Enjoy Dr. Cope’s last piece on traumatic brain injuries. Please be sure to read part 1 and part 2 if you missed them. – Dr. Holt
As recovery from a TBI progresses, more specific, non-psychopharmacologic measures to deal with the confusion and agitation are appropriate. These measures are best applied in a formal rehabilitation setting where the environment can be structured to minimize likelihood of injury. This typically begins within an acute rehabilitation hospital but then, with prolonged delirium, may extend to post-acute rehabilitation residential settings. Occasionally, the agitation dimension has a degree of aggressiveness (e.g. biting, hitting) that requires a specific setting commonly referred to as a “neurobehavioral” program. These are highly specialized, locked environments where the staff is trained in behavioral contingent management techniques and in appropriate physical control methods. Such programs are essential in safely dealing with the assaultive patient until this period resolves with progressive recovery. In a very few cases, however, this aggressiveness never resolves and a permanent placement in a locked facility is indicated.
Cognitive Disturbance and Cognitive Therapy
Cognitive disturbance is the most common significant deficit following TBI. This encompasses many dimensions, including impairment of attention and concentration, increased distractibility, reduced speed of information processing, memory issues, difficulty with logical thinking or problem solving, and so on.
Usually, a variety of these aspects is affected in a unique profile and a comprehensive neuropsychological test battery is needed to measure the extent of each. Most can be expected to significantly improve with time following injury. It is believed that this process of recovery continues for 18 to 24 months. Though it is likely that improvement progresses beyond this period, it becomes progressively so minor as to be ultimately clinically trivial.
The most common approach to these deficits is “cognitive therapy,” which is a collection of rehabilitation techniques intended to guide a recovering TBI survivor through graded cognitive “exercises.” It is believed that these will guide the recovering brain to better function. This basic theory is one which has numerous supporters and detractors. The evidence for its efficacy is not overwhelmingly convincing. Nevertheless, cognitive therapy is generally accepted as, at worst, it teaches compensatory methods to the patient, and at best, it potentially actually advances recovery.
Current clinical standards dictate these treatments be provided for up to the period of “active” recovery, which is the 18 to 24 month period mentioned above. The utility of these approaches should be periodically reevaluated throughout this process. A lack of progress in cognitive ability generally indicates a lack of efficacy for that patient. In such cases, the effort should be discontinued.
However, it is important to recognize that the lack of effect may be because the intervention was attempted too soon after injury (during the period of delirium), or that some co-morbidity (e.g. depression or pain) has interfered with the process. Under these circumstances, a later re-engagement in the effort may be appropriate.
The issue of psychotherapeutic counseling (as distinct from cognitive remediation) arises often in TBI. For minor injuries, this is undoubtedly useful in many cases. For the cases of moderate and severe TBI, there is a question of the efficacy of these psychodynamic approaches when the basic underlying functions of attention, judgment, memory and insight may be significantly impaired. There is clearly some level of severity above which such efforts are futile, yet there are some patients who appear to clearly benefit.
Unfortunately, it is difficult to be prescriptive about when or when not to attempt psychodynamic treatments. The judgment of experienced clinicians should be relied upon in each case.
A more open-minded approach should be kept regarding other aspects of counseling that address more compensatory techniques. Examples include the use of memory notebooks, “time out” responses to emotionally difficult situations, and specific community survival procedures such as public transportation use or emergency responses like dialing 911. Interventions that involve couple or family counseling are also quite beneficial in helping the patient’s social support system adapt to the changes following TBI.
Job coaching and vocational counseling, when appropriate, are also effective ways to aid a survivor to regain some meaningful work opportunity which additionally can do a great deal to help with the emotional distress following TBI. Group therapy with peer survivors has often been reported useful for all types of counseling following TBI.
Wrapping it all up
It is perhaps most important to realize that the neuropsychiatric deficits following TBI are both the most “hidden” to casual observation, but are at the same time the most universally present, and that the neuropsychiatric deficits overall become the most disabling. While there are limitations to the degree to which these can be reduced by current techniques, there are many approaches which have been shown generally effective to some degree and which, for some patients, can have dramatic and “life-saving” impact. In planning for management of the TBI survivor and his or her family, this aspect of care should never be overlooked.
We are happy to share the second post in a series of three from our founder and Senior Medical Officer, Dr. Nathan Cope. Be sure to read part 1 if you missed it. – Dr. Holt
In my post last week, I discussed the general neuropsychiatric overview of TBI as well as the approach to the cognitive and emotional impairments following mild TBI injuries. This week I will discuss the consequences of more severe TBIs and address the role of psychopharmacology in the treatment of such injuries.
Recall that these moderate and severe injuries make up less than 15% of the total incidence of TBI in the United States, but produce the vast majority of long-term, TBI-related disability. Millions of Americans are living with the long-term deficits resulting from these more serious injuries. For many of these survivors, various psychiatric issues emerge. These issues can be addressed via environmental and psychotherapeutic approaches, as well as psychopharmacological approaches.
Consequences of Moderate and Severe TBI
As with any TBI, there is an immediate period of disorder or loss of consciousness. Additionally, with moderate and severe TBI, there is a wide spectrum of syndromes which can occur. For example, for injuries that involve the lower brain areas (brainstem), multiple hard neurologic deficits are commonly seen: difficulty with temperature and blood pressure regulation, reduced function of vital processes such as respiratory drive, difficulty with arousal, reduced autonomic functioning, severe paralysis (locked-in syndrome) and so forth.
With such cases, it can be difficult to ascertain whether beneath the “unresponsive” patient there is an individual who is aware but unable to move or communicate. This is a difficult clinical issue–how do we ever really know that there is not awareness that we as physicians cannot observe? There are also cases where significant error has been made and patients do have awareness that is not appreciated. Moreover, if the patient is sedated with drugs or is significantly ill from another cause (e.g. infection or metabolic disturbance) then an error can be made about the ultimate potential for recovery and awareness. It is important to ensure a sufficient period of expert clinical observation and trial to observe for any sign of awareness.
During this period, the principle psychiatric task is to accurately understand the neurologic damage and prognosis and communicate this to the family of the patient. There is a tremendous psychological “crisis” in this acute injury period which can lead families to form erroneous or maladaptive beliefs leading to much needless treatment and distress. Early efforts to fully educate and counsel families in this early period will be multiple times more effective than similar efforts delayed.
Return to Consciousness and Psychopharmacology
In most cases, even with the most severe TBI, responsiveness eventually returns. Initially, there is usually a period of acute agitation and confusion (delirium). As noted last week, psychoactive medication is rarely needed during this period and treatment should include simple measures to protect the patient from self injury. Only in special circumstances, such as if there are medical I.V. lines or other measures which require a quieter patient, would it be appropriate to use a simple sedative or narcotic to produce calm, and these should be discontinued as soon as medically possible.
In general, pharmacologic treatment is felt to be a later (if not last) resort intervention; to be ventured after inadequate response to more general rehabilitation efforts involving traditional physical, occupation, speech and psychological therapies. No drugs have been validated with large-scale prospective, randomized, blind studies, despite a variety of pharmacologic approaches that have been reported effective to some degree. Nevertheless, the most common classes of drugs indicted as useful following TBI include almost the entire range of psychotherapeutic agents: neuroleptics (antipsychotics), anticonvulsants, mood stabilizers, stimulants, antidepressants and antianxiety agents.
Only under some circumstances is pharmacologic treatment appropriate. For example, it may be important to gain immediate behavioral control of a manically excited or aggressive patient, or it may be felt that a combination of stimulant and traditional therapies is a more efficient way to benefit from limited rehabilitation resources (i.e. limited acute rehabilitation hospital days).
In any case, it is essential when using drugs that good single-case design be followed:
- make good baseline measurements of the specific behavior or mood to be effected
- trial a specific drug at both an adequate dose and for an adequate duration
- follow the rule of “start low and go slow”
- keep specific periodic measures of response to demonstrate change (or lack thereof)
- conduct a drug withdrawal phase to see if the target behavior recurs
- reinstitute the drug when efficacy has been demonstrated by the above procedure
- design a follow-up plan to periodically reevaluate the necessity of the medication
I’d like to emphasize the importance of that last point. Too often, when a drug is found to be therapeutic in the short term (and unfortunately often even when it is not), the drug regimen is continued on “automatic pilot” without reestablishing the need or benefit. All psychoactive drugs have significant side effects and toxicities, including elevated mortality, which have generally been shown to be more a risk with patients with organic conditions of the brain (e.g. TBI).
It is best for a physician with specific training and experience in the treatment of TBI (usually a psychiatrist, behavioral neurologist or a rehabilitation specialist) to manage the psychopharmacologic approach to TBI.
Continued Recovery, Cognitive Disturbance, and Psychotherapeutic Counseling
As a TBI patient continues to recover, more specific, non-psychopharmacologic strategies may be appropriate. I’ll discuss this in more detail in my third and final post next week.
We have an esteemed guest joining us at Outlook on Outcomes for the next few weeks. Dr. Nathan Cope is Paradigm’s Founder and Senior Medical Officer and he’ll be sharing his expertise in the field of traumatic brain injury. Specifically for this series, we’ll discuss TBI and neuropsychiatry. – Dr. Holt
It is unfortunate that the psychiatric community has only recently developed a neuropsychiatric interest in brain injury. For much of modern medical history the injured brain was felt to be irreparable and no real attempts at treatment were developed beyond palliative approaches. More recently, over the past 20 or 30 years, as the plastic capabilities (ability to change or recover from damage) of the brain have become appreciated, more work in how to treat brain injury from the psychiatric perspective have emerged. Yet it is still important to realize that medical science in this area is in its infancy and most recommendations are not based upon gold standard, randomized, blinded investigations which characterize many other areas of medicine.
In a similar vein, the discussion that follows around specific neuroactive or psychoactive medication use is derived from limited evidence. No large scale, prospective studies comparing one medication with another or with placebo are available in TBI. There are scattered small studies and a larger number of case series that suggest efficacy, but they are far from the desired level of proof desired. Complicating this situation is the common observation that TBI patients tend to have individualistic responses to psychoactive drug intervention. Two TBI survivors with essentially similar clinical pictures can have vastly different responses—one can be dramatic improvement; the next a detrimental response. Clinically, all psychoactive pharmacologic treatment should follow a “single-case design” process whereby a baseline is firmly determined before a drug is started and the response carefully tracked. Then, even if an apparent positive response is seen, a period of drug withdrawal is usually indicated to demonstrate continued need for the drug.
Many of the treatments felt useful for TBI are derived from treatment of other psychiatric problems whose symptoms and signs bear some similarity to TBI. While this has to a large extent proven useful, it should also suggest caution in being dogmatic about what does and doesn’t work for TBI. Judicious trial and error in treatment is not an inappropriate attitude to take here.
It is also important to consider just how complicated the brain is. The brain is easily the most complex organ of animals. There are billions of individual neurons in the human brain; each with hundreds or thousands of separate connections to other nerve cells via many diffuse fiber tracts almost literally connecting all areas of the brain with all others. The main outputs of clinical psychiatric or psychologic interest—namely cognition, behavior, and emotion—are all enormously complicated activities which can vary, first due to individual variation, and second from a variety of injury specifics: from essentially “normal” through stages of mild, moderate and severe impairment. Each dimension can change independently although they tend to interact with each other. For example, a survivor of brain injury who has difficulty with their cognition may have secondary depression develop which may eventually evolve to aggressive behaviors due to frustration.
I will only summarize here the most important or common issues, and published sources should be accessed for detail. Entire textbooks have been written about the neuropsychiatry of TBI, most recently and authoritatively by Silver, McAllister and Yudofsky in their work, Textbook of Traumatic Brain Injury (2nd Edition, 2011).
Although the image of traumatic brain injury is commonly a picture of an individual with major physical, sensory and speech deficits (e.g. paralyzed and aphasic), which are seen in the moderate and severe injuries, perhaps the most common and important deficits following trauma to the brain are in the neuropsychiatric area and thus “invisible” to the casual observer. Recent study of concussion has proven beyond doubt that even these so-called minor injuries create significant and often permanent deficits in brain function. Permanent disability is higher with repetitive concussions (the “punch-drunk” syndrome). The CDC estimates the incidence of all TBI in the U.S. to be more than 1,600,000 a year.
One final general point should be appreciated. TBI affects not only the injured individual, but also their family, social and work environments. It is always important to consider the other individuals involved and provide appropriate education, counseling and support as needed. Much of the complications following TBI can be minimized by preparing the injured person’s support structure to have realistic expectations and appropriate reactions to the cognitive and behavioral alterations of TBI.
Loss of Consciousness, Delirium and Confusion
The hallmark of TBI is an immediate disorder or loss of consciousness (LOC). Without this the diagnosis of TBI must be questioned (although rarely TBI can occur without it.) A hallmark of the severity of the injury is the depth and length of the loss (or impairment) of consciousness. A period of a few seconds to minutes of unresponsiveness is typical of a mild injury. Several hours of LOC are characteristic of moderate TBI. When the LOC stretches into days it will typically result in a severe TBI with more pronounced deficits. After the resumption of awareness and responsiveness, there is typically a period of confusion or delirium. The only treatment usually required for this is protection of the individual from hurting himself or herself accidently. Similar to LOC, the duration of confusion or delirium is correlated very highly with the severity of the TBI; confusion may be a permanent result for very severe injuries.
The vast majority (more that 85%) of TBIs are mild injuries. Many of these mild injuries have significant (if often transient) symptoms. These commonly include headache, irritability, sleep disturbance and cognitive impairment (difficulty concentrating, distractibility, slowed speed of processing). Often, counseling about these expected complications and reassurance that they are (usually) transient is all that is needed. A brief period of excusal from day to day work or responsibility and gradual resumption with frequent periods of rest is also often helpful. Analgesics, anti-anxiety and sedative/hypnotic medications (for sleep aid) are also useful on occasion. If problems with cognition persist, it is often useful to give a trial of stimulant medication such as Ritalin or amphetamine. This helps with fatigue, concentration and speed of cognition, although at the risk of more irritability and error. Antidepressants are also useful at this time.
A later complication of mild injury is the development of post-traumatic stress disorder or PTSD. There is still little clarity about distinguishing PTSD from symptoms of mild injury itself which are often similar. PTSD can occur without TBI and vice versa. It is felt that early and aggressive treatment of TBI symptoms when evidence of persistence occurs is the best prevention of longer term development of PTSD. Interestingly, it is rare for PTSD to be associated with more severe TBI, which may be due to the severe memory and cognitive deficits of the latter which “cushion” the emotional trauma of the event.
Other complications may include chronic pain and depression. Similarly to PTSD, chronic pain may develop following mild TBI, often in the form of chronic headache or cervalgia (neck pain). Finally, depression is a later complication. It is also probably more common in mild than in the more severe forms of TBI, although it is quite common with all levels of severity. Early and aggressive treatment, counselling and pharmacotherapy with analgesics and antidepressants are believed to be the most effective in preventing longer term problems.
Moderate and Severe TBI
When the TBI moves beyond the mild into the moderate/severe categories, more pronounced psychiatric issues become prominent. I’ll discuss these in more detail in next week’s post.
Joining us at Outlook on Outcomes for the second consecutive week is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist. See his previous entry for more on this very important topic. – Dr. Holt
Last week we looked at the unique chronic pain patient profile and concluded that clinicians must recognize pain as a biopsychosocial condition. When the treating physician fails to address each of the biopsychosocial components and applies only medical remedies, results are often sub-optimal. Today we’ll explore the appropriate corresponding care plan and resources.
Maladaptive coping combined with the use of medication that is addictive and induces euphoria, is a recipe for addiction. Most chronic pain patients have long medical histories, have become functionally debilitated, and have developed fixed beliefs about their illness. If you simply detoxify a chronic pain patient of their addictive medication, you have the dilemma of a debilitated, poorly functioning person who can easily find a new practitioner willing to treat his pain complaint with opiates. Recidivism is a huge problem in addiction treatment; imagine what happens when a patient shows up at an unsuspecting physician’s office with an MRI showing two back surgeries. When physicians do not take all the biological, psychological and social components into account at every visit, the patients most in need fall through the cracks.
Treating chronic pain addiction based on needs
Successful treatment is in part due to appreciating that addiction is best seen in the context of pain rehabilitation. Physicians can often wean patients who demonstrate adaptive coping and a desire to discontinue opiates. However, less adaptive patients or those on very high doses require more formal detoxification. Treatment can be provided via a specialized office practice, but in many areas these reliable services do not exist. At times, we can piece together a detoxification program followed by a rehabilitation program. For the more complicated case, carefully selected multidisciplinary rehabilitation programs offer detoxification in the context of a highly intensive and multidisciplinary functional restoration program. As an example, I refer you to the Rosomoff Comprehensive Pain Center’s excellent detoxification and rehabilitation results.
A major key to success for Paradigm is the company’s treating physician intervention and concurrent onsite case management intervention with the injured person, healthcare providers and significant others. This course of action promotes entry into a rehabilitation program and ushers the injured person back into the community with a more appropriate care configuration. The Paradigm team recognizes the resources for each individual are dependent on the intensity of their needs, what is or can be made available in their community, and the cooperation of the injured person, his treating physician and, at times, his attorney.
Outcome goal setting
Paradigm recommends the following general outcome goals be a part of any chronic pain program:
1. Medications management: the injured person should be off opiates, decrease intake of other medications, and have decreased side effects.
2. Greater functional capacity: for example, the injured person should become comfortable sitting, walking and lifting through intensive graded exercise.
3. More adaptive coping strategies through cognitive-behavioral techniques
4. Establish MMI status and functional capacity.
5. Family intervention: support the patient’s family so they can assist with greater patient independence and less sick role behaviors.
6. Independent self management and decreased reliance on the health care system.
7. Discharge the injured person to a provider that is competent in conservative care without opiate reinstitution.
Preventing iatrogenic addiction recurrence
Preventing recurrence depends upon avoiding the type of care that initially caused the problem. Once gains are achieved it is important that the patient’s future care be conservative and focused on continuing the interventions that work: therapeutic exercise, independent modalities and avoidance of addictive or habit forming medications. The Paradigm team works to identify such resources and facilitates the transition which can be a bumpy road.
Joining us at Outlook on Outcomes this week and next is Dr. Steven Moskowitz, a physical medicine and rehabilitation specialist. As our first guest blogger, Dr. Moskowitz will cover a very important topic in our healthcare system and particularly in workers’ compensation. Thanks for sharing your expertise! – Dr. Holt
Dr. Holt asked me to comment on why treating prescription medication addiction is not as simple as a forced referral to a drug and alcohol detoxification or rehabilitation program. I believe chronic pain patients present a greater challenge for several reasons, including maladaptive coping with ongoing pain complaints, fear of activity and debilitation, high incidence of untreated concurrent psychological problems, and, lastly, the availability of community clinicians willing to repeatedly treat subjective pain complaints with opiates without addressing the accompanying psychosocial issues. Such physicians increasingly treat chronic pain patients with escalating or high doses of opiates despite dependence, addiction, the development of complications, and limited overall clinical and functional improvement. To break this pattern, we must consider the unique profile of a chronic pain patient and identify appropriate resources for the management of addiction.
This week, I’ll illustrate the main features of iatrogenic addiction in patients with chronic pain and argue that this particular profile requires a comprehensive response. Next week, part two will answer the question of what that methodology for treating iatrogenic addiction looks like.
Defining addiction and dependence
Two major problems with treating chronic pain with opiates are addiction/dependence and side effects. The actual definitions of drug addiction and dependence are very controversial and have been the subject of much debate in the development of the updated criteria for the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5), due out in 2013. The American Society of Addiction Medicine defines addiction as “a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.” It is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and cravings. The term dependence is often used to denote a physiological dependence composed of tolerance and/or withdrawal symptoms, but sometimes is used to describe psychological dependence on a drug. For our discussion, I’ll use these terms interchangeably since the real concept is problem drug use.
What is iatrogenic addiction?
Iatrogenic addiction refers to addiction that is caused by healthcare professionals. The National Institute of Health’s MedLine Plus online dictionary defines iatrogenic as “induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.” Unlike addiction to non-prescription drugs (e.g. alcohol, cocaine, heroin), addiction to prescription opiates requires a clinician who prescribes the medication. It is tempting to classify those with prescription medication problems as “addicts” and to believe all can be fixed by “detox.” This may be true for a small portion of these patients; professionals in the fields of addiction and law enforcement are well aware of illicit drug addicts who find their way into the medical system specifically to acquire prescription drugs. But it is difficult to know exactly what percentage of chronic pain patients is primarily driven by the desire to acquire drugs versus a secondary addiction or psychological dependence as a result of treatment.
Research regarding the chronic pain population suggests that for the majority of cases, addiction or dependence is the result of prescription medication use, not the cause of it. Consider the following:
- “The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%.” (The “Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction (Annals of Internal Medicine, January 16, 2007 vol. 146 no. 2 116-127)
- Fishbain, et. al, in their article, “Comorbidity Between Psychiatric Disorders and Chronic Pain,” estimated that perhaps up to 18.9% of chronic pain patients have issues with abuse, addiction or dependence, but stated that recent studies showed current problems with dependence in up to 34% of chronic pain patients. Up to 12.5 percent were found to use illicit drugs.
- In my informal discussion with colleagues who run comprehensive pain programs, it was felt that of the patients presenting to their program with problematic prescription drug use, perhaps 20-30% had a primary addiction problem, separate of pain issues.
The chronic pain population includes a wide variety of people who can be vulnerable to addiction to prescription medications. Some have addictive habits, such as smoking, over-eating and alcohol, while others have a past history of addictions. Conversely, others had no prior vulnerability to addiction. One of the most common traits in pain patients with problematic opiate use is maladaptive coping abilities. The Fishbain article noted that 71% of chronic pain patients have adjustment disorders.
It is vital that clinicians recognize pain as a biopsychosocial condition. That means most patients not only have biological factors causing pain, but also significant psychosocial aspects prolonging disability and delaying recovery. This makes treatment a more complicated endeavor than standard drug and alcohol detoxification or rehabilitation.
Return next week to learn how to identify the appropriate resources for treating iatrogenic addiction.