Each day the emergency room doctors at Cooper University Hospital in Camden, New Jersey, treat an average of 5 to 15 patients who have overdosed on opioids. While some die, more recover and quickly leave, most in search of their next high, a pattern seen by many if not most hospitals in the United States. Ending that cycle is the holy grail for addiction specialists. About a year and a half ago, doctors at Cooper who were frustrated by patients’ stories of months-long waits for addiction treatment opened their own outpatient addiction treatment center. The center’s doctors, nurses, psychologists, counselors, and social workers do far more than give out addiction treatment drugs. Services include referrals for housing, food, and health insurance as well as individual and group counseling. Rachel Haroz, MD, an addiction specialist and ER doctor at Cooper, says seeing so many repeat patients overdose in the ER drove the doctors to do more. “We would ask them about getting help and hear the same story, that the waiting list for treatment was months long,” Dr. Haroz says. “We decided we could do better.” A key factor is that the staff works both in the clinic and the ER, and everyone knows it can take many tries to beat an opioid addiction. Staffers who see a clinic patient battling an overdose in the ER encourage him or her to come back to the clinic. Between 2014 and 2016, Camden County had 475 drug overdose deaths, the highest per-capita rate in the state. The clinic has more than 100 clients and hopes to bring down the number of deaths. “Long before they dealt with addiction, many of our patients were dealing with toxic stress as infants or very young children,” says Iris Cooper, an addiction counselor at the center. (Cooper isn’t related to the hospital’s namesake.) “Treating the addiction requires treating the stress.”
The Telomere Measure of Chronic Stress Damage
What is toxic stress? According to the experts at the Center for the Developing Child at Harvard University in Boston, “Extensive research on the biology of stress now shows that healthy development can be derailed by excessive or prolonged activation of stress response systems in the body and brain, because of mental and/or physical trauma early in life. That toxic stress can have damaging effects on learning, behavior, and health across the lifespan.” Physiologic studies have attempted to measure the effects of that stress. In a study published in 2004, researchers at the University of California in San Francisco looked at telomeres, formations that resemble caps at the ends of shoelaces and that are found at the tips of the body’s chromosomes. (Chromosomes, the threadlike structures that carry genetic information in the form of genes, are in the nucleus of most living cells.) Telomeres grow shorter as cells age and can be measured by lab analysis of a blood sample. The UCSF researchers looked at two groups of mothers, one group with healthy children and one with children who had chronic illnesses. Measuring their telomeres, they found that mothers who reported feeling chronically stressed were aging up to 17 years faster, judging by their telomere length. The moms who aged faster, however, did so whether their children were chronically ill or not, making the perception of being stressed — not the reality of the stressors being confronted — the critical factor that puts people at risk for biological aging, disease, and addiction.
Abuse, Neglect, Divorce, and Other Early Life Experiences Are Risk Factors
The most famous study on toxic stress was a collaboration from 1995 to 1997 between the U.S. Centers for Disease Control and Prevention (CDC) and Kaiser Permanente of Southern California, a health maintenance organization that provides healthcare to tens of thousands of people. More than 17,000 Kaiser members age 18 and younger completed surveys about their childhood experiences and their current health and behaviors. Adverse childhood experiences (ACEs) in the study included:
Physical abuseSexual abuseEmotional abusePhysical neglectEmotional neglectIntimate partner violenceMother treated violentlySubstance misuse within householdHousehold mental illnessParental separation or divorceIncarcerated household member
The researchers found that the more ACEs people suffer before age 18, the more likely they are to experience consequences later in life including suicide attempts and addiction. Nationally, a focus on trauma to prevent and treat addiction is gaining support. The Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the U.S. Department of Health and Human Services, has established the National Child Traumatic Stress Initiative to provide national technical assistance for traumatic stress in children, says Steve Daviss, MD, the senior medical adviser to SAMHSA. The initiative focuses on the mental, behavioral, and biological aspects of psychological trauma response, prevention of the long-term consequences of child trauma, and early intervention services and treatment to address the long-term consequences of child trauma. Last year the Campaign for Trauma-Informed Policy and Practice, based in Washington, DC, issued a policy brief on ACEs and opioid addiction. The brief cited the evidence that links early childhood stress to opioid addiction including the landmark CDC/Kaiser Permanente ACEs study and others, giving examples of several communities that have launched treatment and prevention programs. It also provides examples of effective programs and describes innovative approaches being used by communities to address the current epidemic. In her preface to the policy brief, the lead author, Andrea Blanch, PhD, a senior consultant for SAMHSA’s National Center on Trauma-Informed Care, writes that there are at least two ways in which knowledge about the correlation between ACEs and opioid addiction can be put to work. The first is through programs to prevent exposure to trauma (primary prevention) and to promote resilience in groups put at risk by exposure to adversity (secondary prevention). Prevention programs help to ensure that the next generation doesn’t abuse substances when they become adults, which is particularly important in communities devastated by addiction. The second strategy is to use trauma-informed treatment approaches to help existing addicts recover and return to productive lives. Both approaches, prevention and treatment, “need to be part of a comprehensive plan to address opioid addiction,” Dr. Blanch says. The policy brief notes that most trauma-informed programs are at their early stages of being implemented and studied.
A West Virginia Experiment
Clay Marsh, MD, the vice president and executive dean for health sciences at West Virginia University in Morgantown, and his staff have used the university’s prestige as a fulcrum to launch several such programs in their home state, which currently leads the United States in opioid-related deaths. Dr. Marsh wrote about this initiative in Stat, a health publication of the Stat media company, which is produced by Boston Globe Media. At the heart of these programs is a potentially deadly sequence that starts with chronic stressful events disrupting children’s brain development. Such disruptions may impair cognitive function, leaving them unable to cope with negative or strong emotions. Growing into adulthood, the youngsters may resort to substance and alcohol abuse, self-harm, and other unhealthy coping that can increase their risk of disease and early death. In an interview with Everyday Health, Marsh says that treating and preventing this maladaptive stress response necessarily informs the effort to both prevent and treat opioid addiction. It’s why the opioid treatment clinic at the health center includes not just medication, but also a 12-step program for addiction recovery and very strong case management. “In our residential programs we are starting a program called ‘reintegrate’ that provides jobs, schooling, and life skills training,” Marsh says. “We want to deliver purpose, caring, and connection. Those are important concepts of not only getting better, but of staying better and of being able to create a warm and supportive environment for people recovering from both trauma and addiction, who go on to have children of their own and hope to shield them from their own harsh experiences.” Marsh says connecting in the community is key to reducing trauma and creating resilience. “We want people to see the miracles in friendship, or a walk outside, stay in the present moment and not be so fearful,” he says. To achieve their goals in West Virginia, the health system is actively supporting coalitions and faith-based groups that are helping to develop a sense of community. Healthy Harrison, for example, a program in middle-income Harrison County, includes in its programming workplace wellness at several sites and an in-school walking program for students and staff that not only provides exercise, but also builds relationships. Almost all the programs are only a few years old, but Marsh, who has fielded inquiries from communities across the United States, is optimistic. “It’s a journey of 1,000 miles,” he says. But there are lots of data to suggest that feeling loved, connected, safe, and purposeful is important to a person’s foundational health. “The key to preventing and treating addiction is to work within our communities to rebuild hope,” Marsh says.
