Trauma-Ignored Care? Going to the MAT on Opioids

Wayne Munchel
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Medication Assisted Treatment (MAT) for opioid addiction is being vigorously touted and expanded across the country in response to the opioid crisis. The Substance Abuse Disorder treatment system is taking a page from the bio-medical model of disease that asserts that addictions are lifelong, incurable brain disorders that require long-term (with no exit strategy) treatment with medications (buprenorphine, methadone, naltrexone). Similar to the current bio-psychiatric, decontextualized approach to mental distress, this strategy overlooks and minimizes the significant role of trauma, toxic stressors and social determinants in driving the alarming rate of opiate-related death and devastation. Trauma-Informed Care (TIC) offers a critical, missing ingredient.

Recently the Campaign for Trauma-Informed Policy and Practice (CTIPP) issued a report: “Trauma and ACEs missing in response to opioid crisis.” The research establishing the clear nexus between trauma and substance abuse is compelling. Studies reveal a strong dose-dependent relationship between the number of traumatic experiences and prescription drug misuse. Opioid dependent individuals report much higher rates of ACEs than the general population. 80% of people seeking treatment for opioid addiction have experienced at least one form of trauma. The trauma-informed lens refocuses our questions from “why the addictions?” to “why the pain?” To be clear, not all people who develop addictions have been traumatized, nor do all traumatized people abuse substances.

Our current, reductionistic approach to mental health issues doesn’t offer any insights or explanations on the etiology of most mental disturbances. Similarly, MAT focuses on the surface symptoms of opiate abuse without addressing the underlying causes of overwhelming distress and pain. Defining addiction as so much damaged neural circuitry creates the same intellectual cul-de-sac that our current pill-for-every-ill treatment strategy for “mental Illnesses” remains stuck in. This myopic paradigm is so rigidly impermeable that when additional symptoms are reported and observed, they are immediately categorized as an additional disease, a “dual disorder.” Two distinct, separate brain diseases are now diagnosed and medicated. A more trauma-informed viewpoint would suggest that they are neither dual, nor disorders. They are both responses and reactions to the same devastating traumatic experiences — evincing normal adaptations to abnormal events.

Imagine someone has the misfortune of being severely beaten and suffers several injuries. The DSM and ASAM (American Society of Addiction Medicine) approach would label the swollen lip as a genetically predisposed lip disease that has been triggered, AND also diagnose the “co-morbid” black eyes as an additional, separate disorder. (Occam would throw away his trusty razor in disgust.) The trauma inflicted by the assault is largely unacknowledged and ignored. Just treat the wounds and numb the pain indefinitely, as if they arose in a vacuum. Also don’t consider the victim’s need for safety and justice, for social support and perhaps a Neighborhood Watch. In America, we prefer to locate problems in our children’s skulls, not in their schools and families — in our neurons, not in our neighborhoods. The medical model of treating addiction not only misses the forest for the trees, it misses the trees for the leaves.

A robust trauma-informed approach widens the lens and extends the compassionate curiosity of “what happened to you?” It can instill a vital sense of hope by affirming that what can be hurt can be healed. Integrating TIC into our substance abuse treatment system can improve upon the current poor retention rates by ensuring that people’s stories are heard and understood. These simple, non-technological acts of listening and empathizing can be deeply healing in and of themselves. (Doctors and other health care providers are often trapped working in rushed, insurance-driven practice settings that afford little time to listen and empathize.) Taking pills to relieve pain and discomfort while avoiding difficult lifestyle choices is our culture’s preferred coping methodology. TIC presents more difficult options that require hard work and perseverance, but that hold the promise of sustainable recovery.

At a more macro level, trauma-informed strategies recognize that we will not be able to effectively beat back the scourge of opioid addiction without addressing the prevalent loneliness, isolation, poverty and unemployment in our increasingly atomized communities. While we must continue the downstream rescue efforts to pluck people from this historic flood, we must also ask the discomforting questions of what forces are pushing so many into the raging waters upstream? Following the dictum that “what can be predicted can be prevented” suggests that asking about ACEs could direct our attention toward the most at-risk among us and preventative measures.

Studies indicate that MAT can be a crucial harm-reducing lifesaver (decreases death rates by 50%) for many people struggling with opiate addictions, especially early in treatment and in the short term. But is this a viable long-term strategy? Surely, we can do better by providing a taper plan supported by intensive teaching of other self-regulation and distress tolerance methods to gradually replace the opiates. An integrated, balanced approach of medical, psychosocial and spiritual options appears necessary. As in the mental health field, the egregious over-reliance on more “magic bullets” promoted by Big Pharma remains a seductive lure that threatens to distort any modicum of balance.

The epidemic of opiate abuse and addiction was facilitated by a (often well-intentioned) campaign to treat pain as the “5th vital sign.” In integrated health care, we should consider taking ACEs scores (and/or other trauma assessments) as the 6th vital sign that may illuminate: why the pain?

30 COMMENTS

  1. You give MAT too much credit in saying it is associated with a 50% lower mortality rate. That just means that addicts who stayed on it died less often. But what about all the people who were not yet an opioid addict, but were lured into becoming one by suboxone-dealing doctors, then moved up from this gateway drug to heroin, and then dropped out of “treatment” and died of overdoses? They are not included in statistics of deaths of people who stayed in MAT, even though their deaths were caused by MAT. And what about all the street drug dealers who claim they are heroin addicts in order to get suboxone from suboxone-dealing doctors, so they can sell it on the streets where it has high value? These street drug dealers, if not addicts themselves, won’t overdose, and thus their statistics will misleadingly make MAT seem safe. Yet many of the clients they illegally sell suboxone to, will move up to heroin habits that will kill them, and their deaths, despite being also caused by MAT, will not be included in these studies’ MAT-associated death statistics.
    Clearly there is nothing well-intentioned about MAT. It is nothing more than the medical field’s getting even more into the drug-dealing business than it already was (and finding a way to adapt to it becoming somewhat harder for MDs to deal unlimited opioids for “chronic pain” in recent years). After all, about 13 million suboxone-type prescriptions are dispensed yearly, even though there are only about 2 million opioid addicts, most of whom are not in “treatment”. And the heroin epidemic accelerated ever since suboxone started to be widely dispensed. So suboxone’s rising use is likely actually a major contributor to the national opioid crisis.

    • Lawrence,
      As a recovering addict, I both agree and disagree with your reply. The first time I tried to get clean, it was through a week-long outpatient program where they gave us buprenorphine for the first 3 days, along with clonidine, ibuprofen and an antidiarrheal. They suggested we attend meetings as well. I stayed clean for that week. There was no follow-up, so there was no good reason or support to stay clean.
      Oh, first, a question, if you don’t mind? Are you a recovering addict? Do you have mental health problems? I ask because over and over through my recovery(I’ve been off illegal opiates for 12 1/2 years now) I’ve had doctors, counselors and therapists with little to no personal experience with either. That’s extremely frustrating.
      So my point is I was on Methadone Maintenance therapy for 12 years. It took 2 1/2 years of being on Methadone for me to finally stop using. This was also while doctors were throwing various psychiatric medications at me to try and balance out my severe depression and anxiety. Seven years ago, I finally went and had 14 rounds of ECT, which many people find barbaric, but it saved my life. After getting my mental health under control, I tried getting off methadone in a very slow taper. Every time I’d get below 30 mgs, I’d want to run back downtown. This was horrible because I was truly done with being on Methadone. It messed my memory up way worse than the ECT. So a bit over 3 years ago, I switched to Suboxone. I feel alive taking it and don’t want to use. How is that a bad thing? I would like to get off of Suboxone eventually but if I can’t, in my mind, it’s better than the alternative. I’m sure you’ve heard stories like mine before but I’m just curious what doctors think of they’ve no experience firsthand with addiction or mental health or the two combined.
      If you could tell me how you can presume what it’s like when you haven’t been through it, I’d be really happy.
      Thank you for your time!

  2. Drugs aren’t the best way to deal with people on drugs, or off drugs for that matter. Duh. I don’t think trauma any better of an explanation for ‘psychic turmoil’, let us say, than genetics, and I dispute both. Trauma theory is popular these days, no doubt about that, but I hope sometime soon maybe somebody can imagine a third way for us to get beyond it. Need I add, there are a lot of people who are not getting beyond it. In that sense, trauma theory can serve, much like drug induced debility, as a disincentive to recovery.

  3. Graffitiwoman:
    You are right that I was being presumptive, and I will try not to do that when commenting in the future. I think I also was not too clear about what I was referring to. I didn’t mean that suboxone is always a bad thing. I agree that for opiate addicts who are unable to quit and want to get clean, it can be a lifesaver. But looking at the huge number of prescriptions being dispensed, it clearly is not only being used for this purpose. And although I am not an addict myself, I have read numerous online posts about how some people have lied about being heroin addicts so they could get suboxone prescribed to them in order to try it out, or how some heroin addicts who can’t get heroin for awhile, use it to tide themselves over until they are able to get heroin again, or get suboxone to sell on the streets to support their heroin habit rather than stop it. Suboxone dispensing is not nearly as controlled/restricted as methadone dispensing is, and full month’s supplies are often given for easy 5 minute visits, which seems to have enabled too much of it to get out there and often end up in the wrong people’s hands. I have read about it being prescribed to 15 year-olds long-term, without first seeing if they might be able to detox and then quit opiates. And I know that some doctors have become suboxone prescribers not to help addicts, but because they can make more money for less work than they were previously. In any event, I am glad suboxone has kept you from potentially overdosing, and apologize for offending you.

    • You didn’t offend me, please know that! I don’t think teens should necessarily be prescribed Suboxone or Methadone, unless it’s an extreme case.
      You are right in the fact that people can easily obtain Methadone or Suboxone without being true addicts. That makes it harder for real addicts. I’ve known people who take like 2 oxycontins to get into treatment. It makes those of us who do need it look bad.
      I’m planning to return to school to pursue a degree in Mental Health/Addiction Counseling for Adolescents. I want to do it because what I’ve been through and I also want to pay my recovery forward. I believe if we can catch addicts at a young age and find the root of why they feel compelled to use substances, then they may have a good chance! Most of my friends who got off opiates by their early 20’s have done really well and stayed off opiates wth no medicinal help. I don’t know if it’s because their brains hadn’t fully developed and were therefore more able to reset neural networks or what, but it’s an interesting theory.
      I indeed know people who’ve rerouted their methadone or Suboxone to others abbr not only is it dangerous, it’s STUPID!
      All I want from my addiction counselor, psychiatrist and primary care doctor is for them to try and put themselves in the addicts shoes. And you made me really happy by saying you could be presumptive.
      I’m a very outspoken 40 yr old, I’ve been through a lot, but I’ve twelve+ years sober and that makes me HAPPY!
      If you have at school suggestions for what I want to pursue, I’d love to hear them. I’m 15 credits away from a B.A. in American Studies with an emphasis in community & diversity, and a minor in Women’s Studies.
      What I’m planning to do is go to community college and get an A.A. in counseling for youth, since I’m on Disability and can go to community college for free.
      Does that sound a god starting point to you?
      I honestly just want to help adolescents avoid my pit falls & poor decisions.
      What do you think, and did you habe any suggestions?
      I really, from the bottom of my heart, thank you for responding!
      I hope September is treating you well!
      Thanks again,
      Becca A.

      • Becca:
        This website is clearly a great place for people from all walks of life to learn from and connect with each other. As far as advice, I don’t see it as my place to tell people what is the best way to live their lives; that is their choice. I just try to listen, understand, and help people understand themselves better, and to see that my field’s claims of permanent, genetic “brain diseases” are complete lies designed to hold people back from developing their capabilities, and instead turn them into permanently ill patients. It sounds like you have not fallen into this trap – you seem to have goals, drive, and faith in yourself, and have been developing and using your capabilities to learn from and overcome your problems. Adolescents who are at key decision points in their lives may well benefit from involvement with people who went through what they are going through, and successfully turned it around. Good luck to you.
        Lawrence

        • I once heard someone talk about how in one small part of Rural Denmark (now I maybe wrong on the country) the community had designed an addiction service that involved family and other networks. It sounded like a variation on Open Dialogue, where family and other important people are invited to conversations with trained staff (therapists, social workers, psychiatrists etc) and those conversations might happen every day for a week or so and then tail off. Central to this model is the idea that someone needs social support and that all treatment decisions are made by discussion with all relevant parties.

          Drugs could still be prescribed in this model and attendance at meetings would be entirely voluntary. People who have been through addiction and come out the other side would probably have useful things to say as the skilled and trained helpers.

          I am interested in this model as families and communities often struggle as to what to do when someone turns to drugs and I think they need support too.

  4. This blog has exposed many problems with MAT (Medically Assisted Treatment). Let’s start with the name. First we must expose how the System cleverly changed the name from “Opioid Replacement Therapy.” to “Medically Assisted Treatment.”

    This change is deliberately designed to make it sound more benign and cover up the fact that they are providing more addictive synthetic opiate “drugs” NOT “MEDICINE,” as an alleged form of “treatment.”

    When discussing this issue we must “ALWAYS” expose their use of deceitful language to cover up their crimes BEFORE we analyze what is wrong with their approach to “treating” opiate addiction problems. Accepting their misuse of the English language is to concede them more power to brainwash people.

    Yes, suboxone and methadone may have some value as a very short term aid for people with these problems. But as some kind of long term “solution,” it is just a highly profitable making business that actually contributes to the continuation and expansion of opiate drug addiction problems.

    Richard

  5. Thank you, for this article. My issue with MAT addiction and psychiatrists prescribing suboxone, methadone, vivitrol and campral is that very few individuals I see at the hospital and in the community ever get off these drugs. This is similar issue as with psychiatric drugs. As a social worker, it is very difficult to get patients into skilled nursing facilities on these drugs and many facilities just will not take individuals on these drugs. Discrimination but also facilities do not have doctors that know enough about them to continue to prescribe them. Some patients swear by the drugs usefulness. I have serious concerns that many individuals with addictions do not do the hard work of recovery and like those taking psychiatric drugs, just listen to the MD who has no financial interest in taking an individual off. Good old fashion 12 step meetings, sponsor and living a life away from people, places and situations that trigger use. Not easy but many people have done it. People in recovery are powerful individuals. I learned a lot from many early in my career. There is a lot of wisdom in those 12 steps.

  6. Thank you for this very good article. I have a more general question about ACEs and wonder if anyone here may be interested. Whenever I read about that research, it always seems to me that it must seriously underestimate the problem because of the prevalence of repressed trauma, especially from very early in life. For my part, I had no idea that I had early life trauma until I had done a lot of careful work with a therapist, trying to understand why I had always had periodic and unexplained turmoil in my head, and until a family member finally told me our great secret, that my mother had had a psychotic break when I was a small child. I also think of Carol Gilligan’s work, which shows so elegantly that, while girls start feeling intense social pressure to conform to narrow gender roles in their early teens, boys get hit with this at about the age of four, and that it is especially about “being a man,” even a little one, and being strong and tough and competitive and not showing emotion, which sure sounds like a recipe for repressed trauma to me, if sometimes (often?) diffuse trauma. That is a rather brutal thing for most boys to encounter at a very tender age. I do not mean to give short shrift to girls at all; plenty there, also. Mostly, it seems to me that the ACE work must substantially underestimate the experiences that lead to later distress (and to addiction as an attempt to alleviate it) and wonder if there are any researchers looking at this, or just clinicians or others writing about it. Any thoughts?

  7. This epidemic is just another revenue stream for psychiatry. All I can hear is DUAL diagnosis center in the back of my brain. They will now have another reason to pass psychotropics out in mass. One of my neighbors daughters was a heroin addict and the little cocktail they had her on was pretty impressive. Do not pass go, do not pay 200 dollars, go directly to a bipolar II diagnosis, all set with an antidepressant, mood stabilizer and of course the best yet, an antipsychotic.

    This will end up being a boondoggle for the pharmaceutical industry and the psychiatrists. Sell Narcan to keep them from overdosing, sell them psychotropics to keep them off opioids. My only question, which is worse?

    • Yup, I think you’re right. And meanwhile, while I know this will be controversial here, other non-pharma substances that can really help will not be part of the picture. A friend of mine who is a palliative care nurse has, on the side, helped several people transition off of opioids with cannabis, but of course the doctors she works with won’t touch it. Meanwhile, one or a few sessions with psychedelics, coupled with ongoing therapy, can be extremely effective with all sorts of addictions. Someone above mentioned Gabor Mate, who I think is probably our best and most eloquent, and compassionate, person working on addiction. Until recently he led ayahuasca retreats in Mexico and has had remarkable success working with addicts in this way. See also the work of Dmitri Mugianis, a former heroin addict in New York who has helped many, many people with Ibogaine, and now has a clinic in, I think, Costa Rica. But those most effective treatments are on the fringes–precisely because they are not part of the pharma-industrial complex.

  8. I think almost all so called mental illness is a form of PTSD.

    Sit in any group therapy with like 20 people for MI or substance abuse and listen for a wile , everyone had the trauma.

    I sat in so many. we all had the trauma usually childhood. No one ever noticed that either in the group as a part or running it ?

    • Yup. This sounds a lot like what Gabor Mate says about drug addicts. You spend a little time with them and…duh! It becomes very clear that trauma lies at the heart of it. I’m sure there are genetic problems, birth defects, brain injuries, etc. that cause “mental illness” but they have got to be rare. There is just no way nature or God designed us so that huge portions of people would have inherent defects of this sort. On the other hand, we live in a hugely traumatized society. I refer to it as the iceberg of trauma. There’s the obvious, spoken, explicit trauma; then there’s the repressed major trauma (those two of themselves are huge); but then also consider, on a subtler level, what we’re all embedded in. We live in isolated sterile lifeless little boxes. Maybe a house plant or two, maybe a dog or a cat. If we’re lucky, a loved one or two, with whom we probably have lots of tension because we’re unnaturally isolated in those boxes, which become familial pressure-cookers. Then we go to work and sit these beautiful bodies down in stupid chairs and stare at electronic screens. In order to connect with anyone or get to work we have to hurtle down to road in two-thousand pound steel boxes, squashing frogs and squirrels and mice, more beautiful miraculous bodies, spewing poisons out our tailpipe that literally kill people and are killing the planetary home we live in, and that originate from fossil fuels from half-way around the world secured by the most violent military machine the world has ever seen or gouging through fragile arctic tundra or rainforest and running through pipelines alone which peaceful native inhabitants are beaten and tear gassed for saying, hey, this is not right. So, you know, that would do a number on a person’s psyche. Then of course we’re also told that religion, which Jung referred to as the world’s great psychological healing systems (yes, I know they have their problems; I mean religion very broadly) are simply wrong or delusional by people who are so crude as to have no concept of how metaphor or symbolism work or just how the human heart works and insist that “rational science” and capitalism combined, which, in the way they’ve been combined, are flushing us all down the toilet, are in fact going to make everything just fine. So long as we keep buying stuff and voting in meaningless elections. Yup, that would do it.

  9. Medication Assisted Treatment … Plain old raw opium right from the poppy would probably be the best thing.

    Smoke , feel better and have a nice day… All these chemicals and chemistry buprenorphine, methadone, naltrexone , just smoke it the way the plant made it if opiates are your thing and again have a nice day.