Trauma and Addiction Together

The worst thing that happened and the substance use are tangled, and you are afraid a program will treat only one of them. SAMHSA's concept paper defines individual trauma as an event, a series of events, or a set of circumstances that a person experiences as physically or emotionally harmful or life threatening, with lasting adverse effects on functioning and on mental, physical, social, emotional, or spiritual well-being. The paper calls those the three E's: the event, the experience of the event, and the effect. NIDA's report on comorbidities says people who have been physically or emotionally traumatized are at much higher risk for drug use and substance use disorders, and that when the conditions occur together, treatment outcomes are worse. The practical response is care that can see both.

If someone is in immediate danger of suicide, is seizing, or cannot be woken, call 911. For a mental health crisis, call or text 988. A family conversation is not a substitute for emergency care.

What the word covers

SAMHSA's definition turns on the lasting effect, not on whether an outsider finds the story dramatic. The concept paper also says many people who experience a traumatic event go on without lasting negative effects, while others have traumatic stress reactions. Post-traumatic stress disorder is one diagnosis in that range. It is not the only way trauma shows up, and a hard year is not automatically PTSD. Sorting that out takes a clinician.

The link to substance use is real in the research NIDA summarizes, and it is not a single story. The report says people with PTSD may use substances in an attempt to reduce anxiety and to avoid dealing with the trauma and its consequences. It also lists early stress and trauma among the environmental factors that raise risk for both substance use disorders and other mental illness. "May" is NIDA's word. It does not mean every person who uses drugs is quieting a trauma, and substances are not a treatment. They can deepen the problem they were meant to quiet.

One figure in that report is easy to over-read. NIDA says approximately 1 in 5 veterans with PTSD also has a co-occurring substance use disorder, in the survey summary it cites. That is about veterans with PTSD. It is not a rate for every adult, and it is not a prediction for one service member. VA and community care are on the veterans treatment guide. Bring the history to that door. Do not wait for a perfect label.

The setting is not the session

SAMHSA separates a trauma-informed approach from trauma-specific services. A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands paths for recovery. It recognizes signs and symptoms in clients, families, staff, and others. It responds by putting that knowledge into policies, procedures, and practices. It tries to resist re-traumatization. SAMHSA's public page and its concept paper use those four moves: realize, recognize, respond, and resist re-traumatization. A count of adverse childhood experiences is a different CDC measure. That student survey is the adverse childhood experiences guide.

The approach, SAMHSA says, reflects six principles rather than a prescribed set of practices or procedures:

• Safety, physical and psychological, as defined in part by the people served
• Trustworthiness and transparency in decisions
• Peer support and mutual help
• Collaboration and mutuality, including a smaller power gap between staff and participants
• Empowerment, voice, and choice
• Cultural, historical, and gender issues

You can ask a program how it handles searches, restraint, mixed-gender spaces, nighttime checks, and the way staff speak to people who are ashamed. Those are safety questions. They are not a script for a therapy hour. SAMHSA is explicit that the principles are not a manual of procedures. A logo that says "trauma-informed" does not tell you whether anyone on the unit can treat post-traumatic stress.

Trauma-specific care is the assessment and the treatment aimed at the trauma itself, done by people trained to do it. NIDA describes one example, Seeking Safety, as a present-focused therapy aimed at treating trauma-related problems, including PTSD, and a substance use disorder at the same time. Patients learn coping skills for both. That sentence is a name and a purpose. It is not the skill list, and it is not something to run from a blog summary in a living room.

NIDA also describes exposure therapy for some anxiety disorders and for PTSD as repeated exposure to a feared memory or situation, always inside a controlled therapeutic environment, with the aim of reducing symptoms. It notes that studies suggest it may help some people with PTSD and cocaine use disorder, and that staying in treatment is a challenge. The controlled environment is the point. Do not assign yourself exposure exercises, recordings, or a plan to talk about the worst day until it fades. People get flooded that way and then use. If a clinician recommends a trauma-focused therapy, ask what training they have and how substance use is handled in the same weeks.

Both conditions, one plan

SAMHSA's name for a mental disorder plus a substance use disorder is co-occurring disorders. PTSD is one of the mental disorders the agency lists as common in that overlap. How screening works, and why treating one problem while ignoring the other loses people, is explained on the dual-diagnosis guide. NIDA's comorbidities report says integrated treatment for a drug use disorder and another mental illness has been found consistently superior to treating each diagnosis separately. SAMHSA's advisory based on TIP 42 says the same thing as a practice principle. The substance use disorder and the mental disorder are treated at the same time.

That principle is not a reason to skip medical withdrawal care, and it is not a reason to force trauma processing on the first night of detox. Evaluation and stabilization are the subject of the first 72 hours guide. Alcohol and benzodiazepines are a special risk in those first days: an overnight stop, without a clinician, can bring seizures. Medicines for opioid use disorder should not be stopped to make a program look drug-free. Those medicines, without doses, are on the medication guide. A trauma history does not cancel them.

SAMHSA says there is no wrong door. Primary care, a mental health clinic, or a substance use program can start the screening. The door still has to open onto both problems. Ask who screens, with what, and who is allowed to treat the trauma-related diagnosis rather than only record it.

Family members hit a wall here. The person in care decides what is shared. Relatives who need support of their own, including groups that are not therapy for the patient, can read the family support guide. Pressing for details of the trauma during a phone call can break trust the program is trying to build. Ask what you are allowed to know. Then ask how you can help without that story.

What to ask

1. Who screens for trauma-related symptoms and for a substance use disorder?
2. Are they treated in one plan, and which clinicians are trained for the trauma-specific work?
3. Which of SAMHSA's principles shows up in the rules of the building, especially safety and choice?
4. Will mental health medicines, and medicines for opioid or alcohol use disorder, be continued?
5. What happens if talking about the trauma increases use or panic? Who is on call?

FindTreatment.gov can narrow a search. A filter is not proof that a program is trauma-informed. Call or text (800) 653-9376 if you want help finding a program that treats substance use and trauma-related symptoms in the same plan.

Nobody should have to tell the worst story of their life in order to get a safe bed tonight.

Additional Resources

Sources cited on this page:

• SAMHSA: Concept of Trauma and Guidance for a Trauma-Informed Approach (SMA14-4884)
• SAMHSA: Trauma-informed approaches and programs
• NIDA: Common Comorbidities with Substance Use Disorders (research report)
• SAMHSA: Co-Occurring Disorders and Other Health Conditions
• SAMHSA Advisory: Substance Use Disorder Treatment for People with Co-Occurring Disorders (based on TIP 42)
• SAMHSA FindTreatment.gov
• 988 Suicide & Crisis Lifeline

Common Questions