Final report: Opioid prescription and use following traumatic brain injury

Garvey Institute news | April 30, 2022

Our Innovation Grants Program launched in 2020 funded a project led by Amy Starosta, PhD, Jeanne Hoffman, PhD, and Kari Stephens, PhD, called “Opioid prescription and use following traumatic brain injury”.

Individuals with Traumatic brain injury (TBI) are often prescribed opioids for pain following their injury, but unfortunately may be especially vulnerable to post-injury alcohol and drug use problems. Despite increased opioid prescriptions and risk factors for this population, there are no clinical practice guidelines for opioid prescription following TBI and limited published research. The project sought to address this knowledge gap by using routinely collected clinical data from several different data sources to examine when and how opioids are prescribed following TBI in a community-based population. Below is their final report.

Project Summary
This project was focused on leveraging existing routinely collected health records (the HMC Trauma Registry, the UW electronic health record, and the WA DOH Prescription drug monitoring program data) to examine the prescription of opioid medications following traumatic brain injury.

First, utilizing the HMC Trauma registry and EHR provided a rich database. While we were finalizing data related to opioid prescription (converting to morphine equivalence), we were able to look at differences in mortality following TBI for using an intersectionality approach which allowed individuals to be categorized based on belonging to multiple social identities that are historically vulnerable to systemic disadvantage. Results demonstrated significant health inequities in mortality and access to inpatient rehabilitation following TBI: Groups with more systemic disadvantage had higher rates of mortality and were less likely to discharge to inpatient rehabilitation following acute care. These findings suggest an additive, deleterious effect for patients who belong to multiple historically disadvantaged social groups.

Next, we examined opioid use for those with TBI during acute care hospitalization. Not only were we able to examine current practices, but we looked at how practice has changed over time, particularly related to changes in state policy implemented in an attempt to reduce the misuse of opioids. At the state level, new policies intended to reduce the misuse of opioid medications were enacted in 2017 following national level guidelines from the CDC and the Joint Commission. Results suggested that although the dose of opioids given over time has decreased following the roll out of these 2017 policies, levels appear to be increasing during the COVID pandemic response.

Our next step is to create a non-TBI matched group to evaluate if the same changes in opioid use apply to other trauma populations and to determine whether opioid use differs for patients with TBI vs. non-TBI. These analyses will be included in our manuscript currently in preparation.

One of our lessons learned is related to collaborating with the WA DOH. Our hope was to be able to examine long-term outcomes related to opioid use utilizing the PMP data. However, the process of gaining access to the PMP data has been quite lengthy, and unfortunately exacerbated by COVID. After almost a year of working with the WA DOH, we have officially received the data from them. We are eager to use this new data to ask additional questions, as outline in future directions but will require additional funding to fully utilize this data. In the future, we will know to budget in much more time than initially anticipated when working with state level organizations.

Project Impact

• Starosta, A.J., (2022, February). Using existing clinical data to examine care following traumatic brain injury. Presented to the Research Faculty Meeting for the University of Washington Department of Rehabilitation. Seattle, WA.
• Starosta, A.J., Humbert, A., Prado, M., Stephens, K., & Hoffman, J. (2022, April) Characterization of opioid use in Traumatic Brain Injury hospital care. Poster presented at the annual meeting of the Society of Behavioral Medicine, Baltimore, MD.

Publications submitted:
• Starosta, A.J., Mata-Greve, F., Au, M.A., Prado, M., Mollis, B., Stephens, K.A., Hoffman, J. (in revision) Intersectionality of systemic disadvantage on mortality and care following TBI. Journal of Head Trauma Rehabilitation

Publications in preparation:
• Starosta, A.J., Humbert, A., Prado, M., Stephens, K., & Hoffman, J. (in preparation). XXX To be submitted to the Health Services Research Journal

Grant applications under review:
• University of Washington Traumatic Brain Injury Model System. Submitted to National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Disability and Rehabilitation Research Projects (DRRP) Program. Proposed next steps to serve as site-specific project

Future Vision and Next Steps
Next steps for this project are focused on examining the long-term impact of opioid use during acute care hospitalization. We plan to merge the current dataset with the PMP data recently obtained and self-reported data collected as part of the UW Traumatic Brain Injury Model Systems (UW TBIMS) longitudinal database. The UW TBIMS data collection has been ongoing since 1998 and longitudinally assesses the experience of individuals living with TBI at 1, 2, and 5 years post-injury, with follow up continuing every 5 years afterwards (so far up to 20 years post-injury at our site). For our current TBIMS grant application, we are proposing to utilize the power of real-time medical record (EHR) and prescription data (PMP), data collected for the local trauma database (HMC trauma registry), and data from the UW TBIMS to create a comprehensive database that includes medical, psychosocial, and environmental factors and spans acute care, inpatient rehabilitation, and reintegration into the community. Our aims for the project are to (1) To identify early medical care and person factors that predict the likelihood of opioid use in the first five years following TBI as potential targets to guide future intervention development; (2) To identify whether early use of opioids predict self-reported psychological, functional, and quality of life outcomes in the first five years following TBI; (3) To identify when pain develops following TBI and what early medical care, psychological, and demographic factors increase the occurrence of chronic pain in the first five years following TBI. While we have identified the above aims as the primary targets of the current research, we expect that the development of this database will create a rich resource that will provide answers for many additional clinical and research questions about care and trajectories following TBI. Therefore, we anticipate that additional questions will be generated and addressed during the course of the proposed research project. This study will advance the understanding of pain following TBI by identifying early predictors of chronic pain and chronic opioid use, including acute medical care factors and health inequities. Through better understanding of the factors that influence the development of pain and chronic opioid use, future research can design more effective interventions to prevent the development of chronic pain and overreliance on opioids.