The Solution to Opioids is Treatment
by Will Dane, Dianna Fahel, and Tiffany Epley; Brain Injury Association of America
Over the past several years, the misuse of opioids – ranging from prescription painkillers to black tar heroin – has reached epidemic proportions. In 2015, the Media Research Center reported that drug overdoses had surpassed motor vehicle accident fatalities nationwide for the first time. Since 1999, nearly 200,000 Americans have died from a prescription drug overdose. Heroin use increased in response to advocate and lawmaker efforts to restrict overprescribing, doctor shopping, and opioid sales via online pharmacies. As prescription drug overdoses fell from 2010 to 2015, the number of heroin overdoses tripled.
Source: National Center for Health Statistics, National Vital Statistics System Mortality, NCHS Data Brief No. 273, February 2017.
Opioids are synthetic or semi-synthetic substances originating from the poppy plant. Examples include heroin, Fentanyl, and prescription opioid painkillers, all of which operate in the same fashion, albeit with varying degrees of strength. Synthetic opioids are among the most dangerous and addictive. The synthetic opioid Fentanyl, for example, is 25 to 50 times more potent than heroin, which is a semi-synthetic substance.
The National Institute on Drug Abuse explains, “[Opioids] act by attaching to specific proteins called opioid receptors, which are found on nerve cells in the brain, spinal cord, gastrointestinal tract, and other organs in the body.” When substances attach to these receptors, they change how the brain perceives pain and instead produce feelings of euphoria. They also slow essential body functions, such as heart rate and breathing.
Opioids are depressants, or “downers,” meaning that they inhibit the central nervous system (CNS). During an overdose, the body experiences CNS depression, which can result in decreased rate of breathing, decreased heart rate, and loss of consciousness, possibly leading to coma or death. In other words, an overdose causes the body to forget to breathe on its own. As such, the most significant risk of an overdose is the lack of oxygen.
Oxygen is essential to the human brain, and a lack of oxygen to the brain causes damage. So, what about those who are overdosing but not dying? The opioid epidemic has led to the creation of a new term: Toxic Brain Injury. This type of brain injury occurs from prolonged substance misuse and nonfatal overdose. This encompasses two forms of brain injury resulting from a lack of oxygen – hypoxic and anoxic brain injury. Hypoxic brain injury occurs when the brain does not receive enough oxygen, while anoxic brain injury occurs when the brain does not receive any oxygen. In these situations, the amount of time the brain is without adequate oxygen dictates the severity of injury.
Toxic Brain Injury has multiple effects on the brain. Brain damage caused by use of drugs could include disruption of nutrients needed by brain tissue; direct damage, injury, and death of brain cells, including neurotransmitter receptors; alterations to brain chemical concentrations, including neurotransmitters and hormones; and deprivation of oxygen to brain tissue. The effects on the brain will differ depending on the type of substance, the amount used, and the duration of use.
Substance Misuse and Brain Injury
There is a strong correlation between substance misuse and brain injury. Approximately one quarter of those entering brain injury rehabilitation are there as a result of drugs or alcohol, while nearly 50 percent of people receiving treatment for substance misuse have a history of at least one brain injury.
Research on the risk of substance misuse following a brain injury is scarce, as are facilities equipped to provide parallel treatment for both brain injury and substance misuse disorders. Oftentimes, substance misuse is ignored in the treatment of brain injury because the symptoms of intoxication and brain injury can appear to be similar. When a person comes into the hospital with a brain injury, the focus is on life-saving measures to treat the injury. The person may then be referred to a brain injury treatment facility, where his or her substance misuse disorder is often overlooked.
Adversely, epidemiological surveys have shown that substance misuse substantially increases the risk of brain injury, and recovery from brain injury is prolonged when substance misuse is present. Together, substance misuse and brain injury increase the negative effects each condition has on brain function and structure. Failure to treat both means that an individual is more likely to return to his or her drug or drink of choice following discharge from brain injury rehabilitation, often leading to a worsened outcome. Individuals are at an increased risk of falls, seizures, decreased cognitive ability, depression, subsequent brain injury, and potential death.
Although there is evidence of reduced drug use within the first year post injury, those with a prior history of substance misuse before their brain injury are 10 times more likely to resume past behavior. Further, studies have indicated that between 10 and 20 percent of people with traumatic brain injury develop a substance misuse problem for the first time after their injury. This could be from stimulants and painkillers that are often prescribed to treat cognitive disruption and pain from their injury, which have their own potential for abuse. The cycle of risky behavior causing negative physical and mental outcomes will continue unless both conditions are treated concurrently.
Parallel Treatment is Essential
The opioid epidemic is not slowing in the United States. Awareness and education may be useful in combating its growth, but the solution is treatment. No matter the state, city, county, village, or neighborhood, communities throughout the nation are suffering from a lack of available treatment options for substance misuse. For every fatal overdose, there may be five nonfatal overdoses, many of which go unreported. Increasing the number of facilities equipped to treat substance misuse disorders and brain injury – together – is essential. Physical and mental recovery from brain injury takes time, as does recovery from addiction. In situations where both are present, parallel treatment is the gold standard of care.
“Toxic Brain Injury may not strike someone you love, but will affect someone you know,” said Susan Connors, BIAA’s president and chief executive officer. Establishing long-term, multi-coordinated therapy, rehabilitation, and support is vital to the treatment and recovery process. The Brain Injury Association of America is dedicated to changing minds about brain injury and opioid abuse and will work diligently to seek new opportunities to bridge the treatment gap between these two deadly diseases.
Addiction.com Staff. (2015, February 10). Brain Injury Treatment and Substance Abuse.
Bjork, J.M. and Grant, S.J. (2009, July 26). Does Traumatic Brain Injury Increase Risk for Substance Abuse? Journal of Neurotrauma.
The Brain Injury Guide and Resources. (2012) Substance Use/Abuse and TBI.
Center for Substance Abuse Treatment. (1999). Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 35. Chapter 3 – Motivational Interviewing as a Counseling Style.
Corrigan, J.D. et al. (2016). The Essential Brain Injury Guide, Edition 5.0. Brain Injury Association of America.
Public Policy of the Brain Injury Network. (2009, September 12). Advocacy by and for people with ABI.
Sullivan, P. (2017, April 13). The Washington Post. Drug overdose deaths top 1,400 in Virginia in 2016.
Virginia Department of Health. (July 2017). Forensic Epidemiology.
Volkow, N. D. (2014). America’s addiction to opioids: Heroin and prescription drug abuse. Senate Caucus on International Narcotics Control: National Institute on Drug Abuse.
This article originally appeared in Volume 12, Issue 1 of THE Challenge! published in 2018.