These results provide strong support for future research that evaluates the role of movement therapies such as tai chi in reducing risk of falls, mobility-related disability and frailty occurrence in older PLWH. This study has several strengths. This is the first study, to our knowledge, employing a multi-component behavioral intervention to address both chronic pain and substance use in older PLWH. Another strength is that we conducted the study in partnership with a community-based agency serving PLWH, and trained its staff to deliver the multi-component intervention, so our model of implementation was pragmatic by design. Several limitations, however, warrant attention. We enrolled English speaking participants only, therefore the extent to which the results generalize to non-English speaking patients remains unclear. The same person conducted recruitment and all study assessments and was therefore not blinded to group assignment. We elected to have rolling enrollment of the groups and this may have affected group cohesion and reduced the efficacy of the CBT protocol. Some of the staff who led the CBT group sessions also led the support groups which could have contributed to some of the beneficial effects observed in the latter group through contamination bias. We also compensated participants to attend the CBT, TC and SG sessions, which likely enhanced participation rates and reduces generalizability, as this is not feasible in non-study settings. It may also be challenging to implement the tai chi component of the intervention with fidelity in community-based settings as skilled instructors may be difficult to find,benefits of vertical farming depending on location, and therefore using other modalities such as technologies to facilitate remote tai chi could enhance real world implementation.
In conclusion, this pilot study demonstrates the feasibility and acceptability of a combined behavioral therapy in a vulnerable and understudied population, as well its preliminary efficacy in reducing substance use and improving physical performance. Suggestions for improvements to the CBT component of the intervention and inclusion of additional text messages will be addressed in a larger study to enhance the intervention’s potential efficacy in further reducing substance use and pain. The next steps, to refine the intervention and test it in a larger RCT, are warranted by the data and needed to facilitate effective and accessible interventions to address substance use, pain and physical performance in the growing population of older PLWH.In 2020, it is estimated that 100,306 drug overdose deaths occurred in the United States, an increase of 28.5% from the 78,056 deaths during the same period the year before.Those with a substance use disorder are at an increased risk for OD, especially those with an opioid use disorder.Those with a history of adverse childhood experiences are at risk for mental health disorders and substance use, and this risk increases with an increased number of ACEs.Adverse childhood experience is a 10-question self-reported measure used in the assessment of stressful or traumatic experiences that occur during childhood in the form of neglect, abuse, and/or household dysfunction.The ACE survey includes questions on physical neglect, emotional neglect, emotional abuse, physical abuse, domestic violence, sexual abuse, family history of mental illness, use of drugs or alcohol in the household, and imprisoned family members before the age of 18 years.Chronic exposure to these stressful events can lead to disrupted neurodevelopment and impaired ability to cope with negative emotions.These adverse outcomes can lead to maladaptive coping mechanisms, such as substance use and misuse.With increasing number of ACEs experienced, there is a greater risk of developing an SUD.In addition, there is a greater prevalence of medical and psychiatric illness in those who have experienced ACEs.
Evidence shows that traumatic stress in childhood can lead to mood and anxiety disorders through the damage caused to the amygdala, hippocampus, limbic, and prefrontal cortex structures.It has been established that there is a relationship between substance use or SUDs and OD. However, there has been little investigation regarding ACEs and their connection to OD.Experiencing a higher level of ACEs could lead to OD through unhealthy coping mechanisms, such as substance use.This relationship has been explored in a medical inpatient population, which reported that a one-point increase in the ACE score was associated with a one-point increase in lifetime OD risk.Previous research has also explored the psychometric properties of the ACEs scale on multiple SUD inpatient populations.How ever, it seems that the relationship between ACEs and OD in an outpatient addiction treatment setting has not been examined.The purpose of this study is to examine the relationship be tween ACE scores and a self-reported history of OD among patients engaging in an addiction and mental health outpatient recovery and treatment program. We hypothesized that higher ACE scores would be significantly associated with a history of OD.Existing, prospective, and past patients participating in a dual-diagnosis outpatient recovery and treatment program at a tertiary healthcare system in Southern California at an academic institution. Patients were invited to have their baseline clinical assessments and medical record data reviewed for re search purposes. Of the 215 patients who agreed to participate from November 1, 2017, to August 2020, 115 completed all 10 questions on the ACE questionnaire at their baseline visit . All patients signed an informed consent to use their past, present, and future information from data collected during routine clinical care, including questionnaires and their elec tronic health record. This study was approved by the Human Research Protection Program and the institutional review board.
Before their first visit, patients were assessed for clinical care with a series of self-report questionnaires, structured evaluation questionnaires, and semi-structured clinical interviews, which included the ACE questionnaire. Information obtained included sociodemographic information, current and past medical, psychiatric, and social history, medication history, family history, substance use history, system review, functioning, and information on specific psychiatric symptoms . The sociodemographic and healthcare information was accessed from paper surveys and from data extracted from the electronic health record. To protect patient confidentiality, analytic databases created from the primary data bases did not include personal identifiers , and subjects were assigned a unique study identification number.Results from the PCA suggested a 2-component solution that explains 63% of the proportion of variance with 40% being explained by the first component and 23% explained by the second component. Loadings indicate how strongly a variable influences the component. Results indicated that all of our 10 ACEs variables had at least moderate loadings to 1 of the 2 components, which is a good indicator of construct validity. The ACE items loaded onto 2 general components that closely followed theoretical domains childhood mistreatment and household dysfunction. The first 5 items of the original ACEs scale generally describe physical, emotional, and sexual abuse, and all five of these items loaded onto the first component . Items 6 to 10 of the original ACEs scale generally describe household dysfunction, and 4 of these 5 items loaded onto a second component . The item that fell outside the theoretical domain was the question “Was your mother or stepmother: Of ten pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist,urban vertical farming or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?” Notwithstanding this one item discrepancy, the items loaded on 2 general components that are consistent with previous studies. Similarly, item #5 loaded onto both components at more than modest rates. How ever, ultimately, item #5 loaded onto the “child mistreatment” component, which is consistent with theoretical domains. The specific item loadings are represented in Table 3. Figure 1 demonstrates the ACEs item distribution based on ACEs question and percentage that endorse experiencing the specific ACE.This study found that higher ACE scores were signifi cantly associated with a self-reported history of OD at initial assessment. The findings from this study are consistent with a larger cross-sectional study published in 2017, which showed that ACE scores were associated with previous OD in a medical inpatient setting.That study by Stein et al had a sample size of that was predominantly male with a White ethnicity , and approximately half of their respondents experienced 4 or more ACEs. Their study showed that a one-point increase in ACE score was associated with a 1.increase in the expected odds of reporting a lifetime OD. The study by Stein et al coupled with our findings suggests that these traumatic childhood experiences could also in crease the likelihood of OD in this population. These results indicate that patients presenting with SUD and a history of OD could also benefit from trauma-informed care. Similarly, screenings for ACEs can serve as an opportunity for referrals to mental health treatment if needed. Our results further indicate that social and structural conditions may be just as significant in the relationship to self-reported OD as the type of substance used. Research has shown that certain populations are more susceptible to a negative impact from ACEs because of their socioeconomic and educational backgrounds.
In a cross-sectional study examining the Behavioral Risk Factor Surveillance System data , those with a history of ACEs were more likely to report a lower socioeconomic status, higher rate of unemployment, and lack of high school com pletion.Prevention programs targeting at-risk youth can also use the ACE score to screen for highly vulnerable populations who might be at risk for early initiation of substances and potential OD. A systematic review of interventions in 2019 showed that parenting education, social service referrals, and social support for families can reduce the impact of ACEs on young children.Results from our study lend support for the critical need to continue addressing the impact of ACEs on substance use and ODs. As expected, we found that those with older age were more likely to report having experienced a nonfatal OD. This is consistent with the US drug OD death data, as adults aged 35 to 44 years have the highest rate of drug OD deaths from 1999 to 2019.The public health implications of these data are vast considering that OD survivors experience health challenges and higher death rates compared with the general public.It is important to note that older patients had a longer duration of substance use history, thereby increasing the opportunity for an OD, so these analyses should be interpreted with caution. Overdose death rates during 2018–2019 increased among persons 65 years or older in the United States.In particular, rates increased among persons 65 years or older, non-Latinx Blacks, and Latinx, and in the Northeast and the West regions. In one study, individuals born between 1947 and 1964 had a notably increased risk for OD death.Several theories have been proposed for the increase of OD history in older age. The generation of the “baby boomers” born between the years of 1946 to 1964 has been reported as having a generational mindset that was more accepting of substance use.Our finding that older age was a risk factor for OD has clinical implications for patient screening in this setting. A study with a larger sample size is needed to confirm this intriguing association.Although the ACEs scale has been validated in previous populations, there has been limited research on the validity of the ACEs scale in people in treatment for SUD. As such, we conducted a principal component analysis to increase the validity of our analysis and findings. Results from the PCA results suggest that the original ACE scale is an appropriate tool to assess child mistreatment and household dysfunction in a population of individuals seeking treatment for substance use and mental health disorders. Almost all of the 10 items fell within 2 theoretical do mains, which provides evidence that all original ACEs are relevant in this population and should all be retained for clinical use. Notably, “physical violence toward the mother” loaded onto the “child mistreatment” component rather than the “house hold dysfunction” component. A recent study by Afi and col leagues16 also found evidence for a 2-factor structure, but consistent with previous studies, exposure to physical intimate-partner violence loaded onto the “household dysfunction” component. The high loading of this item in our study with “child mistreatment” suggests that perhaps witnessing physical violence to ward a mother figure in childhood may have different implications for this population. Future studies should attempt to replicate and better understand these findings in different samples. There are several strengths for this study.