Clinical Treatment Guidelines for Alcohol and Drug Clinicians Co-occurring acquired brain injury / cognitive impairment and alcohol and other drug use disorders Richard Cash Amanda Philactides 2006 State of Victoria. Produced with permission. This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without permission. Copyright enquiries can be made to the Communications and Publications Unit, Turning Point Alcohol and Drug Centre, 54-62 Gertrude St, Fitzroy, Victoria, 3065, Australia. Published by Turning Point Alcohol and Drug Centre under funding provided by the Drug Treatment Services Unit, Department of Human Services, Victoria. The views expressed in this material are not necessarily those of the Victorian Government. The correct citation for this publication is: Cash, R. & Philactides, A. (2006). Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No. 14: Co-occurring acquired brain injury / cognitive impairment and alcohol and other drug use disorders. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc. ISBN: ?? Introduction In late 2005 The Department Of Human Services Drug Policy Branch commissioned Turning Point Alcohol and Drug Centre to develop a set of clinical treatment guidelines for clinicians working with clients with comorbid acquired brain injury (ABI) and alcohol and drug use disorder. The process of development for these guidelines has involved a widespread literature review, consultation with a key-informant group comprising brain injury and alcohol and drug specialists from a variety of backgrounds, and consultation with the state-wide group of alcohol and drug and ABI clinicians and consultants. This clinical treatment guideline is made up of four parts: a literature review, a key informants issues paper, an assessment guide and a set of treatment resources. These guidelines were developed by Dr Richard Cash, Turning Point Alcohol and Drug Centre, with assistance from Mandy Philactides, South East Alcohol and Drug Service. 3 Acknowledgements We would like to thank the following organisations and people: Martin Jackson, Latrobe University for his advice and expertise in Acquired Brain Injury Silvia Alberti and Nicole Lee for their leadership and expertise in overseeing the ABI CTG project. ABI Behaviour Consultancy, ARBIAS, Ballarat Community Health Centre, Caraniche, COATS, Eastern Drug & Alcohol Service, Headway, Turning Point Alcohol and Drug Centre for providing expertise for the Key Informant Interviews Robin Fisher & Marion Simmonds, Department of Human Services for their support and guidance as part of the steering committee. Anna Guthrie, Publications Unit, Turning Point Alcohol and Drug Centre for her editorial assistance 4 Table of contents Introduction ............................................................................................................................3 Acknowledgements................................................................................................................4 Table of contents ...................................................................................................................5 ABI AOD Clinical Treatment Guidelines Part 1: Literature review ........................................7 Introduction.........................................................................................................................8 ABI: An overview ................................................................................................................9 Prevalence of ABI.............................................................................................................11 Substance use and ABI overview ....................................................................................11 Alcohol and cognitive impairment ....................................................................................13 Spectrum of cognitive impairments with alcohol use .......................................................14 Theoretical models of cognitive impairment in alcohol related brain injury .....................15 Process-oriented approaches to CI..................................................................................19 Other illicit and licit substances and ABI ..........................................................................20 Summary – Substance related brain injury......................................................................25 Recovery and abstinence.................................................................................................26 Clinical complexity – Acquired brain injury, traumatic brain injury and substance use ...27 Assessment and diagnosis overview ..............................................................................30 Obtaining valid assessments ...........................................................................................31 Assessment and diagnostic tools.....................................................................................33 Multi-method assessment ................................................................................................36 Models of ABI sensitive AOD treatment...........................................................................38 Incorporating cognitive retraining / rehabilitation into AOD treatment .............................44 Relationship between substance use, brain injury and offending behaviour...................46 Impulsivity review .............................................................................................................47 ABI AOD Clinical Treatment Guidelines Part 2: Expert informant key issues paper ..........50 Introduction.......................................................................................................................50 Assessment of existing AOD service provision for ABI clients ........................................50 Assessment of AOD issues with ABI clients ....................................................................56 Assessment of AOD program outcomes with ABI clients................................................59 Modifications to the existing AOD treatment system for ABI clients................................62 Other relevant approaches to managing AOD issues with ABI clients............................63 ABI AOD Clinical Treatment Guidelines Part 3: Alcohol and drug / acquired brain injury assessment module .............................................................................................................65 5 Introduction.......................................................................................................................65 Levels of ABI treatment needs.........................................................................................66 Categorising clients into levels of treatment needs .........................................................72 ABI AOD assessment module..........................................................................................74 Acquired brain injury screening tool.................................................................................76 Substance use assessment .............................................................................................79 Additional Information regarding substance use history..................................................80 AOD treatment history......................................................................................................81 Inventory of ABI-AOD associated risk-taking behaviour..................................................82 Motivational assessment..................................................................................................82 Assessing the impact of cognitive deficits and the role of substance use.......................84 Medical history and indicators of potential brain injury ....................................................86 Areas of assessment........................................................................................................86 Other BI Indicators from medical history..........................................................................86 Methods of assessing ABI from injury severity - Glasgow Coma Scale..........................87 Methods of assessing ABI from injury severity – Duration of post traumatic amnesia....87 Licit Substance Use History .............................................................................................88 Alcohol O drug use relapse / Risk assessment ...............................................................90 Psychosocial history.........................................................................................................90 Psychiatric history ............................................................................................................91 Suicide/Self harm risk checklist........................................................................................92 Legal and forensic history ................................................................................................98 Working with clients from diverse and non-English speaking backgrounds....................98 ABI AOD Clinical Treatment Guidelines Part 4: ABI-AOD treatment resources .............. 100 Introduction.................................................................................................................... 100 Acquired brain injury: What damage does to different areas of the brain .................... 101