Adverse Childhood Experiences: Effects on Health and Well-being. Opioid Use Disorder in Primary Care November 23, 2018 Meredith MacKenzie, MD

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2 Adverse Childhood Experiences: Effects on Health and Well-being Opioid Use Disorder in Primary Care November 23, 2018 Meredith MacKenzie, MD

3 It is easier to build strong children than to repair broken men. Frederick Douglass ( )

5 Most Important Study in Medicine: Adverse Childhood Experiences (ACEs) Study ACEs are the main determinant of health and social well-being of all peoples ACEs impact access to health and social services

6 ACEs STUDY HISTORY: Accidental Question

8 Mr C: 58 yo man 4 older siblings and 1 twin sister Father and mother both with alcoholism Mother with depression Witness of IPV to mother Fought to protect twin sister vs violence Beaten by father with belt Parents separated Father incarcerated

9 Mr C: OUD, on opioid agonist therapy Amphetamine substance use disorder Smoker Multiple fractures, including recent fractured hip HCV + Multiple soft tissue infections Homelessness

10 Mr C: Removed from home age 7 ( unmanageable ) Placed into training schools Abused at every training school (physical/sexual/emotional) Ran away from homes many times Started using substances at age 12 Incarcerated several times

11 ACEs Predict Future Health and Social Well-being: ACEs are common ACEs don t occur in isolation Dose response relationship

12 Spokane, Washington 2012 ACEs 3+ have: 3x rate of Academic failure 4x Frequently reported poor health 5x Severe attendance problems 6x Severe school behaviour concerns

13 ACEs and Violence: Boys that experienced sexual abuse: By family member: 45 x more likely to engage in dating violence By non-family member, 26x more likely to engage in dating violence (Duke, 2010) ACEs increase chances that youth will be involved in juvenile justice system (Baglivio, 2014)

14 ACEs and Incarceration: Adult male sex offenders: 3x more likely to have history of sexual abuse as children (Jespersen, 2009) Men with ACEs=3 (physical abuse, sexual abuse, mother treated violently: Male offenders in the US: increased risk of IPV (Whitfield, 2003) 50% report physical abuse 30% report sexual abuse Have higher ACE scores than the community (Levenson, 2013)

people experience worse health outcomes compared to other

15 Indigenous Peoples: 13 x more likely to die compared with Canadians of same age 18 x if used injection drugs Indigenous people experience worse health outcomes compared to other Canadians due to ongoing and historical structural violence (eg colonialism, racism)

16 ACE SCORE OF 4+ INCREASES RISK OF OBESITY 160% FRACTURE: 160% DIABETES 160% Any CANCER 190% HEART DISEASE 220% SMOKING 220% HEPATITIS 240% STROKE 240% STI S 250% COPD 390% DEPRESSION 460% ILLICIT DRUG 470% ALCOHOLIC 740% INJECTED DRUG 1,000% SUICIDE ATTEMPTS 1,200% Male with ACE of 6+: IDU 4,600% Die 20 years earlier homelessness Treatment of chronic diseases account for 67% of direct health care costs in Canada (68B treatment, 122B lost productivity total $190B)

17 ACEs: Suicide: IN ADULTS: 64% of suicide attempts were attributable to ACEs IN CHILDREN and ADOLESCENCE 80% of suicide attempts were attributable to ACEs Economics: $124 B total lifetime costs with just 1 year of confirmed child maltreatment cases CDC study: The Economic Burden of Child Maltreatment in the United States and Implications for Prevention

18 What is Mr C s ACE score? ABUSE: Physical Emotional Sexual NEGLECT: Physical Emotional HOUSEHOLD DYSFUNCTION: Mother and Father with alcoholism Mother treated violently Mother with depression Father incarcerated Parents divorced SCORE: 10/10

19 Mr C s ACE related health consequences: Smoking Depression Suicidality Substance use IVDU HCV Fractured bones School Failure Incarceration

20 Disrupted Attachment: Baby Has a Need Trust Develops Baby Cries Caregiver Meets Need

21 Healthy Attachment: requires adults: Safe Predictable Available Results in: higher self-esteem more self-efficacy will seek out social supports will be able to share their feelings more easily MacKenzie, 2018

22 Avoidant/Disorganized/Ambivalent Attachments: Emotional dysregulation Difficulty with relationships Challenges with boundaries Anger, rage, fear, sadness Reduced self-efficacy

23 Adverse Communities: Mr C Lives alone Not a lot of visitors Difficulty securing safe, adequate housing

24 Adverse Communities:

25 Brain Structure and Function: air traffic control =PFC Judgment Inhibitory control Decision making Organizing Planning, Learning, Memory Behaviour control navigating social situations Personality Emotional regulation MacKenzie, 2018

26 Brain Structure and Function: LIMBIC SYSTEM Amygdala- smoke alarm ; F/F/F INTERGENERATIONAL TRANSMISSION-epigenetics

27 PARADIGM SHIFT: When you know about your client/student/patient s experiences and the changes that occur in the body & brain: what is wrong with you?! becomes what has happened to you? And, what is it like to live where you live?

28 Knowing about ACEs changes what people believe about themselves They weren t born bad They are not responsible for the things that happened to them when they were children Their coping was adaptive kept them alive. They can heal neuroplasticity

29 KP Bio-social-physical health assessments: Protocol: 440,000 patients Asking about childhood trauma reduced ED visits by 11 % Could you tell me how these things have impacted you later in life? And we listened, period Patients told us that they had told their darkest secret of their life to the doctor and the doctor was still nice to them, and wanted to see them. The act of listening and acceptance turns out to be a previously unrecognized, remarkably powerful tool

30 THE WAY FORWARD: Enhancing Equity with PARTNERSHIPS Addiction & Mental Health Child and Family Services Health Care Indigenous Peoples Equity Oriented Care Education System Workplaces Public Health Military/First Responders Justice System Housing

31 Partnerships: Reduce Barriers to Equity: poverty homelessness or unsafe housing historical adversity (ACEs) ongoing interpersonal violence various forms of racism stigma (substance use, mental illness, nonconforming gender identities) ongoing colonization of Indigenous peoples Focus: Awareness of widespread nature of trauma and its effects Integrate knowledge into policies, procedures, practices with priority on survivors : Safety, Empowerment, Strengths Move from Reactive to Preventive

32 QUESTIONS?

33 References: Alexander, B. The Globalisation Of Addiction: A Study In Poverty Of The Spirit. Oxford University Press ISBN Baglivio, Michael T.; Epps, Nathan; Swartz, Kimberly; Sayedul Huq, Mona; and Sheer, Amy. (2014). The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders. Journal of Juvenile Justice 3:2. Retrieved from Duke N.N., Pettingell S.L., McMorris B.J., Borowsky I.W. Adolescent violence perpetration: Associations with multiple types of adverse childhood experiences. Pediatrics. 2010;125:e778 e786. doi: /peds Equip Health Care: Franke, H. A. (2014). Toxic Stress: Effects, Prevention and Treatment.Children, 1(3), Jongbloed K et al. The Cedar Project: mortality among young Indigenous people who use drugs in British Columbia. CMAJ 2017 November 6;189:E doi: /cmaj Levenson, J. (2013). Incorporating Trauma-Informed Care into Evidence-Based Sex Offender Treatment. Journal of Sexual Aggression, Doi: / Nurius PS, Green S, Logan-Greene P, Longhi D, Song C. Stress pathways to health inequalities: Embedding ACEs within social and behavioral contexts. International public health journal. 2016;8(2): Robins, L. N., Helzer, J. E., Hesselbrock, M. and Wish, E. (2010), Vietnam Veterans Three Years after Vietnam: How Our Study Changed Our View of Heroin. The American Journal on Addictions, 19: doi: /j x

34 References: Schindler A., Thomasius R., Petersen K., Sack P. M. (2009) Heroin as an attachment substitute? Differences in attachment representations between opioid, ecstasy and cannabis abusers. Attachment & Human Development 11(3): Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. doi: /peds Squeglia, L. M., Jacobus, J., & Tapert, S. F. (2009). The Influence of Substance Use on Adolescent Brain Development. Clinical EEG and Neuroscience : Official Journal of the EEG and Clinical Neuroscience Society (ENCS), 40(1), Volkow, N. D., & Goldstein, R. Z. (2011). Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Nature Reviews Neuroscience, 12(11), doi: /nrn3119 Weeks, R., & Widom, C. S. (1998). Self-Reports of Early Childhood Victimization among Incarcerated Adult Male Felons. Journal of Interpersonal Violence, 13(3), Doi: / Whitfield CL, Anda RF, Dube SR, Felitti VJ (2003a) Violent childhood experiences and the risk of intimate partner violence in adults: assessment in a large health maintenance organization. J Interpersonal Violence 18:

35 Resources: Indigenous Cultural Safety Course: Equity Oriented Health Care: ACEs Community of Practice: ACEs information:

36 Resources: Trauma and the Brain, Brain Story Certificate: Mindfulness for Elementary School Students (UBC): CDC Technical Packages for Violence Prevention:

What nurses need to know about Trauma-Informed Care

What nurses need to know about Trauma-Informed Care Define trauma-informed care Identify how to assess for trauma Tap in to resources for these patients and their families Kaiser Permanente,1995-1997