THE UNITED STATES CENTERS for Disease Control and Prevention (CDC) reported that from 1999 to 2018, almost 450 000 people died from an overdose involving an opioid, including prescription and illicit opioids.1 This high mortality rate led the US Department of Health and Human Services to declare the opioid crisis a nationwide public health emergency.2 Given the known association between traumatic brain injury (TBI) and substance use disorders (SUDs),3 the opioid epidemic would certainly be expected to impact persons living with the chronic effects of these injuries. Two recent commentaries posited that individuals with a lifetime history of TBI may be at an increased risk for negative effects from opioid use; they have a greater likelihood of prescription opioid use and have enhanced vulnerability for misusing such medications.4,5 As described in more detail later, Adams and colleagues4 called this cascade of risk factors a “perfect storm,” making people who have had a TBI uniquely vulnerable to devastating consequences from opioid use.
There may be several reasons why persons with TBI are more likely to receive opioid prescriptions than their peers without TBI. The high rate of chronic pain among persons with TBI6 has been posited as a significant factor in increased exposure.5,7 Across 20 studies representing more than 3000 individuals with TBI, the prevalence of chronic pain was more than 51% compared with approximately 20% of noninstitutionalized adults in a population-based sample.6,8 In a population-based study of prescription medications, including opioids, 239 425 Swedish residents medically treated for a TBI were compared with 199 658 unaffected sibling controls.9 In the 12 months before and after injury, the TBI cohort was more likely than uninjured siblings to have received an opioid prescription. Compared with all other medications, opioids showed the largest post-TBI growth, increasing from 16.3% to 21.6%. Finally, although the reasons for prescribing an opioid were unknown, a study conducted in 10 inpatient brain injury rehabilitation programs found that more than 70% of patients were prescribed opioids during their inpatient stay and almost 50% of these prescriptions were provided new or refilled within 2 days of discharge.10
Regardless of whether a patient has had a TBI, when pain persists and longer-term opioid use is prescribed, the risk of developing an opioid use disorder (OUD) increases dramatically.11 In the “perfect storm,”4 the authors posited that the greater prescribing of opioids for persons with a history of TBI increases the propensity for at-risk substance use in this population and may lead to an increased likelihood of opioid misuse, OUD, or other consequences.12,13 At-risk substance use among individuals with a TBI is likely due to multiple factors, including preinjury risky use,14,15 enhanced physiological vulnerability to addiction,16,17 and injury-related neurobehavioral changes that increase impulsivity and decrease awareness of problems.5,18 Despite these relationships, there are relatively little data on the likelihood that exposure to opioids leads to greater difficulties for individuals with TBI. One study reported that compared with the general population, individuals with TBI are at 10-fold greater risk for overdose deaths, of which 90% were considered “drug-related,” with two-thirds involving opioids.19 Furthermore, while studies with both military/veteran and civilian populations have found an increased risk for death by suicide among persons with TBI,20,21 one study of Veterans Health Administration–utilizing veterans prescribed long-term opioid therapy for chronic pain found that those with TBI were at an increased risk for suicide attempt compared with those without TBI.22
The current study was designed to further investigate associations between a lifetime history of TBI and (1) receipt of prescription opioids and (2) misuse of prescription opioids. Data were drawn from the 2018 Ohio Behavioral Risk Factor Surveillance System (BRFSS), a statewide population-based survey of noninstitutionalized adults in the state. Consistent with the prior literature and the “perfect storm” theory, we hypothesized that a history of TBI would increase the likelihood of both receiving a prescription opioid and misusing prescription opioids.
METHODS
The data set analyzed in the current study is publicly available and was provided by the Ohio Department of Health with an approved data use agreement. This secondary analysis of de-identified data was considered nonhuman subjects research by Brandeis University's institutional review board.
Sample
We analyzed Ohio BRFSS data, a telephone-based survey (landline and cellphone) that is federally funded and jointly administered by the CDC and the Ohio Department of Health.23 The 2018 Ohio BRFSS was administered to a random sample of 12 763 (weighted N = 9 110 933) noninstitutionalized adults, 18 years and older, in Ohio and contained core component questions regarding demographic information included in all state BRFSS surveys, as well as Ohio-specific modules. Two Ohio-specific modules, lifetime history of TBI and prescription pain medication use, were used in the current study.
Respondents completed modules depending on inclusion in “split 1” (n = 8585) or “split 2” (n = 3810). Because the TBI module was only included in split 2, our analytic sample was restricted to those respondents. We then excluded the following: those missing age information (n = 34), those with missing data for all TBI and pain medication items (n = 287), and those with missing data for all TBI items only (n = 41), bringing the analytic sample to 3448 (weighted prevalence of 8 112 159, representing the noninstitutionalized adult population of Ohio).
Measures
Dependent variables
Past year pain medication use (ie, prescription opioid use) was assessed with the following item: “In the past year, did you use any pain medications that were prescribed to you by a healthcare provider?” Additional detail specified that common opioid pain medications include hydrocodone (Lorcet and Vicodin), oxycodone (Percocet), and long-acting opioids (OxyContin, MS Contin). We constructed a dichotomous measure to capture those with past year prescription opioid use.
Past year prescription opioid misuse was defined on the basis of responses to the following items: (1) “The last time you filled a prescription for pain medication, did you use any of the pain medication more frequently or in higher doses than directed by a healthcare provider?” and (2) “In the past year, did you use prescription pain medication that was not prescribed to you?” Self-report of “yes” to at least one of the 2 questions was categorized as past year prescription opioid misuse.
Key independent variable
Lifetime history of TBI. The past occurrence of a TBI was assessed through a modified version of the Ohio State University TBI-Identification Method (OSU TBI-ID), a structured interview that asks participants whether they have sustained injuries to the head or neck in their lifetime. For example, respondents were asked, “In your lifetime, have you ever been hospitalized or treated in an emergency department following an injury to your head or neck?” Respondents who reported a qualifying injury were asked 2 follow-up questions: “(1) Were you ever knocked out or did you lose consciousness (or loss of consciousness [LOC]) from any of the injuries you reported earlier?” and (2) “If you were not knocked out by any of these injuries, did any of them cause you to be dazed or confused, or create a gap in your memory?” On the basis of these items, we constructed the independent variable: lifetime history of TBI (yes/no) reflecting self-report of an injury event that resulted in being dazed, confused, having a gap in memory, or losing consciousness.
Additional information in the TBI module assessed for the age of first injury and severity of injury, allowing us to construct 2 additional TBI measures: (1) any lifetime history of TBI with LOC (yes/no), and (2) age of first TBI with LOC (no TBI with LOC, before the age of 20 years, 20 years or older, TBI with LOC/age unknown). Because of CDC suppression criteria for small sample sizes (described later), these additional TBI measures could not be included in models and are reported in the descriptive table only.
The OSU TBI-ID has high validity and interrater reliability.24,25 The adaptation used for the BRFSS module has been used since 2017 in Ohio as well as other states.
Covariates
Covariates included the demographic variables: sex (female, male), age group (18-44, 45-64, 65+ years), race/ethnicity (non-Hispanic/White; non-White [Black/non-Hispanic, Hispanic, Asian, Native Hawaiian, Other Pacific Islander, American Indian, or Alaska Native]), and marital status (married, never married, or other [widowed, separated, a member of an unmarried couple]). Because of CDC suppression criteria, age categories and race/ethnicity were collapsed into their aforementioned larger categories. Previous analyses with Ohio BRFSS data have revealed that other covariates that capture social determinants of health at the individual level (eg, income, education, employment) are themselves associated with a lifetime history of TBI26 and therefore were not included in the analyses to avoid introducing confounders.
Statistical analysis
BRFSS data include weights constructed by iterative proportional fitting to represent the noninstitutionalized adult population of Ohio.23 Using these weights, we conducted both unweighted and weighted analyses to provide estimates of measures in the study sample (ie, unweighted) and for the noninstitutionalized adult population in the state of Ohio (ie, weighted). To ensure the estimates determined by these analyses were statically reliable, CDC suppression guidelines were followed, which require using both the unweighted and weighted data.27 Estimates were suppressed when the relative standard error was greater than 30 or when the corresponding denominator was less than 50 respondents. The 2 alternative TBI variables (ie, lifetime history of TBI with LOC; age of first TBI with LOC) did not satisfy the CDC suppression criteria and therefore we were required to use the any lifetime history of TBI variable as our key independent variable in the bivariate analyses and models.
As additional preliminary analyses, we conducted bivariate chi-square tests to determine whether our key independent variable regarding a lifetime history of TBI was significantly associated with the 2 study outcomes and whether each covariate was significantly associated with both lifetime history of TBI and our 2 study outcomes. As our main analyses, we conducted 2 logistic regression models to estimate the predictive association of history of TBI with each of our 2 study outcomes, adjusted for the covariates. While using an alternative matching/balancing analytic technique (eg, propensity score matching) would have value, these methods are less protective against false results, particularly if the group being matched/balanced against is of limited size (such as in our current sample) or if the set of covariates for matching is inadequate. Therefore, we concluded that using logistic regression with covariates to adjust for confounding was appropriate for these data. We dropped 46 individuals from the models who did not report race/ethnicity. We reported the significance level associated with each independent variable in these models (eg, P < .05, P < .01, or not significant) and provided 95% CIs for the corresponding odds ratio. All analyses were completed in SAS version 9.4.
Both our bivariate tests and logistic regression models were conducted as unweighted analyses and thus reflect estimated relationships within the sample of respondents, rather than the full population of adults in Ohio. Unweighted analyses for logistic modeling are supported by several considerations, including that they provide unbiased estimates of odds ratios under the modest assumption of equal probabilities of selection within cells defined by the independent variables.28 Because the prevalence of the opioid misuse outcome was only 3%, the corresponding design effect using weighted analyses would likely be large and the power to find significant effects would be greatly reduced compared with unweighted analyses.
RESULTS
Study population
A quarter of the sample (25.5%) reported using a prescription opioid in the past year, and 3.1% met criteria for prescription opioid misuse (see Table 1). The majority of the sample was female (58.4%), non-Hispanic/White (88.9%), and married (49.4%). The largest group of respondents was aged 65+ years (40.6%). More than one-fifth of the sample (22.8%) met criteria for at least one TBI in their lifetime; more than two-thirds of these individuals (68.2%) experienced a TBI with LOC in their lifetime. Among respondents who had a TBI with LOC, most (52.8%) reported that their first TBI with LOC occurred before the age of 20 years.
TABLE 1 -
Lifetime history of traumatic brain injury and past year prescription pain medication use and misuse among adults in Ohio in 2018
a
|
Unweighted data |
Weighted data |
|
n
|
% |
n
|
% |
| Overall |
3448 |
100.0 |
8 112 159 |
100.0 |
| Sex |
|
|
|
|
| Female |
2014 |
58.4 |
4 222 624 |
52.1 |
| Male |
1434 |
41.6 |
3 889 535 |
47.9 |
| Age groups |
|
|
|
|
| 18-44 y |
753 |
21.8 |
3 546 208 |
43.7 |
| 45-64 y |
1294 |
37.5 |
2 697 525 |
33.3 |
| 65+ y |
1401 |
40.6 |
1 868 426 |
23.0 |
| Race/ethnicity |
|
|
|
|
| Non-Hispanic, White |
3024 |
88.9 |
6 571 355 |
82.1 |
| Non-Whiteb |
378 |
11.1 |
1 432 063 |
17.9 |
| Marital status |
|
|
|
|
| Married |
1705 |
49.4 |
4 051 136 |
49.9 |
| Never married |
571 |
16.6 |
2 301 506 |
28.4 |
| Other |
1172 |
34.0 |
1 759 517 |
21.7 |
| Lifetime history of TBI |
|
|
|
|
| No TBI |
2662 |
77.2 |
6 144 129 |
75.7 |
| Yes TBI |
786 |
22.8 |
1 968 030 |
24.3 |
| Lifetime history of TBI with LOC |
|
|
|
|
| No TBI with LOC |
2912 |
84.5 |
6 818 956 |
84.1 |
| Yes TBI with LOC |
536 |
15.5 |
1 293 203 |
15.9 |
| Age of first TBI with LOC |
|
|
|
|
| No TBI with LOC |
2912 |
84.5 |
6 818 956 |
84.1 |
| Before the age of 20 y |
283 |
8.2 |
763 192 |
9.4 |
| ≥20 y old |
237 |
6.9 |
508 873 |
6.3 |
| TBI with LOC, age unknown |
16 |
0.5 |
21 138 |
0.3 |
| Past year prescription opioid use |
|
|
|
|
| Yes |
879 |
25.5 |
2 007 000 |
24.7 |
| No |
2569 |
74.5 |
6 105 159 |
75.3 |
| Past year prescription opioid misuse |
|
|
|
|
| Yes |
106 |
3.1 |
330 044 |
4.1 |
| No |
3342 |
96.9 |
7 782 115 |
95.9 |
Abbreviations: LOC, loss of consciousness; TBI, traumatic brain injury.
aWeighted frequencies and prevalence percentages were analyzed using appropriate variables for stratification and weight to account for the complex sampling procedures.
bIncludes Black/non-Hispanic, Hispanic, Asian, Native Hawaiian, Other Pacific Islander, American Indian, or Alaska Native. These non-White racial/ethnic groups were combined because of suppression rules. In total, 46 respondents were missing race/ethnicity information and were excluded from that variable only in this table.
Bivariate results
Table 2 shows unweighted bivariate associations between a lifetime history of TBI and the 2 study outcomes and between each covariate and both a lifetime history of TBI and the 2 study outcomes. Females were significantly less likely to report a lifetime history of TBI than males (18.3% vs 29.2%, respectively), married adults were significantly less likely to report a lifetime history of TBI (20.1%) than those never married or other marital status (with rates of 26.1% and 25.2%, respectively), and younger adults were significantly more likely to report a lifetime history of TBI, with rates of 29.0% among adults aged 18 to 44 years, 26.9% among adults aged 45 to 64 years, and only 15.7% among adults 65+ years.
TABLE 2 -
Bivariate association between a lifetime history of TBI and past year prescription opioid use and opioid misuse among adults in Ohio in 2018
| Characteristics |
Lifetime history of TBI, yes % |
Past year prescription opioid use, yes % |
Past year prescription opioid misuse, yes % |
| Overall |
22.8% |
25.5% |
3.1% |
| Sex |
...a |
...a |
...a |
| Female |
18.3 |
27.7 |
2.4 |
| Male |
29.2 |
22.4 |
4.0 |
| Age groups |
...a |
...b |
...b |
| 18-44 y |
29.0 |
21.7 |
4.1 |
| 45-64 y |
26.9 |
27.3 |
3.6 |
| 65+ y |
15.7 |
25.9 |
2.1 |
| Race/ethnicity |
... |
...b |
...a |
| Non-Hispanic, White |
22.8 |
24.9 |
2.8 |
| Non-Whitec |
21.7 |
30.4 |
5.3 |
| Marital status |
...a |
...a |
...a |
| Married |
20.1 |
24.0 |
2.3 |
| Never married |
26.1 |
22.9 |
4.9 |
| Other |
25.2 |
28.9 |
3.3 |
| Lifetime history of TBI |
|
...a |
...a |
| No TBI |
N/A |
23.9 |
2.5 |
| Yes TBI |
N/A |
30.9 |
5.0 |
Abbreviations: N/A, not applicable; TBI, traumatic brain injury.
aP ≤ .01.
bP ≤ .05.
cIncludes Black/non-Hispanic, Hispanic, Asian, Native Hawaiian, Other Pacific Islander, American Indian, or Alaska Native. These non-White racial/ethnic groups were combined because of suppression rules. In total, 46 respondents were missing race/ethnicity information and were excluded from bivariates including that measure. Bivariate associations use unweighted data.
Females were significantly more likely to report using prescription opioids in the past year than males (27.7% vs 22.4%, respectively), yet significantly less likely to meet criteria for misuse than males (2.4% vs 4.0%, respectively). Age group was significantly associated with both prescription opioid use and misuse, with adults aged 18 to 44 years reporting the lowest prevalence of past year opioid use (21.7%), yet the highest prevalence of misuse (4.1%). Non-White adults were significantly more likely to report past year prescription opioid use and misuse than non-Hispanic/White adults. Marital status was significantly associated with the outcomes, with adults with an “other” marital status reporting the highest prevalence of past year prescription opioid use (28.9%) and never married adults reporting the highest prevalence of misuse (4.9%).
Among sample adults, subjects with a lifetime history of TBI were significantly more likely to report past year prescription opioid use (30.9% vs 23.9%, respectively) and misuse (5.0% vs 2.5%, respectively) than those without a TBI history.
Logistic regression results
Controlling for covariates, a lifetime history of TBI was significantly associated with an increased odds ratio of past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83) (see Table 3). Females had a significantly increased odds ratio of past year prescription opioid use compared with males (AOR = 1.36; 95% CI, 1.15-1.60), and non-White adults had a significantly increased odds ratio of past prescription opioid use compared with non-Hispanic/White adults (AOR = 1.40; 95% CI, 1.10-1.78). Compared with adults aged 18 to 44 years, adults aged 45 to 64 years had increased odds of past year prescription opioid use (AOR = 1.32; 95% CI, 1.05-1.66).
TABLE 3 -
Characteristics associated with past year prescription opioid use and opioid misuse among adults in Ohio, adjusted odds ratios and 95% CIs
a
|
Model 1: Past year prescription opioid use |
Model 2: Prescription opioid misuse |
| Characteristics |
AOR |
95% CI |
AOR |
95% CI |
| Sex |
|
|
|
|
| Male (reference) |
|
|
|
|
| Female |
1.36b |
1.15-1.60 |
0.67c |
0.45-0.99 |
| Age groups |
|
|
|
|
| 18-44 y (reference) |
|
|
|
|
| 45-64 y |
1.32c |
1.05-1.66 |
1.01 |
0.61-1.68 |
| 65+ y |
1.25 |
0.98-1.58 |
0.63 |
0.35-1.14 |
| Race/ethnicity |
|
|
|
|
| Non-Hispanic, White (reference) |
|
|
|
|
| Non-White |
1.40b |
1.10-1.78 |
1.70c |
1.02-2.83 |
| Marital status |
|
|
|
|
| Married (reference) |
|
|
|
|
| Never married |
0.96 |
0.75-1.22 |
1.76c |
1.02-3.03 |
| Other |
1.16 |
0.97-1.39 |
1.66c |
1.04-2.65 |
| Lifetime history of TBI |
|
|
|
|
| No TBI (reference) |
|
|
|
|
| Yes TBI |
1.52b |
1.27-1.83 |
1.65c |
1.08-2.52 |
Abbreviations: AOR, adjusted odds ratio; TBI, traumatic brain injury.
aModels excluded 46 respondents who were missing race/ethnicity data. Models use unweighted data.
bP ≤ .01.
cP ≤ .05.
Adults with a lifetime history of TBI also had a significantly increased odds ratio for meeting criteria for prescription opioid misuse compared with adults without a TBI (AOR = 1.65; 95% CI, 1.08-2.52). In addition, females had a significantly reduced odds ratio of misuse compared with males (AOR = 0.67; 95% CI, 0.45-0.99), non-White adults had significantly increased odds of misuse compared with non-Hispanic/White adults (AOR = 1.70; 95% CI, 1.02-2.83), and adults who were never married (AOR = 1.76, 95% CI, 1.02-3.03) and those who had an “other” marital status (AOR = 1.66; 95% CI, 1.04-2.65) were both significantly at increased odds of misuse compared with married adults.
DISCUSSION
This study examined the association between experiencing a lifetime history of TBI and past year prescription opioid use and misuse among a sample of noninstitutionalized adults in Ohio. Lifetime history of TBI was significantly associated with both past year prescription opioid use and misuse, even after controlling for demographics (ie, sex, age, race/ethnicity, and marital status), revealing that persons with TBI compared with those without had more than 50% increased risk for using prescription opioids in the past year and more than 65% increased risk for prescription opioid misuse. While there has been increasing concern for individuals with TBI who are prescribed opioids,4,5 our study is among the first to assess a lifetime history of TBI in relation to prescription opioid use and misuse among noninstitutionalized adults. Prior studies have focused on individuals with TBI without a comparison group,29 in military/veteran populations,30,31 receiving inpatient rehabilitation,10,19 or with clinically diagnosed TBI during a relatively brief observation window.30,31 Furthermore, most previous studies have examined prescription opioid receipt using pharmacy data indicating prescription orders or fills, which does not necessarily reflect medication use.10,30,31
While research is emerging, the potential consequences of prescription opioid misuse or long-term opioid utilization among individuals with TBI can be dire and include increased rates of nonfatal overdose, fatal overdose, and suicide risk compared with those without TBI.4,22,32–34 This increased risk for adverse opioid-related consequences among persons with TBI is of grave concern, particularly because a history of TBI is not insignificant in the US adult population. In this sample of more than 3400 adults in Ohio, we found that almost 23% had experienced at least one TBI in their lifetime, with more than two-thirds of these individuals experiencing an injury severe enough to include an LOC. These findings are lower than other population-based estimates, which indicate that approximately 43% of adults have experienced at least one TBI in their lifetime and 24% with an LOC,35 yet are very similar to estimates from 2016-2017 BRFSS data from Ohio.36 This may be partially explained by the fact that our sample had a higher prevalence of older adults, where a lifetime history of TBI has been found to be lower.26,37 We found that more than 8% of adults experienced a TBI with LOC before the age of 20 years, yet, due to small sample sizes, we were unable to examine how earlier injury was associated with opioid outcomes. This is an important area for future research since previous studies have found that experiencing a TBI during childhood increases the risk for future substance use problems, with most existing studies focusing on risk for alcohol problems following childhood TBI.38–40
Our study focused on prescription opioids only and did not include illicit opioids. Since 2010, there has been an increase in overdose and death associated with use of illicit opioids (eg, heroin, fentanyl).41 Yet, prescription opioid utilization remains a common pathway to illicit opioid use,42 and individuals using opioids long term or misusing opioids are at a greater risk for developing OUDs.29 Our study was conducted in 2018, several years after the decrease in prescription opioid prescribing in the United States that started around 2012.43 Yet, in 2016, it was estimated that 66% of all drug overdose deaths involved opioids and approximately 40% of opioid overdose deaths involved a prescription opioid.44
Our study does not reveal information about why individuals with TBI were more likely to receive prescription opioids and experience misuse than persons without TBI, including assessment of risk factors such as pain or mental health problems. Chronic pain is one of the most common health conditions among persons with TBI,6 and poorly managed pain is a common pathway to prescription opioid misuse.45,46 Mental health problems, another potential consequence of TBI,20 are independent risk factors for increased prescription opioid receipt7,47 and may exacerbate risk for adverse consequences among individuals with TBI. Future studies are needed to better understand the role of comorbid pain and/or mental health problems among individuals with TBI in relation to exposure to opioids and risk for adverse opioid-related outcomes. Providing adequate pain management for persons with TBI and chronic pain without increasing risk for development of opioid misuse or OUD is paramount and will require nonpharmacological approaches that are accessible and address the potential cognitive impairments experienced by persons with TBI.
TBI-related impairments in decision making and memory, disrupted emotion self-regulation skills, and poor impulse control can place individuals with cognitive disabilities at an elevated risk for misuse of prescription medications secondary to poor adherence to prescribed dosing schedules.48 Cognitive and neurobehavioral sequelae common after TBI may contribute to the development of OUD due to mismanagement of prescribed medication or poor adherence to prescribed dosing.4,49 If persons with TBI do develop OUD, then accessing and engaging in successful SUD treatment may be more difficult. While little is known specific to treatment of OUD among individuals with TBI, it has been shown that SUD treatment often lacks appropriate accommodations to address the cognitive and behavioral impairments that many persons with TBI experience.50,51
We found that demographic variables imparted varying levels of risk. Females had significantly increased odds of using prescription opioids in the past year yet had reduced odds of misuse compared with males. These findings are similar to prior studies with military and civilian populations.30,52 Future studies should evaluate whether there are potential interactions between a history of TBI and sex in relation to the likelihood of opioid misuse or adverse opioid-related consequences. Despite demonstrated differences in the prevalence of TBI and causes of injury by sex, research examining the effects of sex on outcomes following TBI has been limited.53,54 To date, it remains largely unknown whether there are sex-based differences following TBI in relation to substance use behaviors or outcomes. Adults in our sample who identified as a racial/ethnic group considered non-White (collapsed because of small sample sizes) were at an increased risk for both past year prescription opioid use and misuse compared with non-Hispanic/White adults. Prior research has shown variation in risk for prescription opioid use and misuse by subpopulations within the heterogeneous non-White population.52,55
There were several limitations to the study. Similar to other surveys including assessment of TBI, a positive screen for a lifetime history of TBI was based on self-report and was not confirmed with a clinical diagnosis. However, use of the OSU TBI-ID improves upon other methods of self-reported history of TBI and its standardized method has been shown to elicit accurate and valid results in multiple samples.24,25 Similar to TBI, reports of prescription opioid use and behaviors consistent with misuse were captured via self-report and may have been vulnerable to social desirability bias. Yet, social desirability bias should have been reduced because of the confidential nature of the BRFSS survey and the fact that participants were not asked to self-identify as having “misused” opioids but rather were asked to report using the medications more frequently/in higher doses than prescribed or using an opioid prescription that was not prescribed to them. Because the data are cross-sectional, we do not know for certain whether the TBI preceded prescription opioid use, although for some people we do know that their first TBI occurred during childhood. Finally, because we used unweighted data in our models, our results do not generalize to the population of Ohio. Furthermore, because BRFSS participants are recruited from households, these findings do not generalize to other populations at risk for both TBI and OUD (eg, homeless individuals, incarcerated populations). We were unable to examine how potential geographic variation may have influenced the opioid outcomes. Future research should replicate these analyses in larger samples to determine whether TBI severity or age of first TBI is associated with study outcomes.
CONCLUSION
Results from this study are consistent with the “perfect storm” hypothesis4—that persons with a lifetime history of TBI may be at an increased risk for use of prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Similar to other substances, persons with TBI may be at an increased risk for progression to OUD, and the pathway to dependence may accelerate faster than with other substances due to the highly addictive nature of opioids. Substance use treatment providers should be trained to screen for a lifetime history of TBI and incorporate strategies to address executive functioning limitations common following TBI, which are critical to successful SUD treatment. Similarly, rehabilitation clinicians should incorporate routine screening for substance use when seeing patients with TBI. The consequences of this perfect storm may be devastating, and more research is needed to identify nonpharmacological approaches for treating pain among persons with TBI and to determine the role of opioid use in risk for suicide following TBI.
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