Not why addiction, but why the pain? – Dr. Gabor Maté

What Dr. Maté—a leader in addiction medicine and world-renowned author and speaker—is saying, is something we’ve long known to be true about trauma and addiction, and yet the field of addiction treatment still lags behind the research (links to 6 studies at bottom of page): addiction is usually a symptom of underlying trauma, or mental health issues that are the manifestation of trauma. Dr. Maté uses the word ‘pain’ to refer to trauma and other underlying issues, whether it’s past sexual or physical abuse, the pain of not being able to control one’s thoughts and emotions, loss and grief, physical pain or whatever is causing the unpleasant feelings.

• In the United States, 61 percent of men and 51 percent of women report exposure to at least one lifetime traumatic event (SAMHSA).
• Ninety percent of clients in public behavioral health care settings have experienced trauma (SAMHSA).
• Over two-thirds of people seeking treatment for some sort of addiction report one or more traumatic life events (Back et al., 2000).
• Rates of witnessing serious injury or death of others and experiencing physical assault are two to three times higher in substance-using individuals than in the general population (Cottler et al., 2001; Kessler et al., 1995).

So what is trauma?

Trauma becomes increasingly difficult to define in succinct terms as one further investigates and uncovers the myriad definitions. The reason for this is the subjectivity involved in traumatic experiences, which lends itself to the definition that we think is the clearest, from the Substance Abuse and Mental Health Services Administration (SAMHSA):

Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

“Experienced by an individual…” That is the key. Trauma isn’t an event, but how one experiences or perceives an event. This inherent subjectivity is why people can experience the same seemingly traumatic event, such as being in a car accident or growing up in a war-torn country, and come out of the experience with varying degrees of trauma or distress. Trauma can take all forms, from childhood experiences of divorce, abuse and neglect, bullying, and witnessing domestic violence to loss of a parent, loss of employment, a breakup or being involved in a volatile relationship. It can also result from growing up in an alcoholic or addicted home, or any other environment where individuals are taught to bury their feelings.

Roots through Recovery’s Clinical Director, Diana Kang, PsyD. says, “Trauma does not discriminate can can impact anyone. Everyone has a different perception of trauma, and how it is experienced in the body and mind varies greatly from person to person.” Unfortunately, many people experience trauma at some point in their life and don’t understand or acknowledge the trauma, so it goes untreated and manifests itself in fear and hopelessness, depression, anxiety, and in the most severe cases, Post-Traumatic Stress Disorder (PTSD).

The Adverse Childhood Experiences study conducted by Kaiser Permanente and the CDC in the 90s developed a tool for measuring an individual’s exposure to events that could be experienced as traumatic, including abuse or neglect. Some examples of adverse childhood experiences include: physical and emotional abuse or neglect, sexual abuse, witnessing abuse of a parent or another child, substance misuse in the household, divorce of parents and the incarceration of a family member. Although as one reads through the list and these events seem all too common in households we know or our own, ACEs are strongly related to the development and prevalence of a wide range of health problems throughout life, including those associated with substance use and abuse.

ACEs are a good example of the types of complex issues that the prevention workforce often faces. The negative effects of ACEs are felt throughout the nation and can affect people of all backgrounds. Research has demonstrated a strong relationship between ACEs, substance use disorders, and behavioral problems. When children are exposed to chronic stressful events, their neurodevelopment can be disrupted. As a result, the child’s cognitive functioning or ability to cope with negative or disruptive emotions may be impaired.

How does trauma affect my body?

The human body is highly regulated by the stress response systems that have developed over time as a survival mechanism. Experts in the field of stress and trauma, including the brilliant Dr. Nadine Burke Harris, often cite the example of seeing a bear in the forest. In this case, the body instantly responds to the threat by flooding the body with adrenaline, opening up the airways and increasing our heart rate, stifling fear and allowing you to run or fight for survival. This is a great system to have in these situations of life or death. But, what happens when the bear is your dad who comes home drunk at night, or the bully in your school, or an entire block in your neighborhood? Having the body’s fight, flight or freeze response system activated too frequently is damaging to our physiological systems.

Trauma responses act on several systems that affect one’s physiology. According to the Centers for Disease Control and Prevention, what is currently known is that exposure to trauma leads to a cascade of biological changes and stress responses. These biological alterations are highly associated with PTSD, other mental illnesses, and substance use disorders. These include:

• Changes in limbic system functioning.
• Hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels.
• Neurotransmitter-related dysregulation of arousal and endogenous opioid systems.

“As a clear example, early ACEs such as abuse, neglect, and other traumas affect brain development and increase a person’s vulnerability to encountering interpersonal violence as an adult and to developing chronic diseases and other physical illnesses, mental illnesses, substance-related disorders, and impairment in other life areas” (Centers for Disease Control and Prevention, 2012).

Trauma also affects the brain.

A recent study published by Indian scientists reports new findings on how traumatic experiences affect the brain and how these effects later play out in memories. The study showed heightened electrical activity in the amygdala, located deep within the temporal lobe of the brain. “This region of the brain is known to play key roles in emotional reactions, memory and making decisions. Changes in the amygdala are linked to the development of Post-Traumatic Stress Disorder (PTSD), a mental condition that develops in a delayed fashion after a harrowing experience”. The study also found that a well-known protein involved in learning and memory, NMDA-R, is also involved in the process of creating these unpleasant memories and blocking them during a traumatic event reduced electrical activity at these synapses.

So then how are trauma and substance use connected?

The reasons behind this common co-occurrence of addiction and trauma are complex. For one thing, some people struggling to manage the effects of trauma in their lives may turn to drugs and alcohol to self-medicate. PTSD symptoms like agitation, hypersensitivity to loud noises or sudden movements, depression, social withdrawal and insomnia may seem more manageable through the use of sedating or stimulating drugs depending on the symptom. However, addiction soon becomes another problem in the trauma survivor’s life and before long, their coping mechanism no longer works, and causes far more pain to an already struggling person.

Many people who find themselves in a treatment program aren’t getting the help they need if the program only treats addiction, and does not consider trauma or co-occurring mental health issues (often called “dual diagnosis”) as the root cause of substance use. “Symptoms of someone suffering from trauma include flashbacks, nightmares, feeling like you are reliving the traumatic event, and avoidance of sights, sounds or feelings resembling the traumatic event (i.e. veterans avoiding fireworks during the 4th of July)”, offers Dr. Kang. She goes on to say, “Substance use is often one way to cope and numb out the impact of trauma. Sometimes it may be the only coping method one has. Therefore it is important to treat both the trauma and the addiction. When you address the addiction without looking at the trauma, you are not resolving the root of the addiction.”

With the impact stress responses and trauma have on the body, it’s not surprising that emotional and psychological pain often lead to an endless cycle of self-medicating, which leads to more pain, and inevitably more self-medicating, and so on. Often times, when left undiagnosed and untreated, people will self-medicate with alcohol, illicit drugs or misuse prescription drugs to placate the feelings of depression or anxiety or to numb the pain of the trauma. In these instances, the substances serve a purpose which is why to simply remove the substance, without understanding the individual need for it, is to ignore the cause and is not a long-term solution, much like putting a band aid on a bullet wound. “Over time, and often during adolescence, people with exposure to ACEs may adopt negative coping mechanisms, such as substance use or self-harm, social problems, as well as premature mortality. High ACE scores are associated with substance use disorders in adults:

• Early initiation of alcohol use. Underage drinking prevention efforts may not be effective unless ACEs are addressed as a contributing factor. Underage drinking prevention programs may not work as intended unless they help youth recognize and cope with stressors of abuse, household dysfunction, and other adverse experiences. Learn more from a 2006 study on initial alcohol use among adolescents.
• Higher risk of alcohol abuse as an adult. ACEs such as child abuse, parental alcoholism, and family dysfunction correlate with a higher risk of problem drinking behavior in adulthood. Learn more from a 2002 study on adverse childhood experiences and alcohol abuse as an adult.
• Continued tobacco use during adulthood. Prevalence ratios for current and ever smoking increased as ACEs scores increased, a 2011 study on ACEs and smoking status found.
• Prescription drug use. Prescription drug use increased as ACEs scores increased, according to a 2008 study of adverse childhood experiences and prescription drug use.
• Lifetime illicit drug use, drug dependency, and self-reported addiction. Each ACE increased the likelihood of early initiation into illicit drug use by 2- to 4-fold, according to a 2003 study on childhood abuse, neglect, and household dysfunction and the risk of illicit drug use.” (SAMHSA). 

Am I at particular risk for trauma and/or addiction?

Other possible reasons addiction and trauma are often found together include the theory that a substance user’s lifestyle puts him/her in harm’s way more often than that of a non-addicted person. Unsavory acquaintances, dangerous neighborhoods, impaired driving, and other aspects commonly associated with drug and alcohol abuse may indeed predispose substance abusers to being traumatized by crime, accidents, violence and abuse. There may also be a genetic component linking people prone toward PTSD and those with addictive tendencies, although no definitive conclusion has been made by research so far.

Often times, clients are not consciously aware that they are using substances to cope with the symptoms of trauma. They may have no memory of a traumatic event or experience, and yet, the trauma surfaces in their body or subconsciously in their brain without them knowing, ands they escape with the use of drugs or alcohol. As Primary Therapist Lauren Emmel said on a recent podcast with Todd Zalkins, “[Trauma] can surface after eight months, four years, ten years. It’s in a part of the brain… that doesn’t know any time. So something that impacted us when we were eight, ten, twelve, can impact us when we’re 20, 30, 40 if left unprocessed.” Self-soothing and distraction are ways people use substances to help get through these challenging times, and in order to develop a lifestyle that does not rely on substances, one must identify new ways to cope with unpleasant feelings.

So what can I do to reduce trauma and its effect on me?

To prevent further harm and prevent relapse, it is up to treatment professionals to recognize the prevalence of trauma among individuals coping with addiction, routinely screen for trauma symptoms, and deliver the integrated, multidisciplinary treatment that has proven effective in treating co-occurring disorders. The Substance Abuse and Mental Health Services Administration offers a helpful manual for practitioners or anyone interested in learning more about trauma informed care in their Treatment Improvement Protocol (TIP) 57, Trauma-Informed Care in Behavioral Health Services.

Treatment for co-occurring disorders, such as Roots through Recovery’s extended care program, offers clients effective ways to work through their trauma and find prosocial and physiologically beneficial ways of addressing the body’s response to trauma. Programs that address trauma from a cognitive, emotional and physiological standpoint allow individuals suffering from trauma and addiction to achieve sustainable life change and support the development of coping skills. Some of the evidence-based practices employed by treatment programs who embrace trauma-informed care are EMDR, Somatic Experiencing, Prolonged Exposure Therapy, Cognitive Processing Therapy, meditation and mindfulness, seeking safety and trauma-focused or mindfulness-based cognitive behavioral therapy.

As we learned, unprocessed trauma can affect us dramatically at the core of our physiology and brain development, have a lasting effect on us psychologically, and can surface at any time. Addressing past trauma is a process, that should take place over time, at the right time and with a professional who is equipped to address trauma.

As primary therapist and EMDR specialist, Lauren Emmel, says, “It’s important to look at the different phases of trauma therapy. In the beginning phase of trauma therapy, if you’re working with recovery, is stabilizing, is creating a safe space, resourcing, going to meetings, finding a support group. The mind is all over the place, so if you start going into the trauma work, it’s going to disregulate the system. So first and foremost, it’s stabilizing. It’s finding a safe space that you feel that you can express yourself. And then the middle part is the actual trauma work.

Avoiding trauma, and turning to unhealthy coping mechanisms, only exacerbates trauma and can lead to addiction or other harmful behaviors. Seeking treatment and confronting trauma in a safe place is the best way to address trauma and reprocess it so that one may give traumatic experiences attention and acknowledgement, but not let them negatively impact your life.

To schedule an intake with an addiction and trauma specialist today, call Roots through Recovery at 562.473.0827 or email info@roots-recovery.com.

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