Advanced Issues In Trauma- Informed Care Looking at the Connection between Trauma and Opioid Addiction DISCLOSURE OF COMMERCIAL SUPPORT This program has not received financial support This program has not received in-kind support Potential for conflict(s) of interest: - None 1
FACULTY/PRESENTER DISCLOSURE Faculty: Dr. Pamela Stewart Relationships with commercial interests: None None MITIGATING POTENTIAL BIAS 2
An Epidemic In the News 3
Affects Health Care But are we missing a vital link? 4
Goals and Objectives Definition of Trauma-Informed Approach The statistics linking trauma and opioid use Neurobiological Considerations Looking at other models? Overview of Definitions A review 5
Definition of Trauma Trauma results from an event, series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual s functioning and physical, social, emotional or spiritual well-being. Traumas can affect individuals, families, groups, communities specific cultures and generations It generally overwhelms an individual s or community s resources to cope and it often ignites the fight, flight, or freeze reaction at the time of the event 11 Trauma Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic For most, regardless of the severity of the trauma, the immediate or enduring effects of the trauma are met with resilience -the ability to rise above the circumstances or to meet the challenges with fortitude SAMHAS (2014) 12 6
Trauma Trauma is a dehumanizing experience, one in which those subjected to it are reduced to the status of objects, the victim of someone else s rage, nature s indifference, misfortune or misadventure. It involves being plunged into a state of helplessness and dissociation can be a powerful means of maintaining mental control at a time when physical control is lost. Dissociation, the dis-integration of consciousness, memory, emotion and somatic experience, can buffer the experience of trauma. (Spiegel, 2015) So what is trauma-informed? A trauma-informed approach includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations Involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic 14 7
SAMHAS (2014) THREE KEY ELEMENTS Realizing the prevalence of trauma Recognizing how trauma affects all individuals involved with the program, organization or system, including its own workforce Responding by putting this knowledge into practice 15 Trauma-Informed Care A strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma That emphasizes physical, psychological and emotional safety for both providers and survivors That creates opportunities for survivors to rebuild a sense of control and empowerment It involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma 16 8
Trauma-Informed Care (continued) It upholds the importance of consumer participation in the development, delivery and evaluation of services 17 Trauma-Specific Services Evidence-based and promising practices that facilitate recovery from trauma Refer to prevention, intervention or treatment services that address traumatic stress as well as any co-occurring disorders that develop during or after trauma 18 9
Recognition of Adaptive Strategies Shifting the mindset from pathology to resilience A Mindset that views clients presenting difficulties, behaviors, and emotions as responses to surviving trauma View traumatic stress reactions as normal reactions to abnormal situations Begin relationships with clients from a hopeful, strength-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self=preservation and determination 19 Agency Strategies Universal screening and assessment procedures for trauma Interagency and intra-agency collaboration to secure trauma-specific services Referral agreements and Networks to match clients needs Mission and value statements endorsing the importance of trauma recognition Consumer and community-supported committees and trauma response teams Workplace development strategies, including hiring practices 20 10
Strategies (continued) Professional development plans, including staff-training/supervision Program policies and procedures that ensure trauma recognition and secure traumainformed practices, trauma-specific services and prevention of retraumatization 21 Retraumatization: agency/staff level Being unaware that the client s traumatic history significantly affects his or her life Failing to screen for trauma history prior to treatment planning Challenging or discounting reports of abuse or other traumatic events Using isolation or physical restraints Experiential exercises that humiliate the individual Endorsing a confrontational approach 22 11
(continued) Allowing the abusive behavior of one client toward another to continue without intervention Labeling behavior/feelings as pathological Failing to provide adequate security and safety within the program Limiting participation of the client in treatment decisions and planning processes Minimizing, discrediting counselor-client relationships by changing counselors schedules/assignments Obtaining urine samples in a nonprivate setting 23 What does that mean for your practice competencies? A trauma-informed clinician is one who is: 1. Informed about the prevalence of trauma in their client population 2. Informed about the effects of psychological trauma 3. Able to assess for the presence of symptoms/problems related to that trauma 4. Able to validate the client s experience of trauma, and how it links to their addictive behavior 5. Able to offer service to facilitate recovery; and if not, to recognize what is outside their scope of practice, and make the appropriate referral 24 12
Decreasing the Risk of Secondary Trauma Peer Support Supervision and Consultation Training Personal Therapy Maintaining Balance Setting clear limits and boundaries with clients 25 Epidemiology of PTSD Not all traumatic events lead to PTSD A third of children with verified child abuse (sexual, physical, neglect) developed PTSD in Widom (1999). Women more susceptible to developing PTSD than men National Comorbidity Study (Kessler, 1995) found lifetime prevalence of PTSD 10.4% in women, vs. 5.0% in men. Trauma exposure reported as 51.2% in women vs. 60.7% in men. 13
Co-morbidity of Substance Use in PTSD samples (1) Cottler et al. (1992) (used ECA Survey (Regier et al) sample of 2943 participants): Of those with history of PTSD, the lifetime prevalence for substance use disorder was found to be 30%-75% (2) National Comorbidity Survey (Kessler et al, (1995) used DSM-III-R (sample of 5877): Of those that with history of PTSD, 51.9% had alcohol abuse, 34.5% had drug abuse In Men 27.9% had alcohol abuse, 26.9% had drug abuse in Women PTSD preceded SUD in the majority of cases 27 Co-morbidity of PTSD in Substance- Abusing samples Lifetime rates of PTSD range from 30-75% Current rates range from 12%-62% (Brady et al, 2001; Jacobsen et al, 2001; Najavits et al, 1997): 20-33% of patients with SUD seeking treatment meet criteria for current PTSD (Back et al, 2000; Brown, Recupero, & Stout 1995; Najavits et al, 1998; Triffleman,Marmar, Delucchi & Ronfeldt, 1995) 28 14
Prevalence (continued) Prevalence of trauma histories among people receiving substance use treatment is estimated between 25 and 90% (Bonin et al, 2000, Mills et al, 2005, Najavits et al. 2003; Ouimette et al. 2000, Wu et al, 2010) 29 Ontario Health Study Separate and cumulative effects of adverse childhood experiences on adult health (Chartier et al, 2010) N=9953 age 15 and older (1990-1) ACE events were childhood physical and sexual abuse, parental marital conflict, poor parent-child relationship, low parental education and parental psychopathology CSA and Physical Childhood abuse most predictive of poor health outcomes in adulthood 15
Adverse Childhood Experiences Study Cohort study at Kaiser Permanente which sent surveys to enrolled members during a defined time period Total number of participants about 17000 Asked about a range of Adverse Childhood Experiences For each yes answer given 1 point Points added for ACE score Felitti et al., 1998; www.acestudy.org Adverse Childhood Experience (ACE) study http://www.cdc.gov/ace/pyramid.htm 16
ACE Study: Measures and response Questions asked about: Emotional abuse 11% Physical abuse 28% Sexual abuse 21 % Emotional neglect 15% Physical Neglect 10% ACE Study: Measures and response Mothers being treated violently 13% Mentally ill parent 19% Substance use by someone in the home - 27% Experienced parental separation or divorce 23% Parental incarceration 5% 17
ACE study findings: the risk for the following health problems increases in a strong and graded fashion: 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 http://www.cdc.gov/ace/findings.ht m Higher risk, with higher ACE scores 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 http://www.cdc.gov/ace/findings.htm 18
ACE Score and Intravenous Drug Use N = 8,022 p<0.001 http://www.theannainstitute.org/presentations.html Canadian Statistics 19
Health Canada Phone interviews 11,090 respondents Opioids>Stimulants/Sedatives 16.9% reported use within 12 months 5.7% reported abusing them BC Centre For Excellence in Women s Health 20
Opioid Abuse Gender: possible stress sensitization effects in women predicted disorder stimulant and opiate use among women (Myers, 2014) Prescription opiate group reported a younger age of first traumatic event then the cocaine group and more likely to report childhood traumatic events than cocaine/nicotine groups Lawson, 2013) Opiate users were 2.7 times more likely to have a history of CSA/physical abuse (Huffernan et al) NAOMI STUDY (North American Opiate Medication Initiative) 62.6% of the participants reported emotional abuse 43% reported physical abuse 19.5% sexual abuse (Krausz et al, 2013, Oviedo-Joekes et al, 2008) 21
Program Retention 7.7 fold risk of discontinuation in methadone maintenance if cortisol levels were abnormal (Jaremko, 2014) In Buprenorphine populations, physical/emotional neglect histories predicted early dropout (Kumar, 2016) Fear and the brain 22
DeBellis 2001 23
Substance use and stage 1 trauma treatment Stages of trauma treatment (Herman) Stage 1 Safety Stage 2 Remembrance and Mourning Stage 3 Reconnection General agreement, though some propose more stages (ex. 5-8). Stages are a guide to treatment and understanding. Staging of Trauma Therapy Stage 1 Stage 2 Stage 3 Stages are not linear, as we often need to revisit previous stages as we move forward. 48 24
The first task of recovery is to establish the survivor s safety. This task takes precedence over all others, for no other therapeutic work can possibly succeed if safety has not been adequately secured (Herman, 1992, p. 159) A safe physical environment-one that has building security, good lighting, and quiet rooms or other spaces-is one of the components of a trauma-informed agency (Brown, Harris & Fallot, 2013) 25
Stage One Trauma-Informed Safe Injection Sites 26
Naloxone Kits What can we learn from Other Approaches The literature on restraints and seclusion (Janice LeBel, Trauma Talks 2016) 27
Janet LeBel 2016) (LeBel continued) 28
Changing Our Environment 29
Seeking Safety Best evidence for group treatment for concurrent PTSD and Substance Abuse, developed by Lisa Najavits www.seekingsafety.org Performs better than treatment as usual (generally substance treatment alone) on both PTSD and SUD measures Fairly easy to learn and designed for wide dissemination. Najavits, 2002. Combining Approaches Friendly, environments with light and bright colours Making the links between trauma and addiction Grounding strategies as part of the assessment Making the client part of the decision-making at all levels 30
Questions? Comments? Feedback? 31