Adverse Childhood Experiences and Efficacy of Substance Use Disorders Treatment

Introduction: Exposure to adverse events during childhood increases the risk for early initiation of substance use, and places individuals at greater risk of developing a substance use disorder (SUD) later in life. However, there has been little published comparing SUD treatment outcomes among individuals who report varying levels of childhood trauma. Better understanding the relative effectiveness of intensive psychosocial treatment for SUDs among these groups may help to identify targets for improved or adjunctive treatment efforts if needed.

Methods: A cohort of 170 individuals (62% male), consecutively admitted to a partial-hospitalization addictions treatment center in the southeast United States, completed patient-reported assessment measures at treatment admission and again at discharge. Measures included the Adverse Childhood Experiences (ACE) questionnaire, Patient Health Questionnaire-9 (PHQ-9; depression), Generalized Anxiety Disorder scale (GAD-7; anxiety), alcohol abstinence self-efficacy scales (AASE), and PTSD Checklist for DSM-5 (PCL-5; PTSD). A Random Effects Model was used to test the overall change in symptoms of depression, anxiety, alcohol abstinence self-efficacy, and PTSD symptoms based on childhood trauma exposure (determined by ACE score), controlling for patient length of stay in treatment.

Results: Participants were categorized according to their scores on the ACE measure: 0 (22.9%), 1 (16.5%), 2 (16.5%), 3 (15.3%), or 4+ (28.8%). The average length of stay in treatment was 78 days, with a low of M=71.4 days (SD= 21.2) for the ACE=0 group and a high of M=83.6 days (SD=35.3) for the ACE=1 group. The average score for participants in the 4+ ACE was in the clinically significant range on all four measures (PHQ-9, GAD-7, AASE, and PCL-5) at admission; whereas, average scores for the other groups were not. Differences between the 4+ ACE group and the 0 ACE group were statistically significant for the PHQ-9 (p=.002), GAD-7 (p <.001), AASE (p=.03), and PCL-5 (p <.001). All groups demonstrated improvement on all measures; however, results indicated a negatively graded relationship between ACE category and each of the outcomes measures. Specifically, controlling for length of stay in treatment, participants with increased ACE exposure showed differential patterns in treatment response than those with fewer ACE events, and did not improve to the same level at time of discharge. In fact, the adjusted average discharge scores for the 4+ ACE group were worse than the adjusted average baseline scores for the 0 ACE group on the GAD-7, AASE, and PCL-5.

Conclusions: Poorer scores on patient-reported assessment measures, particularly at the time of discharge from treatment, may be predictive of worse post-treatment outcomes. This study, in tandem with previous research, points to differences in treatment outcomes among individuals with a history of ACEs. The results suggest that patients with significant ACE exposure may need more time in treatment to achieve the same symptom reduction as their peers without such exposure. Assessing ACE exposure early in SUD treatment may provide information vital to individualized treatment planning. Future research should examine how trauma-informed care and other patient-centered therapies may improve long-term outcomes and reduce the risk of relapse for this population

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