Batya Swift Yasgur, MA, LSW
March 23, 2017
Emotional abuse during childhood may lead to opioid addiction and substance-related problems (SRP) in adults who suffer from impulsivity and posttraumatic stress disorder (PTSD), new research shows.
A team of investigators headed by Matthew Price, PhD, assistant professor, Department of Psychological Science, University of Vermont, in Burlington, found that emotional abuse and negative urgency were related to PTSD symptoms, which in turn were related to SRP, suggesting that PTSD plays a key role in SRP.
“People in our sample reported all types of abuse history, but emotional abuse was more relevant to future opioid misuse than the other forms of abuse,” Dr Price told Medscape Medical News.
“Emotional abuse was associated with strong negative urgency, which contributed to the severity of PTSD. Severe PTSD can lead to greater agitation and, in turn, to self-medication with opioids,” he said.
The study was published in the June issue of Addictive Behaviors.
Childhood Maltreatment Common in Opioid Users
People who misuse opioids often report extensive histories of childhood maltreatment, which includes emotional and physical abuse, emotional and physical neglect, and sexual abuse.
Negative and positive urgency are both impulsivity-related traits involving rash action taken under conditions of negative or positive affect, respectively.
“The literature on how these impulsivity traits are related to opioid use and SRP lags behind the study of other substances,” the authors write.
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Childhood maltreatment and urgency are both associated with PTSD, and PTSD is associated with more severe substance-related impairment and poorer response to treatment of substance use disorder.
“Prior work has examined the association between these constructs and SRP independently and it is unclear how these multifaceted constructs are associated with one another and with SRP,” the authors state.
For the study, investigators analyzed and cross-referenced the results of a series of psychological tests administered to a sample of 84 adults who had used heroin or had misused prescription opioids for more than 1 year.
Instruments used to assess their mental health, substance use patterns, and trauma history included the Childhood Trauma Questionnaire (CTQ), the Short Inventory of Problems-Revised (SIPS-R), the Addiction Severity Index-Lite, the Short Form of the UPPS (uregency, premeditation, perseverence, sensation) Impulsive Behavior Scale (SUPPS-P), the PTSD Checklist for DSM-5 (PCL-5), the Structured Clinical Interview for the DSM-5 Disorders (SCID-5), and the Mini–International Neuropsychiatric Interview for DSM-IV.
Reports from the participants indicated overall moderate PTSD symptoms and moderate exposure to childhood maltreatment. The majority (67.9%) met criteria for current PTSD, as determined on the basis of SCID-5 score. Those who met criteria for PTSD scored significantly higher on the PCL-5 scale (P < .001).
Using structural equation modeling, the researchers examined the relationship between childhood maltreatment, trait urgency, PTSD symptoms, and SRP.
Bivariate correlations between the variables found that the PCL-5 was significantly related to all CTQ scales, positive urgency, negative urgency, and the SIPS-R. The SIPS-R, in turn, was associated with positive urgency, negative urgency, and PCL-5, suggesting an association between childhood trauma, PTSD, and positive and negative urgency.
Initially, the researchers used a statistical model fitted to the data, which proposed that the CTQ scales were associated with the urgency scales and the PCL-5. It included direct paths from the urgency scales to the SIPS-R and the PCL-5. They subsequently rejected this model, calling it a “poor fit.”
A revised statistical model in which nonsignificant paths were removed from the urgency scales to the SIPS-R fit the data well (χ2  = 2.12, P = 0.83; RMSEA < 0.01 [95% confidence interval (CI), <0.01 to 0.09]; CFI = 1.00; SRMR = 0.04; BIC = 2143.38) and was considered to be a “significant improvement” over the previous model.
On the basis of the revised model, emotional abuse, as measured by the CTQ (β = 0.37, P < .001) and negative urgency (β = -0.41, P < .001), were related to the PCL-5. Only the PCL-5 had a significant direct effect on the SIPS-R (β = 0.43, P< 0.001).
The researchers also found a significant indirect effect of CTQ–emotional abuse on SIPS-R via the PCL-5 (β=0.16; P = .002; 95% CI, 0.06 – 0.27), suggesting that elevated emotional abuse increased SRP via PTSD symptoms.
“We found that negative urgency contributes to the severity of PTSD symptoms, which are tied to the original trauma,” said Dr Price.
“People who have a tendency to lash out make bad choices when upset, which contributes to worse PTSD symptoms, leading to increased substance use,” he added.
The researchers were surprised about the important role of emotional abuse.
“In physical abuse, it is easier to recognize that the perpetrator is at fault. But in emotional abuse, the perpetrator attacks the victim’s character. ‘You’re stupid, you’re an idiot.’ The victim internalizes the message and feels at fault, making emotional abuse more insidious than physical abuse,” said Dr Price.
This insight has important clinical implications. “Therapeutic strategies successfully used for physical or sexual abuse are less effective in those who have been emotionally abused,” Dr Price added.
Need for Concurrent Treatment
Commenting on the findings for Medscape Medical News, Lynn Webster, MD, vice president of scientific affairs at PRA Health Sciences, Raleigh, North Carolina, and past president of the American Academy of Pain Medicine, said the study authors are to be “congratulated on tackling the difficult task of correlating childhood experiences with the risk of opioid disorder.
“The study is informative and should lead to a better understanding of what drives substance abuse in general,” said Dr Webster.
“These findings illustrate that there are profound emotional issues that may be far more important risk factors than opioid dose or number of pills prescribed,” said Dr Webster, who was not involved with the study.
Dr Price agreed that emotional problems should receive greater focus in substance abuse treatment.
“The common wisdom is to work sequentially, first addressing the substance abuse and then addressing mental health, but this approach is misguided. Our study suggests that the impulsivity and PTSD resulting from early emotional abuse can be pathways to substance abuse, so mental health problems should be addressed in concert with substance issues,” he said.