Traumatic Brain Injury and Opioid Use: Additional Evidence Supporting the “Perfect Storm” of Cascading Vulnerabilities

Adams, Rachel Sayko

doi:10.1097/htr.0000000000000730

Cited by 10 publications

(17 citation statements)

References 53 publications

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“…These findings are consistent with studies with military, veteran, and civilian populations that have found that individuals with TBI are at increased risk for substance use disorders and negative outcomes . In particular, we highlight timely work regarding the opioid epidemic, disproportionate receipt of prescription opioids among individuals with TBI, and associated adverse consequences …”

Section: Discussionsupporting

confidence: 87%

“…25 In particular, we highlight timely work regarding the opioid epidemic, disproportionate receipt of prescription opioids among individuals with TBI, and associated adverse consequences. 26,27 Although research has been conducted regarding the enduring health outcomes associated with TBIs sustained during the recent conflicts in Iraq and Afghanistan 28 (eg, persistent postconcussive symptoms, even after adjusting for mental health conditions), less work to date has been focused on how new-onset conditions after TBI are associated with more distal physical and mental health outcomes. In 2009, Brenner et al 29,30 theorized that outcomes associated with multiple exposures (eg, history of TBI, PTSD) should be conceptualized cumulatively (ie, burden of adversity hypothesis).…”

Section: Jama Network Open | Psychiatrymentioning

confidence: 99%

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Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk

et al. 2023

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ImportanceResearch to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges.ObjectiveTo identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide.Design, Setting, and ParticipantsThis retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022.ExposuresMilitary-related TBI.Main Outcomes and MeasuresThe outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit.ResultsThe study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI.Conclusions and RelevanceIn this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.

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Section: Discussionsupporting

confidence: 87%

Section: Jama Network Open | Psychiatrymentioning

confidence: 99%

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk

et al. 2023

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“…For people with physical disabilities, accessibility may be an ongoing burden. The finding of reduced MOUD continuity for persons with cognitive disability as defined here highlights the perfect storm model 18 of cascading vulnerabilities for persons with TBI, for whom cognitive difficulties may lead to greater challenges in engaging with treatment. 34 Although it might be expected that people with developmental or sensory disabilities would experience similar difficulties with ongoing treatment engagement, they had rates of MOUD continuity comparable to those for people without those conditions.…”

Section: Discussionmentioning

confidence: 61%

“…However, PWD may misuse prescription opioids to relieve pain, suggesting that they are receiving inadequate pain management . Certain PWD subgroups have higher risk of opioid misuse and opioid-related consequences, although findings are not consistent . People with a history of traumatic brain injury (TBI), who are more likely to receive opioids than those without TBI, have greater risk for opioid misuse and overdose .…”

Section: Introductionmentioning

confidence: 99%

Quality of Opioid Use Disorder Treatment for Persons With and Without Disabling Conditions

et al. 2023

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ImportanceAdverse outcomes associated with opioid use disorder (OUD) are disproportionately high among people with disabilities (PWD) compared with those without disability. A gap remains in understanding the quality of OUD treatment for people with physical, sensory, cognitive, and developmental disabilities, specifically regarding medications for OUD (MOUD), a foundation of treatment.ObjectiveTo examine the use and quality of OUD treatment in adults with diagnosed disabling conditions, compared with adults without these diagnoses.Design, Setting, and ParticipantsThis case-control study used Washington State Medicaid data from 2016 to 2019 (for use) and 2017 to 2018 (for continuity). Data were obtained for outpatient, residential, and inpatient settings with Medicaid claims. Participants included Washington State full-benefit Medicaid enrollees aged 18 to 64 years, continuously eligible for 12 months, with OUD during the study years and not enrolled in Medicare. Data analysis was performed from January to September 2022.ExposuresDisability status, including physical (spinal cord injury or mobility impairment), sensory (visual or hearing impairments), developmental (intellectual or developmental disability or autism), and cognitive (traumatic brain injury) disabilities.Main Outcomes and MeasuresThe main outcomes were National Quality Forum–endorsed quality measures: (1) use of MOUD (buprenorphine, methadone, or naltrexone) during each study year and (2) 6-month continuity of treatment (for those taking MOUD).ResultsA total of 84 728 Washington Medicaid enrollees had claims evidence of OUD, representing 159 591 person-years (84 762 person-years [53.1%] for female participants, 116 145 person-years [72.8%] for non-Hispanic White participants, and 100 970 person-years [63.3%] for participants aged 18-39 years); 15.5% of the population (24 743 person-years) had evidence of a physical, sensory, developmental, or cognitive disability. PWD were 40% less likely than those without a disability to receive any MOUD (adjusted odds ratio [AOR], 0.60; 95% CI, 0.58-0.61; P &lt; .001). This was true for each disability type, with variations. Individuals with a developmental disability were least likely to use MOUD (AOR, 0.50; 95% CI, 0.46-0.55; P &lt; .001). Of those using MOUD, PWD were 13% less likely than people without disability to continue MOUD for 6 months (adjusted OR, 0.87; 95% CI, 0.82-0.93; P &lt; .001).Conclusions and RelevanceIn this case-control study of a Medicaid population, treatment differences were found between PWD and people without these disabilities; these differences cannot be explained clinically and highlight inequities in treatment. Policies and interventions to increase MOUD access are critical to reducing morbidity and mortality among PWD. Potential solutions include improved enforcement of the Americans with Disabilities Act, workforce best practice training, and addressing stigma, accessibility, and the need for accommodations to improve OUD treatment for PWD.

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“…Across both age groups, suicide rates for military members in the Other group were higher than in all other racial/ethnic groups. Suicide rates were higher in military members aged 18 to 29 years than in those 30 years of age or older for all racial and ethnic groups (age-specific suicide rate: 44.18 [18][19][20][21][22][23][24][25][26][27][28][29] Crude and adjusted suicide RRs are presented in Table 3. Adjusting for age, significant differences were found for suicide rates in the Other group compared with all other racial/ethnic groups, except for AIAN.…”

Section: Crude and Age-specific Suicide Rates And Adjusted Rate Ratio...mentioning

confidence: 99%

Racial and Ethnic Differences in Deaths by Suicide, Drug Overdose, and Opioid-Related Overdose in a National Sample of Military Members With Mild Traumatic Brain Injury, 1999-2019

Bahraini

Adams²,

Caban³

et al. 2023

Journal of Head Trauma Rehabilitation

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Objective: To examine racial and ethnic differences in suicide and drug and opioid-related overdose deaths among a population-based cohort of military service members who were diagnosed with a mild traumatic brain injury (mTBI) during military service. Design: Retrospective cohort. Setting: Military personnel receiving care within the Military Health System between 1999 and 2019. Participants: In total, 356 514 military members aged 18 to 64 years, who received an mTBI diagnosis as their index TBI between 1999 and 2019, while on active duty or activated. Main Measures: Death by suicide, death by drug overdose, and death by opioid overdose were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes within the National Death Index. Race and ethnicity were captured from the Military Health System Data Repository. Results: Overall crude rates were 38.67 per 100 000 person-years for suicide; 31.01 per 100 000 person-years for drug overdose death; and 20.82 per 100 000 person-years for opioid overdose death. Crude and age-specific rates for military members who self-identified as Other were higher than all other racial/ethnic groups for all 3 mortality outcomes. Adjusting for age, suicide rates for those classified as Other were up to 5 times that of other racial/ethnic groups for suicide, and up to 11 and 3.5 times that of other race/ethnicity groups for drug and opioid overdose death, respectively. Conclusion: Findings extend previous knowledge regarding risk for suicide and deaths by drug overdose among those with mTBI and highlight new important areas for understanding the impact of race and ethnicity on mortality. Methodological limitations regarding classification of race and ethnicity must be addressed to ensure that future research provides a better understanding of racial and ethnic disparities in suicide and drug overdose mortality among military members with TBI.

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Traumatic Brain Injury and Opioid Use: Additional Evidence Supporting the “Perfect Storm” of Cascading Vulnerabilities

Cited by 10 publications

References 53 publications

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk

Quality of Opioid Use Disorder Treatment for Persons With and Without Disabling Conditions

Racial and Ethnic Differences in Deaths by Suicide, Drug Overdose, and Opioid-Related Overdose in a National Sample of Military Members With Mild Traumatic Brain Injury, 1999-2019

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