The connection between trauma and addiction
Myron Yaster MD, Elliot J. Krane MD, and Lynne G. Maxwell MD
I’ve always wondered: “Millions of people are routinely treated with opioids for moderate to severe pain. A small fraction of them become addicted. What makes those who develop an opioid use disorder different than those who don’t? “ In the October 20204 issue of Scientific American, Maia Szalavitz1 discusses the connection between adverse childhood trauma experiences and the development of substance use disorder (SUD). This has enormous implications in how we can go beyond 12 step programs into new treatment strategies. Myron Yaster MD
Original article
Szalavitz M. The Traumatic Roots of Addiction: A new generation of treatments addresses the trauma that often underlies addiction. Sci Am. 2024 Oct 1;331(3):44. doi: 10.1038/scientificamerican102024-6xB36RNXDLNTqrJNtnh0wL. PMID: 39292896.
“A 2021 review2 found that more than 40 percent of people with opioid addiction reported some type of childhood abuse or neglect, and 41 percent of women had been subjected to childhood sexual abuse, much higher than the rate for the general population. A different study3 showed that among those with any type of addiction, at least 85 percent have had at least one adverse childhood experience, with each additional experience raising the risk. The link is most pronounced among those diagnosed with post-traumatic stress disorder (PTSD), characterized by flashbacks and other psychological disturbances that can develop in response to a shocking or terrifying event. Among people treated for any substance addiction, one third have active PTSD—and among those with PTSD, 58 percent have had problems with substance use.1
“The suffering that predisposes someone to addiction doesn’t have to be overt. It can be as seemingly mundane as being raised by depressed parents or being bullied in school. Other circumstances that increase vulnerability include having addicted or mentally ill parents; witnessing violence; losing a parent; or experiencing a life-threatening illness, accident, conflict or disaster. A study4 of the entire Swedish population found that undergoing just one of these potentially traumatizing experiences may double the risk for substance use disorders.1
“Both trauma and addiction experiences change the brain’s reward systems, which motivate people to seek evolutionary essentials such as food, water, sex—and, crucially, safety. Brain signals are complicated, however, and many seemingly separate “systems” share the same circuitry. Systems that predict reward or punishment are deeply intertwined with the modulation of stress: many of the same neurotransmitters and brain regions involved in motivating us to seek pleasure and satiety also help to keep us safe. (See figure below) Dopamine, for example, drives us to seek sources of pleasure linked to survival and reproduction and also to avoid threats. The neurotransmitter acts on the striatum and the prefrontal cortex, both of which are in the forebrain, and helps us predict whether an experience will be rewarding or upsetting. It does so by creating a feeling of “wanting”—either to get more pleasure or to escape from pain. And during scary or stressful experiences, endogenous, or self-generated, opioids known as endorphins and enkephalins are released in the brain. These are guided by hormones from the adrenal and pituitary glands as part of the classic stress-response system, to ease pain and facilitate escape. These opioids also make food, sex and socializing feel good, causing a feeling of “liking” something or someone and of satiety and comfort.1
“Growing up in a threatening and stressful environment can undermine this circuitry. Studies in both humans and animals show that adversity in childhood alters the regulation of stress hormones such as cortisol. These hormones, released during prolonged or acute stress, change brain regions such as the amygdala, which is activated by strong emotions, especially fear and distress. Stress in early life also alters the nucleus accumbens, a part of the striatum that is key to addiction: it makes us want more of what feels good. Memory areas such as the hippocampus are also profoundly affected, making some memories too strong and others too weak. “Our reward system and our stress system become attuned to trying to meet the needs of reducing threat,” says Teresa Lopez-Castro, associate professor of psychology at the City College of New York, who has developed a co-treatment program for PTSD and substance use disorder, in which PTSD symptom reduction is associated with a decrease in SUD problems.
“Genetics affects addiction risk by setting defaults. Some infants are more easily distressed, for example, whereas others have calm temperaments. These variations reflect the responsiveness and resilience of the stress and reward systems. Roughly half5 the vulnerability for substance use disorders is genetically determined, but the way this predisposition plays out is extremely varied. Some genes put people at risk via personality traits such as being prone to thrill-seeking or having difficulties with impulse control; others work by causing difficulty focusing, low moods or anxiety. Yet others, such as the genes related to the metabolism of alcohol, alter the risks associated with particular substances.”
OK, why is this important? Currently, the primary treatment methods for substance abuse are 12 step programs. 12 step programs and other abstinence-based treatments have unequivocally been shown to be far less effective, then medication based treatment. Certainly, concurrent treatment of stress disorders and its behavioral effects AND dealing with addiction should be an alternative strategy to the 12 step programs. Szalavitz’s article describes programs such as that of Professor Lopez-Castro that combine behavioral therapy (either exposure therapy or cognitive processing therapy) with SUD directed therapy, which have demonstrated initial success. Some other initiatives combine these therapies with supplements such as oxytocin and novel use of psychedelics, but the jury is still out regarding the use of psychedelics, and the most recent scientific analyses of psychedelics tempers the enthusiasm of the last few years, such as expressed in Michael Pollan’s book “Changing Your Mind.” These interventions are obviously both labor and specialized personnel intensive and there are very limited access to these for adults and virtually none available for adolescents.
Going forward, we wonder if we should ask about childhood trauma as we prescribe opioids so that the patients at risk can receive enhanced psychotherapy in addition to their analgesics. But, in reality, in the setting of an operating suite, is an anesthesiologist meeting a patient for the first time going to include these probing questions in the medical history?
In the ideal world, and not the world in which we live, recommending enhanced monitoring following the prescription of opioids, and recommending mental health therapy to the many children who have suffered these events is clearly desirable. But in the world in which we live, in which there is a drastic shortage of psychologists and psychiatrists, as well as a paucity of pediatric pain clinics, this clearly is not going to happen.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Szalavitz M. The Traumatic Roots of Addiction: A new generation of treatments addresses the trauma that often underlies addiction. Sci Am 2024; 331(3): 44.
2. Santo T, Jr., Campbell G, Gisev N, et al. Prevalence of childhood maltreatment among people with opioid use disorder: A systematic review and meta-analysis. Drug and alcohol dependence 2021; 219: 108459.
3. Grummitt L, Barrett E, Kelly E, Newton N. An Umbrella Review of the Links Between Adverse Childhood Experiences and Substance Misuse: What, Why, and Where Do We Go from Here? Subst Abuse Rehabil 2022; 13: 83-100.
4. Giordano GN, Ohlsson H, Kendler KS, Sundquist K, Sundquist J. Unexpected adverse childhood experiences and subsequent drug use disorder: a Swedish population study (1995–2011). Addiction (Abingdon, England) 2014; 109(7): 1119-27.
5. Hatoum AS, Colbert SMC, Johnson EC, et al. Multivariate genome-wide association meta-analysis of over 1 million subjects identifies loci underlying multiple substance use disorders. Nat Ment Health 2023; 1(3): 210-23.