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The Relationship of Trauma to Substance Misuse and Mental Illness - 

Finding a Better Way to Treat

by Mandy Bonesteel

According to DrugAbuseStatistcs.org, substance use disorders (SUDs) affect over 20 million Americans over of 12 years of age. 9.5 million adults over the age of 18 have both an SUD and a mental illness, and over 20% of adults have some form of mental illness. Opioids and other painkillers are among the most misused substances, and many times these drugs were initially legally prescribed.

The Issue

Substance use disorders and addiction have long been looked at in the United States as a personal failing, an individual problem, or moral issue. In reality, most people who misuse substances are struggling with something else that, in turn, leads to the use of a drug, then misuse, and then dependency. Trauma, injury, illness, chronic pain, and mental illness can all be linked to reasons why someone might use a drug- to relieve pain, to escape the trauma of an event (PTSD is commonly linked to SUDs, especially alcohol abuse), to mask the feelings associated with a mental illness, and so forth. A traumatic event can be physical, mental, or emotional abuse such as domestic violence, rape, or neglect, a physical injury, a community disaster, death of a loved one, and so forth.



Substance misuse, mental illness, and trauma are frequent bedfellows- 31% of adults with any mental illness (AMI) are binge drinkers, and mental illness and substance misuse are extremely common in veteran populations- 80% misuse alcohol, and twice as many abuse pain medication compared to the general population. Among correctional officers in prisons in the United States, post-traumatic stress disorder (PTSD) is double the rate than that of military veterans (34% meet the criteria for PTSD), suicide rates are double that of police officers, and many indicators of poor mental (suicidal thoughts, nightmares, PTSD symptoms, domestic violence, and more) go unreported for fear of losing their job or being considered unfit (Editorial Staff). These are examples of jobs that have a high rate of traumatic events associated with them- war, prison violence, always feeling the need to be on alert and high-stress environments.

In addition to adults who are or have experienced trauma, childhood traumatic experiences are also an indicator and risk-factor for substance misuse later in life. Adverse childhood experiences (ACEs) are traumatic events that children experience: abuse, divorce of parents, neglect, etc. Having four or more adverse childhood experiences has a strong correlation to early alcohol use and substance use disorders later in life.

Looking at a Better Approach to Help Patients with Addiction

Addiction changes the way the brain works, and trauma and abuse create physical changes in the brain that can be seen on imaging with technology such as MRIs, making substance use disorders a medical problem, not a moral failing. We need to address addiction the same way we address any health issue- with compassion, integrity, and care. Punitive measures have been unsuccessful in curbing our nation’s addiction crisis. This is precisely due to the fact that because addiction changes the brain, punishing the behavior is generally the least successful approach. The person with the addiction many times is unable to physically stop themselves from using, or the issues they are facing (pain, mental health, trauma) are severe enough that using substances seems to be the only way for them to feel “normal”. We need to treat the underlying diseases and causes of addiction. Patients that receive comprehensive treatment combined with support for mental illness, for example, have a reduction in substance use disorders. 

The stigma that surrounds addiction and mental health is one of the major barriers to accessing treatment for SUDs. The way we, as a society, view addiction as a moral failing and something to be ashamed of prevents people from seeking the treatment they need. People do not want to be labeled as an “addict”, nor do they want to be judged by their family, coworkers, or peers for having –seemingly- morally failed. This perception that people with substance use disorders are lesser than others, that they are “bad people”, is one of the biggest reasons that the general public has little understanding of what addiction really is and how it affects an individual from a health and medical perspective. There is often bias and discrimination- even from health care providers- when working with a patient that has a known SUD. Substance use disorders are common in persons experiencing homelessness, in particular opioid misuse, and over three quarters of those that do seek treatment do not receive the highest standard of care, part of that care being medications for opioid use disorder (MOUD) (Benjamin H. Han). In my own work with home visiting programs in Michigan and conducting surveys about experiences in healthcare settings, stigma was the number one reason that prevented people from seeking treatment for a mental illness or substance use disorder.

A different approach to addiction is needed, and perhaps we can begin to learn from other areas that have had more success in curbing this crisis. In 2000, Portugal decriminalized possession and use of all drugs and instead focused on a public health aspect to address their growing drug and HIV crisis, which had the highest rates in Europe (Ferreira). In the 20-plus years that have elapsed, Portugal’s overdoses, drug-related crime, and rates of HIV have fallen drastically. Portugal decided to spend money and resources on social support programs. Instead of being directed into the prison system if found in possession of drugs, a person is instead directed to addiction services, support groups, or harm reduction programs. According to several sources, including International Living and Travel Safe Abroad, Portugal now ranks as the 3rd safest country in the world, whereas in 1990’s it was in an opioid crisis and considered the “heroin capital of the world” (Clay). By focusing on addiction from a health and social support standpoint and reducing the stigma surrounding drugs and addiction Portugal was largely able to overcome the crisis.

All of the information and research to date points to tackling substance use disorders from a healthcare aspect- using compassion and support to not only treat the addiction itself but the root cause. Seeing addiction as the disease of the brain that it is, exacerbated and/or caused by a multitude of factors, we might get on a better path to prevention. It is obvious that our current situation and approach is not working, and if we are to make any inroads into this overwhelming social crisis, there needs to be a cultural shift in how we look at addiction and mental health and the impact that trauma has on both.  


More information can be found in the following articles:

Sheperd et al. "Emotional Demands and Alcohol Use in Corrections: A Moderated Mediation Model." Journal of Occupational Health Psychology (2019): 438-449.

Benjamin H. Han, Kelly M. Doran, Noa Krawczyk. "National trends in substance use treatment admissions for opioid use." Journal of Substance Abuse Treatment (2021).

Clay, Rebecca A. "How Portugal is solving its opioid problem." American Psychological Association (2018): 20.

Editorial Staff. American Addiction Centers: Corrections Officers: Addiction, Stressors & Problems They Face. 31 January 2022. 9 February 2022.

Ferreira, Susana. "Portugal’s radical drugs policy is working. Why hasn’t the world copied it?" Susana Ferreira 5 December 2017.

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Amanda (Mandy) Bonesteel is a current undergraduate at Northern Michigan University pursuing a Bachelor of Science in Sociology and a double-minor in Human Behavior and Political Science. She works as an AmeriCorps VISTA Leader in Marquette, Michigan for OPEN-MSU (Opioid Prevention and Education Network, affiliate of Michigan State University). Mandy is passionate about public health and health education, and plans to pursue a Ph.D. after graduating from NMU. 

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The Patient Portal: One of the Greatest Innovations to Patient Relations

by Bob Kieserman

There are many of us who remember, and really not so long ago, that after seeing your doctor in person, if you had a question or a concern in between scheduled appointments, you had to call and either wait on the phone and have the receptionist take a message that you wish to talk to the doctor and then wait around the house all day until he or she called you back, or you needed to actually make an appointment as quickly as you could to report your symptoms or get your followup question answered. Several years ago, thanks to advancements in medical software technology, medical practices throughout the country introduced what I consider one of the greatest innovations in patient relations – the patient portal.


What is a Patient Portal?

A patient portal is a website for personal healthcare. The patient is provided instructions by the provider’s office on how to use the portal and typically provided with a way to set their user name and password allowing the patient to email their healthcare provider day or night to pose followup questions, questions about prescriptions, report changes in a condition, view test results, request referrals, refill prescriptions, see their billing balances and update their insurance information, and in many cases, actually schedule, cancel, or re-schedule an appointment. It also allows patients to make payments, complete forms ahead a visit, see visit summaries, and view your medical history including your immunizations, diagnoses, and medicines. It also features tips on leading a healthier lifestyle. Many patient portals also allow the doctor to conduct telemedicine visits.


When a Patient Should Not Use the Portal

Patient portals are not for urgent issues. Obviously, if the patient is in distress, going straight to an emergency room is recommended. If the patient feels that they need to be seen by their doctor, most practices recommend calling the office and trying to schedule the most immediate appointment.


How Does a Patient Portal Work Best?

The patient portal only works well if the doctor is responsive to it. As a patient, there have been times when I have written to a doctor with a question, and it has taken two or three times to get the doctor to respond. In some cases, I have actually called the office to tell the receptionist to tell the doctor to respond. But, in most cases, my doctors have responded within 2-6 hours or they have had a nurse respond with an answer to my question. For the doctor, the patient portal promotes better patient communication, it streamlines patient registrations so the patient does need to fill out paperwork in the office, it improves clinical outcomes because the communication between doctor and patient fosters greater compliance by the patient since the patient is able to confirm instructions regarding taking medicines and following treatment plans properly, and the patient portal actually frees up the support staff at the doctor’s office to attend to patients who are physically visiting the office and answering urgent calls from patients.


Patient Portals for Primary Care and Specialists

While most patients use patient portals to communicate with their primary care physicians, many specialists are also providing portal access to their patients which allows patients to schedule screening procedures like colonoscopies and mammograms, surgical procedures, and other tests. At the same time, the portal allows doctors to share with their patients the results of imaging procedures like x-rays, MRI’s, and CT scans, as well as biopsies and other special tests that the specialist has ordered. Obviously, the patient portal allows the same 24/7 communication between the patient and the specialist.


One of the Greatest Innovations for Patient Relations

So, why do I consider the patient portal to be so important in fostering better relationships between the patient and the provider? It improves the healthcare experience for the patient. It allows the patient to become an integral part of the treatment plan and better understand why the doctor is recommending a particular approach to healing. And, most importantly, it opens up ongoing communication between a patient and their provider, which promotes trust, confidence, and reduces anxiety when a patient needs answers. If your doctor is not using a patient portal, I highly recommend that you discuss it. The doctor may actually have one in their practice, but you were never told about it. But if the office does not yet have a portal, as a patient, you have every right to request that they institute one. The patient portal is truly essential to empowering patients, and as patients, that should always be our number one goal.

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Bob Kieserman is the Executive Director of The Power of the Patient Project: The National Library of Patient Rights and Advocacy, and publisher of Today's Patient. Now retired, for over 35 years, he was a professor of healthcare administration and medical ethics and a healthcare consultant. He is the author of over 300 articles and four books on managing the private healthcare practice, the patient/provider relationship, and the rights of patients. Bob is both a medical librarian and a medical sociologist and resides near Philadelphia. 

March's Featured Videos

March is Colorectal Cancer Awareness Month and this short video segment with Dr. Thomas Werth is a most important video to watch along with the video below featuring Amiee Mingus, an administrator for a major endoscopy/colonoscopy center, who describes what a patient can expect when they have a colonoscopy. 

March 2022  page 3