help you cope with anything.
Other unwanted outcomes include unemployment and feeling downcast all the time.
Since the brain is more delicate after TBI, substances in the system can change its chemistry and connections for the worse.
Cognitive dysfunctions after alcohol and drug use include difficulties thinking, remembering, concentrating and comprehending.
2. Effects on the brain
Substance abuse after a brain injury makes it hard to recover and resume normal functioning.
A study by Ian Baguley and colleagues, for example, found out that alcohol abuse and TBI leads to the “additive effect”. This means that the action-potential required for synaptic communication becomes high. TBI alcoholics and druggies, therefore, are slow to respond to stimuli.
TBI recoveries also are prone to make poor decisions, and the effects of drugs in the system is only going to make these decisions worse.
What People Say on SUD after TBI
Brain injury does not only make one susceptible to SUD but also makes the drugs more harmful. Substance abuse after TBI can go from loss of cognitive functions to loss of motor skills and even death.
Here, for example, is what addicts and caregivers say about substance abuse after TBI:
1. High chances of violence
One lady says her husband has become increasingly violent and aggressive after a 2015 assault that resulted in brain injuries. The husband turned to heroin after the incident, became moody, angry and unable to talk. And even though he is now in rehab, he refuses to cooperate with the treatment.
2. Increased Paranoia
This one was posted anonymously at the drugabuse.gov website. The person says her son suffered a brain injury at the age of 13 that resulted in slow changes in behaviour that are now full-blown.
At 44 he’s divorced, smokes a lot of pot and is into Vicodin. He’s very paranoid and lives in his truck. His family says they almost do not recognise him.
3. Intoxication was the cause of their brain injuries.
Many people site intoxication as the leading cause of their brain injuries.
Drugs and alcohol, they say, impair their motor and perceptive functioning while increasing the chances of one getting victimised.
Many concussions are from car wrecks, falling or getting “jumped” at the streets. Brain injury as a result of intoxication makes up 2 per cent of ER admissions and 30 per cent of rehab admissions.
4. Caregivers want to know how to help
Caregivers want to know how they can take care of their recovering loved ones. One concerned it is heartbreaking to see a loved one lose memories one by one and develop shaky hands while you can do nothing to help.
One lady, for example, says that although rehabs have helped her father recover well from brain injuries, they have failed to address his 40+ years of alcohol addiction.
She says he’s losing those long-term episodic memories and is very different from the man she once knew.
Another person says their son’s paranoia has driven him to homeless living, pot-smoking, and they can’t recognise him anymore. They do not know what to do!
Well, for starters, here’s the experts advise on how to care for recovering TBI patients with a history of alcoholism.
How to Care for addicts with TBI
The reason most TBI patients will most likely resume or develop SUD is that they feel lonely.
It’s no secret that the brain recovers slowly than the mind. Therefore, it gets boring to sit and wait for the brain while the body feels fit already.
And this boredom and loneliness can set one up for substance abuse.
But it’s also no secret that an injured brain recovers more slowly or even stops short of recovering when on alcohol or drugs. Not drinking or using drugs, therefore, is vital for getting past TBI.
Personal attention is, therefore, key to helping loved ones avoid the pitfall.
- Consider institutionalising them for behavioural counselling and medication. Such a setting without triggers for drug and alcohol abuse will help put your loved one on the recovery road. 
- Consider hiring your therapist to provide both physical and emotional support.
- Hire the services of a stay-in sobriety coach if you can’t afford to give the personal attention needed.
- Make sure they eat healthily and work out regularly.
- Get in touch with a suicide prevention organisation in case depression or mood swings become frequent. 
Other Suggestions treating SUD in People with Limited Cognitive Abilities
According to the Ohio Valley Center for Brain injury , it’s essential to adapt a SUD treatment program to be specific to a patient’s cognitive limitations. Suggestions include:
1. Finding out the patient’s unique cognitive ability
The treatment provider must make use of motivational interview-style questions to determine the patient’s communication and learning abilities. Determine if they can read, write, comprehend and communicate then tune the program for their specific skills.
Compensating the treatment program for the patient’s learning style will lead to productive results. For example, if more attention is needed, you can meet with the patient individually after or enlist the help of family and friends.
2. Feedback is important
TBI patients are pre-disposed to make wrong decisions in pursuit of immediate aggrandisement.
Always let them know which behaviour is appropriate and which one is not immediately.
But be cautious when making inferences about a patient’s motivation based on the behaviours you have observed. For example, avoid assuming that the patient knows what is right yet he/she chooses to do wrong. TBI patients often fail to invoke the long-term consequences of decisions mentally.
Additionally, if you keep sending mixed signals, or confront the patient, they’re most likely going to shut down and develop resistance.
It’s advisable to keep on rehearsing, reviewing and repeating till the patient gets it. And avoid hastily discharging in case of non-compliance. Try to find out the reasons for non-commitment and resistance instead.
And lastly, there are no safe amounts of alcohol after TBI. So when the patient asks you what levels to drink, tell them not to do that. TBI reduces once tolerance for alcohol and even tiny drops could lead to pronounced effects.