TRAUMA-RELATED SUBSTANCE ABUSE

Prevention providers and treatment specialists, both, have long known of the correlation between experiencing a traumatic event and the subsequent use and abuse of alcohol or other drugs, as well as the connection between trauma and relapse. But while the research is replete with extensive studies on trauma, studies on the concept of a link between trauma and substance abuse are more recent.

The Council, in leading a one-year review of the research, found that victims of trauma are 4-to-5 times more vulnerable and likely to experience alcohol or substance abuse than the general public. Studies after the World Trade Center disaster, studies of the Columbine incident, Oklahoma City bombing, of war veterans and PTSD, and numerous studies of other catastrophes have demonstrated that there is a very strong relationship between experiencing a traumatic event and the subsequent use and abuse of alcohol, cigarettes, street drugs, and misuse of prescription drugs.

These findings hold true across categories of trauma - natural disasters, war, accidents, experiencing terrorism, being a victim of crime or violence, experiencing child abuse or sexual abuse, or with a personal loss - health, possessions or death.

Often the most natural thing to do is to cope with or "self-medicate" the grief, fears and anxieties with these substances. Yet, from virtually every perspective the use of substances following trauma is contra-indicated unless under strict medical protocol. In fact, often, the consequences of substance abuse re-traumatizes the person, or subjects the person to secondary trauma.

The research speaks to ways to mitigate the effects of trauma and reduce the probability of substance abuse post-trauma. Prevention experts and counselors can best accomplish this by helping victims of trauma with:

• (1) spirituality, self-actualization, personal growth, and by reviewing purpose and meaning in life,

• (2) teaching positive coping skills,

• (3) building resiliency,

• (4) enhancing protective factors,

• (5) reducing risk factors,

• (6) encouraging family and community support,

• (7) and by the provision of education and intervention services, support groups, and counseling as needed.

Substance abuse may not develop immediately after the traumatic event. It may not develop for 6-to-18 months - or even years after a traumatic event. In either case - from a prevention or a treatment perspective, educators and counselors both need to mitigate the effects of trauma - and do everything possible to minimize the use of substances after a traumatic incident.

DEFINING STRESS
Any true understanding of trauma and the effects of trauma must be based upon a solid understanding of stress. One definition of stress describes it as a powerful internal communication to raise awareness and increase energy.

Stress is triggered by excessive internal, external or environmental demands or stimulation. The experience of stress can be looked upon as existing on a continuum from mild stress to traumatic stress. Mild stress stimulates the central nervous system, the immune system, the adrenal system and the cardiovascular system and results in increase of blood flow to major organs and muscles, neurotransmitter release, and production of CRF hormone. The effect on the body is increased concentration, energy and memory. Mild stress therefore can result in increased performance and efficacy.

Prolonged stress however, can deplete the body’s capacity and result in negative consequences. It seems to impair the immune system's capacity to respond. Prolonged stress not only makes people more vulnerable to catching illnesses but can also impair their immune system's ability to respond to its own anti-inflammatory signals that are triggered by certain hormones, possibly altering the course of an inflammatory disease.

Traumatic stress is stress resulting from exposure to, or witnessing of events that are severe and/or life threatening. The extent of traumatic stress experiences varies by duration of exposure and number of exposures. Additionally, the amount of stress incurred will vary according to the availability of resources and coping skills.

DEFINING TRAUMA
Individuals who have experienced a traumatic event often suffer psychological stress related to the incident. In most instances, these are normal reactions to abnormal situations. Individuals who feel they are unable to regain control of their lives, or who experience the following symptoms for more than a month, should consider seeking outside professional mental health assistance. A traumatic event is defined by psychiatric professionals as "an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others."

CATEGORIES OF TRAUMATIC EVENTS / RESULTING TYPES OF TRAUMA
Traumatic events are often referred to as disasters or crises. Such events that are considered traumatic fall into two general categories: natural and man-made.
Natural crises include those disasters that are created by the forces of nature such as tornados, hurricanes, fires, earthquakes, floods, and tsunamis. These disasters may be unpredictable or there may be some advance notice giving people time to take precautions or vacate. Natural disasters are generally considered "uncontrollable" in terms of their occurrence although there may be some control over their impact.

Man-made disasters or crises include: building/structural collapse, medical/food tampering, chemical attacks/dispersement, ethnic cleansing, riots and wars, suicide, murder, and crime and violence. When the cause is viewed as man-made, the reactions may be more emotionally devastating. This is likely because the disaster is viewed as within the control of individual persons, and therefore avoidable. It is not only the acts themselves, but the threat of these acts which may have psychologically traumatizing impact. Society at large is at risk due to close proximity of persons in public and working spaces such as office buildings, public transportation and public events. Globally, especially since the events of 9/11, people around the world have begun to see themselves as vulnerable.

TRAUMA, STRESS, AND SUBSTANCE ABUSE
The fact that there is a connection between trauma and substance abuse has been known for decades. The stress-reduction model of substance abuse posits that the distress experienced by trauma is either managed or "self-medicated" by some people by intake of alcohol, tobacco, or other drugs.

In fact, stress - and especially trauma - is considered a major contributor to substance abuse initiation, continuation, and relapse. Studies have consistently shown that there is a greater likelihood of alcohol and drug abuse when stress is high, and now research supports the theory that trauma is one of the pathways into addiction.

Survey results (funded by grants from NIDA) demonstrated increases in the use of tobacco, alcohol, and marijuana among the residents of Manhattan five to eight weeks after the terrorist attacks on the World Trade Center (WTC).

Research demonstrated that in the 4-to-8 month post-trauma period after the Oklahoma City bombing, it was found that 16% of Oklahoma City bombing survivors had used alcohol to cope, and 40% used medication to cope.

Estimates of lifetime substance abuse are from 21% to 43% for persons with PTSD (for persons without PTSD, lifetime substance abuse is estimated from 8% to 25%.)

Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women; twenty-five to seventy-five percent of those who have survived abusive or violent trauma also report problems with alcohol use; and ten to thirty-three percent of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if they are troubled with persistent health problems or pain. In other research sexual abuse in childhood was found to be the strongest predictor of later alcohol and drug abuse.

In a research document called "Stress and Substance Abuse: A Special Report," the NIDA highlighted numerous studies elucidating a scientific basis for the clinical observations that people exposed to stress, stressors and life crises are likely to abuse alcohol and other drugs, and are more vulnerable for self-administration. High stress was found to be predictive of continued drug use, and stress was found to be the number one cause of relapse for recovering individuals.

SUBSTANCE ABUSE IS CONTRA-INDICATED
Self-medication with substances is contra-indicated for survivors of trauma. Use of alcohol, cigarettes, street drugs or a mis-use of prescription drugs is a negative coping mechanism. While it seems to provide some immediate relief from either anxiety or pain, in reality it complicates and confounds the healing and recovery process:

o First, substance use only provides temporary relief, if any at all; it often blocks necessary psychological processing and can prevent or delay the natural completion of the grieving process;

o Second, it often results in lower functioning capacity resulting in poor choices and poor decisions and even behavioral dysfunction;

o Third, rather than calming nerves, alcohol and other drugs can actually increase both anxiety and fears, they intensify and exaggerate emotions so they come out drug-affected... and long term use can even cause emotional stagnation;

o Substances can disrupt sleep, especially stage four or deep sleep, and they can increase nightmares and make them more vivid and believable.

o A person who abuses substances can easily be re-traumatized because of impaired decision making, furthering a use-abuse-trauma-use cyclical dynamic.

Even the most minor use of these substances, unless by physician’s prescription and under a strict medical protocol, can actually make the symptoms of trauma -- especially the more severe symptoms associated with Post Traumatic Stress Disorder -- much more serious.

The healing process is most effective when done in the company of safe, supportive others, and not with the use of substances.

TYPES OF TRAUMA
In general, trauma includes the following types:

Natural Disasters - Includes natural disasters such as tornados, hurricanes, fires, earthquakes, typhoons, floods, and tsunamis. These disasters may have low predictability (such as fires and earthquakes) or there may be some advance notice giving people time to take precautions or vacate. The occurrence of natural disasters is generally considered to have no or little controllability although there may be some control over impact.

Personal Loss - The most prevalent type of trauma is that of the loss of a person who has played a key role in the person’s life. Losses may also include pets, jobs, or any familiar object or environment. This includes loss due to death, divorce, and separation. Separations can be marital, parental, siblings, or other important support persons. Intensity of this trauma varies by the intensity of the relationship with the person, object, or life situation. Repeated personal losses without sufficient recovery time complicates and intensifies the reaction.

Health Trauma - Includes trauma due to the onset of a disability or illness.

Victimization - A physical or emotional trauma that results from abuse or neglect. This includes: physical abuse, sexual abuse, and neglect. Victimization can be repeated, prolonged, or a single event. These may subject the individual to a prolonged period of perceived or actual life threatening situations which increases the intensity of the event. Victims may blame themselves for behaviors prior to or during the trauma, increasing the perception of controllability.

Criminal Violence - Victims are subjected to an individual event such as robbery or homicide, and criminal assault in which they experienced a lack of control over their belongings and/or bodies and may be subjected to a life-threatening situation. Re-victimization may compound reactions.

Wars and Terrorism - These are intense, massive in scale, and long term in nature, exposing victims to repeated life-threatening situations. Additionally, persons may have engaged in perpetuating violence against others. This may intensify the response to trauma because the perpetration can be seen as counter to the self-image. It may be particularly distressful if it comes to be viewed as an unavoidable and uncontrollable occurrence.

COMMON REACTIONS TO TRAUMA
Everyone reacts to trauma. Both the mind and body react to the experience of crisis. These reactions in general can best be described as:
• 1) physical reactions,
• 2) affective reactions,
• 3) cognitive reactions, and
• 4) behavioral reactions.

PHYSICAL REACTINS TO TRAUMA: Immediate reactions of the body are attempts to provide the body with increased attention, energy, and strength. The expenditure of the body’s resources takes a toll which can lead to physical exhaustion and physical problems.

Common physical reactions may include: vascular changes (increased blood flow); cardio-vascular changes (increased heart rate); increase in adrenalin; gastro-intestinal problems (diarrhea, constipation, nausea); allergies; skin rashes; somatic complaints (headaches, body aches, muscle aches); and fluctuations in blood pressure.

AFFECTIVE REACTIONS TO TRAUMA: These reactions encompass the emotional responses to trauma. Frequently a sense of shock or numbness is noted as an initial emotional reaction: anxiety, denial, helplessness, panic, anger, numbness, diminished sense of being, emptiness, lack of enjoyment, shock, fear, hopelessness, despair, frustration, survivor guilt, uncertainty, overwhelmed, lack of enjoyment.
Cognitive Reactions to Trauma: These reactions include the thinking about trauma or the level of capacity to think in an effective manner: poor attention span, flashbacks, nightmares, impaired judgment, self-blame, confusion, diminished concentration, difficulty in decision-making, impaired memory, sense of powerlessness, obsessive thoughts or memories.

BEHAVIORAL REACTIONS TO TRAUMA: These reactions are related to actions taken or avoided during trauma: irritability, unresponsiveness, over-protectiveness, sleep disturbances, withdrawal, eating disturbances, anger outbursts, crying, diminished levels of activity, exaggerated startle response, communication change, alcohol and/or drug abuse, antisocial acts, disorganization, hyper-arousal, change in sexual behavior, excessive use of sick leave, hysterical reactions, isolation from others, fatigue, neglect of health and daily activities, avoidance of situations.

THE PREVENTION OF TRAUMA-RELATED SUBSTANCE ABUSE
Stated simply, there are three levels of recovery from trauma. People will ultimately stay the same, get better, or become worse. While most persons will have decreased functioning for a period of time following a traumatic event, they often return to their former level of functioning after 18-to-24 months.
As prevention providers, there are two distinct goals to strive for:

• (1) to mitigate the negative effects after experiencing a traumatic event, and

• (2) to reduce the probability of the use, abuse or misuse of substances after a traumatic event.

To accomplish these, there are three universal objectives :

• (1) use a holistic prevention framework, that is: promoting health-enhancing behavior and reducing health-compromising behaviors to be supportive of, or contribute to a post-trauma elevated self level.

• (2) to return persons (at least) to the pre-trauma level of functioning;

• (3) to prevent the onset of substance use, or relapse into active addiction..

In this regard, research clearly demonstrates the primary tools of prevention are:

• (1) teach positive coping skills;
• (2) foster (internal) resiliency characteristics;
• (3) enhance protective factors (including family, friends and support groups),
• (4) reduce risk factors,
• (5) encourage personal growth, self-actualization and spirituality,
• (6) and most importantly, develop and integrate effective substance abuse educational program(s) and/or intervention program(s) for the population defined as survivors of trauma.

Source: (Glover-Graf 2003),
Office of Alcoholism and Substance Abuse, New York State
[Thanks to a grant provided by the Ctr. for Subst. Abuse Prev. & Subst. Abuse & Mental Health Serv. Admin.]
(www).trauma-and-alcoholism.com/trauma.htm
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goingonhope: Further Contributions of this Research in, Tips for Helping Adults & Children As Victims of Trauma can be found here: Tips For Helping Adults & Children As Victims Of Trauma in the Pain Management section. As we all can know that any applied tips for developing healthy and constructive coping skills following soon after trauma can greatly reduce the risks of developing PTSD. I believe wholeheartedly in the saying, "An ounce of Prevention is worth a pound of cure." Perhaps PTSS may not have to go untreated and develop into PTSD or any other life and death threatening illnesses and/or disease, one such as that of substance abuse, addiction or alcoholism. As all too often the abuse of alcohol and/or substance or even the disease of alcoholism can result in perpetuating traumas. It can also create a powerlessness/helpless & hopeless state of mind and with patterned, almost predictable behaviors as to complicate, temporarily prevent and/or sometimes almost permently place the healing of trauma out of reach for the individual and their beloved family if they still have one or ever dreamnt of having one.

Hope