National Center for Injury Prevention and Control

Christopher M. Jones, PharmD, DrPH, MPH

CAPT, U.S. Public Health Service

ACEs, Suicide, and Opioids: Intertwined Public Health Challenges

Opioid Overdose SuicideAdverse Childhood Experiences (ACEs)

CDC Injury Center Strategic Priorities

Defining ACEs and Health and Social Impacts

ACEs are experiences that may be traumatic to children and youth during the first 18 years of life such as experiencing violence or other types of emotionally disturbing exposures in their homes and communities.

Graphic Credit: Robert Wood Johnson Foundation

ACES not included in the traditional measure:

▪ Bullying

▪ Teen dating violence

▪ Peer to peer violence

▪ Witness violence in community or school

▪ Homelessness

▪ Death of a parent

Abuse Neglect Household Challenges

Adverse Childhood Experiences (ACEs)

Opportunity

Men

tal H

ealt

h

ACEs

EducationOccupation

Income

Alcohol & Drug AbuseUnsafe Sex

Opioid Misuse

CancerDiabetes

HIVSTDs

Unintended Pregnancy

PregnancyComplicationsFetal death

DepressionAnxietySuicide

ACEs Have Lasting Impacts on Health

ACEs and IV Drug Use ACEs and Adult Suicide Attempts

Source: Source: Dube, Shanta R., et al. "Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study." Jama 286.24 (2001): 3089-3096.Felitti, Vincent J., et al. "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." American journal of preventive medicine 14.4 (1998): 245-258.

Ad

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Adult Suicide Attempts

ACEs and Deaths of Despair

ACE and Life Expectancy

Brown DW, Anda RA, Tiemeier H, Felitti VJ, Edwards VJ, Croft JB, Giles WH. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 2009;37(5):389-396.

Economic Impacts

ACES are Common in the U.S.

36.1%

26.0%

15.9%

9.5%

12.5%

ACE Score PrevalenceCDC-Kaiser ACE Study

Zero One Two Three Four or More

# of ACEs:

38.4%

23.5%

13.4%

8.8%

15.8%

ACE Score Prevalence2011-2014 BRFSS ACE Module

Zero One Two Three Four or More

# of ACEs:

Brain Science Behind ACEs

Building Brain Architecture

https://developingchild.harvard.edu/science/key-concepts/brain-architecture/

Broad Impacts of Toxic Stress

De Bellis & Zisk. The biological effects of childhood trauma. 2014

• Responses to stress• Reward circuits• Emotion processing• Coping strategies• Executive function• Decision making• Cognition• Organ function

Trauma Compromises Early Brain Development

External Manifestations in Children

https://aifs.gov.au/cfca/sites/default/files/publication-documents/cfca_developmental_differences_executive-functioning_practice-guide.pdf

ACEs and Connection to Substance Use

Number of Categories of ACEs

Felitti, Vincent J., et al. "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." American journal of preventive medicine 14.4 (1998): 245-258.

ACEs and Substance Use From Original ACEs Study

0

2

4

6

8

10

12

Current Smoker Alcohol Use Disorder Ever Used Illicit Drugs Ever Injected Drugs

Ad

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ed O

dd

s R

atio

0 1 2 3 ≥4

Misuse of Rx pain medication by ACE Score

0

2

4

6

8

10

Use at higher frequency or dosagethan directed by the doctor

Use without a presciption

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ACE Score 0 1-2 3-4 ≥5

Source: Montana Behavioral Risk Factor Surveillance System, 2011. Behavioral Risk Factor Surveillance System Office, Montana Department of Public

Health and Human Services. The contents are the sole responsibility of the authors. DRAFT – DO NOT DISTRIBUTE

Early Adversity among Adults Using Methamphetamine

18

18

19

27

40

65

46

40

53

66

28

27

23

27

42

52

46

42

27

56

0 10 20 30 40 50 60 70

No place to live

Inadequate food

Inadequate clothes

Not taken care of when sick or hurt

Left by self when too young

Felt unloved

Felt unsafe or in danger

Beaten or seriously hurt by an adult

Ever sexually mistreated, abused or raped

Mentally or emotionally abused or mistreated

Percent

Male Female

Source: Maxwell JC, A new survey of methamphetamine users in treatment: who they are, why they like “meth”, and why they need additional services, 2014

ACEs, Suicide, and Opioids

More than 47,000 people died from

suicide in 2017

1 death every

11 minutes

10.6 million seriously thought about suicide3.2 million made a plan for suicide1.4 million attempted suicide

Suicide is a Leading Cause of Death

RankAge Groups

10-14 15-24 25-34 35-44 45-54 55-64

1 Unintentional Injury Unintentional Injury Unintentional Injury Unintentional Injury Malignant Neoplasms Malignant Neoplasms

2 Suicide Suicide Suicide Malignant Neoplasms Heart Disease Heart Disease

3 Malignant Neoplasms Homicide Homicide Heart Disease Unintentional Injury Unintentional Injury

4 Congenital Anomalies Malignant Neoplasms Heart Disease Suicide SuicideChronic Lower

Respiratory Disease

5 Homicide Heart Disease Malignant Neoplasms Homicide Liver Disease Diabetes Mellitus

6 Heart Disease Congenital Anomalies Liver Disease Liver Disease Diabetes Mellitus Liver Disease

7Chronic Lower

Respiratory DiseaseDiabetes Mellitus Diabetes Mellitus Diabetes Mellitus Cerebrovascular Cerebrovascular

8 CerebrovascularInfluenza & Pneumonia

Cerebrovascular CerebrovascularChronic Lower

Respiratory DiseaseSuicide

9Influenza & Pneumonia

Chronic Lower Respiratory Disease

HIV Septicemia Septicemia Septicemia

10 Benign NeoplasmsComplicated Pregnancy

Complicated Pregnancy

HIV Homicide Nephritis

Suicide Prevention Must Be Broader Than a Focus on Mental Health

Source: CDC

Interrelated Nature of Pain, Addiction, Mental Disorders, Suicide, ACEs

Pain

Mental Disorders Suicide

Substance Use/Addiction

ACEs

Risk Factors for Opioid Overdose

1.5

10.2

3.12.2 2.1 1.6 1.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

COPD Substance usedisorder

Depression Bipolar disorder Schizophrenia Anxiety disorder Benzodiazepines

aOR

Overdose Risk

2.3

1.6 1.71.5

2.0 2.0

0.0

0.5

1.0

1.5

2.0

2.5

Mood disorder Opioid use disorder Alcohol use disorder Cannabis usedisorder

Other non-opioid usedisorder

Any benzodiazepineuse

aHR

Overdose Risk

Source: Nadpara et al., Pain Med, 2018; Campbell et al., Preventive Medicine, 2018 7

Relationship Between Suicidal Ideation & Motivations for Rx Opioid Misuse

Source: Han et al., JCP, 2018

Suicide and Opioids

Risk of Suicide Ideation

▪ Opioid Use Disorder (OUD) involving prescription opioids was associated with an increase of 40 to 60% in the risk of suicidal ideation.

Risk of Suicide Plans and Attempts

▪ People using opioids regularly were about 75% more likely to make suicide plans and twice as likely to attempt suicide as people who did not report any opioid use.

SOURCES: Ashrafioun, Bishop, Conner, and Pigeon (2017); Oquendo and Volkow (2018)

Substance Use Risk Factors

➢ Genetic factors

➢ Initiating substance use early

➢ Low risk perception of use

➢ Peers who use substances

➢ Emotional distress or aggressiveness that starts early and is persistent

➢ Psychiatric disorders

➢ Substance misuse in the family

➢ Family conflict, abuse, or neglect

➢ Parents who favorably view or approve of substance use

➢ Lack of family connectedness

➢ Poor academic performance

➢ Student does not view school as rewarding or meaningful and lack commitment to school

➢ Perception that use of drugs among classmates is high

➢ Poor control over school drug consumption

➢ Lower socioeconomic status, economic stressors

➢ Availability and costs of drugs and alcohol

➢ Community norms favorable toward alcohol and drugs

➢ Lack of community connectedness and supports

Source: Adapted from Volkow et al., 2018, JAMA Psychiatry

Risk Factors for Suicide

▪ Adverse childhood experiences/trauma

▪ Substance use

▪ Mental illness

▪ High conflict or violent relationships

▪ Lack of connectedness

▪ Loss (relational, social, employment, financial, health)

▪ History of suicide attempt, suicide of friend or family member

▪ Barriers to health/behavioral health care access

▪ Stigma

▪ Availability of lethal means

Source: CDC

Shared Protective Factors

➢ Resiliency

➢ Self-efficacy

➢ Spirituality

➢ Interpersonal skills, including social, emotional, and cognitive skills

➢ Treatment of underlying psychiatric disorders

➢ Attachment to family, school, and community

➢ Meaningful involvement in family, school, or community

➢ Safe, stable, nurturing relationships

➢ Positive behavior is recognized

➢ Norms in the family, school, and community that drug use, violence are not acceptable; helping seeking is acceptable

➢ Opportunity for fulfilling extracurricular activities

Source: Adapted from Volkow et al., 2018, JAMA Psychiatry

Prevention Policy, Program, and Practice Strategies

The power of prevention

Source: CDC Vital Signs 2019

Promote social norms that protect against violence and adversity

Ensure a strong start for children

Strengthen economicsupports for families

Teach skillsLessen harms

and prevent future risk

6 Strategies to Prevent ACEs

Connect youth to caring adults and activities

Suicide Prevention Technical Package

Source: CDC Suicide Prevention Technical Package: https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

Resilience Catalysts (RC) ProjectBuilding Community Resilience

▪ Advances efforts of local health departments to address and prevent individual and community ACEs.

▪ Includes a focus on opioid misuse.

Awarded Sites

▪ Cambridge, Massachusetts

▪ Louisville, Kentucky

▪ Mesa County, Colorado

▪ Dallas, Texas

▪ Appalachian District, North Carolina

▪ Focuses on ACES to create a trauma informed community working to build resilience in children.

▪ Partnership between Berkeley County Schools, Martinsburg Police Department, Shepherd University and community organizations including The Boys & Girls Club of the Eastern Panhandle.

▪ Program advocates for children with high ACE scores and connect individuals with the services they need to succeed.

▪ Program is tiered and provides universal supports, target prevention programs, and wrap-around services for children in need.

An Innovative and Holistic Police-school-community Partnership

Expanded Essentials for Childhood (EfC)

▪ Assuring safe, stable, nurturing relationships and environments for children

▪ Supplemental opioid funding

Awarded Sites▪ California▪ Colorado▪ Kansas ▪ Massachusetts▪ North Carolina▪ Utah ▪ Washington

Communities that Care (CTC)

Compared to a comparison group,

students receiving CTC were…

– 60% less likely to initiate alcohol use

– 41% less likely to engage in delinquency

– 25% less likely to engage in violence

Veto Violence - ACE Online Training

https://vetoviolence.cdc.gov/apps/aces-training

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348www.cdc.gov/injury

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

@CDCInjury

Christopher M. Jones, PharmD, DrPH, MPHCAPT, US Public Health ServiceSenior AdvisorDirector, Strategy and Innovationfjr0@cdc.gov