Even though commonly overshadowed, emotional trauma forms the fundamental core of many types of addictions.
Since the 1970s, trauma has been understood and recognized as a key component in the development of substance abuse disorders and relapse. Recent years have, however, witnessed a much-needed resurfacing of awareness and treatment of trauma, including post-traumatic stress disorder (PTSD), as a co-occurring disorder alongside addiction.
According to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH), approximately 7.9 million adults in the United States had co-occurring disorders, that is, struggling with both addiction and a mental health disorder. Of these people, only a small minority seeks treatment for both conditions, and most receive no treatment at all. 
Post-Traumatic Stress and Addiction
Trauma is an emotional response to an extremely stressful or life-threatening event, including an accident, rape, abuse and neglect, bullying or natural disaster, whether experienced or witnessed.
Shock and denial are typical right after. Long-term reactions of post-traumatic stress include unpredictable emotional outbursts, intense fear, depression, addictive or impulsive behaviors, flashbacks, strained relationships and even physical symptoms, like headaches or nausea.
Trauma is subjective, meaning what matters most are the individual’s internal beliefs and their innate sensitivity to stress, not whether a family member, therapist or other outsider deems an experience traumatic.
Trauma’s association with drug addiction extends further toward overeating, compulsive sexual behavior and other types of addictions, as well.
The Adverse Childhood Experiences study, which is based on data from over 17,000 Kaiser Permanente patients, found correlations between severe childhood stress (e.g., abuse, neglect, loss of a parent, domestic violence, or having an addicted or mentally ill parent) and various types of addictions.
Results uncovered that a child with four or more traumatic childhood experiences was five times more likely to become an alcoholic and 60 percent more likely to become obese. A boy with four or more of these experiences is 46 times more likely to become an injection drug user than other children. The researchers found that the effects of trauma are accumulative over the years. 
Complexities in Diagnosis and Prognosis
Co-occurring disorders are difficult to diagnose owing to the intricate complexities of symptoms, as both may differ in terms of severity and an overlap of biological, psychological and social implications. Often, patients receive treatment for one disorder while the other disorder remains untreated.
Patients with co-occurring disorders generally have been found to have poorer prognoses.
Research suggests that persons with co-occurring disorders are at higher risk of suicide, psychiatric hospitalization, legal complications and incarceration, homelessness, fatal infectious diseases, domestic violence, abuse or neglect of their children, unemployment, and other interpersonal problems.
Treatment Modalities for Dual Diagnosis
People with co-occurring disorders are best served through integrated treatment where health practitioners acknowledge both mental and substance use disorders simultaneously, yielding lowered costs and better outcomes. Early detection and treatment can improve outcomes and the quality of life for those who need these services.
Such integrated treatment requires staff members, whether of opioid addiction treatment or mental health facility, to be trained in dealing with both disorders.
Medication-assisted treatment (MAT). This is treatment for addiction that includes the use of medication along with counseling and other support.
Treatment that includes medication is often the best choice for opioid addiction.
The most common medications used in treatment of opioid addiction are methadone, buprenorphine and naltrexone. The former two trick the brain into thinking it is still receiving an opioid dose and the latter takes away the withdrawal symptoms.
Pharmacotherapy. In many ways, an opioid treatment is an optimal setting to initiate and monitor psychiatric pharmacotherapy for co-occurring disorders as physicians and other staff can observe the reactions of patients to psychotropic medications and addiction treatment medications on a daily basis.
Where the administration of psychotropic medications in concerned, these should only be prescribed when the patient in stabilized on treatment medication and need to be closely monitored. Medications with least abuse potential should be prioritized.
Psychoeducation. Group sessions present information about certain issues to help patients and their families. Patients can explore relevant themes in context of positive coping strategies and sharing experiences. Topics may include psychosocial effects of co-occurring disorders, information regarding medications and the recovery process amongst many others.
Counseling, Psychotherapy, and Mutual-Help Groups. The focus of these treatment modalities is to encourage the patient to open up about their feelings and experiences, alongside imparting to them new constructive coping skills to overcome their problems in desired ways. 
Since patients in MAT exhibit a wide array of co-occurring disorders, early treatment planning and resource management should include categorizing patients, at least tentatively, into the types and severity of co-occurring disorders. This tailors treatment individually in a more efficient manner. These are as follows:
Patients in acute psychiatric danger
Patients exhibiting suicidal or homicidal tendencies, and psychotic symptoms, like hallucinations and paranoia, need to be evaluated and treated immediately. Outpatient care, under such circumstances, may be an unsafe option.
Hence, admission to a psychiatric unit is necessary as the symptoms persist. Antipsychotic drugs may also be needed to initiate behavioral control.
Patients with established, severe co-occurring disorders
Such patients should receive medication with the lowest abuse potential for their condition. If the staff of an opioid treatment program is fully trained to treat patients with severe co-occurring disorders, such as schizophrenia, then treatment can continue onsite. Otherwise, treatment needs to be coordinated with other mental health providers effectively.
Patients with less severe, persisting or emerging symptoms of co-occurring disorders
Such patients in a medically-assisted treatment should continue or begin medication, psychotherapy, or both for their co-occurring disorders, given that the staff onsite is adequately trained.
Patients with less severe, presumptively substance-induced co-occurring disorders
Patients in MAT with symptoms of Axis I disorders but no history of primary co-occurring disorders receive no new psychotropic medications until they are stabilized on MAT because their symptoms might remit or significantly diminish after a period of substance abuse treatment. 
Raising Awareness for Trauma and Addiction
In order to improve treatment for people with co-occurring disorders, including post-traumatic stress, roles of competent practitioners need to be defined and a common framework for working collaboratively across social service systems needs to be established.
These guidelines for clinical supervisors must be utilized and incorporated into existing job descriptions, training plans, supervision meetings, personal evaluation, and credentialing and licensure to ensure a comprehensive, integrated care system.
About the Author:
A journalist and social media savvy content writer with wide research, print and on-air interview skills, Sana Ahmed has previously worked as staff writer for a renowned rehabilitation institute focusing on mental health and addiction recovery, a content writer for a marketing agency, an editor for a business magazine and been an on-air news broadcaster.
Sana graduated with a Bachelors in Economics and Management from London School of Economics and began a career of research and writing right after. The art of using words to educate, stir emotions, create change and provoke action is at the core of her career, as she strives to develop content and deliver news that matters.
The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer discussion of various issues by different concerned individuals.
We at Addiction Hope understand that addictions result from a combination of environmental and genetic factors. If you or a loved one are suffering from an addiction, please know that there is hope for you, and seek immediate professional help.
Published on July 27, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on July 27, 2017
Published on AddictionHope.com