Adia Scrubb, MD, MPP
Approach the Intersection of Substance Use Disorder and ACEs When I met Robert, he was very motivated to stop his alcohol use. He was in his mid 50s and already had a long history of brief periods of sobriety with multiple relapses. He was tired of the relapses and really wanted my help to find something that would work for him. Robert was a little bit of a challenge, however, in that he had already gone to AA meetings, residential recovery programs, and had even taken disulfiram. But things were starting to take a toll on his liver and he was willing do any of those things again if it would somehow help him this time. About 50% of individuals experiencing substance use disorder have a co-occurring mental illness. Since he had been currently sober for a about 6 months, we decided to start working on what turned out to be moderate depression. Once he was connected to a community therapist and started on medications, he felt some improvement and was optimistic. He came in at regular intervals to update me on his progress and sobriety. With each conversation that we had, I realized that he was eager to understand why nothing had really worked in the past for his sobriety. I learned that he was unemployed, had a marriage that ended in divorce, and had a strained relationship with his daughter that he really wanted to repair. He was very hard on himself as he blamed himself for the relationships that fell apart. I remember asking Robert what his trigger to drink alcohol was, and he said, “being alone”. Isolation allowed him to ruminate about his personal failures and he would turn to drinking alcohol. His self-esteem was higher when he was around other people or working. I thought about why being alone, even for short periods of time, would send Robert into a spiral. He shared with me that his parents separated when he was young, and he didn’t have much of a relationship with his father. His father died before he could reconcile with him. He had a relationship with his mother, but she wasn’t entirely emotionally available. He thought that perhaps that had an influence on really wanting relationships to work and then feeling guilty when they failed. Robert expressed to me that his heavy drinking worsened after his own divorce. I now understood that 16
California Family Physician Fall 2021
Robert possibly had at least one Adverse Childhood Experience in connection to his alcohol use. Adverse Childhood Experiences (ACEs) has a very strong association with substance use disorder through the alteration of the hypothalamic pituitary adrenal (HPA) axis in an environment of toxic stress. This impacts brain development and can lead to maladaptive behaviors. Chronic stress has been associated with increased vulnerability to substance use and is a significant risk factors for relapse. Childhood parental divorce and emotional neglect are ACEs that can lead to substance use disorder and depression. Once I understood how important his relationships were, I wondered if Robert had taken steps to repair his connections or if there was a way to help him build new ones. I encouraged him to try additional group therapy and reconnect with his daughter with the hopes that working on these relationships could help prevent a relapse. After a few months, he was happy that things were going well after reconnecting with her. He also liked the group therapy session and attended when he could. My heart sank when I got a note from the ED for a head laceration after Robert fell while intoxicated. The note was followed by a message from Robert stating that he would be checking himself into residential rehab program for a month. During his stay he focused on the relationship with his father that he never had the chance to repair. In an office visit after his program was completed, he seemed to reach a point of closure about their relationship, and he felt ready to move forward. At my last visit with Robert, he was one year sober, working part time, and very happy that he understood himself better. Given the strong association with SUDs and mental illness, a trauma informed approach can help with establishing the rapport needed to encourage a patient through treatment. Considering and/or screening for a history of ACEs can not only add perspective about a patient and their difficulty with treatment, but it can sometimes be the key to helping a patient move forward in their treatment progress.
