NEW ORLEANS – The chemically induced dissociation that can occur with opioid use may affect the development of substance use disorder among victims of childhood abuse and interfere with recovery from the disorder, Eli Somer, Ph.D., said at the annual conference of the International Society for the Study of Dissociation.
Evidence from the literature and a qualitative study of 100 patients recovering from a drug use disorder provides preliminary support for this theory, said Dr. Somer of the Israel Institute for Treatment and Study of Stress, Haifa.
A chemical dissociation serving a purpose similar to nonchemical dissociation, and inducing the same powerful tranquilizing and numbing effects, appears to occur in many individuals with opiate disorder. It may be a tool for coping with intolerable experiences when psychological coping–such as dissociation–fails, he explained, adding that, in some cases, dissociative symptoms themselves are distressing enough to lead to “self-medication” with heroin.
The literature shows that a childhood trauma history is present in a substantial proportion of opioid users. In fact, several studies show that the odds of a comorbid substance abuse disorder are three times greater in those with posttraumatic stress disorder versus those without PTSD, he said.
In one study, PTSD occurred first in up to 65% of men and 84% of women with comorbid PTSD and substance use disorders, which suggests that substance use among survivors of childhood abuse develops out of attempts to self-medicate.
“Indeed, the most prominent consequence of childhood abuse turns out to be adult substance use disorder,” Dr. Somer noted.
This has been demonstrated in at least three major studies, and data consistently show higher traumatization history scores–typically reflecting childhood abuse or neglect–among patients recovering from opiate use disorder, compared with the scores of nonusing patients presenting to outpatient stress clinics, he said.
An apparent neurobiologic basis for the heroin-induced dissociation theory also exists. Areas of the brain most responsible for emotions and stress–such as the hippocampus and amygdala–share a high density of both norepinephrine and opioid receptors, and when a person is in danger these areas produce high levels of natural opioids, which can temporarily mask pain.
“Scientists have found that people with PTSD continue to produce these higher levels even when the danger has passed, so this may be associated with the blunted emotions” that occur in the condition, he said.
Other studies show that serious physical threat can induce analgesia, and anesthesia and analgesia in these studies were the symptoms that best predicted cases of posttraumatic dissociative disorders. Traumatized individuals appear capable of producing elevated levels of natural opioids that can temporarily mask emotional and physical pain, Dr. Somer explained.
“Therefore, it is conceivable that traumatized individuals would find the effects of exogenous opioids to be a gratifying shield between posttraumatic torment and conscious awareness,” he added, explaining that abuse survivors might self-medicate with opioids to mimic the chemically endogenous release to attenuate traumatic stress.
In a study of 100 recovering heroin addicts, Dr. Somer found that patients who were more traumatized were more likely to experience dissociative experiences when they had been under the influence of the drug. “We found preliminary evidence that recovering heroin users experiencing dissociation phenomena live through heroin intoxication differently than heroin users who are low 'dissociators,'” he said, noting also that abstinence periods were shorter for those experiencing dissociation.
Qualitative interviews with the patients about their experiences with heroin revealed four common uses for the drug. The first was induction of chemical amnesia. As one patient described, the drug temporarily erased the horrors of his childhood.
The second use–suppression of posttraumatic arousal symptoms–was defined by one patient as elimination of her many fears. The third use was chemical numbing or depersonalization and derealization. For one patient, this meant pain relief; for another it meant diminished self-hatred.
And the fourth use, induction of soothing and gratifying pleasure, meant warmth for a patient who said she always felt cold from the inside out except for when she was using heroin.
“These results render credible, preliminary support for the idea that some survivors of abuse or neglect use heroin as a dissociative agent,” said Dr. Somer, adding that some recovering addicts assigned benevolent, nurturing, human qualities to the drug.
“This was, to our minds, a sad testimonial to the emotional emaciation of these individuals,” he said.