Harms related to drug overdose are not limited to death. It’s important to remember that, when research has indicated there are approximately 15 non-fatal overdoses for every fatal overdose in the United States.
For those who survive, brain injury is a real threat that’s been described as a “hidden epidemic.” The accurate number of people impacted across North America is unknown.
A 2023 study found that overdose survivors were many times more likely to have a brain injury (toxic encephalopathy) compared with the general population in British Columbia.
“Severe cases of toxic encephalopathy can develop into toxic leukoencephalopathy, delayed post-hypoxic leukoencephalopathy, and amnesia,” the researchers noted. “It has been demonstrated to impact memory, executive functions and psychomotor abilities; ability to concentrate and recall information; speech; the visual system; and, in severe cases, lead to coma or death.”
Opioids such as fentanyl impact specific receptors in the brain that also regulate breathing. An opioid-involved overdose depresses respiratory activity to the extent that you’re deprived of oxygen. If this is not rectified quickly—through rescue breathing, another means of supplying oxygen and/or naloxone administration—brain damage begins to occur in as little as 3 minutes. The longer you go without oxygen, the higher the chance of brain injury.
I’ve been wondering if I might be one of the people affected by brain injury.
I’ve used drugs for most of my adult life, and have experienced a lot of non-fatal overdoses. Sometimes I wonder how I survived. But since I was introduced to the issue through my work for a harm reduction organization in Canada, I’ve also been wondering if I might be one of the people affected by brain injury.
One time in Montreal, I overdosed and there was no naloxone in sight. Thank God for my colleague at the time, who provided rescue breathing for 16 minutes. It took me a while to recover after that, and I wasn’t sure if I ever really would. Did this or other incidents cause lasting damage to my brain?
Chloé Xavier, MPH, is an epidemiologist affiliated with the British Columbia Centre for Disease Control in Vancouver. She led that study on the prevalence of brain injury among people who use drugs in BC, which was published in the Substance Abuse Treatment, Prevention, and Policy journal in 2023.
“Since the public health emergency was declared nine years ago, more than 16,000 people in British Columbia have died from the toxic, unregulated drug supply, and many others have survived and are experiencing ongoing long-term health challenges,” Xavier told Filter. “Given that the drug poisoning emergency has impacted communities across Canada, brain injury resulting from drug poisoning is a concern nationally as well.”
“People in BC who experienced drug poisoning were 19.5 times more likely to have a brain injury compared to people with no history of drug poisoning.”
“Our research study found that people in British Columbia who experienced drug poisoning were 19.5 times more likely to have a brain injury compared to people with no history of drug poisoning,” she continued. “We recently updated our analysis, and found a significant increase in the number of people with brain injury in 2020 and 2021 compared to the period from 2015 to 2019.”
Xavier and other experts agree that tracking and diagnosis of overdose-related brain injuries is inadequate, masking the extent of the problem.
Dr. Mauricio Garcia-Barrera is a professor at the University of Victoria, where he specializes in neuropsychology. He’s passionate about raising awareness of brain injury to change the course of an emerging crisis, and he has a personal motivation for that.
“One of my uncles had a brain injury, a traumatic brain injury,” Garcia-Barrera told Filter. “He fell off a stair ladder under the intoxication of alcohol.”
“I do remember very clearly the significant change he had in the way he spoke, in the way that he moved, in the way he thought,” he continued. “He wasn’t the same person. I was very puzzled by that. I grew up with that very clear memory of a significant change in my uncle.”
After Garcia-Barrera shared that story, I felt comfortable opening up about my history of drug use and overdoses. I told him about my concern that I might have a brain injury, and asked him what he would say to someone with that fear.
“There are areas of the brain that cannot fully heal, but it is also true there are areas of the brain that can generate new cells to support neuroplasticity.”
“When we talk about brain damage and brain injury, oftentimes those are heavy words,” he replied. “They are often compared to terminal cancer or things that have no reverse, because we have learned in our culture misconceptions that the brain doesn’t produce new cells.”
“What is true,” he continued, “is that there are areas of the brain that cannot fully heal, but it is also true there are areas of the brain that can generate new cells to support neuroplasticity—allowing healthy brain regions to compensate for and take over functions lost due to brain damage.”
I found that pretty comforting. I may well have some damage—I intend to find out more—but the main thing Dr. Garcia-Barrera wanted to convey to me is that there is hope.
Knowing about the risk is key. And to address the lack of awareness of brain injury following non-fatal overdose, Garcia-Barrera led a three-year project, the BC Consensus on Brain Injury, advocating for a national strategy on the issue in Canada.
This project—which recently concluded, with a report expected soon—brought together community members and families impacted by brain injury, as well as politicians, to exchange information and engage with the research team about their experiences and perspectives.
“We really wanted to have a conversation about the intersections between brain injury, mental health and addictions, ‘cause we notice it’s very common, but not so common to talk about it,” Garcia-Barrera said.
“Prevention is the number one intervention,” he emphasized. “Anything that can be done before an overdose or drug toxicity event occurs helps reduce brain injuries.”
But if an overdose has already happened, how people respond to it is vital.
“During a drug poisoning event, it is important for people responding to call 911 and follow the SAVE ME protocol, which includes giving rescue breaths or administering oxygen to reduce damage to the brain,” Xavier said.
After that, as both Xavier and Garcia-Barrera noted, a big problem is the lack of diagnoses of brain injuries following non-fatal overdoses.
For people who come very close to death during an overdose, or who end up in a coma for a short time, medical providers may draw more attention to the possibility of brain injury. But from my own experience of overdoses, you’re typically seen quite briefly in an emergency department, then discharged without any mention of brain injury.
“Brain injury can significantly affect a person’s life, impacting relationships and compounding existing barriers such as housing access and employment opportunities.”
If that happens to you, one way you can do your own followup is to access community support. It costs nothing to engage with a provincial brain injury association in Canada. And one program that Garcia-Barrera wanted to highlight is the Cognitive Assessment and Rehabilitation for Substance Use program (CARSU), offered by Vancouver Coastal Health.
CARSU provides free assessment and treatment through a team of occupational therapists, social workers, neuropsychologists and psychiatrists. Treatment for brain injuries varies case by case, but typically involves rehabilitative work with specialists, and potentially medications. CARSU helps patients to improve their thinking skills through brain exercises and lifestyle changes, among other services.
The program aims to help people with cognitive impairment related to substance use, and their supporters, to better understand their needs and improve quality of life. In keeping with the principles of harm reduction, it doesn’t require anyone to be abstinent from drugs to receive support.
Unfortunately, such programs are rare. The gaps are glaring, given the scale of the long-running overdose crisis that North America continues to endure.
“Brain injury can significantly affect a person’s life, impacting relationships and compounding existing barriers such as housing access, employment opportunities and access to community support,” Xavier noted.
Researchers like Xavier are building the knowledge needed to bring more awareness and expertise to the issue. I asked her for an example of a particular area where more study is needed.
“Young adults (19-39 years) are over-represented among people experiencing drug poisoning events, and may not immediately develop brain injury symptoms,” she responded. “Young people who use drugs and experience repeat drug poisonings may see future impacts on health, which has implications for long-term care provision. I think this is something that requires attention and additional research.”
As someone who falls squarely into that particular at-risk category, I’ll be endlessly grateful if this happens.
One of the consequences of stigma is that when problems are seen as something you can’t talk about, it keeps them hidden, neglected and more painful than they need to be.
June is Brain Injury Awareness Month in Canada, which sees campaigns to raise awareness of the prevalence of brain injuries, the obstacles faced by those affected and the support people need. It’s a welcome event, but it seems like there’s much more to do to spread fuller awareness of overdose-related brain injury.
Fresh from his BC Consensus on Brain Injury project, Garcia-Barrera has further ideas on how to go about this. He suggested a massive educational campaign to reduce the stigma of mental health conditions and substance use. That’s because effectively reducing stigma, he feels, would have all kinds of knock-on effects on the care impacted people receive.
If neurologists, occupational therapists, emergency department personnel and other clinicians could finally understand why people who use drugs use drugs, he believes, doors would open—and not only the doors those professionals work behind. Policymakers and government agencies might finally allocate more resources to where they are sorely needed.
One of the consequences of stigma is that when problems are seen as something you can’t talk about, it keeps them hidden, neglected and more painful than they need to be. It helped me a lot to be able to speak with two inspiring experts who are working to shed light on overdose-related brain injuries. I wish more people in my position could feel similarly supported.
Image via Picryl
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