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Visions Journal

What Do Trauma and Gender Have to Do with Opioid Use?

Natalie Hemsing, MA, Nancy Poole, PhD, and Lorraine Greaves, PhD

Visions Journal, 2018, 13 (3), p. 32

The majority of women and men with substance use problems report having experienced some form of trauma, and most have experienced multiple traumas.1 People often report that they use substances to help cope with the stress or negative emotions that result from trauma. Our work at the Centre of Excellence for Women’s Health (CEWH) suggests that a gendered and trauma-informed approach to responding to opioid use is essential to improving practice and policy to meet the needs of all opioid users.

Compared to other substance users, women and men who are addicted to prescription opioids are more likely to report a traumatic event.2 They also tend to have first experienced trauma at a younger age and are more likely to report a childhood trauma, including childhood abuse or neglect, or to report having witnessed violence.2 Women and men who have a history of trauma tend to report more severe addiction to opioids, and poorer physical health.3 Depression, anxiety, self-harm and suicide are also common among women and men who are addicted to opioids (including prescription opioid misuse and illegal opioid use).4

Women and men who are addicted to opioids report different experiences. Among women, the greatest risk for opioid addiction is receiving a prescription for opioid medication.5 In general, women tend to report experiencing more chronic physical pain, and are more likely to receive a prescription for an opioid painkiller.6,7 The risk for chronic physical pain is even greater among women who have been victims of violence and abuse.8 Women may also be more likely to use prescription opioids to manage the effects of trauma. There is some evidence that women are more likely than men to use prescription opioids to cope with negative emotions and pain.9

In contrast, men are more likely to use illegal sources of opioids, and engage in riskier drug use, including using the drug while alone, increasing the amount used and ingesting the opioid in a way other than the drug was intended to be ingested (for example, by crushing and snorting or injecting).10-13 Men are also more likely to die from an opioid-related overdose (fentanyl in particular).13 However, trauma is also a risk factor for prescription opioid abuse among men. For example, among young injection drug users, men with post-traumatic stress disorder (PTSD) are at the greatest risk for prescription opioid abuse and addiction.14

Both women and men addicted to opioids report complex needs, including the need for mental health, legal, financial and family supports.15 While women are more likely to be victims of sexual violence, childhood abuse is linked with greater risk for prescription opioid abuse in both women and men.16,17 Clearly, the evidence suggests that gendered and trauma-informed approaches to early intervention and support are needed to address opioid misuse for both women and men.

How can trauma-informed practice help?

Trauma-informed practice (TIP) is a set of ideas and ways of working with clients that recognizes how important it is to offer safe, non-judgemental services so that people with a history of trauma can access and benefit from available substance use supports and treatment. Trauma-informed approaches do not require that the service provider ask about or discuss the trauma. Instead, trauma-informed approaches are designed to ensure client safety, choice and control in the decisions that impact their substance use. They also provide opportunities for the client to build appropriate coping skills to manage trauma responses.

There are four key principles of TIP:

  1. Trauma awareness. TIP involves developing awareness (among both service providers and clients) regarding trauma, the effects and responses to trauma and the links with substance use and other health effects. Basic training of all staff and administrators is key to creating this awareness.

  2. Safety and trust. Trauma can negatively impact client trust and safety, feelings of self-worth, emotional control and interpersonal relationships.18 Creating an environment that considers the emotional, physical and cultural safety of clients is central to TIP. Such an environment will provide welcoming, friendly reception, calm waiting areas and posters with supportive messages.

  3. Choice, collaboration and connection. Service providers use an open and non-judgemental communication style, work together with clients and provide options for change and growth. It’s fundamental that clients have choice in how they seek treatment—choice based on safe and healthy relationships with service providers.

  4. Strengths and skills-building. In TIP, clients are supported to identify and build on their strengths and use healthy coping skills. This may include identifying triggers and practising calming and grounding techniques (for example, breathing, mindfulness and meditation). It also means making change at a pace the client feels comfortable with.

Practical steps towards assessment and early intervention

Trauma-informed approaches involve all levels of staff. Dr. Sandra Bloom describes a trauma-informed agency as a “strong, resilient, structured, tolerant, caring, knowledge-seeking, creative, innovative, cohesive and nonviolent community where staff are thriving, people trust each other to do the right thing, and clients are making progress in their own recovery within the context of a truly safe and connected community.”19

Trauma-informed approaches to assessment and early intervention offer an opportunity to begin support on opioid use with a conversation with the client.

Here are some practical approaches to early intervention conversations:20

  1. Ensure the safety of the client in the conversation—asking about trauma is not necessary to provide trauma-informed care.

  2. Let clients know that they do not need to provide details of any traumatic event and they do not need to answer questions that make them feel uncomfortable. Let them know they can take a break from the conversation whenever they need to.

  3. Ensure that service providers are trained to recognize and respond to signs of re-traumatization, and have the training and knowledge of resources and referrals to support clients who want specific support related to trauma.21

  4. Ensure the client’s privacy and a safe physical environment. For example, ask the client if he or she is comfortable with the door being closed, offer the client water and determine how to make the client most comfortable.

  5. Tell the client up front how information from the conversation will be used or shared.

  6. Explain why you are asking questions, and regularly check in with the client, listening closely to make sure the client is still comfortable with the pace and subject-matter of the conversation.

  7. Attend to signs of a trauma response (e.g., sweating, shaking, a change in breathing) and offer calming or grounding support if it is needed.

  8. Ask about the client’s strengths, including the client’s goals and interests, coping mechanisms and available supports.

Trauma, gender and equity issues that are central in determining and shaping opioid use need to be addressed in our conversations and in our support strategies for opioid-related treatment programs. At CEWH, we are working on integrating trauma- and gender-informed approaches into Canada’s substance use response system. As one report on trauma-informed approaches sums up, “trauma informed care is as much about social justice as it is about healing.”22

 
About the authors

Natalie is a research associate at the Centre of Excellence for Women’s Health (CEWH), in Vancouver, BC, hosted by BC Women’s Hospital and Health Centre, with an extensive background in sex- and gender-based analysis, research on women’s substance use, and systematic reviews and knowledge syntheses on a range of girls’ and women’s health issues

Nancy is the Director of the CEWH, leading knowledge translation, network development and research related to improving policy and service provision for girls and women with a range of health issues, including substance use and trauma

Lorraine is the founding Executive Director and current Senior Investigator at the CEWH. She is an international expert on women’s substance and tobacco use, gender and health promotion, and the integration of sex and gender in research, program and policy development

Footnotes:
  1. Hughes, T., McCabe, S.E., Wilsnack, S.C., West, B.T. & Boyd, C.J. (2010). Victimization and substance use disorders in a national sample of heterosexual and sexual minority women and men. Addiction, 105(12), 2130-2140.

  2. Lawson, K.M., Back, S.E., Hartwell, K.J., Moran-Santa, M.M. & Brady, K.T. (2013). A comparison of trauma profiles among individuals with prescription opioid, nicotine, or cocaine dependence. American Journal on Addictions, 22(2), 127-131. 

  3. Danovitch, I. (2016). Post-traumatic stress disorder and opioid use disorder: A narrative review of conceptual models. Journal of Addictive Diseases, 35(3), 169-179. 

  4. Benningfield, M.M., Arria, A.M., Kaltenbach, K., Heil, S.H., Stine, S.M., Coyle, M.G., Fischer, G., Jones, H.E. & Martin, P.R. (2010). Co‐occurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women. American Journal on Addictions, 19(5), 416-421. 

  5. Hachey, L.M., Gregg, J.A., Pavlik-Maus, T.L. & Jones, J.S. (2017). Health implications and management of women with opioid use disorder. Journal of Nursing Education and Practice, 7(8), 57-62. 

  6. Bawor, M., Dennis, B.B. Varenbut, M., Daiter, J., March, D.C., Plater, C., Worster, A., Steiner, M., Anglin, R., Pare, G., Desai, D., Thabane, L. & Samaan, Z. (2015). Sex differences in substance use, health, and social functioning among opioid users receiving methadone treatment: A multicenter cohort study. Biology of Sex Differences, 6(1), 21. doi: 10.1186/s13293-015-0038-6.

  7. Hemsing, N., Greaves, L., Poole, N. & and Schmidt, R. (2016). Misuse of prescription opioid medication among women: A scoping review. Pain Research and Management. doi: 10.1155/2016/1754195.

  8. Peles, E., Seligman, Z., Bloch, M., Potik, D., Sason, A., Schreiber, S. &Adelson, M. (2016). Sexual abuse and its relation to chronic pain among women from a methadone maintenance clinic versus a sexual abuse treatment center. Journal of Psychoactive Drugs, 48(4), 279-287. 

  9. McHugh, R.K., DeVito, E.E., Dodd, D., Carroll, K.M., Potter, J.S., Greenfield, S.F., Connery, H.S. &Weiss, R.D. (2013). Gender differences in a clinical trial for prescription opioid dependence. Journal of Substance Abuse Treatment, 45(1): 38-43.

  10. Back, S.E., Payne, R., Waldrop, A.E., Smith, A., Reeves, S. & Brady, K.T. (2009). Prescription opioid aberrant behaviors: A pilot study of gender differences. Clinical Journal of Pain, 25(6), 477-484. 

  11. Gladstone, E.J., Smolina, K. & Morgan, S.G. (2016). Trends and sex differences in prescription opioid deaths in British Columbia, Canada. Injury Prevention, 22(4), 288-290. 

  12. Kaplovitch, E., Gomes, T., Camacho, X., Dhalla, I.A., Mamdani, M.N. & Juurlink, D.N. (2015). Sex differences in dose escalation and overdose death during chronic opioid therapy: A population-based cohort study. PLOS ONE 10(8): e0134550. doi.org/10.1371/journal.pone.0134550.

  13. BC Coroners Service. (2017). Illicit drug overdose deaths in BC January 1, 2007 to October 31, 2017 (Report). www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf.

  14. Mackesy-Amiti, M.E., Donenberg, G.R. & Ouellet, L.J. (2015). Prescription opioid misuse and mental health among young injection drug users. American Journal of Drug and Alcohol Abuse, 41(1), 100-106. 

  15. Schäfer, I., Gromus, L., Atabaki, A., Pawils, S., Verthein, U., Reimer, J., Schulte, B. & Materns, M. (2014). Are experiences of sexual violence related to special needs in patients with substance use disorders? A study in opioid-dependent patients. Addictive Behaviors, 39(12), 1691-1694.

  16. Austin, A.E., Shanahan, M.E. & Zvara, B.J. (2018). Association of childhood abuse and prescription opioid use in early adulthood. Addictive Behaviors, 76 (Supplement C), 265-269. doi: 10.1016/j.addbeh.2017.08.033.

  17. Quinn, K., Boone, L., Scheidell, J.D., Mateu-Gelabert, P., McGorray, S.P., Beharie, N., Cottler, L.B. & Khan, M.R. (2016). The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use. Drug and Alcohol Dependence, 169, 190-198. 

  18. Canadian Centre on Substance Abuse. (2014). Trauma-informed Care. Ottawa: Author. www.ccsa.ca/Resource%20Library/CCSA-Trauma-informed-Care-Toolkit-2014-en.pdf .

  19. Bloom, S.L. (n.d..). The sanctuary model. www.sanctuaryweb.com/TheSanctuaryModel.aspx

  20. British Columbia Centre of Excellence for Women’s Health. (2013). Trauma-informed practice guide. Victoria, BC: British Columbia Centre of Excellence for Women’s Health and Ministry of Health, Government of British Columbia. http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf.

  21. Jean Tweed Centre. (2013). Trauma matters: Guidelines for trauma-informed practices in women’s substance abuse services. Toronto: Author. www.jeantweed.com/wp-content/themes/JTC/pdfs/Trauma%20Matters%20online%20version%20August%202013.pdf.

  22. Blanch, A. (2012). SAMHSA’s National Center for Trauma-Informed Care: Changing communities, changing lives. www.nasmhpd.org/sites/default/files/NCTIC_Marketing_Brochure_FINAL(2).pdf.

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