Beyond the tip of the iceberg: Brain injury after drug poisoning

The toxic drug crisis has claimed the lives of tens of thousands of Canadians. However, non-fatal drug toxicity events (also called overdoses) are much more common than fatal events. Brain injury is a lesser known harm related to drug toxicity that can happen when people survive a drug poisoning event. A brain injury affects how the brain works. It can occur during a drug toxicity event because breathing slows down or stops and there is a lack of oxygen to the brain.

CATIE spoke to Shanell Twan, assistant manager at Streetworks, a harm reduction program in Edmonton, and Dr. Kaylynn Purdy, a neurologist, to better understand the impact that brain injury is having in communities and how it can be prevented.

How does brain injury happen during or after a drug poisoning?

Kaylynn Purdy: There are a couple ways that brain injury can be caused by drug poisoning. It happens when a drug poisoning leads to someone not being able to breathe and not getting enough oxygen, which damages or kills brain cells. This is probably the majority of what we see. Many people are having repeated episodes of poisoning, where they have a lack of oxygen for brief periods of time that are not long enough to cause death, but over time can lead to brain injury. Brain damage can also happen over time from certain drugs or certain cuts in the drugs being used.

What are some of the impacts of brain injury on individuals who experience drug poisoning?

Kaylynn Purdy: Certain parts of the brain are really sensitive to lack of oxygen, such as the part that controls movement. So, sometimes brain damage can impact people’s movement, such as affecting the way that they walk or their posture or causing tremors. Other parts of the brain can be affected too, which can impact behaviours like decision-making, impulse control and interactions with other people. You might be more likely to get into fights or altercations if you don’t have the same level of impulse control due to a brain injury.

Sometimes, people can have immediate severe injuries from a drug toxicity event, where they are in hospital for long periods of time and end up in rehabilitation units.

Shanell Twan: I have definitely seen those chronic physical impacts in my community – impacts on people’s coordination and motor skills, as well as on posture and the way that they’re walking. We’ve been running clinics and collecting donations of walkers to help support people with these physical issues.

I am also seeing brain injury leading to long-term cognitive impairments, as well as mental health impacts like anxiety and personality changes. And then, obviously, there’s the reduced quality of life for people and the impact on their overall well-being as a result of these physical or cognitive impairments.

Kaylynn Purdy: People might not be able to function like they used to, which can impact quality of life. For example, not being able to get into the church where they got their meals because they can’t climb stairs very well anymore. And it can be extra difficult for people who are unhoused or living precariously if they have trouble functioning independently.  

How is the healthcare system responding to this growing emerging need?

Shanell Twan: There will be long-term implications for the healthcare system and so far, people aren’t really paying attention to this. The reality is, we are going to require many more supports in community at a time when we are losing funding for necessary programming. It’s going to be all types of things: physical therapy, occupational therapy, speech therapy or medication assistance. Many folks in community are already living in complex situations, those who have now sustained a brain injury are going to require all kinds of additional help.

Kaylynn Purdy: There is not a lot of talk about brain injury. But there are a lot of system-level implications for both trying to treat brain injury and also giving people access to appropriate and high-quality rehabilitation and supports in the community.

I think B.C. may be the only province to acknowledge that this problem exists. Last year, B.C. started a new rehab program for people with brain injuries from substance-use-related poisonings. We’re going to need more of these types of programs, as well as supportive long-term housing that can help people return to or improve their independent functioning. It’s a huge system burden and we need more resources.

Part of the problem is that we don’t have a medical term or an actual diagnosis for a brain injury related to toxic drug poisonings. Without a diagnostic code, it’s hard to measure how many people are affected and how they’re being affected. We think the number is probably higher than what we’re seeing, but without a formal diagnosis we don’t have the numbers, only estimates, so it’s hard to advocate for more resources.

Given the significant impacts on individuals and on the health system, how can brain injury be prevented?

Shanell Twan: People need to know that this can happen, and how to prevent it. The education and awareness piece is really important. So, raising awareness about the signs of drug poisoning and how people can help promptly. Also, making sure people have the skills, knowledge, resources and supports in place to be safer and healthier while they’re using drugs.

Kaylynn Purdy: Preventing brain injury is the goal. Supervised consumption or using with other people is key so that when you are having a lack of oxygen, even for a brief moment, someone can respond quickly.

Shanell Twan: Supervised consumption services (SCS) also need to provide spaces for inhalation, to accommodate people who smoke drugs. Here in Edmonton and in a lot of other places, most people have switched to inhalation. But most SCS do not permit people to smoke their drugs.

The availability of naloxone is another important thing. Here at Streetworks, we give out hundreds of kits a week, and we are doing outreach seven days a week in the community. But with so many toxic drug poisonings we’re finding there’s fatigue in people who have responded to so many poisonings for their friends. Naloxone can feel like a temporary measure, like we’re out here putting Band-aids on bullet wounds. The illicit market is so heavily tainted with toxic substances.

Kaylynn Purdy: The other big part of preventing brain injury is harder to control – the lack of access to a safe supply of drugs. A big part of the poisoning aspect is that people don’t know what they’re taking.

Since prevention is so important, what should people know about responding to drug poisonings/overdoses?

Kaylynn Purdy: It is so important to respond quickly. Something that all of us can do on an individual level is actually respond to people who may be experiencing a poisoning. It’s important to know that brain injury starts happening at four minutes of low oxygen – not zero oxygen, just low oxygen. And four minutes is not a lot of time. This is why it is so important to check a person’s breathing rate and give rescue breaths when responding to a drug poisoning. We can call emergency medical services while supporting a person’s breathing so that they have less chance of brain damage from a lack of oxygen.

In SCS we can give a person oxygen to support them until they wake up or help them to breathe with a bag-valve-mask. We don’t need to use massive amounts of naloxone, if we don’t have to. That’s painful and not needed. Oftentimes responding is just supporting airways and supporting breathing and using the minimum dose of naloxone needed. Especially since there are substances, like benzodiazepines, that can’t be reversed with naloxone, so people might not wake up right away.

But there’s a ton of stigma in the community. For instance, some people are afraid that they will have an overdose or be poisoned by touching someone who has consumed a substance, which is just not true. And I know some people will just walk past someone who is clearly unconscious in the street instead of stopping to check on them. If people are breathing, but their head is slumping against a wall, it could go a long way to straighten them out, then all of a sudden they’re breathing well and wake up. So, there are very simple things we can do to help people avoid actually developing brain injuries caused by lack of oxygen. The most important thing is to start supporting that person immediately and call for help.

Shanell Twan: I think it’s important to thank and encourage the people in our communities who are natural helpers. We often think of the front line as us – the outreach workers, the nurses, the doctors. But the front line really lies in community because when we all go home at the end of the day the community is still there. These are the people who are saving the lives of their friends, their family and loved ones. The people who stop, who carry naloxone, who actually give a shit about other people. Thank you so much, because you people are literally lifesavers.

 

Shanell Twan works in harm reduction at Streetworks in Amiskwacîwâskahikan (colonially known as Edmonton). She is connected to municipal, provincial and federal substance user groups. Shanell is an Indigenous woman who has a vested interest in improving the health of her community.

Dr. Kaylynn Purdy is a neurologist and critical care medicine fellow at the University of Calgary, who also works in harm reduction and street outreach.