Chat with us, powered by LiveChat
Adverse Childhood Experiences (ACE): How they Affect Health and Well-being

Adverse Childhood Experiences (ACE): How they Affect Health and Well-being

In past articles and our most recent article on trauma, we have mentioned the impact that Adverse Childhood Experiences, or ACEs, can have on an individual. While it wasn’t long ago that we figured it out, there is a great deal of research supporting the notion that one of the key contributing factors to substance abuse, mental health and other behavioral disorders is childhood trauma. Adverse Childhood Experiences, known widely as ACEs, are common and seemingly passive experiences that one may have as a child, that, when occurring repeatedly or in combination, have a devastating impact on a person’s development and long-term health.

When an Adverse Life Event takes place during one’s life in later adolescence or as an adult, the connection for the survivor to make between the traumatic experience and their future issues can be clear. Whether it’s a singular “Big T” trauma or a series of less severe “Little T” traumatic events, the link between these experiences and a person’s behaviors can often be made easily. For example, a 58-year-old man who recently went through a divorce, was laid off and then lost his house, might make the connection between these experiences and his increased drinking and isolation.

However, the link between ACEs and mental health or substance abuse issues that develop later in life can be more difficult, for a couple of reasons. For one thing, the mental health or substance abuse issues often don’t surface until years, or even decades, after the Adverse Childhood Experience occurs. What starts as general family dysfunction, divorce, neglect, or abuse may seem relatively normal through childhood and even into adulthood. The early signs and symptoms of a greater issue often manifest themselves as isolation, lack of trust, avoidance and other social and emotional issues before they ever develop into substance abuse or severe mental illness.

What are ACEs?

The notion of Adverse Childhood Experiences, or ACEs, began with the research of the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study. The study was conducted between 1995 and 1997 and studied nearly 17,000 Kaiser patients in a San Diego Health Clinic[1]. Patient health was studied through physical exams and surveys of current health and behaviors, while they also completed surveys about childhood experiences. What this groundbreaking study was looking at was the link – which was not understood at the time – between childhood trauma and physical, mental and emotional health later in life.

The ten childhood experiences they were looking at were:

Childhood abuse

1.     Emotional Abuse

2.     Physical Abuse

3.     Sexual Abuse

Childhood neglect

4.     Physical Neglect

5.     Emotional Neglect

Household challenges

Growing up in a household were there was:

6.     Substance abuse

7.     Mental Illness

8.     Violent Treatment of a mother or step-mother

9.     Parental Separation/divorce

10.  An incarcerated household member

 

Participants in the study were then given an ACE Score between 0 and 10, the total sum based on how many of the 10 types of adverse experiences they reported experiencing.

The Findings of the CDC-Kaiser ACE Study

The ACE Score, from 0 to 10, is used to assess cumulative childhood stress – now sometimes referred to as “Little T” trauma or by association with this study – a person’s “ACEs”. One of the clearest and most widely understood finding of the study was that Adverse Childhood Experiences (ACEs) are more common than one might think, or thought at the time. More than half (52%) of the participants from the original CDC-Kaiser study reported having at least one ACE, and more than 1 in 5 (20%) reported exposure to 3 or more ACEs, while another 6.2% reported 4 or more exposures[2].

The most prevalent of the categories of childhood exposure was substance abuse in the household (25.6%); the least prevalent exposure category was evidence of criminal behavior in the household (3.4%)[3]. Another finding was that the susceptibility of a person’s exposure to multiple ACE categories, as the relationship between single categories of exposure was significant. If someone reported any single category of exposure, the probability of exposure to any additional category ranged from 65%–93%; and then not surprisingly, the probability of more than two additional exposures ranged from 40%–74%[4].

The key finding of the study as it related to health outcomes, and which changed the way we understood childhood trauma, was that as one’s ACE Score increases, so does the risk for serious diseases and conditions, including:

  • Alcoholism and alcohol abuse
  • Illicit drug use
  • Depression and other mental health issues
  • Suicide attempts
  • Health-related quality of life
  • Smoking
  • Chronic disease
  • Heart and liver disease
  • Poor academic achievement
  • Poor work performance and financial stress
  • Risk for intimate partner violence
  • Multiple sexual partners
  • STDs and unintended pregnancies
  • Risk for sexual violence and intimate partner violence

The increased risk for these negative health outcomes and well-being are dramatic. Compared to someone with an ACE Score of 0, a person with an ACE Score of 4 or more is:

  • 18 times as likely to have attempted suicide
  • Twice as likely to have had two or more weeks of depressed mood in the past year
  • Nearly 5 times as likely to have ever used illicit drugs
  • More than 11 times as likely to have ever inject drugs
  • More than 5 times as likely to be an alcoholic

How are ACEs Linked to Health Issues?

There is a large and growing body of research about how childhood stress and trauma affect brain development, brain chemistry and, thus, the regulation of the body’s emotional, stress and fear response systems are impacted. Repeated stress and activation of these systems of the brain dramatically alter the formation of myelinated axons and the amygdala, the part of the brain that activates the autonomic nervous system (ANS) and releases hormones like adrenaline and cortisol into the body. If you’re walking through the woods and see a bear approaching, or you see a kid walking into oncoming traffic, the activation of this system is very effective in increasing your heart rate, opening your airways, and increasing blood flow to your organs and muscles, and away from certain parts of the brain.

However, if the stress response system is activated every night by the sound of your dad coming home, or the sight of your mom reaching for a bottle of alcohol, your body and brain are hit with the same fight-flight-freeze response. The repeated activation of this system take a toll on your vital organs as well as your brain’s ability to regulate emotions and responses to triggers. When the body produces too much of, or stops producing, the natural chemicals to sooth or excite you, it is very common for people to turn to external stimuli to compensate this: depressants like alcohol and benzodiazepines, stimulants like cocaine and methamphetamine, or even behaviors like gambling and sexual intercourse.

Exposure to abuse and neglect also impact the prefrontal cortex, the part of the brain responsible for high level cognition and controlling impulse, and the nucleus accumbens, the brain’s pleasure-reward center which releases the body’s natural dopamine. The nucleus accumbens was first discovered in 1954 by two scientists when rats became addicted to pressing a lever that activated this part of the brain. The role of the nucleus accumbens and its connection to the amygdala and hippocampus[5] have great implications in the study of psychiatric disorders, substance abuse and addiction, obsessive compulsive disorder and Tourette’s Syndrome, and more studies are being conducted.

Dose-Response Relationship

The CDC-Kaiser study also found a “dose-response” relationship between ACEs and negative health and well-being outcomes across a person’s lifetime. A dose-response relationship is one where as the dose or intensity of the trigger increases, so does the intensity of the maladaptive behavior or response. For example, the more a person is exposed to abuse or neglect, the more severe the negative health outcomes will be.

Follow-Up Studies

Dr. Nadine Burke-Harris

One of the most notable cases of these results in action was the work of Dr. Nadine Burke-Harris, a pediatrician in San Francisco who was originally unaware of the CDC-Kaiser ACE Study. She noticed when she began working in a hospital in Bayview-Hunter’s Point, a low-income area of the city riddled with addiction and violence, that there was an abnormal number of children being referred to her for Attention Deficit Hyperactivity Disorder (ADHD). One of her colleagues made her aware of the ACE Study, which led her down a path of studying her patients’ exposure to trauma and how the brain and body were impacting their health. She subsequently started the San Francisco Center for Youth Wellness, where Dr. Burke-Harris made it routine to screen children for their ACE Score to better understand the risk factors of these youth across their lifetime.

See her TED Talk on How Childhood Trauma Affects Health Across a Lifetime:

Behavioral Risk Factor Surveillance System (BRFSS)

In 2009, the CDC began collecting annual ACE data through the Behavioral Risk Factor Surveillance System (BFRSS) from voluntary respondents telephonically. It is now the longest-running phone survey in the world. The BFRSS asks questions modified from the original ACE Study, from people across 32 states, using randomly dialed numbers. The data collected from the BRFSS are:

All ACE questions refer to the respondent’s first 18 years of life.

  • Abuse1
    • Emotional abuse: A parent or other adult in your home ever swore at you, insulted you, or put you down.
    • Physical abuse: A parent or other adult in your home ever hit, beat, kicked or physically hurt you.
    • Sexual abuse: An adult or person at least 5 years older ever touched you in a sexual way, or tried to make you touch their body in a sexual way, or attempted to have sex with you.
  • Household Challenges
    • Intimate partner violence:2 Parents or adults in home ever slapped, hit, kicked, punched or beat each other up.
    • Household substance abuse: A household member was a problem drinker or alcoholic or used street drugs or abused prescription medications.
    • Household mental illness: A household member was depressed or mentally ill or a household member attempted suicide.
    • Parental separation or divorce: Parents were ever separated or divorced.
    • Incarcerated household member: A household member went to prison.

The findings of the BFRSS are similar to that of the original CDC-Kaiser ACE Study:

  • More than two-thirds of the participants reported at least one adverse childhood experience
  • More than 1 in 5 reported exposure to 3 or more ACEs

Similarly, they also found a dose-response relationship with ACE Scores correlated to an increase in the following:

  • Myocardial infarction
  • Asthma
  • Mental distress
  • Depression
  • Smoking
  • Disability
  • Reported income
  • Unemployment
  • Lowered educational attainment
  • Coronary heart disease
  • Stroke
  • Diabetes

Treatment of Childhood Trauma

Understanding the role that adverse childhood experiences (ACEs) play in brain development and prevalence of addiction, mental illness and life-threatening diseases is a pivotal precursor to addressing these issues. Identifying and acknowledging the root of the issues is an important step in the recovery process, and only once a person can work through the lasting effects of exposure to Adverse Childhood Experiences can they truly recover. Because of the way these experiences embed themselves in our brain and body, the process of resolving them can take months or even years, but even the most complex trauma can be resolved with enough time and commitment.

Despite the acceptance of this research in the medical field, behavioral health professionals have been slower to integrate the identification and treatment of trauma into practice. It is important for someone who has been exposed to these adverse childhood experiences to find help at trauma-focused treatment programs like Roots Through Recovery, who utilize evidence-based approaches like Eye Movement Desensitization and Reprocessing (EMDR), Somatic Experiencing (SE), Mindfulness-Based Stress Reduction (MBSR), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and expressive approaches like music and sound therapy, trauma-focused yoga, and art therapy.

EMDR at Roots Through Recovery

Resources:

[1] https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext

[2] https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext

[3] Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext

[4] https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext

[5] https://www.eurekalert.org/pub_releases/2014-05/cafn-itp052114.php

Trauma: Big T and Little T

Trauma: Big T and Little T

The word “trauma” is used widely today to refer to an experience that is damaging to a person’s psychological health, and as we’ve mentioned in previous articles, the magnitude of this experience is completely dependent on the individual. What most people outside of the behavioral health profession don’t know is that trauma can be categorized into two classifications: what are known as “Big T” and “Little T.”

BIG T TRAUMA

In general, the Big T variation of trauma refers to a single, traumatic event that can leave a survivor of the event with symptoms associated with Post Traumatic Stress Disorder, or PTSD. Experiences like sexual assault, serious injuries, violent attacks, and near-death experiences all fall under this category, and it’s now widely understood what kind of impact Big T trauma can have on a person’s life. People coping with the effects of a traumatic event, and may be suffering from PTSD, experience various symptoms including:

Re-experiencing
  • Flashbacks
  • Bad dreams
  • Frightening thoughts
Avoidance
  • Staying away from places, events, or objects that are reminders of the experience
  • Avoiding thoughts or feelings related to the traumatic event
Arousal and reactivity
  • Being easily startled
  • Feeling tense or “on edge”
  • Having difficulty sleeping, and/or having angry outbursts
Cognition and mood
  • Trouble remembering key features of the traumatic event
  • Negative thoughts about oneself or the world
  • Distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Adapted from National Institute of Mental Health (NIMH)

POST TRAUMATIC STRESS DISORDER (PTSD)

Given the general public knowledge of trauma, you might find it surprising that it wasn’t until 1980 that the American Psychiatric Association recognized PTSD as a clinical diagnosis, when they added it to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). According to the U.S. Department of Veterans Affairs, the diagnosis was both controversial and groundbreaking as it suggested for the first time that the cause, “was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis)”. The introduction, research and development of the PTSD diagnosis has paved the way for more trauma-informed and trauma-focused care. You can read the latest criteria for diagnosing PTSD in the DSM-V below.

LITTLE T TRAUMA

Little T trauma is a very different thing though, because it includes virtually every other adverse life experience — each hardship and struggle that people deal with throughout life — that doesn’t fall under the Big T umbrella. Whether it’s a case of bullying, loss of friends or family members, or an emotionally abusive relationship, Little T trauma tends to be the tough situations that many people deal with on a daily basis that don’t necessarily result in a clear diagnosis of a lasting effect. Because trauma is subjective and depends entirely on a person’s resilience and perception, adverse life experiences include anything that could potentially result in trauma; not only the presence of a negative experience, but also the absence of a positive one.

Trauma is anything short of love.

-Unknown

Everyone handles trauma (in either variety) in different ways, and there is now a fairly prevalent belief — and the scientific backing to prove — that dealing with repeated Little T trauma can be just as significant as a single occurrence of its Big T counterpart. Much like experiencing a traumatic life event such as a natural disaster or surviving a serious car crash, experiencing repeated events that engage the body’s stress response system can alter the neural network, especially when these experiences take place in early childhood.

ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY

Thanks to a study conducted by the CDC and Kaiser Permanente Health in the late 90s, we now know the impact the Adverse Childhood Experiences, or ACEs, have on a person’s neurodevelopment and social-emotional-cognitive development, and as a result, their later in life health outcomes. In the ACE Study, seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.

What the study found was that a person with a higher ACE score was at significantly higher risk for substance abuse, mental health issues, intimate partner violence, and a host of health issues. Before the study was conducted and accepted by the medical and behavioral health community, these experiences that know refer to as adverse life events, adverse childhood experiences or Little T trauma, had been considered a normal part of life. Much like combat veterans returning home from war and being shamed or dismissed as being weak are now being treated for PTSD, these seemingly common but potentially damaging experiences are starting to garner the attention, empathy, or treatment that a Big T survivor might receive.

WHY ARE THESE IMPORTANT?

As mentioned above and in previous articles, exposure to trauma — whether it be Little T or Big T — can cause psychological (and sometimes physical) pain that often leads to destructive coping mechanisms, behavioral adaptations and health-risk behaviors. As a means to escape or numb the pain endured during the trauma, and the recurring discomfort that follows, survivors often turn to self-medicating with controlled substances. As with many addictions, it then becomes a vicious cycle that is generally only broken through proper trauma-focused treatment.

In all likelihood, every person will deal with some type of Little T trauma in their lifetime, and many will be no worse for the wear. But now that it has become recognized as a legitimate cause of maladaptive behaviors that can lead to mental health and substance use disorders, it can finally be treated and viewed on an even playing field with its “bigger” sibling.

Resources:

https://www.ajpmonline.org/article/S0749-3797(98)00017-8/abstract

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html

https://www.sciencedirect.com/science/article/pii/S2352289516300273

https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/index.shtml#pub3

https://www.ptsd.va.gov/professional/treat/essentials/history_ptsd.asp

 

WE ARE HERE TO HELP YOU

For immediate assistance, please call our Admissions Specialists at +1(562) 473-0827 or +1(866) 766-8776.

For more information or to start admissions – fill out the form below and we’ll reach out to you as soon as possible:

Medication-Assisted Treatment (MAT): Myths Debunked

Medication-Assisted Treatment (MAT): Myths Debunked

In 2015, Michael Botticelli, the director for the Office of National Drug Control Policy stated:

“Medication-assisted treatment saves lives while increasing the chances a person will remain in treatment and learn the skills and build the networks necessary for long-term recovery.”[1]

So why is it that the use of medication-assisted treatment remains staggering and access is limited for those who need it?

When it comes to medication-assisted treatment, there is a whole host of misinformation and confusion surrounding its use and purpose, which leaves it rejected or ignored by the vast majority of treatment centers. Medication-assisted treatment is the use of legal, FDA-approved medications in combination with counseling and behavioral services provided by treatment professionals and family and peer support (Source: SAMHSA).

But for those who don’t understand the benefits or its place in treatment, it can seem simply as replacing one drug with another. Of course, that’s not the case for any accredited medication-assisted treatment programs, which is often the best option for some people looking to achieve long-term sobriety.

 

Here are a few of the debunked myths surrounding medication-assisted treatment.

MYTH: If you take medications like Suboxone, you aren’t really sober.

TRUTH: While it’s true that opioid replacements, such as Suboxone which contains Buprenorphine and Naloxone, act on the same receptors as heroin or an opioid, the medication attaches to these receptors but does not activate them, and also blocks other opioids from these receptors[2]. The combination of these two mechanisms helps control cravings in a person who is physically dependent on opiates without getting the person high.

 

MYTH: Medication-assisted treatment is for people who aren’t serious about their recovery.

TRUTH: In certain cases, even the most intensive counseling and behavioral treatments just aren’t enough to achieve sobriety and prevent relapses in the future. For these situations—particularly when opioids or severe alcohol use is involved—using medication-assisted treatment to neutralize the physiological effects may help someone attain this critical first step of recovery, allowing them to focus on the underlying issues and move forward in their recovery.

 

MYTH: It’s always better to just get people off of all drugs.

TRUTH: Although going “cold turkey” and just outright stopping the use of any substances is the ideal scenario for many, using medication-assisted treatment to ease the body away from its previous addiction can be both easier and medically necessary in some situations. “Ripping the bandage off” may seem preferable at the time, but it can also lead to complications, permanent damage, and even death if a person’s health is too fragile to handle the severity of the physiological repercussions.

 

MYTH: Medication-assisted treatment is just taking the easy way out.

TRUTH: If one accepts that addiction is a chronic disease, like diabetes or hypertension, then the use of medication should be understood to be a critical component of treatment in some cases. Like hypertension, if someone is able to address their condition by changing their lifestyle, such as their diet and physical activity, that is ideal; however, for some, that isn’t enough[3]. We wouldn’t shame someone with hypertension for taking Beta-blockers or ACE inhibitors, and addiction should be treated with the same understanding and compassion.

 

MYTH: People using medication-assisted treatment are less likely to stay sober.

TRUTH: When utilized correctly, medication-assisted treatment carries with it lower risk, and higher probability of success than solely doing counseling and behavioral services[4] for many people looking to address their addiction, stay in treatment[5], and remain sober for the long-term. One study found that patients who were still on an opioid agonist 18 months post-treatment, were twice as likely to be sober from opioid pain killers than those who were not (80% versus 36.6%).[6]

Figure Below. Abstinence Rate Exceeds 60 Percent in Long-Term Follow-Up of Medication-Assisted Therapy for Dependence on Opioid Pain Relievers Dependence on pain relievers dropped below 20 percent at 18 months, and below 10 percent at 42 months, after patients were stabilized on, and then tapered off, Bp/Nx. At all three follow-up points, patients who were currently engaged in opioid agonist therapy had markedly higher odds of positive outcomes. (Source: National Institute of Drug Abuse)

 

Like any form of treatment, medication-assisted treatment isn’t for everyone, and the decision to start these medications is made after consultation with a treatment team, and a thorough assessment is completed. If you’ve struggled with relapse and traditional treatment hasn’t worked for you, contact Roots Through Recovery or another certified provider to consult on whether it would be an appropriate course of action.

 

References:

[1] https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder

https://obamawhitehouse.archives.gov/the-press-office/2015/09/17/remarks-ondcp-director-michael-botticelli

[2] https://www.naabt.org/faq_answers.cfm?ID=5

[3] https://archives.drugabuse.gov/publications/drug-abuse-addiction-one-americas-most-challenging-public-health-problems/addiction-chronic-disease

[4] https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24

[5] https://jamanetwork.com/journals/jamapsychiatry/fullarticle/209312

[6] https://www.drugabuse.gov/news-events/nida-notes/2015/11/long-term-follow-up-medication-assisted-treatment-addiction-to-pain-relievers-yields-cause-optimism

 

WE ARE HERE TO HELP YOU

For immediate assistance, please call our Admissions Specialists at +1(562) 473-0827 or +1(866) 766-8776.

For more information or to start admissions – fill out the form below and we’ll reach out to you as soon as possible:

Chronic Pain and Chemical Dependency

Chronic Pain and Chemical Dependency

In the world of scientific journals and medical studies, there are dozens of reports about chronic pain all finding the same thing — that it often goes hand in hand with chemical dependency and substance abuse. Of course, each of the researchers, scientists, and doctors have their own thoughts on the matter, but they all pretty much come back to the point that chronic pain starts a vicious cycle that often leads to relying on some type of painkillers. It’s an issue that’s plagued mankind since the pain reducing properties of opium were discovered several millennia ago, and there’s no sign of it going away anytime soon.

Pain and Suffering

Regardless of what type of chronic pain a person may be dealing with, constantly being uncomfortable leads to a loss of both productivity during the day and sleep at night. Without the ability to function at a normal level, people are more likely to turn to controlled substances — whether they’re opioids, alcohol, or even cannabis-based — as a means to cut down on their discomfort and get back to a more regular lifestyle.

Unfortunately, what’s first used in moderation can quickly fall into a pattern of dependency and abuse. Even before true withdrawal symptoms would set in, just going back to the status quo of annoying (or possibly agonizing) pain can be bad enough to keep the painkiller usage going around the clock. The chronic pain sufferers end up having to increase the dosage to get the same result once they’ve become accustomed to the 24-hour usage, and things can quickly spiral out of control from there.

In addition to the physical discomfort, the mental and emotional strain of chronic pain can also play a major factor in developing a chemical dependency. The constant state of discomfort can lead to increased aggression, feelings of hopelessness, depression, and a wide variety of other unpleasant mental states — which are then often exacerbated by lack of sleep — leaving the person even more susceptible to substance abuse than ever before.

Factoring in how quickly chemical dependency can get out of hand for even the healthiest individual, the descent for someone suffering from chronic pain can take over before it is even noticed. The good news is that even the worst case scenarios can be turned around with some help and a push in the right direction from a treatment program that specializes in treating chronic pain without medication.

Treatment for Chronic Pain

Treatment for chronic pain in a comprehensive pain rehabilitation program can include a combination of medical and psychological care, cognitive behavioral therapy, psychoeducation and physical and occupational therapy. Although chronic pain may not go away entirely, its severity and the impact on our emotional well-being can be significantly lessened with a comprehensive pain rehabilitation program, coupled with a change in diet, light exercise, and a variety of other lifestyle switches.

Please contact us if you need additional support or professional help. Call us at (562) 473-0827 or complete the form below.

Sources:

https://europepmc.org/abstract/med/1633386
https://www.sciencedirect.com/science/article/pii/088539249390154N
https://journals.lww.com/pain/fulltext/2007/06000/Opioid_dependence_and_addiction_during_opioid.3.aspx
https://www.sciencedirect.com/science/article/pii/S0885392498001109

 

WE ARE HERE TO HELP YOU

For immediate assistance, please call our Admissions Specialists at +1(562) 473-0827 or +1(866) 766-8776.

For more information or to start admissions – fill out the form below and we’ll reach out to you as soon as possible:

The Considerable Benefits of Getting Outdoors in Recovery

The Considerable Benefits of Getting Outdoors in Recovery

Getting outdoors in recovery is one of the most effective and easy therapeutic techniques. Exploring the natural world improves your physical and mental health. There are considerable benefits to connecting with nature and doing outdoor physical activity.

Recharge by Visiting the Water

A University of Exeter article detailed the benefits of exercising by the water. Any type of clean and healthy marine environment, such as rivers, bays, lakes and oceans, provides numerous benefits for human health. That’s because they’re sources of recreation, exercise and relaxation. If you like to fish, it can be a food source as well.

Take advantage of these health benefits and enjoy the outdoors in recovery by walking the trails around a lake or along a river bank. Or visit the beach, soak up the sunshine and enjoy the rhythmic sound of the waves. You’ll return home rested and refreshed.

Improve Your Mental and Physical Health

Walking in a natural setting can improve your mental health. A walk among the trees has been shown to improve human health conditions, because people feel better and heal faster when they’re in natural environments.

Visiting natural environments means moving around. You have to walk around to see and hear all the wonderful things nature has to offer. The potential for healthy exercise is enormous when you get outdoors in recovery, which tones and shapes your muscles.

Relieve Stress and Heal Faster

Stress reduction is part of getting outdoors in recovery. Stress makes you more vulnerable to relapse. Strolling through or gazing at natural beauty can lower your stress levels. It can also help you heal faster. One study showed that patients recovering from surgery who had a view of a tree from their window recovered more quickly, took less medication and had less post-surgical complications, compared to post-surgical patients whose window view was a brick wall.

Boost Your Creativity

Studies show that immersing yourself in nature and turning off electronic devices can boost your creativity. Modern technology monopolizes our attention and distracts us from our surroundings. By spending time in nature and turning off phones and tablets, creative problem-solving may become easier.

Different Ideas for Enjoying the Outdoors in Recovery

  • Have a picnic at your favorite outdoor spot. If you can’t get away from home, have your picnic on your porch, terrace or backyard.
  • Go on a boat. Instead of enjoying the water from land, rent a boat or book a charter and enjoy the water from a different perspective.
  • Try a zip-line ride, which is an exciting and fun way to commune with nature.
  • Take up photography as a hobby. Take pictures of your outdoor surroundings, such as flowers, trees and animals.
  • Take a walk. Put on your walking shoes and get outside in the fresh air and sunshine. Maybe you can’t always get to a totally natural environment, but a relaxing stroll in the fresh air and sunshine will still make you feel good.
The Opioid Epidemic: A Love Affair with Painkillers Turned Deadly

The Opioid Epidemic: A Love Affair with Painkillers Turned Deadly

You can’t turn on the news today without seeing something about the nation’s opioid crisis. Deadly painkillers and heroin are ravaging communities across the country, children are finding and overdosing on their parents’ candy-shaped prescriptions and fentanyl—a synthetic opioid 50 times more powerful than morphine—is causing an unprecedented number of overdoses. Headlines describe tragedy after tragedy.

We are in the middle of one of the deadliest drug epidemics in our country’s history. Whether you’re a pain management physician who believes there is a place for opioids in treatment or an advocate in the addiction treatment field who believes the risks outweigh the benefits and opioids should never be allowed on the market, one thing is certain: the history of the opioid epidemic is a long and complicated one.

Timeline of Opioid Use in the United States

The earliest records of opium use date back to poppy cultivation in Mesopotamia around 3400 B.C. Derivatives of opium have been in use medicinally since the 1500s, though use in the U.S. began in the early 1800s. Spanning multiple centuries, the timeline of how opioids came to be so widespread in American medicine reveals a convoluted history that began with good intentions and mercy and was twisted by corporate greed that exploited the human body’s natural responsiveness to opioids.

Early 1800s

1806

German chemist Friedrich Sertürner isolates opium’s active ingredient and names it morphine; morphine quickly becomes recognized as a universal cure-all

1827

Merck, the eventual pharmaceutical giant, begins selling morphine commercially

Early 1850s

Following the influx of Chinese to America during the gold rush, opium dens begin to spring up around San Francisco

Civil War Era

1861-1865

Morphine is widely used on battlefields to treat pain; many veterans of the war subsequently fall victim to opioid addiction

1868

An estimated 80,000-100,000 Americans are addicted to opium. Horace Day pens a report referencing thousands of opium users of the time who are dying of blood poisoning, speaking to the complexity of the matter when he wrote that they “ought to be able to say something as to the good and the evil there is in the habit”

Late 1800s

1875

The country’s first drug control law passes, banning opium smoking in opium dens

1898

Bayer & Co. begins commercially producing and aggressively marketing heroin, a synthetic morphine derivative, as a “wonder drug”; heroin use increases as people discover heroin’s effects are stronger when injected

Early 1900s

Bayer advertises liquid heroin as the best cure for childhood bronchitis and as a household cough suppressant; at a time when tuberculosis is responsible for 1 in 4 of all deaths, advertisements claim heroin ensures an immaculate bill of health

1914

The Harrison Narcotics Tax Act passes, imposing a tax on the production and sale of derivatives of opium or coca leaves

1920s

Physicians are now aware of the highly addictive nature of opioids and medical use declines

1924

Congress passes a law banning the manufacture, distribution or importation of heroin

1980

A letter published without peer review in the prestigious New England Journal of Medicine claims that “the development of addiction is rare in medical patients with no history of addiction,” based on a briefly examined sample of patients who received limited narcotics in controlled settings; medical opioid use begins increasing as pharmaceutical companies misleadingly point to the letter as a voucher of safety

1986

Pain specialist Dr. Portenoy releases a study of 38 patients, claiming opioid pain therapy is safe and sparking a movement to increase pain management practices and to include opioids

1996

OxyContin bursts onto the scene; pharmaceutical reps from Purdue Pharma make a splash in the medical field with presentations backed by selective research, OxyContin-branded gifts and a campaign centered around humane pain relief. Opioid prescriptions increase from 2 million a year to 11 million

2000 to Present

Opioid abuse and overdoses double between 1998 and 2008

2002

An estimated 6.2 million Americans are abusing opioids

2009

Opioids lead to 730,000 emergency department visits in 2009, almost double from 2004

2014

Of the 21.5 million people with a substance use disorder, 1.9 million cases involve pain relievers and .6 million involve heroin; 3 out of 4 people with a heroin use disorder report their addiction began with prescription opioids

2015

52,404 fatalities in 2015 make drug overdose the leading cause of accidental death in the U.S.; 20,101 overdose deaths are related to prescription opioids and 12,990 are related to heroin

The Role of Big Pharma

Even with this timeline, you have to go behind the scenes to see how we’ve gotten to where we are today. In 2015, physicians wrote nearly 300 million prescriptions for opioids, accounting for 80 percent of global opioid use. More Americans died of opioid overdose in 2016 than died during the entire Vietnam War.

Large pharmaceutical companies like Purdue Pharma put billions of dollars each year into marketing their products as safe, effective and non-addictive. At the same time, these organizations have powerful lobbies that influence legislation, which provides a dismal insight into why, with so many people dying every day, our government isn’t doing more.

The government has taken several small and seemingly insignificant actions to impact the opioid epidemic, including forcing Purdue Pharma to add an anti-abuse element to OxyContin to reduce the ability to crush or snort it.

Studies show that although this reduced abuse of the drug, it did very little to slow the epidemic. One opioid user said, “Most people that I know don’t use OxyContin to get high anymore… They have moved on to heroin (because) it is easier to use, much cheaper and easily available.”

The study also showed that 66 percent of those surveyed switched to other opioids. Still, makers of some of the other opioid drugs on the market maintain that their products are safe, and the government regulatory agencies continue to allow the prescription of these drugs with little oversight.

In 2011, Dr. Portenoy, the doctor who wrote one of several studies that claimed there was little risk of addiction in using opioids to treat chronic pain, spoke out about his own role in the epidemic, saying that if he had an inkling then of what he knows now he would not have spoken the way he did. He reported, “we often left evidence behind” and “it was clearly the wrong thing to do”.

Why Do People Use Opioids?

Three out of four heroin addicts started out misusing prescription opioids before turning to heroin. This startling fact that has recently come to the forefront of our attention raises the question, why would anyone start using opioids to begin with?

Humans, and all animals for that matter, are pleasure-seeking by nature and look for ways to escape from or avoid unpleasant feelings at all costs. These feelings can be physical or emotional, and come as a result of injury, grief, loss or other trauma that has gone untreated.

If you ask 100 people with opioid use disorder why they started and how they became addicted, you will likely get 100 different answers. For some, their addiction started with a prescription for back pain and eventually became physically dependent upon it, some began using to treat a different kind of pain: the pain of unpleasant thoughts, feelings or memories.

Like all controlled substances, opioids have addictive qualities that make them habit forming, but not everyone who uses them becomes addicted, leading some to the hotly debated conclusion that it isn’t necessarily the substance—it’s the person using the substance. One such proponent of this position is addiction specialist, Dr. Carl Hart.

Dr. Hart stands firmly in this position behind empirical evidence he cites, including the fact that only 25% of all people who use heroin at least once in their lifetime become addicted. His theory is that those who do become addicted and continue to suffer in their addiction do so because they don’t have a more valuable incentive to stop.

He found in his own study that when a person who is addicted is offered a reward great enough, they will almost always choose the reward over the substance; it is then our job to help people understand the value in the reward of recovery. Hart believes that the recent emphasis on the opioid crisis is a way to increase law enforcement budgets and will ultimately result in the criminalization and policing of drug addiction and bringing no positive change, like the crack epidemic in the 80s and 90s.

Whether you agree with this position on the language or not, the statistics about the increase in opioid addiction are clear—they are staggering.

Just When You Thought It Couldn’t Get Any Worse

As pressure from the FDA and DEA have mounted on doctors who overprescribe, doctors have started to track drug-seeking patients and cutting them off from their prescriptions, forcing many to turn to the street for their fix. With the high cost and scarcity of pills on the black market, many turn to heroin as it is both cheaper and easier to find.

This is a huge part of the recent spike in heroin abuse and addiction. To make things worse, there has been a recent boom of synthetic opioids that are flooding the streets and causing an unprecedented number of overdoses. The Centers for Disease Control and Prevention (CDC) has gone so far as to refer our current state as an “opioid overdose epidemic”. From the CDC:

Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid.1  Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled2. From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose.

We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled2, yet there has not been an overall change in the amount of pain that Americans report3,4. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 19995.

Life Saver or False Sense of Safety?

One of the solutions Dr. Hart offers to the epidemic is to make naloxone more readily available and for our current administration to go after pharmaceutical companies who have hiked the prices as opioid use has increased. Given the spike in opioid use and overdose in the last 15 years, the use of naloxone (commonly known by the brand name Narcan or Evzio)—a life-saving drug that blocks the effects of opioids and reverses an overdose—has also increased.

Once limited to only first responders and medical professionals, anyone with an opioid use disorder can now be prescribed naloxone and carry it with them to be used in the event that they overdose. Today, everyone from police officers to addiction treatment professionals to drug addicts themselves are carrying naloxone and reviving people across the country every day, narrowly escaping death.

3.2 million prescriptions of Naloxone were given in 2015, and administered more than 12,000 times last year, just in the state of Ohio. In 2014, 208 people died from overdoses in the state of Maine alone. That year, emergency responders in Maine saved 829 lives with naloxone. However, most uses go unreported.

According to a national survey conducted by the CDC, in 83% of case of naloxone use, the drug is given by other drug users, the people most likely to be on the scene, not by emergency responders. A new model of the injectable that gives verbal prompts, called Evzio, allows someone without any medical training or experience to give the drug to someone who has overdosed.

This recent rise in the general public’s use of naloxone raises a new question of whether the availability and accessibility of the drug has had a counter effect of giving some addicts a false sense of immortality. The fear factor of overdose has been eliminated knowing that with a simple injection or nasal spray, they can be brought back to life.

This truly is a fallacy now that the prevalence of naloxone-resistant synthetic opioids like fentanyl and carfentanil are increasing—both intentional and unintentional with heroin often being unknowingly laced with fentanyl. Because of the increased half-life of these synthetic compounds, some drug addicts have died from overdose despite multiple unsuccessful naloxone injections.

One Step Forward, Two Steps Back

In the midst of this seemingly endless crisis, many people found a glimmer of hope in 2016—when we saw the largest spike in overdose deaths—as, then Surgeon General, Vivek Murthy was publicly and explicitly fighting to hold doctors responsible for unethical pain management practices, over-prescription of opioids, and forcing them to make referrals to treatment a priority.

Murthy wrote an open letter to physicians, which you can read here, chronicling the path that led to the current opioid epidemic including the role medical professionals have played, and offered a three-pronged solution to address it:

“First, we will educate ourselves to treat pain safely and effectively. A good place to start is the enclosed pocket card with the CDC Opioid Prescribing Guideline. Second, we will screen our patients for opioid use disorder and provide or connect them with evidence-based treatment. Third, we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing.”

This statement alone, being made publicly, was incredibly impactful in reducing the stigma and supported the federal requirement of insurance policies to cover treatment of substance abuse. Unfortunately, President Trump quickly replaced Surgeon General Murthy, stopping these efforts in their tracks. In addition to this, Trump had an opportunity—under substantial public pressure—to properly address the crisis on the national stage; however, he missed the mark.

In October of 2017, Trump declared a nationwide public health emergency to fight the opioid crisis, rather than issuing a national disaster declaration. To the lay person, this sounded like a victory; however, the difference between these two declarations is that one comes with financial support—the latter—while the former does not.

It is unclear what actions will be taken to address this crisis at a national level, but many state and local governments are taking steps in their own communities—but funding is limited, and continues to decrease with the Trump administration’s cuts to Medicaid. With an issue as large and far-reaching as this, it is going to take a concerted effort from communities and governments at every level.

What Now?

While there seems to be no end to the opioid epidemic in sight, all hope is not lost. We are seeing more preventative and responsive measures to curb the deaths associated with opioid use, including the increase in access to: life-saving drugs like naloxone, training and education, and effective treatment. One course of action being taken by the government is an attack on the source, through lawsuits against Big Pharma and sanctions against unethical doctors.

These measures don’t seem to be slowing down the rate of opioid use disorder or the amount of drugs available on the street as they flood in from Mexico, Canada and China. The hope seems to lie in the societal and legislative support for the treatment of opioid use disorder and its underlying causes, with conversations happening at every level about the need to expand treatment.

One of the revelations in the drug treatment industry has been the emergence of Medication Assisted Treatment (MAT)—the integration of prescription opioid receptor partial anogist and antagonist medications like Buprenorphine and Naltrexone. Taken by mouth, injection or implant, these prescription drugs help reduce cravings in people with opioid use disorder and act on or block opioid receptors to eliminate the effect of opioid use on the brain and negating the potential for life-threatening respiratory depression.

For many, the use of MAT has been the life-saving factor, however, its use is still not widely accepted in the addiction treatment industry, and is the great divide, embraced by only a select few in a field which remains mainly abstinence based.

Medication Assisted Treatment is not a silver bullet to end the opioid epidemic, and it certainly is not the answer for everyone. Although the integration of these medications into therapy is referred to as the “Gold Standard of Care” by the medical field and strongly encouraged by the Substance Abuse and Mental Health Services Administration (SAMHSA), very few treatment centers offer MAT.

However, in combination with effective group and individual therapy, MAT has its place for people with chronic relapse and chronic overdose to finally be able to sit in a therapeutic setting and get something out of the information they are receiving. Some of these medications also provide pain relief to people suffering from chronic pain.

As with most prescription drugs, some of the medications used in MAT are addictive and are often misused, so it is important that they are prescribed responsibly and closely monitored by a medical doctor who has knowledge of addiction and who will remain involved in the person’s treatment, including being a part of a multidisciplinary team of professionals involved in a person’s treatment.

Seeing the need for expansion of MAT, legislation was passed in 2017 allowing Nurse Practitioners and Physicians Assistants to prescribe medications like Suboxone and Subutex.

Because prescription opioids or heroin are being replaced by another substance with MAT, the overwhelming majority of people who work in addiction don’t see its place in treatment beyond detox. However, there are certain cases where a longer taper of these drugs or a medication maintenance treatment program can be the difference between life and death.

Roots Through Recovery is an example of an outpatient treatment program that supports the responsible integration of medication assisted treatment into the care plan of some individuals. These clients meet regularly with a board-certified physician who works closely with the treatment team to ensure dosage is correct and that clients are managing their medication responsibly and safely.

Where We Go from Here

There is no one singular action or step that is going to be the deciding factor in the fight to end the opioid epidemic, but rather it requires a combination of critical steps and open minds from addicts, treatment providers and lawmakers. These steps include:

Prevention and Early Intervention – A realistic plan to shift our society away from one that has come to rely on shame, guilt and self-medication toward one of acceptance, support and alternative approaches.

Restrictions on Prescription Opioids – No doubt there is a place for opioids in the treatment of pain, but clear guidelines and restrictions on their use should be implemented.

Reframing of our Understanding of “Pain” – Pain is a real thing, and doctors have a responsibility to treat it to keep patients comfortable, but when we consider context, pain is over-reported (site the study of soldiers versus ER patients).

Trauma-Informed Addiction Treatment – As mentioned, many of the people suffering from addiction began self-medicating other kinds of pain, including past trauma. Trauma often goes unidentified and untreated, which manifests itself both psychologically and physically.

Acceptance of Medication Assisted Treatment (MAT) – Until the behavioral health field comes around to accepting the place of medication in the treatment of addiction, we are going to continue to see the dismal outcomes we see currently.


References:

  1. http://www.theatlantic.com/sponsored/purdue-health/a-brief-history-of-opioids/184/
  2. https://www.theatlantic.com/health/archive/2017/06/nejm-letter-opioids/528840/
  3. https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/the_opioid_crisis_0.pdf
  4. https://apnews.com/4d69f4b41cbc475ca42f424524003d21
  5. https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
  6. https://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html
  7. https://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html