June 8, 2018

From Lydia Anne M. Bartholow, DNP, PMHNP, CARN-AP, Associate Medical Director of Outpatient Substance Use Disorders at Central City Concern

Trauma informed care (TIC) is a both a theoretical approach and a way of structuring services based on what we know about the prevalence and neurobiology of trauma. There has been much written about TIC and how to infuse trauma-informed, or trauma-sensitive values into larger systems of care—specifically in the mental health system or our public educational system. And yet, as someone who is substance use disorder service (SUDS) leadership, I have found that there is a dearth of literature on how to specifically make substance use disorder programs and services more trauma informed. Substance use services are rife with traumatizing experiences: urine drug screens, invasive assessments, group therapy, etc., and yet there is little to guide us in building systems that feel emotionally and physically safe for everyone.

A history of childhood trauma makes one significantly more likely to develop a substance use disorder later in life. For example, for male childhood trauma survivors, there is a 4600% increase in the development of intravenous drug use in adulthood. This statistic alone should encourage those offering substance use disorder treatments to immediately transform their systems to be more trauma informed. It is time for SUDS providers to offer programs and services that are truly trauma informed.   The following list of core tenets begins a conversation on ensuring that services can practically, programmatically, and genuinely engage with the values of trauma informed care.

1. Peer Inclusion

Peers are the true experts in the experience of addiction. They should be included in program development, leadership and front line clinical care. Peers can guide the rest of a SUDS treatment team in making the most trauma informed choices that are specific to having a lived experience of a shameful relationship to a substance or substances.  Peers also have the ability to engage in radical candor with clients (i.e., What the hell are you doing?) in a way that is contraindicated for those who are seen as carrying significantly more power than the client in clinical interactions.

2. Understand and address historical trauma

Trauma-informed SUDS are attentive to historical and current inequities, and understand that inherent social systems of oppression and structural violence must be named and combated within services. Within trauma-informed SUDS, we pay special attention to race, gender, and class with a close eye on historical trauma. This is especially essential when considering pharmacotherapies for addiction, including buprenorphine, methadone, and naltrexone. Providers offering pharmacotherapies for substance use disorders are mindful of how historical relationships to allopathic medicine may affect treatment engagement. Providers must also bring an awareness of historically untreated pain and addiction in people of color and mindfully correct this in their practices. Moreover, trauma-informed SUDS treatment acknowledges that the vast majority of people of color in this country are accessing SUD services within the prison system and names this as a continuation of trauma within Black, Native, and Latinx communities.

3. Love as contingency management

Contingency management is gaining popularity in the SUDS treatment world—it is the phenomenal idea that rather than punishing people away from addictive behavior, we should reward people for engaging in recovery behavior. An (non-traumed-informed) example would be giving donuts or pizza to reward a urine drug screen that confirms no illicit substances. In trauma-informed SUD services, we believe that positive and caring human interaction IS the reward and that change happens in the context of rewarding, warm relationships. Trauma-informed addictions services celebrate any positive change and actively combats the shaming of the symptoms of a chronic illness (addictive behavior). Trauma-informed clinicians give ample (genuine) praise for showing up to treatment, using fewer substances, or using substances more safely.  The praise is not restricted to times wherein the client is meeting their goals as stated in the original assessment. Rather, praise and reward come freely in the context of rewarding relationships.

4. Harm reduction

Harm reduction is, among other ideas, a respect for the rights and humanity of people who use drugs. Harm reductions offers services to people who use drugs, regardless of where they land within the stages of change. Harm reduction allows drug users the ultimate control over their lives and supports them even if or when their choices don’t reflect our desires for their lives, while minimizing harm. Moreover, harm reduction interventions allow for rewarding, respectful interactions with care providers that over time, allow for more engagement with services. Harm reduction encourages people who are often stigmatized and marginalized to have a sense of self-agency and respect, meaning that they are more likely to make positive changes in the future. Self respect is contagious and builds over time. And, on a practical note, harm reduction helps to keep active drug users alive; dead addicts don’t recover.

5. Immediate access to pharmacotherapies for addiction

SAMSHA now identifies medication assisted treatment (aka, pharmacotherapies for substance use disorder, or alternately medication supported recovery) as the standard of care. Gone are the days where medications such as suboxone or methadone are hidden in dark corners. And yet, a trauma-informed approach to these medications necessitates that they are available immediately utilizing low barrier models of care. SUDS treatment providers have a history of expecting people to navigate structural barriers to access treatment care. It is the norm, for example, to present to detox only to be asked to return the following day to get a bed, or potentially return a third day. When patients present to the emergency room post overdose, they are given a list of treatment centers and instructed to follow up at their leisure/ability, and told emphatically NOT to overdose again. Rather than asking patients to conform to our soiled and confusing medical system, trauma informed SUDS care ensures that pharmacotherapies, and all other treatments for addiction, are easily accessible, low barrier, and comprehensive.

6. Core beliefs about addiction

TIC identifies the core nature of addiction differently than conventional models. In TIC, we don’t identify a substance use disorder as a choice or bad morals. We identify substance use disorders as a disease and yet we understand that most chronic illnesses arise within a specific context and are influenced by structural violence and social determinants. The primary context that gives rise to substance use disorders is trauma. We understand that substance use is a mode of self-care or a coping skill. Trauma interferes with our ability to both believe that we deserve care and with our ability to regulate emotions. Substance abuse becomes the easiest way (if you were not instructed in deep breathing or other emotional regulation techniques as a child) to regulate a dysregulated central nervous system. Opioids in particular offer the equivalent of a neuro-hormonal warm hug from a safe and loving person.  Thus, addiction is not a hedonistic behavior. Rather, it is a skill (a skill that will generally cease to serve the desired goal over a period of time) that many use to escape pain, trauma, and a lack of connection. Trauma informed SUDS understand, embody, and reflect this belief about the etiology of harmful substance use.

In closing, a medical system which does not meet the needs of its clients is sure to fail. To support our most vulnerable community members, we must create systems that are attentive to the patient experience as well as the patient outcomes. These trauma-informed systems are ours to create. They are within reach and will not only save lives—they will transform them.

Special thanks to Anthony Jordan, Tracy Bitz and Dr. Laura Kehoe who inspired some of the thoughts above.

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Lydia Anne M Bartholow, DNP, PMHNP, CARN-AP  is a doctorally prepared psychiatric nurse practitioner, substance use disorder specialist, and educator located in Portland, Oregon. She is the Associate Medical Director of Outpatient Substance Use Disorders at Central City Concern, a well-known houseless health services center. She provides direct care for clients with co-occurring disorders, as well as overseeing the safety and clinical quality of all patient care. Lydia completed both her masters and her doctorate in psychiatric nursing at Oregon Health and Sciences University; her doctoral work focused on the intersection between psychological trauma and substance use disorders. Lydia lectures across the state on topics such as medication assisted treatment, trauma informed care, and difficult conversations. She carries a deep commitment to harm reduction, health justice and holistic care. Lydia lives in Portland, Oregon with one child, one pit bull and one husband.