March 3, 2025 • 36 mins
Trauma plays a pivotal role in the journey of addiction, with many individuals using substances as a means to cope with unresolved issues. Addressing PTSD is crucial for effective recovery, as understanding the link between trauma and addiction can empower individuals toward healing.
In this episode we discuss:
• Trauma and its historical context in PTSD understanding
• Description of brain responses to trauma and the feedback loop
• Big T and little t traumas and their cumulative effects
• The connection between adverse childhood experiences (ACEs) and adult illnesses
• The importance of a trauma-informed approach in treatment
• Case studies illustrating the impact of trauma on addiction recovery
• Recommendations for therapeutic interventions and medication options
I reference a podcast episode at the beginning of the episode. Here's a link to that episode
https://lemonadamedia.com/podcast/trauma-with-dr-gabor-mate/
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today we are going to be talkingabout post-traumatic stress
(00:43):
disorder, also known as PTSD.
As a part of my work as amedical director for a drug and
alcohol treatment program, Igive monthly educational
lectures to the staff, and thismonth I lectured on PTSD.
It's a very personal topic forme, as I have been diagnosed
(01:04):
with PTSD from my 14 yearsworking as a doctor in the
emergency department, and nearlyall of my patients have lived
through traumatic experiences,and many of them also have PTSD.
This lecture is a greatoverview of the topic.
Before we start, I gave thislecture while I was in my car
due to my busy schedule, so Iapologize, the audio quality
isn't perfect given therecording conditions.
(01:25):
Okay, let's dig in.
Okay, so today we are going totalk about post-traumatic stress
disorder, and I apologize thatthis may be triggering, and I
will do my best to keep iteducational and also be mindful
(01:47):
about the link between traumaand addiction.
Okay, so I want to share wherethis came from.
So I was at a high schoollecturing parents about drugs
and alcohol as a way to informparents about what their kids
may be facing in school, and oneof the moms came up to me and
(02:08):
said we should chat.
And I said okay, and that's theperson you see at the center of
the screen.
Her name is StephanieWhittleswax.
She is the author of a New YorkTimes bestseller about her
brother's death from heroinoverdose, and she and another
woman formed a podcast calledLast Day, which was initially
(02:28):
about both of their brothersdying of heroin overdose and
they wanted to explore the lastday of their lives to understand
what they could learn aboutaddiction.
And if anyone recognizes theperson on the right of the
screen, that's Dr Gabor Mate,who's one of the world's experts
on the link between addictionand trauma.
And so Stephanie and Iconnected.
(02:49):
She's writing a book aboutaddiction and we met for coffee
and I started learning about thefact that she has this
incredibly successful podcastand she encouraged me to listen
to it, as the entire firstseason was on opioid addiction
and opioid overdose and weconnected.
So I went to her daughter'sschool.
She was a parent.
She actually came andparticipated in the naloxone
training and I'm working onhelping her writing her book.
(03:12):
I was able to participate withhelping her write one of the
chapters Extremely intelligentperson and has a great podcast
and one of the episodes she letDr Gabor Mate interview her
about her life story to betterunderstand why her brother
developed addiction and he wentso deep into trauma and the link
between addiction and traumaand Stephanie, to her credit,
(03:36):
was actually able to share herown life trauma and how she has,
as an adult, has developed anaddiction to work, and it was
absolutely mind-blowing for meas an addiction medicine doctor.
I realized I was really missinga lot of the trauma that was
contributing to addiction.
So I listened to that, maybe inabout October, and I've been on
(03:58):
about a four to five monthjourney of trying to understand
the link between trauma andaddiction.
So I will also share that.
I personally have post-traumaticstress disorder from my 14
years as a doctor in theemergency department and I'll
talk about occupational PTSD asa part of this.
So what is PTSD?
Ptsd is post-traumatic stressdisorder and we are aware of it
(04:21):
going back literally thousandsof years.
There are some descriptions ofsomething that we think to be
PTSD in Assyrian soldiers in1300 BCE.
Now, we didn't reallyunderstand it for many years and
I put some historical names forthis condition Railway spine
stress syndrome, soldier's heart, traumatic war neurosis, shell
(04:44):
shocked there's all these termsthat describe the phenomena, but
we didn't really understand thewhy until modern times.
So what exactly ispost-traumatic stress disorder?
And the best way I can describeit is bad things happen to us
as a part of life and our brainand body does not know what to
(05:05):
do with these bad feelings.
And there's a lot of negativeenergy, which we'll talk about
in the actual trauma itself, anda lot of times that negative
energy doesn't know where to goand the body stores it almost
like a scar, and every time thatmemory gets touched, that scar
hurts, if you will, leading tomental and physical symptoms.
(05:28):
So here's the why and I'm surethere are many different reasons
why people can explain PTSDhappens, but here's how it makes
sense to me.
Our brain as humans is the mostsophisticated brain on the
planet.
However, we share a lot of thesame structures with more
(05:49):
primitive animals.
In other words, the lizardbrain has grown and developed
into the mammalian brain, theprimate brain and eventually the
human brain.
We keep adding on the olderstructure to make it more
complicated.
So if you've ever heard of theterm lizard brain, that refers
to a very primitive brain thatlizards have where they're
(06:10):
basically wired for survival,food and sex.
That's really it.
And when they're threatenedthey go into a fight-or-flight
response.
And if you think about it,lizards have very simple brains.
And if you think about it,lizards have very simple brains.
Lizards don't getpost-traumatic stress disorder.
If they get threatened, they gointo their fight-or-flight
(06:30):
response and then they go abouttheir day as long as they
survive.
Now the human brain is much morecomplicated.
We like to understand things,we like to have reasons, we have
philosophy and theory and ourbrain, as human human tries to
understand the trauma, tries tounderstand why we had the fight
or flight event.
(06:51):
Why me?
Why that day?
Why couldn't it have beensomebody else?
What if it happens again?
What if it happens tomorrow?
All the what ifs come from thehuman brain trying to understand
the trauma.
And here's the issue.
We were never meant tounderstood trauma.
We were simply meant to justsurvive and move on.
(07:13):
So I put here squirrels don'tget PTSD, they just fight or
flight and escape and then moveon.
And so, unfortunately, thehuman brain is trying to
understand something that wasnever meant to be understood in
the first place.
Now there are a couple otherresponses in humans.
We can also fawn, particularlywith women who are victims of
(07:36):
sexual assault.
They have this weird responsewhere they try to really please
their aggressor.
And then in both animals andhumans we can also freeze.
So it's probably best fight,flight, freeze or fawn.
But just for the sake of thiswe're going to say fight or
flight, just because that's whatmost people are familiar with.
Now, the issue with PTSD inhumans is that we end up with
(07:58):
this really complex negativefeedback loop.
So let's say, a person issexually assaulted, they have
their fight or flight response.
That memory is seared intotheir brain.
Once the trauma is over.
They try to process it, theytry to understand it and they
can't.
Why me?
Why that day, what did I do?
And so what happens isbasically the fight or flight
(08:20):
response sends this negativeenergy up to the human part of
the brain.
The human part of the braincan't understand it and process
it.
So that negative energy up tothe human part of the brain.
The human part of the braincan't understand it and process
it, so that negative energy getsunresolved and stored and
eventually, when a new triggercomes up that reminds the person
of the original assault, thatfight-or-flight response
triggers again and they try toprocess it again and it becomes
(08:41):
this negative feedback loop.
Now how do we diagnose PTSD?
The simple answer is, for me isif you have a traumatic history
and you have addiction, chancesare you have PTSD.
Now the official answer is iswe use the Diagnostic and
Statistical Manual 5th Edition,or the DSM-5, and it's the book
(09:04):
in psychiatry that contains allthe criteria for every
psychiatric diagnosis.
And because in psychiatry wecan't run a blood test or a scan
, we're really just trying tosee if the person's symptoms
match the criteria and then wegive them the diagnosis.
So pardon the very small font,but as you can see here there's
(09:26):
a lot of complicated criteriafor PTSD.
The first is they had to havehad an exposure to the trauma.
Then they have to haveintrusive thoughts or memories.
They have to try to avoid thosethoughts and memories.
It has to have a negativeeffect on their mood and how
their brain works.
And then they have to be hyperaroused, like they're constantly
(09:50):
ready to trigger that fight orflight response again.
It has to last for greater thana month, it has to be
significant, in other words it'sactually affecting their life
in a meaningful way, and thenit's not from something else.
So you can look up these DSM-5criteria for PTSD.
I actually read them to mypatients in clinic when I'm
trying to make the diagnosis.
(10:12):
But here's a simplified way tothink about the diagnostic
criteria for PTSD.
Number one a person was exposedto trauma.
Number two they persistentlyexperienced that trauma over and
over again, and common thingsare flashbacks and nightmares.
Number two they persistentlyexperience that trauma over and
over again, and common thingsare flashbacks and nightmares.
Number three people try toavoid anything that reminds them
of the trauma.
Number four their mental healthdeclines.
(10:35):
And then, number five peopleare easily triggered or reactive
, which can include beinghypervigilant, startling easily,
not sleeping well, beingirritable or engaging or risky
and destructive behavior, whichincludes addiction.
So for me, so I havepost-traumatic stress disorder
from my time in the emergencydepartment.
(10:55):
Trauma can happen in manydifferent ways.
A person could be traumatized,and they get PTSD.
A person could have witnessed atrauma firsthand and they get
PTSD.
People can get PTSD throughtheir work like firefighters,
first responders and policeofficers, and as I go through
this, I can see all the thingsthat happen in my body.
So, yes, I have too manyhorrible stories to remember
(11:19):
from the ER.
I get flashbacks multiple timesa day.
I had nightmares for years.
I get flashbacks multiple timesa day.
I had nightmares for years.
I still, to this day, willavoid walking through the ER at
all costs.
My mental health was reallydeclining in the emergency
department and absolutely I washaving difficulty sleeping and I
(11:39):
was hypervigilant in the ER.
It really has a profound effecton people.
Now, in terms of what actuallycauses post-traumatic stress
disorder, what I'm going to tellyou now isn't really
science-based, but it's more howit makes sense in my mind and
how people have explained it tome.
We have big T's and we havelittle t's.
So big T's are a way toreference large, complicated,
(12:06):
singular events a stabbing, ashooting, a near fatal car
accident, sexual assault.
It's like an event that'shorrible and you don't want to
have to go through it again.
It can be many big T's in a row, like I have one patient who
was a soldier in Central Americaand was forced to, you know,
(12:28):
assassinate other soldiers andengage in battle.
He has lots of big T's.
Little T's are smaller, moremicro traumas that add up over
time.
So when a person has a big T,it leaves a big emotional scar
in their brain.
Little T's would be like apersistently verbally abusive
(12:48):
parent Bullying, persistentbullying from a sibling.
It's not one big event, butit's many small events that add
up over time and the smallindividual scars add up to have
the cumulative effect of a bigscar and of course, you can have
both.
Now, as I mentioned, there'smany different ways that a
(13:10):
person can be exposed to traumathat leads to PTSD.
You can experience it directly.
You were robbed at gunpoint.
You can have witnessed itfirsthand, as in you were there
when a car accident happened andyou saw the person die in front
of you.
There can even be some caseswhere the trauma that a loved
(13:32):
one or very, very close friendexperiences affects you as well,
as you help them try to dealthrough the negative emotions of
their trauma.
One of my patients was tellingme that her husband was a
Vietnam veteran and was horriblytraumatized and she talked
about for her.
She experienced PTSD throughher husband, which can
absolutely happen.
(13:53):
And then you can get exposed totrauma through work.
Like me, I still to this dayget flashbacks all the time
about early COVID and several ofmy most horrible cases.
The one that stands out to methe most is a young woman who
hung herself successfully andshe died and we couldn't
resuscitate her.
And that could be through yourwork as a first responder.
(14:15):
I've met hospital socialworkers that have PTSD.
I just want to acknowledge thatit's important that we
acknowledge that you can get itprofessionally Now.
Very closely linked with PTSDare ACEs, adverse Childhood
Experiences, and I want to givea little bit of history on this.
(14:37):
So everyone's heard of Kaiser.
That's a hospital system inmany states.
It's in our region not so much,but it's very strong in the San
Francisco Bay Area and inSouthern California and I used
to work at Kaiser when IFrancisco Bay Area and in
Southern California and I usedto work at Kaiser when I was in
my training in my residency.
And Kaiser is all aboutprevention.
(14:57):
They've realized that if peopledon't get sick, you don't have
to spend the money to take careof them because they're not sick
.
So Kaiser's big into preventionand so Kaiser was doing some
research on why people get illHeart disease, diabetes, high
(15:22):
blood pressure, depression,anxiety, addiction what actually
causes people to get ill asadults and what they found is
that there was a correlationbetween adverse childhood
experiences and adult illnesses.
This is if a child is a victimof physical abuse, physical
neglect, there's a householdmember who has severe mental
health issues, sexual abuseaffecting the child, loss of a
(15:46):
parent due to death, abandonmentor divorce, emotional abuse,
emotional neglect, a householdmember with addiction, a
household member who wasincarcerated or witnessing
domestic violence in the home.
There's actually 10 criteria.
And so, yes, kaiser found thatall of these adverse childhood
experiences were correlated withadult illness, and it's not the
(16:11):
traumatic experiencespecifically, but it's
multifactorial.
In other words, if you have afamily member with mental
illness and addiction, what'syour nutrition like?
Do you have access to exercise?
Do you have stable housing?
Do you get good access toeducation?
Do you have enough to eat?
So, in other words, childrenliving in an unstable
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environment or, frankly, atraumatic environment, has a
profound effect on their growthand development in many
different facets, and I'vetalked to my patients.
One of my patients had eight ofthese.
One of my very dear friends whohelps me in many ways.
She's helping me learn abouttrauma through her trauma.
(16:54):
She has nine and one of myother patients has eight.
I personally have one which wasthe death of a parent.
But if you look at these andstart to really screen in
patients with addiction, youwill find that a lot of our
patients with addiction have asignificant number of adverse
childhood experiences.
(17:16):
Now, medicine is not set up tounderstand trauma.
Okay, medicine is all aboutdiagnoses.
We ask the question what'swrong with you?
So you come to the doctor andyour stomach hurts.
We run ultrasounds, cat scans,blood work and we give you a
diagnosis right, it's gastritis,that's too much acid in the
(17:40):
stomach, it's appendicitis,let's say you're tearful and
you're crying.
We give you the diagnosis ofdepression.
And this is actually one of thethings that made me leave the
emergency department is we wouldsee people really struggling
with drugs and alcohol andemotions and we just focused on
the diagnosis and not theperson's story.
(18:04):
So I spoke to over 5,000children in 2024.
I went to, I think, 27different schools and if I ask
those kids, what do you want tobe when you grow up?
Nobody says addicted, in jail,homeless, injecting substances.
They've got better plans andyet we all know people who are
(18:27):
in jail, in and out of prison,injecting drugs, addicted.
Something happened right andthat's this book's suggestion.
It's by Bruce Perry and OprahWinfrey.
Yes, that, oprah, and it's thetitle of the book is what
Happened to you and that's whatI encourage healthcare providers
(18:47):
to do when they're strugglingwith a patient's behavior.
What happened to you?
Because that really asks thequestion what traumatic
experiences did you have in yourlife that led you to, at 35
years old, being incarcerated,using meth and hallucinating in
the emergency department?
That wasn't part of the planwhen you were in third grade
(19:15):
department.
That wasn't part of the planwhen you were in third grade.
So I'm going to make a pointhere to really just drive home
the profound effect of traumaand the relationship with trauma
and addiction, and realize I'mexaggerating.
To make a point, I am veryaware that patients have drug
and alcohol cravings.
But when I talk to my patients,usually what they feel is
(19:36):
something that they don't likeand they want to feel better and
the drug or the alcohol makesthat bad feeling temporarily go
away.
We all know it doesn't fix itand I think deep down our
patients don't, but they justdon't know what else to do.
So my patients don't cravedrugs and alcohol, they crave
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feeling better, particularlywhen they're traumatized and
can't sleep because they getflashbacks and nightmares all
night.
Why do they drink?
To black out?
Because they can't deal withthe trauma.
I'll give you an example.
One of my patients is a greatyoung guy and I was chatting
with him about two weeks ago andhe was telling me he's got
(20:21):
about a year sober from alcoholand we were talking about when
he did drink and he said that hewas the type of drinker that
would just black out.
And I never really asked himabout his alcohol use, because
he came to me about two or threemonths sober and I said why
were you trying to black out?
And he said I don't really know.
(20:42):
And so the little light bulbwent off in my head I wonder if
there's some trauma.
And so I asked him did you haveany traumas as a kid?
And he said yeah, yeah.
And so we started talking aboutit and he got sexually
assaulted in middle school by abunch of older boys in his
neighborhood.
One day after school hecouldn't actually finish the
(21:03):
story.
So I went through the PTSDcriteria and he met all of them
and I apologized to him.
Him I said I'm so sorry Ididn't ask about trauma sooner,
because we need to address yourtrauma to really help you heal
from your alcohol addiction.
So what do we do once wediagnose someone with PTSD?
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Well, we need to give themtrauma-focused psychotherapy so
they can work on actuallyprocessing the trauma, and I'll
talk about that in some detail.
We can often use medications tohelp a person feel better while
the psychotherapy starts to work, and actually my recommendation
is that we use both together.
(21:48):
In terms of medications, thefirst-line treatment for PTSD
are the selective serotoninreuptake inhibitors, and here
are some common names Fluoxetineor Prozac, sertraline or Zoloft
, citalopram or Celexa andS-Citalopram or Lexapro or
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Celexa and escitalopram orLexapro.
These are my go-to, my personalfavorites.
There's a little data thatwould suggest that maybe Zoloft
is a little better in PTSD and,anecdotally, lexapro seems to
help better for anxiety.
Those are usually my go-to fortrauma.
You can also use their cousins,serotonin and norepinephrine
(22:31):
reuptake inhibitors.
There's not as much data onthem, but they can still be used
, and an example of that wouldbe venlafaxine, also known as
Effexor.
Now, if you didn't know, thereis a very effective medication
for nightmares and I started oneof my patients on it today and
that's Prazacin, which its brandname is Minipress, and Prazacin
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is interesting.
So we all are probably prettyfamiliar with Klonidine, and
Klonidine is a medication thatsuppresses the release of stress
hormones from the brain.
That's actually why it's usedto treat either alcohol
withdrawal or opioid withdrawal,because that's a high stress
hormone state.
Right, we're in a fight orflight response.
(23:16):
We're hyper-stimulated as we'recoming off of opiates or
alcohol.
So clonidine works by reducingthe release of stress hormones
from the brain and prazosin isits cousin, like Lexus and
Toyota.
Prazosin is its cousin, likeLexus and Toyota, and prazosin
(23:36):
works by also decreasing therelease of stress hormones from
the brain.
It's a little bit sedating andit suppresses nightmares, so it
helps with sleep and then ithelps reduce some of the
traumatic nightmares that comeout.
I use it all the time in mypractice, particularly when
people are new in recovery andthey're really struggling with
sleep.
Now there are two othermedications that we can also use
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with PTSD and for me personally, I feel my PTSD in my solar
plexus.
I get a lot of tightness rightthere and then I get a lot of
tingling in my extrem, then Iget a lot of tingling in my
extremities and when I gettingling in my extremities I can
feel my ptsd being triggered,as I can when I get that
tightness in my solar plexus.
So there are two othermedicines that can be used To to
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blunt those physical reactivefeelings, that hyper vigilance,
that over stimulation that comeswith ptsd.
One of them is clonidine, likewe just talked about.
It reduces the amount of stresshormones coming out of the
brain and so it actually bluntsthose physical symptoms.
The other is propranolol, whichis a blood pressure medicine
(24:46):
which also suppresses thosestress hormones as well.
They can be very effective.
Which also suppresses thosestress hormones as well.
They can be very effective.
The only major issue is thatthey can drop the blood pressure
.
So I actually have one patientright now and I'll share her
story in just a second who hasPTSD and she is on sertraline or
Zoloft, prazosin andpropranolol.
Now you might be interested inlearning more about trauma.
(25:09):
There are some fairly famousbooks on the topic.
This is one called the BodyKeeps the Score and it's by a
psychiatrist named Bessel vander Kolk, and if you ask around
the trauma community, there's alot of awareness of this book
and it's a really wonderfuljourney that a psychiatrist
details of how he went fromworking with World War II
(25:31):
veterans to trauma in the modernera and how people's awareness
and acceptance of the diagnosisof PTSD has changed.
And basically this is hishypothesis when you are
traumatized, the body keepstrack.
In other words to point out thetitle the body keeps the score.
This is another one calledWaking the Tiger by Peter Levine
(25:56):
.
Peter Levine is apsychotherapist who has created
a style of trauma therapy calledsomatic therapy and what he
does is he really focuses on thetrauma and goes back to the
traumatic time and tries to helppeople in the moment experience
(26:16):
the trauma and focus on whatthey're feeling in their body to
process the trauma.
And he has some reallyinteresting chapters in that
book that describe how theanimal brain processes trauma
versus the human brain.
It's a really enjoyable read.
So I have countless traumatizedpatients.
(26:40):
I have so many female victimsof sexual assault.
It really can be verychallenging some days.
As I dig into this more, I seeso much trauma in my practice.
So here's my approach to trauma, putting this all together.
Number one I have to actuallybe aware that a trauma has
(27:03):
occurred and has made again thatimprint on the patient's brain
and their psyche and their body.
So I am now asking routinelywhat sort of traumatic
experiences have you had?
Some of my patients are veryforthcoming with me.
One of my patients this weekwas very honest in the first
minute of our encounter that shewas sexually assaulted as a
(27:24):
child.
Sometimes I have to pull it outof people.
Step two people need to be in aplace where they are safe to be
able to process the trauma.
So for me, I had to leave theER.
I had to get away of what wascontinuing to traumatize me.
Some of my patients aren'tthere yet.
(27:44):
I'm thinking of one patient whogot assaulted this weekend and
we're just trying to get her toa place where she can be
physically safe.
She has no safety in her life.
She is not yet ready to processher trauma.
So a person has to be away fromthe trauma to be able to
process it.
(28:05):
Next, a person needs to startprocessing that trauma.
We need to help the brain toget the negative energy to be
able to be processed.
So it's not constantly in thatnegative feedback loop and
people can do this on their own.
They can journal, they can doart, they can do music, they can
also work with a therapist.
(28:25):
They can do equine therapy,they can do EMDR, which is eye
movement, desensitization andreprocessing.
That's a particular type oftherapy.
There's lots of different waysto do this but, as I say to my
patients all the time, thenegative energy has to go
somewhere, otherwise it's goingto stay in that vicious,
negative feedback loop oftriggering trauma, processing,
(28:49):
not being able to process,triggering trauma, trying to
process.
It's a vicious cycle.
And then, while people aregoing through this, we start
medication to reduce thesymptoms of PTSD, while the
therapeutic modality is takingtime to work.
So I'm going to share twopatient stories to illustrate
(29:10):
what I've been working on andthis approach to addiction and
hopefully this helps usunderstand the relationship
between trauma and addiction.
So patient number one is a womanin her 30s and she came to me
wanting to get off of alcohol.
She had been about maybe threeweeks sober.
She was trying, she hadrecently slipped up and so I put
(29:34):
her on standard addictionmedications for alcohol.
I put her on some naltrexoneand I added in a little bit of
gabapentin because she wasanxious.
So I kept seeing her.
She was sober for about twomonths she relapsed.
She came back to me about twomonths later, tried again, put
her on standard medicationsfocusing on her alcohol use.
(29:54):
I put her on naltrexone and Iput her on topamax to try to
suppress her cravings.
She did well again for abouttwo months and she relapsed
again and then she came back tome in November and so in my
November visit with her I saidyou know, maybe we're barking up
the wrong tree here.
(30:15):
Have you had any traumaticexperiences in your life?
And she said well, not really.
So I started probing and Istarted asking targeted
questions about common traumasand what came out is that she
was repeatedly verbally andphysically assaulted by her
stepdad, starting at about age12.
And then she was in a horrificcar accident, starting at about
(30:40):
age 12.
And then she was in a horrificcar accident, I think around 19
or 20.
That left her in the hospitalfor several weeks and then she
had several years of court datesand legal proceedings related
to the accident and we wentthrough the DSM criteria for
PTSD and I looked at her and Isaid you may have a problem with
alcohol, but I think PTSD is adeeper issue.
And she found this soempowering and again I
(31:03):
apologized to her that I hadn'taddressed PTSD sooner and so I
stopped the naltrexone, Istopped the topamax.
I put her on sertraline, alsoknown as Zoloft.
I put her on Prazacin she cannever remember the names, she
knows Zoloft, so she callsPrazacin Nightmare.
And I put her on somepropranolol and she calls that
Trigger.
(31:23):
And then she started changingher pivot with her therapist
from alcohol to trauma and she'snow about three months sober
and is really, really empoweredto realize that there's more to
her addiction than she realized.
And I actually just sent her,after I saw her last week, some
podcasts on trauma and she'sreally been very interested in
(31:49):
learning more and understandingherself more.
Here's a second case.
A woman in her late 40s wasreferred to me by another
addiction medicine physician forincurable alcohol use disorder.
He'd been working with her forseveral years and had really
been unable to make any progressaround her alcohol addiction.
(32:09):
She was also usingbenzodiazepines.
So she came to me drinking andusing clonazepam and asked me to
get her off of alcohol and gether off of clonazepam.
First visit.
She cried the whole visit.
She was intoxicated during thevisit and my initial thoughts
were just oh man, oh man, thisis going to be.
(32:31):
This is going to be really hard.
This feels like a big mess.
What am I going going to do?
So I worked with her about six,eight months and we tried
various medications for alcohol.
We tried some naltrexone, wetried some acamprosate, we tried
to pyromate.
We have her on gabapentin.
We tried her on diazepam.
(32:52):
Then she would relapse and thenwe'd have to wean her off of
alcohol with diazepam.
We tried clonazepam.
Again she would relapse, we'dhave to get her off of alcohol
and get her on benzos again.
We just weren't making anyprogress.
So again around the same time inthe fall, I said you know, can
(33:12):
we talk about some traumas?
And she hit puberty early andshe looked like a woman when she
was 10, and her stepdadsexually assaulted her and then
proceeded to repeatedly sexuallyassault her, and unfortunately
she's had a lot of traumaticrelationships.
(33:34):
She cannot count the number oftimes she's been sexually
assaulted.
I don't know that alcohol isher primary problem or that
benzos are her primary problem.
She has been horriblytraumatized too many times to
count and her brain knows thatbenzos and alcohol make the pain
not as bad from her multipletraumas, and so I'm really
(33:56):
trying to help her understandwhat she's been feeling and to
understand the why.
I can get her sober for maybeabout eight weeks at the most
and then something happens Ourrelationship goes bad and she
falls apart and she's beentraumatized so many times to
count.
(34:16):
Her brain is so full of theseemotional scars that she's so
full of triggers and I'm notable to get her to a point where
she's stable to really processthem.
Yet the first patient isactually doing very well.
She's away from her trauma,she's ready to start processing
and she's really enjoying thatwith her therapist.
The second patient is not.
(34:37):
She got sexually assaultedwithin the last few months again
, and what breaks my heart isshe knows that alcohol numbs her
emotional pain.
She's been very honest with methat on several occasions after
being sexually assaulted shewill ask her abuser for a bottle
of alcohol as they leave,because at least she can numb
(34:58):
the pain and try to get somesleep and then figure out what
to do next.
So, as I said, that was apotentially triggering topic and
I apologize, but that is a lotof what I'm trying to work on
right now with my patients,which is to understand that
they've been very traumatizedand a lot of what they're just
(35:20):
trying to do is feel better.
So I realize that drugs andalcohol are a significant part
of what we're working on, but Ialways try to understand the why
, and trauma is such a big partof that.
So I want to stop here and seewhat questions people have and
then discuss as a group Beforewe wrap up.
(35:41):
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenon-profit Central Coast
Overdose Prevention for teamingup with me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
(36:03):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(36:26):
saves lives.
I'll see you next time.
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today we are going to be talkingabout post-traumatic stress
(00:43):
disorder, also known as PTSD.
As a part of my work as amedical director for a drug and
alcohol treatment program, Igive monthly educational
lectures to the staff, and thismonth I lectured on PTSD.
It's a very personal topic forme, as I have been diagnosed
(01:04):
with PTSD from my 14 yearsworking as a doctor in the
emergency department, and nearlyall of my patients have lived
through traumatic experiences,and many of them also have PTSD.
This lecture is a greatoverview of the topic.
Before we start, I gave thislecture while I was in my car
due to my busy schedule, so Iapologize, the audio quality
isn't perfect given therecording conditions.
(01:25):
Okay, let's dig in.
Okay, so today we are going totalk about post-traumatic stress
disorder, and I apologize thatthis may be triggering, and I
will do my best to keep iteducational and also be mindful
(01:47):
about the link between traumaand addiction.
Okay, so I want to share wherethis came from.
So I was at a high schoollecturing parents about drugs
and alcohol as a way to informparents about what their kids
may be facing in school, and oneof the moms came up to me and
(02:08):
said we should chat.
And I said okay, and that's theperson you see at the center of
the screen.
Her name is StephanieWhittleswax.
She is the author of a New YorkTimes bestseller about her
brother's death from heroinoverdose, and she and another
woman formed a podcast calledLast Day, which was initially
(02:28):
about both of their brothersdying of heroin overdose and
they wanted to explore the lastday of their lives to understand
what they could learn aboutaddiction.
And if anyone recognizes theperson on the right of the
screen, that's Dr Gabor Mate,who's one of the world's experts
on the link between addictionand trauma.
And so Stephanie and Iconnected.
(02:49):
She's writing a book aboutaddiction and we met for coffee
and I started learning about thefact that she has this
incredibly successful podcastand she encouraged me to listen
to it, as the entire firstseason was on opioid addiction
and opioid overdose and weconnected.
So I went to her daughter'sschool.
She was a parent.
She actually came andparticipated in the naloxone
training and I'm working onhelping her writing her book.
(03:12):
I was able to participate withhelping her write one of the
chapters Extremely intelligentperson and has a great podcast
and one of the episodes she letDr Gabor Mate interview her
about her life story to betterunderstand why her brother
developed addiction and he wentso deep into trauma and the link
between addiction and traumaand Stephanie, to her credit,
(03:36):
was actually able to share herown life trauma and how she has,
as an adult, has developed anaddiction to work, and it was
absolutely mind-blowing for meas an addiction medicine doctor.
I realized I was really missinga lot of the trauma that was
contributing to addiction.
So I listened to that, maybe inabout October, and I've been on
(03:58):
about a four to five monthjourney of trying to understand
the link between trauma andaddiction.
So I will also share that.
I personally have post-traumaticstress disorder from my 14
years as a doctor in theemergency department and I'll
talk about occupational PTSD asa part of this.
So what is PTSD?
Ptsd is post-traumatic stressdisorder and we are aware of it
(04:21):
going back literally thousandsof years.
There are some descriptions ofsomething that we think to be
PTSD in Assyrian soldiers in1300 BCE.
Now, we didn't reallyunderstand it for many years and
I put some historical names forthis condition Railway spine
stress syndrome, soldier's heart, traumatic war neurosis, shell
(04:44):
shocked there's all these termsthat describe the phenomena, but
we didn't really understand thewhy until modern times.
So what exactly ispost-traumatic stress disorder?
And the best way I can describeit is bad things happen to us
as a part of life and our brainand body does not know what to
(05:05):
do with these bad feelings.
And there's a lot of negativeenergy, which we'll talk about
in the actual trauma itself, anda lot of times that negative
energy doesn't know where to goand the body stores it almost
like a scar, and every time thatmemory gets touched, that scar
hurts, if you will, leading tomental and physical symptoms.
(05:28):
So here's the why and I'm surethere are many different reasons
why people can explain PTSDhappens, but here's how it makes
sense to me.
Our brain as humans is the mostsophisticated brain on the
planet.
However, we share a lot of thesame structures with more
(05:49):
primitive animals.
In other words, the lizardbrain has grown and developed
into the mammalian brain, theprimate brain and eventually the
human brain.
We keep adding on the olderstructure to make it more
complicated.
So if you've ever heard of theterm lizard brain, that refers
to a very primitive brain thatlizards have where they're
(06:10):
basically wired for survival,food and sex.
That's really it.
And when they're threatenedthey go into a fight-or-flight
response.
And if you think about it,lizards have very simple brains.
And if you think about it,lizards have very simple brains.
Lizards don't getpost-traumatic stress disorder.
If they get threatened, they gointo their fight-or-flight
(06:30):
response and then they go abouttheir day as long as they
survive.
Now the human brain is much morecomplicated.
We like to understand things,we like to have reasons, we have
philosophy and theory and ourbrain, as human human tries to
understand the trauma, tries tounderstand why we had the fight
or flight event.
(06:51):
Why me?
Why that day?
Why couldn't it have beensomebody else?
What if it happens again?
What if it happens tomorrow?
All the what ifs come from thehuman brain trying to understand
the trauma.
And here's the issue.
We were never meant tounderstood trauma.
We were simply meant to justsurvive and move on.
(07:13):
So I put here squirrels don'tget PTSD, they just fight or
flight and escape and then moveon.
And so, unfortunately, thehuman brain is trying to
understand something that wasnever meant to be understood in
the first place.
Now there are a couple otherresponses in humans.
We can also fawn, particularlywith women who are victims of
(07:36):
sexual assault.
They have this weird responsewhere they try to really please
their aggressor.
And then in both animals andhumans we can also freeze.
So it's probably best fight,flight, freeze or fawn.
But just for the sake of thiswe're going to say fight or
flight, just because that's whatmost people are familiar with.
Now, the issue with PTSD inhumans is that we end up with
(07:58):
this really complex negativefeedback loop.
So let's say, a person issexually assaulted, they have
their fight or flight response.
That memory is seared intotheir brain.
Once the trauma is over.
They try to process it, theytry to understand it and they
can't.
Why me?
Why that day, what did I do?
And so what happens isbasically the fight or flight
(08:20):
response sends this negativeenergy up to the human part of
the brain.
The human part of the braincan't understand it and process
it.
So that negative energy up tothe human part of the brain.
The human part of the braincan't understand it and process
it, so that negative energy getsunresolved and stored and
eventually, when a new triggercomes up that reminds the person
of the original assault, thatfight-or-flight response
triggers again and they try toprocess it again and it becomes
(08:41):
this negative feedback loop.
Now how do we diagnose PTSD?
The simple answer is, for me isif you have a traumatic history
and you have addiction, chancesare you have PTSD.
Now the official answer is iswe use the Diagnostic and
Statistical Manual 5th Edition,or the DSM-5, and it's the book
(09:04):
in psychiatry that contains allthe criteria for every
psychiatric diagnosis.
And because in psychiatry wecan't run a blood test or a scan
, we're really just trying tosee if the person's symptoms
match the criteria and then wegive them the diagnosis.
So pardon the very small font,but as you can see here there's
(09:26):
a lot of complicated criteriafor PTSD.
The first is they had to havehad an exposure to the trauma.
Then they have to haveintrusive thoughts or memories.
They have to try to avoid thosethoughts and memories.
It has to have a negativeeffect on their mood and how
their brain works.
And then they have to be hyperaroused, like they're constantly
(09:50):
ready to trigger that fight orflight response again.
It has to last for greater thana month, it has to be
significant, in other words it'sactually affecting their life
in a meaningful way, and thenit's not from something else.
So you can look up these DSM-5criteria for PTSD.
I actually read them to mypatients in clinic when I'm
trying to make the diagnosis.
(10:12):
But here's a simplified way tothink about the diagnostic
criteria for PTSD.
Number one a person was exposedto trauma.
Number two they persistentlyexperienced that trauma over and
over again, and common thingsare flashbacks and nightmares.
Number two they persistentlyexperience that trauma over and
over again, and common thingsare flashbacks and nightmares.
Number three people try toavoid anything that reminds them
of the trauma.
Number four their mental healthdeclines.
(10:35):
And then, number five peopleare easily triggered or reactive
, which can include beinghypervigilant, startling easily,
not sleeping well, beingirritable or engaging or risky
and destructive behavior, whichincludes addiction.
So for me, so I havepost-traumatic stress disorder
from my time in the emergencydepartment.
(10:55):
Trauma can happen in manydifferent ways.
A person could be traumatized,and they get PTSD.
A person could have witnessed atrauma firsthand and they get
PTSD.
People can get PTSD throughtheir work like firefighters,
first responders and policeofficers, and as I go through
this, I can see all the thingsthat happen in my body.
So, yes, I have too manyhorrible stories to remember
(11:19):
from the ER.
I get flashbacks multiple timesa day.
I had nightmares for years.
I get flashbacks multiple timesa day.
I had nightmares for years.
I still, to this day, willavoid walking through the ER at
all costs.
My mental health was reallydeclining in the emergency
department and absolutely I washaving difficulty sleeping and I
(11:39):
was hypervigilant in the ER.
It really has a profound effecton people.
Now, in terms of what actuallycauses post-traumatic stress
disorder, what I'm going to tellyou now isn't really
science-based, but it's more howit makes sense in my mind and
how people have explained it tome.
We have big T's and we havelittle t's.
So big T's are a way toreference large, complicated,
(12:06):
singular events a stabbing, ashooting, a near fatal car
accident, sexual assault.
It's like an event that'shorrible and you don't want to
have to go through it again.
It can be many big T's in a row, like I have one patient who
was a soldier in Central Americaand was forced to, you know,
(12:28):
assassinate other soldiers andengage in battle.
He has lots of big T's.
Little T's are smaller, moremicro traumas that add up over
time.
So when a person has a big T,it leaves a big emotional scar
in their brain.
Little T's would be like apersistently verbally abusive
(12:48):
parent Bullying, persistentbullying from a sibling.
It's not one big event, butit's many small events that add
up over time and the smallindividual scars add up to have
the cumulative effect of a bigscar and of course, you can have
both.
Now, as I mentioned, there'smany different ways that a
(13:10):
person can be exposed to traumathat leads to PTSD.
You can experience it directly.
You were robbed at gunpoint.
You can have witnessed itfirsthand, as in you were there
when a car accident happened andyou saw the person die in front
of you.
There can even be some caseswhere the trauma that a loved
(13:32):
one or very, very close friendexperiences affects you as well,
as you help them try to dealthrough the negative emotions of
their trauma.
One of my patients was tellingme that her husband was a
Vietnam veteran and was horriblytraumatized and she talked
about for her.
She experienced PTSD throughher husband, which can
absolutely happen.
(13:53):
And then you can get exposed totrauma through work.
Like me, I still to this dayget flashbacks all the time
about early COVID and several ofmy most horrible cases.
The one that stands out to methe most is a young woman who
hung herself successfully andshe died and we couldn't
resuscitate her.
And that could be through yourwork as a first responder.
(14:15):
I've met hospital socialworkers that have PTSD.
I just want to acknowledge thatit's important that we
acknowledge that you can get itprofessionally Now.
Very closely linked with PTSDare ACEs, adverse Childhood
Experiences, and I want to givea little bit of history on this.
(14:37):
So everyone's heard of Kaiser.
That's a hospital system inmany states.
It's in our region not so much,but it's very strong in the San
Francisco Bay Area and inSouthern California and I used
to work at Kaiser when IFrancisco Bay Area and in
Southern California and I usedto work at Kaiser when I was in
my training in my residency.
And Kaiser is all aboutprevention.
(14:57):
They've realized that if peopledon't get sick, you don't have
to spend the money to take careof them because they're not sick
.
So Kaiser's big into preventionand so Kaiser was doing some
research on why people get illHeart disease, diabetes, high
(15:22):
blood pressure, depression,anxiety, addiction what actually
causes people to get ill asadults and what they found is
that there was a correlationbetween adverse childhood
experiences and adult illnesses.
This is if a child is a victimof physical abuse, physical
neglect, there's a householdmember who has severe mental
health issues, sexual abuseaffecting the child, loss of a
(15:46):
parent due to death, abandonmentor divorce, emotional abuse,
emotional neglect, a householdmember with addiction, a
household member who wasincarcerated or witnessing
domestic violence in the home.
There's actually 10 criteria.
And so, yes, kaiser found thatall of these adverse childhood
experiences were correlated withadult illness, and it's not the
(16:11):
traumatic experiencespecifically, but it's
multifactorial.
In other words, if you have afamily member with mental
illness and addiction, what'syour nutrition like?
Do you have access to exercise?
Do you have stable housing?
Do you get good access toeducation?
Do you have enough to eat?
So, in other words, childrenliving in an unstable
(16:33):
environment or, frankly, atraumatic environment, has a
profound effect on their growthand development in many
different facets, and I'vetalked to my patients.
One of my patients had eight ofthese.
One of my very dear friends whohelps me in many ways.
She's helping me learn abouttrauma through her trauma.
(16:54):
She has nine and one of myother patients has eight.
I personally have one which wasthe death of a parent.
But if you look at these andstart to really screen in
patients with addiction, youwill find that a lot of our
patients with addiction have asignificant number of adverse
childhood experiences.
(17:16):
Now, medicine is not set up tounderstand trauma.
Okay, medicine is all aboutdiagnoses.
We ask the question what'swrong with you?
So you come to the doctor andyour stomach hurts.
We run ultrasounds, cat scans,blood work and we give you a
diagnosis right, it's gastritis,that's too much acid in the
(17:40):
stomach, it's appendicitis,let's say you're tearful and
you're crying.
We give you the diagnosis ofdepression.
And this is actually one of thethings that made me leave the
emergency department is we wouldsee people really struggling
with drugs and alcohol andemotions and we just focused on
the diagnosis and not theperson's story.
(18:04):
So I spoke to over 5,000children in 2024.
I went to, I think, 27different schools and if I ask
those kids, what do you want tobe when you grow up?
Nobody says addicted, in jail,homeless, injecting substances.
They've got better plans andyet we all know people who are
(18:27):
in jail, in and out of prison,injecting drugs, addicted.
Something happened right andthat's this book's suggestion.
It's by Bruce Perry and OprahWinfrey.
Yes, that, oprah, and it's thetitle of the book is what
Happened to you and that's whatI encourage healthcare providers
(18:47):
to do when they're strugglingwith a patient's behavior.
What happened to you?
Because that really asks thequestion what traumatic
experiences did you have in yourlife that led you to, at 35
years old, being incarcerated,using meth and hallucinating in
the emergency department?
That wasn't part of the planwhen you were in third grade
(19:15):
department.
That wasn't part of the planwhen you were in third grade.
So I'm going to make a pointhere to really just drive home
the profound effect of traumaand the relationship with trauma
and addiction, and realize I'mexaggerating.
To make a point, I am veryaware that patients have drug
and alcohol cravings.
But when I talk to my patients,usually what they feel is
(19:36):
something that they don't likeand they want to feel better and
the drug or the alcohol makesthat bad feeling temporarily go
away.
We all know it doesn't fix itand I think deep down our
patients don't, but they justdon't know what else to do.
So my patients don't cravedrugs and alcohol, they crave
(19:58):
feeling better, particularlywhen they're traumatized and
can't sleep because they getflashbacks and nightmares all
night.
Why do they drink?
To black out?
Because they can't deal withthe trauma.
I'll give you an example.
One of my patients is a greatyoung guy and I was chatting
with him about two weeks ago andhe was telling me he's got
(20:21):
about a year sober from alcoholand we were talking about when
he did drink and he said that hewas the type of drinker that
would just black out.
And I never really asked himabout his alcohol use, because
he came to me about two or threemonths sober and I said why
were you trying to black out?
And he said I don't really know.
(20:42):
And so the little light bulbwent off in my head I wonder if
there's some trauma.
And so I asked him did you haveany traumas as a kid?
And he said yeah, yeah.
And so we started talking aboutit and he got sexually
assaulted in middle school by abunch of older boys in his
neighborhood.
One day after school hecouldn't actually finish the
(21:03):
story.
So I went through the PTSDcriteria and he met all of them
and I apologized to him.
Him I said I'm so sorry Ididn't ask about trauma sooner,
because we need to address yourtrauma to really help you heal
from your alcohol addiction.
So what do we do once wediagnose someone with PTSD?
(21:27):
Well, we need to give themtrauma-focused psychotherapy so
they can work on actuallyprocessing the trauma, and I'll
talk about that in some detail.
We can often use medications tohelp a person feel better while
the psychotherapy starts to work, and actually my recommendation
is that we use both together.
(21:48):
In terms of medications, thefirst-line treatment for PTSD
are the selective serotoninreuptake inhibitors, and here
are some common names Fluoxetineor Prozac, sertraline or Zoloft
, citalopram or Celexa andS-Citalopram or Lexapro or
(22:10):
Celexa and escitalopram orLexapro.
These are my go-to, my personalfavorites.
There's a little data thatwould suggest that maybe Zoloft
is a little better in PTSD and,anecdotally, lexapro seems to
help better for anxiety.
Those are usually my go-to fortrauma.
You can also use their cousins,serotonin and norepinephrine
(22:31):
reuptake inhibitors.
There's not as much data onthem, but they can still be used
, and an example of that wouldbe venlafaxine, also known as
Effexor.
Now, if you didn't know, thereis a very effective medication
for nightmares and I started oneof my patients on it today and
that's Prazacin, which its brandname is Minipress, and Prazacin
(22:55):
is interesting.
So we all are probably prettyfamiliar with Klonidine, and
Klonidine is a medication thatsuppresses the release of stress
hormones from the brain.
That's actually why it's usedto treat either alcohol
withdrawal or opioid withdrawal,because that's a high stress
hormone state.
Right, we're in a fight orflight response.
(23:16):
We're hyper-stimulated as we'recoming off of opiates or
alcohol.
So clonidine works by reducingthe release of stress hormones
from the brain and prazosin isits cousin, like Lexus and
Toyota.
Prazosin is its cousin, likeLexus and Toyota, and prazosin
(23:36):
works by also decreasing therelease of stress hormones from
the brain.
It's a little bit sedating andit suppresses nightmares, so it
helps with sleep and then ithelps reduce some of the
traumatic nightmares that comeout.
I use it all the time in mypractice, particularly when
people are new in recovery andthey're really struggling with
sleep.
Now there are two othermedications that we can also use
(23:59):
with PTSD and for me personally, I feel my PTSD in my solar
plexus.
I get a lot of tightness rightthere and then I get a lot of
tingling in my extrem, then Iget a lot of tingling in my
extremities and when I gettingling in my extremities I can
feel my ptsd being triggered,as I can when I get that
tightness in my solar plexus.
So there are two othermedicines that can be used To to
(24:23):
blunt those physical reactivefeelings, that hyper vigilance,
that over stimulation that comeswith ptsd.
One of them is clonidine, likewe just talked about.
It reduces the amount of stresshormones coming out of the
brain and so it actually bluntsthose physical symptoms.
The other is propranolol, whichis a blood pressure medicine
(24:46):
which also suppresses thosestress hormones as well.
They can be very effective.
Which also suppresses thosestress hormones as well.
They can be very effective.
The only major issue is thatthey can drop the blood pressure
.
So I actually have one patientright now and I'll share her
story in just a second who hasPTSD and she is on sertraline or
Zoloft, prazosin andpropranolol.
Now you might be interested inlearning more about trauma.
(25:09):
There are some fairly famousbooks on the topic.
This is one called the BodyKeeps the Score and it's by a
psychiatrist named Bessel vander Kolk, and if you ask around
the trauma community, there's alot of awareness of this book
and it's a really wonderfuljourney that a psychiatrist
details of how he went fromworking with World War II
(25:31):
veterans to trauma in the modernera and how people's awareness
and acceptance of the diagnosisof PTSD has changed.
And basically this is hishypothesis when you are
traumatized, the body keepstrack.
In other words to point out thetitle the body keeps the score.
This is another one calledWaking the Tiger by Peter Levine
(25:56):
.
Peter Levine is apsychotherapist who has created
a style of trauma therapy calledsomatic therapy and what he
does is he really focuses on thetrauma and goes back to the
traumatic time and tries to helppeople in the moment experience
(26:16):
the trauma and focus on whatthey're feeling in their body to
process the trauma.
And he has some reallyinteresting chapters in that
book that describe how theanimal brain processes trauma
versus the human brain.
It's a really enjoyable read.
So I have countless traumatizedpatients.
(26:40):
I have so many female victimsof sexual assault.
It really can be verychallenging some days.
As I dig into this more, I seeso much trauma in my practice.
So here's my approach to trauma, putting this all together.
Number one I have to actuallybe aware that a trauma has
(27:03):
occurred and has made again thatimprint on the patient's brain
and their psyche and their body.
So I am now asking routinelywhat sort of traumatic
experiences have you had?
Some of my patients are veryforthcoming with me.
One of my patients this weekwas very honest in the first
minute of our encounter that shewas sexually assaulted as a
(27:24):
child.
Sometimes I have to pull it outof people.
Step two people need to be in aplace where they are safe to be
able to process the trauma.
So for me, I had to leave theER.
I had to get away of what wascontinuing to traumatize me.
Some of my patients aren'tthere yet.
(27:44):
I'm thinking of one patient whogot assaulted this weekend and
we're just trying to get her toa place where she can be
physically safe.
She has no safety in her life.
She is not yet ready to processher trauma.
So a person has to be away fromthe trauma to be able to
process it.
(28:05):
Next, a person needs to startprocessing that trauma.
We need to help the brain toget the negative energy to be
able to be processed.
So it's not constantly in thatnegative feedback loop and
people can do this on their own.
They can journal, they can doart, they can do music, they can
also work with a therapist.
(28:25):
They can do equine therapy,they can do EMDR, which is eye
movement, desensitization andreprocessing.
That's a particular type oftherapy.
There's lots of different waysto do this but, as I say to my
patients all the time, thenegative energy has to go
somewhere, otherwise it's goingto stay in that vicious,
negative feedback loop oftriggering trauma, processing,
(28:49):
not being able to process,triggering trauma, trying to
process.
It's a vicious cycle.
And then, while people aregoing through this, we start
medication to reduce thesymptoms of PTSD, while the
therapeutic modality is takingtime to work.
So I'm going to share twopatient stories to illustrate
(29:10):
what I've been working on andthis approach to addiction and
hopefully this helps usunderstand the relationship
between trauma and addiction.
So patient number one is a womanin her 30s and she came to me
wanting to get off of alcohol.
She had been about maybe threeweeks sober.
She was trying, she hadrecently slipped up and so I put
(29:34):
her on standard addictionmedications for alcohol.
I put her on some naltrexoneand I added in a little bit of
gabapentin because she wasanxious.
So I kept seeing her.
She was sober for about twomonths she relapsed.
She came back to me about twomonths later, tried again, put
her on standard medicationsfocusing on her alcohol use.
(29:54):
I put her on naltrexone and Iput her on topamax to try to
suppress her cravings.
She did well again for abouttwo months and she relapsed
again and then she came back tome in November and so in my
November visit with her I saidyou know, maybe we're barking up
the wrong tree here.
(30:15):
Have you had any traumaticexperiences in your life?
And she said well, not really.
So I started probing and Istarted asking targeted
questions about common traumasand what came out is that she
was repeatedly verbally andphysically assaulted by her
stepdad, starting at about age12.
And then she was in a horrificcar accident, starting at about
(30:40):
age 12.
And then she was in a horrificcar accident, I think around 19
or 20.
That left her in the hospitalfor several weeks and then she
had several years of court datesand legal proceedings related
to the accident and we wentthrough the DSM criteria for
PTSD and I looked at her and Isaid you may have a problem with
alcohol, but I think PTSD is adeeper issue.
And she found this soempowering and again I
(31:03):
apologized to her that I hadn'taddressed PTSD sooner and so I
stopped the naltrexone, Istopped the topamax.
I put her on sertraline, alsoknown as Zoloft.
I put her on Prazacin she cannever remember the names, she
knows Zoloft, so she callsPrazacin Nightmare.
And I put her on somepropranolol and she calls that
Trigger.
(31:23):
And then she started changingher pivot with her therapist
from alcohol to trauma and she'snow about three months sober
and is really, really empoweredto realize that there's more to
her addiction than she realized.
And I actually just sent her,after I saw her last week, some
podcasts on trauma and she'sreally been very interested in
(31:49):
learning more and understandingherself more.
Here's a second case.
A woman in her late 40s wasreferred to me by another
addiction medicine physician forincurable alcohol use disorder.
He'd been working with her forseveral years and had really
been unable to make any progressaround her alcohol addiction.
(32:09):
She was also usingbenzodiazepines.
So she came to me drinking andusing clonazepam and asked me to
get her off of alcohol and gether off of clonazepam.
First visit.
She cried the whole visit.
She was intoxicated during thevisit and my initial thoughts
were just oh man, oh man, thisis going to be.
(32:31):
This is going to be really hard.
This feels like a big mess.
What am I going going to do?
So I worked with her about six,eight months and we tried
various medications for alcohol.
We tried some naltrexone, wetried some acamprosate, we tried
to pyromate.
We have her on gabapentin.
We tried her on diazepam.
(32:52):
Then she would relapse and thenwe'd have to wean her off of
alcohol with diazepam.
We tried clonazepam.
Again she would relapse, we'dhave to get her off of alcohol
and get her on benzos again.
We just weren't making anyprogress.
So again around the same time inthe fall, I said you know, can
(33:12):
we talk about some traumas?
And she hit puberty early andshe looked like a woman when she
was 10, and her stepdadsexually assaulted her and then
proceeded to repeatedly sexuallyassault her, and unfortunately
she's had a lot of traumaticrelationships.
(33:34):
She cannot count the number oftimes she's been sexually
assaulted.
I don't know that alcohol isher primary problem or that
benzos are her primary problem.
She has been horriblytraumatized too many times to
count and her brain knows thatbenzos and alcohol make the pain
not as bad from her multipletraumas, and so I'm really
(33:56):
trying to help her understandwhat she's been feeling and to
understand the why.
I can get her sober for maybeabout eight weeks at the most
and then something happens Ourrelationship goes bad and she
falls apart and she's beentraumatized so many times to
count.
(34:16):
Her brain is so full of theseemotional scars that she's so
full of triggers and I'm notable to get her to a point where
she's stable to really processthem.
Yet the first patient isactually doing very well.
She's away from her trauma,she's ready to start processing
and she's really enjoying thatwith her therapist.
The second patient is not.
(34:37):
She got sexually assaultedwithin the last few months again
, and what breaks my heart isshe knows that alcohol numbs her
emotional pain.
She's been very honest with methat on several occasions after
being sexually assaulted shewill ask her abuser for a bottle
of alcohol as they leave,because at least she can numb
(34:58):
the pain and try to get somesleep and then figure out what
to do next.
So, as I said, that was apotentially triggering topic and
I apologize, but that is a lotof what I'm trying to work on
right now with my patients,which is to understand that
they've been very traumatizedand a lot of what they're just
(35:20):
trying to do is feel better.
So I realize that drugs andalcohol are a significant part
of what we're working on, but Ialways try to understand the why
, and trauma is such a big partof that.
So I want to stop here and seewhat questions people have and
then discuss as a group Beforewe wrap up.
(35:41):
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenon-profit Central Coast
Overdose Prevention for teamingup with me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
(36:03):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(36:26):
saves lives.
I'll see you next time.
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