The intersection of lifetime history of traumatic brain injury and the opioid epidemic

Ten Priorities for Research Addressing the Intersections of Brain Injury, Mental Health and Addictions: A Stakeholder-Driven Priority-Setting Study

OBJECTIVES

The purpose of this study was to engage key stakeholders in a health research priority-setting process to identify, prioritize and produce a community-driven list of research questions addressing intersectional issues on mental health and addictions (MHA) in acquired brain injury (ABI).

METHODS

A multiphasic health research priority-setting process was co-designed and executed with community-based stakeholders, including researchers, health professionals, clinicians, service providers, representatives from brain injury associations, policy makers and people with lived experience of ABI and MHA, including patients and their family members. Stakeholders' ideas led to the generation of research questions, which were prioritized at a 1-day workshop.

RESULTS

Fifty-nine stakeholders participated in the priority-setting activity during the workshop, which resulted in a rank-ordered list of the top 10 questions for research addressing the intersections of ABI and MHA. Questions identified touched on several pressing issues (e.g., opioid crisis, homelessness), encompassed multiple subtypes of ABI (e.g., hypoxic-ischaemic, mild traumatic), and involved different domains (e.g., identification, intervention) of health research.

CONCLUSIONS

This community-driven health research priority-setting study identified and prioritized research questions addressing the intersections of ABI and MHA. Researchers and funding agencies should use this list to inform their agendas and address stakeholders' most urgent needs, fostering meaningful improvements to clinical services.

PATIENT OR PUBLIC CONTRIBUTION

An 11-person working group comprised of people with lived experience, service providers, researchers, healthcare professionals and other key stakeholders collaboratively developed and informed the scope, design, methodology and interpretation of this study. Over 50 community-based stakeholders contributed to the research priority-setting activity. One co-author is a person with lived experience.

Associations with experience of non-fatal opioid overdose in British Columbia, Canada: a repeated cross sectional survey study

INTRODUCTION

Lives lost in North America due to the unregulated drug poisoning emergency are preventable and those who survive an opioid overdose may suffer long-term disability. Rates of opioid overdose more than doubled following the onset of the COVID-19 pandemic in British Columbia, Canada.

MATERIALS AND METHODS

Our analytical sample was comprised of 1447 participants from the 2018, 2019, and 2021 Harm Reduction Client Survey who responded yes or no to having experienced an opioid overdose in the past 6 months. Participants were recruited from harm reduction sites from across British Columbia. We used logistic regression to explore associations of experiencing an opioid overdose.

RESULTS

Overall, 21.8% of participants reported experiencing an opioid overdose in the last six months (18.2% in 2019 and 26.6% in 2021). The following factors were positively associated with increased adjusted odds of experiencing a non-fatal opioid overdose: cis men relative to cis women (AOR 1.49, 95% CI 1.10-2.02), unstably housed compared to people with stable housing (AOR 1.87, 95% CI 1.40-2.50), and participants from 2021 compared to those from 2019 (AOR 3.06, 95% CI 1.57-5.97). The effects of both previous experience of a stimulant overdose and having witnessed an opioid overdose depended on the year of study, with both effects decreasing over subsequent years.

CONCLUSIONS

Overdoses have increased over time; in 2021 more than one in four participants experienced an overdose. There is an urgent need for policy and program development to meaningfully address the unregulated drug poisoning emergency through acceptable life-saving interventions and services to prevent overdoses and support overdose survivors.

The Impact of Non-opioid Analgesic Usage on Total Opioid Load During Traumatic Brain Injury Rehabilitation: A Retrospective Study

Background Patients staying in acute rehabilitation often use large amounts of opioids during their stay. There are a number of reasons for this increased opioid exposure, including but not limited to daily exercises with physical and occupational therapists, increased demand on a healing body, and use of previously atrophying musculature. Some physiatrists have noticed that patients who concurrently are prescribed medications such as Robaxin seem to require fewer opioids during their stay in acute rehabilitation. This study aimed to determine the association between non-opioid analgesic use and total opioid load, as measured using morphine milligram equivalents (MMEs), during inpatient rehabilitation for traumatic brain injury. Methodology A retrospective study of individuals with a diagnosis of traumatic brain injury admitted to an acute inpatient rehabilitation program was performed. Non-opioid medications that were reviewed in the study included acetaminophen, amitriptyline, baclofen, diclofenac, gabapentin, ibuprofen, lidocaine, methocarbamol, nortriptyline, and pregabalin. Five of the most-used non-opioid medications (acetaminophen, diclofenac, gabapentin, lidocaine, and methocarbamol) were statistically analyzed using regression and analysis of variance to evaluate for any significant variables. Results Results showed that the average daily dose of acetaminophen has a significant effect on the average daily MME and that the average daily dose of gabapentin and methocarbamol each have a significant effect on the change of daily MME usage from admission to discharge from acute rehab (ΔMME). Results also showed that the mere presence of methocarbamol (regardless of daily or total dosage) had a significant effect on the ΔMME. Conclusions Based on these findings, physicians may want to consider prescribing acetaminophen, gabapentin, or methocarbamol for patients admitted for inpatient rehabilitation following traumatic brain injury who require high amounts of opioids.

Association between traumatic brain injury and suicidality using a mediation approach and MarketScan

INTRODUCTION

Negative outcomes, including suicidal ideation/attempts, are a major public health concern, particularly among individuals who sustain a traumatic brain injury (TBI). TBI is associated with high rates of postinjury substance use, psychiatric disorders, post-traumatic stress disorder and sleep disturbances. This study examines the mediation effects of substance use, psychiatric disorder and sleep disorder on the associations between TBI and suicidal ideation/attempts.

METHODS

A matched case-control study using data from MarketScan databases for private health insurance and Medicaid from October 2015 to December 2018 estimated the association between TBI and suicidal ideation/attempts using a mediation approach. Individuals less than 65 years of age were included.

RESULTS

In the Medicaid sample, psychiatric disorders mediated 22.4% of the total effect between TBI and suicidal ideation/attempt, while substance use disorders other than opioid use disorder mediated 7.47%. In the private health insurance sample, psychiatric disorders mediated 3.97% of the total effect, opioid use disorders mediated 2.08% of the total effect and sleep disorder mediated 1.25% of the total effect.

CONCLUSIONS

Mediators explained less than 30% of the relationship between TBI and suicidal ideation/attempt. Findings reinforce the importance of primary prevention of TBI and monitoring patients with a TBI for risk of suicide in the first 6-12 months following injury.

An fMRI analysis of verbal and non-verbal working memory in people with a past history of opioid dependence

Introduction

Working memory describes the ability to maintain and manipulate information held in mind, and it is a fundamental aspect of executive function. Within drug addiction, impairments of executive control over behavior are thought to lead to poor decision making and risky behaviors. Previous research has demonstrated working memory (WM) and executive function difficulties in opioid-dependent individuals, but the neural underpinnings of such impairments in this population are not well understood.

Methods

This study used functional magnetic resonance imaging to examine the neural mechanisms involved in WM in 13 opioid-dependent, methadone-maintained participants (OP) and 13 matched, healthy controls (HC). A Sternberg item-recognition task was administered with three conditions: (1) a "verbal" condition in which participants determined whether any six visually presented target letters matched a probe item that was presented 4-6 s later, (2) a "non-verbal" condition in which participants were presented with a Chinese character and, following a 4-6 s delay, determined whether the character matched the probe item, and (3) a "control" condition in which participants were presented with three horizontal lines and following the same delay, determined whether the lines matched a probe item (always the same three lines). Functional magnetic resonance imaging (fMRI) contrasts focused on the delay (or "maintenance") phase for verbal and non-verbal conditions relative to the control condition.

Results

Accuracy on the WM task did not differ between groups, but the OP group was significantly slower to respond. The fMRI imaging results indicated differences in brain activity between the OP and HC groups. fMRI-guided regions of interest correlated with age of first alcohol and THC use, suggesting that early substance use, in addition to years of opioid-abuse, may have played a role in the OP group's WM performance.

Discussion

A deeper understanding of these neural differences between opioid-dependent individuals and their healthy control counterparts helps shed light on fundamental ways in which substance use impacts the brain and cognition, potentially opening up novel avenues for therapeutic targets to treat substance use disorder.

Repeated blast mild traumatic brain injury and oxycodone self-administration produce interactive effects on neuroimaging outcomes

Traumatic brain injury (TBI) and drug addiction are common comorbidities, but it is unknown if the neurological sequelae of TBI contribute to this relationship. We have previously reported elevated oxycodone seeking after drug self-administration in rats that received repeated blast TBI (rbTBI). TBI and exposure to drugs of abuse can each change structural and functional neuroimaging outcomes, but it is unknown if there are interactive effects of injury and drug exposure. To determine the effects of TBI and oxycodone exposure, we subjected rats to rbTBI and oxycodone self-administration and measured drug seeking and several neuroimaging measures. We found interactive effects of rbTBI and oxycodone on fractional anisotropy (FA) in the nucleus accumbens (NAc) and that FA in the medial prefrontal cortex (mPFC) was correlated with drug seeking. We also found an interactive effect of injury and drug on widespread functional connectivity and regional homogeneity of the blood oxygen level dependent (BOLD) response, and that intra-hemispheric functional connectivity in the infralimbic medial prefrontal cortex positively correlated with drug seeking. In conclusion, rbTBI and oxycodone self-administration had interactive effects on structural and functional magnetic resonance imaging (MRI) measures, and correlational effects were found between some of these measures and drug seeking. These data support the hypothesis that TBI and opioid exposure produce neuroadaptations that contribute to addiction liability.

Endogenous Opioid Dynorphin Is a Potential Link between Traumatic Brain Injury, Chronic Pain, and Substance Use Disorder

Traumatic brain injury (TBI) is a serious public health problem associated with numerous physical and neuropsychiatric comorbidities. Chronic pain is prevalent and interferes with post-injury functioning and quality of life, whereas substance use disorder (SUD) is the third most common neuropsychiatric diagnosis after TBI. Neither of these conditions has a clear mechanistic explanation based on the known pathophysiology of TBI. Dynorphin is an endogenous opioid neuropeptide that is significantly dysregulated after TBI. Both dynorphin and its primary receptor, the ĸ-opioid receptor (KOR), are implicated in the neuropathology of chronic pain and SUD. Here, we review the known roles of dynorphin and KORs in chronic pain and SUDs. We synthesize this information with our current understanding of TBI and highlight potential mechanistic parallels between and across conditions that suggest a role for dynorphin in long-term sequelae after TBI. In pain studies, dynorphin/KOR activation has either antinociceptive or pro-nociceptive effects, and there are similarities between the signaling pathways influenced by dynorphin and those underlying development of chronic pain. Moreover, the dynorphin/KOR system is considered a key regulator of the negative affective state that characterizes drug withdrawal and protracted abstinence in SUD, and molecular and neurochemical changes observed during the development of SUD are mirrored by the pathophysiology of TBI. We conclude by proposing hypotheses and directions for future research aimed at elucidating the potential role of dynorphin/KOR in chronic pain and/or SUD after TBI.

Examining differences in prescription opioid use behaviors among U.S. adults with and without disabilities

We aimed to identify differences in prescription opioid-related behaviors between adults with and without disabilities in the U.S. We analyzed data from the 2015-2017 National Survey on Drug Use and Health (128,740 individuals; weighted N of 244,831,740) to examine disability-based differences in (1) reasons and sources of last prescription opioid misuse and, in multivariate models overall and stratified by disability, the likelihood of (2) prescription opioid use, and if used, (3) misuse and prescription opioid use disorder (OUD), overall and stratified by disability. Adults with disabilities were 11% more likely than adults without disabilities to report any past-year prescription opioid use, adjusted for sociodemographic, health, and behavioral health characteristics. However, among adults with any prescription opioid use, which is more common among people with disabilities, likelihood of prescription OUD did not vary by disability status. Pain relief as the reason for last misuse was associated with 18% increased likelihood of prescription OUD, if any use. To reduce risk of opioid misuse among people with disabilities, accessible and inclusive chronic pain management services are essential. Further, the substance use treatment field should provide accessible and inclusive services, and be aware of the need for pain management by many people with disabilities, which may include the use of prescription opioids. These findings highlight essential opportunities for public health and policies to improve access, accommodations, and quality of health and behavioral health care for people with disabilities, and to encourage a holistic perspective of people with disabilities and their needs.

Reported History of Traumatic Brain Injury Among Suicide Decedents: National Violent Death Reporting System, 2003-2017

INTRODUCTION

Traumatic brain injury is a major cause of death and disability in the U.S., and research shows that individuals who suffer traumatic brain injury have an increased risk for suicide. This study examines the characteristics of suicide decedents with a documented traumatic brain injury history using a database containing circumstantial data on suicides and examines the differences in traumatic brain injury‒ and nontraumatic brain injury‒related suicides within the general population and within individuals with a history of military service.

METHODS

Logistic regression models estimated AORs and 95% CIs of suicide among those with and without a previous traumatic brain injury using data from the 2003-2017 National Violent Death Reporting System (analyzed in 2020).

RESULTS

From 2003 to 2017, a total of 203,157 suicide decedents were identified, and 993 had a documented traumatic brain injury before suicide. Among those with a documented traumatic brain injury, a higher percentage were White non-Hispanic. Firearm injuries were the most common method of suicide for both groups. Poisoning was more common among decedents with a previous traumatic brain injury than among those without. Male individuals, those who were single, and those who served in the military were 1.4 times more likely to have a documented traumatic brain injury history before the suicide. Almost 1 in 5 suicides (18.9%) documenting traumatic brain injury occurred among individuals with a history of military service.

CONCLUSIONS

Comprehensive suicide prevention approaches are imperative. Healthcare providers can play a role in assessing and identifying patients at increased risk of suicide, including those who have experienced falls or injuries that often result in traumatic brain injury, and provide tailored interventions or referrals.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults

OBJECTIVE

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults.

PARTICIPANTS

Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448).

DESIGN

Secondary analyses of a statewide population-based cross-sectional survey.

MAIN MEASURES

Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent.

RESULTS

In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status.

CONCLUSION

Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Risk Factors Associated With the Prescription of Opioids Among Service Members Following a First Mild Traumatic Brain Injury

OBJECTIVE

To evaluate factors impacting opioid receipt among active-duty service members (SMs) following a first mild traumatic brain injury (mTBI).

SETTING

Active-duty SMs receiving care within the Military Health System.

PARTICIPANTS

In total, 14 757 SMs who have sustained an initial mTBI, as documented within electronic health records (EHRs), between 2016 and 2017.

DESIGN

A retrospective analysis of EHR metadata.

MAIN MEASURES

Multivariable logistic regression assessed factors impacting opioid receipt and initiation. Factors include demographics, military characteristics, and preexisting clinical conditions, including prior opioid prescription.

RESULTS

Of the sample population, 33.4% (n = 4927) were prescribed opioids after their initial mTBI, of which, 60.6% (n = 2985) received opioids for the first time following injury. Significant risk factors associated with the increased probability of opioid receipt included age, gender, and preexisting behavioral health and musculoskeletal conditions. Military characteristics also exhibited changes in the probability of opioid receipt, both among initiation and new prescription. No changes were observed among race, nor among those with preexisting headaches or migraines.

CONCLUSION

Despite concerns about the negative impact on recovery, the prescribing of opioids is common in this population of active-duty SMs first diagnosed with an mTBI. As several demographic and preexisting health conditions are factors in the receipt of opioids post-mTBI, the entire medical history of these patients should be considered prior to prescription. Understanding these factors may further inform policy for opioid use in the Military Health System.

Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury

OBJECTIVE

Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon.

SETTING

Oregon VA and non-VA outpatient care.

PARTICIPANTS

Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019.

DESIGN

Historical cohort study.

MAIN MEASURES

Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics.

RESULTS

Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models.

CONCLUSION

Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

Traumatic Brain Injury and Treatment of Behavioral Health Conditions

Traumatic brain injury (TBI) is a common neurological condition that results from an external force altering normal brain function, whether temporarily or permanently. A concussion is one type of TBI. TBIs vary greatly in severity, which concomitantly creates tremendous variability in their manifestation. The fingerprint of TBI is damage to the frontal areas of the brain, which, with sufficient magnitude, results in impairment of a person's ability to regulate cognition, emotion, and behavior. These consequences of TBI make recognition in the context of treating behavioral health conditions of utmost importance. TBI not only causes behavioral health problems but also produces associated deficits that can undermine the effectiveness of treatment for a behavioral health condition. This overview delineates key characteristics of TBI and describes its association with behavioral health conditions. Mechanisms underlying the relationship between TBI and behavioral health are presented, and a series of recommendations for professionals are proposed. This article is intended to raise awareness about TBI and simultaneously introduce key concepts for accommodating the effects of TBI in behavioral health care.

Scoping Review of Opioid Use After Traumatic Brain Injury

OBJECTIVE

To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI).

DATA SOURCES

The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings.

RESULTS

Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder.

CONCLUSIONS

Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications.

SETTING

Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites.

DESIGN

Cross-sectional, secondary analyses.

MAIN MEASURES

The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index.

RESULTS

After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids.

CONCLUSION

Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Association between Lifetime History of Traumatic Brain Injury, Prescription Opioid Use, and Persistent Pain: A Nationally Representative Study

Pain is common among adults with traumatic brain injury (TBI), yet little data exist regarding prevalence of opioid use in this population. The objective of this retrospective cohort study was to evaluate the association between lifetime TBI exposure, opioid use, and pain in a nationally representative sample of 1022 adults aged 50+ who participated in the Health and Retirement Study (HRS). Our primary exposure was lifetime TBI history measured via the Ohio State University TBI Identification Method. We evaluated three alternate TBI exposures (years since most recent TBI, age at first TBI, and number of lifetime TBIs) in sensitivity analyses. We evaluated two outcomes: recent opioid medication use, and moderate-to-severe pain measured over two HRS waves. We classified three pain groups (persistent, intermittent, and no pain). Prevalences of opioid use among individuals with and without TBI were 19.7% and 13.6%, respectively. After adjustment for age, sex, and race, individuals with TBI had a 52% increased risk for opioid use compared with individuals without TBI (relative risk = 1.52, 95% confidence interval: 1.11, 2.04). Individuals with recent TBI (1-10 years ago), first TBI after age 40+, and 2+ lifetime TBIs had greatest risk for opioid use. Compared with individuals without TBI, individuals with TBI had 4.9-times increased odds for persistent versus no pain, and 1.9-times increased odds of intermittent versus no pain. Persistent pain among adults with lifetime TBI is elevated compared with the general population, which may contribute to increased opioid use among persons with TBI, particularly those with recent injuries or multiple lifetime TBIs.

Psychotropic and pain medication use in individuals with traumatic brain injury-a Swedish total population cohort study of 240 000 persons

OBJECTIVE

To examine psychotropic and pain medication use in a population-based cohort of individuals with traumatic brain injury (TBI), and compare them with controls from similar backgrounds.

METHODS

We assessed Swedish nationwide registers to include all individuals diagnosed with incident TBI between 2006 and 2012 in hospitals or specialist outpatient care. Full siblings never diagnosed with TBI acted as controls. We examined dispensed prescriptions for psychotropic and pain medications for the 12 months before and after the TBI.

RESULTS

We identified 239 425 individuals with incident TBI, and 199 658 unaffected sibling controls. In the TBI cohort, 36.6% had collected at least one prescription for a psychotropic or pain medication in the 12 months before the TBI. In the 12 months after, medication use increased to 45.0%, an absolute rate increase of 8.4% (p<0.001). The largest post-TBI increases were found for opioids (from 16.3% to 21.6%, p<0.001), and non-opioid pain medications (from 20.3% to 26.6%, p<0.001). The majority of prescriptions were short-term; 20.6% of those prescribed opioids and 37.3% of those with benzodiazepines collected prescriptions for more than 6 months. Increased odds of any psychotropic or pain medication were associated with individuals before (OR: 1.62, 95% CI: 1.59 to 1.65), and after the TBI (OR: 2.30, 95% CI: 2.26 to 2.34) as compared with sibling controls, and ORs were consistently increased for all medication classes.

CONCLUSION

High rates of psychotropic and pain medications after a TBI suggest that medical follow-up should be routine and review medication use.

Prescription Opioids and Patient Sex: A National Cross-Sectional Study

Background: Surveillance data suggest that women are prescribed more opioid analgesics than men. It remains unclear whether these sex-related differences solely reflect the associations with other characteristics more prevalent among women (e.g., adverse socioeconomic and health status-related factors, and more contact with the health system). Materials and Methods: We examined the factors associated with opioid prescriptions and sex in a large, nationally representative U.S. sample. This observational analysis of the 2005-2015 Medical Expenditure Panel Survey included all adults aged ≥18 years with prescription and health service utilization data (n = 106,233). Negative binomial regressions examined associations between sex and number of opioid prescriptions. Analyses sequentially adjusted for sociodemographics, health status-related factors, and nonnarcotic prescriptions. Results: Overall, 9,387 women (16.2%) and 5,679 men (11.7%) received opioid prescriptions (female/male incidence rate ratio [IRR] = 1.35 (95% confidence interval [CI] = 1.24-1.44). The IRR was lower with adjustment for sociodemographics (1.23 [95% CI = 1.14-1.31]) and additional adjustment for health status-related factors (1.12 [95% CI = 1.05-1.19]). With further adjustment for number of nonnarcotic prescriptions, the IRR was not significant (0.97 [95% CI = 0.91-1.03). Conclusions: In this nationally representative sample, women received higher rates of prescription opioids, consistent with prior surveillance data. However, this relationship was attenuated with adjustment for sociodemographic and health status-related factors, and nonsignificant with adjustment for higher rates of nonnarcotic prescriptions among women. Higher opioid prescription rates in women may simply be reflective of these other factors, and the overall greater use of health care among women.

Traumatic brain injury and the misuse of alcohol, opioids, and cannabis

Traumatic brain injury (TBI), most often classified as concussion, is caused by biomechanical forces to the brain resulting in short- or long-term impairment in brain function. TBI resulting from military combat, sports, violence, falls, and vehicular accidents is a major cause of long-term physical, cognitive, and psychiatric dysfunction. Psychiatric disorders associated with TBI include depression, anxiety, and substance use disorder, all having significant implications for post-TBI recovery and rehabilitation. This chapter reviews the current preclinical and clinical literature describing the bidirectional relationship between TBI and misuse of three commonly abused drugs: alcohol, opioids, and cannabis. We highlight the influence of each of these drugs on the incidence of TBI, as well as trends in their use after TBI. Furthermore, we discuss factors that may underlie post-injury substance use. Understanding the complex relationship between TBI and substance misuse will enhance the clinical treatment of individuals suffering from these two highly comorbid conditions.

Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments

OBJECTIVES

To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization.

SETTING

VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma.

PARTICIPANTS

Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011.

DESIGN

Population-based cohort study.

MAIN MEASURES

Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization.

RESULTS

In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization.

CONCLUSION

CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.