The term “disorder” is more medically accurate than “addiction” and helps to signify substance use disorders as a legitimate medical condition. Its use is only appropriate in cases where the individual meets the conditions required for diagnosis of a substance use disorder specified in DSM-V.
Substance use disorders can be diagnosed according to severity (low, moderate or severe). The term “addiction” has historically been adopted to describe the severe end of substance use disorders. Many substances and behaviors can become addictive; however, addiction itself is not, and has never been, an independent diagnosable condition. (10)
Our understanding of substance use has grown enormously over the last two decades. From the Regan era “war on drugs” to the current work to de-stigmatize substance use, we now grasp that human use of psychoactive molecules – from plants, other animals or compounds we’ve made ourselves – is as old as history itself. Altering our minds with substances is sociological, personal, cultural, spiritual and psychological.
While most people who use substances do so within the bounds of a more-or-less socially-accepted lifestyle – raising a glass of champagne to toast the New Year, perhaps – some people will face problems with substance use. Substance use disorders (SUDS) is the appropriate catch-all diagnostic term within health care, used to describe certain symptoms of problematic substance use. As paramedics, we see SUDS often.
Empirical research clearly shows us that punishment for problematic substance use has been an overall failure as a deterrent. If we take incarceration as an example of one of the major punishments meted out in Canadian society over the last century (before that, mind-altering drugs were not criminalized), we see that the number of people jailed with concurrent problematic drug use is estimated at a staggering 75% (1). At both the federal and provincial levels in Canada, programs and services to aid people in jail to work through problematic use are few, and those that exist are hard to access. The trend of jailing people with problematic drug use continues despite our knowledge of risk factors and treatment (2).
Sometimes, as we are caring for our patients we, too, hold onto old feelings that punishment is a deterrent to substance use and a solution for SUDS. Unfortunately, our paramedic education and life experience doesn’t always deliver to us the knowledge of why people develop and live with substance use disorders or addiction. Without this understanding, we are left grappling for answers. Paramedics and other health professionals end up frustrated at what may look like poor life choices and bad behaviour when we don’t have a better, truer rationale: substance use disorder and addiction are health problems, not behavioural ones.
Origins of SUDs and Addictions
Childhood has been proven to be an incredibly impactful time for the development of an individual’s personality, and the environment in which a child develops is one of the most significant factors in the development of the adult personality (3). Childhood maltreatment has the potential to cause structural, behavioural, and hormonal changes in the individual. These alterations can lead to personality traits that put the individual at a great risk of developing a substance use disorder, whether as a means to cope or as an effect of their personality.
Around the turn of the last century, researchers at the Kaiser Permanente Hospital in the United States performed a landmark research trial. The large longitudinal study examined the impact of Adverse Childhood Experiences (ACEs) on the whole health of approximately 17,000 participants (4).
The results were stunning. The study found a distinct connection between ACEs and addiction or SUDS, but it didn’t stop there. It turned out that health concerns such as heart disease and diabetes were also associated with ACEs. What’s more, researchers noted that the risk for disease, SUDS, and mental illness increased significantly with each additional ACE that a participant reported.
When attempting to conceptualize experiences that would impact the child’s emotional, behavioural, and physical development, the Kaiser-Permanante researchers offered a long list of ACEs that included abuse of the child (sexual, physical, and emtional), household challenges (substance use in the household, mental illness in the household, (step)mother treated violently, parental separation or divorce, and incareceration of a household member), and neglect (emotional or physical).
Since this initial study was published, many more have supported the findings. Some studies have expanded on the impact of ACES while others have provided us with reasons why ACEs have such an impact on the individual.
Understanding ACEs’ Impact
One way to conceptualize the why behind the impact of ACES is to understand how the childhood environment impacts the development of certain personality traits that have been positively linked to SUDs. Notably, “childhood maltreatment may not only trigger the development of maladaptive emotion regulation skills but also disrupt goal-oriented self-regulation skills and delay the development of prosocial behavior” causing significant, persistent changes to a person’s adjustment system and negative effects on their personality traits and behaviour (5). Such changes impact the formation of pathological personality traits such as instrumental aggressiveness, thought disorder or unrealistic beliefs, impulse control problems and acting out tendencies.
The human body, in its glorious ability to adapt, makes adjustments to the very neural pathways of the developing child who has been exposed to trauma and adversity. The effect of childhood trauma has been noted in both the hormonal system through the hypothalamic–pituitary–adrenal axis, and to the structural and functional systems of the hippocampus, amygdala and cerebellum (6). These neurobiological changes are thought to occur in childhood as a reaction to adverse events. And, importantly, the changes persist into adulthood.
Some of the neural structures affected play large roles in controlling aggressive behaviour, like the cerebellum and amygdala. Others are key in behaviour and behavioral inhibition such as the hippocampus. If ever there was an example of adding insult to injury, the affected individual appears to be at greater risk for other trauma after these changes in personality and behaviour occur, as these maladaptive traits increase the likelihood of more negative life events.
Early Childhood Attachment
Looking at how ACEs alter our physiology is only one of the fields of research that’s showing promise. Other research has focused on the impact of early attachment as the guiding principle behind the behavioural changes related to ACES (7).
Attachment theory postulates that in the first years of life, human children seek to find attachment in their caregivers. Securely attached children experience caregivers who (relatively) consistently meet their needs with security and love. When children’s needs are not met consistently, and with insecurity and lack of safety, they respond with anxious/resistant or anxious/avoidant behaviours.
When bids for attachment are met with inconsistency from caregivers, disorganized attachment behaviour follows. Caregivers who sometimes respond caringly and sometimes ignore children or even respond with mistreatment, are priming children for disorganized attachment.
In instances where the child does not have a consistent caregiver due to neglect, abandonment, or other unstable relationships, disrupted attachment occurs.
Many of the caregiver behaviours that occur with insecure attachment intersect with those of the ACES study. Neglect, inability to be present with the child physically or emotionally, and abuse can be seen in both ACES and negative attachment experiences.
Bringing New Knowledge to Paramedicine
The medical community’s understanding of SUDS has evolved considerably over the past two decades. Yet, in paramedicine we’ve been slow to incorporate this new knowledge into our assessment and treatment planning when caring for people who use substances.
What does bringing this new information into paramedicine look like? One possibility is that we examine our own lives and experiences. It’s possible that our own personal experiences with ACEs or trauma can impact how we appraise the behaviour of others. We may have developed our own coping mechanisms or behavioural traits that impact our approach to others.
It may also be that our experiences with years of ineffective anti-drug campaigns have vilified those who use substances as losers and criminals, people who cannot be trusted or valued. Such moralizing is an effective social tool for marginalizing people whose behaviour isn’t understood. But, now that we have much more knowledge of the mechanisms that introduce substance use disorders into peoples’ lives, we can critically look at our approaches to health and substance use to see if they align with this new knowledge or if they are merely beliefs.
As medical professionals we have a duty to provide appropriate care for our patients, and this includes working to better understand the current knowledge of SUDS.
McKiernan, A. (2017). Supporting Reintegration in Corrections by Addressing Problematic Substance Use, Ottawa, Ont.: Canadian Centre on Substance Use and Addiction. https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Reintegration-Corrections-Problematic-Substance-Use-Environmental-Scan-2017-en.pdf
Chandler, R. K., Fletcher, B. W., & Volkow, N. D. (2009). Treating drug abuse and addiction in the criminal justice system: improving public health and safety. JAMA, 301(2), 183–190. https://doi.org/10.1001/jama.2008.976
Tilson, E. C. (2018). Adverse childhood experiences (aces). North Carolina Medical Journal, 79(3), 166–169. https://doi.org/10.18043/ncm.79.3.166
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine,14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8
Centers for Disease Control and Prevention. (2021, April 6). About the CDC-Kaiser Ace Study |Violence prevention|injury Center|CDC. Centers for Disease Control and Prevention. Retrieved December 6, 2021, from https://www.cdc.gov/violenceprevention/aces/about.html.
Choi, J. Y., & Park, S. H. (2018). Childhood Maltreatment as Predictor of Pathological Personality Traits Using PSY-5 in an Adult Psychiatric Sample. Journal of Personality Disorders,32(1), 1-16. doi:10.1521/pedi_2017_31_282
Pos, K., Boyette, L. L., Meijer, C. J., Koeter, M., Krabbendam, L., & Haan, L. D. (2016). The effect of childhood trauma and Five-Factor Model personality traits on exposure to adult life events in patients with psychotic disorders. Cognitive Neuropsychiatry,21(6), 462-474. doi:10.1080/13546805.2016.1236014
Jamieson, K. (2021, July 16). Aces and attachment: Why connection means everything. Center for Child Counseling. Retrieved December 7, 2021, from https://www.centerforchildcounseling.org/aces-and-attachment-why-connection-means-everything/.
Lanius, R., Vermetten, A., and Pain, C. (2010). The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press
Public Health Agency of Canada. (2020). Communicating ABout Substance Use in Compassionate, Safe, and Non-stigmatizing Ways. MInister of Health. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/communicating-about-substance-use-compassionate-safe-non-stigmatizing-ways-2019/guilding-rinciples-eng.pdf