Screening for Adverse Childhood Experiences (ACEs) As a Way to Predict Overdose Risk in Adult Sickle Cell Patients

Background: Formally assessed Adverse Childhood Experiences (ACEs), which include common traumatic experiences in childhood, predict not only later chronic health complications, but also later substance misuse, suicide and overdose [1,2,4]. The US opioid mortality epidemic may be in part due to prior ACEs among pain patients [2,3]. Therefore, our Adult SCD Medical Home (ASCDMH) explored how behavioral health, including ACEs, impacted adult Sickle Cell Disease (SCD) health. We report here the relationship between prior ACEs and current Overdose Risk Score (ORS) among a sample of adult SCD patients.

Method: We administered a screening survey battery to 103 ASCDMH patients. ASCDMH physicians periodically monitored both their urine sample results for prescribed opioids and illicit substances, and their legally required chronic daily Morphine Milligram Equivalents (MME) and ORS. The survey included a previously validated formal ACE screening tool. We categorized ACE scores as 0 ACEs = No risk; 1-4 ACEs = Moderate risk; 5-10 ACEs = High Risk. Further, we categorized ACE questions according to types of experiences: answering yes to questions 1-3 = abuse; answering yes to questions 4-5= neglect, and; answering yes to questions 6-10 = household dysfunction. To obtain the ORS, we used the raw MME value. Analysis used Spearman's correlation of individual ACEs versus individual ORS, as well as Analysis of Variance (ANOVA) to compare ORS and category values.

Results: (Table 1) The ORS raw mean was significantly higher as household dysfunction score (0-6 score) rose (ANOVA R-square=0.11, P-Value=0.04<0.05).

Further, the overall ACE score correlated with ORS (Spearman Correlation R=0.20, P-Value=0.04).

As well, ACE categories (abuse, neglect, household dysfunction, Table 2) often significantly correlated directly with either MME or ORS.

Conclusion: The ANOVA results showing higher mean ORS among patients with higher household dysfunction suggest that some SCD patients may be chemically coping with opioids as a means to tolerate emotional distress that has been compounded throughout their life. The correlation of the ACE scores with MME and ORS suggests that those who experience childhood abuse require larger doses of opioids as adults to manage their SCD pain. In addition to the above household dysfunction postulate, we posit some connection between childhood trauma and the body's later ability to control pain. Further, confirmed in other samples, we postulate these results may legitimize the use of the ACE to give SCD chronic opioid prescribers the ability and time to intervene with alternative pain management options as well as behavioral health interventions and perhaps avoid overdoses. We postulate ACE screens of all patients living with SCD may not only reveal abuse indicators and household dysfunction indicators, but also may target those at risk for overdose, likelihood of substance misuse or chemical coping and other secondary gain, and those responsive to behavioral health resources specific to SCD patient's needs and overdose risk.

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2. Cheatle MD, Klocek JW, McLellan AT. Managing pain in high-risk patients within a patient-centered medical home. Transl Behav Med. 2012 Mar;2(1):47-56. doi: 10.1007/s13142-012-0113-z. PMID: 24073097; PMCID: PMC3717821.

3. Matthew S. Karafin, Arun Singavi, Jawad Hussain, Nancy Wandersee, Thomas Heinrich, Robert W. Hurley, Liyun Zhang, Pippa Simpson & Joshua J. Field (2018) Predictive factors of daily opioid use and quality of life in adults with sickle cell disease, Hematology, 23:10, 856-863, DOI:

4. Stein MD, Conti MT, Kenney S, 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. doi:10.1016/j.drugalcdep.2017.07.007

Smith:Novartis: Consultancy, Honoraria; Novo Nordisk: Other: DSMB; Agios: Research Funding; Forma Therapeutics: Consultancy, Research Funding; Emmaus: Consultancy; Global Blood Therapeutics: Consultancy, Honoraria, Research Funding, Speakers Bureau; Pfizer: Consultancy, Research Funding; Imara: Research Funding.