Both experiencing and witnessing drug overdose can be traumatic and lead to PTSD, reveals study on sex workers
Drug overdoses can be psychologically traumatic events and they can lead to symptoms of post-traumatic stress disorder (PTSD). The findings from a new study that focused on female sex workers in the US suggest that drug overdose is linked to PTSD. The analysis could help inform overdose treatment programs that typically look at reducing physical harms but largely avoid addressing psychological consequences, say researchers from the Johns Hopkins Bloomberg School of Public Health and The University of Texas at Austin.
According to the authors, overdose is currently the leading cause of injury-related death in the US, exceeding vehicle crashes and firearms as the opioid crisis continues to grow. However, by itself the fatality numbers do not capture the full picture of the overdose crisis, they explain. To fill in the gaps, the authors analyzed information from 380 sex workers in Baltimore City, Maryland, who reported whether they had witnessed or experienced any overdoses (fatal and non-fatal) in the past six months and PTSD symptoms. They team found that more than one-half reported symptoms of PTSD in the six months after experiencing or witnessing an overdose and after accounting for other traumas they may have experienced.
“For every overdose fatality, there are even more non-fatal overdoses. It’s been unclear what mental health toll these events take on survivors and witnesses, particularly in the vulnerable and marginalized populations that overdose often affects. These findings suggest the consequences are not insignificant,” explains Dr Kristin Schneider, first author and postdoctoral research fellow at the Bloomberg School. Supported by the National Institute on Drug Abuse, and Johns Hopkins University Center for AIDS Research, a National Institutes of Health-funded program, the findings has been published in the International Journal of Drug Policy.
The researchers used data from Enabling Mobilization, Empowerment, Risk Reduction, and Lasting Dignity (EMERALD), a long-running study of female sex workers in Baltimore City. As part of this study, they recruited female sex workers to answer questions on a tablet in a mobile van. These questions covered a variety of topics, including participants' demographic characteristics, sex work history, drug use, overdose experiences, mental health symptomology, police interactions, and drug and sexual risk behaviors. The data cover responses from September 2017 to January 2019.
The study participants also answered a 20-item questionnaire that evaluates PTSD symptoms in four separate domains outlined in the Diagnostic and Statistical Manual of Mental Disorders 5 (DMS-5). This includes intrusion, which involves re-experiencing the event through unwanted memories, nightmare, or flashbacks; avoidance, which includes intentionally trying to avoid trauma-related thoughts, feelings, and external reminders; cognition/mood, involving negative thoughts and feelings that were brought on or worsened by trauma; and arousal/reactivity symptoms that covers irritability, aggression, and hypervigilance.
Most participants were under 40 years old (63.7%) and few were over 50 (10.8%). Most were single (73.4%), one-third identified as a sexual minority (32.2%), over half of the participants were White (56.8%), and one-third were Black (35.8%). The drugs most commonly reported by participants were cocaine (86.3%) and heroin (80.8%). Non-cocaine stimulants (13.7%) and illicit buprenorphine (14.7%) were the least commonly reported.
More than half (59.6%) of the participants had recently witnessed an overdose, with close to a third (35.3%) witnessing a fatal overdose and about half (51.9%) witnessing a non-fatal overdose, reveals analysis. Close to a third (28.3%) of these volunteers had experienced a recent overdose themselves. More than half or 199 participants met the cutoff for a provisional diagnosis of PTSD using the criteria from the 20-item questionnaire. Most participants reported symptoms in each PTSD domain.
“In our sample, 35.3% witnessed a fatal overdose, 51.9% witnessed a non-fatal overdose, and 28.3% experienced an overdose in the past six months. More than half (52.4%) met the criteria for PTSD. Most endorsed symptoms within each PTSD domain: 63.2% for intrusive, 58.4% for avoidance, 66.1% for cognition/mood and 64.7% for arousal/reactivity symptoms. Our findings suggest that both experiencing and witnessing overdoses are likely psychologically traumatic, and this aspect of the opioid epidemic has largely been overlooked to date,” says the report. It adds, “Experiencing an overdose was associated with meeting PTSD criteria and symptoms in all domains in bivariate models. Witnessing an overdose was associated with PTSD diagnoses and intrusive and arousal/reactivity symptoms in bivariate models. Adjusting for sociodemographic characteristics and drug use, experiencing an overdose was associated with intrusive and cognition/mood symptoms, while neither trauma remained associated with PTSD diagnoses.”
The participants reported having faced other kinds of trauma: for example, two-thirds of these women (66.6%) had been homeless in the past six months, two-thirds (62.4%) had gone hungry at least once a week, 44% reported client violence, and 22% reported intimate partner violence. However, the researchers found that even after accounting for other types of traumas experienced by the female sex workers, overdose trauma was still closely linked with PTSD symptoms. While experiencing an overdose was associated with symptoms in all four domains, witnessing an overdose was associated with intrusive and arousal/reactivity domains. The researchers conclude that traumas related to overdose, coined “overdose traumas” appear to be extremely psychologically traumatic, though the relationships vary by type and symptom.
According to the authors, the analysis demonstrates that psychological trauma is an important consideration for public health research and practice when addressing the health impacts of the opioid epidemic. Based on their findings, they argue that existing measures for PTSD do not always accurately represent the effects of overdose traumas on populations that have high rates of “cumulative trauma,” like street-based female sex workers. “The traumas of witnessing and experiencing an overdose often add to a history of trauma, such that in addition to having an impact, overdoses can be triggering. Besides, the effects of some drugs such as cocaine and other stimulants can mimic the agitation of the arousal/reactivity domain,” explains co-author Dr Susan Sherman, principal investigator of the EMERALD study and professor in the Bloomberg School’s Department of Health, Behavior, and Society.
The researchers recommend that linking overdose trauma to PTSD could help guide new treatment paradigms for overdose that are focused on harm reduction, not just for those who experience overdose themselves, but for witnesses, who are increasingly becoming first responders in overdose events. “Largely the treatment for overdose has been focused on saving lives. That's incredibly important, and it should be the first priority. But in addition to physical harms, we should also be addressing the enormous psychological harms that accompany overdose to help people fully recover from the trauma in their lives,” suggests Schneider.