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Opioid Use Disorder After Self-medicating Pain From Traumatic Brain Injury

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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Article Information

Corresponding Author: Thomas R. Kosten, MD, MEDVAMC, 2002 Holcombe Blvd, Bldg 110, Room 229, Houston, TX 77030 (kosten@bcm.edu).

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.

References
1.
Guy  GP  Jr, Zhang  K, Bohm  MK,  et al.  Vital signs: changes in opioid prescribing in the United States, 2006-2015.  MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704.PubMedGoogle ScholarCrossref
2.
Fishbain  DA, Cole  B, Lewis  J, Rosomoff  HL, Rosomoff  RS.  What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? a structured evidence-based review.  Pain Med. 2008;9(4):444-459.PubMedGoogle ScholarCrossref
3.
Corps  KN, Roth  TL, McGavern  DB.  Inflammation and neuroprotection in traumatic brain injury.  JAMA Neurol. 2015;72(3):355-362.PubMedGoogle ScholarCrossref
4.
Wang  X, Loram  LC, Ramos  K,  et al.  Morphine activates neuroinflammation in a manner parallel to endotoxin.  Proc Natl Acad Sci U S A. 2012;109(16):6325-6330.PubMedGoogle ScholarCrossref
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Violin  JD, Lefkowitz  RJ.  Beta-arrestin-biased ligands at seven-transmembrane receptors.  Trends Pharmacol Sci. 2007;28(8):416-422.PubMedGoogle ScholarCrossref
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Kosten  TR.  Neurobiology of abused drugs: opioids and stimulants.  J Nerv Ment Dis. 1990;178(4):217-227.PubMedGoogle ScholarCrossref
7.
Sigmon  SC, Bisaga  A, Nunes  EV, O’Connor  PG, Kosten  T, Woody  G.  Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice.  Am J Drug Alcohol Abuse. 2012;38(3):187-199.PubMedGoogle ScholarCrossref
8.
Pasternak  GW, Pan  YX.  Mu opioids and their receptors: evolution of a concept.  Pharmacol Rev. 2013;65(4):1257-1317.PubMedGoogle ScholarCrossref
9.
Yoburn  BC, Shah  S, Chan  K, Duttaroy  A, Davis  T.  Supersensitivity to opioid analgesics following chronic opioid antagonist treatment: relationship to receptor selectivity.  Pharmacol Biochem Behav. 1995;51(2-3):535-539.PubMedGoogle ScholarCrossref
10.
Mattick  RP, Breen  C, Kimber  J, Davoli  M.  Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.  Cochrane Database Syst Rev. 2014;(2):CD002207.PubMedGoogle Scholar
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