Opioid medication: a brain injury rehabilitation complication
Opioid addiction has received growing publicity in the US in recent years, with hundreds of thousands affected. Despite regulatory changes the problem remains significant, to the extent that the issue has featured in the 2020 race for the White House. The US numbers are stark:
- In the decade to 2007, volumes of opioid prescription increased by 600%.
- In 2017, 17% of all Americans had at least one prescription.
- One study showed that 21% - 29% of patients misused opioids prescribed for chronic pain, 8%-12% went on to develop a diagnosable opioid use disorder, and an estimated 4%-6% of those who misused transitioned to heroin once their access to prescription opioids ended.
In the UK, direct marketing of opioids is not permitted and doctors are not able to receive financial incentives for the prescription of particular drugs. However, opioid use is growing amongst the general population, with a 35% increase in prescriptions in the last ten years to over 50 million prescriptions last year.
Brain injuries and opioids
Research has shown additional opioid risks and complications following traumatic brain injury (TBI).
1. Likelihood of opioid prescription
In the US, one study showed that 70% of moderate-to-severe TBI patients received opioids as inpatients. 45% of those were prescribed opioids during their last two days of in-patient care. There are no equivalent statistics for the UK, but it is clear that such injuries frequently requiring medication.
In an accident sufficient to cause TBI, there is trauma to the head and to the brain. This can cause headaches of sufficient severity to warrant opioid pain management; one study suggested that 33% of adults suffering from moderate-to-severe TBI suffered new or worse headaches at both one and five years post-injury.
There can also be additional physical polytrauma, the most common example being significant orthopaedic injuries.
2. Likelihood of progression to long-term opioid use
Impulsive behaviours from frontal lobe damage, or cognitive deficits such as memory problems, make it more difficult to self-regulate dosage or to monitor a patient’s medication intake. TBI is also associated with psychiatric co-morbidities and sleep disturbance, which are additional predisposing factors for substance misuse.
3. Barriers to treatment of substance misuse
A patient with neuro-behavioural impairments following TBI will be less able to participate in conventional treatments or to sustain any improvements. If there is an interlinking psychiatric issue, there can be voluntary and involuntary failure to participate in treatment.
Opioid addiction may reduce brain healing, impede rehabilitation, and increase the risk of further TBIs from misadventure. Substance misuse is of itself a risk factor for TBI; for example pedestrian accidents from alcohol intoxication and traffic misjudgement.
Opioid prescription or its risk factors such as ongoing pain are therefore potentially significant warning signs for both the clinical and legal teams. The following practical steps may help to pre-empt and minimise the potential for medication-related complications:
- The prescribing clinician must be aware of the relevant research and interplay between TBI and opioid misuse.
- Non-pharmacological interventions for pain relief may be preferable where appropriate, such as TENS, heat/cold treatments, massage, relaxation, counselling etc. In the US, the availability of some treatments has increased due to the proliferation of telehealth solutions since the pandemic.
- Following discharge home, compensators should ensure that adequate protocols are in place for medication management.
- Family and carers should be acutely aware of opioid medication and watch for any signs of misuse.
- The opioid epidemic: a painful threat to Europe?
- Opioids: the important gatekeeping role of UK pharmacists in supporting safe prescription
- Opioid litigation keeps moving forward and continues to raise coverage issues
- Emerging psychiatric inflation factors: Complex PTSD, gaming disorder and opioid dependence
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