Did I Mention the Teeth?
Jennifer Bogner and Gary Lamb-Hart
The story is told that Little Red Riding Hood's
father had been to his mother's house the week before Red went. On the
way he had run across the wolf as well, but being older and wiser had
not fallen for the wolf's tricks. When he got home he thought to himself,
"I must tell Red about the wolf". It was late and he wasn't sure how to
tell her, so he put it off. Later in the week he wanted to tell her again
but thought, "I don't want to scare her from going to see her grandmother."
The next day is when Red went to her grandmother's house and we all know
that story. When her father got home from work and heard her story he
was sad and angry that he hadn't talked with her about the wolf beforehand.
Fortunately for him, things turned out fairly well. Red was shaken but
alive and safe.
There are some subjects that are hard for us to talk about as individuals and families. We know we need to talk about them, but the words get caught in our throat or we avoid the subject and hope things will just get better or we hope people will guess what it is we want. Sex, death, abuse, disabilities, and alcohol/other drug use are some of these subjects. There are as many excuses why we avoid these subjects as there are people among us. Some of the big excuses are: we are uncomfortable and don't know what to say to get started; our parents avoided these subjects with us and we never learned how to talk about them; we are afraid of the other person's reaction; we don't like confrontation and conflict, we don't want to make things worse; we feel guilty about our own experiences with these subjects; and we feel we are invading another person's space.
It is not the purpose of this article to try to tackle all of these subjects. Rather, we would like to tackle one subject which can have an enorrnous impact on the fate of the individual who sustains a traumatic brain injury: substance use. Substance use and traumatic brain injury are inextricably linked. Over half of all incidents leading to brain injury involve alcohol. Not only do a large number of adolescents and adults who sustain injury have a positive bloc~ alcohol level at the time of the injury, but about one half are legally intoxicated. Of these individuals, about half have used/ abused alcohol and other drugs for the past several years of their lives.
Substance use not only increases the chances of sustaining a brain injury, but also tends to worsen the prognosis for optimal recovery from the injury. Those with alcohol in their system at the time of the injury tend to have a longer period of coma and are more likely to show signs of agitation after emerging from coma. They usually require a longer hospitalization and their cognitive abilities are more impaired at the time of discharge. People who have a history of abusing alcohol stand a 41% chance of dying from the iniury, and few survivors have a positive prognosis for satisfactory outcomes.
If individuals continue to use alcohol or other drugs after a brain injury, their chances for a good recovery and a satisfactory quality of life become even slimmer. They run the risk of any number of medical complications, particularly when mixing prescribed medications with alcohol or other-drugs. The chances of experiencing seizures rise. These individuals experience greater cognitive deficits and are less likely to return to work successfully.
Given the serious consequences, why would someone continue to drink or use other drugs after an injury? For some, substance use was a problem prior to their injury; it has become a lifestyle issue. For others it may be a lack of awareness as the result of cognitive deficits, poor informadon or general Iack of thought about consequences. In some instances there is a-"conspiracy of silence" by survivors, families and professionals. Persons with traumatic brain iniury are more likelyto engage in substance use if their environment supports this behaviour. Not talking about issues, covering up or making excuses for another person's behaviour, protecting persons from the natural consequences of their behaviour, pressuring the person to "join the crowd", or doing for someone what they can be reasonably expected to do for themselves are all examples of actions that support the unwanted behaviour. In the case of brain injury the line between helping and hurting often becomes blurred.
The effect of the chemicals themselves can be another reason for continued use. Emotional escape and pain relief are two common reasons survivors give for continued use, despite the recognition that it is not a long-term solution. Chemical use tends to reduce motivation to change old habits. Peer pressure and social convention also contribute to continued use of alcohol or other drugs.
Sounds discouraging, but there is much that can be done. Family members, other survivors, and professionals can play an important role in decreasing substance use. The primary method for addressing this issue is for those involved to start talking about it. Secret keeping is the biggest obstacle to overcome. How information is presented is as critical as what is presented. Information needs to be presented in an atmosphere where there is trust, and a lack of judgementalism; and where the information is factual, consistent and repetitive.
We offer the following list of eight messages individuals with brain injury have identified as important to know in considering drinking or drug use after a brain injury.
1. People who use alcohol or other drugs after they have had a brain injury don't recover as much or as fast as people who don't use alcohol or other drugs.
If an individual with a brain injury begins to use alcohol and other drugs much of the progress that they gained during the recovery process may be lost. Because brain cells were lost in the injury, the remaining brain cells must work harder for the person to do some of the same activities that they did before the injury. If the remaining cells are compromised by alcohol or drugs, they will not be able to take over the duties of the dead cells. Skills that could have been regained are lost.
2. Brain injuries cause problems in balance, walking or talking that get worse when a person uses alcohol or other drugs.
For people whose brain injury caused difficulties with balance, mobility and production of speech, alcohol and other drugs exacerbate the problem. Even without a brain injury, alcohol and other drugs impair functioning in these areas.
3. People who have had a brain injury often say or do things without thinking first, a problem that is made worse by using alcohol and other drugs.
Disinhibition is a common problem associated with both traumatic brain injury and substance use. Not being able to control what you say or do can lead to a myriad of problems, such as increased risk-taking, arguments, or other socially inappropriate behaviour. While the person with the brain injuly may learn compensatory strategies to control their hehaviour, they are unable to utilize these strategies effectively when under the influence of alcohol or other drugs.
4. Brain injuries cause problems with thinking, like concentration or memory, and using aicohol and other drugs makes these worse.
Many people have to learn new skills, or relearn old ones, following a brain injury. People may have trouble with concentration, memory, problem-solving, and other thinking skills. Alcohol and other drugs can also interfere witn the ability to think and learn new information. The combination can produce even more serious impairments.
5. After a brain injury, alcohol and other drugs have a more powerful effect.
Brain injury results in a loss of brain cells. Those cells that remain must do their own work plus the work of the cells that are lost. Because there are less cells after a brain injury, more alcohol/drugs go to fewer cells, increasing the impact of the alcohol/drugs on that person's ability to function effectively. The individual becomes intoxicated more quickly, and the effect of the alcohol or other drug is much greater. In addition, alcohol and other drugs interfere with the effectiveness of prescribed medications.
6. People who have had a brain injury are more likely to have times when they feel low or depressed and drinking alcohol and getting high on other drugs makes this worse.
Being depressed is fairly common after a brain injury. Some people may attempt to cope with these feelings by drinking alcohol or using other drugs. While initially people may "forget" their problems, when they become sober the problems are still there. They may begin to drink more, so that the forgetfulness will last longer. However, alcohol is a depressant. It becomes an endless cycle, with depression leading to substance use, which leads to increased depression, which decreases functional activity. which increases depression once more.
7. After a brain injury, drinking alcohol or using other drugs can cause a seizure.
Some people who sustain a brain injury have an increased risk for seizures. Those who are at a very high risk are given medication to prevent seizures. Alcohol and other drugs increase the chance that even those at the lower levels of risk will have a seizure. Further. alcohol and other drugs prevent the seizure medications from doing their job, increasing the risk of seizures even more.
8. People who drink alcohol or use other drugs after a brain injury are more likely to have another brain injury.
A person who has difficulty thinking clearly, walking smoothly, reacting quickly due to a brain injury is at triple the risk for another injury. The person who then further clouds his abilities with alcohol or drugs will have an even higher risk for another injury for some of the same reasons. Second and subsequent injuries will cause more harm than the initial injury. The destruction of more cells as the result of a second injury will leave even fewer cells to do the same jobs, and some abilities will be lost because there are not enough cells to make these functions possible.
Individuals with brain injury have found that these eight messages are important to consider when contemplating choices about alcohol and other drug use following a brain injury. We support abstinence for persons who have survived traumatic brain injury as the choice that provides the best possibility for quality recovery, regardless of a person's previous use history. To help persons start the conversation or for consideration of persons that have had a brain injury we suggest the booklet User's Manualfor Faster..More Reliable Operation of a Brain after Head Injury available from the Ohio Valley Center for Head Injury Prevention and Rehabilitation, 1335 Dublin Road, Ste 50-A, Columbus, Ohio. USA. 43215 or 614-481-0611. Let s not be like Little Red Riding Hood's father; let's start talking about the issues of substance use.
About the authors:
Jennifer Bogner, Ph.D. is a Project
Administrator for the Ohio Valley Center for Head Injury Prevention and
Rehabilitation, Department of Physical Medicine and Rehabilitation, The
Ohio State University. She is Assistant Professor of Rehabilitation Psychology
and Program Director for the Head Injury Unit in the Department of Physical
Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio.
Gary Lamb-Hart, MDiv., CCDC III is the Training Coordinator for TBI and Substance Abuse Issues for the Ohio Valley Center for Head Injury Prevention and Rehabilitation, Department of Physical Medicine and Rehabilitation, The Ohio State University. He is a State and Internationally Certified Chemical Dependency Counselor.
i.e Magazine, Vol. 3 (1), 1995
This article is reprinted with the permission of i.e
Magazine and the authors.
i.e is a publication of the Ontario Head Injury Association, for more
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Editor at 905-641-8877; International contact i.e Magazine at 1-800-321-7037.