The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study

A population-based analysis of over 17,000 middle-class American adults undergoing comprehensive, biopsychosocial medical evaluation indicates that three common categories of addiction are strongly related in a proportionate manner to several specific categories of adverse experiences during childhood. This, coupled with related information, suggests that the basic cause of addiction is predominantly experiencedependent during childhood and not substance-dependent. This challenge to the usual concept of the cause of addictions has significant implications for medical practice and for treatment programs. Purpose: My intent is to challenge the usual concept of addiction with new evidence from a population-based clinical study of over 17,000 adult, middle-class Americans. The usual concept of addiction essentially states that the compulsive use of 'addictive' substances is in some way caused by properties intrinsic to their molecular structure. This view confuses mechanism with cause. Because any accepted explanation of addiction has social, medical, therapeutic, and legal implications, the way one understands addiction is important. Confusing mechanism with basic cause quickly leads one down a path that is misleading. Here, new data is presented to stimulate rethinking the basis of addiction. Background: The information I present comes from the Adverse Childhood Experiences (ACE) Study. The ACE Study deals with the basic causes underlying the 10 most common causes of death in America; addiction is only one of several outcomes studied. In the mid-1980s, physicians in Kaiser Permanente's Department of Preventive Medicine in San Diego discovered that patients successfully losing weight in the Weight Program were the most likely to drop out. This unexpected observation led to our discovery that overeating and obesity were often being used unconsciously as protective solutions to unrecognized problems dating back to childhood. 4 Counterintuitively, obesity provided hidden benefits: it often was sexually, physically, or emotionally protective. 12/28/2003 page 2 Felitti ACE-Addiction article, DE Our discovery that public health problems like obesity could also be personal solutions, and our finding an unexpectedly high prevalence of adverse childhood experiences in our middle class adult population, led to collaboration with the Centers for Disease Control (CDC) to document their prevalence and to study the implications of these unexpected clinical observations. I am deeply indebted to my colleague, Robert F. Anda MD, who skillfully designed the Adverse Childhood Experiences (ACE) Study in an epidemiologically sound manner, and whose group at CDC analyzed several hundred thousand pages of patient data to produce the data we have published. Many of our obese patients had previously been heavy drinkers, heavy smokers, or users of illicit drugs. Of what relevance are these observations; do they imply some unspecified innate tendency to addiction? Is addiction genetic, as some have proposed for alcoholism? Is addiction a biomedical disease, a personality disorder, or something different? Are diseases and personality disorders separable, or are they ultimately related? What does one make of the dramatic recent findings in neurobiology that seem to promise a neurochemical explanation for addiction? Why does only a small percent of persons exposed to addictive substances become compulsive users? Although the problem of narcotic addiction has led to extensive legislative attempts at eradication, its prevalence has not abated over the past century. However, the distribution pattern of narcotic use within the population has radically changed, attracting significant political attention and governmental action. The inability to control addiction by these major, well-intended governmental efforts has drawn thoughtful and challenging commentary from a number of different viewpoints. In our detailed study of over 17,000 middle-class American adults of diverse ethnicity, we found that the compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse life experiences during childhood. This of course supports old psychoanalytic views and is at odds with current concepts, including those of biological psychiatry, drug-treatment programs, and drug-eradication programs. Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found. Study design: Kaiser Permanente (KP) is the largest prepaid, non-profit, healthcare delivery system in the United States; there are 500,000 KP members in San Diego, approximately 30% of the greater metropolitan population. We invited 26,000 consecutive adults voluntarily seeking comprehensive medical evaluation in the Department of Preventive Medicine to help us understand how events in childhood might later affect health status in adult life. Seventy percent agreed, understanding the information obtained was anonymous and would not become part of their medical records. Our cohort population was 80% white including Hispanic, 10% black, and 10% Asian. Their average age was 57 years; 74% had been to college, 44% had graduated college; 49.5% were men. In any four-year period, 81% of all adult Kaiser Health Plan members seek such medical 12/28/2003 page 3 Felitti ACE-Addiction article, DE evaluation; there is no reason to believe that selection bias is a significant factor in the Study. The Study was carried out in two waves, to allow mid point correction if necessary. Further details of Study design are described in our initial publication. The ACE Study compares adverse childhood experiences against adult health status, on average a half-century later. The experiences studied were eight categories of adverse childhood experience commonly observed in the Weight Program. The prevalence of each category is stated in parentheses. The categories are: recurrent and severe physical abuse (11%) recurrent and severe emotional abuse (11%) contact sexual abuse (22%) growing up in a household with: an alcoholic or drug-user (25%) a member being imprisoned (3%) a mentally ill, chronically depressed, or institutionalized member (19%) the mother being treated violently (12%) both biological parents not being present (22%) The scoring system is simple: exposure during childhood or adolescence to any category of ACE was scored as one point. Multiple exposures within a category were not scored: one alcoholic within a household counted the same as an alcoholic and a drug user; if anything, this tends to understate our findings. The ACE Score therefore can range from 0 to 8. Less than half of this middle-class population had an ACE Score of 0; one in fourteen had an ACE Score of 4 or more. In retrospect, an initial design flaw was not scoring subtle issues like low-level neglect and lack of interest in a child who is otherwise the recipient of adequate physical care. This omission will not affect the interpretation of our First Wave findings, and may explain the presence of some unexpected outcomes in persons having ACE Score zero. Emotional neglect was studied in the Second Wave. The ACE Study contains a prospective arm: the starting cohort is being followed forward in time to match adverse childhood experiences against current doctor office visits, emergency department visits, pharmacy costs, hospitalizations, and death. Publication of these analyses soon will begin. Findings: Our overall findings, presented extensively in the American literature, demonstrate that: Adverse childhood experiences are surprisingly common, although typically concealed and unrecognized. ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness. Adverse childhood experiences are the main determinant of the health and social well-being of the nation. 12/28/2003 page 4 Felitti ACE-Addiction article, DE Our overall findings challenge conventional views, some of which are clearly defensive. They also provide opportunities for new approaches to some of our most difficult public health problems. Findings from the ACE Study provide insights into changes that are needed in pediatrics and adult medicine, which expectedly will have a significant impact on the cost and effectiveness of medical care. Our intent here is to present our findings only as they relate to the problem of addiction, using nicotine, alcohol, and injected illicit drugs as examples of substances that are commonly viewed as ‘addicting’. If we know why things happen and how, then we may have a new basis for prevention. Smoking: Smoking tobacco has come under heavy opposition in the United States, particularly in southern California where the ACE Study was carried out. Whereas at one time most men and many women smoked, only a minority does so now; it is illegal to smoke in office buildings, public transportation, restaurants, bars, and in most areas of hotels. When we studied current smokers, we found that smoking had a strong, graded relationship to adverse childhood experiences. Figure 1 illustrates this clearly. The p value for this and all other data displays is . 001 or better. This stepwise 250% increase in the likelihood of an ACE Score 6 child being a current smoker, compared to an ACE Score 0 child, is generally not known. This simple observation has profound implications that illustrate the psychoactive benefits of nicotine; this information has largely been lost in the public health onslaught against smoking, but is important in understanding the intractable nature of smoking in many people. 11, 12, 13 ACE Score vs. Smoking 0 2 4 6 8 10 12 14 16 18