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A 29-year old man who is married and an employed Army veteran presented with headache from a mild traumatic brain injury (TBI) diagnosed before his Army discharge. He came to a Veterans Affairs hospital requesting buprenorphine/naloxone and complained of marital problems and job absenteeism. His TBI occurred when a roadside bomb overturned his supply truck in Afghanistan. He lost consciousness during the bombing and awoke with severe head and neck pain but no radiological brain, spine, or skull damage or focal neurological signs. He was given 20 oral morphine (5 mg) tablets and consumed them in 4 days rather than the intended 2 weeks. After finishing the morphine, he mitigated his pain with alcohol and ibuprofen (400-800 mg daily).
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Opioid use disorder and mild TBI
D. Prescribe buprenorphine at 16 mg daily
This patient with opioid use disorder (OUD) illustrates a casualty of our iatrogenic OUD epidemic, which included 14% of Americans reporting opioid abuse by 2007.1 Opioids were overprescribed in response to gross underestimation of iatrogenic OUD rates in patients treated for chronic pain.1,2 Pharmacotherapy of OUD with TBI should consider 6 neurobiological principles: (1) coactivation of neuronal and inflammatory immune receptors (Toll-like receptor 4), (2) 1 receptor activating 2 second messenger systems, (3) convergence of 2 receptor types on 1 second messenger, (4) antagonist-induced receptor trafficking, (5) genetic receptor variants (μ-opioid) influencing analgesia and tolerance, and (6) cross-tolerance vs receptor antagonism.3,4
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Corresponding Author: Thomas R. Kosten, MD, MEDVAMC, 2002 Holcombe Blvd, Bldg 110, Room 229, Houston, TX 77030 (firstname.lastname@example.org).
Published Online: April 25, 2018. doi:10.1001/jamapsychiatry.2018.0098
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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