“We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma,Grief,and Learned Coping Mechanisms Among People Who Inject Drugs

Abstract

Background and objectives:

Early traumatic exposure to factors such as household substance use, violence, and familial death increase the likelihood of substance use across a person’s lifespan. Our qualitative analysis sought to explore the social and relational drivers of substance use among people who inject drugs (PWID).

Design and methods:

We conducted qualitative interviews with 30 PWID (n = 30) in Los Angeles, CA from July 2021 to April 2022. To be eligible for this study, participants had to report being 18 years of age or older and self-report any opioid and injection drug use within the past 30 days. We used constructivist grounded theory to analyze the contexts that contribute to lived experiences surrounding familial trauma, resource scarcity, and substance use as a coping mechanism.

Results:

Participants in this study described drivers of current substance use patterns as related to childhood and familial trauma. These included: (1) early exposure to chaotic and/or disordered substance use by household members, (2) traumatic experiences, such as death of a family member, which they linked to substance use initiation, and (3) relying on substance use as a coping strategy which was modeled by family members.

Conclusions:

Early traumatic experiences and exposure to disordered substance use (ie, household family members using substances to emotionally regulate) combined with experiencing resource deprivation (ie, lacking trauma-informed mental health support and financial and wraparound care) contributed to participants’ experiences of substance use as a learned coping mechanism. Integrating social and structural support interventions, such as mental health service provision and financial stabilization services, into policy-making decisions may help to address the cyclical relationship between childhood exposure to trauma and adult substance use initiation.

Keywords

relationships harm reduction childhood trauma traumatic experiences substance use opioids resource deprivation

Introduction

Nearly 64% of adults in the United States report experiencing at least one early traumatic event, with the most common events reported including emotional abuse, parental separation, and household substance abuse.¹ Traumatic experiences in early life include experiences such as physical and emotional abuse and neglect, sexual abuse, having an incarcerated family member, witnessing physical violence, and household exposure to substance use.^1,2 Witnessing and living with household and/or family members who have substance use disorders accounts for more than 25% of reported traumatic events.^3-6 Racialized, gendered, and income-based factors increase the likelihood of experiencing traumatic events.⁷ For example, adults with a household income of less than $15 000 are more likely to experience greater numbers of traumatic experiences.³ Women report more traumas compared to men and are significantly more likely to report experiencing 4 or more traumatic events.⁸

Childhood trauma is associated with both mental and chronic physical health outcomes such as depression, anxiety, post-traumatic stress, suicidal ideation, and chronic conditions such as cancer, heart disease, obesity, and chronic obstructive pulmonary disease.^9-11 Experiencing childhood trauma is also associated with violent injury (either externally or self-inflicted), lower school attendance or graduation rates, housing insecurity or instability, and substance use disorders.^3,5,12,13 Extant data suggests a compounded effect of traumatic experiences. Those who report experiencing more than one trauma in early life are more likely to also report serious physical or mental health issues requiring medical intervention which may increase the likelihood of later substance use.⁸ Randhawa et al have identified that childhood trauma is associated with difficulty accessing healthcare among people who inject drugs (PWID).¹⁴ This experience may contribute to having unmet mental health needs which prior research has found to drive substance use as a self-supplied remedy.¹⁵

Early traumatic experiences are also associated with later illicit substance use. Adverse childhood experiences are associated with increased overall lifetime substance use along with increased rates of early initiated substance use.¹⁶ In turn, predictors of injection drug use include early age of substance use initiation.¹⁷ Injection drug use comprises opioids as well as substances such as cocaine and methamphetamine.¹⁸ In 2018, U.S. rates of injection drug use were estimated to have increased from 1 million in 2011 to approximately 4 million.^18,19 Injected drug use can be considered a separate category of drug use that involves riskier behaviors compared to non-injected drug use and is a predictor of specific negative health and social outcomes. Those reporting injection drug use are more likely to report poorer housing stability.²⁰ Non-fatal injection drug-related overdoses are estimated to affect between 40% and 68% of PWID.²¹ Prior research estimates that between 2000 and 2018, fatal injection drug overdoses have increased 8-fold.²² Negative health outcomes from injection drug use include overdose, abscess development, and infectious diseases such as HIV, infective endocarditis, and hepatitis B and C.^18,23

Less is known about the socio-structural influences on patterns of substance use among adults with traumatizing childhood experiences, particularly among community samples of PWID^3,9 experiencing resource deprivation. Resource deprivation is the experience of lacking necessary materials and services for living. These may include social and financial services, healthcare, or affordable and safe housing. People who are resource deprived may have limited access to food, water, sanitation and hygiene services, mental health services, employment, education, and other basic needs.^24,25 Exposure to resource deprivation is associated with adverse mental health outcomes such as psychosis. Mental healthcare services are also less likely to be available and utilized within areas with high resource deprivation.²⁴ As such, communities experiencing resource deprivation, including those comprised of PWID, may have less professional support to equip them to cope with adverse childhood experiences. In this study, we analyzed how resource deprivation and socioeconomic marginalization shaped maladaptive coping processes (ie, substance use behaviors as exhibited within family dynamics) from early traumatizing experiences to current patterns of opioid and cannabis use among people who inject drugs in Los Angeles, California.

Methods

This qualitative, analytic sample was part of a longitudinal, prospective cohort study aimed at determining if changes in cannabis use frequency are associated with changes in frequency of opioid use and related health outcomes among opioid-using people who inject drugs (PWID) in 2 states with legal medicinal and adult cannabis. This study utilized constructivist grounded theory (CGT) methods^17,18 for data collection and analysis. The study methods are described in-depth elsewhere.²⁶ In short, CGT is a qualitative analysis method where iterative qualitative data collection generates themes and categories co-constructed from empirical data to generate theories which reflect participants’ lived experience.^26,27 We applied this method to study the dynamic relationship between traumatizing experiences and disordered substance use.^27,28

We conducted qualitative interviews with 30 PWID (n = 30). To be eligible for this study, participants had to report: (1) being 18 years of age or older and (2) any opioid use, cannabis use, and injection drug use (confirmed via self-report and visual inspection of injection sites) within the past 30 days.¹⁶ Interviews were conducted at 2 sites frequented by opioid-using PWID. The first was affiliated with a syringe services program, and the second was near a methadone clinic, both located in Los Angeles, California. These locations were selected due to long-standing relationships between the community sites and the study PI. Data collection at the 2 sites took place between July 2021 and April 2022. Interviews took approximately 60 minutes and were conducted by 1 member of the research team (RCC). This is a qualitative study, therefore items used for data collection are semi-structured interview guides. We developed the semi-structured interview guide (Supplemental Appendix 1: Interview Guide) by referencing prior qualitative and quantitative research as well as the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework.^26,29 Charmaz²⁷ describes the process of data collection according to CGT methods as developing an interview guide that explores concepts relevant to the research questions, analyzing emerging data and how it fits with initial ideas, and developing the interview guide questions by iteratively revising to capture unanticipated emergent themes. A key component of the semi-structured approach is that it facilitates 2 major contributions to the corpus of scientific literature by allowing (1) expansion into previously unexplored/underexplored directions and (2) for participants, particularly those who are underrepresented in the extant data (ie, community-recruited PWID), to co-construct findings with researchers.^26-28

Following data collection, we developed the codebook for analysis (Supplemental Appendix 2: Codebook) and analyzed the data using ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH). We conceptually grouped the codes and applied them to the text via ATLAS.ti. We then compared code applications across the data to develop a conceptual theory to explain participants’ experiences of childhood exposure to disordered substance use in the household. For this analysis, we evaluated the application of codes (ie, Changing use due to life event) and development of memos (ie, Accessibility of alternative resources, structurally enforced coping mechanisms) to develop 3 results.

Results

The analysis of the in-depth interviews yielded 3 major findings as they pertain to present-day substance use patterns among our sample of PWID, all who shared experiences of childhood exposure to substance use and trauma, and a lack of access to resources for coping and support.

Participant demographics are described in Table 1. Authors anonymized study participants via pseudonyms.

Table 1.

Participant Demographics.

Participant characteristics	Mean (SD)/Frequency (%)
Age	41.5 (11.2)
Race/Ethnicity
Non-Hispanic White	13 (43.3%)
Hispanic/Latinx	9 (30.0%)
Non-Hispanic Black	2 (6.7%)
Native American	2 (6.7%)
Asian	1 (3.3%)
Other	3 (10.0%)
Gender
Male	21 (70%)
Female	8 (26.7%)
Other	1 (3.3%)
Education
Did not complete high school	6 (20.0%)
Completed high school or more	24 (80.0%)
Income level (past 30 days)
$2100 or less	21 (70.0%)
$2101 or more	9 (30.0%)
Housing stability (unstably housed)
Yes	17 (56.7%)
No	13 (43.3%)

Result 1: Early Exposure to Disordered Substance Use by Significant Individuals

Participants were asked to discuss their first exposure to opioids or other substances. Several participants described early exposure to chaotic and/or disordered use of substances by significant individuals in their lives.

For example, Dana recounted her father and his friends using substances in her childhood home as chaotic and disruptive:

[My father’s] friends would come over and they’d leave [pills] laying around . . . That’s what they used to get high on back in the day and they dropped them on the floor and I guess they look like little M & Ms [candies] so of course kids are going to pick it up and put it in [their] mouth. And then my brother took it and put it in his mouth and we had go to the doctor. [My mom] told me the reason why she left my father was because he couldn’t keep his friends away and they kept dropping drugs and OD’ing in the closet. She’d come home and someone new would be in the closet. She’d have to call [emergency services] and she just didn’t want us kids around that and so she left him. (Dana – 67, Female, Housed)

In this example, Dana described her father using substances in such a way that the children would accidentally encounter pills and overdose events in their home. This was a point of contention in their family, with her mother trying to shield Dana and her brother from it with varying degrees of success. Despite this, she witnessed numerous destabilizing events in her childhood home (exposure to substance use, overdose, and substance ingestion by another child in the house) which posed significant health and safety risks to herself and her sibling. The ensuing familial separation also invited further instability.

Adeline was exposed to heroin early on by her family members. She described starting out with transporting heroin from a young age for her family to sell to later using it herself:

I was born into a life of heroin . . . I started [using heroin] when I was 14 . . . I was 12 and I . . . was transporting heroin . . . [I was asking] my brother all the time . . . “what does it feel like? I want to try that.” He tells me, “No, I’m never going to give you some, don’t ever ask me again because I’ll get mad and I’ll slap you . . .” . . . I would then transport [it] to his clients. I would take what they wanted and get the money and run it back to him so I never [was] able to be a little girl . . . I grew up fast . . . I had a large responsibility on me at 12 years old. That was a lot. (Adeline – 31, Female, Unhoused/unstably housed)

Adeline made a direct connection between her childhood exposure to heroin and her later use of it. She described being “born into” it, that it was all around her growing up. Despite her family’s unwillingness to let her use heroin, she felt not only curious about it but also a sense of maturation associated with her transportation duties which warranted being able to try it.

Result 2: Linking Substance Use Initiation to Traumatic Experiences

Participants described traumatic experiences such as loss, grief, and familial death, which they linked to initial substance use patterns. While early exposure to chaotic use introduced participants to the possibility of substance use, many pinpointed a singular traumatic event that prompted the start of their use of substances.

Dana explained how she first started using heroin upon the death of her mother:

I really miss [my mom] a lot and that’s the reason . . . why I do drugs, I’m sad . . . I didn’t like my mom when I was younger because it was her fault that I was molested by a guy she brought home . . . and I blamed it all on her . . . everything I did [that was] bad I blamed it on her because she was a drunk. She was never there for us kids. She worked five days a week so we all had to raise ourselves . . . cook for ourselves . . . I got really mad at her for years and then I sat and talked to her for a long time and I forgave her for everything and it wasn’t her fault. I’m sure she didn’t bring him home to do that. I’m sure that she didn’t plan on that. She didn’t like the beatings she got from him . . . I was able to get over that and we became best friends . . . when I was 16 and then she died when I was 26 . . .. that’s when I started doing heroin. (Dana – 67, Female, Housed)

Dana described growing up with a mom who engaged in substance use. Additionally, Dana experienced abuse, including sexual abuse by her mother’s boyfriend that she initially blamed her mother for. She felt she had to act as her own parent as each of hers were unavailable due to their substance use. Despite this, she felt her mother was one constant presence in her life after they moved away from her biological father. Following her and her mother’s reconciliation and her mother’s subsequent death, Dana shared that she had multiple things to grieve on her own. For her, using heroin was a natural response to this trauma.

Camila started using substances after running away from home to escape her home life. When she left home to stay with her cousins, they introduced her to cannabis and alcohol, which she started using heavily:

I ran away . . . when I was 13 I went to [my cousins’ house] and I told my mom . . . if she made me go back [to her home] there I was going to make the cops shoot me . . . so she didn’t . . . make me come back . . . and I started drinking, [and using] weed . . . That was when I was 13, 14 years old . . . I drank heavy when I was there with my cousins. They were all alcoholics real young . . . I also think they [had] hard liquor not beer. I was so young when I was there. I was so stupid . . . [I ran away because] I know I’m not like everyone. (Camila – 62, Female, Housed)

Camila described the extreme pain of feeling like an outsider in her family of origin. She felt that the only way to escape this was to run away, an event which was accompanied by grief and the loss of most of her social connections. While she didn’t use substances when she lived with her parents, she initiated use after running away.

Noah shared how familial death prompted his first use of substances:

[The first time I used cannabis] I just found out my grandma died . . ., I used to be way against it . . . ’cause I had an older brother with [a] drug abuse history . . . But then, I figured my grandma died., “F it, why am I not doing it,” . . . [After] I lost both my parents, I . . . fell deeper into marijuana . . .. me and my girl at the time had a heroin addiction too. (Noah – 32, Male, Unhoused/unstably housed)

For Noah, despite his reservations about drug abuse, he felt that the grief attributed to losing a grandparent overrode these concerns and influenced his decision to use cannabis for the first time. Noah felt this was a familiar strategy when additional familial deaths occurred and prompted his increased use of substances. The pain of the loss of these family members was significant for him, outweighing his reservations about substance use.

Result 3: Relying on Substance Use as a Learned Coping Strategy

Participants described relying on substance use as a coping strategy they learned from significant individuals in their lives to manage grief. They felt that since they lacked coping skills, this was an inevitable occurrence, especially as they did not feel that they had any accessible alternatives or models of coping they could adapt to their lives.

Noah described how he had to manage his mental health on his own in whatever ways were accessible, resulting in substance use as a coping skill:

We weren’t taught how to cope with tragedy. It’s so dumb because all of us people go through tragedy at some point in our lives and we suffer and that’s like the one thing that you can treat as taboo or don’t teach kids growing up just how to cope with that . . . that’s something that can take . . . a kid that’s on a right path to being on the other side of the coin . . . I didn’t know what to do when my parents died. . .I just wish I knew how to cope with it . . . [Heroin] isn’t something that I chose . . . I did, but it’s the only thing . . . offered [to] me to cope with it. I didn’t have people standing around me saying, “Here, now go to counseling,” . . . [just] “Here’s some heroin. It takes it away.” (Noah – 32, Male, Unhoused/unstably housed)

After experiencing loss and additional traumatic events in childhood, Noah felt he needed support to reduce his suffering attributed to grief. Because mental health treatment was not widely discussed or normalized in his family, he felt it was not an avenue that he could pursue. Further, while he was unaware of less harmful ways to cope with trauma beyond substance use, he also noted the absence of social support prompting him to get help, such as counseling to deal with his grief.

Adeline similarly emphasized that she was not taught how to talk about or cope with pain, resulting in her decision to use substances:

People [use substances] because they want to feel better and they want to get through the day and [there’s] bad stigma on people who do have addiction and problems [but] we all have trauma or things that we haven’t really got [a way] to really cope with or fix or got to really talk about . . . that’s why we do it is to . . . keep . . . our mind on something else. (Adeline – 31, Female, Unhoused/unstably housed)

Adeline felt that the stigma and lack of alternatives available to her to deal with trauma meant that substance use was her only coping mechanism when she first needed one. While she felt substance use allowed her to function throughout her daily routine and not dwell on traumatic experiences, she described it as a distraction rather than an actual remedy.

Dana felt it was inevitable that she would engage in substance use as a coping strategy due to her early familial exposure:

I think because I started at such a young age I was able to do it and if your parents tell you to go do ahead and they’re do[ing] it [too], I mean, of course you’re going to, you want to be, you know, grown up and be a part of the family and everything. But I just wish that my family would’ve been a little bit more into, you know raising kids right instead of raising them as drunks or something. My whole family is dysfunctional. I mean we all are but it’s not a bad thing. We’re not bad people or anything, it’s just that, I was born into [using substances]. I didn’t find out [how to use substances] through somebody else. My family pretty much taught [me] how to be bad. (Dana – 67, Female, Housed)

For Dana, having been exposed so early on by her family and others in her household, she described substance use as a natural solution to rely on when she experienced difficulties. She felt this was an unavoidable occurrence because she had observed others engaging in this behavior and learned that this was an option to use as a means of coping with life’s demands and traumas.

Discussion

We explored how a history of familial trauma and ongoing resource deprivation shape current substance use patterns among people who inject drugs (PWID) in Los Angeles, California. Participants in this sample reported: (1) observing and experiencing the collateral effects of chaotic and/or disordered relationships with substances by significant individuals in their lives, (2) traumatizing experiences, such as familial death and estrangement, that prompted their own initiation of substance use, and (3) relying on substance use to manage feelings of grief and pain after substance use was normalized by significant individuals in their lives. The core insights generated from this data hold value for public health stakeholders and mental health providers, especially those focused on providing trauma-informed³⁰ therapy and substance use treatment, and who are aimed at addressing cyclical³¹ and intergenerational³² relationships between childhood trauma and substance use. This data contributes valuable insights on the lived experiences of a structurally vulnerable community sample of people who use opioids and inject drugs in Los Angeles, California, and their motivations for using substances. Further, participants presented in this analysis are almost entirely female PWID, which is a group underrepresented in current research.

Participants described how disordered substance use, overdose, and drug sales within the household were present from a young age. They personally interacted with substances via involvement in drug transportation, encountering errant substances within their homes, or witnessing other siblings’ accidental ingestion of substances. This exposure to chaotic substance use was disruptive to their sense of safety in the home. Participants expected familial spaces to provide them with a stable base to draw security from, but instead they recalled fearing for their own well-being as well as that of their family members, both those using substances (ie, potentially overdosing) and those who were not (ie, accidental ingestion of substances). Prior research has also found that witnessing events such as familial medication (ie, opioids) overdose co-occurred with additional childhood trauma,^33,34 which increases the likelihood of substance use,³⁵ overdose events,^35,36 initiating opioid use at earlier ages,³⁶ and injection drug use.³⁶ Our study expands on this work by exploring the underlying causes of this pathway from exposure to initiation. Exposure to overdose events often correlated with other stressors necessitating support (such as financial hardship),³³ indicating the need for multilevel interventions to address each negative event.

Participants identified loss and grief as major drivers for initiating substance use. The dysregulation prompted by traumatic events necessitated intervention for emotional well-being, which, in this case, amounted to substance use. The pain of these traumatic events overshadowed any hesitations they had about using substances and outcompeted previous coping skills they may have deployed to deal with the trauma. They lost sources of social and emotional support, in some cases losing the only stabilizing force they knew (ie, their only parent). Coming from a background of great instability, participants described the need to engage in alternative coping mechanisms to handle additional stressors. Prior research supports emotional regulation as a motivator for substance use.³⁴ Early exposure to death is a traumatic event and increases likelihood of developing substance use disorders.^9,37-41 Moreover, experiencing greater numbers of traumatic events is associated with increased severity of opioid use disorders as evidenced by summed scores of lifetime heroin use, opioid withdrawal symptoms, medication for opioid use disorder (MOUD) use, financial burden of use, and overdose events.¹ Existing evidence shows that among those involved in inpatient treatment for substance use who had lost a family member, high levels of mental health and behavioral problems were comorbid with substance use disorder.⁴²

Participants described implicitly learning from familial relationships to self-regulate their emotions of grief and pain with substances. They described substance use as an inevitable, learned coping mechanism – a tool to mitigate negative, unwanted emotional states.³⁴ After witnessing family members use substances to cope, they came to see this as an option for themselves as well. Participants also identified early traumatizing experiences coupled with resource deprivation (ie, a lack of social and structural economic support and mental health services), leading to current substance use patterns. Resource deprivation is linked to substance use as a primary means of coping.⁴³ Without adequate resources to cope with trauma, substance use may be an accessible and/or familiar option to people growing up around substance use and trauma.^44-46 Substance use initiation may be attributed to the cumulative burden of these traumatic events and the familial-learned behavior of substance use.³³ Prior research has found that drivers of substance use also include social isolation (brought on by familial death and estrangement) and unmet mental health treatment needs,^1,15,34,47 experiences which were reported by our study participants. Prior data and ours together suggest that without adequate intervention such as mental health services, familial modeling of substance use as a coping mechanism perpetuates an intergenerational cycle of substance use.³⁵

This data supports the theorized and empirically observed pathway between early exposure to disordered substance use in the household and the development of substance use as a learned behavior.²³ We observed that the exposure to disordered substance use during childhood may result in substance use initiation during adolescence or as emerging adults. Our data highlights a vulnerable period which necessitates early intervention to reduce exposure to chaotic substance use and prevent downstream effects on substance use initiation.

Research, Practice, and Policy Implications

According to our findings, potential drivers of opioid and injection drug use for PWID include experiencing early traumatic events alongside material deprivation and lacking resources, such as trauma-informed mental health support and financial assistance. Preventing occurrence of traumatic events in early life may reduce the likelihood of subsequent substance use. Factors that have been shown to drive disparities in traumatic exposure^9,10 and substance use as a coping strategy⁴⁸ include resource deprivation, racialization, and minoritization,⁴⁸ factors which disproportionately affect the participants of this sample. These risks are compounded for individuals who sit at the intersection of multiple marginalized identities.⁴⁹ Racialized, gendered, age, and class and income-based disparities in traumatic event burden may be mitigated by policies focused on economic and resource equity.^1,9 This analysis largely captured the experiences of trauma and coping among female PWID, a historically understudied group. Addressing the unique motivations and needs of this demographic is paramount to ensure appropriate prevention strategies.

Inversely, traumatic event risk may be socially reinforced in areas where there are less opportunities for socioeconomic mobility.⁴⁸ Basic income programs may mitigate socioeconomic risk factors by allotting households a fixed amount of money per month to help pay for living expenses. Results from the Los Angeles County basic income pilot program for households living under the poverty line and with a dependent child during 2022⁵⁰ indicated that financial security for food and housing spending increased while children were better able to pursue non-academic recreational activities. Strengthening federal, state and/or local financial support programs for low-income households is one measure to address resource deprivation. As such, public health stakeholders must integrate financial services into policy-making decisions to address the cyclical relationship between childhood exposure to trauma and substance use.

Once traumatic events have occurred in a household, ensuring adequate support and treatment are paramount to minimize the risk of substance use initiation. Substance use may act as a maladaptive coping strategy in that it distances but does not address painful emotions and can come with poor health outcomes. Thus, spaces which can equip individuals with adaptive coping mechanisms are needed. Prior research has found that trauma-informed mental healthcare reduces grief and mental distress symptoms in vulnerable populations.⁵¹ For instance, the utilization of school-based mental health services for elementary school children is associated with improved mental health outcomes, especially if such services are offered more than once a week.⁵² Institutions such as mental health agencies and child social and health services must be better equipped to support vulnerable populations via training on the complexities of grief, loss, and other traumatic experiences like intergenerational trauma^42,53 as intergenerational trauma may take the form of substance use.

Health Equity Implications

It is difficult to change substance use patterns without attaining basic needs. Housing first initiatives,^54,55 basic income,⁴⁰ and healthcare access, including mental health,^15,35,46 are needed to manage the needs that substance use is meeting. These include coping with childhood trauma and trauma incidents following substance use initiation (ie, overdose, street-based violence, etc.). Clinicians must understand substance use outside of a prohibitionist lens to have honest, helpful conversations with patients.⁵⁶ Faith-based interventions to reduce opioid use utilizing churches^57,58 have also been successful. Exploring the role of community and interconnectedness is important in evaluating interventions.

The prevalence of illicit opioid use or not as prescribed opioid use can in part be understood as an issue of access to mental health care and substance use treatment.¹⁵ Healthcare access issues are also more prevalent among minoritized populations.⁴⁶ Barriers to mental health treatment such as economic burden, physical access to clinicians and care sites, and discrimination may be mitigated by integrating mental health services with standard medical and OUD treatment.¹⁵ The literature identifies social stigma as a barrier to seeking access to mental health services.⁴⁶ However, systemic (ie, financial constraints), physical (ie, geographic proximity to care), and social (racial and ethnic discrimination) access barriers significantly limit engagement with healthcare even when individuals are open to seeking care.^15,46 Addressing both availability of resources and public perception of them are paramount to ensuring that PWID engage with mental health resources and develop adaptive coping strategies.

The importance of this data is its contribution to the literature around the necessity of early resource investment in socioeconomically disadvantaged families leading to the development of positive coping mechanisms. Resource availability functions as a preventative measure as well as improving treatment seeking behavior and efficacy.^59,60 In this way, we can achieve better, trauma-informed interventions and education to reduce morbidity and mortality associated with injection drug use.

Beyond the extracted concepts we describe from our interviews, we would also like to emphasize again that most participants included in this analysis identified as female. Women using injected drugs are more likely to report syringe sharing,^61-65 and, in turn, negative health outcomes such as injection drug use-related infective endocarditis⁶⁶ and HIV.⁶⁷ Furthermore, exposure to and effects of trauma are inherently gendered. Previous research has identified that women are at higher risk of developing post-traumatic stress disorder (PTSD), potentially due to higher exposure to interpersonal trauma.⁶⁸ Female PWID are also more likely to encounter traumatic events such as interpersonal and intimate partner violence from shared drug use.^68,69 Our cohort, having a majority composition of women, may suggest how women who use drugs face a higher baseline risk for psychological impacts from childhood trauma. In tandem, much of our cohort and individuals in extant data are more likely to be exposed to high-risk environments related to injected drug use, which creates the potential for further damage to physical and mental well-being.^57-65 With this understanding of the inherent gendered risk of traumatization, we believe that interventions developed based on these findings must account for gender disparities. Considering our own and existing evidence on the gendered risk of trauma is paramount to improve successful delivery and increase efficacy of the proposed interventions.

Limitations

There are limitations to this research. First, it was conducted in California where cannabis is medically and recreationally legal and may include a study population with greater access to cannabis and thus might not be generalizable to other regions with differing legality. Individuals in this sample may have differing access to cannabis early in life due to this. Second, convenience sampling approach to recruitment means that results may not be generalizable to other PWID in Los Angeles or elsewhere. Despite these limitations, this research yields important knowledge about navigating grief and trauma within hostile socio-structural conditions. This research provides important insights to guide interventions for alternative coping resources among opioid-using PWID. We set out to study social and structural factors that shape drug use and grief emerged as a part of the grounded theory approach. Future studies can expand upon our findings by examining bereavement through a structural lens among PWID.

Conclusion

We found that participants drew connections between childhood exposure to disordered substance use in the household and their own subsequent substance use initiation. Early traumatic experiences of witnessing disordered substance use (ie, family members use substances to emotionally regulate) combined with resource deprivation (ie, trauma-informed mental health support and financial and wraparound care) contributed to the development of participants’ substance use as a learned coping behavior. Counteracting resource deprivation by investing in social and structural support interventions may help to address the cyclical relationship between childhood exposure to trauma and adult substance use as well as the downstream negative health implications of injection drug use.

Supplemental Material

sj-docx-1-sat-10.1177_29768357251383754 – Supplemental material for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs

Supplemental material, sj-docx-1-sat-10.1177_29768357251383754 for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs by Erin E. Gould, Siddhi S. Ganesh, Daniel Trigo, Lizbeth Becerra, Amanda Cowan, Ricky N. Bluthenthal and Rachel Carmen Ceasar in Substance Use: Research and Treatment

Supplemental Material

sj-docx-2-sat-10.1177_29768357251383754 – Supplemental material for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs

Supplemental material, sj-docx-2-sat-10.1177_29768357251383754 for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs by Erin E. Gould, Siddhi S. Ganesh, Daniel Trigo, Lizbeth Becerra, Amanda Cowan, Ricky N. Bluthenthal and Rachel Carmen Ceasar in Substance Use: Research and Treatment

Supplemental Material

sj-docx-3-sat-10.1177_29768357251383754 – Supplemental material for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs

Supplemental material, sj-docx-3-sat-10.1177_29768357251383754 for “We Weren’t Taught How to Cope With Tragedy”: Early Childhood Trauma, Grief, and Learned Coping Mechanisms Among People Who Inject Drugs by Erin E. Gould, Siddhi S. Ganesh, Daniel Trigo, Lizbeth Becerra, Amanda Cowan, Ricky N. Bluthenthal and Rachel Carmen Ceasar in Substance Use: Research and Treatment

Footnotes

Acknowledgements

We would like to thank our study participants for their contribution to this research. Thank you to our current and past research assistants from the Bluthenthal Lab and Maternal Cannabis Lab who contributed meaningfully to this study.

ORCID iDs

Erin E. Gould

Siddhi S. Ganesh

Daniel Trigo

Ethical Considerations

The study was performed in accordance with the Declaration of Helsinski and approved by the University of Southern California Institutional Review Board (Study ID: 21-00282).

Consent to Participate

All subjects provided informed consent for participation.

Consent for Publication

All subjects provided informed consent for publication of their data.

Author Contributions

Erin E. Gould: Formal analysis, Data curation, Writing – original draft, Writing – review & editing.

Siddhi S. Ganesh: Formal analysis, Data curation, Writing – original draft, Writing – review & editing.

Daniel Trigo: Writing – review & editing.

Lizbeth Becerra: Writing – review & editing.

Amanda Cowan: Writing - review & editing.

Ricky N. Bluthenthal: Conceptualization, Methodology, Resources, Writing – review & editing, Supervision, Funding acquisition.

Rachel Carmen Ceasar: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Data curation, Writing – review & editing, Supervision, Project administration, Funding acquisition.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by NIDA R01DA046049-01A1S1. Ricky N. Bluthenthal and Siddhi S. Ganesh were supported by NIDA R01-DA046049. Siddhi S. Ganesh is also supported by Institute for Addiction Science pilot award PG1033682. The National Institute on Drug Abuse had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data, preparation, review, or approval of the manuscript, nor decision to submit the manuscript for publication.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data generated during this study is confidential. Data access is limited to only study personnel approved within the University of Southern California Human Research Protection Program (IRB). Additionally, this data is protected by a Certificate of Confidentiality issued by the National Institutes of Health (NIH) due to the potentially identifiable nature of this data. While participants consented to participate in this study and have their de-identified quotes disseminated for publication, they did not consent to sharing of the entire dataset due to the sensitivity of the research topic and potential for legal ramifications, withdrawal of social support, and loss of housing and/ or employment should they be identified. Participants were assured that access to their personal information would be limited to the research team, and that information collected as part of the study, even once de-identified, would not be distributed for future research studies. Researchers who meet the requirements for data access may contact the University of Southern California Human Research Protection Program (IRB) with data access requests at HRPP@usc.edu or (323) 442-0114.

Supplemental Material

Supplemental material for this article is available online.

References

Dunn

Turner

Oswald

LM.

Effects of early life trauma on risks for adult opioid use disorder are mediated by stress and occur independent of depression and anxiety. J Addict Med. 2022;16:709.

Centers for Disease Control and Prevention Violence Prevention. About the CDC-Kaiser ACE Study. Centers for Disease Control and Prevention; 2021. Accessed August 2, 2024. https://www.cdc.gov/violenceprevention/aces/about.html

Swedo

Aslam

Dahlberg

, et al. Prevalence of adverse childhood experiences among U.S. adults – Behavioral Risk Factor Surveillance System, 2011-2020. MMWR Morb Mortal Wkly Rep. 2023;72:707-715.

Felitti

Anda

Williamson

, 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. Am J Prev Med. 1998;14:245-258.

Merrick

Ports

Ford

, et al. Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse Negl. 2017;69:10-19.

CDC. About Adverse Childhood Experiences. Adverse Childhood Experiences (ACEs); 2024. Accessed January 23, 2025. https://www.cdc.gov/aces/about/index.html

Brewer-Smyth

, ed. Racial, ethnic, gender, and economic disparities and trauma. In: Brewer-Smyth

, ed. Adverse Childhood Experiences: The Neuroscience of Trauma, Resilience and Healing throughout the Life Course. Springer International Publishing; 2022:155-175.

Bryant

Coman

Damian

AJ.

Association of adverse childhood experiences (ACEs) and substance use disorders (SUDs) in a multi-site safety net healthcare setting. Addict Behav Rep. 2020;12:100293.

Kalmakis

Chandler

GE.

Health consequences of adverse childhood experiences: a systematic review. J Am Assoc Nurse Pract. 2015;27:457-465.

10.

Hughes

Bellis

Hardcastle

, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2:e356-e366.

11.

Merrick

MT.

Vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention – 25 States, 2015-2017. MMWR Morb Mortal Wkly Rep. 2019;68:999-1005.

12.

Webster

EM.

The impact of adverse childhood experiences on health and development in young children. Glob Pediatr Health. 2022;9:2333794X221078708.

13.

Boccio

Cardwell

Jackson

DB.

Adverse childhood experiences and truancy in high school: an analysis of Florida adolescents. Deviant Behav. 2024;46:1-19.

14.

Randhawa

Azarbar

Dong

, et al. Childhood trauma and the inability to access hospital care among people who inject drugs. J Trauma Stress. 2018;31:383-390.

15.

Cruden

Karmali

Opioid misuse as a coping behavior for unmet mental health needs among U.S. adults. Drug Alcohol Depend. 2021;225:108805.

16.

Dube

Felitti

Dong

, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111:564-572.

17.

Trenz

Scherer

Harrell

, et al. Early onset of drug and polysubstance use as predictors of injection drug use among adult drug users. Addict Behav. 2012;37:367-372.

18.

Kalinoski

DeWitt

Belani

Harm reduction readiness for illicit IV drug use among safety-net primary care practices in the San Fernando Valley. Arch Public Health. 2022;80:110.

19.

Bradley

Hall

Asher

, et al. Estimated number of people who inject drugs in the United States. Clin Infect Dis. 2023;76:96-102.

20.

Havinga

van der Velden

de Gee

, et al. Differences in sociodemographic, drug use and health characteristics between never, former and current injecting, problematic hard-drug users in the Netherlands. Harm Reduct J. 2014;11:6.

21.

Wagner

Valente

Casanova

, et al. Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. Int J Drug Policy. 2010;21:186-193.

22.

Hall

Sullivan

Bradley

Estimated number of injection-involved overdose deaths in US states from 2000 to 2020: secondary analysis of surveillance data. JMIR Public Health Surveill. 2024;10:e49527.

23.

Levitt

Mermin

Jones

, et al. Infectious diseases and injection drug use: public health burden and response. J Infect Dis. 2020;222:S213-S217.

24.

Vargas

Conley

Mittal

VA.

Chronic stress, structural exposures and neurobiological mechanisms: A stimulation, discrepancy and deprivation model of psychosis. Int Rev Neurobiol. 2020;152:41-69.

25.

Avelar Portillo

Kayser

, et al. Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California. Int J Equity Health. 2023;22:108.

26.

Ganesh

Gould

Conner

, et al. “Smoking weed it gets you over the hump”: Cannabis co-use as a facilitator of decreased opioid use among people who inject drugs in Los Angeles, California. Drug Alcohol Depend Rep. 2024;12:100257.

27.

Charmaz

Constructing Grounded Theory. 2nd ed. Sage Publications; 2014.

28.

Charmaz

The power and potential of grounded theory. Med Sociol. 2012;6:2-15.

29.

National Institute on Minority Health and Health Disparities. NIMHD Research Framework; 2025. Accessed August 14, 2024. https://www.nimhd.nih.gov/resources/research-framework/nimhd-research-framework-details

30.

Roche

Shimmin

Hickes

, et al. Valuing All Voices: refining a trauma-informed, intersectional and critical reflexive framework for patient engagement in health research using a qualitative descriptive approach. Res Involv Engagem. 2020;6:42.

31.

Knight

Belenko

Dennis

, et al. The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth. BMC Health Serv Res. 2022;22:1535.

32.

Woods-Jaeger

Cho

Sexton

, et al. Promoting resilience: breaking the intergenerational cycle of adverse childhood experiences. Health Educ Behav. 2018;45:772-780.

33.

Mitchell

Nolte

Turner

, et al. Exposure to medication overdose as an adversity in childhood. J Pediatr Nurs. 2018;38:127-132.

34.

Gold

Stathopoulou

Otto

MW.

Emotion regulation and motives for illicit drug use in opioid-dependent patients. Cogn Behav Ther. 2020;49:74-80.

35.

Wisdom

Govindu

Liu

, et al. Adverse childhood experiences and overdose: lessons from overdose data to action. Am J Prev Med. 2022;62:S40-S46.

36.

Stein

Conti

Kenney

, et al. Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder. Drug Alcohol Depend. 2017;179:325-329.

37.

Norton

Hatch

Munger

, et al. Family member deaths in childhood predict systemic inflammation in late life. Biodemography Soc Biol. 2017;63:104-115.

38.

Liew

Cnattingius

, et al. Association of mortality with the death of a sibling in childhood. JAMA Pediatr. 2017;171:538-545.

39.

Cullen J. The History of Mass Incarceration. Brennan Center for Justice; 2018. Accessed January 24, 2025. https://www.brennancenter.org/our-work/analysis-opinion/history-mass-incarceration

40.

Cohen

Vakharia

Netherland

, et al. How the war on drugs impacts social determinants of health beyond the criminal legal system. Ann Med. 2022;54:2024-2038.

41.

Grecco

Andrew Chambers

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness. Transl Psychiatry. 2019;9:1-11.

42.

Horton

Luna

Malloy

Premature, untimely, and traumatic death of family members, and mental health disorders among inpatient substance users. Illn Crisis Loss. 2018;26:79-97.

43.

Hobfoll

SE.

Conservation of resources: a new attempt at conceptualizing stress. Am Psychol. 1989;44:513-524.

44.

Kishore

Theall

Robinson

, et al. Resource loss, coping, alcohol use, and posttraumatic stress symptoms among survivors of Hurricane Katrina: a cross-sectional study. Am J Disaster Med. 2008;3:345-357.

45.

Andrade

ALM

Scatena

Lavezzo B de

, et al. Substance use disorder among bereaved individuals: a systematic review. Paid Ribeirão Preto. 2023;33:e3308.

46.

Coombs

Meriwether

Caringi

, et al. Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM Popul Health. 2021;15:100847.

47.

Sinha

Stress and substance use disorders: risk, relapse, and treatment outcomes. J Clin Invest. 2024;134:e172883.

48.

Camacho

Clark Henderson

The social determinants of adverse childhood experiences: an intersectional analysis of place, access to resources, and compounding effects. Int J Environ Res Public Health. 2022;19:10670.

49.

Collins

da Silva

ECG

Ergun

, et al. Intersectionality as critical social theory. Contemp Polit Theory. 2021;20:690–725.

50.

Sheidlower

Balevic

. Los Angeles gave families $1,000 a month in the biggest basic income pilot in the country. Now the results are in. Business Insider; 2024. Accessed January 24, 2025. https://www.businessinsider.com/los-angeles-guaranteed-basic-income-pilot-ubi-partner-violence-employment-2024-7

51.

Spiegel

Graziano

Arcia

, et al. Addressing mental health and trauma-related needs of sheltered children and families with trauma-focused cognitive-behavioral therapy (TF-CBT). Adm Policy Ment Health. 2022;49:881-898.

52.

Sanchez

Cornacchio

Poznanski

, et al. The effectiveness of school-based mental health services for elementary-aged children: a meta-analysis. J Am Acad Child Adolesc Psychiatry. 2018;57:153-165.

53.

Isobel

Goodyear

Furness

, et al. Preventing intergenerational trauma transmission: a critical interpretive synthesis. J Clin Nurs. 2019;28:1100-1113.

54.

Woodhall-Melnik

Dunn

JR.

A systematic review of outcomes associated with participation in Housing First programs. Hous Stud. 2016;31:287-304.

55.

Milaney

Passi

Zaretsky

, et al. Drug use, homelessness and health: responding to the opioid overdose crisis with housing and harm reduction services. Harm Reduct J. 2021;18:92.

56.

Bowers

Abrahamson

. Kicking the habit: the opioid crisis and America’s addiction to prohibition. Cato Institute; 2020. Accessed January 27, 2025. https://www.cato.org/policy-analysis/kicking-habit-opioid-crisis-americas-addiction-prohibition

57.

Jordan

Babuscio

Nich

, et al. A feasibility study providing substance use treatment in the Black church. J Subst Abuse Treat. 2021;124:108218.

58.

Jordan

Costa

Nich

, et al. Breaking through social determinants of health: results from a feasibility study of Imani Breakthrough, a community developed substance use intervention for Black and Latinx people. J Subst Use Addict Treat. 2023;153:209057.

59.

Ford

Ganesh

Ninh

, et al. “It’s not just one decision, It’s a whole lifestyle change”: mixed methods analysis of factors associated with readiness to change substance use patterns among community recruited people who inject drugs. Subst Use Misuse. 2025;60:1787-1798.

60.

Goldshear

Kitonga

Angelo

, et al. “Notice of major cleaning”: a qualitative study of the negative impact of encampment sweeps on the ontological security of unhoused people who use drugs. Soc Sci Med 1982. 2023;339:116408.

61.

Lorvick

Martinez

Gee

, et al. Sexual and injection risk among women who inject methamphetamine in San Francisco. J Urban Health. 2006;83:497-505.

62.

Shannon

Kerr

Allinott

, et al. Social and structural violence and power relations in mitigating HIV risk of drug-using women in survival sex work. Soc Sci Med 1982. 2008;66:911-921.

63.

Sherman

Latkin

Gielen

AC.

Social factors related to syringe sharing among injecting partners: a focus on gender. Subst Use Misuse. 2001;36:2113-2136.

64.

Spittal

Bruneau

Craib

KJP

, et al. Surviving the sex trade: a comparison of HIV risk behaviours among street-involved women in two Canadian cities who inject drugs. AIDS Care. 2003;15:187-195.

65.

Strathdee

Philbin

Semple

, et al. Correlates of injection drug use among female sex workers in two Mexico–U.S. border cities. Drug Alcohol Depend. 2008;92:132-140.

66.

Ganesh

Goldshear

Wilkins

, et al. Risk factors for infective endocarditis and serious injection related infections among people who inject drugs in Los Angeles, CA and Denver, CO. Drug Alcohol Depend. 2025;269:112588.

67.

Tross

Feaster

Thorens

, et al. Substance use, depression and sociodemographic determinants of HIV sexual risk behavior in outpatient substance abuse treatment patients. J Addict Med. 2015;9:457-463.

68.

Lotzin

Grundmann

Hiller

, et al. Profiles of childhood trauma in women with substance use disorders and comorbid posttraumatic stress disorders. Front Psychiatry. 2019;10:674.

69.

Frye

The informal social control of intimate partner violence against women: exploring personal attitudes and perceived neighborhood social cohesion. J Community Psychol. 2007;35:1001-1018.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.04 MB

0.03 MB

0.02 MB