A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

Abstract

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a “prestabilization” phase of treatment for TRD – largely analogous to the precontemplation Stage of Change – creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Keywords:

• Trauma
• opioid use disorder
• opioid epidemic
• harm reduction
• complex PTSD
• policy
• trauma-related disorders
• phasic treatment
• screening

Acknowledgments

The authors gratefully acknowledge Riley J. Belcher-Pasztor and Hannah C. Smith for help with the design of Figure 1. Additionally, we thank Nora D. Volkow for reading an early draft of the manuscript.

Disclosure statement

Drs. Israel and Belcher have no disclosures or interests to declare. Dr. Ford receives royalties from the University of Connecticut for revenues from the TARGET© intervention that he developed as a faculty member of the University and that is disseminated by Advanced Trauma Solutions Professionals, LLC.

Notes

1 The overlapping effects of social-ecological systems – family, community, institutions, culture, prejudice, social policy, and other large-scale processes – and their collective impacts on social identity formation and health outcomes, are often termed intersectionality. Intersectional effects are widely accepted and well-developed, conceptually, though they are difficult to measure with precision (Seng et al., 2012).

2 While McLellan et al. (1993) found that administering adjunctive counseling early in MOUD treatment significantly improved retention among male veterans, Schwartz et al. (2012) found that counseling did not improve MOUD retention in a community sample. Of note, the former study involved a well-staffed, comparatively resourced program, in which counselors had masters-level training; whereas, the latter study described frequent counselor shortages and long waiting lists. Thus, while the veterans’ study suggests that psychosocial support offers promise early in MOUD treatment, the community result is more likely generalizable. We note that neither study incorporated a trauma-informed approach.

3 E.g, primary, secondary, and/or tertiary ACE prevention strategies proposed by the National Child Traumatic Stress Network, SAMHSA, Blue Knot Foundation, Centers for Disease Control and Prevention, the National Institute for Healthcare Management, the American Academy of Pediatrics, the U.S. Department of Education, and many others. Numerous organizations (including some just cited) propose plans, also, for preventing domestic violence, child neglect, sexual assault, elder abuse and other traumas that may occur across the lifespan.

Additional information

Funding

Dr. Ford received federal funding from the Department of Health and Human Services and the Substance Abuse and Mental Health Service Administration through the Center for the Treatment of Developmental Trauma Disorders (1H79SM085080-01), Center for Trauma Recovery and Juvenile Justice (1H79SM085113-01), and the Sichel Career Development Study (1 K23 MH129606-01A1).