THE IMPACT OF TRAUMA ON SUBSTANCE ABUSE. Agnes Ward, PhD, LP, CAADC

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1 THE IMPACT OF TRAUMA ON SUBSTANCE ABUSE Agnes Ward, PhD, LP, CAADC

Event that includes physical, psychological, and sexual abuse, terrorism and war, domestic violence, witnessing violence against others, accidents and

2 Event that includes physical, psychological, and sexual abuse, terrorism and war, domestic violence, witnessing violence against others, accidents and natural disasters. Three clusters of symptoms: 1) Reexperiencing 2) Avoidance of reminders of the trauma and emotional numbing 3) Increased physiological arousal

3 DSM V does not separate abuse and dependence. Criteria are provided for substance use disorder, alcohol intoxication, alcohol withdrawal, other alcohol-induced disorders, and unspecified alcohol-related disorder.

4 Approximately 46.4% of people with PTSD meet criteria for one or more SUD. Individuals with these disorders demonstrate worse treatment outcomes, less improvement during treatment, increased legal problems, greater risk for experiencing violence, poorer social functioning, increased physical health problems, and higher rates of suicide attempts. Three models have been proposed for how PTSD- SUD co-morbidity can develop: Self-medication hypothesis Substance induced anxiety enhancement hypothesis Shared vulnerability hypothesis

5 Developed by the Centers for Disease Control. Provides retrospective and prospective analysis on the effects of traumatic experiences during the first 18 years of life on adolescent and adult medical and psychiatric disease, sexual behavior, healthcare costs, and life expectancy.

6 One of the largest investigations ever conducted to assess associations between childhood maltreatment and later life health and well-being. A population-based analysis of over 17,000 middleclass American adults undergoing comprehensive biopsychosocial medical evaluation. (ACEs) are stressful or traumatic experiences, including abuse, neglect and a range of household dysfunction (witnessing domestic violence, growing up with SA, MI, parental discord, or crime in the home. ACEs are strongly related to development and prevalence of a wide range of health problems, including substance use.

7 Abuse Emotional Physical Contact Sexual Abuse 7

8 Household Dysfunction Mother treated violently Household member was alcoholic or drug user Household member was imprisoned Household member was chronically depressed, suicidal, mentally ill, or in a psychiatric hospital Not raised by both biological parents 8

9 Neglect Physical Emotional

10 ACEs Are Common 2/3 of participants reported at least 1 ACE ACEs tend to occur in groups Of persons who reported at least 1 ACE: 87% reported at least one other ACE 70% reported 2 or more, More than half had 3 or more

11 Abuse Emotional 10% Physical 26% Sexual 21% Neglect Emotional 15% Physical 10% Household Dysfunction Mother treated violently 13% Mental illness 20% Substance abuse 28% Parental separation or divorce 24% Household member imprisoned 6%

12 As the ACE score increased the chances of being a user of street drugs, tobacco or having problems with alcohol abuse increased. Compared to persons with an ACE score of 0, those with an ACE score of 4 or more: were twice as likely to be smokers 12 times more likely to have attempted suicide 7 times more likely to be alcoholic 10 times more likely to have injected street drugs

13 As the Ace score increased, the risk of depression and alcohol abuse in adulthood increased regardless of parental alcohol abuse. As the Ace score increased, so did the risk of the number of prescriptions and classes of drugs used.

14 Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy

15 Since the launch of the initial ACE study in the 1980s, numerous other studies with different populations have been conducted with similar results.

16 Why does only a small percentage of persons exposed to addictive substances become compulsive users? The ACE study found that compulsive use of nicotine, alcohol, and injected street drugs increases proportionately to the intensity of adverse life experiences during childhood. At least half of traumatized individuals try to dull their inner world with drugs or alcohol.

18 Past trauma experiences trigger a trauma reaction in the brain, which causes the thalamus to interpret even small losses or rejections losing a shoe, being asked to do a chore, being denied a snack as a new traumatic event. Once the thalamus has interpreted the experience as a trauma, the amygdala shifts into overdrive. The amygdala has a disproportionate fear/emotional response to the experience and sends signals to the brain stem. The fight, flight, freeze response has been activated. Consequently, the individual gets a dose of cortisol and adrenaline. The reason is that the Prefrontal Cortex was skipped. The memories of this event can be foggy and stored erratically in the hippocampus. If the prefrontal cortex is involved at all, it may be after the crisis is over, when the individual thinks about what just happened.

19 EXPERIENCE creates EXPECTATION which alters PERCEPTION which SHAPES BEHAVIOR

20 Child sexual abuse in women attending a methadone treatment clinic has been found to range from 29% to 55%. A high rate of intimate partner violence has been found among women with a SUD and child sexual abuse history. Women who experienced child sexual abuse and adult sexual victimization had more PTSD symptoms than women who experienced child sexual abuse only. More of the women who experienced both types of trauma reported using drugs to cope (CSA&ASV 32%, CSA 10%).

21 Among individuals with cocaine dependence the following traumatic experiences were most common: Witnessing a death or serious injury Experiencing a disaster Experiencing physical assault Experiencing an accident Experiencing sexual abuse

22 More people die from tobacco use than HIV, illegal drug use, alcohol use, motor vehicle accidents, homicide, and suicide combined. Individuals who develop PTSD following a trauma are less likely to achieve remission from nicotine dependence. Anxiety sensitivity is elevated in smokers with PTSD and the motivation to smoke is related to reducing negative affect.

23 Approximately 55% of IPV incidents include alcohol consumption by the perpetrator and these incidents resulted in 12.6 billion per year in medical and judicial costs in the U.S. Between 1976 and 2002, 11% of homicides in the U.S. were committed by an intimate partner. IPV is more likely to occur and more likely to result in significant injury when the perpetrator has been drinking. Substance abuse is associated with increased rates of IPV perpetration in men and IPV victimization in women. Cocaine use evidenced the strongest relationship to psychological, physical and sexual aggression although marijuana use is also significant.

24 Women who have experienced IPV have shown an increased prevalence of drug and alcohol problems. A history of assault has been found associated with more than 2 times the risk of having an alcohol use disorder and more than 4 times the risk of having a drug use disorder.

25 Numerous Studies on the World Trade Center attacks on Sep.11, 2001 and studies on hurricane Katrina and Rita have indicated: Smoking behaviors increased (9.1%) Increase in drinking and hazardous drinking among Red Cross workers (3%-5%) Heavy episodic drinking was predicted by the number of traumatic events experienced related to 9/11.

26 Alcohol or drug abuse, smoking, or sexual promiscuity are likely the result of the effects of ACEs on childhood development (neurodevelopment). The behaviors may act as a short-term solution to alleviate the emotional or social distress caused from ACEs but have detrimental long term effects. These individuals are at higher risk for health and medical conditions resulting from their choices of remedies for their pain.

28 Findings from the ACE study indicate that: Adverse childhood experiences are surprisingly common, although typically concealed and unrecognized. ACEs have a profound effect 50 years later, although they are transformed from psychosocial experience into organic disease, social malfunction, and mental illness.

29 Research has demonstrated a strong relationship between ACEs and: Problem drinking behavior into adulthood Increased likelihood of early smoking initiation Continued smoking, heavy smoking during adulthood Prescription drug use Lifetime illicit drug use, ever having a drug problem, and self-reported addiction

31 The ACE study s findings imply that addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal life experiences, many of which are hidden by shame, secrecy, and social taboo. It is an attempt to gain relief from well-concealed prior life traumas by using substances. Because it is difficult to get enough of something that doesn t quite work, the attempt is ultimately unsuccessful.

32 Individuals with a substance use diagnosis relapse at greater rates when they also continue to have the diagnosis of PTSD. An integrated approach to treatment addressing SUD and PTSD has been found more likely to succeed, more sensitive to clinical needs, preferred by patients, and more cost-effective. Clinicians need to be able to conceptualize how each disorder affects the other and how to engage in strategies to address each without worsening the other.

33 Integrated Cognitive Behavioral Therapy Seeking Safety & Creating Change Medications for PTSD such as the SSRIs Prozac, Paxil, and Zoloft in combination with Revia,Vivitrol, or Antabuse have shown efficacy Significant Other-Enhanced CBT is undergoing evaluation Concurrent treatment for PTSD and cocaine dependence (CTPCD) Substance dependent PTSD therapy Exposure therapy

34 Present focused treatments have been more appealing, than past focused, but both were viewed as useful for PTSD-SUD. A note about treating clinicians: Clinicians who rate PTSD-SUD clients as most challenging to treat are those who work in a mental health setting, have no personal trauma history, no personal history of SUD, with a PhD, with lower allegiance to a 12-step orientation, older clinicians, and those who find clinical work less stimulating.

35 THANK YOU! Questions?

Anda, R.F., Brown, D.W., Felitti, V.J., Dube, S.R., Giles, W.H. (2008). Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC Public Health, 4(8),198.

36 Anda, R.F., Brown, D.W., Felitti, V.J., Dube, S.R., Giles, W.H. (2008). Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC Public Health, 4(8),198. Anda, R.F., Whitfield, C.L., Felitti, V.J., Chapman, D., Edwards, V.J., Dube, S.R., Williamson, D.F. (2002). Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatric Services, 53(8), Coffey, S. et al. (2016). Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: a randomized controlled trial. Psychology of Addictive Behaviors, 30(7), Najavits, L.M., Hyman, S.M., Ruglass, L.M., Hien, D.A., & Read, J.P. (2017). Substance use disorder and trauma. In S.Gold, J. Cook, & C. Dalenberg (Eds.), Handbook of trauma psychology (pp ): American Psychological Association. SAMHSA. (2013, March 6). Adverse childhood experiences: risk factors for substance abuse and mental health. Retrieved from Sheerin, C. et al. (2016). A population-based study of help seeking and self-medication among trauma-exposed individuals. Psychology of Addictive Behaviors, 30(7), TEDI BEAR Children s Advocacy Center. (2011, July 11). Personal and parental reflections on adverse childhood experiences. Retrieved from TEDI BEAR Children s Advocacy Center. (2015, May 28). Wounds that won t heal. Retrieved from Quimette, P., & Read, J.P. (Eds). (2014). Trauma and substance abuse: causes, consequences, and treatment of comorbid disorders (2nd ed). Washington, D.C.: American Psychological Association.

37 Van der Kolk, B. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. New York, New York: Penguin Books Vujanovic, A., Bonn-Miller, M., & Petry, N. (2016). Co-occuring posttraumatic stress and substance use: emerging research on correlates, mechanisms, and treatments-introduction to the special issue. Psychology of Addictive Behaviors, 30(7), Zanberg, L.J., Rosenfield, D., McLean, C.P., Powers, M.B., Asnaani, A, & Foa, E.B. (2016). Current treatment of posttraumatic stress disorder and alcohol dependence: predictors and moderators of outcome. Journal of Consulting and Clinical Psychology, 84(1),

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