Archives for March 2017

Medication-Assisted Treatment for Opioid Use Disorder – Infographic

Medication-assisted treatment (MAT) with methadone and buprenorphine is the only known treatment – not abstinence, not counseling, not 12-step approaches – to cut death rates from opioid use disorder by 50-70% or more.

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”

U.S. federal officials decry opioid misuse as a public health crisis, yet federal rules limit access to the only known effective treatment. Due to federal restrictions, few health care professionals are approved to dispense methadone or prescribe buprenorphine. Further, laws dictate how many patients those few can prescribe and, increasingly to whom, in what form, and how much medication can be prescribed. People suffer, even die, on wait lists to receive medication. In contrast, countries that effectively address their overdose crises, loosen, not tighten restrictions. Indeed, Stefan G. Kertesz, M.D. states, “The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder.”

In the event that lack of understanding of MAT may be contributing to restricting access to it, we offer this simple infographic explaining medication-assisted treatment (MAT) for opioid use disorder (OUD).

Medication-Assisted Treatment for Opioid Use Disorder

Medication-assisted treatment (MAT) does not replace one addiction with another. It creates stability by treating the medical condition of addiction. Currently, effective medications for addiction create dependence – negative symptoms from withdrawal if doses are discontinued – but not addiction, which, per its definition, involves continued use despite negative consequences.

Tolerance occurs when people’s bodies adapt to a drug over time, responding less and less to the same dose. In order to have an effect, doses must keep increasing for people to continue to get high, or to keep from getting sick. When people use opioids regularly, therefore, they tend to use more and more of the drug over time. Even if they stop using, then return to use, they are at risk for overdose because illegal drugs are not monitored, and so they may be cut with much more powerful drugs, such as heroin with fentanyl.

(Recent increased rates in drug overdose are due to heroin and illicit fentanyl, not prescription pain medications. Reported deaths in 2015 from opioids by prescription account for under 15%. Of those addicted to prescription pain medications, 75% received them from a family member, friend or dealer, not through medication prescribed to them.)

When people with OUDs enter abstinence-based treatment, or otherwise stop using, their tolerance drops. They may not know their tolerance is diminished, or they may not know how much it has decreased, and if they take an opioid at the high dose they were once used to, they are likely to overdose and die.

People who are given MAT for OUD take an opioid (buprenorphine or methadone) at a consistent dose, which effectively stabilizes them. Once stabilized on an effective dose, they do not experience withdrawals, cravings, or highs. They can provide child or dependent care, hold a job, adhere to treatment, and comply with the law.

In contrast, people who are not on MAT will experience withdrawal symptoms and strong cravings, especially when under stress. People with OUDs permitted only abstinence-based treatment are at high risk for all of the same problems people with untreated addiction are at risk for: recidivism and crime, unemployment, contracting and transmitting diseases, overdose and hospitalization, and fatal overdose. Up to 90% of people with opioid use disorder relapse when not on medication-assisted treatment.

Maintenance may need to be long-term, or even life-long, because while addiction lasts, people who terminate maintenance treatments are at elevated risk for fatal overdose.

The US opioid epidemic has changed profoundly in the last 3 years, in ways that require substantial recalibration of the US policy response…Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015…The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among US adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years. A credible epidemiologic account of the opioid epidemic is as follows: although opioid prescribing by physicians appears to have unleashed the epidemic prior to 2012, physician prescribing no longer plays a major role in sustaining it. The accelerating pace of the opioid epidemic in 2015–2016 requires a serious reconsideration of governmental policy initiatives that continue to focus on reductions in opioid prescribing. The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients.
– Stefan G. Kertesz, M.D.

People with opioid addiction can live full lives as family members and citizens. MAT benefits the general public health, employers, law enforcement, taxpayers, and the human beings who need our help.

Infographic by Laurel Sindewald. A printable .pdf version is here.

Laurel Sindewald contributed to this article.

Related reports on addictions treatment, addictions recovery, and addictions policy from Handshake Media, Incorporated:

This post was last updated 5/4/17.

Why 12-Step Approaches Are Not Evidence-Based as Addictions Treatment

When I read Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [1], I was surprised to see Twelve-Step Facilitation (TSF) included as an evidence-based behavioral treatment for addiction. I had just done a literature review on the efficacy of 12-step-based interventions [2], and found the evidence insufficient to support the prescription of 12-step groups as treatment. TSF is a standardized form of therapy where professional counselors try to engage their patients in participating actively in 12-step groups, in part by emphasizing 12-step philosophy during therapy sessions [3].

12-step folding chair

Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character, and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment [4]. A spiritual disease concept is not the same as a medical disease concept. Twelve-Step Facilitation treats addiction as a spiritual and biopsychosocial disease, retaining the spiritual emphasis of 12-step philosophy [5].

TSF was classified as a professional behavioral treatment in the Surgeon General’s Report. How can a professional, medical treatment be based on a definition of addiction as a spiritual disease? Baffled, I knew I would not be able to understand if I got stuck in bias against Twelve-Step Facilitation. I had studied the research on 12-step groups, but had only dipped my toe into the research on TSF. The Surgeon General’s Report cites hundreds of studies, and over a dozen in support of TSF. So, I did what all good scientists must do: I set aside my bias, knowing that if I want truth, I must assume first that I am wrong and dig deeper.

I conducted a preliminary literature review to investigate the effectiveness of TSF as a treatment, and then examined each of the sources the Surgeon General’s Report cited in support of TSF. I looked at the methodology, results, and conclusions for each. In this article, I define “evidence-based” to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. I use “12-step approaches” to refer to all 12-step-based rehab programs, TSF, and 12-step mutual help groups.

The key to understanding research on TSF is to know why the treatment was created in the first place. Researchers had documented an association between 12-step group attendance and abstinence, but association is not causation and research had been limited in several ways:

  • Studies evaluating the effectiveness of 12-step groups could not eliminate self-selection bias, which happens when group members are not randomly selected and participants opt in or select themselves, creating biased samples. The people participating in the studies had chosen to participate, and researchers could not determine whether successes observed were due to 12-step participation or qualities in the self-selected participants, such as greater motivation to enter recovery, more resources, or greater receptivity to messages of God, faith and/or acceptance. The people who chose not to participate, or who dropped out of the study, were not always accounted for. Researchers could not determine whether the association they observed between 12-step participation and abstinence was due to the treatment or to the characteristics of the people participating.
  • Twelve-step groups have no standardized methods or conditions. Leaders of the groups are often laypeople in recovery from addiction themselves. The quality of social support in the group depends on the people who are participating. The literature is interpreted by the members, who create their own cultures around the interpretation. Twelve-step cultures also pass around other information and advice, which may or may not permeate every group. Each sponsor is a different layperson in recovery from addiction, with different character traits. Researchers could not control for all of these variables all of the time.
  • Researchers struggled to maintain rigorous control groups throughout studies. At minimum, to determine whether 12-step groups have effect, researchers needed a no-treatment control group for each study. Ethically and logistically, they could not prevent people in the control groups from receiving treatment or from attending 12-step groups.

Twelve-Step Facilitation was developed by researchers working on Project MATCH, a well-known and extensive study funded by the National Institutes of Health. Project MATCH compared TSF to Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT), seeking to establish what patient characteristics corresponded with the best results for each treatment. The study found there “was little difference in outcomes by type of treatment” based on the primary outcome measures of percent days abstinent and drinks per drinking day [6].

By standardizing methodology for TSF, Project MATCH made some headway on strengthening the quality of evidence, but they did not find a way around self-selection bias and they did not have a control group. Many patients, however, did drop out of the assigned treatments early on in the study. Two researchers later examined the outcomes of the zero-treatment dropout group, and found that “two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero-treatment group” [7]. This means that the people in Project MATCH’s treatment groups did not have significantly better abstinence outcomes than the people who dropped out of the study. Importantly, we do not know whether the dropout group sought treatment on their own, and it seems probable that they did. Based on their analysis, none of the interventions in Project MATCH seem to be effective, but without an actual control group the results are equivocal regardless.

Some researchers have sought to re-analyze other parts of the Project MATCH data [8,9], but their findings, while supportive of TSF, are subject to the same methodological limitations of the parent study. Many other studies cited by the Surgeon General’s Report seem to support TSF as effective for improving abstinence outcomes [1014] and/or for relatively increasing 12-step participation compared to treatment as usual (TAU) [1520], but none of these studies had control groups. The Surgeon General’s Report cited one source in support of TSF that was actually an article reviewing information about 12-step programs to educate social workers, not an experimental study [21]. The Report also cited a study in support of TSF that examined two active referral interventions, 12-step peer intervention (PI) and doctor intervention (DI), compared to no intervention (NI). The study found that while the active referral interventions significantly increased participation in 12-step groups compared to no intervention, “abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI])” [22]. This study was the only one cited in the Surgeon General’s Report in support of TSF that approximated a control group, and it does not actually support the efficacy of TSF in increasing abstinence outcomes. The NI pseudo-control group still received a list of 12-step group meeting times and locations, but was not encouraged to attend. The PI group attended meetings twice as much as the NI group, and yet the researchers found no significant difference in abstinence outcomes. The DI group, essentially TSF, was less effective than the PI group at increasing attendance, and again, did not significantly improve abstinence.

My own literature review turned up articles the Surgeon General’s Report did not reference, both in support of TSF [5,2328] and not supporting TSF [7,29,30], but none of the studies I found had control groups either. Results of my literature review, including my assessment of the Surgeon General’s report sources, were therefore as ambivalent as the 2006 Cochrane Review, a systematic meta-study of all 12-step-based programs that found that, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” [31]. A more recent systematic review by the Campbell Collaboration found evidence on 12-step approaches for other drug use disorders to be weak as well, with only 9 studies meeting all of their inclusion criteria. What evidence they did find indicated no difference between 12-step approaches and other psychosocial interventions in reducing illegal drug use, and some evidence that 12-step approaches have higher dropout rates than other interventions [32]. Researchers have not been able to methodologically eliminate self-selection bias, and most often fail to utilize adequate controls in their studies of 12-step groups and TSF.

One study to date attempted to use instrumental variables models, a recently developed statistical method, to determine what percentage of increased 12-step group attendance can be attributed to TSF without self-selection bias [33]. The researchers, Humphries et al. 2014, re-analyzed data from 5 randomized clinical trials, though none of these clinical trials had control groups. They determined that TSF did significantly increase participation in 12-step groups for people who had not previously participated much or at all, though not for people who already had high levels of participation. Their methods were inadequate for determining whether increased participation is causally linked to increased abstinence, or whether increases in abstinence occurred without self-selection bias.

My review answers a question that cannot be answered by simply counting the number of studies apparently supporting or not supporting 12-step approaches like TSF. Are 12-step approaches evidence-based for treating addiction – supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples? No, 12-step approaches are not evidence-based, because no studies decisively demonstrate their effectiveness. In fact, research on 12-step approaches faces insurmountable obstacles. Practically speaking, researchers cannot ethically design and conduct experiments that eliminate self-selection bias and utilize adequate controls.

In medical science, if a treatment is ineffective or faces prohibitive methodological challenges, the treatment is either revised or abandoned. Twelve-step philosophy prohibits either approach. Twelve-step literature is comparable to the Bible for Christians or the Qur’an for Muslims; if the literature is removed, the identity of the group goes with it. The same basic text has been used for AA since the publication of its “Big Book,” Alcoholics Anonymous, in 1939. Twelve-step literature also explicitly states that, “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average” [34]. Twelve-step philosophy, by taking this position, is asserting that its methods can never be wrong. If the 12 Steps do not work for people, 12-step philosophy explicitly states it is their fault, and that the fault is inborn and irreversible. The 12 Steps and attendant literature, however, are not modified.

Research does support the concept that changing “people, places, and things” and finding a network of people with a culture of abstinence can improve chances of recovery [35]. However, mutual help groups other than 12-step groups do exist that may provide the social support needed by people in recovery. A study by Zemore et al. [36], compared the relative, personal satisfaction of participants in 12-step groups vs. 12-step alternatives: SMART Recovery, LifeRing, and Women For Sobriety. The study did not examine abstinence or drinking/using outcomes among participants, but interviewed all participants on demographics, level of participation in their mutual help group (MHG) of choice, and level of satisfaction and group cohesion they experienced in their MHG. They found that, “despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members.” The participants who engaged in alternative MHGs tended to be less religious, and to have higher levels of education and income. The study demonstrates that alternative MHGs not only exist, but are of comparable efficacy in terms of social support. People who are not religious may be able to make 12-step groups work for them as social support if they have no other choices [37], but other options will most often be available.

Social support may be subjectively helpful as an individual seeks medical treatment, but ultimately medical treatment is necessary to ameliorate disorder symptoms. Social support is also not sufficient to prevent addiction from developing. Researchers using statistical analysis to determine whether social support and social networks reduced the odds of developing AUD following stressful life events and chronic stressors, among other disorders, found no statistically significant effect of social support or networks on later rates or effects of AUD [38].

A study in 2001 by Humphreys and Moos [39] found that TSF may reduce health care costs for people in recovery by emphasizing reliance on free 12-step groups, as opposed to cognitive behavioral therapy. Yet their conclusions that the study indicates people should be diverted from CBT to TSF because it is ultimately cheaper amounts to advocating malpractice. TSF itself is not free and is not decisively supported by evidence; twelve-step groups, while free, are not evidence-based or treatment, and other available mutual help groups are equally free options for social support. Even if TSF were demonstrably effective at promoting abstinence for some people, 12-step philosophy is heavily spiritual (specifically Christian-based), so it would be unethical to recommend TSF simply because it might save money.

In Unbroken Brain: A Revolutionary New Way of Understanding Addiction [40], Maia Szalavitz, citing Anne M. Fletcher’s Inside Rehab: The Surprising Truth About Addiction Treatment–and How to Get Help That Works [41], reports that 12-step approaches are “a required curriculum” in 80% of American addiction treatment programs. Many addictions treatment facilities state that that they are 12-step based. Based on my literature review, that means that these facilities are not offering effective, evidence-based treatment.

After extensive research, I assert with confidence that 12-step approaches are not evidence-based treatments. They may be strong recovery support options for people to choose in addition to a medical treatment plan, but 12-step approaches—including TSF—are not established as evidence-based for treating addiction. Due to the methodological limitations identified in this article, I question continuing to spend thousands of dollars, hundreds of hours, and limited expertise on researching a spiritually-based treatment for addiction that cannot be proven to be effective for most people most of the time compared to “spontaneous,” or natural, remission rates. It is time to relegate 12-step approaches to the realm of recovery support services (RSS, as defined in the Surgeon General’s Report) and allocate our research resources to promising treatments that can be studied rigorously and without such crippling methodological limitations.

References

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Laurel Sindewald is a writer and researcher for Handshake Media, IncorporatedAnne Giles contributed to this report.

A version of this report was originally published by The Fix as “AA Is Not Evidence-Based Treatment” on 3/16/17. We broaden the scope, update with the latest research, and provide full citations using APA style guidelines. We will continue to update the report as new research warrants. This report was last updated on 6/23/17.

After the Shootings: Community Violence, Collective Trauma and Addiction

It’s Fourth of July in a small town in America, and people of all ages and races, classes and creeds are gathered in a park for the fireworks display. People in lawn chairs are chatting over drinks. Here and there people are stretched out on old blankets or beach towels, reading or scrolling through Facebook. Kids are tearing up and down the playground equipment, playing with glowsticks or laughing at gravity on the swings. Everywhere the people breath deep and smell wafting barbecue above fresh grass, spiced with smoke from exhausted sparklers.

The community seems happy with the warmth of summer, and nothing around could show you the difference between this town and so many other small towns in America. But the people of this town have been changed. One April ten years ago, someone walked onto the local college campus, entered a building and locked the doors, killed 32 people and wounded 17 before committing suicide.

About 500 people are gathered to see the fireworks. Because of that violent event, research suggests that 75 of those gathered are suffering symptoms of trauma severe enough to be diagnosed with post-traumatic stress disorder (PTSD).

Statue on Virginia Tech Campus

Photo: “The Garden Sprite” statue on Virginia Tech Campus in the Hahn Horticulture Garden, a rendition of Frank Lloyd Wright’s “Maid in the Mud”

Mass shootings are one type of community violence, a term that includes terrorist attacks, riots, gang wars, workplace assaults, torture, bombings, war, and many other acts of violence. Community violence has far-reaching effects very different from some other forms of trauma, and impacts people who may not have been directly present at the violent event.

“Several aspects of community violence make it different from other types of trauma. Although there are warnings for some traumas, community violence usually happens without warning and comes as a sudden and terrifying shock. Because of this, communities that suffer from violence often experience increased fear and a feeling that the world is unsafe and that harm could come at any time. Although some traumas only affect one individual or a small group of people, community violence can permanently destroy entire neighborhoods. Finally, although some types of trauma are accidental, community violence is intentional, which can lead survivors to feel an extreme sense of betrayal and distrust toward other people.”
– Hamblen and Goguen, US Department of Veterans Affairs, 2016

An estimated 1015% of people who experience community violence report severe PTSD symptoms afterward. (Researchers estimate that 15-30% of people in the Blacksburg community experienced PTSD symptoms after the Virginia Tech shootings.)

Risk factors include female gender, proximity to the violence, knowing victims of the violence, pre-existing psychological conditions, emotion regulation difficulties, anxiety sensitivity, and low social support (Lowe and Galea, 2017; Bardeen et al., 2013; Grills-Taquechel et al., 2011; Stephenson et al., 2009; Scarpa et al., 2006Norris et al., 2002; North et al., 1994). The mental health effects include “psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident” (Schultz et al., 2014).

Researchers report that people in the surrounding community may also experience these effects, even if they did not witness the violence first-hand. For example, people who experience stronger emotional reactions, regardless of proximity, are at higher risk for later PTSD symptoms.

“For some people it’s water off a duck’s back. Some people are drowning.”
– Anne Giles, private interview

People who were unable to contact or locate loved ones during the Virginia Tech shootings were subject to trauma symptoms, even years later, as Victoria Sagstetter discovered.

“As an English teacher, she found herself re-reading student poems that seemed unusually dark, looking for the kind of clues Cho left behind in his writings before his killing spree.”
Jacob Demmitt of The Roanoke Times

After the Virginia Tech shootings, 4.5 years went by before some people sought treatment for trauma. Among the mental health effects people experience after trauma are substance use disorders (SUDs) and other addictions. The connection between trauma and addiction is well-documented, and current research indicates that trauma is a causal factor leading to addiction.

“Consistent with the self-medication hypothesis, the theory that people use substances to cope with psychological distress, PTSD tends to precede and predict SUD.”
Trauma and Addiction: Common Origins and Integrated Treatment

About 34% of people diagnosed with PTSD also suffer from addiction, and about two-thirds of people with addiction have experienced past trauma. Therefore, of the revelers at the Fourth of July celebration, an estimated 25 are at risk for developing addiction due to the event of community violence alone.

If people have experienced other traumatic events in their lives, as 1 in 4 American children have (CDC 2014; Felitti et al., 1998), they will be at even higher risk for addiction. For example, women who had experienced sexual trauma prior to the Virginia Tech shootings reported significantly more depressive symptoms, shooting-related PTSD, and lower belief in benevolence and family support.

“Maia Szalavitz, in her book Unbroken Brain, reports that, ‘Even just one extreme adversity – like losing a parent or witnessing domestic violence – before age 15 doubles the odds of substance use disorders, according to a study of the entire Swedish population’ (Unbroken Brain, 65).”
– Trauma and Addiction: Common Origins and Integrated Treatment

The estimated 75 people with trauma and 25 people with addiction watching the fireworks display are therefore a low estimate of the true risk for trauma and addiction in this small American town. Trauma and addiction are already very likely to occur, and an event of community violence such as the mass shootings in this community means trauma and addiction are almost certain to happen.

After community violence happens, everyone should be screened for trauma. (If resources are limited, those exhibiting risk factors should be prioritized, as should those with pre-existing disorders that put them at higher risk for addiction.) Community members must be aware that their friends and family and neighbors are at risk for developing addiction, and that if they do, they need treatment not tough love.

Some variables are known to reduce the risk of PTSD (and therefore addiction) after community violence. If a person has a belief in his or her ability to handle the trauma, i.e., self-efficacy, he or she will be less likely to experience PTSD symptoms. After community violence, in-person social support is known to mitigate resource loss (social or physical) and compensate for low levels of self-efficacy, reducing PTSD risk (Warner et al., 2015; Hawdon et al., 2012; Littleton et al., 2009). Specifically, sharing about thoughts and emotions with others may attenuate PTSD risk, but sharing bare facts will likely not help, and may increase the risk of developing PTSD.

“Thus, it is argued here that efforts to reduce risk and resource inequities, engage local people in mitigation, create organizational linkages, boost and protect social supports, cultivate trusted and responsible information resources, and enhance decision-making skills will augment more specific intervention efforts to promote safety, calming, efficacy, hope, and connectedness in the aftermath of mass trauma.”
Norris and Stevens, 2007

People in a community have a choice to make after community violence. What they choose determines how long and how badly the violence continues to affect their community. People who come together, in person, to share thoughts and feelings about the violence during and after it occurs are less likely to suffer from PTSD and addiction in the future. People who continue to come together, who recognize that some of their friends and neighbors will inevitably be suffering, and who affirm their own and others’ abilities to cope with the violence will be more likely to heal.

Let’s say you’re sitting on a towel on the 4th of July in that small town, surrounded by your friends and neighbors as the fireworks begin. You share, together, openly and shamelessly, about the trauma or addiction with which you may struggle.  In a special place created by “safety, calming, efficacy, hope, and connectedness,” you may start to feel a little bit better.

Author’s note: To estimate the number of people in my imagined 500 likely to develop PTSD, I reviewed the literature. One source estimated 10-15%, another estimated 15.4%, and a third estimated 15-30% of people who experience a mass shooting (directly or indirectly) develop PTSD. I chose 15% as a conservative estimate, because I do not have access to the data sets for each of these three sources. I multiplied 500 by 0.15, and arrived at my estimate of 75 people at high risk for PTSD in my imagined gathering of 500.

To estimate the number of people in my imagined 500 likely to develop addiction, I again reviewed the literature and found that 34% of people diagnosed with PTSD also have addiction. I multiplied 75 by 0.34 to arrive at 25 estimated people with addiction in the gathering of 500. One may also multiply 0.15 by 0.34 to obtain 0.05, or 5%, and multiply the full 500 by 0.05, again equaling 25 people at risk for addiction.

In a gathering of 500 people who experienced community violence, 15% are at risk for PTSD, or 75, and 5% are at risk for addiction, or 25 – due to the event of community violence alone.

PDF of Research Excerpts

Photo: Laurel Sindewald, statue, Hahn Horticulture Garden, Virginia Tech

A personal note from Anne Giles, added 4/5/17: I am one among a likely cohort of 300 who developed addiction in Blacksburg, Virginia after the Virginia Tech shootings. Of the 40,000+ people living in Blacksburg in 2007, research predicts 15% of them would develop PTSD. That would be 6,000. Of that 6,000, research predicts 5% would develop addiction. That’s 300.

Handshake Media maintains a list of addiction recovery resources for people living in the Blacksburg, Virginia area.

This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.