Brain injury occurs without warning or preparation, and families get “on the job” training in ways to manage life after brain injury. Seldom do time and insurance funding provide the extended rehabilitative efforts that might better prepare the individual and the family for many of the real life problems that persist. Many family members erroneously believe that once formal rehabilitation ends, the individual with brain injury will return to a normal or near normal life and pick up where he/she left off. Sometimes that pre-injury lifestyle included use of drugs and alcohol, either habitually or recreationally. Families are generally unprepared for the negative effects created when drugs and alcohol are consumed after brain injury.
Abuse of alcohol and illegal substances is a frequently discussed topic at support group meetings. Several common themes consistently surface during these discussions:

1)  When alcohol and/or other substances were used prior to the brain injury without appropriate intervention and guidance, the problem is usually exaggerated after the injury.
2)  Even though abuse was a problem before the brain injury and may even have contributed to the injury, therapeutic intervention involving both the individual and family caregivers during rehabilitation enhances management of substances post-injury.
3)  All treating professionals should discuss the risks associated with the use of alcohol or substances after TBI and its effect on cognitive functioning. In the absence of professional instructions, the individual with brain injury typically assumes that drinking and/or drug use is as harmless as they thought pre-injury.
4)  It is not uncommon for substance abuse to surface some months or years after injury as an emotional response to depression when life does not return to “normal.”
5)  Reestablishing relationships with old friends and the desire to return to pre-injury social settings where substances were used can sabotage rehabilitation goals.

Each individual’s rehabilitation program is different, and the limitations of insurance and other funding sources place the major emphasis on the more obvious physical and cognitive problems. Little time is spent on redirecting social problems, and patients often leave facilities without being told of the increased danger when using alcohol and illegal substances after brain injury.

In the absence of professional and/or long-term intervention, it falls to the family to seek help in the community. Of necessity, they often must assume a monitoring role. Many families report that use of existing “general population” programs such as Alcoholics Anonymous (AA) and/or the typical 30-day inpatient addictive disorder programs have limited value in overcoming the problem. Most existing programs are designed for those who admittedly have a problem and are anxious to overcome an addiction. The individual with TBI may truly want to overcome the addiction and have every intention of staying on the program, but cognitive and memory deficits may sabotage the most sincere efforts.

I was fortunate that addiction was not one of my son’s problems. His rehabilitation was very individualized to his needs. For his own safety, he requires supervision on a continuous basis, and therefore has no access to harmful substances. While in rehabilitation he was well warned about the dangers of substance use in conjunction with prescription drugs plus the increased affect of alcohol or substances on persons with TBI. Although closely monitored, he has activities he can manage semi-independently. A few years ago, I was somewhat nervous about his attendance at a 10-year high school reunion where there would be an open bar. Some classmates were unaware of his situation and the extent of his brain damage. Many who knew him as a “party boy” and a “class clown” would think it was a joke that he no longer drank alcoholic beverages.

We rehearsed appropriate responses if offered alcohol; we practiced and polished his social skills. He doesn’t drive so I had to help him arrange transportation and do some minimal “in-servicing” for the benefit of those who agreed to “keep an eye” on him.

All of the effort was well worth it. He got home sober, talked about having a great time, drinking gallons of 7-Up, dancing his heart out, and for a brief period in his somewhat dull routine he felt like a celebrity of sorts. Sadly, by the next day it was all but forgotten without external cuing to jog his recall. Some suggested strategies for families coping with addiction or pre-addictive behaviors include:

1)  Don’t forbid consumption, without risking the “dare me” syndrome. Casually and frequently discuss the hazards of using alcohol/substances and their effect on cognitive functioning.

2)  Enlist the assistance of a doctor to be the “bad guy.” Information from a medical professional is more meaningful. The doctor should emphasize the danger inherent with the use of drugs and alcohol in conjunction with anti-convulsants and other prescription drugs used by some individuals with brain injury.

3)  Contact BIA and your state brain injury association for articles and other helpful information about brain injury and addictive disorders.

4)  If your family member previously enjoyed a cold beer, try some of the non-alcoholic (“near beer”) versions. Even the non-alcoholic ones contain small amounts of alcohol, so read the labels first.

5)  If there’s a need to “fit in” when others are consuming alcohol, try cocktail-sized glasses, or add a twist, cherry or olive to a non-alcoholic beverage. Many people in bars and restaurants order “virgin” drinks (sans alcohol), so it’s socially acceptable.

6)  Take a strong stand, impress upon the “old gang” that use of alcohol/substances post-injury could be very dangerous and expect their cooperation in helping your family member stay healthy and safe. Friends may be lost, but they were clearly not the right friends.

7)  When the problem is related to depression, take inventory of what your family member is doing (or not doing) with his days that contributes to depression. Whatever it is, change that! Maybe he/she needs to get out, volunteer some time, get into a program or be assigned some chores. Use your imagination but find something that stimulates and motivates your family member to see the world around them. Busy people have less reliance on “crutches.”

8)  Once an addiction problem is identified and the individual is willing to be helped, get into AA or Narcotics Anonymous (NA). The selection of a sponsor is important and that person needs to be made aware of TBI and its consequences. The individual and sponsor can jointly benefit from use of the Brain Injury/Addictive Disorders 12-Step Workbook, available free of charge from Healthcare Rehabilitation Center, 1106 W. Dittmar Rd., Austin, TX 78745.

9)  If the situation is out of control, families need to know about legal measures to protect themselves and others. The Baker Act (mental health) is not applicable when drugs and/or alcohol are used. There are statutes that vary from state to state about the way individuals with addiction problems can be ordered into treatment. In some cases, these statutes require more family involvement in locating appropriate placement and/or responsibility for payment for services.

Addiction is a major public health problem and difficult to control after TBI. Treatment works but requires that lessons learned be reinforced on an ongoing basis. To be forewarned is to be forearmed, so be watchful that alcohol and illegal substances do not become a crutch on which your family member leans.

Carolyn Rocchio is the parent of a son with a brain injury sustained in a 1982 automobile crash. She is the founder of the Brain Injury Association of Florida and a former board member of the Brain Injury Association.