Addiction treatment often overlooks trauma. That's a major hurdle in stopping the overdose crisis

The fourth step in Alcoholics Anonymous requires participants to take a “moral inventory” of the problems their substance use has caused in their lives before asking God to remove their “defects of character” in a later step.

A portion of the millions of people in the U.S. participating in AA find the 12-step program helpful, but others have criticized it for lacking efficacy and taking a white-knuckle approach to recovery. Moreover, many treatment models like this fail to take into account co-occurring and underlying traumatic experiences that drive a large portion of people to self-medicate with drugs in the first place, said Maia Szalavitz, a journalist who writes about trauma, addiction and her experience going through some of these programs.

“So much of our addiction treatment is actively traumatic,” Szalavitz told Salon in a phone interview. “It tells people, ‘Sit down and shut up, and your best thinking got you here,’ and there is this idea that you should take moral inventory because you have a problem you created.”

Estimates suggest roughly three-quarters of people who use drugs have experienced trauma, but many addiction treatment facilities do not incorporate the level of trauma-informed care people with co-occurring trauma and substance use require, risking further stigmatization and even retraumatization, Szalavitz said.

“If you want to actually treat addiction, we need to help people deal with trauma,” Szalavitz said. “Now this does not mean that you go to rehab and they tell you, ‘Okay, tell me about your sexual abuse,’ because this could be actually very harmful. You need to deal with this stuff sensitively and on the person's timetable.”

Research shows that treating post-traumatic stress disorder (PTSD) or other symptoms of a traumatic experience also helps people with their substance use, likely because most people use drugs as a way to self-medicate or cope with stressors or overwhelming emotions — like those accompanying trauma, said Dr. Denise Hien, the director of the Center of Alcohol & Substance Use Studies at Rutgers-New Brunswick. 

“Our messaging around it is… we have to get you to face the feelings and realize that you can live through them and you can heal,” Hien told Salon in a phone interview. “When we do that, it’s amazing what happens to people in their transformation, and they stop using substances or reduce how much they are using.”

In one randomized control trial, clinicians assigned people with these co-occurring conditions to receive one of the standard treatment models for trauma called prolonged exposure, in which physicians review the traumatic event with patients in a structured manner to help them regain autonomy over it, in addition to relapse prevention therapy and relapse prevention therapy alone. The group that received both had significantly improved mental health symptoms compared to the control group of people that received relapse prevention therapy only.

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Although substance use remained constant in this trial, other studies have shown that changes in traumatic symptoms can have downstream effects on substance use, said Dr. Teresa Lopez-Castro, an associate professor of psychology at the City College of New York and one of the trial's investigators.

“We did all of this work with people and their substance use was not exacerbated,” Lopez-Castro told Salon in a phone interview. “What we see is this mediation effect where the change in substance use disorder is taking place through PTSD symptom reduction.”

Understanding the origins of substance use 

Deep-seeded stigma surrounding substance use can ostracize people who use drugs and put them in the moral wrong, with programs like AA focusing on confronting the behavioral factors that lead a person to use drugs. In recent years, as the understanding of addiction has improved, more research has been focused on the biological underpinnings of substance use, mapping neurological differences in people who use substances and those who do not, developing questionable genetic tests that claim to predict the risk of developing substance use disorder, and even creating an addiction vaccine.

Although understanding addiction as a biological mechanism can potentially help reduce stigma and make it easier to develop better treatments for substance use disorder, some argue that this model strips people who use drugs of their autonomy and makes addiction seem like an irreversible condition from which people can’t recover — which is not the case.

“When we only focus on the brain component and you kind of disembody it and remove it from the person’s psychology, the social context, and the physical context, that’s when we get into trouble,” Lopez-Castro said.

The reasons people gravitate toward substance use are still being understood but are thought to share both biological and environmental influences. Substance use does seem to involve some sort of genetic vulnerability that can be exacerbated when paired with certain exposures or experiences in one’s environment like trauma, Hien said.

Nevertheless, once both occur, trauma and substance use can help “maintain,” each other, Lopez-Castro said. Trauma and the body’s chronic stress around it has been shown to change certain parts of the brain involved with executive functioning and the body’s reward system, which are also impacted by substance use when people use these agents to cope.

When considering the criminalization of drug use, the relationship between trauma and substance use becomes even more complicated. Dr. Kim Sue, an addiction medicine physician whose book "Getting Wrecked" concerns women with substance use disorder who were incarcerated, said the experience of being imprisoned makes existing trauma or mental health symptoms worsen for the people she works with. 

“Addressing trauma also means addressing community systems, racialized traumas caused by drug policy, and providing and being able to meet people's current and future needs in a stable environment,” Sue wrote to Salon in an email. “We should also think about what it would look like to prevent trauma and prevent substance use disorders, by early treatment and  timely intervention after traumatic events, especially for young people.”

Barriers to incorporating trauma-centered care

Some trials are being conducted to test whether certain pharmaceuticals could target the shared biological underpinnings of trauma and substance use, including MDMA-assisted therapy, which utilizes the psychedelic-adjacent drug also known as ecstasy. But many of the recovery programs tasked with the overwhelming task of treating the millions of Americans with substance use disorder do not incorporate a trauma-centered approach, Hien said. 

“A lot of places will say [they] do trauma-informed care, but what trauma-informed really means is that they understand that people have trauma, and maybe they're kinder to people,” Hien said. “But it’s not really doing the trauma-focused treatments and giving the medications that have been shown to actually work and help people.”

Many harm reduction programs do the best they can to treat people with the resources they have. Yet these programs are chronically underfunded in relation to the scale of resources needed to treat the U.S. population seeking help. 

“There are system-level barriers because specialists have to know how to treat mental health conditions or need to be in conversation with people if it demands a system that is integrated, with collaboration between psychiatrists, psychologists and counselors,” Lopez-Castro said. “That takes energy and a culture change, which we see happening, but it is quite slow.”

Some providers also fear that treating trauma in people with substance use would be opening Pandora’s box and could cause a person to relapse, although that has proven to not be the case, Lopez-Castro said. 

“It's almost like, ‘don't ask, don't tell’ in the sense that they don't even want to ask about it because if they ask about it, then they'll feel like they have to do something,” Hien said. “But they don't have anything to offer.”

Ultimately, that approach ignores the root of substance use disorder for so many. Although progress has been made in recognizing and treating co-occurring substance use disorder and trauma conditions, there is still a long way to go to ensure people using substances are getting the resources they need to heal from both.

“We have this whole false idea that most addiction is about seeking excess pleasure, and, in fact, most addiction is about trying to be okay,” Szalavitz said. “If we want to have less addiction and less harm associated with addiction, we have to improve people's lives.”