In 2017, approximately 20.3 million adults had a diagnosed substance use disorder (SUD), yet only 8% (1.6 million) received specialized treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). In the United States, SUDs have become an epidemic, with major negative consequences including compromised health and well-being, destruction of family systems, and death. In fact, SUD overdoses are the leading cause of injury-related death, claiming 130 lives every day (Centers for Disease Control and Prevention, 2019). SUDs are chronic medical conditions often requiring lifelong intervention. Even with treatment, 60%-90% of people with SUDs experience a relapse during recovery (Yaghubi et al., 2017), making therapeutic interventions challenging for health care providers (HCPs).

Numerous factors can contribute to a person's susceptibility to developing an SUD, such as genetics and epigenetics. Some estimates suggest nearly 40%-60% of SUD susceptibility directly relates to a person's genetics (National Institute on Drug Abuse, 2014). There is a direct correlation between traumatic experiences and the development of SUDs. Some studies estimated that 67%-92% of patients with SUDs reported having experienced at least one traumatic event (according to The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-IV), post traumatic stress disorder (PTSD) criterion A) in their lifetime (Carletto et al., 2018); thus, trauma can be a contributing factor inhibiting the lifelong process of recovery and its long-term goal of abstinence. Trauma can be directly or indirectly experienced (American Psychiatric Association, 2013), making it difficult to predict or prepare for the effects events may have upon those with SUDs.

With trauma noted as a common factor feeding into substance use, HCPs are recognizing the lack of interventions to directly address trauma as a cause of client relapse and substance seeking. Treatment as usual within outpatient facilities typically consists of cognitive behavioral therapies, 12-step programs, and medication-assisted therapies. Without a focus on interventions addressing both the SUD and underlying trauma, HCPs may not be providing the best possible evidence-based care and chance of recovery for patients (DiPirrio, 2017).

Some facilities have begun implementing trauma-focused therapies such as Eye Movement Desensitization and Reprocessing (EMDR). EMDR is a Level A trauma treatment endorsed by the SAMHSA and the World Health Organization as an evidence-based approach in treating those who experience trauma and its related symptoms (SAMHSA, 2014; World Health Organization, 2013). EMDR methodology allows for adaptive information processing taking place while reprocessing traumatic memories that may trigger maladaptive coping strategies such as overuse and misuse of substances. Traditional recovery programs take a top-down approach by helping to change thoughts and behaviors using cognitive behavioral techniques as part of the therapeutic process. EMDR takes a bottom-up approach, which has the potential to calm the limbic system (the emotional brain) and eliminate the fight/flight/freeze response, which is the start of the addiction cycle (Shapiro, 2018).

EMDR therapy originates from a three-pronged adaptive information processing model in which the past, present, and future experiences are attended to. What the limbic system holds on to from early childhood are the negative cognitions that are carried on into adulthood unless there is an adaptive resolution to the negative life event, coincidentally causing this negative, cognitive distorted loop in the prefrontal cortex (Solomon, 2014). This bottom-up approach, limbic to prefrontal cortex, is the theoretical mechanism of action of EMDR. Clinicians target negative life events and allow patients to reprocess the adverse life events until there is an emotional resolution and a decrease in tenacity of the emotional response. In other words, the thoughts of "I am not good enough" because of a verbally abusive parent, does not have the same emotional impact it once had, which with patients with SUDs, has a direct correlation with abusing substances in the first place (Shapiro, 2018). EMDR therapy targets symptoms associated with SUDs, such as cravings and triggers contributing to relapse focusing on the inner emotional brain of the limbic system, starting from the bottom of the brain working upward to the prefrontal cortex where behaviors, thoughts, and judgments take place. The implementation of EMDR therapy has seen encouraging results in outpatient settings, resulting in the reduction of SUD symptoms (Back et al., 2006; Ouimette et al., 2010). According to a systematic review by Pilz et al. (2017), EMDR has a positive effect in decreasing cravings, fears, and depression and to help those experiencing SUDs with emotional regulation and self-esteem. Training is available; clinicians can visit the EMDR International Association website at https://www.emdria.org/ for more information. Clinicians who are licensed to provide psychotherapy are eligible to be trained and can receive certification in the therapeutic approach. The price of training ranges from $850 to $2,000 depending on the trainer and takes at least 3-6 months of individual and group supervision to become proficient in its use for best client outcomes.

Although the work of trauma-focused therapies for patients with SUDs has attracted international attention, a gap in the literature regarding its implementation and results remains for this population. More research is needed to measure the impact therapies such as EMDR have on recovery, resilience, anxiety, and trauma symptoms of those experiencing an SUD compared with those who are receiving treatment as usual. Nurses and advanced practice nurses working with the population with SUDs can advocate for and implement EMDR therapy and provide yet another tool to assist them on their journey to recovery.

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