Traumatic Brain Injury and Substance Use Related Disorders

Traumatic Brain Injury and Substance Use Related Disorders: Building Supports With Our Community Partners Presenter: Gabriela Lawrence-Soto, Massachusetts ACL Opioid and Mental Health Concerns Work Group March 8, 2019 - West Virginia Traumatic Brain Injury Conference

Disclaimer This project was supported, in part by members of the ACL Opioid and Mental Health Concerns Workgroup grant numbers 90 TBSG 0034 -01 -00 (Indiana), 90 TBSG 0029 -01 -00 (Kentucky), 90 TBSG 0033 -01 -00 (Massachusetts), 90 TBSG 0027 -01 -00 (Maryland), 90 TBSG 0042 -01 -00 (North Carolina), 90 TBSG 0035 -01 -00 (Virginia), and 90 TBSG 0038 -01 -00 (West Virginia), from the U. S. Administration for Community Living, Department of Health and Human Services, Washington, D. C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

Objectives • • • The Public Health Emergency What is the Opioid and Mental Health Concerns Work group? SUD-TBI Prevalence and Intersections Barriers to Treatment for TBI populations Highlight Missed opportunities Partnerships Models used to address the SUD continuum of Care

The Public Health Emergency In 2017 overdose-related deaths were 6 times higher than 1999 President Trump declared the Opioid Crisis a National Public Health emergency Five-point Strategy to combat the Opioid Crisis 1. Better Substance Use Disorder Prevention, Treatment and Recovery Services 2. Better Data 3. Better Pain Management 4. Better Targeting of Overdose Reversing Drugs 5. Better Research Source:

Grant $$ to Combat the Crisis Center for Disease Control and Prevention (CDC) • Prescription Drug Overdose: Prevention for States (Pf. S) • Prescription Drug Overdose: Data-Driven Prevention Initiative (DDPI) • Enhanced State Opioid Overdose Surveillance (ESOOS) Health and Resource Services Administration (HRSA) • Expanding Access to Quality Substance Use Disorder and Mental Services • Behavioral Workforce Education and Training And Enhancing Behavioral Health Workforce awards • Rural Communities Opioid Response Program-Planning Substance Abuse and Mental Health Services Administration (SAMHSA) • • • Medication Assisted Program - Prescription Drug And Opioid Addiction (MAT-PDOA) State Target Response to the Opioid Crisis Grants (Opioid-STR) Opioid State Target Response Supplement grant (STR Supplement) Opioid State Targeted Response Technical Assistance (STR TA) Partnerships for Success (PFS) First Responders - Comprehensive Addiction and Recovery Act (FR CARA)

Grant $$ to Combat the Crisis …Continued Bureau of Justice Administration • • • Comprehensive Opioid Abuse Site-based Program (COAP) Innovative Prosecution Solutions for Combating Violent Crime and Opioid Abuse Justice and Mental Health Collaboration Program (JMHCP) Helping Children and Youth Impacted by Opioids Opioid Affected Youth Initiative Mentoring Strategies for Youth Impacted by Opioids Adult Drug Court Discretionary Grant Program Veterans Treatment Courts Drug Treatments Courts Program Opioid-Related Research for Criminal Justice Purposes Paul Coverdell Forensic Science Improvement Grant Program National Institute on Drug Abuse (NIDA) • NIH – HEAL Initiative (Helping to End Addiction Long-Term) Administration for Community Living (ACL) • NIDDLR – Brandeis INROADS Project • Traumatic Brain Injury State Partnership Program (TBISPP) State level appropriated dollars List is not exhaustive of all $$ allocated to the Opioid Crisis

Evidence-Based Approaches • Medication Assisted Treatment • Eliminating Prior authorizations • Initiating it in Emergency Departments • Expanding to other settings • • Naloxone – Wide Distribution Academic Detailing - (Technical Assistance for Medical providers) Prescription Drug Monitoring Programs in 49 States Enhanced Morbidity-Mortality Surveillance in 45 States Fentanyl screening in Clinical toxicology testing 911 Good Samaritan Laws Syringe Service Programs

Opioid Use and Mental Health Concerns Workgroup Traumatic Brain Injury State Partnership Program (TBISPP) 2018 -2021 Grant Cycle • Mentor States: Massachusetts and Virginia (participation from Indiana) • Partner States: Kentucky, Maryland North Carolina “The mission of the ACL - Opioid Use and Mental Health Concerns workgroup is to identify and share best practices across states with regard to addressing the intersections between substance use-related disorders, mental health and brain injuries. This will be accomplished by developing and widely-sharing tools related to that goal. ”

Substance Use-Related Disorders (SUD)

Diagnostic and Statistical Manual-V Clinical Criteria: Substance Use Disorder Based on a problematic pattern of use of the substance with clinical significant distress or impairment (at least two symptoms in a 12 month period) • • • Impaired control Social impairment Risky Use Pharmacological criteria Determination of severity ACL WORKGROUP FOCUS – Alcohol, Drugs, and Prescription Use and Misuse

Impairs Initiation + + Marijuana ? + + Heroin and Other Opioids + + Depression, Anxiety, Psychosis Increased Likelihood of Risky Behavior/ Legal Problems + Increased Health Risks (e. g. Major Organ Function) Impaired Memory and New Learning + Higher Risk of Additional Brain Injury(s) Impairs Balance / Coordination + Increases Seizure Risk Slows Brain Cell Repair and Growth Substance Alcohol + + ? + + + Research is ongoing and more is known on the impact of alcohol and opioids at this time than marijuana.

Substance Use Related Disorder Brain Injuries 5. 8 Million 16. 4 Million Dual SUD-MH 2. 6 Million Mental Health Concerns 7. 7 Million

TBI OPIOIDS Substance Use Disorder Prevalence ALCOHOL In Relation to Brain Injury (2017) 11. 4 M People currently misuse prescription opioids Leading substance used Falls is the leading cause of death for old and young 153 Die every day of TBI 1. 7 M Diagnosed with an OUD - Prescription Pain ILLICIT DRUGS Reliever Use MENTAL HEALTH 0. 7 M Diagnosed with an OUD – Heroin Use 7. 7 M Mental health disorder only 130+ die every day from Opioid-Related Overdose Top 3 ways prescriptions are accessed – Friend, Family, Prescriber Accidental overdose leading cause death for under 4. 1 Million – 50 Marijuana years olduse Dx 140. 6 M Current alcohol users 12. 2 M Alcohol use disorder only 2. 6 M Co-occurring SUD and MH disorder 2. 8 M Sustained a TBI annually 3. 4 Million – Other illicit drugs Disability post-overdose use Dx Chronic Pain, SUD, Mental Illness are common co-occurring disorder survival 3. 2 M people made Suicidal plans 2. 3 M Alcohol and Illicit Drug disorder

Brain Injury (BI)

Acquired Brain Injuries An ABI is an insult to the brain that has occurred after birth and is not hereditary or congenital Acquired Brain Injury (ABI) Non-Traumatic Brain Injury (ABI) No External Force • Strokes, Aneurisms • • Tumors, Cancer Meningitis, HIV Anoxia Hypoxia Traumatic Brain Injury (TBI) External Force • • Falls, Motor Vehicle Accidents Sports, Recreational Activities Work Related Accidents Assaults, Military Combat

Non-Fatal Overdoses Overdose event where the person is revived • Naloxone Suppressed breathing and heart rate • Shallow breaths OR Not breathing • Loss of consciousness may occur Time sensitive emergency • 3 -6 minutes irreversible brain damage Overdose survivors can sustain various injuries • Hypoxic Injury – NOT ENOUGH oxygen flow to the brain • Anoxic injury – NO oxygen flow to the brain • TBI – Increase risk of Fall during overdose event

Consequences of Non-Fatal Overdoses Oxygen deprivation impacts Thinking skills: • Memory • Attention • Ability to learning to NEW information • Problem Solve • Ability to manage our emotions • Lability • Impulsivity • Irritability • Apathy Residuals effects of non-fatal overdoses not yet studied

Acquired Brain Injuries Continued… Brain Injury can result in a chronic disability that may • Worsen with age • Complicate pre-existing/co-morbid condition(s) • Increase risk of sustaining additional brain injuries • Further decline functioning with every SUBSEQUENT injury

Intersections: SUD and Brain Injuries

SUD-TBI Risks: Bidirectional Relationship Substance Use Disorder (SUD) • Sustain initial TBI • Sustain repeated BI • Post-TBI alcohol use susceptible to OUD • Post-TBI mental illness susceptible to SUD • Chronic pain post-TBI susceptible to OUD • Non-Fatal Opioid overdose is risk of sustaining an anoxic, hypoxic injuries and/or TBI • Post TBI increase seizure risk Substan ce Use Disorde r Mental Illness (MI) • Sustain a TBI • Develop SUD • Develop OUD Brain Injury (BI) Mental Illness • • 3 -8 x risk of repeated BI Develop mental illness 2 -4 x Risk of suicide Develop SUD/OUD TBI with co-occurring conditions are 11 x more likely to die of accidental poising from drug or alcohol

Intersecting Problems PHYSICAL • Dizziness • Fatigue • Headache • Coordination • Visual deficits • Auditory impairments • Seizure Disorders risk • Sleep Disturbances COGNITIVE • • • Communication Issues Poor Concentration Disorientation Memory Problems Poor Organization Slow Processing Speeds Poor Initiative Lack Follow Through Poor Judgement Problem solving BEHAVIORAL • Anger • Anxiety • Depression • Unawareness • Confabulation • Perseveration • Irritability • Personality Changes • Inability to Control Emotions

Challenges to Engagement Resulting from TBI Families & Caregiver • Can feel trapped, isolated, abandoned • Can become be targets of abuse by survivor • Can be annoyed and impatient with survivor Service Providers • May end services pre-maturely if survivors are viewed (labeled) as resistant, aggressive, disinterested, not motivated, lazy, or non-compliant. • Survivors can overtime burn bridges with service providers • Patience, accommodating symptoms of TBI and connecting to brain injury services can help

Brain Injuries Substance Related Disorders Mental Health Concerns

ADDICTION RECOVERY PATH OVERVIEW Emergency Care Detox Emergency Room Inpatient Hospitalization ER Service Providers Outpatient Detox Services Common Challenges for Non-TBI Motivation/Ambivalence (2 in 3 people) Ability to self-advocate Adequate insurance (1 in 3 people) Logistical coordination Transportation Decline ability to cope with stressors Declined ability to perform every day tasks Stabilization Crisis Stabilization Services Ongoing Treatment Outpatient Home-Based • Individual Therapy • Psychiatrist Residential Programs Recovery Support Peer Support Groups Recover Centers Recovery Housing Treatment Approaches Used for SUD-TBI Medication Assisted Treatment Motivational Interventions Cognitive Behavioral Therapy Therapeutic Community Harm Reductions vs. Abstinence models Alcoholic Anonymous Narcotic Anonymous

CHALLENGES AND BARRIERS FOR TBI Emergency Care • • Detox Stabilization Ongoing Treatment Recovery Support No or limited screening for brain injury (BI) Under-resourced at times; collaboration with outside resources is difficult Staff not trained in working with BI Lack of understanding of brain injury history and impact on cognitive functioning abilities • Incidence tracking delayed or not available • Acute needs overshadow cognitive functioning abilities of the individual • No or limited accommodations for cognitive impairments • Poor resource facilitation or transition planning • Often discharged without brain injury supports in place

CHALLENGES AND MISSED OPPORTUNITIES Emergency Care • • • Detox Stabilization Ongoing Treatment Recovery Support No or limited screening for brain injury Under-resourced at times; collaboration with outside resources may be challenging Staff not trained in working with brain injury Lack of understanding of brain injury history and impact on cognitive functioning abilities Insurance coverage limits Consent for services is an issue • Treatment options vary; protocols may be too rigid • Not always equipped for complex medical needs • Medication restrictions at intake impede access to treatment • Length of stay varies (30 -60 days) • Remaining for full treatment period can be an issue • Lag time connecting to outpatient detox services • Shortage of intensive case management

CHALLENGES AND MISSED OPPORTUNITIES Emergency Care Detox Stabilization Ongoing Treatment Recovery Support • No or limited screening for BI done in this setting • Under-resourced at times; collaboration with outside resources may be challenging • Staff not trained in working with BI • Lack of understanding of BI history and impact on cognitive functioning abilities • Insurance coverage limitations • Consent for services is an issue • Expectation of ability to self-advocate • Need engage in CBT, DBT, Motivational Interviewing, Individual and Group counseling treatment. • No or limited accommodations made

CHALLENGES AND MISSED OPPORTUNITIES Emergency Care Detox Stabilization Ongoing Treatment Recovery Support No or limited screening for BI done in this setting Under-resourced at times; collaboration with outside resources may be challenging Staff not trained in working with BI Lack of understanding of BI history and impact on cognitive functioning abilities Insurance coverage limitations Consent for services is an issue Assumption often made - All therapists are equipped to work with or treat SUD and/or BI Inconsistent management of halfway/residential homes • Some halfway/residential homes will require individuals to be able to work and pay room/board • Some halfway/residential homes don’t have clinicians on hand • Use of AA/NAA programs to talk out behavior may be challenging for BI individual (impairments) • Religious ideology & meeting length range can pose difficulty for individuals • Attendance can at times trigger relapse in TBI clients because easy to find people to use with • Missing physician involvement for medication assisted treatment options • •

CHALLENGES AND MISSED OPPORTUNITIES Emergency Care Detox Stabilization Ongoing Treatment Recovery Support No or limited screening for BI done in this setting Under-resourced at times; collaboration with outside resources may be challenging Staff not trained in working with BI Lack of understanding of BI history and impact on cognitive functioning abilities Insurance coverage limitations Consent for services is an issue Issues with treatment services and with AA/NA Recovery Coaches vary between good and bad Some recovery coaches themselves are at-risk of relapsing as they rage in state of sobriety (anywhere between 6 months to 2 yrs to qualify for the role. ) • Brain injured person has limited or no access to brain injury psychosocial clubhouse programs • Limited access to social/recreational options for structure • Limited formal and informal supports available. • • •

Partnership Models

Kentucky’s Cabinet for Health and Family Service – Department of Aging and Independent Living Partnerships: Activities: Department of Behavioral Health Psychiatric Centers • • Outpatient Treatment Centers Target: Community Mental Health Centers County Jails Develop sustainable relationship Identify magnitude of the problem BI Screening Technical Assistance • Providers

Massachusetts Rehabilitation Commission Partnerships: Activities: • SUD-TBI Train-the-Trainer Model MA Department of Public Health • Screening for BI and SUD Executive Office of Elder Affairs • Technical Assistance Mass. Health Target: Brain Injury Association of MA BAMSI – New Start Head Injury Center • Intensive Case Management Pilot • MRC SUD Task Force • SUD/OUD Providers, Brain injury Providers • Aging agencies and Independent living centers staff • Hospital and Nursing facility Staff • Community Health Centers • Recovery Coaches and Peer mentors • Mass. Health navigators • Home Care providers, Day programs

Maryland Behavioral Health Administration Partnerships: MD Department of Aging Activities: • Training and Education • BI Screening • Technical Assistance MD Department of Disabilities MD Developmental Disability Administration MD Crisis Intervention Target: • Behavioral Health professionals • Local Police Department Crisis Intervention Training Coordinator • Overdose Fatality Review Teams

North Carolina Department of Health and Human Services Partnerships: SUD Section in the Department Brain Injury Association of NC Managed Care Organizations Activities: • Training and education • TBI screening • Surveillance – BRFSS • Prison system pilot • Technical Assistance 1115 Waiver SUD providers Prison System (future goal) Target: • Community Based providers • SUD Providers

Virginia Department of Aging and Rehabilitation Services Partnerships: Virginia Alliance of Brain Injury Service Providers Brain Injury Alliance of Virginia VA Department for Behavioral Health and Developmental Disabilities and Local Community Services Boards Executive Leadership Team on Opioids and Addiction Virginia Department of Health, Emergency Medical Service Advisory Board National Alliance on Mental Illness, Virginia Chapter University of Virginia Activities: • Training and education • BI Screening • Technical Assistance Target: • Crisis Intervention Service providers • 2 Area Aging Agencies • 2 Free Charitable Clinics • 2 Independent Living Center • 2 Community Service Boards

West Virginia University Center for Excellence in Disabilities in TBI Services Program Activities: • Hosting this forum to talk about SUD-TBI • Expansion of TBI screening in additional populations • Technical assistance and resource coordination to individual with TBI • Exploring the expansion of the TBI definition to include additional causes of anoxia • WVDHHR Bureau for Medical Services implementation of a statewide SUD Waiver Target: • Providers • People living with brain injuries Potential Partnerships: WVDHHR Bureau for Medical Services Local health organizations Community support organizations Great River Regional Systems for Addiction/Project Hope (Marshall Health) Recovery Point Mental health agencies

Take Away • Gather data on TBI –SUD sub-populations. • Expand Brain Injury services to include secondary injury due to opioid overdose(s) • Establish cross systems partnerships • Improve resource facilitation across intervention settings and community based providers • Develop or expand on a Day program/Club House Model • Find more ways to support families and caregivers

West Virginia Center for Excellence in Disabilities http: //cedwvu. org/resources/ RESOURCE

Contact Information • Gabriela Lawrence-Soto, ACL Grant Project Manager, Massachusetts Rehabilitation Commission Gabriela. Lawrence-soto@massmail. state. ma. us • Donna Cantrell, Med – ACL Grant Program Specialist, Brain Injury Services Coordinator, Virginia Department for Aging & Rehabilitative Services donna. cantrell@dars. virginia. gov • Tonia Wells - Director of Brain Injury Services, ACL Project Director, Kentucky Cabinet for Health and Family Services, Department of Aging and Independent Living. Tonia. A. Wells@ky. gov • Anastasia B. Edmonston MS CRC, - ACL Grant Program Coordinator, Maryland Behavioral Health Administration anastasia. edmonston@maryland. gov • Scott Pokorny, MSW, CBIS, Traumatic Brain Injury Team Lead, Division of Mental Health, Developmental Disabilities and Substance Abuse Services Scott. Pokorny@dhhs. nc. gov

THANK YOU

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