Substance Misuse and ABI: Managing Dual Diagnosis Safely in Community Services
Substance misuse is a common complicating factor in acquired brain injury (ABI) services and is often intertwined with trauma, low mood, anxiety, social exclusion and fluctuating insight. For some people, substance use predates the injury; for others it emerges afterwards as a coping strategy, a consequence of changed social networks, or a feature of impaired executive function and impulse control. This article sits within mental health and dual diagnosis in ABI and should be delivered through robust ABI service models and care pathways that link neuro-rehab, community services, mental health and safeguarding.
Good practice does not mean tolerating unsafe substance use, but it also does not mean defaulting to exclusion, rigid “zero tolerance” approaches or defensive restrictions that push people away from support. Effective ABI providers manage risk proactively, document decisions clearly and evidence improvement through outcomes, not intention.
Why substance misuse looks different after ABI
ABI can change a person’s relationship with alcohol or drugs. Reduced inhibition, impaired judgement, memory problems and difficulties learning from consequences can lead to repeated high-risk patterns. Some people are more vulnerable to exploitation, coercion or harmful relationships. Others struggle to understand cause-and-effect: they may link distress to “bad luck” or other people rather than recognising triggers.
Services need to avoid simplistic narratives. Substance misuse can be both a risk factor and a symptom of unmet need. Practice should distinguish between:
- Dependence and withdrawal risk
- Chaotic use linked to trauma, grief or social stress
- Impulsivity and opportunity-led use linked to executive dysfunction
- Exploitation, cuckooing or unsafe peer networks
Operational example 1: Alcohol, impulsivity and repeated incidents
A man in supported living with ABI repeatedly binged on alcohol, leading to falls, aggression and missed appointments. Earlier plans focused on warnings and sanctions. Incidents continued and staff confidence reduced.
The service rebuilt the approach around function and routine. Day-to-day delivery included a consistent morning structure, community activity planning during known “risk windows”, and staff coaching to use brief, non-judgemental prompts (“Let’s check your plan for today”) rather than confrontation. A harm reduction plan was agreed with the GP and local alcohol service, including hydration prompts, safer drinking goals, and early escalation triggers. Effectiveness was evidenced through reduced falls, fewer police call-outs and improved engagement documented in weekly summaries and incident trend reviews.
Operational example 2: Cannabis use and deteriorating mental health
A woman with ABI used cannabis daily and began reporting heightened paranoia, refusing support and isolating in her flat. Staff initially framed this as “non-engagement”.
A joint meeting with mental health services and the substance misuse team clarified that cannabis use was likely worsening anxiety and paranoid thinking. The provider introduced consistent staffing, shorter visits with clear purpose, and an agreed script to acknowledge distress without reinforcing delusions. A relapse and crisis plan was created, setting out who to contact, what to monitor (sleep, appetite, escalation patterns), and what immediate steps reduce risk. Progress was evidenced through improved sleep routines, re-established contact with mental health professionals and reduced incident frequency over eight weeks.
Operational example 3: Exploitation, supply networks and safeguarding
A man with ABI was found repeatedly in contact with individuals supplying drugs, and there were signs of financial exploitation. Staff were unsure how to intervene without breaching autonomy.
The provider treated this as a safeguarding concern linked to vulnerability. Day-to-day practice included increased check-ins at high-risk times, welfare calls, support to change phone settings and privacy controls, and support to rebuild positive community networks. A multi-agency risk management meeting was convened with safeguarding partners, housing and the police, with actions assigned and reviewed. Evidence of effectiveness included reduced contact with exploitative individuals, stabilised finances and documented outcomes in safeguarding logs and monthly governance reports.
What “good” looks like day to day
In ABI services, substance misuse planning must translate into consistent shift-by-shift delivery. Key features typically include:
- Harm reduction goals documented in the support plan, not left to informal conversations.
- Clear risk thresholds for escalation (intoxication indicators, missing episodes, self-neglect, threats from others).
- Relapse planning that names triggers, early warning signs, and agreed responses.
- Medication and health integration (withdrawal risk, liver issues, seizure risk, interaction with prescribed medicines).
- Staff coaching so practice is consistent and not dependent on one “strong” worker.
Governance and assurance mechanisms
Providers need defensible governance because substance misuse frequently intersects with safeguarding, mental health and restrictive practice decisions. Useful assurance mechanisms include:
- Monthly incident trend review with thematic learning (time of day, location, triggers, staffing variables).
- Audit of relapse plans and evidence they are used during real events.
- Supervision templates prompting discussion of professional curiosity, exploitation indicators and least restrictive practice.
- Multi-agency meeting minutes linked to action tracking and review dates.
Commissioner expectation
Commissioner expectation: commissioners will expect the provider to demonstrate placement stability, risk management and effective system working. They will look for evidence that substance misuse is actively managed (not ignored), that escalation pathways are used appropriately, and that outcomes are tracked over time (reduced incidents, improved engagement, reduced crisis interventions).
Regulator expectation (CQC)
Regulator / inspector expectation (CQC): CQC will expect safeguarding risks linked to vulnerability and exploitation to be recognised early and acted on. Inspectors will also scrutinise whether responses remain person-centred and proportionate, including whether restrictions are justified, reviewed and documented, and whether staff understand how ABI affects capacity, insight and decision-making in substance misuse contexts.
Impact and outcomes
When substance misuse is addressed through consistent, neuro-informed practice, services typically see reduced incidents, fewer safeguarding escalations, improved engagement with health partners, and better quality-of-life outcomes. For providers, the benefit is defensible assurance: decisions are transparent, learning is embedded, and commissioners and regulators can see that risk is managed through good practice rather than avoidance.