This is the first study to examine lifetime trauma experiences among a large sample of individuals in MOUD. The results highlight the high prevalence of trauma in both childhood and in adulthood, as well as both interpersonal and non-interpersonal traumatic events in both men and women. While differences across gender and chronic pain status are notable, the remarkable prevalence of exposure to all trauma categories across all groups points to the critical need for both trauma assessment and mental health services that are accessible and integrated into MOUD treatment. Individuals in this sample were stabilized on MOUD for a substantial amount of time and reported high levels of abstinence from substance use yet were not accessing a level of mental health care commensurate with their need. Also notable is the particularly high report of sudden and unexpected death of a close friend or loved one – reflecting the tragic experience of loss among this sample likely due to drug overdose in their communities.
There were distinct gender differences in trauma exposure, the most striking being the higher number of women who reported sexual abuse in childhood and sexual assault in adulthood compared to men. This finding aligns with prior research and the identified need for women-specific programs in SUD treatment to address the high prevalence of sexual trauma (9, 10). Perhaps unexpected, although similar to study findings examining interpersonal trauma in the past 12 months among those in MOUD (14), was the high number of men who reported being victims of intimate partner violence (IPV); while not as high as the report of IPV among women, this finding warrants further research and clinical attention as it points to the need for more assessment and clinical support for IPV, for everyone regardless of gender/sex. Overall, these results point to the need to ensure that support services and trauma treatment are available and integrated into treatment to optimize outcomes for those receiving MOUD.
In this study, 41% of participants screened positive for PTSD, congruent with previously published literature (45, 46). Given the high prevalence of many types of traumatic experiences across the participants in this sample, we could not link PTSD diagnostic status to particular types of traumatic event (i.e., whether they occurred during childhood or as an adult; whether interpersonal or non-interpersonal). However, the results demonstrate the link between the number of traumatic events experienced and PTSD symptomatology and diagnosis. These findings align with previous studies (47), and the understanding that traumatic events in both childhood or adulthood can impact symptom severity, expression, and complexity (48).
The high prevalence of chronic pain in MOUD populations allowed us to examine the relationship between trauma exposure and chronic pain. Congruent with previous studies among individuals with and without SUD, our study found that individuals with OUD and chronic pain were more likely to report traumatic accidents (e.g., car accidents, falls, natural disasters) (27–30, 32, 33, 35–37, 49). Impaired cortisol secretion and psychological stress in response to a traumatic injury/ accident has been associated with development of chronic pain over time (27). Prior life circumstances that result in sustained, long term cortisol surges or activations, are known to contribute to cortisol dysfunction, and may then increase risk the risk of development of chronic pain (50). The relationship between abnormal physiological stress reactivity (i.e., heart rate, blood pressure, respiration rate, cortisol secretion) on negative health outcomes is well-established (51), and linked to pain somatization disorders (52, 53).
We also found that individuals who endorsed chronic pain were more likely to report childhood violence, including physical abuse, sexual abuse, and witnessing IPV in childhood. Most prior studies that have examined chronic pain, OUD, and childhood trauma exposure have been limited to single types of childhood abuse or neglect (33, 36). Our findings align with prior research showing a link between childhood trauma and chronic pain in community and SUD samples, highlighting the importance of assessing PTSD among those with chronic pain in MOUD and the potential need for psychological treatment in the context of recovery.
Providing trauma-focused therapy alongside treatment for opioid use disorder (46, 54), may prove to be beneficial. There is evidence that patients with chronic pain and a co-occurring history of physical trauma demonstrate a diminished response to treatment, when compared with a cohort of patients without a history of trauma. Moreover, recent clinical reports have described the indirect and successful treatment of intractable and chronic pain in patients with comorbid PTSD, only after instituting behavioral therapy targeting the PTSD symptoms. Cognitive-behavioral therapies with proven efficacy for the treatment of PTSD are now available to pain practitioners, and it is noteworthy that these interventions are now being tailored within comprehensive pain rehabilitation programs. Incorporating novel mindfulness and body therapy approaches to increase sensory and emotional awareness may also benefit individuals with PTSD and co-occurring OUD, and further research is needed in this area.
There are important related clinical implications of these findings for medical providers. Given the high prevalence of trauma exposure and PTSD among individuals with OUD, evidence-based PTSD screenings, assessments, and treatments should be provided alongside MOUD (55). Although calls to lower barriers and increase access to MOUD treatment have resulted in more primary care providers treating people with OUD (56–59) and national guidelines recommend that primary care clinics screen for depression (60) and anxiety (61), there is not a similar recommendation for universal PTSD screening (62) and, thus, detection rates are low (63, 64).
Study limitations include the characteristics of the sample: the majority were white, low SES, and from one region of the United States. The findings may not generalize to a more racially, ethnically or economically diverse population. Also, only two individuals in this study identified as non-binary, limiting our ability to learn more about this population and highlighting an important line of future research. The TLEQ, the questionnaire we used to collect trauma exposure data, is comprehensive and has been used in prior research; however, until there is a more standard measure used consistently across studies, it will continue to be challenging to compare findings from one study to another in order to gather a more subtle understanding of the sequelae of trauma exposure across the lifespan (5). This study has multiple strengths. First, it is a multi-site study including participants from urban and rural areas and multiple practice settings (opioid treatment program, mental health clinic, addiction clinic, and primary care clinic.) Patients reported a high proportion of days abstinent, and the majority had been in prolonged MOUD treatment, reducing the possibility that mental health symptoms were primarily substance-induced.