physical trauma & addiction the interplay · 2018-07-27 · 6/11/18 1 physical trauma &...

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PhysicalTrauma&AddictionTheInterplay

SpencerRichards,Ph.D.ServicesforOutpatientAddictionRecovery(SOAR)

StephenR.Sheppard,Ph.D.SubstanceAbuseResidentialRehabilitation

TreatmentProgram(SARRTP)

March2014

VETERANSHEALTHADMINISTRATION

GenericCaseStudy…Ø Age:Yours

Ø Gender:Yours

Ø Occupation:Yours

Ø SocialSupportSystem:Yours

Ø MentalHealth:LikelyObsessive-compulsiveTraits

Ø OtherStrengthsandWeaknesses:Yours

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GenericCaseStudyContinuedØ SuddenEvent:SingleMotorVehicleAccident

Ø Lossofconsciousness

Ø ImmediateparalysisatC8level

Ø EmergentCare:AirMed Transport,EmergencySurgery,IntensiveCare

And, then you wake up…


PhysicalRehabilitationØMobility

• Learningtorollsidetoside• Sittingup• Transferringfrombedtowheelchair• Wheelchairmobility

ØActivitiesofDailyLiving• Bathing• Grooming• Dressing• Eating

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PhysicalRehabilitationØHealth

• SkinProtection• BladderFunction• BowelFunction• SexualFunction

Ø Pain• Musculoskeletal• Neuropathic

Ø Spasticity


Howdoyouthinkyouwoulddo?Ø EmotionallyandExistentially?

ØWorkandFinances?

Ø SocialSupport?

Ø Recreation?How would you rebuild your Quality of

Life?What if…?

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GoalsforTodayØ Reviewtheoreticalmodelsofadjustmenttodisability

Ø Reviewfactorsthatinfluenceadaptation.

ØDiscusstheinterplaybetweensubstanceusedisordersandadaptationtodisabilityandchronicillness.

Ø Identificationofkeyclinicalroadblocksandintroduceabroadconceptualframeworkthatcanguideintervention.


SpinalCordInjury(SCI)Ø Approximately17,000newcasesperyear

Ø 78%male

Ø AgeRange:16-30,ModalAge:about24

Ø Ethnicity• 61%Caucasian• 22%African-American• 13%Hispanic• 3%Asian

National Spinal Cord Injury Statistical Center 2018.

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MoreSCIFacts&Figures

Ø Causes:MVA 38%Falls 32%Violence 14%Sports 8%

Ø LevelofInjury:IncompleteTetraplegia 47%CompleteTetraplegia 12%IncompleteParaplegia 20%CompleteParaplegia 20%


HighRiskBehaviors

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SCIandSubstanceUse

Ø Approximately33%hadpre-injuryalcoholusedisorder.

Ø 31-50%wereundertheinfluenceofalcoholattimeofinjury.

Ø 32-35%wereusingillicitsubstancespriortoinjury

Ø 16-33%undertheinfluenceofillicitsubstancesattimeofinjury.

Ø 26%wereundertheinfluenceofalcoholandothersubstancesatthetimeofinjury.

Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.


QualityofLife(WHO?)ØAnindividuals’PERCPTIONSoftheirpositioninlife.Ø IntheCONTEXToftheCULTUREandVALUEsystems.Ø InrelationtotheirGOALS,EXPECTATIONS,STANDARDSandCONCERNS.

Ø ItisaBROADCONCEPTaffectedinacomplexwayby:• PhysicalhealthandPsychologicalstate• Levelofindependence• Socialrelationships• Salientfeaturesoftheenvironment

Chan, F., Cardoso, E. D. S., & Chronister, J. A. (2009). Understanding Psychosocial Adjustment To Chronic Illness and Disability: A Handbook for Evidence-Based Practitioners in Rehabilitation. New York: Springer Publishing Company.

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QualityofLife

Productivity

SocialConnection

HealthRecreation

Spirituality

BasicNeeds


QualityofLifeØNotastaticachievement

Ø Itisalifelongendeavor

A disabling condition virtually always results in physical & psychosocial pain.

Positive biopsychosocial adaptation is difficult and fundamentally important.

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Whatdoesitmeanto“adjust?”Ø Toundergoaprocessofpsychosocialadaptationwherethedisabilitybecomesintegratedintotheindividual’slife,identity,andself-concept.

Ø Stateofperson-environmentintegration.

Ø Thepersonincreasinglyexhibitssuccessinsolvingproblemsandmanagingenvironment.

Smedema, S.M., & Ebner, D. (2010). Substance Abuse and Psychosocial Adaptation to Physical Disability: Analysis of the Literature and Future Directions. Disability and Rehabilitation.32 (16), 1311-1319..


Whatdoesitmeanto“adjust?”Ø Thepersonplacesvalueonexistingabilitiesandmovesbeyondpersonalloss.

ØHopefullycreateorrebuildasenseof“well-being”andQualityofLife

Smedema, S.M., & Ebner, D. (2010). Substance Abuse and Psychosocial Adaptation to Physical Disability: Analysis of the Literature and Future Directions. Disability and Rehabilitation.32 (16), 1311-1319..

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StageModelsofAdjustmentØCrisis

Management:ØShockØAnxietyØDenial

ExperiencingLoss:ØDepression

ØAnger

ØAdaptation:ØAcknowledgement

ØAcceptanceØ…Adjustment

ØLegitimizesufferingandneedtoundergoaprocessofadaptation

ØPeoplearen’tnearlysomethodical…

ØSupport/Information…Processing…Action


CaseExamples:TomØ “Tom”Slippedonice:C4Tetraplegia

Ø Caucasianman,Mid- 50’s

Ø Travellingsalesman

Ø Verynicewifeandgrownson

Ø Moderatetoheavyalcoholuse

Ø LONER!

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CaseExample:JimØ “Jim”Injuredwhilesnowmobiling

Ø Caucasianman,Mid-40’s

Ø Computerengineer

ØVerynicewifeandextendedfamily

Ø SOCIABLEANDWELL-CONNECTED


“Somatopsychological Models”

ØEmphasizes the personal meaning of the disability and the value it holds for a person.

ØPerception of loss of personal value.

ØCoping or Succumbing to the Disability?• SUCCUMBING: Emphasizing negative affects, and

avoiding the challenge for change, fixated on unrealistic attempts to return to normal.

• COPING: Focusing on their intrinsic value, oriented on what can be done, and experiencing changes in their value system. Chan, F., Cardoso, E. D. S., & Chronister, J. A. (2009).

Understanding Psychosocial Adjustment To Chronic Illness and Disability: A Handbook for Evidence-Based Practitioners in Rehabilitation. New York: Springer Publishing Company.

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FourMajorChanges

Ø Expansionofthescopeofvalues.

Ø Decreasedimportanceofphysicalmatters.

Ø Containmentoftheeffectsofthedisability.

Ø Shiftfrommakingcomparisonstopreinjurylifetointrinsicvalues(improvedself-concept).


CaseExample:KerryØ “Kerry”-T1SpinalCordInjury-IntoxicatedCycling

Ø Early30’s

Ø Physicalandemotionalabuseinchildhood

Ø College-educatedandEmployed

Ø Avidoutdoorrecreation

Ø Moderatetoheavyalcoholandmarijuanausewhennotworking

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Somatopsychology ClinicalIntervention

ØEmphasizesanactiveapproachtocoping.

ØRecommendshelpingpersonsidentifyandexplorevalues.

ØWorktohelpreplacephysicalvalueswithmoreintangiblevalues.

ØHelppersonstakeprideinaccomplishment.

ØHelppersonsanticipateandprepareforchallenges.


“Cyclical”ModelsofAdjustment

•Sadness/Depression•Anxiety/Fear•Anger•Etcetera…

•ShiftingPerceptions•ChangingValues•CopingChanges•EnvironmentalModification•Andsoon…

“Normal”

“Event”

Disarray!Processing

Adaptation

Kendall, E., & Buys, N. (1998). An integrated Model of Psychosocial Adjustment Following Acquired Disability. Journal of Rehabilitation. 64(3), 16-20.

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CaseExample:AdamØ “Adam”-C6TetraplegiainaMVA

Ø 17yearsold

Ø Multipleadversechildhoodevents

Ø Substanceuse:methamphetamine,alcohol,MJ

Ø “BootCamp”

Ø SupportiveUncle

VETERANSHEALTHADMINISTRATION 6/11/18

“Cyclical”ModelsofAdjustment

Ø Experiencingemotionalpainandworkingthroughitisanimportantpartoftheprocess.

Ø Peopleinterrupttheprocessifthey“block”painfulfeelingsorget“stuck”indepression,anxiety,etc.

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CommonGroundofAdjustmentModels

ØLegitimizeemotionaldistressandpain.

ØAcknowledgepeopleneedtodealwithpain,somehow.

ØAcknowledgepeopleneedtoavoidpainpartofthetimeinordertocontinuefunctioning.

Across all models OVERUSE of AVOIDANT coping strategies is

problematic!


PersonalityFactorsRelatedtoAdjustment

Ø Sociable.

Ø InternalLocusofControl.

ØActiveCoping:Willingto“leanin”tothechallenge.

ØAbletotoleratefrustrationanddiscomfort.

Ø Stablesenseofselfandself-worth.

Ø Cognitiveflexibility-BenefitFinding

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OtherIndividualFactorsRelatedtoAdjustment

Ø Priorexperienceorhavingarolemodel.

ØHistoryofPsychiatricDisorderorSubstanceAbuse.

Ø SocialSupport.

ØMaritalStatus.

ØAgeandGender.

Ø Socioeconomicstatus.


DisabilityFactorsRelatedtoAdjustment

Ø Painorothercomplications(e.g.,spasticity,infections).

ØDegreeofimpairment:Generallythemoreimpairmentthemorechallenging.

Ø Bodyimagechanges.

Ø Prognosis:Poorerprognosiscanbeaharderadjustment,but…

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EnvironmentalFactorsRelatedtoAdjustment

Ø EnvironmentalObstaclesandAccessibility.

Ø LackofPositiveStimulation.

Ø Isolation.

Ø CulturalAttitudesandBeliefs.

VETERANSHEALTHADMINISTRATION6/11/18

Values Behaviors Goals

Heredity

Personality/Early Experiences

Beliefsabout SelfandtheWorld

INJURY/ILLNESSADJUSTMENTDIFFICULTIES

CognitiveFactors(Unhelpful)

•High perceived stress•Wishful thinking or avoidance•Uncertainty about illness•Appraisal of illness as threatening•Dysfunctional cognitions•Helplessness•Perceived barriers to health behaviours•Unhelpful illness/symptom representations•Unhelpful beliefs about pain

Behavioral Factors (Unhelpful)•Coping through avoidance•Unhelpful responses to symptoms (avoidance/resting)

Disruption of Emotional Equilibrium and Quality of Life

SUCCESSFULADJUSTMENT

CognitiveFactors(Helpful)

•Positivere-appraisal•Perceived control over life•Self-efficacy regarding illness•Optimism/Hope•Benefit finding•Self-efficacy regarding general life•Acceptance of illness•Spirituality

Behavioral Factors(Helpful)

•Problem-focussedstrategies•Seekingsocialsupport•Health behaviors

Social/environmental Factors•High perceived social support•Positive relationships/interactions

Adapted from: Dennison, L., Moss-Morris, R., * Chalder, T. (2009) “A model of cognitive and behavioral factors of adjustment in patients with multiple sclerosis. Clinical Psychology Review, 29, 141-153.

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MentalHealthandSCIØApproximately30-50%experiencedepression.

ØDeclines2-5yearspost-injury.

Ø SomestudiesshowanincreaseindepressionlaterinlifewithSCI.

ØApproximately20-40%experienceanxiety

ØAntidepressantsandpsychologicalTxhelp.


OtherRelevantPsychosocialFactors

ØDivorceratesareelevatedcomparedtothegeneralpopulation.

ØMaritalsatisfactionisgenerallyhigherforcouplesthatmetaftertheinjury.

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HowwillaHistoryofSubstanceUseDisorderImpactAdjustment?

ØAvoidantcoping?!?

Ø Co-occurringmentalhealthdisorders.

Ø Socialsupportchallenges.

ØVocationalfunctionandincome?

ØAndsoon…


ConsequencesofAlcoholIntoxicationattheTimeofInjury

ØExtendedlengthofhospitalstay,includingICU.

ØLongertimeonventilator.

ØGreaterriskofcomplications:pneumonia,bloodclots,urinarytractinfections,andpressuresores.

ØHigherpost-injurymortalityrate.

Crutcher, C.L., Ugiliweneza, B., Hodes, J.E., Kong, M., & Boakye, M. (2014). Alcohol Intoxication and Its Effects on Traumatic Spinal Cord Injury Outcomes. Journal of Neurotrauma. 31, 798-802..

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ConsequencesofIntoxicationattheTimeofInjury

Ø Lessactiveinrehabilitation.

Ø Lowerleveloffunctionalindependenceatthetimeofdischarge.

Ø Morelikelytobedepressed.

Ø Increasedprobabilityofbankruptcyfollowinginjury.

Strongly suggestive of avoidant coping and difficulty adjusting.

Crutcher, C.L., Ugiliweneza, B., Hodes, J.E., Kong, M., & Boakye, M. (2014). Alcohol Intoxication and Its Effects on Traumatic Spinal Cord Injury Outcomes. Journal of Neurotrauma. 31, 798-802..


“RockBottom?”

ØApproximately50%ofpersonswithapre-injuryhistoryofalcoholorothersubstanceusedisorderreturntopre-injurylevels.

ØAsmallpercentageofpersonswithoutapre-injuryhistorydevelopapost-injurysubstanceusedisorder.

Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.

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RelapseAfterInjury…


HowDoesSubstanceUseDisorderImpactAdjustment?

Ø Increasedlikelihoodofdepression.

Ø Limitedactivityandparticipation

Ø Lowerqualityoflife

Ø Increasedlikelihoodofphysicalcomplications(e.g.,pressuresores,UTI).

Ø Earliermortality.Tetrault, M. & Courtois, F. (2014). Use of Psychoactive Substances in persons with spinal cord injury: A Literature Review. Annals of Physical Medicine and Rehabilitation. 57, 684-695.

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Let’sPausetoStretch…

OK…So, we’ve identified major challenges.How do we navigate out of this?


Assembling Parts to a Whole (WHO)

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Maximizing participation is the stepping stone to improved Quality of Life!

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Challenges of Rebuilding Basic Function and Activities

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Motivation is a key challenge!


Challenges of Rebuilding the Environment

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Solving problems and addressing environmental barriers…

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Challenges of Rebuilding Personal Factors

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Function

PersonalFactors

Activity

Participation!!!

QualityofLife

Environment

Emotions…self-concept…changing values…


ConclusionsØ Seriousphysicaltraumarepresentsanextraordinarychallenge.

Ø Substanceabuseisthesinglebiggestcontributortotraumaticinjuryresultingindisability.

Ø Substanceusepredictsamorechallengingrehabilitation.

Ø But,thereisroomforresilienceandextraordinarysuccesses.

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Questions

46


References

Ø Chan,F.,Cardoso,E.D.S.,&Chronister,J.A.(2009).UnderstandingPsychosocialAdjustmentToChronicIllnessandDisability:AHandbookforEvidence-BasedPractitionersinRehabilitation.NewYork:SpringerPublishingCompany.

Ø Crutcher,C.L.,Ugiliweneza,B.,Hodes,J.E.,Kong,M.,&Boakye,M.(2014).AlcoholIntoxicationandItsEffectsonTraumaticSpinalCordInjuryOutcomes.JournalofNeurotrauma. 31,798-802..

Ø Dennison,L.,Moss-Morris,R.,*Chalder,T.(2009).Amodelofcognitiveandbehavioralfactorsofadjustmentinpatientswithmultiplesclerosis.ClinicalPsychologyReview,29,141-153.

Ø Kendall,E.,&Buys,N.(1998).AnintegratedModelofPsychosocialAdjustmentFollowingAcquiredDisability.JournalofRehabilitation. 64(3),16-20.

Ø Tetrault,M.&Courtois,F.(2014).UseofPsychoactiveSubstancesinpersonswithspinalcordinjury:ALiteratureReview.AnnalsofPhysicalMedicineandRehabilitation.57,684-695.

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DifficultyAdjustingandHealthManagement

Ø Self-MonitoringandSelf-Careareessential.

Ø Emotionaladjustmentcansignificantlyinfluenceself-care.

ØMortalityandSpinalCordInjury• Pulmonary• Infection:BladderandSkin• HeartDiseaseandcancer• Suicide(10-15%,5-7Xhigherthangeneralpublic)

Among persons with SCI…Depression may well be the #1 cause of death in the first 2-5 years…

physical trauma & addiction the interplay · 2018-07-27 · 6/11/18 1 physical trauma &...

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