Brain injury is one little-known offshoot of New Hampshire’s drug crisis

Three minutes.

That’s the window of time overdose victims have before their brain starts to die.  

“Everything will eventually die, but the brain is probably the most dependent, second by second, needing oxygen,” said Dr. David Nierenberg, a neurologist at Dartmouth-Hitchcock Medical Center in Lebanon. 

When someone takes too large a dose of heroin, prescription painkillers or injects a potent drug like fentanyl, their body relaxes so much that they stop breathing.

That’s when the race against time starts.

Without a steady flow of oxygen, carbon dioxide builds up in a person’s lungs. The brain becomes crippled first; organs like the heart will eventually follow.

Narcan and CPR are crucial tools first responders and people on scene can use to revive those who have overdosed. But even if the body survives, the brain may not.

“Death is certainly not the only possible outcome,” Nierenberg said.

One little-known offshoot of New Hampshire’s opioid crisis is a rise in brain injuries sustained from overdoses.

Close to 4,000 people were “effectively” revived from drug overdoses using Narcan during 2014 and 2015, according data reported to the state Bureau of Emergency Medical Services. But the level of success might not be so clear.

People tend to think of drug overdoses in black and white terms: either you are revived with Narcan and are fine, or you die. But there is also a gray area, where the brain is damaged by lack of oxygen.

“There are people who fall in this horrible middle,” said Dr. Frederick Bruch, chief medical officer at Crotched Mountain Specialty Hospital in Greenfield, which focuses on brain injury rehabilitation. “We see people with lots of different levels of disability from it.”

Even some of the best emergency response times in the state’s urban areas can take more than three minutes – the time it takes for brain damage to start – and even longer in rural areas of the state. With more than 5,000 people being revived with Narcan in the past three years, the number of people affected by brain injury could be in the hundreds, even thousands.

Bruch said over the past two years, about 20 percent of the hospital’s patients have had a brain condition either caused by or worsened by opioid use. Out of the 44 patients the hospital had admitted in October, four fell into that category.

“That is definitely a change from four, five, six years ago,” he said. “It’s definitely an increase.”

The overdose reversal drug Narcan may be lulling drug users into a false sense of security, health officials said. But they add Narcan is still a crucial, life-saving tool that should be distributed so that more people have access to it and can reverse overdoses as quickly as possible.

“We’re all happy when we do save people, but there is a cost,” said Barb Kresge, program director at the Krempels Center, a nonprofit rehabilitation organization in Portsmouth. “It’s probably a side of the heroin crisis that people aren’t aware of.”

Besides tracking admissions to rehab facilities, hard numbers on overdose-related brain injuries are tough to come by. Depending on the severity of the damage, or the level of addiction, people may not know they have a brain injury.

“This has been on our radar screens for a while but it’s really hard to get a handle on,” said Steven Wade, executive director of the New Hampshire Brain Injury Association.

The brain is a complex organ and lack of oxygen can affect two people in completely different ways. Some people might experience memory loss and cognitive impairment, others might no longer be able to speak or dress themselves. Still others will find their behavior impacted, making them more impulsive or apt to get angry faster.

It’s possible for subtle brain injuries to get worse over time if someone overdoses repeatedly.

“Like a concussion on the playing field, they’re cumulative injuries,” Wade said. “The brain is very sensitive.”

Nierenberg agreed.

“Every bit of damage you do to your brain can be additive to the next amount of damage you do to your brain,” he said.

Health officials say drug-related brain injuries pose a real problem. Because so many drug users are young people, many will need varying levels of care for the rest of their lives.

“It’s just such a cost to society,” Bruch said.

People who are severely damaged may need many years of physical therapy and intensive medical care, from feeding and tracheostomy tubes to trying to regain their ability to walk, talk, feed and dress themselves.

Some people lose their sense of time and their daily routine. For instance, a person might remember they need to go to work, but can’t initiate the process of getting out of bed and getting dressed. They might not be able to remember where they’re supposed to go, or how to get from one end of their office to another.

“They can’t string together a day,” said Kresge. “You don’t understand what you need help with and what your problems are.”

That can prove to be very expensive for families, who may have to become caretakers themselves or hire people to look after their adult children.

It proves doubly difficult when you consider a drug user with a brain injury is still addicted to drugs, forcing families to deal with two complicated and difficult medical conditions at once.

Opioids already make users impulsive and impair judgement; add a brain injury into the mix and it can make the problem far worse.

“It really, really complicates things,” Kresge said.

At the Krempels Center in Portsmouth, people with brain injuries slowly learn how to get their lives back. The center provides day programs for rehabilitation, but it also serves as an emotional support network for brain injury survivors and their families.

Kresge, the center’s program director, said there are just a few Krempels members whose brain injuries came as a result of drug overdoses.

“We haven’t necessarily noticed an uptick. That being said, I wouldn’t be surprised at all if that happens,” Kresge said.

In her line of work, Kresge sees brain injury survivors ranging from people who are nonverbal and need full care to people whose brain injury effects are much more subtle.

She said her organization’s mission is to help all brain injury survivors regain their independence, “getting to the point where they’re participating actively in their life decisions.”

There is a lot of emotional support as well; Kresge said there’s less emphasis on how people got their brain injury and more on how to get better.

The centers runs about 15 groups per day, everything from helping people improve their functional skills like learning how to cook and use the computer to how to take care of their physical health, to emotional support networks.

“People improve and change and grow as long as they’re in an environment that stimulates them,” Kresge said. “This is a place where you are challenged on a daily basis.”

(Ella Nilsen can be reached at 369-3322, enilsen@cmonitor.com or on Twitter @ella_nilsen. Editor’s note: This story has been updated to reflect the correct number of Crotched Mountain patients with a brain injury related to an overdose.)