Brain Injury and Opioids

Brain Injury and Opioids – Part 1Acquired Brain Injury and the Toxic Brain

Monica VaccaroBrain Injury Association of Pennsylvania

Director of Programsvaccaro@biapa.org

Funded by TBI State Implementation Partnership Grant SAP# 4100081563 from the U.S. Department of Health and Human Services, Administration

for Community Living (ACL). Contents are the responsibility of the authors and do not necessarily represent the official

view of ACL.

The Opioid Epidemic

The Numbers

• 2.5 million Americans are addicted to opioids and heroin• After one week of regular opioid use, all persons

become dependent (Sutherland and Fessenden, 2018)• It is estimated that 33% of pain killer users don’t know

they are taking an opioid (reference??)

The Opioid Crisis and Relation to Acquired Brain Injury

• 67% of people in brain injury rehab have a history ofsubstance abuse prior to their injury

• 20% of people who did not have substance abuse problemsbefore their injury develop them after brain injury

• 50% of people in substance use disorder rehab have evidenceof an acquired brain injury

• People who survive an opioid overdose may suffer ananoxic brain injury

American Society of Addiction Medicine

• Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry

• Drug addiction manifests as a compulsive drive to take the drug without regard to severe adverse consequences (Volkow and Li, 2005)

• There is an interaction between the brain's opioid and dopamine (DA) systems in the reinforcing and addictive effects of substances of abuse (Volkow, 2011)

Opioids and the Toxic Brain

6

Roads to Recovery: Overdose and Brain Injury

Documentary produced by PBS New Hampshire

• Looks at the lesser-known effects of overdose - anoxic brain injury

• Tells the story of what happens to the brain during and after an event

• How it can affect treatment and recovery.

https://video.nhpbs.org/video/overdose-and-brain-injury-rbcycv/

Opioids and the Brain

• Drug addiction is a chronic and relapsing disorder • Considered a brain disorder because it involves

“functional changes to brain circuits involved in reward, stress, self-control (Goldstein and Volkow, 2011)

• Addiction is a behavior that originates from our brains• Brain circuits involved in reward, stress, self-control in the limbic system

and prefrontal cortex• Interferes with the way neurons send, receive and process signals via

neurotransmitters

How Do Opioids Act on the Brain

● Opioids - are depressants, downers

○ slow down body functions, such as heart rate and breathing

○ can lead to loss of consciousness, coma, or death

○ significant risk of an overdose is lack of oxygen to the brain

The Toxic Brain - A New Kind of Brain Injury...

● Toxic Brain Injury - occurs from prolonged substance misuse

and nonfatal overdose

○ Hypoxic Brain Injury - occurs when the brain does not

receive enough oxygen

○ Anoxic Brain Injury occurs when the brain does not receive

any oxygen

The Toxic Brain - A New Kind of Brain Injury

● Toxic brain damage is caused by:

○ 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

○ deprivation of oxygen to brain tissue

Chemical Messengers

Dopamine Lights it Up!

Rewards Feel Good!

• Food• Sex• Nurturing

Opioids and Dopamine

Opioids and the Brain.

• Our brains are wired to increase the odds that we will repeat pleasurable activities- dopamine is central to learning this• Reward circuit is signaled by a burst of dopamine that something

important is happening and needs to be remembered.• This is how we make a habit

• Neural connectivity is altered making it easier and easier to repeat the activity without thinking

• These surges of dopamine teach the brain to seek the drug at the expense of other goals

Opioids and the Brain..

• In response to drug-related dopamine dumps• Our brains produce fewer neurotransmitters in the

reward circuit and there is reduced pleasure from naturally occurring and rewarding activities• People appear flat, unmotivated, and depressed• This is a cortical depression

• In order to experience pleasure• Increased dosages• Increased risk

Opioids and the Brain...

• Addiction is characterized by a loss of behavior• “Continued use, in apparent awareness of

associated adverse consequences, suggest that addicted behavior may involve deficits in inhibitory control, decision making, and regulation of affect” (Yucci, Lubman, neuropsychology of drug abuse)

Brain Injury and Substance Abuse

Treatment

19

Impact of Brain Injury on Success in Programming

Brain injury impacts an individual’s ability to use the treatment they are provided.

How can we adapt SUD treatment to facilitate success for those with brain injury?

3 Reasons for Negative Outcomes in SUD Treatment due to ABI

• Neurobehavioral consequences of injury undermine the ability to participate in “conventional” treatment

• There is a greater likelihood of co-occurring behavioral issues in this population

• Less ability to sustain improvements from treatment without continued structure and support

Ways Cognitive Impairment Interferes with Treatment

• Ability to attend for a certain period of time

• Ability to remember what was discussed in last meeting

• Ability to abstract - to understand how what is being

talked about applies to me

Ways Cognitive Impairment Interferes with Treatment...

• Sleep and its impact on attention and endurance

• Ability to prospectively remember the appointment

• Ability to plan to get to the appointment• Leaving in enough time to arrive on time

• Planning their travel to the appointment

Individual Sessions

• The person:• May not accurately report “how they are doing”• May not follow through as agreed

upon• May have difficulty developing

insight• May not recognize their need

for treatment• May not remember from session

to session

Treatment Groups/Counseling

• May have trouble understanding the content or processing the info quickly enough

• May have limited ability to recognize content’s applicability to self

• May over or under-contribute

• May repeat self

• May not be able to initiate or complete homework tasks

• May come to group/session unprepared

Selected References

• New Hampshire Public Broadcasting (NHPBS) (2019). Roads To Recovery - Overdose and Brain injury

• Parry-Jones BL, Vaughan FL, Miles Cox W. Traumatic brain injury and substance misuse: a systematic review of prevalence and outcome s research (1994–2004) Neuropsychological rehabilitation. 2006;16:537–560.

• Sutherland and Fessender (2018) Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/.

• Volkow ND, Fowler JS, Wang GJ, Goldstein RZ. (2005) Role of dopamine, the frontal cortex and memory circuits in drug addiction: insight from imaging studies. Neurobiology of Learning and Memory. 78: 610-24. PMID 12559839 DOI: 10.1006/nlme.2002.4099

For further information

www.biapa.org www.health.pa.govToll Free Brain Injury Resource Line

1-800-444-6443PA Department of Health

1-717-772-2763