Several years ago, a colleague asked me what I thought about his “four months and done” buprenorphine treatment program. He believed that virtually all people with opioid use disorders could “learn” how to stay drug-free in that time. All his patients were titrated to an effective dose in the first weeks, maintained for the first two months, and tapered off over the next two months. He offered anecdotal evidence of success of his approach, but it became clear that most of those he tapered simply disappeared. He had no meaningful data, even in the short term. I asked him whether he took a trauma history when his patients initially presented, and it was clear that he had no idea what I was talking about.
I am an individual in recovery as well as a treatment professional, and I have treated tens of thousands of patients with addiction. Most of those patients, when questioned, had a history of serious early-life trauma, or of such significant neglect that it was the equivalent of trauma. Yet, as little training as I received in medical school and residency about substance use disorders, there was even less on the role of trauma. This was true in my addiction fellowship as well. I have reviewed scores of intake forms for treatment programs, and only in the last several years have I seen questions about traumatic experiences routinely asked. I was involved in an audit of an internal medicine practice which was concerned about the overprescribing of opioids and benzodiazepines by “outlier” physicians. They had an excellent electronic medical record that had a section on early-life trauma. Out of hundreds of charts reviewed, however, this section was not completed for even one patient.
The current epidemic of prescription opioid use—now the leading cause of accidental death in young people—spotlights the tragedy that resulted from making opioids much more available than previously. Among those who misuse these substances (though they may have initially taken them as prescribed), are large numbers of people with early-life trauma. My experience assessing patients in this new population who progressed to addiction confirmed for me that early-life trauma is no less an antecedent of addiction for them than it was for my traditional population of heroin users.
Studies have shown, just as my clinical observations have shown, that up to 90 percent of patients who present for the treatment of addiction, particularly women, have a history of trauma, usually recurrent, that involved physical, emotional, and sexual abuse, often perpetrated by caregivers or other trusted individuals in their lives. More recent studies have also shown that such trauma more often progresses to PTSD, depression, and substance use disorders when the abused person represents a “fertile field” – that is, the individual is more vulnerable to those consequences due to a lack of protective factors often termed “resilience,” which itself is partly a reflection of early-life nurturance. This is comparable to combat-related trauma, where multiple individuals may experience the same terror in battle, but only a fraction of them develop PTSD and/or substance use disorders.
All health care workers, not just addiction program intake workers, mental health clinicians and addiction medicine/psychiatry physicians, need to integrate information about both traumatic experiences and resiliency factors whenever they assess a patient. At present, only 10 to 20 percent of individuals with substance use disorders receive professional treatment. But nearly all individuals who later develop substance use disorders will have seen medical professionals at some point in their childhood, adolescence, and adult life. If their history of trauma had been identified and addressed then, they might have been at lower risk for subsequent substance misuse and addiction. Therefore, in addition to promoting SBIRT (screening, brief intervention and referral to treatment) to all clinicians in general practices and emergency departments, we must promote the adoption of trauma screening and effective treatment of trauma.
A considerable proportion of our treatments for addiction are both generic and effective – detoxification, recovery education, cognitive behavioral therapy (CBT), motivational enhancement, and use of 12-Step and other mutual help programs (SMART Recovery, LifeRing Secular Recovery and others). We must add specific trauma-focused care if most of those we wish to help are to avoid frequent relapse and attain a stable and sober life.
Trauma-focused care, often in groups of individuals with similar traumatic events, has been repeatedly shown to be more effective than “treatment as usual.” Specialized treatments, such as Eye Movement Desensitization and Reprocessing (EMDR), specific forms of CBT such as Dialectic Behavioral Therapy (DBT), and specific forms of mindfulness therapy such as Acceptance and Commitment Therapy (ACT) can be particularly effective in individuals with histories of trauma. Whether or not individuals with trauma and addiction meet criteria for other psychiatric disorders (such as PTSD, other anxiety disorders, or major depressive disorder), they are prone to recurrent relapses if their trauma has not been addressed. They keep returning to substances such as opioids, alcohol, benzodiazepines, and cannabis to temporarily relieve their symptoms.
Treatment of trauma can be time-consuming and costly, but it is clearly cost-effective. Its value is under-appreciated, however, by healthcare providers and other stakeholders, including insurers. The United States lags other developed nations, such as the United Kingdom, in recognizing and managing the consequences of early-life trauma. In this country, we have made too few efforts at prevention, either primary or secondary, in terms of teaching effective parenting, reducing unwanted pregnancies in vulnerable populations, and training pediatricians and other professionals working with children and adolescents in the early recognition and treatment of childhood trauma. And not all treatments are costly. For example, there are promising research findings that simple interventions, such as starting a beta blocker at the time of a single traumatic event, may lessen the ultimate impact of the experience.
To reduce the human and dollar costs of addiction in America, this Nation must make the prevention, recognition, and treatment of early-childhood trauma a priority. Professionals in the field of addiction are positioned to champion solutions to other professionals and the public. We can highlight—to clinicians in primary care, nursing, dentistry, and other practices—the importance of screening all patients for early-life trauma and exercising great care in prescribing to these at-risk individuals. We can urge all concerned to advocate for additional funding to support related research and improve access to prevention and treatment. We can promote education on this topic for educators, government officials, healthcare administrators, healthcare regulators, and others including officials in the correctional system.
Individuals who were abused, particularly physically and/or sexually, are not only more vulnerable to psychiatric and substance use disorders, but a fraction of this group are also at higher risk for traumatizing others. So, treating trauma—like treating addiction—helps protect the next generation.
All of us have a stake in the resolution of this problem. What will we do?
Alan Wartenberg, MD
NCADD Medical-Scientific Committee