Patterns and Predictors of Prescription Opioid Initiation Following Traumatic Brain Injury: A Systematic Scoping Review

Background and purpose: In 2016, the Centers for Disease Control and Prevention introduced opioid prescribing guidelines to mitigate consequences of the U.S. opioid epidemic. However, prescription opioid initiation and misuse remains a major public health concern among individuals with traumatic brain injury (TBI). Evidence suggests that prescription opioids may be more harmful for survivors of TBI due to post-TBI psychological and emotional outcomes that predispose these individuals to misuse opioids. Individuals with TBI may be 10 times more likely to die from unintentional overdose than the general population. The objective of this review was to identify and synthesize patterns and predictors of prescription opioid initiation following TBI.

Methods: A systematic scoping review was conducted using the PRISMA extension for Scoping Reviews (PRISMA-ScR) and managed through Covidence systematic review software. Studies were identified through CINHAL, Embase, PubMed, Scopus, Web of Science, and Google Scholar. Eligible studies were included if: (a) prescription opioid initiation or chronic use was specified for individuals with TBI; (b) published between 2010 – 2020; (c) written in English language; (d) TBI was the primary injury type; (e) peer reviewed; and (f) empirical research. Data were extracted on study characteristics, participant demographics, TBI severity, comorbidities, opioid prescribing setting, main outcomes, and adjunctive non-pharmacological treatments. Two coders independently screened full texts for eligibility and extracted data from the final set of articles.

Results: Of the 912 initially identified articles, eight met inclusion criteria. Six studies specifically examined prescription opioid initiation among military service members or veterans with TBI, where prescriptions were obtained through Veterans Affairs pharmacies. Two studies examined opioid initiation while survivors of TBI were in intensive care or inpatient rehabilitation units. Overall, younger age (≤ 45 years) and White race was associated with increased likelihood of opioid initiation. However, earning a college degree or higher protected against opioid initiation. While women were significantly more likely to initiate short-term opioid therapy, men were more likely to initiate long-term opioid therapy and exhibit chronic opioid use. The majority of studies reported higher risks of opioid initiation associated with greater injury severity and disability burden. Indeed, while physical pain was a significant predictor of opioid initiation, nearly all studies identified presence of depression, anxiety, post-traumatic stress disorder, or history of substance use disorder with significantly increased likelihood of prescription opioid receipt or initiation. Presence of multiple co-occurring mental health conditions was the strongest predictor of opioid initiation. Only two studies reported on non-pharmacological mental health treatments.

Conclusions and Implications: Presence of emotional and psychological pain were among the strongest predictors of opioid initiation and chronic use. Prior history of opioid or other substance use disorders also strongly predicted post-injury opioid receipt. Yet, non-pharmacological treatments were sparsely reported across studies. Multidisciplinary care approaches that include non-pharmacological treatments offered by mental health providers could have important implications for the health and safety of individuals with TBI. Tailored strategies are needed to reduce potential barriers to accessing and engaging in non-pharmacological treatments.