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?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.