Quiz

Traumatic Brain Injury

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

JAMA Psychiatry

June 1, 2018

JAMA Psychiatry Clinical Challenge

Article Information and Disclosures

Thomas R. Kosten, MD^1,2;

David P. Graham, MD^1,2;

David A. Nielsen, PhD^1,2

Author Affiliations

¹Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
²Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas

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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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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

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Corps KN, Roth TL, McGavern DB. Inflammation and neuroprotection in traumatic brain injury. JAMA Neurol. 2015;72(3):355-362.PubMed Google Scholar Crossref

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.PubMed Google Scholar Crossref

Violin JD, Lefkowitz RJ. Beta-arrestin-biased ligands at seven-transmembrane receptors. Trends Pharmacol Sci. 2007;28(8):416-422.PubMed Google Scholar Crossref

Kosten TR. Neurobiology of abused drugs: opioids and stimulants. J Nerv Ment Dis. 1990;178(4):217-227.PubMed Google Scholar Crossref

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.PubMed Google Scholar Crossref

Pasternak GW, Pan YX. Mu opioids and their receptors: evolution of a concept. Pharmacol Rev. 2013;65(4):1257-1317.PubMed Google Scholar Crossref

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.PubMed Google Scholar Crossref

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.PubMed Google Scholar

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

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Neurobiology of Opioid Use Disorder and Comorbid Traumatic Brain Injury

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

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Neurobiology of Opioid Use Disorder and Comorbid Traumatic Brain Injury

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