I recently received the sad news that a colleague of mine had lost his daughter. Reading the obituary, I found out the cause. It was not shrouded in code, like “died suddenly” or “unexpectedly”. Her parents spelled it right out: she was a victim of her addiction to opioids.
Her funeral was jarring, full of young people, friends in their 20s. They were not joking over fond memories or talking about a good long life; they were in shock.
At the front of the receiving line, I met her father, my colleague. What could I say? I hugged him. I told him it was brave to put the truth in the newspaper, not to hide it as some shameful fact. And he nodded, his eyes desperate. “I wanted to be honest. Because, you know, we didn’t know how to help her. No one could. We tried everything. Nothing worked.”
As I walked out of the funeral home into a bright, sunny afternoon, it struck me that she could have been a case I was reading, yet another electroencephalogram (EEG) that I would sigh over and write my report on. As a neurologist, I interpret these readouts every day – diagnostic tests that measure the electricity of the brain. And for the past few years, I’ve been watching the results change as the opioid epidemic has taken its toll.
What the EKG is to the heart, the EEG is to the brain. Scalp electrodes translate neurological activity into waves, cerebral squiggles that show how well our brain machines are working. Rhythms in alpha, beta and delta reflect our states of mind: awake, asleep, seizing, sick or dead.
Electrical beings wired for empathy
There is a certain beauty in the electricity of the brain. While awake, a waxing and waning sinusoidal rhythm predominates from the back of the brain. During sleep, faster beta rhythms called spindles appear, as well as larger complexes over the centre of the brain called vertex waves.
In a seizure, the brain produces an electrical storm, sharp waves or spikes that can spread to the whole cortex. The sick brain tends to slow down. The anoxic brain, gone too long without oxygen, looks different. The EEG may show a “burst-suppression” pattern – where brain cells fire in fruitless overactivity, then fade again – or only flat lines. This is the intra-cerebral silence of brain death.
Seeing this is part of the job, and neurologists’ medical training instils in us a certain emotional detachment so we can look at unfortunate, but routine, results: an elderly man with the right side of his EEG slowed from a stroke, or a woman with dementia who is brain-dead after a heart attack. We are electrical beings, after all, and eventually, we run out.
Still, we’re also human, with brains wired for empathy, and sometimes I can’t help but feel the sadness radiating through the flat lines of these EEGs. The hardest ones are the unexpected cases: a toddler with a flat rhythm after two hours in a pool. A teenager with a low voltage slowing after hanging from a light fixture in her bedroom. Luckily, these cases are rare.
Brains ‘killing themselves for drugs’
But lately, thanks to America’s opioid crisis, the tragedies are coming at a faster pace. In New York state, where I practise, overdose deaths involving opioids ticked up from 1604 per 100,000 people in 2013 to 2185 in 2015. In 2010, the rate was less than half that.
[In Australia, the National Drug and Alcohol Research Centre reported that, in July this year, the rate of accidental deaths due to opioids has more than doubled among Australians aged 35 to 44 since 2007 with more than two-thirds of the deaths due to pharmaceutical opioids rather than heroin. In 2013, the last year for which finalised data is available, 597 Australians between 15 and 54 died from accidental overdose of opioids with 70 per cent being due to opioids other than heroin, including strong prescription painkillers. Initial estimates for 2014 and 2015 indicate that the number of accidental opioid deaths is continuing to increase. In a reversal of the heroin epidemic of the late ’90s and early 2000s, the 2013 figures show that accidental death related to opioid overdose is more likely to affect older Australians – those aged 35 to 54.]
In the US, the young make up a significant portion of those affected: in 2010, New York lost 858 people per 100,000 between 18 and 44 to opioid-related overdoses; by 2015, the number had risen to 1291. In the past five years or so, I have begun to see more burst-suppression patterns and flat waves not just in the elderly but in 24-year-olds, in 19-year-olds, in 15-year-olds. I’m seeing brain death in people who haven’t lived their lives yet, whose brains haven’t even fully developed, brains that are literally killing themselves for drugs.
Lethal pain killers
Neurologically speaking, opioids are crafty. They turn the brain’s own electricity against it, rewiring connections in an endless feedback loop for more drugs. They trick the brain into a death trap, as users chase the chemical bliss from the drugs with more drugs. Acute opioid usage (that is, the high itself) translates into slowing on the EEG. Usually, such an effect is transient, carefully monitored by an anaesthesiologist during surgery, for instance. But when the patient becomes the anaesthesiologist, the cycle can become lethal.
Opioids suppress pain, but they can also suppress breathing. If an overdose is caught in time, Narcan can reverse the effects, taking the toxin out of the system and awakening the patient. Otherwise, the opioids overwhelm the brain’s respiratory centre, causing cardiac arrest. Reviving a patient may restart the heart, but if the brain has been starved of oxygen, the brain machine no longer works. This is the opioid epidemic as seen through the screen of an EEG.
How can we ever stop this, when life is painful and these drugs literally kill pain?
I’m a neurologist, not an addiction doctor. I don’t pretend to have the training to treat these patients. I am just examining the brain damage after the fact, watching the waves slow down and go flat on the placid yellow of a computer screen. But even from kilometres away, I realise that those electrodes are attached to a scalp, to a head, to a person someone loved. A person like my colleague’s daughter.
Someday, we will have an answer. Someone smarter than I am will come up with a way to short-circuit the brain back to its native and wondrous electrical state, so it won’t crave the drugs that will kill it.
I await that day, when I won’t pull up so many young birthdays in my readings, watching waves that do not dance, witnessing only the flat lines of profound and final electro-cerebral silence.
This piece by Sandra Block was published on ‘The Sydney Morning Herald’, 11 December 2018.
Sandra Block is a novelist and a practising neurologist in New York State.