The Opioid Crisis: Consequences of Nonfatal Overdose


Brain scan

For the past year and a half, we’ve all had our attention on the coronavirus pandemic. And with good reason: it’s taken the lives of far too many of our friends and loved ones, disrupted the lives of almost every citizen in the country, and complicated issues that affect us all. The ongoing pandemic affects the economy, education from kindergarten to college, work, socializing, non-COVID related healthcare, entertainment, and politics.

That’s not including the personal, emotional, and psychological effects the entire experience has had — and continues to have — on us all.

However, while the pandemic gets our attention, the opioid crisis has not disappeared.

In fact, it’s gotten worse.

The latest data show these alarming facts:

· Overdose deaths increased dramatically in March of 2020, at the beginning of the pandemic.

· They stayed elevated at unprecedented levels throughout the summer months, between April — August 2020.

· These monthly overdose deaths were the highest monthly overdose deaths ever recorded.

· Last year, 93,331 people died of opioid overdose.

As a physician working in addiction treatment, primarily supporting people with opioid use disorder (OUD), that last statistic is hard to read. It’s the largest number of opioid overdose deaths in the U.S. since we’ve kept records on overdose deaths. It’s an increase of more than 20,000 from 2019 — the previous worst year ever for overdose deaths — and it’s the largest percentage increase for a single year recorded since 1999.

It’s hard for me to read that statistic because I know I can’t help those people: we didn’t get to them on time.

I’m sharing all this information on the opioid crisis and opioid overdose because there’s a group of people out there we can still help. And due to their specific circumstances, they need targeted support that considers their personal history with overdose.

That’s what I’m getting at. It’s a topic few people in the general public think about. We focus on fatal overdose, for obvious reasons. Every death is a tragedy. And if we can quantify degrees of tragedy, preventable deaths are even more tragic.

But for every person who dies of overdose, there are substantially more people who suffer overdose and do not die.

That’s the subject of this article: nonfatal opioid overdose. More specifically, I want to talk about how we — meaning me, my colleagues, and all of us — can help people who experience overdose and survive.

Nonfatal Opioid Overdose: The Numbers

Experts estimate that around 80% of people who experience opioid overdose survive the overdose event. When we do some simple algebra with the numbers from last year, we learn that close to half a million people in the U.S. survived an opioid overdose in the year 2020.

Nonfatal overdose is a traumatic event with significant physical, psychological, and emotional consequences. A recent study took a deep dive into those consequences — one of the first studies of its kind — and published information that changes how we understand overdose survivors and will inform how to support them in the future.

And by the future I mean starting now, today, with each patient I see.

What I knew — facts-wise — about the consequences of nonfatal overdose before I read this study were relatively straightforward:

1. A nonfatal overdose increases risk of subsequent overdose

2. A nonfatal overdose increases risk of subsequent premature mortality (death)

3. A nonfatal overdose without follow-up treatment and support exacerbates the increased risks identified in (1) and (2).

I knew these things, and I had solid ideas about the why behind these consequences. The main thing I knew was that people who survive overdose need treatment — right away. The study published this summer, though, teaches us more about the kind of treatment that might be best for people who survive an overdose. And the study fills in a lot of the why questions outstanding in everyone’s minds.

I’ll now discuss those consequences and what they mean for treatment.

Nonfatal Opioid Overdose: Physical, Cognitive, Emotional Challenges

The majority of harm caused by nonfatal opioid overdose is related to opioid-induced respiratory depression (OIRD). In plain language, that means an opioid overdose slows down breathing to very dangerous levels, levels which result in hypoxia. That’s a term that means “a lack of oxygen reaching the tissues of the body.” In the case of overdose, the worst damage caused by hypoxia results from insufficient oxygen reaching the tissues of the brain.

This phenomenon is called opioid-induced hypoxic brain injury. Opioid-induced hypoxic bran injury can cause severe physical and mental disability.

Physical impairments and disabilities may include:

· Ataxia: loss of control of body movement

· Paralysis

· Incontinence

· Disturbance in gait (walking)

· Reduced or impaired motor skills

· Seizures

Cognitive impairments and disabilities may include:

· Disorientation

· Confusion

· Memory problems, including amnesia

· Decreased overall cognitive function

· Impaired rational decision-making skills

· Impaired impulse control

Emotional consequence of nonfatal overdose may include:

· Increased depressive symptoms

· Increased suicidal ideation

o Increased risk of suicide

· Decreased ability to manage symptoms of depression

· Decreased ability to manage symptoms of any co-occurring mental health disorder

The physical consequences of nonfatal overdose can be extreme, and some people who experience overdose never regain full physical or mental function. For those who do regain a semblance of their pre-overdose level of general function, however, the cognitive and emotional consequences present real barriers to full recovery.

That’s where the study I mention above — published just this past summer — sheds light on how we can help survivors of nonfatal overdose.

Neurocognitive Testing to Identify Challenge Areas

Since nonfatal overdose can change the structure and function of the brain — due to hypoxic brain injury — it stands to reason that if we learn exactly what those changes are, we can tailor subsequent addiction treatment to address the cognitive, psychological, and emotional impairments present in overdose survivors.

That’s what the researchers in this new study did: they found a way to identify exactly what those changes are. And they’re expanding their research effort right now, as I write this article, in order to seek important information that can improve addiction treatment, especially for those who’ve experienced nonfatal overdose.

In their first round of research, they identified the most common neurophysiological impairments caused by nonfatal overdose. This led to their current research effort: their goal is to develop metrics that identify the specific deficits caused by overdose-related hypoxic brain injury. To that end, they’re using real-time brain imaging techniques, such as fMRI, and a “comprehensive battery of neurocognitive tests” to compare the brains of people with OUD with a history of overdose to the brains of people with OUD without a history of overdose.

The combination of personal questionnaires, brain imaging, and cognitive testing means the comprehensive battery of testing will include more information than previous tests. These new tests will include the standard information on age, education level, intellectual function, duration of substance use, types of substances used, mental health history, treatment history, and overdose history.

Here’s where the study gets interesting. In addition to those standard metrics, they’ll collect information on the following tests, all while observing real-time brain function via fMRI:

· Specific brain areas impacted by overdose

· Performance on memory tests

· Performance on tests that measure problem-solving skills

· Performance tests that measure rational thinking skills

· Performance on tests that measure impulse control

· Performance on tests that measure decision-making skills

The goal of the testing is to synthesize all the information in order to understand how the brain changes caused by hypoxic brain injury affect an individual’s ability to participate in treatment and recover from opioid addiction.

How This Can Help

In the words of lead researcher James Mahoney:

“If we are able to target those at a higher risk of cognitive impairment — perhaps those who have had five or six overdoses — and individualize their treatment plans to address those deficits as early in the treatment process as possible, we may be able to improve their outcomes, given what is known about cognition and treatment dropout.”

Mahoney echoes what many of us in the field of addiction see every day: the long-term effects not only of opioid use but also nonfatal overdose can impede the ability of our patients to productively participate in, understand, internalize, adhere to, and benefit from professional treatment and support.

That’s a tough situation for both the person in treatment and people like me, who help them, to overcome. It challenges us because in most cases, we don’t know the impairments exist until we run into figurative brick walls during treatment, which are often unpredictable and unexplainable. Neither patient nor physician know objectively the brick wall we encounter may be the direct consequence to an impairment caused by nonfatal overdose.

If we can identify the impairments and define their psychological, emotional, and behavioral effects, then, as Mahoney says, we can better tailor their treatment plan — short-term and long-term — to leverage their strengths and mitigate their deficits.

That’s a positive step in right direction. In light of the negative effects of the pandemic on overdose rates in the U.S., we need positive news like this to give us hope and help us help our patients do the hard work of recovery.

I’ll end on a note that will help you understand our capacity for finding hope even in the midst of crisis: one consequence of nonfatal overdose is that in some cases, it’s the only incident powerful enough to cause someone with severe opioid addiction to seek professional treatment.

In other words, sometimes it’s the only thing that gets them through our doors.

And now we can be even better prepared to offer them the support they need.



Christopher Johnston, MD, ABPM-ADM

Christopher Johnston, MD, ABPM-ADM, is the Chief Medical Officer for Pinnacle Treatment Centers and has practiced addiction medicine for the past 15 years