Both traumatic brain injury (TBI) and opioid use disorder (OUD) are significant causes of death and disability in the United States that disproportionally impact persons who are historically marginalized and under-resourced (CDC, 2022). There is growing evidence that TBI and OUD are frequently comorbid, although little research has empirically evaluated the onset or trajectory of co-occurring TBI and OUD (Adams et al., 2020; Starosta et al., 2021).

The present study intended to clarify several facets of the relation between TBI and OUD among persons in treatment for OUD in a rural Appalachian region of the United States. The first objective was to evaluate the severity and frequency of TBI among individuals with OUD and establish the typical timeline between TBI and first opioid use. The second objective was to examine the relation between TBI and factors influencing the harm potential of OUD, including overdose, polysubstance use, route of opioid administration, and behavioral health comorbidities.

Participants were adults receiving outpatient treatment for OUD (N = 158). The sample was mostly comprised of women (52.1%) with educational attainment of a GED/high school degree or less (77.5%) and a mode annual income of $14,999 or less (48.6%). Participants completed a semi-structured interview to assess for TBI history and completed a battery of self-report questionnaires on mood, pain, psychological tendencies, and demographic information. The affiliated University’s IRB approved all study procedures.

Nearly half (48.7%) of participants in the study had experienced at least one TBI in their lifetime. Among those who were positive for a history of TBI, 44.2% had experienced multiple TBIs. Most TBIs occurred during childhood. For participants with TBI, the likelihood of incurring a TBI before first using opioids was 1.5 times greater than first opioid use predating the TBI.

Approximately 90% of participants who had suffered a TBI had received a prescription for opioid medication from a healthcare professional at some point, which was significantly higher than for persons without a TBI history. Notably, few differences were observed in psychosocial characteristics between those with and without TBIs, including educational attainment, marital status, age, and gender.

Participants with a history of TBI faced an increased risk of overdose, were more likely to use fentanyl, engaged in riskier routes of administration, and experienced more pronounced symptoms of chronic pain and anxiety when compared to those without TBIs. However, there were no notable differences in the use of certain substances (e.g., alcohol; marijuana), or the presence of symptoms of post-traumatic stress disorder or depression based on TBI history.

The findings suggest that TBI is relatively common among patients undergoing treatment for OUD. TBI usually occurs before the onset of opioid use, highlighting a possible need for caution when prescribing opioids to individuals with a history of TBI. The data also provide evidence for a connection between TBI and indicators of risky health behaviors and medical complexities, including the risk of overdose. These findings provide rationale for TBI assessments to be integrated into standard medical evaluations and factored into the development of treatment strategies.