Introduction

Opiate use disorder (OUD) is defined as a pattern of opioid use leading to problems or distress that may result in physical and psychological dependence attributed to complex interactions among brain circuits, genetics, environment, and life experiences (American Psychiatric Association, 2013; American Society of Addiction Medicine (ASAM), 2020). Risk factors for opiate use disorder include adverse childhood experiences (ACES), psychological trauma exposure, younger age of first use, co-occurring mental health disorders, and diminished availability of recovery resources and mental health services (ASAM, 2020). Recreational opiate use and OUD may result in increased morbidity and mortality. Opiate overdose deaths in the US are increasing every year, claiming over 100,000 lives in 2022 (American Medical Association, 2020; Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (CDC), 2020; National Institutes of Health, 2023). OUD is a subcategory of substance use disorder (SUD). SUD is a complex brain disease characterized by the uncontrolled use of a substance despite harmful consequences. Examples of types of substances include opiates, cocaine, methamphetamine, marijuana, alcohol, etc. (APA, 2013).

Trauma exposures are a common occurrence. The results of a worldwide survey study by Benjet et al. (2015) reported that over 70 % of respondents reported a traumatic event, and 30.5 % of respondents were exposed to four or more PTEs in their lifetime. A trauma exposure is defined as an encounter with a negative event that may lead to an emotional response that overwhelms a person's mental capacity to process and integrate the event such as violence, sexual assault, a terrorist attack, or a natural disaster. Trauma exposure can lead to a trauma -or- stressor-related disorder or posttraumatic stress disorder (PTSD). The DSM-5 criteria for PTSD include direct or indirect exposure to a traumatic event, followed by a total of eight symptoms in four categories including, intrusion, avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity (APA, 2013). However, people's lives can be negatively impacted by symptoms that don’t meet diagnostic criteria for a disorder. For example, experiencing psychological trauma exposures can manifest with symptoms that don’t meet diagnostic criteria for a disorder, but these symptoms can cause significant impairment in function and health depending on the number of trauma exposures. Trauma exposures may consist of psychological trauma exposure (PTE), trauma and stress-related disorders including PTSD, and adverse childhood experiences (Substance Abuse and Mental Health Services Administration (SAMHSA), 2022). This study will focus on PTE and PTSD. Persons with a history of PTEs, PTSD, and comorbid SUD may experience a more complicated and costly course of treatment including chronic physical and mental health problems, poorer social functioning, higher rates of suicide attempts, increased risk of violence, as well as poor treatment adherence and outcomes (Watkins et al., 2022). Based on these findings, some studies support integrated trauma treatment for veterans with co-occurring PTE, PTSD, and SUD (Blakey et al., 2022).

While the relationship between PTE, PTSD, and SUD is well documented (Brady et al., 2021, p. 123)., these factors are understudied concerning OUD (Bernardy & Montaño, 2019). Several studies have reported that 52 % of persons diagnosed with OUD also screened positive for comorbid PTSD (Hassan et al., 2017; Hooker et al., 2020; Shiner et al., 2018; Smith et al., 2016). Other studies have reported that veterans with concurrent PTSD treatment remained in OUD treatment longer (Meshberg-Cohen et al., 2019; Mills et al., 2018).

While some studies have shown a high rate of PTSD among SUD clients, none have specifically studied the influence of PTE on OUD. Bernardy and Montaño (2019) notes that difficulties in determining the rate of PTE among OUD clients result from OUD diagnosis being grouped with SUD diagnosis. This has limited our knowledge of the extent of PTE among persons suffering from OUD. Understanding the influence of PTE on OUD is crucial for the formulation of targeted interventions that support the prevention, treatment, and recovery of PTE and OUD. The purpose of this descriptive study is to examine the influence of PTE on the development of OUD in an urban treatment facility in Pennsylvania and to provide foundational work for future interventional studies involving PTEs and OUD.

Aim 1: Describe the demographic characteristics of OUD and SUD participants.

Aim 2: Examine the associations between PTE and PTSD diagnoses of OUD and SUD participants.

Aim 3: Examine the number PTE of occurrences in OUD and SUD participants.

Theoretical framework

The “self-medication hypothesis” (SMH) of substance use disorder states that persons may self-medicate with substances to attempt to manage emotional dysregulation and/or distressful emotional symptoms (Khantzian, 1997). The purpose of the “self-medication hypothesis” (SMH) is to explain the relationship between distressing emotional states and the development of SUD. The theory structure is linear and is consistent with a health model. The overall assumption about the theory is that substances are consumed selectively, based on their pharmacological effects to lessen emotional reactivity or distress. Another assumption of the theory is the disease model of addiction. The “SMH” uses concepts of person, distressing symptoms with maladaptive coping, and substance use disorder.

These concepts are similar to those of interest to professionals caring for clients in recovery from SUD. Although not explicitly stated, it can be inferred that the concept was defined as a human comprised of biological, psychological, and social factors since the “SMH” was formulated by a psychiatrist in 1997. Distressing symptoms are defined as affective symptoms of anxiety, depression, and emotional dysregulation. Maladaptive coping is defined as, “characteristic patterns of defense and avoidance that both reveal and disguise the intensity of their suffering, their confusion about their feelings, or how they are cut off from their feelings” (Khantzian, 1997). SUD is defined as the compelling, progressive, and deteriorating use of addictive substances that can lead to a loss of function, relationships, and life (Khantzian, 1997) (Fig. 1). The “SMH” describes one possible relationship between distressing symptoms and SUD, however, other clinically relevant circumstances were missing. For example, the “SMH” attributed distressing symptoms to mental health conditions, such as diagnosis of PTSD, depression, anxiety, or schizophrenia. However, people’s lives can be negatively impacted by symptoms that don’t meet diagnostic criteria for a disorder.

The adapted SMH framework’s concepts comprise the individual, TE, and OUD/SUD. The individual concept includes demographics and TE concepts consist of PTE and PTSD. The maladaptive coping concept includes OUD/SUD (Fig. 2).

Materials and methods

The study employed a chart review of participants from the outpatient substance use facility at the drug and alcohol division of Crozer Chester Medical Center (CCMC) in the city of Chester, Pennsylvania. An exempt IRB approval from Case Western Reserve University (CWRU) and CCMC was obtained.

A convenience sample size of n = 150, comprised of 75 OUD clients and 75 SUD clients was used to collect data from the medical records of the most recently admitted clients. The sample size was met by counting backward until the target sample size was met starting from April 2022. All identifiable information was removed or redacted. The investigator manually reviewed subjects' medical records for inclusion and exclusion criteria, as well as, collected data for variables of interest over two weeks, and stored an encrypted and locked file.

An investigator-developed demographic survey was used to collect demographic data and “The Life Events Checklist for DSM-5 (LEC-5) was used to measure PTE. The demographic tool assesses gender, age, as well as race, and ethnicity. The LEC-5 is a self-report screening tool that measures potentially traumatic events in a respondent's lifetime. The LEC-5 assesses exposure to sixteen events known to potentially result in emotional distress or PTSD. The LEC-5 includes one additional item assessing any other extraordinarily stressful event not captured in the first sixteen items” (Weathers et al., 2013).

The LEC-5 does not have a recognized scoring method. However, the respondents designate levels of exposure to each type of possible traumatic event included on a 6 categorical scale. The categories are “happened to me”, “witnessed it”, “learned about it”, “part of my job”, “not sure “ or “doesn't apply” The categories of “happened to me” and/or “witnessed it” will be counted as PTE if selected. PTE occurrences will be counted as 1–17, as the number of items detailed on the LEC-5 (Weathers et al., 2013). Psychometrics are not currently available for the LEC-5 (Gray et al., 2004).

Results

Demographic characteristics are listed in Table 1. In a sample size of n = 75 OUD, the clients' ages ranged from 18 to 63 with an average participant age of M = 37.12 (SD = 10.52), 51 % were female, 49 % were male, 21 % were African American/Black, 73 % were White, Non-Hispanic, and 5 % were Hispanic/Latino. In the SUD group (n = 75), the clients' ages ranged from 18 to 73, with an average participant age of M = 46.64 (SD = 14.14). In this group, 41 % were female, 58 % were male, 55 % were African American/Black, 43 % were White, Non-Hispanic, 1 % were Hispanic/Latino, and 1 % were Asian.

Psychological traumatic experiences

As noted in Table 2, the majority of participants reported experiencing at least three traumatic events. There was not a significant difference in the PTE scores for OUD, N = 75 (M = 3.49, SD = 3.33) and SUD, N = 75 (M = 2.87, SD = 2.54); t (148) = −1.296, p = 0.98. However, these results suggest a trend that supports PTE may influence the occurrence of OUD, based on higher PTE mean scores in the OUD group when compared to the PTE mean scores in the SUD group (Table 3). Regarding the diagnosis of PTSD, there was not a significant difference in the number of participants diagnosed with PTSD in either OUD or SUD groups, Chi-Square (χ² = 1.918, df = 1, p = 0.166) (Table 4).

An odds ratio did not show a significant relationship in the trauma scores between the OUD and SUD groups, (χ² = 1.684, df = 1, p = 0.194). However, a PTE score of > four is associated with a higher risk of poorer mental health outcomes (SAMHSA, 2018). A chi-square test of independence showed that there was no significant association of TE 0 < 4 between SUD and OUD groups, Chi-Square (χ² = 1.407, df = 1, p = 0.236). Although, further scoring revealed that participants with PTE > five are more likely to develop OUD, Chi-Square (χ² = 5.17, df = 1, p = 0.023). A frequency tabulation revealed that among clients with a TE > five, OUD was 38.6 % (N = 29), and SUD was 24.9 % (N = 19) respectively (see Table 5).

Discussion

The purpose of this study was to examine the influence of psychological traumatic experiences (PTE) on the development of opiate use disorder (OUD) in an urban treatment facility in Pennsylvania.

Aim One: Demographic Findings

Demographic findings of OUD participants revealed a mean age of 37, 51 % female, and predominantly White. These results are consistent with prior research on OUD demographics in the U.S., showing that OUD treatment is associated with older age and Caucasian race (Brorson et al., 2013; Bullinger et al., 2022). However, our results regarding the number and percentage of African Americans in OUD treatment are not consistent with current research that indicates OUD rates are similar for both Blacks and Whites (3.5 % for Blacks, 4.7 % for Whites) or the community demographics for the study site (Gramlich, 2022; Substance Abuse and Mental Health Services Administration, 2020).

Aim Two: Trauma Exposure

Our results indicated that 75 % of OUD participants experienced one or more traumatic events. These results align with other studies (Rosic et al., 2021; Keyser-Marcus et al., 2016). However, the percentage of co-occurring PTSD diagnoses within the OUD (18.7 %) group was lower than expected when compared to other studies, which have reported that 41 % of OUD clients have a lifetime history of PTSD and 33.2 % meet the criteria for a current PTSD diagnosis (Dahlby and Kerr, 2020).

Aim Three: Influence of PTE on OUD

Our study found that PTE may influence the occurrence of OUD based on higher PTE mean scores in the OUD group than in the comparison SUD group. Study results were significant on the influence of PTE on OUD when TE > 5. These findings are in line with emerging studies. A recent study by Rosic et al. (2021) showed that trauma and PTSD are prevalent among patients with OUD, stressing the importance of integrating addiction and mental health services for this population. Furthermore, Santo et al. (2022) found that childhood trauma exposure was a common, independent risk factor for OUD.

Racial Disparities

The study's racial findings did not reflect the community demographics or the emerging post-pandemic demographic data on OUD prevalence. The study site's community demographics report a 69 % African American population and a 17 % Caucasian population. Therefore, one would expect the racial makeup of study participants to reflect the community demographics and the study's racial demographics to be higher than the national average. Possible disparities may exist within the pool of available jail court referrals for OUD treatment, indicating that persons of color may be incarcerated rather than offered OUD treatment in place of incarceration. Other possibilities include ineffective or lack of community marketing of services at the Drug & Alcohol unit, implicit bias, and community mistrust. This phenomenon supports future research on when and where these disparities occur.

Unexpected Findings

The lack of a significant association between PTE and OUD in some of the analyses is unexpected, given previous research on PTE and SUD. Several factors may have contributed to this finding, including the small sample size and underreporting of PTE and PTSD in the sample data.

Implications

Measuring PTE in persons with OUD is crucial for the formulation of targeted interventions that support high-quality outcomes for individuals and families recovering from OUD. Our study found higher PTE scores in persons with OUD, emphasizing the importance of identifying PTE and PTSD and implementing trauma-based and trauma-informed strategies during OUD treatment planning. This study also indicated that the small number of PTSD diagnoses observed in the OUD sample is inconsistent with public domain statistics and prior research on PTSD and SUD, highlighting the need for structured evaluations for the assessment and diagnosis of PTSD as a best practice initiative.

Limitations

Our study limitations include threats to the internal validity selection of subjects. This study used a convenience sample of two groups from a single site, limiting its generalizability to that site. Although selection bias did not occur, random sampling and random assignment to groups may increase the possibility of result generalization to other populations. This study also used a descriptive retrospective design, which fits with the scheme of available studies and fills the gap of the lack of studies on the influence of PTE on OUD. Although this design establishes precedence, causality cannot be determined. Finally, the study's limitations include the use of paper medical records that required hand data collection and tabulation.

Implications for Future Research

Implications for future research from this study include examining how PTE predicts OUD using a larger sample size, either as a descriptive design with broader generalization, correlational, or experimental study. Further research is also needed on social determinants of health (e.g., housing and food instability, community violence, adverse childhood experiences) and disparities among OUD individuals. Future research should also expand on other outcome variables that are important to the OUD population and use a site with electronic medical records for data collection.

Conclusion

In conclusion, our study found evidence of a significant relationship between PTE > 5 and OUD, as well as some insignificant findings. While these insignificant findings may seem counterintuitive given existing research on PTE and SUD, they do underscore the complex nature of the relationship. Further research is needed to better understand these phenomena.

Introduction

Opiate use disorder (OUD) is a condition characterized by a problematic pattern of opioid use that leads to significant issues or distress. This disorder can result in both physical and psychological dependence, influenced by complex interactions involving brain function, genetics, environment, and personal life experiences. Factors that increase the risk of OUD include challenging childhood experiences, past exposure to psychological trauma, starting opioid use at a younger age, having co-occurring mental health conditions, and limited access to recovery support and mental health services.

Both recreational opiate use and OUD can lead to serious health problems and increased deaths. The number of opiate overdose deaths in the United States continues to rise annually, with over 100,000 lives lost in 2022. OUD is a specific type of substance use disorder (SUD), which is a complex brain disease marked by the uncontrolled use of a substance despite its harmful consequences. SUD encompasses the problematic use of various substances, such as opiates, cocaine, methamphetamine, marijuana, and alcohol.

Exposure to traumatic events is common. One global study indicated that over 70% of individuals reported experiencing a traumatic event, and 30.5% reported exposure to four or more potentially traumatic events (PTEs) in their lifetime. A traumatic exposure is defined as encountering a negative event, such as violence, sexual assault, a terrorist attack, or a natural disaster, which can lead to an emotional response that overwhelms a person's ability to cope and process the event. Such exposures can result in trauma- or stressor-related disorders, including post-traumatic stress disorder (PTSD). Criteria for PTSD include direct or indirect exposure to a traumatic event, followed by a combination of symptoms across categories such as re-experiencing the event, avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity. However, even symptoms that do not meet the full diagnostic criteria for a disorder can significantly impair a person's function and health, depending on the number of traumatic exposures. This study focuses specifically on PTE and PTSD. Individuals with a history of PTEs, PTSD, and co-occurring SUD may face a more complicated and costly treatment journey, including chronic physical and mental health issues, poorer social functioning, higher rates of suicide attempts, increased risk of violence, and less effective treatment adherence and outcomes. Based on these findings, some research supports integrated trauma treatment for veterans who experience co-occurring PTE, PTSD, and SUD.

While the connection between PTE, PTSD, and SUD is well-documented, these factors have been less studied specifically in relation to OUD. Several studies have reported that 52% of individuals diagnosed with OUD also screened positive for co-occurring PTSD. Other studies have found that veterans receiving concurrent PTSD treatment remained in OUD treatment for longer periods.

Although some studies have shown a high rate of PTSD among individuals with SUD, few have specifically examined the impact of PTE on OUD. Difficulties in determining the rate of PTE among OUD clients often arise because OUD diagnoses are grouped with broader SUD diagnoses. This has limited understanding of the extent of PTE among individuals suffering from OUD. Understanding the influence of PTE on OUD is vital for developing targeted interventions that support the prevention, treatment, and recovery from both PTE and OUD. The purpose of this descriptive study was to explore the influence of PTE on the development of OUD at an urban treatment facility in Pennsylvania and to provide foundational information for future intervention studies involving PTEs and OUD.

The study aimed to:

1. Describe the demographic characteristics of participants with OUD and SUD.

2. Examine the connections between PTE and PTSD diagnoses in participants with OUD and SUD.

3. Examine the number of PTE occurrences in participants with OUD and SUD.

Theoretical framework

The "self-medication hypothesis" (SMH) of substance use disorder suggests that individuals may use substances to try and manage emotional dysregulation or distressing emotional symptoms. The SMH aims to explain the relationship between distressing emotional states and the development of SUD. This theory proposes a linear connection, consistent with a health model. The main idea behind the theory is that substances are chosen based on their pharmacological effects to reduce emotional reactivity or distress. Another core assumption of the theory is the disease model of addiction. The SMH uses concepts such as the individual, distressing symptoms with maladaptive coping, and substance use disorder.

These concepts are relevant to professionals caring for individuals in recovery from SUD. Although not explicitly stated, it can be inferred that the individual is defined as a human being with biological, psychological, and social factors. Distressing symptoms are defined as emotional symptoms of anxiety, depression, and emotional dysregulation. Maladaptive coping is described as "characteristic patterns of defense and avoidance that both reveal and disguise the intensity of their suffering, their confusion about their feelings, or how they are cut off from their feelings." SUD is defined as the compulsive, progressive, and deteriorating use of addictive substances that can lead to a loss of function, relationships, and life. The SMH describes one possible relationship between distressing symptoms and SUD; however, it did not account for other clinically relevant circumstances. For example, the SMH attributed distressing symptoms to mental health conditions such as PTSD, depression, anxiety, or schizophrenia, but it did not fully address how symptoms that do not meet diagnostic criteria can still negatively impact lives.

The adapted SMH framework used in this study includes the individual, traumatic experience (TE), and OUD/SUD. The individual concept encompasses demographics, and the TE concept includes PTE and PTSD. The maladaptive coping concept includes OUD/SUD.

Materials and methods

This study involved a review of medical charts from participants at an outpatient substance use facility within a medical center in Chester, Pennsylvania. Approval for the study was obtained from the Institutional Review Boards of both Case Western Reserve University and the medical center.

A convenience sample of 150 participants, consisting of 75 individuals with OUD and 75 with SUD, was used. Data were collected from the medical records of the most recently admitted clients, counting backward from April 2022 until the target sample size was reached. All identifiable information was removed or redacted. The investigator manually reviewed subjects' medical records over two weeks for inclusion and exclusion criteria and collected data for variables of interest, storing the information in an encrypted and locked file.

An investigator-developed demographic survey was used to collect information on gender, age, race, and ethnicity. The Life Events Checklist for DSM-5 (LEC-5) was used to measure PTE. The LEC-5 is a self-report screening tool that assesses exposure to potentially traumatic events over a person's lifetime. It evaluates exposure to sixteen events known to potentially cause emotional distress or PTSD, with one additional item for any other extraordinarily stressful event not covered by the initial sixteen.

The LEC-5 does not have a formal scoring method. However, respondents indicate their level of exposure to each possible traumatic event using a six-category scale: "happened to me," "witnessed it," "learned about it," "part of my job," "not sure," or "doesn't apply." For this study, selection of "happened to me" and/or "witnessed it" was counted as a PTE. The number of PTE occurrences was counted as 1–17, based on the items detailed on the LEC-5. Psychometric data are not currently available for the LEC-5.

Results

Demographic characteristics are presented. In the sample of 75 OUD clients, ages ranged from 18 to 63, with an average age of 37.12 years. Among this group, 51% were female, 49% were male, 21% were African American/Black, 73% were White, Non-Hispanic, and 5% were Hispanic/Latino. In the SUD group of 75 clients, ages ranged from 18 to 73, with an average age of 46.64 years. In this group, 41% were female, 58% were male, 55% were African American/Black, 43% were White, Non-Hispanic, 1% were Hispanic/Latino, and 1% were Asian.

The majority of participants reported experiencing at least three traumatic events. No significant difference was found in the PTE scores between the OUD group (average of 3.49) and the SUD group (average of 2.87). However, these results suggest a trend indicating that PTE may influence the occurrence of OUD, as the OUD group had higher average PTE scores compared to the SUD group. Regarding a diagnosis of PTSD, no significant difference was observed in the number of participants diagnosed with PTSD in either the OUD or SUD groups.

An odds ratio analysis did not show a significant relationship in trauma scores between the OUD and SUD groups. However, a PTE score greater than four is associated with a higher risk of poorer mental health outcomes. A chi-square test of independence indicated no significant association of traumatic experiences between zero and four between the SUD and OUD groups. Further analysis revealed that participants with five or more PTEs were more likely to develop OUD. A frequency tabulation showed that among clients with five or more traumatic experiences, OUD was present in 38.6% (29 individuals), and SUD was present in 24.9% (19 individuals).

Discussion

The purpose of this study was to examine the influence of psychological traumatic experiences (PTE) on the development of opiate use disorder (OUD) at an urban treatment facility in Pennsylvania.

Demographic findings for OUD participants revealed an average age of 37, with 51% being female and the majority being White. These results align with previous research on OUD demographics in the U.S., which often shows OUD treatment associated with older age and Caucasian ethnicity. However, the proportion of African Americans in OUD treatment in this study was not consistent with current research indicating similar OUD rates for both Black and White individuals, nor with the community demographics of the study site.

The study's results indicated that 75% of OUD participants had experienced at least one traumatic event, consistent with other studies. However, the percentage of co-occurring PTSD diagnoses within the OUD group (18.7%) was lower than expected compared to other studies, which have reported a higher lifetime history of PTSD and current PTSD diagnoses among OUD clients.

The study found that PTE may influence the occurrence of OUD, based on higher average PTE scores in the OUD group compared to the SUD group. The study results were significant regarding the influence of PTE on OUD when participants reported more than five traumatic experiences. These findings are in line with emerging research; recent studies have shown that trauma and PTSD are common among patients with OUD, emphasizing the importance of integrating addiction and mental health services. Furthermore, childhood trauma exposure has been identified as a common, independent risk factor for OUD.

The study's racial findings did not reflect the community demographics or the emerging post-pandemic demographic data on OUD prevalence. The study site's community demographics show a significantly higher African American population compared to Caucasian, suggesting that the study participants' racial makeup should have reflected this. Possible disparities may exist in the availability of jail court referrals for OUD treatment, potentially indicating that individuals of color might be incarcerated rather than offered OUD treatment. Other contributing factors could include ineffective or absent community marketing of services at the Drug & Alcohol unit, implicit bias among providers, and community mistrust. This phenomenon highlights a need for future research into when and where these disparities occur.

The lack of a significant association between PTE and OUD in some analyses was unexpected, given prior research on PTE and SUD. Several factors may have contributed to this finding, including the small sample size and potential underreporting of PTE and PTSD in the sample data.

Implications

Measuring PTE in individuals with OUD is crucial for developing targeted interventions that support high-quality outcomes for individuals and families recovering from OUD. This study found higher PTE scores in individuals with OUD, underscoring the importance of identifying PTE and PTSD and implementing trauma-based and trauma-informed strategies during OUD treatment planning. The small number of PTSD diagnoses observed in the OUD sample, which is inconsistent with public statistics and prior research, highlights the need for structured evaluations for the assessment and diagnosis of PTSD as a best practice initiative.

Limitations

The study's limitations include issues related to the internal validity of subject selection. The use of a convenience sample from a single site limits the generalizability of the findings to other populations. While selection bias did not occur, random sampling and random assignment to groups could increase the generalizability of results. The study also used a descriptive retrospective design, which aligns with existing studies and addresses the gap in research on the influence of PTE on OUD. However, this design means that causality cannot be determined. Finally, the study was limited by the use of paper medical records, which required manual data collection and tabulation.

Implications for Future Research

Future research stemming from this study could examine how PTE predicts OUD using a larger sample size, employing a descriptive design with broader generalization, or a correlational or experimental study. Further research is also needed on social determinants of health relevant to the OUD population, such as housing and food instability, community violence, and adverse childhood experiences, as well as disparities among individuals with OUD. Future research should also explore other outcome variables important to the OUD population and utilize sites with electronic medical records for data collection.

Conclusion

In conclusion, this study found evidence of a significant relationship between five or more psychological traumatic experiences (PTE) and OUD, along with some findings that were not significant. While the insignificant findings may seem counterintuitive given existing research on PTE and SUD, they emphasize the complex nature of this relationship. Further research is necessary to better understand these phenomena.

Introduction

Opiate use disorder (OUD) is characterized by a pattern of opioid use that leads to significant problems or distress. This condition can result in physical and psychological dependence, influenced by complex interactions among brain circuits, genetic factors, environmental influences, and life experiences. Risk factors for OUD include adverse childhood experiences (ACEs), exposure to psychological trauma, starting opioid use at a younger age, co-occurring mental health disorders, and limited access to recovery and mental health services. Both recreational opiate use and OUD can lead to increased illness and death. Opiate overdose deaths in the U.S. have been rising annually, claiming over 100,000 lives in 2022. OUD is a specific type of substance use disorder (SUD), which is a complex brain disease marked by the uncontrolled use of a substance despite harmful consequences. SUDs can involve substances such as opiates, cocaine, methamphetamine, marijuana, or alcohol.

Trauma exposure is a common experience globally. A worldwide survey found that over 70% of respondents reported a traumatic event, and 30.5% experienced four or more potentially traumatic events (PTEs) in their lifetime. A trauma exposure is defined as an encounter with a negative event—such as violence, sexual assault, a terrorist attack, or a natural disaster—that may overwhelm a person's mental capacity to process and integrate the experience. Trauma exposure can lead to a trauma- or stressor-related disorder, including posttraumatic stress disorder (PTSD). The diagnostic criteria for PTSD include direct or indirect exposure to a traumatic event, followed by symptoms across four categories: intrusion, avoidance, negative changes in thoughts and mood, and changes in arousal and reactivity. However, individuals' lives can be negatively impacted by symptoms that do not fully meet diagnostic criteria for a disorder. For example, experiencing psychological trauma exposures can manifest with symptoms that cause significant impairment in function and health, depending on the number of exposures. Trauma exposures encompass psychological trauma exposure (PTE), trauma and stress-related disorders including PTSD, and adverse childhood experiences. This study focuses specifically on PTE and PTSD. Individuals with a history of PTEs, PTSD, and co-occurring SUD may face a more complex and costly treatment path, including chronic physical and mental health problems, poorer social functioning, higher rates of suicide attempts, increased risk of violence, and less successful treatment outcomes. These findings suggest the benefit of integrated trauma treatment for veterans with co-occurring PTE, PTSD, and SUD.

While the relationship between PTE, PTSD, and SUD is well documented, these factors have been less studied in relation to OUD specifically. Several studies have reported that 52% of individuals diagnosed with OUD also screened positive for co-occurring PTSD. Other studies have indicated that veterans receiving concurrent PTSD treatment remained in OUD treatment for longer periods.

Although some studies have shown a high rate of PTSD among individuals with SUD, none have specifically examined the influence of PTE on OUD. Determining the rate of PTE among OUD clients has been difficult because OUD diagnoses are often grouped with broader SUD diagnoses. This limitation has restricted knowledge about the extent of PTE among individuals with OUD. Understanding how PTE influences OUD is vital for developing targeted interventions that support the prevention, treatment, and recovery from both PTE and OUD. This descriptive study aimed to examine the influence of PTE on the development of OUD within an urban treatment facility in Pennsylvania. The findings are intended to provide foundational work for future interventional studies involving PTEs and OUD.

The study had three primary aims:

• To describe the demographic characteristics of participants with OUD and SUD.

• To examine the associations between PTE and PTSD diagnoses among OUD and SUD participants.

• To examine the number of PTE occurrences in OUD and SUD participants.

Theoretical framework

The "self-medication hypothesis" (SMH) proposes that individuals may use substances to cope with and manage emotional dysregulation or distressing emotional symptoms. The purpose of SMH is to explain the link between difficult emotional states and the development of SUD. The theory follows a linear structure, consistent with a health model. A core assumption of the theory is that substances are chosen selectively based on their pharmacological effects to reduce emotional reactivity or distress. Another assumption of SMH is aligned with the disease model of addiction. The "SMH" uses the concepts of the individual, distressing symptoms with maladaptive coping, and substance use disorder.

These concepts are relevant to professionals who care for clients in recovery from SUD. Although not explicitly stated, it can be inferred that the individual is defined as a human being with biological, psychological, and social factors, given that the "SMH" was formulated by a psychiatrist. Distressing symptoms are defined as emotional symptoms such as anxiety, depression, and emotional dysregulation. Maladaptive coping is characterized by patterns of defense and avoidance that both reveal and conceal the intensity of suffering, confusion about feelings, or detachment from emotions. SUD is defined as the compelling, progressive, and deteriorating use of addictive substances that can lead to a loss of function, relationships, and life. While the "SMH" describes one possible relationship between distressing symptoms and SUD, it did not fully account for other clinically relevant circumstances. For instance, the "SMH" primarily attributed distressing symptoms to diagnosed mental health conditions like PTSD, depression, anxiety, or schizophrenia, overlooking the impact of symptoms that do not meet diagnostic criteria for a formal disorder.

The adapted SMH framework used in this study includes concepts such as the individual, trauma exposure (TE), and OUD/SUD. The individual concept encompasses demographic information, while the TE concept includes PTE and PTSD. Maladaptive coping is represented by OUD/SUD in this framework.

Materials and methods

This study involved a chart review of participants from the outpatient substance use facility at the drug and alcohol division of Crozer Chester Medical Center (CCMC) in Chester, Pennsylvania. Ethical approval was obtained from the Institutional Review Boards (IRBs) of Case Western Reserve University (CWRU) and CCMC, and the study was deemed exempt.

A convenience sample of 150 participants, consisting of 75 individuals with OUD and 75 individuals with SUD, was used to collect data from recently admitted clients' medical records. The target sample size was met by reviewing records backward from April 2022 until the required number of participants was reached. All identifiable information was removed or redacted to ensure privacy. An investigator manually reviewed subjects' medical records over two weeks, collecting data for variables of interest and storing them in an encrypted and locked file.

A demographic survey developed by the investigator was used to collect data on gender, age, race, and ethnicity. The Life Events Checklist for DSM-5 (LEC-5) served as the tool for measuring PTE. The LEC-5 is a self-report screening tool designed to assess exposure to potentially traumatic events across an individual's lifetime. It evaluates exposure to sixteen specific events known to potentially cause emotional distress or PTSD, and includes an additional item for any other exceptionally stressful event not covered by the initial sixteen.

The LEC-5 does not have a standardized scoring method. However, respondents indicate their level of exposure to each potential traumatic event using a six-category scale: "happened to me," "witnessed it," "learned about it," "part of my job," "not sure," or "doesn't apply." For this study, selections of "happened to me" and/or "witnessed it" were counted as PTE. The number of PTE occurrences was determined by counting the items endorsed on the LEC-5, ranging from 1 to 17. Psychometric properties for the LEC-5 are not currently available.

Results

Demographic characteristics are presented in a table (not included here). In the OUD group (N=75), participant ages ranged from 18 to 63, with an average age of 37.12 years (SD = 10.52). The group was 51% female, 49% male, 21% African American/Black, 73% White, Non-Hispanic, and 5% Hispanic/Latino. In the SUD group (N=75), participant ages ranged from 18 to 73, with an average age of 46.64 years (SD = 14.14). This group comprised 41% female, 58% male, 55% African American/Black, 43% White, Non-Hispanic, 1% Hispanic/Latino, and 1% Asian.

Regarding psychological traumatic experiences, the majority of participants in both groups reported experiencing at least three traumatic events. There was no statistically significant difference in the PTE scores between the OUD group (M = 3.49, SD = 3.33) and the SUD group (M = 2.87, SD = 2.54), as indicated by a t-test (t (148) = -1.296, p = 0.98). However, these results suggest a trend indicating that PTE may influence the occurrence of OUD, given the higher mean PTE scores in the OUD group compared to the SUD group. Concerning the diagnosis of PTSD, there was no significant difference in the number of participants diagnosed with PTSD in either the OUD or SUD groups (Chi-Square (χ2 = 1.918, df = 1, p = 0.166)).

An odds ratio did not reveal a significant relationship in trauma scores between the OUD and SUD groups (χ2 = 1.684, df = 1, p = 0.194). However, a PTE score greater than four is associated with a higher risk of poorer mental health outcomes. A chi-square test of independence showed no significant association for TE scores between 0 and 4 within the SUD and OUD groups (χ2 = 1.407, df = 1, p = 0.236). Further analysis, however, indicated that participants with more than five PTEs (PTE > 5) were more likely to develop OUD (χ2 = 5.17, df = 1, p = 0.023). A frequency tabulation revealed that among clients with TE > 5, OUD was present in 38.6% (N = 29), and SUD was present in 24.9% (N = 19).

Discussion

This study sought to examine the influence of psychological traumatic experiences (PTE) on the development of opiate use disorder (OUD) at an urban treatment facility in Pennsylvania.

The demographic findings for OUD participants showed an average age of 37, with a slight majority being female and predominantly White. These results align with previous research on OUD demographics in the U.S., which often associate OUD treatment with older age and Caucasian ethnicity. However, the proportion of African Americans in OUD treatment found in this study is inconsistent with current research, which indicates similar OUD rates for both Black and White individuals, as well as with the community demographics of the study site. Regarding trauma exposure, 75% of OUD participants reported experiencing at least one traumatic event, consistent with other studies. Yet, the percentage of co-occurring PTSD diagnoses within the OUD group (18.7%) was lower than expected compared to other studies, which have reported higher lifetime and current PTSD rates among OUD clients. The study found that PTE may influence the occurrence of OUD, evidenced by higher mean PTE scores in the OUD group compared to the SUD group. The results were statistically significant regarding the influence of PTE on OUD when the number of traumatic events was greater than five, a finding consistent with emerging research highlighting the prevalence of trauma and PTSD among OUD patients and stressing the importance of integrated addiction and mental health services. Furthermore, prior research indicates that childhood trauma exposure is a common and independent risk factor for OUD.

The racial findings of the study did not reflect the community demographics or the emerging post-pandemic demographic data on OUD prevalence. The study site's community consists of a larger African American population (69%) and a smaller Caucasian population (17%). Therefore, the racial makeup of study participants would be expected to reflect the community demographics and show higher rates than the national average. Possible disparities may exist within the pool of available jail court referrals for OUD treatment, suggesting that individuals of color may be incarcerated rather than offered OUD treatment in place of incarceration. Other potential reasons include ineffective or absent community marketing of services at the Drug & Alcohol unit, implicit bias, and community mistrust. This phenomenon warrants future research to identify when and where these disparities occur.

The absence of a significant association between PTE and OUD in some analyses was unexpected, given previous research on PTE and SUD. Several factors may have contributed to this finding, including the relatively small sample size and potential underreporting of PTE and PTSD within the sample data.

Measuring PTE in individuals with OUD is crucial for developing targeted interventions that support high-quality outcomes for individuals and families recovering from OUD. The study's finding of higher PTE scores in individuals with OUD underscores the importance of identifying PTE and PTSD and implementing trauma-based and trauma-informed strategies during OUD treatment planning. The small number of PTSD diagnoses observed in the OUD sample, which is inconsistent with public domain statistics and prior research on PTSD and SUD, highlights the need for structured evaluations for the assessment and diagnosis of PTSD as a best practice initiative.

Limitations

The study had limitations, including threats to internal validity related to the selection of subjects. The use of a convenience sample drawn from two groups at a single site limits the generalizability of its findings to that specific location. Although selection bias was not observed, employing random sampling and random assignment to groups could enhance the generalizability of results to broader populations. The study also utilized a descriptive retrospective design, which aligns with existing studies and addresses a gap in research regarding the influence of PTE on OUD. However, this design precludes the determination of causality. Finally, the study was limited by its reliance on paper medical records, which necessitated manual data collection and tabulation.

Implications for Future Research

This study suggests several directions for future research. Investigations could examine how PTE predicts OUD using a larger sample size, employing either a descriptive design with broader generalizability, a correlational study, or an experimental study. Further research is also needed on social determinants of health (e.g., housing and food instability, community violence, adverse childhood experiences) and disparities among individuals with OUD. Future research should also expand to include other outcome variables important to the OUD population and consider using a site with electronic medical records for more efficient data collection.

Conclusion

In conclusion, the study found evidence of a significant relationship between more than five PTEs and OUD, alongside some findings that were not statistically significant. While these insignificant findings might seem contradictory to existing research on PTE and SUD, they underscore the complex nature of this relationship. Further research is necessary to better understand these phenomena.

Introduction

Opioid use disorder (OUD) is a condition where a person uses opioids in a way that causes problems or distress. This can lead to physical and mental dependence. Many factors contribute to OUD, including brain function, genetics, environment, and personal experiences. Risk factors for OUD include difficult childhood experiences, past exposure to psychological trauma, starting opioid use at a younger age, having other mental health conditions, and not having enough access to recovery support or mental health services. Both casual opioid use and OUD can lead to serious health problems and death. The number of opioid overdose deaths in the U.S. increases annually, with over 100,000 lives lost in 2022. OUD is a type of substance use disorder (SUD), which is a complex brain disease marked by uncontrolled substance use despite harmful outcomes. Other substances involved in SUD include cocaine, methamphetamine, marijuana, and alcohol.

Exposure to trauma is common. A global study showed that over 70% of people surveyed reported experiencing a traumatic event, and about 30% experienced four or more such events in their lives. A traumatic event is a negative experience that can overwhelm a person's ability to cope, such as violence, sexual assault, a terrorist attack, or a natural disaster. Exposure to trauma can lead to a trauma- or stress-related disorder, including Post-Traumatic Stress Disorder (PTSD). PTSD is diagnosed when a person has been directly or indirectly exposed to a traumatic event and then experiences at least eight specific symptoms across four areas: reliving the event, avoiding things related to the event, negative changes in thoughts and feelings, and changes in reactions or arousal. However, symptoms that do not fully meet the criteria for a diagnosed disorder can still greatly affect a person's life and health, especially with multiple trauma exposures. This study will focus on psychological trauma exposure (PTE) and PTSD. Individuals with a history of PTEs, PTSD, and a co-occurring substance use disorder (SUD) often face more complex and expensive treatment. They may also have ongoing physical and mental health issues, difficulty functioning socially, higher rates of suicide attempts, an increased risk of violence, and worse treatment results. Because of these findings, some research supports combining trauma treatment with substance use treatment for veterans who have both PTE, PTSD, and SUD.

While the link between psychological trauma exposure (PTE), Post-Traumatic Stress Disorder (PTSD), and substance use disorder (SUD) is well-known, these connections have not been as thoroughly studied for opioid use disorder (OUD). Several studies have shown that more than half of individuals diagnosed with OUD also tested positive for PTSD. Other research indicates that veterans who received PTSD treatment at the same time as OUD treatment stayed in OUD treatment for a longer period.

Although some studies show high rates of PTSD among people with SUD, none have specifically looked at how psychological trauma exposure (PTE) affects opioid use disorder (OUD). It has been noted that it is hard to figure out how many OUD clients have PTE because OUD is often grouped with other substance use disorders. This has limited understanding of how widespread PTE is among people with OUD. Learning about how PTE affects OUD is essential for creating specific programs to prevent, treat, and support recovery for both conditions. This study's goal is to examine how PTE influences the development of OUD at a treatment center in Pennsylvania. It also aims to lay the groundwork for future studies that will test new treatments for PTE and OUD.

The study had three main goals:

1. To describe the demographic information of individuals participating in the study who had OUD and SUD.

2. To look at the connections between psychological trauma exposure (PTE) and PTSD diagnoses among participants with OUD and SUD.

3. To examine how many times participants with OUD and SUD reported experiencing PTEs.

Theoretical framework

The "self-medication hypothesis" suggests that individuals might use substances to cope with difficult emotions or distress. The main idea of this hypothesis is to explain the link between upsetting emotional states and the development of substance use disorder (SUD). This theory is straightforward and aligns with a health-based view of addiction. It assumes that people choose substances based on their effects, using them to reduce emotional responses or discomfort. Another idea within this theory is that addiction is a disease. The hypothesis focuses on three main ideas: the individual person, distressing symptoms combined with unhealthy coping methods, and substance use disorder.

These core ideas are similar to what addiction recovery professionals consider. Although not directly stated, it can be understood that the "individual" in this theory refers to a person's biological, psychological, and social aspects, since the hypothesis was developed by a psychiatrist. Distressing symptoms include feelings of anxiety, depression, and difficulty managing emotions. Unhealthy coping is described as typical ways people defend themselves or avoid feelings, which both show and hide how much they are suffering, how confused they are about their emotions, or how disconnected they are from their feelings. Substance use disorder (SUD) is defined as the strong, worsening use of addictive substances that can lead to losing one's ability to function, relationships, and even life. While the self-medication hypothesis explains one possible link between distressing symptoms and SUD, it did not include other important real-world situations. For instance, it mainly connected distressing symptoms to diagnosed mental health conditions like PTSD, depression, anxiety, or schizophrenia. However, a person's life can be negatively affected by symptoms that are not severe enough for a formal diagnosis.

This study used an updated version of the self-medication hypothesis framework. This adapted framework includes the individual, trauma exposure (TE), and opioid use disorder (OUD) or substance use disorder (SUD). The individual concept covers demographic information, while the trauma exposure concept includes psychological trauma exposure (PTE) and Post-Traumatic Stress Disorder (PTSD). The concept of unhealthy coping then covers OUD and SUD.

Materials and methods

The study involved reviewing patient charts from an outpatient substance use clinic at Crozer Chester Medical Center (CCMC) in Chester, Pennsylvania. Approval for the study was received from the Institutional Review Boards (IRBs) of both Case Western Reserve University (CWRU) and CCMC, noting it was exempt from full review.

A total of 150 client records were reviewed, made up of 75 clients with opioid use disorder (OUD) and 75 with other substance use disorders (SUD). This sample was chosen from the most recently admitted clients, working backward from April 2022 until the target number was reached. All identifying information was removed from the records. A researcher manually reviewed each client's medical records over two weeks, checking for study requirements and collecting specific data. This information was then stored in an encrypted and locked file.

A survey created by the researchers was used to gather basic demographic information like gender, age, race, and ethnicity. To measure psychological traumatic experiences (PTE), the "Life Events Checklist for DSM-5 (LEC-5)" was used. The LEC-5 is a self-report tool where individuals indicate if they have experienced any of sixteen specific events known to potentially cause emotional distress or PTSD during their lifetime. It also includes an extra item for any other very stressful events not listed.

The LEC-5 does not have a formal scoring system. Instead, individuals mark how they were exposed to each possible traumatic event using one of six categories: "happened to me," "witnessed it," "learned about it," "part of my job," "not sure," or "doesn't apply." For this study, an event was counted as a PTE if the person selected "happened to me" and/or "witnessed it." The number of PTE occurrences was counted based on the total items (1 to 17) marked as experienced. Information about the psychological validity and reliability of the LEC-5 is not currently available.

Results

In the group of 75 participants with opioid use disorder (OUD), ages ranged from 18 to 63, with an average age of 37. About 51% were female and 49% were male. For racial background, 21% were African American/Black, 73% were White (not Hispanic), and 5% were Hispanic/Latino. In the group of 75 participants with other substance use disorders (SUD), ages ranged from 18 to 73, with an average age of 47. About 41% were female and 58% were male. For racial background, 55% were African American/Black, 43% were White (not Hispanic), 1% were Hispanic/Latino, and 1% were Asian.

Most participants in the study reported experiencing at least three traumatic events. There was no major statistical difference in the average psychological trauma exposure (PTE) scores between the OUD group (average 3.49) and the SUD group (average 2.87). However, the results hint at a pattern where PTE might influence OUD, given that the OUD group had a slightly higher average PTE score than the SUD group. When looking at PTSD diagnoses, there was no significant difference in the number of participants diagnosed with PTSD between the OUD and SUD groups.

A statistical analysis called an odds ratio did not show a major link in trauma scores between the OUD and SUD groups. However, experiencing more than four psychological traumatic events (PTE) is generally linked to a higher risk of worse mental health. A statistical test also showed no significant connection between experiencing fewer than four traumatic events and being in either the SUD or OUD groups. Despite this, further analysis showed that participants who experienced more than five PTEs were more likely to develop OUD. Specifically, among clients who had experienced more than five traumatic events, 38.6% had OUD, compared to 24.9% who had SUD.

Discussion

This study aimed to explore how psychological traumatic experiences (PTE) affect the development of opioid use disorder (OUD) at a treatment center in an urban area of Pennsylvania.

The demographic information for OUD participants in this study, with an average age of 37 and a majority being White, aligns with previous research on OUD demographics in the U.S. However, the percentage of African Americans in OUD treatment in this study did not match current research or the local community's demographics, where a higher African American population might suggest more equitable representation. This difference raises questions about potential disparities in OUD treatment access, possibly due to factors like court referrals, community outreach, unconscious bias, or a lack of trust.

This study found that 75% of OUD participants had experienced at least one traumatic event, which is consistent with other research. However, the rate of PTSD diagnoses within the OUD group (18.7%) was lower than typically reported in other studies, which often show higher lifetime or current PTSD rates among OUD clients. This suggests that structured evaluations for PTSD during OUD treatment might be a necessary best practice.

The study indicated that psychological trauma exposure (PTE) might influence the occurrence of OUD, as the OUD group had slightly higher average PTE scores. Specifically, the findings showed a significant link between experiencing more than five traumatic events and developing OUD. This supports emerging research that highlights how common trauma and PTSD are among OUD patients, emphasizing the importance of combining addiction and mental health services. Childhood trauma, for instance, has been identified as an independent risk factor for OUD. Despite some significant findings, the study also found some unexpected results, such as the overall lack of a strong link between PTE and OUD in some analyses. This could be due to the relatively small sample size or potential underreporting of trauma experiences.

Identifying and measuring PTE in people with OUD is critical for creating effective treatment plans that lead to better outcomes for individuals and families recovering from OUD. Given the higher PTE scores found in OUD participants in this study, it is important to incorporate trauma-focused approaches when planning OUD treatment.

The study had limitations, including using a convenience sample from a single treatment center, which limits how broadly its findings can be applied. The descriptive and retrospective design means it can show connections but not cause-and-effect relationships. Future research should use larger samples to examine how PTE predicts OUD, and explore other social factors affecting OUD individuals. It would also be beneficial for future studies to use electronic medical records for more efficient data collection.

Conclusion

In summary, this study found evidence of a significant relationship between experiencing more than five psychological traumatic events (PTE) and developing opioid use disorder (OUD). However, some of the study's other findings were not statistically significant. While these less significant results might seem unexpected compared to existing research on trauma and substance use disorder, they highlight the complex nature of this relationship. More research is needed to fully understand these connections.

Introduction

Opioid use disorder (OUD) is when a person uses opioids in a way that causes problems or upset in their life. This can lead to the body and mind needing the drug. Many things can cause OUD, like what happens in a person's brain, their genes, their surroundings, and life events.

Things that make it more likely to get OUD include bad experiences as a child, going through upsetting events (trauma), starting to use drugs at a young age, having other mental health problems, or not having enough help for recovery or mental health care. Using opioids can cause severe sickness and death. Deaths from opioid overdose are going up each year in the U.S. Over 100,000 people died in 2022. OUD is a type of substance use disorder (SUD). SUD is a serious brain sickness where a person keeps using a substance even when it causes harm. Examples of substances include opioids, cocaine, meth, marijuana, and alcohol.

Experiencing trauma is common. A study found that over 70 out of 100 people said they had a bad event happen to them. More than 30 out of 100 people had four or more such events in their life. An upsetting event is when something bad happens that makes a person feel extremely overwhelmed, like violence, sexual assault, a terror attack, or a natural disaster. These events can lead to problems like post-traumatic stress disorder (PTSD). PTSD means a person was directly or indirectly part of an upsetting event and then has eight or more signs in four areas: re-living the event, trying to avoid things that remind them of it, bad changes in thoughts and mood, and feeling jumpy or easily startled. However, even if a person does not have all the signs for a full disorder, these events can still cause a lot of problems in their daily life and health, especially if many bad events have happened. These upsetting experiences can be called psychological trauma exposure (PTE), or they can be part of stress-related problems like PTSD. This study will look at PTE and PTSD. People who have a history of upsetting events, PTSD, and SUD at the same time may have a harder and more costly recovery. They might have ongoing health problems, trouble getting along with others, a higher risk of trying to end their life, and may not stick with their treatment. Because of this, some studies suggest that treatment for upsetting events should be part of treatment for veterans who have PTE, PTSD, and SUD together.

While it is well known that upsetting events, PTSD, and SUD are connected, these links have not been studied enough when it comes to OUD. Some studies have found that about half of people with OUD also showed signs of PTSD. Other studies found that veterans who got PTSD treatment stayed in OUD treatment longer.

Even though some studies show many people with SUD also have PTSD, none have specifically looked at how upsetting events affect OUD. One expert noted that it is hard to know how many people with OUD have experienced upsetting events because OUD is often grouped with all other SUD diagnoses. This has limited what is known about how widespread upsetting events are among people with OUD. Understanding how upsetting events affect OUD is very important for creating specific ways to help prevent, treat, and recover from both upsetting events and OUD. This study aimed to look at how upsetting events affect whether a person develops OUD at a treatment center in Pennsylvania. It also wanted to set the groundwork for future studies on upsetting events and OUD.

Aims

• Understand who the people with OUDs and SUDs are.

• See if there is a link between traumatic events (PTE) and PTSD in people with OUD and SUD.

• Count how many upsetting events happened to people with OUD and SUD.

Theoretical framework

The "self-medication idea" for substance use disorder says that people might use substances to try to handle strong feelings or upset emotions. This idea tries to explain the link between feeling upset and getting a substance use disorder. The idea suggests that people choose substances that will help calm their feelings. It also suggests that addiction is a sickness. The "self-medication idea" uses concepts like the person, upsetting signs with unhelpful ways of coping, and substance use disorder.

These ideas are similar to what helpers caring for people recovering from SUD are interested in. Even though it is not directly said, it can be understood that the idea sees a person as having body, mind, and social factors. Upsetting signs are defined as feelings like worry, sadness, and trouble controlling emotions. Unhelpful coping means ways a person acts to hide or deal with their strong feelings. SUD is when a person uses addictive substances more and more, which can lead to losing their ability to function, their relationships, and even their life. The "self-medication idea" describes one possible link between upsetting signs and SUD. However, it does not cover all real-life situations. For example, it mostly linked upsetting signs to mental health problems like PTSD, sadness, worry, or schizophrenia. But a person's life can be badly affected by signs that do not quite meet the official rules for a mental health problem.

The changed self-medication idea has concepts for the person, upsetting events (TE), and OUD/SUD. The person concept includes things like their age and background. The TE concept includes PTE and PTSD. The unhelpful coping concept includes OUD/SUD.

Materials and methods

This study looked at past records of people from a drug and alcohol treatment center in Pennsylvania. Permission was received from two review boards (IRB) to do this study.

Records from 150 people were used. This included 75 people with OUD and 75 people with SUD. These were the newest people to join the program, starting from April 2022 and going backward until 150 records were found. All personal information was removed or hidden. A researcher looked at each person's records by hand to see if they fit the study rules and to gather needed information. This took two weeks. The information was kept in a protected, locked computer file.

A survey made by the researcher was used to gather basic information about the people, like their gender, age, race, and background. The "Life Events Checklist for DSM-5 (LEC-5)" was used to measure upsetting events (PTE). The LEC-5 is a tool where people report on their own if they have experienced upsetting events in their lives. It asks about 16 types of events that can cause emotional upset or PTSD. It also has a spot for any other very stressful event.

The LEC-5 does not have a formal way to score it. However, people say how much they were exposed to each upsetting event on a 6-part scale. These parts include "happened to me," "witnessed it," "learned about it," "part of my job," "not sure," or "does not apply." If a person chose "happened to me" or "witnessed it," it was counted as an upsetting event. The number of upsetting events was counted from 1 to 17, based on the items in the LEC-5. There are no current official reports on how well the LEC-5 measures what it is supposed to measure.

Results

Most people in the study were between 18 and 63 years old. For the 75 people with OUD, the average age was about 37. Half were female, and half were male. Most were White (73%), some were African American/Black (21%), and a few were Hispanic/Latino (5%). For the 75 people with SUD, the average age was about 46. About 4 out of 10 were female, and about 6 out of 10 were male. About half were African American/Black (55%), about 4 out of 10 were White (43%), and a very small number were Hispanic/Latino or Asian.

Psychological traumatic experiences

Most people in the study said they had at least three upsetting events happen to them. There was no big difference in the number of upsetting events between the OUD group and the SUD group. However, the OUD group had a slightly higher average number of upsetting events. This suggests that upsetting events might affect OUD more. When looking at a diagnosis of PTSD, there was no big difference in how many people in either the OUD or SUD groups had PTSD.

The study did not find a strong link in the number of upsetting events between the OUD and SUD groups. However, having more than four upsetting events is linked to a higher risk of more mental health problems. The study found no strong link between having less than four upsetting events and being in the SUD or OUD groups. But, a closer look showed that people with more than five upsetting events were more likely to have OUD. Among those with more than five upsetting events, about 39 out of 100 people had OUD, and about 25 out of 100 people had SUD.

Discussion

This study wanted to see how upsetting events (PTE) affect whether a person develops opioid use disorder (OUD) at a treatment center in Pennsylvania.

Aim One: Demographic Findings

The study found that people with OUD were, on average, 37 years old, mostly female, and mostly White. These findings are similar to what other studies have found about who gets OUD treatment in the U.S. However, the number of African Americans in OUD treatment in this study was not what was expected based on other research or the local community's population.

Aim Two: Trauma Exposure

The study showed that 75 out of 100 people with OUD had at least one upsetting event. This is similar to other studies. But, the number of OUD people also diagnosed with PTSD (about 19 out of 100) was lower than expected, as other studies found closer to 30 to 40 out of 100 people with OUD have PTSD.

Aim Three: Influence of PTE on OUD

This study found that upsetting events might affect how often OUD happens, because the OUD group had a higher average number of upsetting events. The study results were clear that if a person had more than five upsetting events, it did affect whether they had OUD. These findings match newer studies. A recent study also showed that upsetting events and PTSD are common in people with OUD, which means addiction and mental health care should work together. Also, another study found that upsetting events in childhood were a common, separate risk factor for OUD.

Racial Disparities

The study's findings on racial groups did not match the local community's population or new information about how common OUD is after the pandemic. The study area's community is mostly African American (69%) and less White (17%). So, one might expect more African Americans in the study. Possible reasons for this difference could be that people of color might be sent to jail instead of OUD treatment. Other reasons could include not enough advertising for the drug and alcohol services, unconscious biases, or a lack of trust from the community. This situation means more research is needed to understand when and why these differences happen.

Unexpected Findings

It was surprising that some parts of the study did not show a clear link between upsetting events and OUD, given what other studies have found about upsetting events and SUD. Several things might explain this, such as the small number of people in the study and that people might not have reported all their upsetting events or PTSD.

Implications

Knowing about upsetting events in people with OUD is very important for creating specific ways to help people and their families recover well from OUD. This study found more upsetting events in people with OUD. This shows how important it is to find out if someone has experienced upsetting events or PTSD and to use trauma-focused care plans during OUD treatment. This study also showed that the small number of PTSD diagnoses in the OUD group does not match official numbers or other research. This means there is a need for clear ways to check for and diagnose PTSD as a standard part of care.

Limitations

This study had some limits. It used a group of people who were easy to find from only one location. This means the results might not be true for other places. While the study tried to avoid favoring certain people, using random selection for groups would make it more likely that the results could apply to more people. Also, this study looked back at past records. While this type of study is helpful for understanding, it cannot prove that one thing caused another. Lastly, a limit was using paper medical records, which meant data had to be gathered and written down by hand.

Future Research

This study suggests that future research could look at how upsetting events predict OUD using more people. This could be done with a study that describes what is happening, or one that looks at links, or an experiment. More research is also needed on social factors that affect health (like not having stable housing or enough food, violence in the community, and bad childhood experiences) and differences among people with OUD. Future studies should also look at other things that are important to people with OUD and use places that have electronic medical records for gathering data.

Conclusion

In short, this study found some evidence of a strong link between having more than five upsetting events and OUD, as well as some findings that were not strong. While these less strong findings might seem confusing given other research on upsetting events and SUD, they do show that this link is complex. More research is needed to understand these things better.