(65) Beyond Trauma-Informed Care: Insights from a Qualitative Study

Background: The impact of opioid use disorder (OUD) upon communities across the United States remains at epidemic levels, with a record number of overdose deaths recorded in 2020. As many communities have responded to this ongoing crisis with evidence-based treatment, harm reduction interventions and pharmacotherapy, recent efforts have focused on trauma-informed approaches to SUD care, taking into account the high prevalence of Adverse Childhood Experiences and related trauma in the lives of people living with OUD (Felliti, 1998; Stein, 2017). However, experiences of trauma and the manifestations of trauma in contemporary experience are never uniform (Maté, 2009). Qualitative research among individuals with a background of ACEs offers some promising directions for understanding the various ways through which ACEs contribute to contemporary experiences of SUD, as well as suggestions for how clinicians might move beyond the blanket label of “trauma-informed care” and develop more nuanced approaches for addressing the ongoing manifestations of past trauma when treating patients with an SUD.

Methods: This study is a secondary analysis of data generated from the qualitative component of a longitudinal study on buprenorphine diversion, self-treatment, and treatment utilization (Daniulaityte, 2019). Qualitative interviews were conducted with 67 adult individuals who met the DSM-5 criteria for moderate to severe OUD. Interviews were transcribed in their entirety and thematically coded. Select codes were analyzed using iterative categorization (Neale, 2016) to determine how interviewees describe past childhood trauma and how those incidents have affected their substance use. Positional mapping was used to refine data analysis and develop key typologies for the manners through which adverse childhood experiences manifested in participant narratives.

Results: Four distinctive typologies emerged from the data: (1) Casual Mentioners, (2) Haunted by Trauma, (3) Seeking Redemption, and (4) Reckoning with Inevitability. Casual mentioners were participants that nonchalantly mentioned ACE-type experiences as relevant to their substance-use trajectory. Participants haunted by trauma strongly attribute traumatic ACE-type experiences to their substance use and/or propose that substances are used to avoid or numb memories. Individuals seeking redemption are described as those who acknowledge that ACE-type experiences contributed to their substance use but articulated a desire to triumph over them. Individuals reckoning with inevitability understand their drug use to be unavoidable or inevitable due to their intergenerational experiences or family history.

Discussion: The findings of this study will offer health care providers insight into differences in the manners through which adverse childhood experiences and related traumas are present in the contemporary experiences of people living with an SUD. The four typologies described here can be used as a guideline for clinicians employing a “trauma-informed care” approach, and offer suggestions for how we might develop a more dynamic approach to trauma in clinical practice. The typologies described can offer clinicians a framework for understanding the various ways ACEs have contributed to the trajectory of a SUD. Future research is necessary to determine how these typologies might guide treatment providers towards specific interventions.

References: Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.

Stein, M. D., Conti, M. T., Kenney, S., Anderson, B. J., Flori, J. N., Risi, M. M., & Bailey, G. L. (2017). Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder. Drug and alcohol dependence, 179, 325-329.

Maté G. (2009). In the realm of hungry ghosts: Close encounters with addiction. Toronto, Ontario, Canada: Vintage Canada.

Daniulaityte, R., Nahhas, R. W., Silverstein, S., Martins, S., Zaragoza, A., Moeller, A., & Carlson, R. G. (2019). Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis. Drug and alcohol dependence, 204, 107574.

Neale J. Iterative categorization (IC): a systematic technique for analysing qualitative data. Addiction. 2016;111(6):1096-1106. doi:10.1111/add.13314