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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: J Psychiatr Res. 2024 Jan 23;171:171–176. doi: 10.1016/j.jpsychires.2024.01.041

Trauma-Related Shame Predicts Daily Non-Medical Prescription Opioid Use Among Individuals with PTSD Symptoms

Tanya C Saraiya 1,2,*, Alyssa C Jones 2,3, Teresa Lopez-Castro 4, Caitlyn O Hood 5, Jessica Flores 6,7, Christal L Badour 7
PMCID: PMC10922897  NIHMSID: NIHMS1963671  PMID: 38290235

Abstract

Non-medical prescription opioid use (NMPOU) is the use of opioids without a prescription or in a way different from how they were prescribed and is the fourth most common type of drug use in the United States. Separate research has shown that trauma-related shame is linked to posttraumatic stress disorder (PTSD) and, respectively, opioid use. However, no study to date has empirically examined the association between trauma-related shame and NMPOU among individuals with PTSD symptoms. Forty adults with clinical or subclinical PTSD who reported engaging in NMPOU at least one day in the prior month before the study completed 28 days of daily surveys. Trauma-related shame was measured at baseline. NMPOU and underlying motives to engage in NMPOU were assessed once daily via a smartphone app. Twenty-four participants (60%) reported NMPOU over the 28-day period. After controlling for PTSD symptoms and covariates, mixed models showed that higher trauma-related shame significantly predicted higher risk of daily NMPOU (B=0.06, SE=0.03, t=2.14, p=.03). After controlling for false discovery rates, trauma-related shame also significantly predicted NMPOU due to the following motives (p’s<.031): to manage depression/sadness, to manage anxiety, to manage other stress/worry, and to get high. Among individuals with PTSD, higher baseline trauma-related shame prospectively and positively predicted greater NMPOU over a four-week daily monitoring period. Findings suggest a need to attend to trauma-related shame and its impact on subsequent motivations to engage in NMPOU. Future research should examine how treatments may effectively target trauma-related shame to reduce NMPOU and more severe PTSD symptoms.

Keywords: prescription opioids, opioid use, posttraumatic stress disorder, shame

1. Introduction

Non-medical prescription opioid use (NMPOU) is the use of opioid medications without a prescription or in a different way than prescribed by a health care professional (NIDA, 2023). This can include using more of an opioid than the prescribed dose, combining it with other substances, using someone else’s prescription, purchasing non-prescribed opioids, or using it via a route of administration different than prescribed (e.g., snorted). In the U.S., NMPOU is the fourth most common type of substance used (following alcohol, tobacco/nicotine, and cannabis) and an ongoing public health crisis (Chisholm-Burns et al., 2019; SAMHSA, 2020). The opioid susceptibility model, more commonly known as the self-medication hypothesis, suggests that individuals may use opioids to cope with traumatic memories and posttraumatic stress disorder (PTSD) symptoms (Danovitch, 2016). Several studies have empirically supported this theory where among individuals using substances, those with PTSD show a greater likelihood of engaging in NMPOU to manage PTSD symptoms of hyperarousal, reactivity, emotional numbing, and negative affect (Fareed et al., 2013; Goodrum et al., 2022; Meier et al., 2014; Smith et al., 2016).

A common affect in the wake of trauma is trauma-related shame, defined as an emotional state where an individual perceives themselves as defective due to their traumatic experiences (Harman & Lee; Wilson et al., 2006). Trauma-related shame is strongly associated with PTSD symptoms (López-Castro et al., 2019) and can lead to behavioral withdrawal and isolation in an attempt to obscure one’s perceived worthlessness (Øktedalen et al., 2014). Research also shows that trauma-related shame is significantly associated with avoidant coping. Avoidant coping consists of cognitive avoidance, the process through which one shifts their attention away from internal distress through emotional suppression or denial, and behavioral avoidance, the process of withdrawing the self from others (Held et al., 2015; Taylor, 2015; Tiet et al., 2006; Tipsword et al., 2022). Substance use is one way to engage in avoidance coping; it allows individuals to numb, or escape, internal distress and can facilitate withdrawal from others. This pathway of trauma-related shame leading to avoidance coping, such as substance use, suggests that trauma-related shame is likely associated with NMPOU (Held et al., 2015). Moreover, the strong relationship between trauma-related shame and PTSD symptoms suggests that trauma-related shame may particularly influence NMPOU among individuals with co-occurring PTSD symptoms. Despite these possible relationships, no research to date has examined the longitudinal associations between trauma-related shame and NMPOU among individuals misusing opioids and with PTSD symptoms. Such an investigation could elucidate the reinforcing relationship between trauma-related shame, avoidance coping, NMPOU, and PTSD symptoms that may be one mechanism underlying the comorbidity of opioid use disorder (OUD) and PTSD (i.e., OUD/PTSD).

Although there has been limited research on trauma-related shame and NMPOU, there has been significantly more prior research on trait shame, defined as the general tendency to experience shame (Tangney & Dearing, 2003), and substance use. Studies have shown that trait shame significantly predicts increased substance use (Batchelder et al., 2022; Snoek et al., 2021), and qualitative research has richly documented high levels of trait shame among individuals misusing opioids (e.g., Andraka-Christou et al., 2022; Bakos-Block et al., 2022) and with co-occurring OUD/PTSD symptoms (e.g., Saraiya et al., 2020; Sugarman et al., 2021). Some of these studies have even shown that reducing shame could increase retention on medications for OUD (Hooker et al., 2022) highlighting the powerful effect reducing shame could have on treatment outcomes. However, a limitation of these studies is their focus on trait shame rather than trauma-related shame. Trauma-related shame may be more salient to examine because it is more strongly associated with PTSD symptoms (DeCou et al. 2021; Jones & Badour, 2023; Semb et al., 2011). To our knowledge, only one study to date has examined trauma-related shame among individuals using substances. Among a substance use treatment-seeking sample (49% opioids), Held and colleagues (2015) found that trauma-related shame was significantly associated with more severe PTSD symptoms as well as engagement in avoidance coping. These findings suggest that trauma-related shame is associated with avoidance coping and PTSD among individuals using primarily opioids. However, it remains unclear if trauma-related shame is also associated with risk of NMPOU.

The present study is a secondary analysis of a larger, daily diary study of individuals with NMPOU and PTSD symptoms (Badour et al., 2023). There are two study aims. First, the study aims to examine if trauma-related shame predicts daily NMPOU. We hypothesized that after controlling for PTSD symptoms and covariates, higher trauma-related shame would predict NMPOU. Secondly, the study aims to examine if trauma-related shame predicts underlying motivations to engage in NMPOU. We hypothesized that trauma-related shame would predict the underlying motive of engaging in NMPOU to cope with psychiatric symptoms (i.e., anxiety, depression, stress/worry, and traumatic memories) based on findings in prior literature (Danovitch, 2016). All together, these study findings have the potential to inform the role of trauma-related shame in risk of NMPOU, and thus be a possible treatment target in the design of treatments for co-occurring OUD/PTSD. Additionally, findings could inform the underlying motivations to engage in NMPOU which will enhance knowledge on how to best mitigate NMPOU.

2. Material and methods

Detailed information on study methods is reported in the primary outcome paper (Badour et al., 2023). Multiple recruitment methods were used to recruit participants, including advertisements, flyers, opioid programs associated with the State Department of Health, and social media. A total of 156 individuals completed a preliminary phone screen. Ninety individuals were eligible, forty-three were enrolled into the study, and three were removed due to being deemed ineligible during the intake at the baseline appointment. Consequently, eligible participants were N = 40 community-recruited adults with PTSD or subclinical PTSD (60% women, Mage = 39.85 years, SD = 11.61 years) who reported at least one day of NMPOU in the month prior to participation. Participants identified as White (67.5%), Black/African American (15.0%), or belonging to more than one racial/ethnic group (17.5%). Primary clinical characteristics for the sample can be found in Table 1; additional information is in [Badour et al. (2023].

Table 1.

Clinical characteristics of the total sample (N=40)

%(n)
PTSD
 Full clinical 67.5% (27)
 Subclinical1 32.5% (l3)
Major depressive episode
 Current 50.0% (20)
 Past 80.0% (32)
Any substance use disorder 92.5% (37)
 Opioid use disorder 82.5% (33)
 Stimulant use disorder 52.5% (21)
 Alcohol use disorder 50.0% (20)
 Cannabis use disorder 50.0% (20)
 Sedative, hypnotic, anxiolytic use disorder 20.0% (8)
 Other substance use disorder2 22.5% (9)
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1

Subclinical PTSD was defined as meeting 2 or 3 of criteria B-E diagnosis for PTSD as well as distress or impairment per the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013; McLaughlin et al., 2015).

2

The most common ‘other’ substance use disorder was related to gabapentin use.

Study procedures were approved by the affiliated Institutional Review Board. Participants provided informed consent before completing a brief phone screening. The study screening was followed by a baseline appointment with in-person interviews and online self-report questionnaires. Following the baseline appointment, participants were asked to complete four weeks of once-daily self-report measures administered on LifeData, a smartphone app. A total of N=40 participants were enrolled into the study and completed the baseline appointment. One participant withdrew during the four-week period; available data for this participant were retained for analyses. Two participants did not complete any daily diary entries during the four-week period. These two individuals were excluded from primary outcome analyses (N=38). All participants were compensated for their time in the study.

At baseline, participants completed the Trauma-Related Shame Inventory (TRSI; Øktedalen et al., 2014) which ranges from 0–72 where higher scores suggest higher trauma-related shame. Additionally, study staff administered the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013) and the MINI International Neuropsychiatric Interview for DSM-5 (Sheehan et al., 1998). Daily assessments included the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) adapted to inquire about daily symptoms, questions assessing daily prescription opioid medication use, and whether use was nonmedical (non-prescribed medication, more frequent or higher dose than prescribed, or use for non-prescribed reasons). Participants could also report the following motives for use (McCabe et al., 2007): pain management, coping-related motives (to manage nervousness/anxiety, depression/sadness, other stress/worries, or traumatic or stressful memories), to improve sleep, to get high, to prevent withdrawal because it is seen as safer than “street” drugs, and to counteract the effects of other drugs. Participants were instructed to endorse all relevant motives each day they engaged in NMPOU.

Generalized linear mixed models (GLMM) were employed for analyses. GLMM is ideal for analyzing longitudinal data because models account for the dependent nature of the repeated outcome measures nested within individuals by incorporating appropriate covariance structures. GLMM models can also fit various distributions of data thereby allowing greater model specification. The distribution for outcome variables was binary. A total of eight separate GLMM models were fit to these data to assess if trauma-related shame predicted NMPOU and the following NMPOU motives: to manage pain, to get high, to manage depression/sadness, to manage nervousness/anxiety, to manage stress/worries, to manage traumatic/stressful events, and to avoid withdrawal. The final two motives (i.e., to prevent withdrawal because it is seen as safer than “street” drugs, and to counteract the effects of other drugs) were not analyzed due to a low endorsement rate among participants. Across models, covariates included the fixed effects of day (−13.5 [day 1] to 13.5 [day 28]), between- and within-person PTSD symptoms, gender, and current major depressive episode. All models were specified with random intercepts to account for the correlation of daily diary responses within participants. All models were also fitted with restricted maximum likelihood criteria to account for missing data (25.19%) due to participants not completing daily diary surveys. Restricted maximum likelihood criteria is ideal for handling missing data because it uses all observed and partial data to calculate model estimates and standard errors. Statistical power and the robustness of results were increased by the large number of observations (n = 796) in the level 1 sample size of GLMMs. Although the level 2 sample size of this study was small and a limitation, simulation studies have shown that for GLMM, a level 2 sample size of thirty yields unbiased estimates of fixed effects and standard errors (Maas & Hox, 2005). Thus, the combination of a sample size above thirty and the high number of level 1 observations suggested sufficient power for statistical analyses. Nevertheless, to control for the number of multiple comparisons, the false discovery rate controlling procedure was used (Benjamini & Hochberg, 1995).

3. Results

Detailed information regarding patterns and motives of NMPOU can be found in Badour et al. (2023] and McCann et al. (in preparation). Across N=38, there was a total of 1064 surveys (38 × 28 days = 1064) participants could complete. Participants completed 796 of 1064 (74.81%) possible daily surveys, a response rate akin to other substance using samples (Jones et al., 2019). The average number of surveys completed per participant was M = 20.95 (SD = 8.07; range = 1–28) where more than 80% of the sample completed more than half (i.e., 14 days) of the daily diary assessments. A NMPOU observation was defined as participant self-report of NMPOU. Of the completed 796 surveys, 198 observations of NMPOU were recorded (24.87%) across 24 participants. Of these participants, the average report of NMPOU was on M = 46.84% (SD = 34.76%; range = 4.17–100%) days. This equates to NMPOU on M = 13.12 (SD = 9.73; range = 1.17–28) days. The remaining observations among participants were not included due to solely engaging in opioid use as prescribed or lacking information to discern medical versus NMPOU (see Badour et al., 2023).

Pain relief was the most common motive for NMPOU (endorsed on 71.7% of all NMPOU days) followed by coping-related motives for NMPOU (nervousness/anxiety [57.6%], depression/sadness [49.5%], other stress/worries [48.0%], and traumatic or stressful memories [30.8%]). NMPOU was also frequently endorsed to avoid withdrawal (42.9% of all NMPOU days), to improve sleep (37.4%), and to get high (33.8%). Less commonly, NMPOU was reported because it was seen as safer than street drugs (10.6% of all NMPOU days) or to counteract the effects of other drugs (5.6%).1 The average score on the TRSI was 25.42 (SD = 16.24, range = 0 – 60). The average score on the TRSI for individuals who endorsed NMPOU during the 28-day period (n = 24) was M = 30.13 (SD = 15.55; range = 1–60). The average score on the TRSI for individuals who did not endorse NMPOU during the 28-day period and completed at least one survey during this period (n = 14) was M = 17.37 (SD = 14.55; range = 0–56).

Model outcomes are in Table 2. Men were more likely to report NMPOU and to endorse NMPOU to manage other stress/worry, to manage memories of a traumatic or stressful event, and to get high. Controlling for covariates, higher trauma-related shame at baseline predicted an increased likelihood of daily NMPOU, as well as an increased likelihood of reporting the following motives when engaging in NMPOU: to manage depression/sadness, to manage anxiety, to manage other stress/worry, to manage memories of a traumatic or stressful event, and to get high. Correction for false discovery for multiple comparisons on motives outcomes (Benjamini & Hochberg, 1995) resulted in a corrected critical p-value of .031. Thus, the association between trauma-related shame and NMPOU to manage trauma memories became non-significant. All other associations survived correction. Trauma-related shame was unrelated to NMPOU to manage pain, to improve sleep, or to prevent withdrawal.

Table 2.

Fixed Effects Estimates from Generalized Linear Mixed Models (N=38)

Model B SE t OR 95% CI p Accuracy
Daily NMPOU
Intercept −5.45 1.35 −4.03 .004 0.0003, 0.061 <.001
Gender 1.86 0.86 2.16 6.42 1.18, 34.84 .03
Day −0.34 0.02 −2.31 0.97 0.94, 0.995 .02
Current Major Depressive Disorder 0.12 1.35 0.10 1.13 0.80, 16.06 .93 88.1%
PTSD symptoms (between-person) 0.45 0.04 1.04 1.05 0.96, 1.14 .30
PTSD symptoms (within-person) 0.03 0.02 1.49 1.03 0.99, 1.07 .14
Trauma-Related Shame 0.06 0.03 2.14 1.06 1.01, 1.12 .03
NMPOU to Manage Depression/Sadness
Intercept −7.77 1.19 −6.53 0.0004 0.00004, 0.004 <.001
Gender 1.28 0.66 1.94 3.59 0.99, 13.08 .05
Day −0.05 0.02 −2.57 0.95 0.92, 0.99 .01 90.4%
Current Major Depressive Disorder 0.46 1.11 0.41 1.58 0.18, 13.85 .68
PTSD symptoms (between-person) 0.06 0.04 1.62 1.06 0.99, 1.14 .11
PTSD symptoms (within-person) 0.04 0.03 1.39 1.04 0.98, 1.10 .16
Trauma-Related Shame 0.08 0.02 3.64 1.08 1.04, 1.13 <.001
NMPOU to Manage Anxiety/Nervousness
Intercept −8.04 1.48 −5.44 0.0003 0.00002, 0.01 <.001
Gender 1.44 0.84 1.71 4.21 0.81, 22.01 .09
Day −0.03 0.02 −1.22 0.98 0.94, 1.02 .22
Current Major Depressive Disorder 0.23 1.41 0.17 1.26 0.80, 20.01 .87 97.2%
PTSD symptoms (between-person) 0.08 0.04 1.78 1.08 0.99, 1.18 .08
PTSD symptoms (within-person) 0.04 0.03 1.46 1.04 0.99, 1.10 .15
Trauma-Related Shame 0.07 0.03 2.46 1.08 1.02, 1.14 .01
NMPOU to Manage Other Stress/Worry
Intercept −8.89 1.50 −5.94 0.0001 −0.00001, 0.003 <.001
Gender 1.87 0.77 2.44 6.50 1.44, 29.29 .02
Day −0.04 0.03 −1.73 0.96 0.91, 1.01 .08 92.4%
Current Major Depressive Disorder 1.02 1.19 0.86 2.76 0.27, 28.08 .39
PTSD symptoms (between-person) 0.07 0.04 1.74 1.07 0.99, 1.16 .08
PTSD symptoms (within-person) 0.02 0.02 0.93 1.02 0.98, 1.07 .35
Trauma-Related Shame 0.08 0.03 3.11 1.08 1.03, 1.14 .002
NMPOU to Manage Memories of a Traumatic or Stressful Event
Intercept −9.42 1.58 −5.98 0.0001 0.000004, 0.002 <.001
Gender 1.63 0.80 2.03 5.12 1.06, 24.82 .04
Day −0.01 0.02 −0.47 0.99 0.95, 1.03 .64 93.7%
Current Major Depressive Disorder −0.32 1.28 −0.25 0.73 0.06, 8.97 .80
PTSD symptoms (between-person) 0.11 0.02 2.49 0.99 0.95, 1.03 .01
PTSD symptoms (within-person) 0.05 0.04 1.36 1.05 0.98, 1.13 .18
Trauma-Related Shame 0.06 0.03 2.19 1.06 1.01, 1.12 .03
NMPOU to Get High
Intercept −7.94 1.11 −7.14 0.004 0.00004, 0.003 <.001 92.3%
Gender 1.62 1.13 2.23 5.06 1.21, 21.16 .03
Day −0.06 0.02 −2.79 0.94 0.90, 0.98 .01
Current Major Depressive Disorder 0.44 1.13 0.39 1.08 1.03, 1.13 .001
PTSD symptoms (between-person) 0.05 0.04 1.28 1.05 0.98, 1.12 .20
PTSD symptoms (within-person) 0.02 0.02 0.90 1.02 0.98, 1.07 .37
Trauma-Related Shame 0.08 0.02 3.30 1.08 1.03, 1.13 .001
NMPOU To Manage Pain
Intercept −6.13 1.53 −4.01 0.002 0.0001, 0.04 <.001
Gender 1.09 0.85 1.27 2.96 0.55, 15.83 .20
Day −0.06 0.02 −2.93 0.95 0.91, 0.98 .003
Current Major Depressive Disorder 0.52 1.51 0.34 1.68 0.09, 32.42 .73 89.1%
PTSD symptoms (between-person) 0.06 0.05 1.24 1.06 0.97, 1.16 .21
PTSD symptoms (within-person) 0.02 0.02 1.16 1.02 0.99, 1.05 .25
Trauma-Related Shame 0.04 0.03 1.45 1.68 0.99, 1.11 .15
NMPOU To Improve Sleep
Intercept −8.15 1.44 −5.65 0.0003 *0.00002, 0.01 <.001
Gender 1.36 0.82 1.66 3.91 0.78, 19.59 .10
Day −0.05 0.02 −2.31 0.96 0.92, 0.99 .02
Current Major Depressive Disorder 0.11 1.32 0.09 1.12 0.08, 14.88 .93 92.9%
PTSD symptoms (between-person) 0.08 0.04 2.06 1.08 1.00, 1.17 .04
PTSD symptoms (within-person) 0.05 0.03 1.53 1.05 0.99, 1.12 .13
Trauma-Related Shame 0.05 0.03 1.84 1.05 1.00, 1.12 .07
NMPOU to Prevent Withdrawal
Intercept −6.63 1.53 −4.35 0.001 0.0001, 0.03 <.001
Gender 0.96 1.12 0.86 2.62 1.01, 1.08 .39
Day 0.04 0.03 1.32 1.05 0.98, 1.11 .19
Current Major Depressive Disorder 0.18 1.69 0.11 1.20 0.04, 32.75 .92 95.6%
PTSD symptoms (between-person) 0.03 0.06 0.44 1.03 0.91, 1.15 .66
PTSD symptoms (within-person) 0.04 0.02 2.26 1.04 1.01, 1.08 .02
Trauma-Related Shame V0.06 0.03 1.83 1.06 1.00, 1.12 .07
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Note: NMPOU = Non-medical prescription opioid use; PTSD = posttraumatic stress disorder symptoms; gender is coded as 0 = woman, 1 = man

4. Discussion

This secondary analysis of a daily monitoring study examined how baseline trauma-related shame predicted daily NMPOU and motives to engage in NMPOU among participants with PTSD symptoms across a 28-day period. The first hypothesis was supported. For the 60% of participants across the full sample who engaged in NMPOU, higher baseline levels of trauma-related shame significantly predicted a higher likelihood of engaging in daily NMPOU, after controlling for the effect of PTSD symptoms and other relevant covariates. The second hypothesis was partially supported. Higher trauma-related shame significantly predicted NMPOU to cope with depression/sadness, anxiety, stress/worry; and to get high. Although pain relief was the most common motive for NMPOU, results did not show a significant relationship between trauma-related shame and NMPOU for pain relief. Findings suggest that higher trauma-related shame predicts NMPOU and is thereby important to assess and address among individuals with PTSD symptoms and NMPOU. Findings also suggest that trauma-related shame predicts engaging in NMPOU as a form of avoidance coping (i.e., to cope with distressing emotion states), which is consistent with prior research (Held et al., 2015). Future work should examine whether NMPOU yields subsequent increases in trauma-related shame, supporting a potential negative feedback loop.

Results showed that trauma-related shame predicted NMPOU above and beyond PTSD symptoms. Clinically, these findings suggest that it may be beneficial to target trauma-related shame in treatments for co-occurring OUD/PTSD. There are several existing treatment approaches which may be capitalized upon to attend to individuals with trauma-related shame, PTSD symptoms, and NMPOU. For instance, a recent review of treatments for trauma-related shame found that exposure-based therapies were slightly more efficacious than cognitive-based therapies (Serfioti et al., 2022), potentially due to the intense affective and behavioral dimensions of shame (e.g., withdrawal and hiding the self) that may not always have associated cognitive components. Additionally, mindfulness treatments appear effective for shame by increasing self-compassion among individuals with PTSD (Au et al., 2017) and among individuals with trauma exposure and substance use disorders, including OUD (Held et al., 2018; Moore et al., 2022; Schuman-Olivier et al., 2022). Greater compassion may decrease the strength of trauma-related shame and associated self-criticism and self-blame. These findings are particularly compelling given that mindfulness treatments have also been shown to be therapeutic for individuals with severe childhood trauma, which is common among individuals with OUD (Joss & Teicher, 2021). It will be beneficial for future research to investigate if these interventions can not only reduce trauma-related shame in co-occurring NMPOU and PTSD symptoms, but also reduce co-occurring OUD/PTSD symptoms.

This study has strengths and limitations warranting consideration. This study focused on individuals with dimensional levels of OUD and PTSD symptoms by including individuals with subclinical PTSD symptoms and anyone who endorsed at least one day of NMPOU in the past 30 days prior to the study. This broad inclusion criteria may be seen as a limitation since participants did not have co-occurring OUD/PTSD. However, it is also a strength because results are more generalizable to individuals with dimensional levels of OUD and PTSD symptoms (Ruglass et al., 2017; Zlotnick et al., 2002). As such, findings help to identify targets for early intervention. Another strength was the daily monitoring design, offering the opportunity to test prospective hypotheses. However, a limitation was the small sample size. Although this was offset by the large number of level 1 observations from the daily monitoring design, a small level 2 sample size can increase bias in standard error estimates for variance parameters and did not allow for further exploration of potential gender differences. Findings should be replicated in a larger sample particularly to consider whether non-significant associations between shame and underlying motives for NMPOU were due to possible type II error. For instance, pain relief was the most common motive for NMPOU, but there was no significant association in our sample. It is possible that in a larger sample such an association would be statistically significant.

An additional limitation to this study was the assessment of trauma-related shame solely at baseline and not at multiple timepoints throughout the study. Given that trauma-related shame often persists throughout treatment (e.g., Larsen et al., (2019)), it seems unlikely that trauma-related shame would fluctuate weekly. Nevertheless, future studies should examine how weekly fluctuations in trauma-related shame may influence NMPOU. Our study also did not assess for other possible covariates such as chronic pain. Such assessments were not included to balance data collection with participant burden. Future studies are encouraged to incorporate repeated chronic pain and sleep quality assessments to capture temporal associations. Lastly, the sample was predominantly non-Hispanic white, limiting the generalizability of findings to other diverse individuals. Shame can be higher among individuals with marginalized backgrounds (Johnson et al., 2022; Saraiya et al., 2019). It will be imperative for future work to understand trauma-related shame among minoritized groups. Limitations aside, these preliminary findings demonstrate trauma-related shame as an important intervention target to reduce NMPOU among individuals with PTSD symptoms and thus, worthy of additional investigation.

Highlights.

  • Daily monitoring study of non-medical prescription opioid use (NMPOU) for 28 days.

  • Trauma-related shame predicted non-medical prescription opioid use (NMPOU).

  • Trauma-related shame predicted motives to engage in NMPOU.

  • Trauma-related shame may be an important treatment target for OUD and PTSD.

Funding:

This study was supported in part by grants from the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Career Award at the University of Kentucky (K12 DA035150 PI: Badour), the National Institute on Drug Abuse K23 DA055209 (PI: Saraiya), the Disparities Researchers Equalizing Access for Minorities (DREAM) Scholars Program at the University of Kentucky’s Center for Clinical and Translation Science (TL1TR001998: Flores), and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs for Dr. Alyssa C. Jones.

Footnotes

Declarations of Interest: None

1

Given infrequent endorsement of NMPOU because it was seen as safer than street drugs (or to counteract the effects of other drugs), these motives were not examined in subsequent models.

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