What can a study of childhood experiences teach us about substance use?
In June 2024, I spoke with Dr. Steven Pratt, a senior medical director at Magellan Health. He has spent many years treating people with substance use disorders. We talked about the Adverse Childhood Experiences Study, often called the ACEs study. We also talked about what it changed in health care and how to reach people who are not ready to change.
What did the Adverse Childhood Experiences Study find?
At 0:28, Dr. Pratt described how the study worked. It was carried out in the mid-1990s and published in 1998, and it surveyed patients of a clinic in the San Diego area about their childhoods. The questions covered physical abuse, sexual abuse, neglect, witnessing domestic violence, and alcohol or drug use in the home.
In his view, the findings sparked a revolution in behavioral health, in substance use care, and in health care in general. People with many adverse childhood experiences were more likely to smoke and to use substances, and they carried a whole host of physical and behavioral health consequences.
Can a child from a stable home still experience trauma?
I asked whether a child whose home looked perfect from the outside could still have a traumatic childhood. At 2:35, Dr. Pratt said yes. He pointed to earlier work on how well a child’s temperament fits the temperament of the parents.
A very sensitive child raised by very blunt parents can experience ordinary family life as traumatic. Interestingly, the authors of that work chose not to call it abuse. They described it as a poor fit between child and parents, one that can still shape a child’s development.
What does trauma-informed care look like in a clinic?
From 4:50, Dr. Pratt explained that trauma-informed care means recognizing the impact trauma has on people’s lives and shaping the treatment setting around it. Public mental health centers are often in old concrete buildings, and he said that softening that environment helps.
He compared it to universal precautions for bloodborne pathogens: clinicians can assume that anyone who walks in may carry some trauma. So, the setting avoids loud, jarring noises, and staff speak to people with respect rather than abrasiveness.
At 7:15, I added that a welcoming room may help people stay. A calmer setting may keep a nervous first visitor from leaving.
Why does trauma matter for understanding substance use?
At 9:24, Dr. Pratt said one takeaway from the study was the idea of self-medication. Many people once heard that idea as making excuses. Yet, as he described it, the study found far higher rates of injection drug use, alcohol use, and other drug use among people with several categories of adverse childhood experiences.
In his view, this helped move the field from seeing substance use as a character flaw to seeing it as a behavioral health condition. People are not bad people making bad choices. To see good outcomes, he said, care has to address the trauma as well as the substance use.
If it is not your fault, whose job is it to change?
At 11:35, I raised a tension I see in 12-step programs, which describe a disease and also ask people to work on defects of character. At 12:14, Dr. Pratt answered with an idea from his training in dialectical behavior therapy (DBT). It is not your fault that you have these issues, but it is your responsibility to solve them.
Clinicians can add tools, he said, but only the person can do the work. Medication can ease high blood pressure, yet changing the underlying cause still takes exercise and a healthy diet.
How do you reach someone who is not ready to change?
At 13:43, I asked whether there is a stage when nothing but harm reduction can help. Dr. Pratt called harm reduction an essential tool, even though the treatment world has historically resisted it. He does not see it as the end point, but as an important step along the way.
From 14:13, he walked through motivational interviewing. When a person answers “yes, but,” he backs up and expresses empathy, because resistance arises in the conversation rather than inside the person. In fact, he put it simply: we cannot change the way they hear it, so we have to change the way we say it.
Is tough love ever the right approach?
At 17:11, I asked about tough love as it is sometimes taught to families. At 17:42, Dr. Pratt said that expelling someone from care for a relapse is like removing a cancer patient from a clinic because the tumor came back.
Still, he would not discard the idea completely. He separated artificial consequences, which he rarely sees as helpful, from natural ones. Parents can tell an adult child that living at home depends on following the house rules, as a landlord would. The limit has to be set without blame or hostility.
What can drug policy in other countries teach us?
From 21:20, Dr. Pratt pointed to countries that replaced the war on drugs with structured access, naming Portugal and Switzerland. Portugal decriminalized personal possession and expanded treatment, and Switzerland pioneered the programs that prescribe pharmaceutical grade heroin inside a supervised treatment setting, a model a handful of other countries have since adopted. As he told it, access works when it is tied to treatment or work training, because a structured supply undercuts the dealers’ market.
However, at 23:03, he said he did not know enough about what happened in Oregon to judge it. His point was that structure is the key to success.
Should every doctor’s office ask about trauma?
At 23:53, Dr. Pratt said he thinks so. In his view, adverse childhood experiences shape smoking, overeating, and other health behaviors, along with heart disease, cancer, and emphysema. Awareness of trauma helps clinicians be less judgmental and build the empathic connection that a treatment alliance depends on.
At 25:37, I noted how well buprenorphine works for many people with opioid dependence, and how hard it is to help someone who uses several substances at once. At 26:40, Dr. Pratt answered that no single tool works for everyone. Care has to be individualized, and the more varied the approach, the more people it can help.
Who is Dr. Steven Pratt?
Dr. Steven Pratt is a senior medical director at Magellan Health. He has long clinical experience treating people with substance use disorders, trained as a DBT therapist and works with motivational interviewing and trauma-informed care.
What can listeners take away from this conversation?
Most people who walk into a clinic carry some history that shapes how they hear what is said to them. Of course, that does not remove a person’s own part in change. Yet, it does mean that patience, empathy, and a respectful setting give people a better chance of coming back and doing that work.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For opioid dependence I prescribe buprenorphine, which steadies the body so a person can rebuild their life without the cycle of withdrawal. Visits are monthly, or weekly when needed. Some people stay on it for a long time, and that is a legitimate choice. Others later taper slowly, using the same gradual approach I use for every other medication.
I prescribe in Florida only.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (28 minutes)
Dr. Mark Leeds [00:00] Dr. Steven Pratt, Senior Medical Director at Magellan Health, and you’re also a clinician for 25 plus years with experience in treating patients with substance use disorder and overseeing substance use disorder treatment programs. And we’re going to be talking today about the Adverse Childhood Experiences Study, which I believe was about 25 years ago. And it looks very interesting. So yeah, tell us a little bit about that study.
Dr. Steven Pratt [00:28] Yeah, so the study was conducted through the mid-1990s and published in 1998 by Felitti et al. He worked in the San Diego area. And what the study consisted of was a questionnaire that was sent to or a survey sent to about 13,000 people who were patients at the clinic where he worked. And they got over 9,000 responses. So a very high response rate. And the survey was asking people about their childhood experiences and adverse childhood experiences across multiple different domains, including physical abuse, sexual abuse, neglect, witnessed domestic violence, the presence of chemical use in the home. And I think there were a total of seven categories. And so the results really prompted a revolution in behavioral health care, in substance use care, and in health care in general, because the findings were so significant. Having a lot of adverse childhood experiences led to poor health choices like smoking, like substance use, and a whole host of health consequences in the physical health realm as well as in the behavioral health realm. And as I said, kind of sparked a revolution in the field.
Dr. Mark Leeds [02:06] Well, I’m curious about, you know, the things that were asked in the questionnaire. Is it possible that a person who in every way seemed to have a perfectly normal, healthy childhood, you know, that maybe there was no drug use or heavy alcohol use in the home, no weapons, no people going to prison, you know, two parents and everything looks perfect from the outside and maybe even mostly perfect from the inside. Could it be possible that a child in that situation could have a traumatic childhood?
Dr. Steven Pratt [02:35] Yes. You know, I think there’s a dose response curve in that the greater the amount of adverse childhood experiences, the greater the consequences. But in the 1970s, there was a publication about correctness of fit was the way they described it. And it was about temperament of the child compared to temperament of the parents. So if you have a child whose temperament is that they’re very sensitive and you have parents whose temperament is that they’re very blunt, very just, you know, say it like it is, no holds barred, you didn’t do your homework, you can’t do this. The child can experience that as traumatic. And rather than having that labeled as any kind of abuse, what the authors of this study decided to label it was a poor correctness of fit, the temperament of the child and the parents don’t match. And so that can lead to some issues in development where the child has some consequences as a result of that.
Dr. Mark Leeds [03:57] Yeah, I would think a lot of people can probably relate to that. I’m also curious about how this study may have affected the way that we treat addiction. And I noticed that there’s some things that you specialize in or have an interest in, things such as motivational interviewing, which I had learned about in a class and still to this day find a little bit confusing, trauma-informed care, positive behavior supports. There’s another one here, person-centered culture. And I don’t know if these things are these things part of what, because from my point of view, you know, we’re in an opioid epidemic. And the first thing is, you know, buprenorphine is like really good at getting people off the streets and off opioids and functioning very well. But besides that, and maybe including that, what have we changed based on this study?
Dr. Steven Pratt [04:50] Yes. So to provide treatment in a trauma-informed manner means that we recognize the impact that trauma has in people’s lives. And we shape the treatment environment to take that into account. For example, some health care settings have been sort of physically harsh at times. Public mental health centers are often in old buildings with a lot of concrete, and things that we can do to soften that environment are helpful. And so based on the prevalence of trauma of adverse childhood experiences that we know from the original ACEs studies and many others that have followed, we know that the majority of people have some, at least some small amount, if not a lot of adverse childhood experiences of trauma in their past. And so one of the things that we want to do then is shape our environment to sort of anticipate that everyone who comes to see us is potentially traumatized in some ways. There’s a concept of universal trauma precautions, which follows from the idea of universal bloodborne pathogen precautions, right, in which we want to make sure that we’re not exposing ourselves or the people we serve to the potential of bloodborne pathogens. So we wear gloves when we draw blood, things of that sort. And so the idea of universal trauma precautions means that we want to shape the environment so that there aren’t loud jarring noises, for example. And that there’s a softness of the environment. There’s a softness of the way that people interact. We be respectful and not abrasive in the way we talk to people. So all of those things have really been emphasized through the ACEs work and the advent of trauma-informed care.
Dr. Mark Leeds [07:15] Yeah, that’s incredible. And I think, you know, part of what you might be talking about is also related to public health, you know, making sure that everybody has access to those universal precautions or treatments of, you know, not just the person that goes to a private doctor, but someone that goes to a public health clinic and, you know, to get mental health care. And I think that’s definitely important. And, you know, everything from, you know, obviously you don’t want to pop a balloon, you know, around someone with a history of trauma, you know, like PTSD or something. But all the way to like having the right colors and people being pleasant, knowing not how to trigger someone or how to avoid triggering someone. So that’s really good. And I would think that would also help people to keep them in treatment. Because I can see someone walking in for their first treatment, whether it’s for suboxone or for some kind of detox or some kind of addiction treatment. Maybe they’re on methamphetamine or cocaine. And probably their feeling when they walk in the clinic for the first time is, this isn’t for me. I’m leaving. You know, I’ll come back some other time and try this. And but maybe by following all those guidelines, there’s a better chance that they’ll stay for their appointment.
Dr. Steven Pratt [08:29] Right. Right. A well-welcoming environment.
Dr. Mark Leeds [08:35] Oh, that sounds really good. So the study was from, it looks like it was from 1994, around that time. I think there was probably a-
Dr. Steven Pratt [08:46] It was published in 98, yeah.
Dr. Mark Leeds [08:48] Okay. So, but now, like today, like in addition to the trauma-informed treatment of people walking into a clinic and seeing a nice environment and not being triggered in those ways. How is it also affecting our handling of the opioid epidemic and the fentanyl? You know, some people see the fentanyl problem as being almost more of like a chemical warfare poisoning rather than, you know, normal drug use. It’s not the same as what we’ve seen in the past with, you know, prescription medication and even heroin. So how does it apply to today?
Dr. Steven Pratt [09:24] Yeah, well, I think one of the concepts that really was a takeaway from that original ACEs study was the idea of self-medication. Now, people talked about this before that study was published. And a lot of people who heard that thought, oh, it’s making excuses. The idea that self-medicating is the rationale for why people use substances. But when you look at the results of that initial study, what they found was something like over 10 times more use of IV drugs in people who had four or more categories of ACEs compared to those with none. So trauma seems to be one of the main triggers for injecting substances. There were also very similar high rates of alcohol use and other illicit drug use, not the same 10 times, but like seven times more common in people who have these adverse childhood experiences. So, you know, a 1,000% increase in IV drug use, that is really telling that trauma is a factor in people ending up with a substance use issue. And so I think it’s changed our conceptualization from, you know, going back over years with a lot of other factors coming into play, too, from the idea that substance use is a character flaw to substance use is a disorder, is an illness, a behavioral health condition. And that means that we don’t approach people like they’re making bad choices and they’re bad people, but rather that they’re in some ways victims and that we have to address the trauma as well as the addictive behavior if we want to see positive outcomes.
Dr. Mark Leeds [11:35] How does that relate to the Alcoholics Anonymous and the 12 Steps that have been deeply entrenched in addiction treatment for a long time? Because it seems like the 12 Steps are kind of do put, even though they say, I think, in recovery and those kind of programs that it is a disease. But at the same time, the person has to take responsibility and work on defects of character and things like that. And it does kind of seem like, you know, you’re saying like, well, it’s not your fault, but it is kind of your fault. And you have a moral deficiency of some kind. So how does that play with it?
Dr. Steven Pratt [12:14] Yeah. For that, I’ll take something that I learned from becoming a DBT therapist many years ago, which is the idea that we would communicate to people in DBT who have a lot of self-injurious behavior. Your, it’s not your fault that you have these issues, but it’s your responsibility to solve them. You know the old joke, how many psychiatrists does it take to change a light bulb? One, but the light bulb has to want to change. I think that’s not true because we can influence it with motivational interviewing, but it’s a background concept that I think is important to keep in mind. And whether or not it’s someone’s fault, you know, even if it’s completely not their fault, no one else can change their attitude, their mindset. We can add tools. We can use tools. We can try to influence. But in the end, the only person who can do the work is the person who has the issues. I mean, that comes down to it’s not just substance use. I mean, think about general health. Let’s say that you’re obese and you’ve got high blood pressure and high cholesterol. Yes, you can take medications. Yes, medications can alleviate those symptoms. But if you want to fundamentally change the etiology, it’s upon you to make lifestyle changes, to get regular exercise, to eat a healthy diet. And no one else can do that for you.
Dr. Mark Leeds [13:43] Yeah. Yeah, definitely. That’s a good point. Do you think that when a person is in that first stage, that pre-contemplation stage, where they, it seems like nothing works, you know, you just can’t convince them, you know, is there actually like a stage where we can’t really do anything other than harm reduction? Or do you, can you, like through motivational interviewing or other therapies, can you get to a person even when they seem unreachable?
Dr. Steven Pratt [14:13] Yeah. First of all, I think that harm reduction is an essential tool. And there’s been historically resistance in the substance use treatment world to that idea. A lot of traditional treatments are abstinence-based. I don’t think that harm reduction is the end that we necessarily want to get to, but it’s a really important tool to use along the way. And then motivational interviewing has strategies to use when someone’s in pre-contemplative stage, which is express empathy and roll with resistance. Those are the two key kinds of interventions that we use. If you say something and the response is yes, but, we used to think of that as resistance. In motivational interviewing, they change the conceptualization of resistance to not something that’s intrinsic in this person I’m talking to, but something that has arisen in the context of our interpersonal interaction with them. And so we can’t change the way they hear it. We have to change the way we say it. And so as soon as I hear yes, but, or anything that means yes, but, I back up and I think express empathy. Oh, yeah, I can understand that. That would be difficult for you to try and think about that change, let alone make it. And so we have to do that over and over and over again. And I read in the literature somewhere, I can’t remember where, that 90 percent of people are in the pre-contemplative or contemplative stage of change readiness when they come to us for a new problem. And, you know, just think about your own experience when you’ve come to the point where you think I have to make a change in my life. That’s contemplative. But even so, it takes months before you get to the point of action. And so we have to just over and over again, express empathy for how big a challenge it is. Roll with resistance when people say that they can’t. And then we look for these opportunities where someone is saying their goal is this, but their behavior is leading them in the opposite direction to say, oh, that seems like it conflicts. You said your goal is to do X, but, you know, this behavior is going to get you to a goal of Y. How’s that going to work for you? And that’s in motivational interviewing. They call it creating discrepancy. I like to think of it as identifying discrepancy. We’re not creating it. It’s there. We’re just calling it out. And then the person has to kind of go, huh. Often you then get a yes, but, and you go back to expressing empathy. But over the course of multiple sessions, even sometimes months or in some cases years, the person does get to the point of saying, I have to make this change.
Dr. Mark Leeds [17:11] Yeah well that’s yeah so it’s not you know as far as getting someone to start treatment start therapy it’s not always going to in fact in most cases like you’re saying 90 probably we’re not going to get someone started right away always and would you agree that the traditional like tough love is probably not a good idea like what they might teach in like a Nar-Anon or Al-Anon meeting, like, you know, lock the doors and kick them out or whatever tough love is.
Dr. Steven Pratt [17:42] Right. I don’t think that’s a good approach. I mean, kick them out for relapsing when they’re in substance use treatment. I think of that as being like someone who’s in cancer treatment and they’ve been in remission and they have a recurrence and you say, I’m going to kick you out of this cancer clinic because you’re tumor relapsed. We can’t have that. You know, I think of it as being very similar to that. I wouldn’t just throw out the concept of tough love altogether. I would say that there’s a really important role of natural consequences. If we interfere with natural consequences and the person doesn’t experience negative natural consequences for their behavior, then we’re protecting them from an opportunity to be forced to make a change. I don’t think it’s good 99.9% of the time for us to introduce artificial consequences, but to allow natural consequences to have an impact on someone’s life and then to help them figure out how to remediate those negative consequences. Huh, this happened to you. So that wasn’t good. You didn’t like that. What kinds of things could you do differently in the future to see that doesn’t happen again? I don’t think you’ll get it. Nothing. I wasn’t doing anything wrong. They just did this to me. And so then you go, yeah, yeah, that’s the way it feels, right? That’s a bad position to be in. And that’s the roll with resistance. And then we keep going over and over again, express empathy, roll with resistance, keep going back to it. But so tough love, I think when we’re doing it as some sort of artificial sense, is not a good treatment intervention. But when tough love is allowing natural consequences, that’s okay. And that can include things like parents saying to a child, you can’t live in my house if you can’t follow these rules, an adult child. Because if this adult child was renting an apartment and they kept having parties that got the police called, they’d probably get evicted. Parents can do the same thing, and that’s a natural consequence. You have to shape it right. You can’t be blaming and hostile and aggressive in the way you set that limit with a child, but it’s okay to set the limit.
Dr. Mark Leeds [20:07] Yeah, it’s a very difficult problem. It seems like I meet a lot of patients or prospective patients that are at about 40 years old, plus or minus a year or two and living with their parents and things are getting worse. And it’s always a difficult decision. You know, do they not allow them to stay in the house or do they provide other housing, alternate housing for them? Of course, everybody pretty much agrees don’t give them money because that’s never a good idea. But then when people are given, even when they’re given food and other things, they find ways to get money, you know, selling their, you know, I think I had heard a patient was returning her groceries at the grocery store to get the refund money. And I’ve heard about people buying gas for other people with their parents’ credit card and getting cash that way. And there’s just so many difficult ways. And I know I think to an extreme, you know, like if you look at probably what Oregon did, you know, make all the drugs decriminalized and are in Canada, you know, give people all the drugs that they need. And when they’re ready, they’ll come around. And maybe those to that extreme, it doesn’t work so well. Or do you think that could work? I mean, like what they do in British Columbia, like making a lot of things available to people.
Dr. Steven Pratt [21:20] Yeah, and they’ve done similar things in a number of countries. Portugal did that. I think Switzerland ending the quote unquote war on drugs and replacing it with access. But tied to that access are other things like in Portugal. They started this program at least 10 years ago. I can’t remember exactly when, but you could get free heroin, pharmaceutical grade heroin, clean needles, but you also had to be enrolled in some sort of a work training program. And so what they found was that, you know, to allow illicit substance use and illegal transactions to be going on means that there’s someone who’s a drug dealer. And that’s their business. And when you’re in business, one of the keys to success is marketing. First one’s free, right? And so now drug dealers are motivated to expand the drug using population so that they’re expanding their market and making more money. What they found in Portugal was that idea of providing free pharmaceutical grade heroin, but also requiring involvement in some type of rehab, that the number of drug dealers dropped dramatically and the rate of new abusers dropped dramatically.
Dr. Mark Leeds [22:52] Oh, that’s so. So things are working there. But how would you say that they do you think that they failed in Oregon? And how would you compare? I mean, was it just a free for all there?
Dr. Steven Pratt [23:03] Yeah, I don’t have enough familiarity with what went on in Oregon. But I mean, as I was saying on the Portugal example, it has to be structured right. The structure of it is the key to success.
Dr. Mark Leeds [23:14] That’s what I think. I think the difference is, I don’t know much about it either other than some headlines and some news reports I saw where I think they’re backing off on some of the decriminalization of really hard drugs because I don’t think, it doesn’t sound like there was much control of it. Like it was just people using more and more drugs and just out of control ramping homelessness and drug use everywhere. But, yeah, so as far as going back to the adverse childhood experiences study, how can that, should every doctor’s office include like a questionnaire or something, or is that something we should standardize, like evaluating people’s history of trauma?
Dr. Steven Pratt [23:53] I think so. I think so, as I mentioned at the beginning. Trauma, adverse childhood experiences has been found to be etiological in health conditions. Too. Smoking rates, overeating rates, obesity, and all the health consequences, heart disease, cancer, emphysema, all of these bad health behaviors, negative health behaviors, and the health consequences of them have been influenced by adverse childhood experiences and trauma. And so I think the idea of trauma awareness really helps us as an industry be less judgmental and more able to make empathic connections. Empathic connections are essential to a treatment alliance, to helping people buy into, you know, making health care changes. Yeah
Dr. Mark Leeds [24:55] Yeah and there’s a lot of talk discussion on social media of people identifying as being some kind of an empath and there’s all kinds there’s the healing empath and the earth empath the animal empath you know all kinds of different distinctions and maybe we can encourage some of these people to use their powers and get into the substance use disorder treatment business you know maybe even in counseling you know and help people with those powers of empathy.
Dr. Steven Pratt [25:24] Yeah. There’s no one pathway that works for everyone. And so as many tools as we can have available to us, the better we probably are.
Dr. Mark Leeds [25:37] Yeah. It does seem like with opioids, we have these incredible buprenorphine, I mean, also methadone and naltrexone and for different people that, you know, medication assisted treatment works incredibly well. And also for even even for alcohol, there’s different medications that can help. And naltrexone works incredibly well. And the Canadian Alcohol Use Disorder Society has a long list of medications that people can learn about. Doctors can learn about that in addition to naltrexone even and but it seems like with there’s very limited medication assisted treatment for things like cocaine and methamphetamine and you know especially and when people get start using multiple things like they use like say methamphetamine or cocaine or crack along with opioids then it gets really difficult because it’s like if you give them a prescription for suboxone they’re probably not taking it there and it’s very difficult to get them started. How can we approach that differently?
Dr. Steven Pratt [26:40] Yeah. Well, I think the more, as I just said, the more tools we have available to us, the better. I think trying to approach substance use with one tool, medication-assisted treatment, or there’s a newer term, because they want to de-emphasize the assistance. As sometimes it’s primary, opioid addictions being a clear case where, you know, replacement therapies or partial replacement therapies seem to be the most effective part of our treatment armamentarium. But across the board, I think we can’t take just a single approach and expect to have positive results across the board. We have to have tools that work for the individual, we have to individualize treatment, then the more multifaceted our treatment approach is, the more likely we are to be able to help more people.
Dr. Mark Leeds [27:42] Dr. Steven Pratt, thank you for joining me today.
Dr. Steven Pratt [27:45] Thank you very much. I really appreciate the opportunity to talk about these things that I’m passionate about.
