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National Center for Injury Prevention and Control
Christopher M. Jones, PharmD, DrPH, MPH
CAPT, U.S. Public Health Service
ACEs, Suicide, and Opioids: Intertwined Public Health Challenges
Opioid Overdose SuicideAdverse Childhood Experiences (ACEs)
CDC Injury Center Strategic Priorities
Defining ACEs and Health and Social Impacts
ACEs are experiences that may be traumatic to children and youth during the first 18 years of life such as experiencing violence or other types of emotionally disturbing exposures in their homes and communities.
Graphic Credit: Robert Wood Johnson Foundation
ACES not included in the traditional measure:
▪ Bullying
▪ Teen dating violence
▪ Peer to peer violence
▪ Witness violence in community or school
▪ Homelessness
▪ Death of a parent
Abuse Neglect Household Challenges
Adverse Childhood Experiences (ACEs)
Opportunity
Men
tal H
ealt
h
ACEs
EducationOccupation
Income
Alcohol & Drug AbuseUnsafe Sex
Opioid Misuse
CancerDiabetes
HIVSTDs
Unintended Pregnancy
PregnancyComplicationsFetal death
DepressionAnxietySuicide
ACEs Have Lasting Impacts on Health
ACEs and IV Drug Use ACEs and Adult Suicide Attempts
Source: Source: Dube, Shanta R., et al. "Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study." Jama 286.24 (2001): 3089-3096.Felitti, Vincent J., et al. "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." American journal of preventive medicine 14.4 (1998): 245-258.
Ad
just
ed o
dd
s ra
tio
Adult Suicide Attempts
ACEs and Deaths of Despair
ACE and Life Expectancy
Brown DW, Anda RA, Tiemeier H, Felitti VJ, Edwards VJ, Croft JB, Giles WH. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 2009;37(5):389-396.
Economic Impacts
ACES are Common in the U.S.
36.1%
26.0%
15.9%
9.5%
12.5%
ACE Score PrevalenceCDC-Kaiser ACE Study
Zero One Two Three Four or More
# of ACEs:
38.4%
23.5%
13.4%
8.8%
15.8%
ACE Score Prevalence2011-2014 BRFSS ACE Module
Zero One Two Three Four or More
# of ACEs:
Brain Science Behind ACEs
Building Brain Architecture
https://developingchild.harvard.edu/science/key-concepts/brain-architecture/
Broad Impacts of Toxic Stress
De Bellis & Zisk. The biological effects of childhood trauma. 2014
• Responses to stress• Reward circuits• Emotion processing• Coping strategies• Executive function• Decision making• Cognition• Organ function
Trauma Compromises Early Brain Development
External Manifestations in Children
https://aifs.gov.au/cfca/sites/default/files/publication-documents/cfca_developmental_differences_executive-functioning_practice-guide.pdf
ACEs and Connection to Substance Use
Number of Categories of ACEs
Felitti, Vincent J., et al. "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." American journal of preventive medicine 14.4 (1998): 245-258.
ACEs and Substance Use From Original ACEs Study
0
2
4
6
8
10
12
Current Smoker Alcohol Use Disorder Ever Used Illicit Drugs Ever Injected Drugs
Ad
just
ed O
dd
s R
atio
0 1 2 3 ≥4
Misuse of Rx pain medication by ACE Score
0
2
4
6
8
10
Use at higher frequency or dosagethan directed by the doctor
Use without a presciption
Ad
just
ed O
dd
s R
atio
ACE Score 0 1-2 3-4 ≥5
Source: Montana Behavioral Risk Factor Surveillance System, 2011. Behavioral Risk Factor Surveillance System Office, Montana Department of Public
Health and Human Services. The contents are the sole responsibility of the authors. DRAFT – DO NOT DISTRIBUTE
Early Adversity among Adults Using Methamphetamine
18
18
19
27
40
65
46
40
53
66
28
27
23
27
42
52
46
42
27
56
0 10 20 30 40 50 60 70
No place to live
Inadequate food
Inadequate clothes
Not taken care of when sick or hurt
Left by self when too young
Felt unloved
Felt unsafe or in danger
Beaten or seriously hurt by an adult
Ever sexually mistreated, abused or raped
Mentally or emotionally abused or mistreated
Percent
Male Female
Source: Maxwell JC, A new survey of methamphetamine users in treatment: who they are, why they like “meth”, and why they need additional services, 2014
ACEs, Suicide, and Opioids
More than 47,000 people died from
suicide in 2017
1 death every
11 minutes
10.6 million seriously thought about suicide3.2 million made a plan for suicide1.4 million attempted suicide
Suicide is a Leading Cause of Death
RankAge Groups
10-14 15-24 25-34 35-44 45-54 55-64
1 Unintentional Injury Unintentional Injury Unintentional Injury Unintentional Injury Malignant Neoplasms Malignant Neoplasms
2 Suicide Suicide Suicide Malignant Neoplasms Heart Disease Heart Disease
3 Malignant Neoplasms Homicide Homicide Heart Disease Unintentional Injury Unintentional Injury
4 Congenital Anomalies Malignant Neoplasms Heart Disease Suicide SuicideChronic Lower
Respiratory Disease
5 Homicide Heart Disease Malignant Neoplasms Homicide Liver Disease Diabetes Mellitus
6 Heart Disease Congenital Anomalies Liver Disease Liver Disease Diabetes Mellitus Liver Disease
7Chronic Lower
Respiratory DiseaseDiabetes Mellitus Diabetes Mellitus Diabetes Mellitus Cerebrovascular Cerebrovascular
8 CerebrovascularInfluenza & Pneumonia
Cerebrovascular CerebrovascularChronic Lower
Respiratory DiseaseSuicide
9Influenza & Pneumonia
Chronic Lower Respiratory Disease
HIV Septicemia Septicemia Septicemia
10 Benign NeoplasmsComplicated Pregnancy
Complicated Pregnancy
HIV Homicide Nephritis
Suicide Prevention Must Be Broader Than a Focus on Mental Health
Source: CDC
Interrelated Nature of Pain, Addiction, Mental Disorders, Suicide, ACEs
Pain
Mental Disorders Suicide
Substance Use/Addiction
ACEs
Risk Factors for Opioid Overdose
1.5
10.2
3.12.2 2.1 1.6 1.8
0.0
2.0
4.0
6.0
8.0
10.0
12.0
COPD Substance usedisorder
Depression Bipolar disorder Schizophrenia Anxiety disorder Benzodiazepines
aOR
Overdose Risk
2.3
1.6 1.71.5
2.0 2.0
0.0
0.5
1.0
1.5
2.0
2.5
Mood disorder Opioid use disorder Alcohol use disorder Cannabis usedisorder
Other non-opioid usedisorder
Any benzodiazepineuse
aHR
Overdose Risk
Source: Nadpara et al., Pain Med, 2018; Campbell et al., Preventive Medicine, 2018 7
Relationship Between Suicidal Ideation & Motivations for Rx Opioid Misuse
Source: Han et al., JCP, 2018
Suicide and Opioids
Risk of Suicide Ideation
▪ Opioid Use Disorder (OUD) involving prescription opioids was associated with an increase of 40 to 60% in the risk of suicidal ideation.
Risk of Suicide Plans and Attempts
▪ People using opioids regularly were about 75% more likely to make suicide plans and twice as likely to attempt suicide as people who did not report any opioid use.
SOURCES: Ashrafioun, Bishop, Conner, and Pigeon (2017); Oquendo and Volkow (2018)
Substance Use Risk Factors
➢ Genetic factors
➢ Initiating substance use early
➢ Low risk perception of use
➢ Peers who use substances
➢ Emotional distress or aggressiveness that starts early and is persistent
➢ Psychiatric disorders
➢ Substance misuse in the family
➢ Family conflict, abuse, or neglect
➢ Parents who favorably view or approve of substance use
➢ Lack of family connectedness
➢ Poor academic performance
➢ Student does not view school as rewarding or meaningful and lack commitment to school
➢ Perception that use of drugs among classmates is high
➢ Poor control over school drug consumption
➢ Lower socioeconomic status, economic stressors
➢ Availability and costs of drugs and alcohol
➢ Community norms favorable toward alcohol and drugs
➢ Lack of community connectedness and supports
Source: Adapted from Volkow et al., 2018, JAMA Psychiatry
Risk Factors for Suicide
▪ Adverse childhood experiences/trauma
▪ Substance use
▪ Mental illness
▪ High conflict or violent relationships
▪ Lack of connectedness
▪ Loss (relational, social, employment, financial, health)
▪ History of suicide attempt, suicide of friend or family member
▪ Barriers to health/behavioral health care access
▪ Stigma
▪ Availability of lethal means
Source: CDC
Shared Protective Factors
➢ Resiliency
➢ Self-efficacy
➢ Spirituality
➢ Interpersonal skills, including social, emotional, and cognitive skills
➢ Treatment of underlying psychiatric disorders
➢ Attachment to family, school, and community
➢ Meaningful involvement in family, school, or community
➢ Safe, stable, nurturing relationships
➢ Positive behavior is recognized
➢ Norms in the family, school, and community that drug use, violence are not acceptable; helping seeking is acceptable
➢ Opportunity for fulfilling extracurricular activities
Source: Adapted from Volkow et al., 2018, JAMA Psychiatry
Prevention Policy, Program, and Practice Strategies
The power of prevention
Source: CDC Vital Signs 2019
Promote social norms that protect against violence and adversity
Ensure a strong start for children
Strengthen economicsupports for families
Teach skillsLessen harms
and prevent future risk
6 Strategies to Prevent ACEs
Connect youth to caring adults and activities
Suicide Prevention Technical Package
Source: CDC Suicide Prevention Technical Package: https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf
Resilience Catalysts (RC) ProjectBuilding Community Resilience
▪ Advances efforts of local health departments to address and prevent individual and community ACEs.
▪ Includes a focus on opioid misuse.
Awarded Sites
▪ Cambridge, Massachusetts
▪ Louisville, Kentucky
▪ Mesa County, Colorado
▪ Dallas, Texas
▪ Appalachian District, North Carolina
▪ Focuses on ACES to create a trauma informed community working to build resilience in children.
▪ Partnership between Berkeley County Schools, Martinsburg Police Department, Shepherd University and community organizations including The Boys & Girls Club of the Eastern Panhandle.
▪ Program advocates for children with high ACE scores and connect individuals with the services they need to succeed.
▪ Program is tiered and provides universal supports, target prevention programs, and wrap-around services for children in need.
An Innovative and Holistic Police-school-community Partnership
Expanded Essentials for Childhood (EfC)
▪ Assuring safe, stable, nurturing relationships and environments for children
▪ Supplemental opioid funding
Awarded Sites▪ California▪ Colorado▪ Kansas ▪ Massachusetts▪ North Carolina▪ Utah ▪ Washington
Communities that Care (CTC)
Compared to a comparison group,
students receiving CTC were…
– 60% less likely to initiate alcohol use
– 41% less likely to engage in delinquency
– 25% less likely to engage in violence
Veto Violence - ACE Online Training
https://vetoviolence.cdc.gov/apps/aces-training
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348www.cdc.gov/injury
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
@CDCInjury
Christopher M. Jones, PharmD, DrPH, MPHCAPT, US Public Health ServiceSenior AdvisorDirector, Strategy and [email protected]