Many people with TBI have problems with the use of alcohol or other drugs prior to their injuries. It is not surprising that there is a strong link between being intoxicated and having a serious injury. Being intoxicated puts a person at greater risk for a TBI due to problems with motor control, blurred vision, and poor decision-making. People who are intoxicated are also at greater risk of being victimized. Even adolescents and adults who are not intoxicated at the time of injury tend to be much heavier drinkers than their peers who have not had a TBI. Up to 60% of those requiring inpatient rehabilitation for TBI may have had prior problems with alcohol and other drug use. Individuals with these problems before the injury are at risk for even greater problems if they continue to drink or use drugs after the injury.

In addition, some studies have shown that between 10% and 20% of persons with TBI develop a substance use problem for the first time after their injury. A TBI can lead some people to drink more alcohol or use more drugs than they intend. In comparison to others the same age, people with TBI tend to drink more alcohol.

Some people initially stop drinking or using drugs after the injury. They may recognize that the use of alcohol and other drugs will affect their recovery. The support of family and friends can also help people stay away from alcohol and other drugs. Unfortunately, after a while, some people start to drink or use drugs again. Many people think that it is 'safe' to use alcohol or other drugs after a certain amount of time has passed. However, there is no evidence indicating that there is a safe time to use.

Some people are surprised by how little is considered to be a safe amount to consume, even for people without TBI. Based on what we know about how alcohol and traumatic brain injury add together to change brain structure and function, we believe that there is no safe amount after TBI. We suspect that alcohol and other drugs can interfere with natural healing after a brain injury. The effects of substance use are more severe for individuals with TBI and can result in further brain damage. We also believe that substance use can have an impact on how a person is functioning many years after the injury.

When to seek help

Many people benefit from professional help when their drinking or other drug use is too much and is creating problems for them. One sign that a person could use some assistance is when they have tried to cut down on their own, but somehow the problem continues. Another sign is when people who care about a person begin worrying that he or she is drinking too much. Finally, if a person is facing legal or medical problems due to use (including having another injury) it is advisable to seek help.

A tool to assess use is available at Rethinkingdrinking.niaaa.nih.gov

Substance abuse treatment often includes both the individual and family or friends. The greater a person's cognitive impairments after brain injury, the more important it becomes that people in his or her surroundings are willing to be involved in the treatment process. Similarly, for people who do not see themselves as having a problem, it is more important that family and friends be willing to join professionals to get a person started in addressing their substance use.

How ready a person is to address problems related to their alcohol or other drug use can be described in the following stages:

1. Precontemplation (a person sees no problem with his or her alcohol or other drug use when there is one)
2. Contemplation (the person is weighing the pros and cons of changing substance use)
3. Preparation (the person has decided that a change is needed, but does not yet have a specific goal)
4. Action (the person is making changes in order to reduce or eliminate the use of alcohol and other drugs)
5. Maintenance (the person is sustaining successful change despite urges to use again).

Substance abuse counselors usually tailor treatment to a person's Stage of Change. Regardless of a person's readiness to address an alcohol or other drug use problem, there is always something a professional substance abuse counselor or treatment program can provide.

Motivational interventions have been used to help individuals become ready for treatment. Research in the substance abuse field has shown that "Motivational Enhancement Techniques" are associated with greater participation in substance abuse treatment and positive treatment outcomes. The intervention techniques must be matched to a person's stage of readiness to change. Motivational interventions seem like a promising way to promote positive change for people with substance abuse problems and brain injuries, though like most therapeutic approaches it needs to be adapted to the individual.

Cognitive-Behavioral Therapy uses cognitive and/or behavioral strategies to identify and replace an individual's irrational beliefs that arise from substance abuse (e.g., "the only time I feel comfortable is when I'm high") with rational beliefs (e.g., "it's hard to learn to be comfortable socially without doing drugs but people do it all the time"). Cognitive-Behavioral Therapy can be conducted as part of individual or group treatment. Whether or not someone has had a brain injury, Cognitive-Behavioral Therapies need to be adapted to a person's ability to understand the connections between beliefs and feelings.

Sometimes substance abuse treatment needs to take place in an environment where there is 24-hour per day supervision and treatment. One of the most common residential treatment approaches is the Therapeutic Community , or "TC". TC has been used to address the needs of people with substance use disorders for more than 30 years and its methods and effectiveness have been well-documented. TC views substance abuse as a problem of conduct, attitudes, moods, values, and emotional management. The approach focuses on creating a community, including other people addressing these problems, that promotes self-evaluation and recovery. For persons who have had brain injuries, the TC approach may need to be adapted to the individual, possibly with more flexibility and decreased intensity.

When it comes to the use of prescription medications for the treatment of substance abuse, there are not a lot of choices. The most common addiction-related medications is methadone for the treatment of heroin and other opioid addiction. Methadone cannot be given outside designated methadone treatment programs. A newer drug, buprenorphin, is available for the treatment of opioid abuse and dependence when prescribed and monitored by a certified physician. In our clinical work we have seen that prescription medications for depression or anxiety are sometimes important for getting started on changing alcohol or other drug abuse. Another medication, disulfiram or antibuse, is a well-established medication used to discourage alcohol consumption. However, its use by individuals with brain injuries is generally discouraged. Naltrexone has been used to reduce a person's cravings for alcohol, but there is no research on its effectiveness for people who have had brain injuries.

Professional treatment sometimes has natural limits and continuing care beyond formal treatment is critical to achieving a long-term, satisfactory outcome for individuals affected by substance use disorders. Self-help or peer support programs can be an important resource.

Self-help approaches began with Alcoholics Anonymous (AA) and have grown to address a wide variety of addictions. Rational Recovery and Moderation Management are two other self-help approaches for alcohol problems. Narcotics Anonymous (NA) and Cocaine Anonymous (CA), both based on AA, are two of the largest self-help organizations addressing illegal drug use. AA, NA and CA use the "12-step" method, with its focus on developing personal responsibility within the context of peer support.

AA, NA, or CA groups are not for everyone at all stages of recovery. For those still at a point that they are resistant to exploring their use of alcohol or drugs as problematic, the introduction of AA/NA/CA may be too early and counterproductive. Forcing a self-help group on a person too early may create greater resistance later in the process of recovery when AA/NA/CA could be very helpful. A person may find support in other areas of their life that are as productive as AA/NA/CA, and it may be better to use these natural supports. However, we have found that people who participated in self-help groups before their injury can be more open to involvement after.

When attendance at AA, NA or CA groups is being considered there is a certain amount of planning that should take place. We think it is important for someone to accompany a person who has had brain injury and has never attended self-help groups to the first few meetings. Having someone to share the initial experience with, and talk about it afterward, can make the difference between dropping out or staying with the group.

Nuts and Bolts of Using Self-Help Groups describes what will happen at a meeting.