Physical, sexual or emotional abuse as a child, or other childhood stresses, can lead to higher levels of health service use throughout adulthood, found a UK analysis. A separate US report on Adverse Childhood Experiences (ACE) explains opioid addiction as a ‘normal response’ to ACE.
It’s not the drugs. It’s the ACEs – adverse childhood experiences, says addiction specialist Daniel Sumrok. He is quoted in an Aces Too High report as saying: “Addiction shouldn’t be called addiction. It should be called ritualised compulsive comfort-seeking”. He says: Ritualised compulsive comfort-seeking (what traditionalists call addiction) is a normal response to the adversity experienced in childhood, just like bleeding is a normal response to being stabbed.
According to the report, he says: “The solution to changing the illegal or unhealthy ritualised compulsive comfort-seeking behavior of opioid addiction is to address a person’s adverse childhood experiences (ACEs) individually and in group therapy; treat people with respect; provide medication assistance in the form of buprenorphine, an opioid used to treat opioid addiction; and help them find a ritualised compulsive comfort-seeking behavior that won’t kill them or put them in jail.”
Sumrok is the director of the Centre for Addiction Sciences at the University of Tennessee Health Science Centre’s College of Medicine – the first to receive the Centre of Excellence designation from the Addiction Medicine Foundation, a US organisation that accredits physician training in addiction medicine. Sumrok is also one of the first 106 physicians in the US to become board-certified in addiction medicine by the American Board of Medical Specialties.
The report says Sumrok, a family physician and former US Army Green Beret who’s served the rural area around McKenzie, TN, for the last 28 years, combines the latest science of addiction and applies it to his patients, most of whom are addicted to opioids – but also to alcohol, food, sex and gambling.
Since he first sat down in the early 1980s to write a research paper to describe the symptoms of the newly named post-traumatic stress disorder in Vietnam veterans – “problems with the law, having trouble sleeping, anxiety, divorce, sleep troubles, substance use disorders, depression, anxiety, cognitive and chronic pain issues” – the report says Sumrok has pieced together the ingredients for a revolutionary approach to addiction. It’s an approach that’s advocated by many of the leading thinkers in addiction and trauma, including Drs Gabor Maté, Lance Dodes and Bessel van der Kolk.
Surprisingly, the report says, it’s a fairly simple formula: Treat people with respect instead of blaming or shaming them. Listen intently to what they have to say. Integrate the healing traditions of the culture in which they live. Use prescription drugs, if necessary. And integrate adverse childhood experiences science: ACEs. “My patients seem to respond really well to this,” he says.
Learning about ACEs more than two years ago was a big turning point for his understanding of addictions, explains Sumrok. “I was working in an eating disorders clinic and someone told me ‘90 percent of these folks have sexual trauma’. I remember thinking: That can’t be right. But that was exactly right. Since I’ve learned about ACEs, I talk about it every day.”
He also practices it every day, by integrating ACEs assessments for all patients in his clinics. He currently has about 200 patients who are addicted, most to opioids (heroin and prescription pain relievers, including oxycodone, hydrocodone, codeine, morphine, and fentanyl). “I’ve seen about 1,200 patients who are addicted,” he says. “Of those, more than 1,100 have an ACE score of 3 or more.”
Sumrok knows that score says a lot about their health and ability to cope: ACEs comes from the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), groundbreaking research that looked at how 10 types of childhood trauma affect long-term health. They include: physical, emotional and sexual abuse; physical and emotional neglect; living with a family member who’s addicted to alcohol or other substances, or who’s depressed or has other mental illnesses; experiencing parental divorce or separation; having a family member who’s incarcerated, and witnessing a mother being abused.
Subsequent ACE surveys include racism, witnessing violence outside the home, bullying, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, witnessing a sibling being abused, witnessing a father or other caregiver or extended family member being abused, involvement with the criminal justice system, attending a school that enforces a zero-tolerance discipline policy, etc.
The report says the ACE Study is one of five parts of ACEs science, which also includes how toxic stress from ACEs damage children’s developing brains; how toxic stress from ACEs affects health; and how it can affect our genes and be passed from one generation to another (epigenetics); and resilience research, which shows the brain is plastic and the body wants to heal. Resilience research focuses on what happens when individuals, organizations and systems integrate trauma-informed and resilience-building practices, for example in education and in the family court system.
The ACE Study found that the higher someone’s ACE score – the more types of childhood adversity a person experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and a bunch of other consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700% and the risk of attempted suicide by 1200%.
High ACE scores also relate to addiction: Compared with people who have zero ACEs, people with ACE scores are two to four times more likely to use alcohol or other drugs and to start using drugs at an earlier age. People with an ACE score of 5 or higher are seven to 10 times more likely to use illegal drugs, to report addiction and to inject illegal drugs.
The ACE Study also found that it didn’t matter what the types of ACEs were. An ACE score of 4 that includes divorce, physical abuse, an incarcerated family member and a depressed family member has the same statistical health consequences as an ACE score of 4 that includes living with an alcoholic, verbal abuse, emotional neglect and physical neglect. Subsequent research on the link between childhood adversity and addiction corroborates the findings from the ACE Study, including studies that have found that people who’ve experienced childhood trauma have more chronic pain and use more prescription drugs; people who experienced five or more traumatic events are three times more likely to misuse prescription pain medications.
“ACEs just doesn’t predict substance abuse disorders,” says Sumrok. “All of our major chronic diseases link to substance abuse, so this is too big to ignore.” Whether you’re talking about obesity, addiction to cigarettes, alcohol or opioids, the cause is the same, he says: “It’s the trauma of childhood that causes neuro-biological changes.” And the symptoms he saw 40 years ago in soldiers returning from Vietnam are the same in the people he sees today who are addicted to opioids or other substances or behaviors that help them cope with the anxiety, depression, hopelessness, fear, anger, and/or frustration that continues to be generated from the trauma they experienced as children.
The report says learning about ACEs helped him understand that the original definition of PTSD, which many people still cling to, is not accurate. In the 1980s, PTSD was defined as a result of trauma that was outside the realm of normal experience. “That was just wrong,” says Sumrok. “Divorce, living with depressed or addicted family members are very common events for kids. My efforts are around helping people to see the connections, and that their experiences are predictable and normal. And the longer the experiences last, the bigger the effect.”
He also says, “Drop the ‘D’, because PTSD is not a disorder.” It’s what he learned from van der Kolk. “Bessel says we’ve named this thing wrong. Post-traumatic stress is a brain adaptation. It’s not an imagined fear. If one of your feet was bitten off by a lion, you’re going to be on guard for lions,” explains Sumrok. “Hypervigilance is not an imagined fear, if you’ve had one foot bitten off by a lion. It’s a real fear, and you’re going to be on the lookout for that lion. I tell my patients that they’ve had real trauma that’s not imagined. They’re not crazy.”
Sumrok normalises their addiction, which he explains is the coping behavior they adopted because they weren’t provided with a healthy alternative when they were young. He explains the science of adverse childhood experiences to them, and how their addictions are a normal – and a predictable – result of their childhood trauma. He explains what happens in the brain when they experience toxic stress, how their amygdala is their emotional fuse box. How the thinking part of their brain didn’t develop the way it should have. How it goes offline at the first sign of danger, even if they’re not connecting the trigger with the experience. Drugs like Zoloft don’t really help much, he tells them. Zoloft and other anti-depressants don’t remove the memory triggered by the odor of after shave that was worn by your uncle who sexually abused you when you were eight, or the memory triggered by a voice that sounds just like your mother who used to beat you with a belt, or by a face of a man who looks like your father who used to scream at you about how worthless you were…the examples are infinite. That’s why van der Kolk says, “’The body keeps the score’,” Sumrok says.
“After I explain all this to them, many of them stare at me and say: ‘You mean I’m not crazy?’” says Sumrok. “I tell them, ‘No, you’re not crazy’.” Sometimes he yells out the door to his nurse: ‘Patsy! Where’s my not-crazy stamp? I need to stamp this person’s chart.”
The report says for people who are addicted to opioids, he prescribes buprenorphine (one of the brand names: Suboxone), which helps them to withdraw from opioids and to keep their job, or return to work. For most people, the drug is less addictive than other opioids. Sometimes if people are young, healthy and haven’t been addicted long, they can withdraw from opioids without buprenorphine. “There’s no buzz associated with buprenorphine,” says Sumrok. “They can concentrate and think. Once they’re free of the continuous distraction of the acquisition and use of substances, they become pretty valuable employees.”
For people who are addicted to alcohol, he prescribes naltrexone (one of the brand names: Revia), because alcoholics have a high risk of death if they aren’t provided medication. And in this current national attention on opioids, Sumrok is careful to point out that although 33,000 people died from opioid overdose in 2015, 88,000 people die annually from alcohol-related causes, and 480,000 from cigarette smoking. The complicating factor – and why policies don’t work when they chase the eradication of one drug, only to focus on eradicating the next popular drug of choice for “ritualized compulsive comfort-seeking” – is that many people use opioids and alcohol and cigarettes. And if they receive no help to get at why they’re using legal or illegal substances, they will move on to another, more easily accessible drug when the current drug they’re using becomes more difficult to find.
Because Sumrok has kept fastidious records of the patients who have done their ACE scores, Dr Karen Derefinko, a clinical psychologist and assistant professor in the department of preventive medicine at the University of Tennessee Health Science Centre, is starting a research project to examine all 1,200 records in Sumrok’s clinic in McKenzie to look at the relationship between people’s ACE scores and their adherence to treatment and their relapses.
“We think that people with high ACE scores are likely to have more relapses,” she says. “And that may be because people with higher scores have fewer resources and more difficulty associated with adhering to their treatment plans.”
Through the records and the focus groups, Derefinko hopes to identify barriers to care, which include basics such as how people can find good care easily (most of Sumrok’s patients find out about him through word of mouth), being wary of the treatment because it isn’t explained to them, or – what Sumrok hears a lot – being judged or talked down to instead of given understanding and respect. “In Shelby County, people complain about barriers to care, which many people think is because of economics,” she says. “But it may not be just economics that is keeping people from accessing treatment; it may be more about being judged, and not knowing what the treatment looks like.”
Prescription and illicit opioids are the “main driver of drug overdose deaths,” according to the CDC, with 33,091 deaths in 2015. The report says that’s four times more than 1999. And between 2014 and 2015, Tennessee saw a 13.8% increase in opioid deaths. More than 1,000 people died from opioid overdoses in 2014, and tens of thousands of people lead desperate lives, most of them unknowingly fueled by their childhood experiences. Only 10% of these are getting the help they need, says Sumrok.
Dr David Stern, Robert Kaplan executive dean and vice-chancellor for clinical affairs for the University of Tennessee’s College of Medicine and the University of Tennessee Health Sciences Centre, who launched the Centre for Addiction Science, says: “… When I developed the Centre for Addiction Science, it had to be like a cancer centre, it had to be multi-disciplinary. In the old days, we thought people who had addictions were weak in the moral department. You really needed someone to straighten you out, because your mother didn’t do a good enough job.”
But that approach doesn’t work. Neither does criminalising addictions. Stigma drives problems underground, says Stern, instead of driving them to a solution. The center is taking an integrated approach to using research and education to help people in all possible ways, from physiology to genetics to counselling.
Stern believes that every physician should know about ACEs science, which is one of the reasons he chose Sumrok to lead the centre, along with his willingness to be creative and seek solutions across disciplines. “Two of the most prevalent things in acute care are depression and addiction,” says Stern. “I think it’s important to be able to understand what ACEs mean to patients, what addiction is all about, how to recognize it, how to treat it.” He’s in the process of finding an associate dean for medical education, and is looking for someone who will integrate ACEs and other social determinants of health into the school’s curriculum.
“I think a medical school should provide for the community it serves,” says Stern. “This medical school should be the medical school for Memphis. We should develop solutions that are scalable.”
Dr Altha Stewart, associate professor of psychiatry in the University of Tennessee College of Medicine, learned about ACEs in 2009 when a group in Shelby County began educating people about ACEs science. They brought Dr Vincent Felitti, co-founder of the ACE Study, and Robin Karr Morse to give a presentation. “It’s become a core part of what I do now in my professional work,” says Stewart, who was recently named president-elect of the American Psychiatric Association. She’s working with the Shelby County community and the local criminal justice system to integrate trauma-informed and resilience-building practices to find ways to help youth who enter the justice system – all of whom have likely experienced ACEs – instead of shaming, blaming or punishing them.
The things that have happened to kids – as well as to many people who come into the health care system – are out of their control, Stewart is quoted in the report as saying. “When you’re a child, you don’t control the people who abuse and assault you, who create hostile environments, who don’t provide you with clean clothes,” she says, “If a child can’t control their environment, because of these things they grow up thinking they’re bad, different, horrible people. This new approach (integrating trauma-informed and resilient-building practices based on ACEs science) helps them feel like they’re not drowning anymore. When they can pop their head out of the water and get a breath, and see outstretched hands, a life preserver, a life boat, that changes their entire perspective.”
When Sumrok began integrating ACEs into addiction treatment, that was innovative, says Stewart. “If you don’t ask these questions, people tend not to tell you,” she says. Sumrok’s approach is part of a shift in patient engagement and involvement. “The trend in health care is that patients are partners in their treatment.”
This new knowledge about why and how humans behave the way they do also speaks to how “we have trained the medical profession,” says Stewart. The traditional approach is that physicians “know everything. The people whom we treat know nothing. We tell them what to do, and if they don’t get better or do what we say, it’s their own fault.
“That’s simply not true,” she emphasises. “Some of us have come to understand that there’s more expertise in the community and our patients than we’ve understood. That takes a bit of humility on the part of a physician, and an understanding that we are partners in helping a person heal.”
The report says Sumrok’s experience with the young fellows at the Centre for Addiction Science is giving him some real hope that the medical profession can change. When he’s explained to them how important it is to ask patients about ACEs and other aspects of their lives – such as food availability, safe housing, transportation, jobs (in the medical profession vernacular: social determinants of health) – “they say ‘isn’t that just taking a patient history?’”
He and others at the University of Tennessee Health Sciences Centre have an opportunity to educate young physicians outside the state, too, the report says. Derefinko is also director of the newly created National Centre for Research of the Addiction Medicine Foundation. The foundation oversees the 130 addiction medicine fellowships at 46 medical schools across the country.
“We want metrics to understand the impact they’re having” when they go out in the world, says Derefinko: where they go, whom they’re treating, how they’re practicing, whether they’re integrating ACEs science. In addition, the foundation will be developing some accreditation guidelines so that all fellows receive the latest and best education in addiction medicine.
One of those elements, says Sumrok, has to be empathy, which physicians can practice by listening, acknowledging and understanding how the experiences in a person’s childhood and adulthood have shaped their lives and health.
Now new research has shown experiencing physical, sexual or emotional abuse as a child, or other stresses such as living in a household affected by domestic violence, substance abuse or mental illness, can lead to higher levels of health service use throughout adulthood. This research paper provides, for the first time, the statistical evidence showing that, regardless of socio-economic class or other demographics, people who have adverse childhood experiences use more health and medical services through their lifetime.
The research showed that individuals who suffered multiple types of ACEs (physical, sexual or emotional abuse or other stresses such as living in a household with domestic violence or with adult substance abuse or mental illness) are more than twice as likely to use hospital emergency departments, require overnight hospital stays or be frequent users of general practices as adults.
The study of 7,414 adults in England and Wales compared those who suffered ACEs with those whose childhoods were ACE free. Those with four or more ACEs showed substantially increased levels of health care use even as young adults (18-29 years) with these increases still apparent decades later.
In young adults with no ACEs 12% needed to attend an emergency department in the last year, rising to 29% in those with four or more ACEs. By the age of 60-69 years 10% of individuals with no ACEs required at least one overnight hospital stay (in the last year) rising to 25% of those with four or more ACEs.
High levels of ACEs are common. In this general population sample 10% of all adults had experienced four or more ACEs as a child meaning that childhood trauma may be a major contributor to pressures on adult health services.
The researchers from Bangor University’s College of Health and Behavioural Sciences conclude that investing in preventing or reducing adverse childhood experiences as well as addressing the resulting trauma in those who have experienced ACEs, can help reduce future health service demand and costs.
Mark Bellis, professor of public health at Bangor University’s College of Health & Behavioural Sciences said: “Even at the most basic biological levels, experiencing ACEs can change children leaving them more likely to develop poor physical and mental health throughout their lives. A safe and nurturing childhood is a recipe for building stronger, happier children, with a much greater chance of becoming healthy adults.”
“Our results demonstrate that the more adverse experiences people suffer as a child the more likely they are as adults to be frequent users of basic health services such as GPs and emergency services as well as requiring more specialist overnight hospital support. As costs of health care escalate in the UK and abroad, it is essential we take a life course approach to health that recognises the problems we frequently see in adults begin with childhood traumas.”
Commenting on the study, Professor John Middleton, president of the UK Faculty of Public Health said: “The vast majority of parents want to set their children on healthy life courses and there is a great deal that health and other public services can do to help, especially in the poorest communities. Investing in quality childhoods can break cycles of adversity that have affected families for generations. However, cutting corners with support for families and children will mean we continue to pay in poor adult health and increased pressures on health services for generations to come.”
Professor Karen Hughes, of Bangor University, a co-author of the paper added: “Adult risks of becoming smokers or heavy drinkers and of developing cancers, diabetes and other life-threatening diseases are all increased in those with a history of childhood adversity. This study shows how the health consequences of ACEs impact not just on the individual but also on the health services that support them. Health professionals already play a substantive role in treating the life-long impacts of childhood adversity but recognising the role ACEs play in adult ill health should provide opportunities for better treatment and a greater focus on prevention.”
Objectives: The lifelong health impacts of adverse childhood experiences are increasingly being identified, including earlier and more frequent development of non-communicable disease. Our aim was to examine whether adverse childhood experiences are related to increased use of primary, emergency and in-patient care and at what ages such impact is apparent.
Methods: Household surveys were undertaken in 2015 with 7414 adults resident in Wales and England using random probability stratified sampling (age range 18–69 years). Nine adverse childhood experiences (covering childhood abuse and household stressors) and three types of health care use in the last 12 months were assessed: number of general practice (GP) visits, emergency department (ED) attendances and nights spent in hospital.
Results: Levels of use increased with increasing numbers of adverse childhood experiences experienced. Compared to those with no adverse childhood experiences, odds (±95% CIs) of frequent GP use (≥6 visits), any ED attendance or any overnight hospital stay were 2.34 (1.88–2.92), 2.32 (1.90–2.83) and 2.67 (2.06–3.47) in those with ≥ 4 adverse childhood experiences. Differences were independent of socio-economic measures of deprivation and other demographics. Higher health care use in those with ≥ 4 adverse childhood experiences (compared with no adverse childhood experiences) was evident at 18–29 years of age and continued through to 50–59 years. Demographically adjusted means for ED attendance rose from 12.2% of 18-29 year olds with no adverse childhood experiences to 28.8% of those with ≥ 4 adverse childhood experiences. At 60–69 years, only overnight hospital stay was significant (9.8% vs. 25.0%).
Conclusions: Along with the acute impacts of adverse childhood experiences on child health, a life course perspective provides a compelling case for investing in safe and nurturing childhoods. Disproportionate health expenditure in later life might be reduced through childhood interventions to prevent adverse childhood experiences.
Mark Bellis, Karen Hughes, Katie Hardcastle