The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use

Highlights

• Prevalence of prescription pain reliever misuse was 28% by adulthood.

• Injection drug use prevalence was 1.24% by emerging adulthood.

• 28% reported at least one of nine traumatic events before age 18.

• Increasing number of childhood traumas is associated with drug misuse in adulthood.

Abstract

Background

We examined associations between childhood trauma and adulthood prescription pain reliever misuse (PPRM) and injection drug use (IDU) in a nationally-representative U.S. sample to further understanding of factors associated with these epidemics.

Methods

National Longitudinal Study of Adolescent to Adult Health data (N = 12,288) yielded nine childhood traumas: neglect; emotional, physical, sexual abuse; parental incarceration and binge drinking; witnessed, threatened with, and experienced violence. We estimated adjusted odds ratios (AOR) and 95% confidence intervals for the association of each trauma and cumulative trauma and drug initiation in emerging and later adulthood.

Results

Outcome prevalences were 20% (PPRM) and 1% (IDU) in emerging adulthood and 10% PPRM in adulthood. We observed dose-response relationships that varied across outcomes. Cumulative trauma (referent = none) was associated with 34–79% greater odds of PPRM (emerging adulthood) across one to five+ trauma categories. The gradient was most consistent and associations strongest for adulthood PPRM: one trauma AOR = 1.46(1.12, 1.91); two AOR = 1.71(1.23, 2.36); three AOR = 2.16(1.43, 2.36); four AOR = 2.70(1.42, 5.62); five+ AOR = 3.09(1.52, 6.30). Dose-response was less consistent for IDU, but 4 and 5+ traumas were associated with approximately seven and five times the odds of IDU. Neglect, emotional abuse, and parental incarceration and binge drinking were associated with 25–55% increased odds of PPRM. Sexual abuse and witnessed violence were associated with nearly 3 and 5 times the odds of IDU.

Conclusions

Associations between childhood trauma and PPRM/IDU highlight the need for trauma-informed interventions for drug users and early trauma screening and treatment for prevention of drug misuse over the life course.

Introduction

Prescription pain reliever misuse (PPRM) is a serious public health problem in the United States that has contributed to a dramatic increase in overdoses and an overdose mortality rate that quadrupled from 1999 to 2008 (Paulozzi et al., 2011). Injection drug use (IDU) prevalence, estimated to be 2.6% in the United States, is alarming not only because of overdose risk but because IDU facilitates transmission of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) (Lansky et al., 2014). Gender disparities are emerging: women are prescribed PPR at higher rates, higher doses, and for longer periods of time than men (Campbell et al., 2010, Williams et al., 2008). In 2010, PPR were involved in 71% of prescription drug deaths and 10% of suicides among women, contributing to a PPR mortality rate that increased by 415% (and 265% for men) from 1999 to 2010 (Centers for Disease Control and Prevention, 2013). While qualitative and quantitative data suggest, but have not thus far fully elucidated, a pathway from PPRM to IDU, a strong association is evident (Lankenau et al., 2012, Mars et al., 2014, Mateu-Gelabert et al., 2015, Muhuri et al., 2013, Young and Havens, 2012).

Childhood trauma is associated with substance abuse over the life course (Briere et al., 2008, Dube et al., 2003, Felitti et al., 1998, Huang et al., 2011, Khoury et al., 2010, Kilpatrick et al., 2000, Widom et al., 2006). Limited research links some traumatic events in childhood to non-medical use of prescription drugs (Khoury et al., 2010, Lawson et al., 2013, McCauley et al., 2010), and IDU has been linked to sexual (Ompad et al., 2005, Roy et al., 2003) and physical abuse (Kerr et al., 2009). A cumulative effect of trauma that extends past childhood has been documented (Dube et al., 2003, Felitti et al., 1998, Khoury et al., 2010). The Adverse Childhood Events (ACE) study has made valuable contributions to understanding childhood trauma by examining ten distinct categories and documenting their associations with early initiation and lifetime use of illicit drugs (including IDU but not PPRM), and also by demonstrating a strong gradient for the relationship between cumulative trauma and drug-related outcomes from adolescence into adulthood (Dube et al., 2003). It is critical to better understand trauma’s role in PPRM specifically given its high potential for addiction and strong correlation with heroin use and injection. Gender differences in the association of childhood trauma and drug misuse have not been clarified (Cottler et al., 2001, Danielson et al., 2009, Khoury et al., 2010, Widom et al., 2006) and deserve urgent attention given the emerging PPR epidemic among women.

This analysis explores the hypothesis that childhood trauma is associated with adulthood PPRM and IDU. We use data from The National Longitudinal Study of Adolescent to Adult Health (Add Health) described at http://www.cpc.unc.edu/projects/addhealth (accessed May 16, 2016). We advance the scholarship on trauma in several ways: 1) Our main exposures are informed by a comprehensive perspective of childhood trauma that includes nine types; 2) In addition to identifying the main effect of each trauma by controlling for all others, we investigate dose-response relationships using a cumulative trauma score; 3) We examine relationships in emerging adulthood and adulthood, which is important since stress sensitivity resulting from trauma may vary over time and PPRM and IDU may emerge and peak during different stages of life; 4) We explore whether the associations of trauma and drug use differ by gender. Results will inform the development and timing of trauma-informed interventions with regard to providers’ prescribing patterns; monitoring of PPR use and associated morbidity and mortality; screening and treatment for target populations such as youth, women of childbearing age, those with pain, and for mental health issues; and ultimately, prevention of misuse, addiction, and mortality.