1625 - Medication-Assisted Treatment After Traumatic Brain Injury

Case Diagnosis: Substance use disorder in the setting of a TBI patient

Case Description: A 53-year-old woman with remote penetrating TBI, ventriculoperitoneal
shunt, seizure disorder, depression, anxiety, polypharmacy, and chronic pain was referred to an
outpatient acquired brain injury clinic. For more than a decade, she received 15mg of
oxycodone three times daily for severe, unremitting headaches. The patient fell frequently, more
than five times in the last 18 months, twice resulting in fractures and hospitalizations.
Outpatient attempts to down-titrate the opioid regimen, initiated with patient consent, failed due
to patient anxiety, manipulative behavior, and communication failures between the rehabilitation
physician, primary care, and the patient’s assisted living facility. Following the most recent
hospitalization after a fall, the patient transitioned to inpatient rehabilitation, where the team,
including her outpatient physiatrist, aggressively titrated her off oxycodone, followed by
buprenorphine-naloxone and occipital nerve blocks. The patient’s pain and emotional lability
improved markedly, down to an average of 3/10 from 8-9/10, without further falls.

Discussions: Substance use disorders and abuse are remarkably common in the acquired brain
injury population with ongoing use associated with poor outcomes. Unfortunately, there is a lack
of associated physical medicine and rehabilitation physician and team education on evidence-
based practices that could be initiated and leveraged in interdisciplinary inpatient and outpatient
settings.

Conclusions: With further education and emphasis by accreditation bodies, neurorehabilitation
teams are well-positioned to identify appropriate patients, begin evidence-based therapies, and
increase participation in existing substance use treatment programs through outreach and
collaborative efforts.