Addressing The Link Between Trauma And Addiction

Many Americans have experienced traumatic events, toxic stress, and other types of adversity in childhood. However, repeated exposure to trauma and adversity in childhood predicts a variety of poor health outcomes, including the development of substance use disorder (SUD).

Population-level research, neuroscience, epigenetics, and other fields have established that the connection between childhood adversity and SUD, as well as risk for intergenerational transmission of both trauma and SUD, occurs through impacts of adverse experiences on brain development. There are various risk and protective factors at play that can exacerbate or mitigate this relationship. Many of the risk factors tend to cluster together and compound in predictable ways—for example, childhood poverty, housing insecurity, and community violence. On the other hand, positive childhood experiences, such as secure attachment and social support networks, can attenuate the relationship and increase resiliency even among children who experience significant adversity.

Given the variety of influential factors and the significant plasticity of the brain and behavior during child development, there are many opportunities to prevent adversity in childhood, disrupt the development of SUD, and support individuals with SUD who have histories of trauma and adversity. States and territories have a variety of policy levers at their disposal, as well as compendiums of evidence-based prevention programming and best practices. The NGA Center for Best Practices is committed to supporting Governors and their states and territories to expand Adverse Childhood Experiences (ACEs) prevention, address root causes of poor health outcomes, and mitigate the relationship between childhood adversity and SUD.

As part of this effort, the NGA Center launched a Policy Academy in February 2024 to strengthen state responses to SUD through a trauma-informed policy and practice lens . The NGA Center worked with teams from New Mexico and West Virginia to support their Governors’ respective goals. New Mexico focused on improving SUD treatment for parents whose children are at risk for involvement with the Department of Children, Youth, and Families. West Virginia aimed to assess current practices and trauma-informed care training needs among SUD providers, promote positive messaging over ACEs, and pilot a form of trauma-informed therapy. These teams continue to make progress on improving trauma-informed SUD prevention and treatment in their states.

Childhood Adversity, Traumatic Events, And Long-Term Health Effects

Trauma and Childhood Adversity

Traumatic events, trauma, and post-traumatic stress disorder (PTSD) are often conflated in popular culture and media; however, these terms are defined in the Diagnostic and Statistical Manual of Mental Disorders in ways that differentiate between normal responses and long-lasting harmful effects. Traumatic events are those in which a person is exposed to actual or threatened death, serious injury, or sexual violence. This exposure may be direct, witnessed as it occurs to others, or through learning about a violent or accidental traumatic event that happened to a family member or close friend. Exposure to traumatic events may also be occupational, where individuals are closely and often repeatedly exposed to the details of events impacting others. Exposure to traumatic events is extremely common, with 7 out of 10 people in the United States experiencing at least one traumatic event in their lifetime.

People have wide-ranging physical, cognitive, relational, and behavioral responses to traumatic events and are overwhelmingly resilient. The term “trauma” refers to an inherently disturbing, stressful or frightening event and is associated with varying physical and emotional responses, from an expectable reaction to those that are either extreme or, conversely muted. Most people who experience a traumatic event do not meet criteria for an acute diagnosis of a mental health condition and even fewer develop PTSD, a diagnosis which includes long-lasting physical and mental effects. Trauma responses can include self-damaging behaviors. Some people may react to traumatic events by engaging in impulsive, high-risk behavior or self-medicating with psychoactive substances.

Exposure to adversity in childhood, as well as traumatic events, can cause alterations in brain development, and function. Adverse experiences and traumatic events are increasingly harmful with repeated exposure, causing toxic stress which is associated with elevated fight-or-flight hormones over time. Adversity in childhood includes abuse, neglect, and household challenges such as divorce, parental mental illness, substance use in the home and witnessed violence; these are often referred to as Adverse Childhood Experiences, or ACEs. The landmark study on ACEs published in 1998 described seven categories, including three categories of childhood abuse and four categories of household challenges. Since this study, additional ACEs that occur outside the home and can equally influence health outcomes have been identified, such as bullying, racism, homelessness, and witnessing community or school violence.

Relationship between childhood adversity and SUD

SUD is often rooted in trauma, toxic stress, and childhood adversity, though there are several hypotheses describing the exact nature of the reciprocal relationship. Much research supports the self-medication theory that individuals with traumatic events in their history may use substances to manage trauma or PTSD symptoms. In addition, some research suggests complex reciprocal relationships; for example, trauma may increase risk for substance use which, in turn, can increase the risk of exposure to further traumatic events.

Regardless of the mechanism, the relationship between childhood adversity and substance use is evident in population-level research and data. Nearly half of people with PTSD also have a substance use disorder (SUD). About 3 out of 4 people with SUD have experienced trauma in their lives, and 60% of youth with PTSD eventually develop problems with substance use. Research has demonstrated a graded relationship between childhood adversity and poor health outcomes, including illicit substance use; in a large population, as the number of ACEs increased, the odds of having ever used illicit drugs and having ever injected drugs also increased.

The link between trauma, childhood adversity, and SUD also has multi-generational implications. Parental SUD may facilitate the transmission of trauma and SUD from parent to child through various complex mechanisms. Children of parents with SUD are more likely to develop SUD themselves. Parental substance use is considered an ACE—children whose parents have/had substance use problems are more likely to initiate substance use at an early age, use illicit substances, and misuse licit substances. This link is particularly salient amid data showing that one in eight children in the US live with a parent who has SUD.

Individual, social, and environmental factors can either mitigate or exacerbate the impact of traumatic events or adversity on health and wellbeing. Those that mitigate are described as “protective” factors while those that exacerbate are considered risk factors. Given the accumulating impact of adversity and traumatic events, the risk and protective factors in social and community contexts to which individuals are exposed can be the difference between resilience and poor long-term health outcomes. Protective factors include experiences such as having healthy peer role models, connectedness in school, family communication, and adult role models. Risk factors may include exposures such as poverty, substance use in the home environment, community violence, parental mental illness, or early use of substances. Research shows that protective factors mitigate the impact of multiple ACEs on health and mental distress, even among those who had experienced four or more ACEs.

Positive Childhood Experiences, or PCEs, are a way of characterizing protective factors that influence health outcomes in the same way that ACEs describe risk factors in childhood. Dr. Bethell et al. delved further to define and measure the impact of specific PCEs, such as feeling a sense of belonging in high school, being able to talk to one’s family about feelings, and participating in community traditions, among others. In direct contrast with the ACEs study result, greater numbers of PCEs were associated with greater mental and relational health in adulthood.

Policy and Program Levers to Disrupt the Pathway to SUD

There are various policy levers that can be used to prevent childhood adversity, disrupt the pathway to SUD, and support individuals with co-occurring PTSD and SUD. Many states have sought to prevent childhood adversity through legislation, with 13 states enacting at least one bill into law on the topic between 2019 and 2021. Governors can also leverage their executive order authority to champion trauma informed policies, such as making Delaware a trauma-informed state, or to implement policies that strengthen families, such as paid family medical leave for state employees in Tennessee. States also have the role of providing education resources and information about ACEs and the relationship with SUD to the public and across agencies. Many state agencies touch this issue—including health, education, Medicaid, and children, youth, and families. These agencies create policy, implement and evaluate programs, provide support for support community-based organizations, administer funding, and develop public-facing communications—all which can be leveraged to exact change.

Each policy and program approach may address one or several of the complex factors at play in the relationship between childhood adversity and SUD. Given the multitude of influencing factors, there are many opportunities for intervention to prevent the development of SUD and mitigate its impacts. Policies and programs may intervene at various stages of prevention—either preventing the occurrence of adversity, interrupting the development of SUD, or supporting people with SUD. Preventing the occurrences of adversity and traumatic events represents the earliest type of intervention. The next level of prevention includes strengthening protective factors and mitigating risk factors in at-risk populations before problems emerge. Supporting those individuals with problems that have already emerged and mitigating those problems is the next level. And finally, the focus is on individuals who are already impacted, managing crises and addressing challenges.

Interrupting the relationship between childhood adversity and SUD also requires interventions at multiple levels of influence from a socioecological lens—individual, family, school and community, and society. Risk factors, protective factors, and prevention opportunities exist at each of these levels. There are compendiums of evidence-based programs and interventions that improve overall wellbeing and disrupt the pathway to SUD across the lifespan and at each of these levels of influence and prevention. For example, the National Academies for Sciences, Engineering, and Medicine in 2019 published “Fostering Health mental, Emotional, and Behavioral Development in Children and Youth,” which catalogs strategies and evidence across settings including familial, educational, health care, and policy.

Given the intergenerational nature of trauma and SUD, supporting the family unit serves to support children and prevent adversity in childhood. Upstream prevention also includes supporting pregnant people and parents with SUD and keeping families together by reducing unnecessary removal of children. Policies and programs that keep families together, bolster child social and emotional skills, strengthen economic and social wellbeing, and support parents have implications for the long-term health and wellbeing of children. For example, home visitation programs have been shown to have positive outcomes for child academics and behavioral health. Multicomponent interventions that build skills in teachers, parents, and children have shown positive outcomes across generations and improved behavioral health outcomes in children. From a family economic wellbeing lens, state financial support programs for families—such as Supplemental Nutrition Assistance Programs (SNAP), earned income tax credits, and family income supplements—have demonstrated benefits in lower rates of substance use. With a better understanding of the impact of adversity and protective factors, the child welfare system nationally has shifted toward a model that keeps families together and away from surveillance and punishment when possible. In addition, Medicaid continues to explore new mechanisms for addressing the health related social needs that support healthy families.

<table>

The prevalence of trauma among people with SUD also has implications for SUD treatment systems, which can inform improvements to service provision and subsequent outcomes. People with PTSD and SUD discontinue treatment at a higher rate and face internal as well as external barriers to treatment. In addition, most people who meet criteria for SUD do not seek or access treatment, and only about one-third of people with PTSD seek professional help. This highlights the importance of integrated SUD and PTSD treatment that is high quality and evidence-based. At a basic level, provider understanding of the trauma and addiction link can inform greater empathy for the patient and more availability of evidence-based treatments for PTSD, including those specific to SUD systems—such as Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) and Seeking Safety. Treatment choice considerations are also important for this patient population. There are hurdles facing SUD treatment providers seeking to implement a trauma focus, including the research suggesting that patients “should not be required to abstain from substance use before engaging in trauma focused therapy.” This presents a significant challenge particularly for abstinence-based SUD treatment programs.