Full length articleThe relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use
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.
Section snippets
Study population and design
The Institutional Review Boards at the University of Florida and NYU Langone School of Medicine approved this study. We analyzed Add Health survey data, a nationally-representative, stratified, random sample of 20,745 U.S. middle school and high school students, including Waves I (adolescence, 11–21 years), III (emerging adulthood, 18–28 years), and IV (adulthood, 24–34 years). Analyses included 12,228 participants in the restricted-use dataset who had sample weights at each Wave. We used a
Univariable and bivariable descriptives
The majority (65%) of the analytic sample were white, and three-quarters had more than high school education (Table 1). The proxy for poverty was low and similar in childhood and emerging adulthood (17% vs. 14%, respectively), and the sample was equally distributed by gender. Covariates were very similar for males and females with the exception of females having a somewhat higher percentage with post-high school education.
Prevalence of the individual exposures ranged from 5.13% (experienced
Discussion
A strong and consistent dose-response relationship emerged for the PPRM drug outcomes when cumulative number of traumas was examined. There is evidence that the cumulative trauma load (Cohen et al., 1995) during stress-sensitive childhood has negative effects on well-being (Khoury et al., 2010, Neuner et al., 2004, Weber et al., 2008). Furthermore, easy availability of illicit drugs and experimentation among adolescents in the course of normal developmental processes likely contribute to high
Conflict of interest
The authors declare no conflict of interest.
Contributors
All authors are responsible for this reported research. K. Quinn conceptualized and designed the study, conducted the analyses, and drafted the manuscript. L. Boone, J. Scheidell, S. McGorray, N. Beharie and M. Khan helped conceptualize and design the study and interpret results. P. Mateu-Gelabert, L. Cottler, and M. Khan critically reviewed the manuscript. All authors reviewed and approved the submitted manuscript.
Role of funding source
This work was supported by National Institute on Drug Abuse (NIDA) study R01DA036414: Longitudinal Study of Trauma, HIV Risk, and Criminal Justice Involvement and The Center for Drug Use and HIV/HCV Research (CDUHR) grant P30DA011041. These sponsors had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Acknowledgments
This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for
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