Health and well being of substance use disorder patients with and without posttraumatic stress disorder

Predictors of undocumented PTSD in persons using public mental health services

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

Examining the role of social support in treatment for co-occurring substance use disorder and posttraumatic stress disorder

Objective

Social support may be a critical mechanism in the treatment of co-occurring substance use disorder (SUD) and posttraumatic stress disorder (PTSD). However, no studies have examined how social support changes as a function of treatment or predicts treatment outcome in a Veteran population with co-occurring SUD and PTSD.

Method

The current study is a secondary analysis that examined social support over the course of treatment for co-occurring SUD and PTSD (N = 81). Analyses were conducted to examine if a) social support predicts change in substance use and PTSD symptoms, respectively, over the course of treatment and during follow-up, and b) substance use and PTSD symptoms, respectively, predicts change in social support over treatment and during follow-up.

Results

The findings revealed that between-person social support moderated decreases in substance use (B = -0.17, SE = 0.07, p = 0.017) and PTSD symptom severity (B = -0.12, SE = 0.05, p = 0.009) during treatment but not during follow-up. Within-person substance use and PTSD symptom severity predicted social support but substance use and PTSD symptoms did not moderate changes in social support during treatment or follow-up.

Conclusions

The findings highlight the critical role of social support during treatment in enhancing outcomes for individuals with co-occurring SUD and PTSD.

Protective Behaviors for COVID-19 Were Associated With Fewer Psychological Impacts on Nurses: A Cross-Sectional Study in Taiwan

Objective: The COVID-19 pandemic has increased psychological distress among common people and has caused health care providers, such as nurses, to experience tremendous stress. Methods: This prospective cross-sectional study assessed the psychological impacts on nurses in a community hospital in Taiwan, including major depressive disorder (MDD), posttraumatic stress (PTS), and pessimism. According to transactional theory, coping strategies and personal factors have psychological impacts. We hypothesized that behavioral responses to COVID-19 (problem-focused coping) are more effective in reducing psychological impacts than emotional responses to COVID-19 (emotion-focused coping). Independent variables were the use of behavioral and emotional coping strategies for COVID-19 and 3 personal factors, namely sleep disturbance, physical component summary (PCS-12), and mental component summary (MCS-12) of the 12-Item Short Form Health Survey (SF-12) obtained from the Medical Outcomes Study. Dependent variables comprised 3 psychological impacts, namely MDD, PTS, and pessimism. Results: We determined that behavioral coping strategies had significant negative effects on PTS and pessimism; however, emotional coping strategies had significantly positive effects on PTS and pessimism. Sleep disturbance was significantly associated with increased MDD and pessimism. PCS-12 had a significant negative effect on PTS, whereas MCS-12 was not significantly associated with any of the 3 psychological impacts. Conclusions: Nurses who adopted protective behavior against COVID-19, such as washing hands, wearing masks, avoiding touching eyes, and mouth, and avoiding personal contact, were associated with less posttraumatic stress and pessimism. Healthcare providers should consider strategies for improving preventive behaviors to help ease their worries and fears concerning COVID-19.

Polysubstance use classes and health outcomes among women attending specialist substance use treatment services

INTRODUCTION

Substance use is increasingly prevalent among women. Little research examines subgroups of women with substance use issues to identify their characteristics and thus enable treatment recommendations. The present study used latent class analysis to identify subgroups of substance use among women in substance-use treatment based on use in the 30 days prior to intake and examined changes in mental health and treatment outcomes following 60 days of treatment.

METHODS

Participants were women (N = 493) attending specialist non-government substance use treatment services in New South Wales, Australia.

RESULTS

Four distinct classes of substance users were identified: (i) Amphetamine Type Stimulants (ATS) Polysubstance (40.6%, n = 200); (ii) Alcohol Only (33.1%, n = 163); (iii) Cannabis and Alcohol (17.0%, n = 84) and (iv) Other Polysubstance (9.3%, n = 46). Women in the ATS Polysubstance class were the youngest and those in the Alcohol Only class were the oldest.

DISCUSSION AND CONCLUSIONS

Findings show that classes with high polysubstance use (ATS Polysubstance) differed from the single-substance use class (Alcohol Only). The ATS Polysubstance class had significantly greater improvements in health outcomes after 60 days compared to the Alcohol Only class. These findings suggest that although women with polysubstance use can benefit from substance use treatment, younger women (ATS Polysubstance) may benefit even more than older women (Alcohol Only). Future research should utilise a longitudinal design and examine additional psychosocial characteristics to extend on current findings.

Longitudinal assessment of PTSD and illicit drug use among male and female OEF-OIF veterans

OBJECTIVES

Posttraumatic stress disorder (PTSD) and substance use share both directional ("self-medication") and mutually-reinforcing associations over time. Research on gender differences regarding the co-occurrence of PTSD and substance use over time remains limited and largely focused on alcohol use; less is known regarding the co-occurrence of PTSD and illicit drug use, especially among veteran men vs. women. As the proportion of women in the military expands, we believe a greater focus on gender differences is warranted.

METHOD

We conducted a cross-lagged panel analysis of PTSD symptoms and drug use problems using two waves of data from a large, nationwide longitudinal registry of post-9/11 veterans. Participants included 608 men and 635 women (N = 1243; M_age = 42.3; 75.2% White) who completed self-report PTSD and drug use problem questionnaires at T1 and again at T2 15-37 months later.

RESULTS

Veteran men reported more severe drug use and related problems overall, yet the cross-sectional correlation between PTSD and drug use problems was strongest among drug using veteran women. In our cross-lagged models, we found that PTSD symptoms predicted future drug use problems among veteran men, whereas drug use problems predicted future PTSD symptom severity among women.

CONCLUSIONS

These results support the self-medication pathway among veteran men but not women, for whom drug use problems might prolong or exacerbate PTSD symptom severity over time. These results are consistent with some emerging evidence but also provide novel insight into functional associations governing the longitudinal course of PTSD and drug use problems for men vs. women.

Determining clinical cutoff scores for the Australian Treatment Outcomes Profile psychological health, physical health and quality of life questions

INTRODUCTION

The Australian Treatment Outcomes Profile (ATOP) is a brief instrument that measures self-reported substance use, health, and wellbeing in the previous 28 days for people in alcohol and other drug treatment. Previous studies have established the concurrent validity, inter-rater, and test-retest reliability of the tool. The current study sought to identify recommended cutoff scores for ATOP items for psychological health, physical health and quality of life that identify clients reporting clinically significant problems warranting further assessment and/or intervention, compared to cutoffs used by 'gold-standard' measures for these domains.

METHODS

Clients attending for treatment for problems with opioid (n = 144) or alcohol use (n = 134) completed the ATOP and comparison standardised questionnaires (Kessler-10, Short Form Survey 12 and the Personal Wellbeing Index) with a researcher. Receiver operating characteristics analysis, along with clinician perspectives, were used to recommend cutoff scores for ATOP items indicative of clinically significant problems.

RESULTS

A cutoff score of 5 or less out of 10 was identified as an optimal pragmatic cutoff for ATOP items relating to psychological health, physical health and quality of life items with regards to balancing sensitivity, specificity, and application in a treatment setting.

DISCUSSION AND CONCLUSIONS

The recommended clinical cutoffs will support clinicians and treatment services to identify clients who require further assessment and follow up for their psychological health, physical health and quality of life. The current study provides further evidence for the utility of the ATOP for individual clinical review, service planning and research.

Brain reward circuitry: The overlapping neurobiology of trauma and substance use disorders

Mental health symptoms secondary to trauma exposure and substance use disorders (SUDs) co-occur frequently in both clinical and community samples. The possibility of a shared aetiology remains an important question in translational neuroscience. Advancements in genetics, basic science, and neuroimaging have led to an improved understanding of the neural basis of these disorders, their frequent comorbidity and high rates of relapse remain a clinical challenge. This project aimed to conduct a review of the field's current understanding regarding the neural circuitry underlying posttraumatic stress disorder and SUD. A comprehensive review was conducted of available published literature regarding the shared neurobiology of these disorders, and is summarized in detail, including evidence from both animal and clinical studies. Upon summarizing the relevant literature, this review puts forth a hypothesis related to their shared neurobiology within the context of fear processing and reward cues. It provides an overview of brain reward circuitry and its relation to the neurobiology, symptomology, and phenomenology of trauma and substance use. This review provides clinical insights and implications of the proposed theory, including the potential development of novel pharmacological and therapeutic treatments to address this shared neurobiology. Limitations and extensions of this theory are discussed to provide future directions and insights for this shared phenomena.

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans

Background: Intensive treatment programmes (ITPs) for posttraumatic stress disorder (PTSD) produce large symptom reductions and have generally higher completion rates compared to traditional weekly care. Although ITPs do not appear to increase substance use, it has yet to be determined whether their effectiveness differs for veterans with and without hazardous alcohol use (HAU). Objective: This study examined the effectiveness of a 3-week Cognitive Processing Therapy-based ITP for 538 veterans with PTSD (66.0% male; mean age = 41.22 years) and with (n = 193) or without HAU (n = 343) for reducing PTSD and depression symptoms. Method: Veterans' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, during treatment, and at post-treatment. HAU (AUDIT-C total score ≥4 for males; ≥3 for females) was measured at intake. Results: Treatment completion rates were high for both individuals who endorsed HAU (92.68%) and those who did not (93.37%), likely due to veterans being housed near the treatment facility. Mixed effects regression models revealed a significant time by alcohol use interaction when predicting both PCL-5 (p < .001) and PHQ-9 (p = .003), suggesting time-trends over the course of the ITP differed based on alcohol use. Veterans who endorsed HAU improved to a statistically significantly lesser extent. However, endpoint differences between groups for both outcomes were small (Cohen's ds between 0.15 and 0.20). Conclusions: Veterans with and without HAU reported significant reductions in PTSD and depression symptoms and completed the ITP at comparably high rates. Findings support the effectiveness of intensive PTSD treatment programmes for individuals with PTSD and HAU. Future studies should utilize controlled designs to evaluate whether intensive PTSD treatment can reduce HAU.

Subgroups of comorbid PTSD and AUD in U.S. military veterans predict differential responsiveness to two integrated treatments: A latent class analysis

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Integrated treatments are effective, but not all patients respond and predicting outcome remains difficult. In this study, latent class analysis (LCA) identified symptom-based subgroups of comorbid PTSD/AUD among 119 veterans with PTSD/AUD from a randomized controlled trial of integrated exposure therapy (I-PE) versus integrated coping skills therapy (I-CS). Multilevel models compared subgroups on PTSD severity and percentage of heavy drinking days at post-treatment and 3- and 6-month follow-up. LCA revealed three subgroups best fit the data: Moderate PTSD/Low AUD Impairment (21%), High PTSD/High AUD Impairment (48%), and Low PTSD/High AUD Impairment (31%). There was a three-way interaction between time, treatment condition, and subgroup in predicting PTSD outcomes (p < .05). For the Moderate PTSD/Low AUD Impairment class, outcomes at post-treatment and 3-months were similar (ds = 0.17, 0.55), however I-PE showed greater reductions at 6-months (d = 1.36). For the High PTSD/High AUD Impairment class, I-PE demonstrated better post-treatment (d = 0.83) but comparable follow-up (ds = -0.18, 0.49) outcomes. For the Low PTSD/High AUD Impairment class, I-PE demonstrated stronger outcomes at every timepoint (ds = 0.82-1.15). Heavy drinking days declined significantly through follow-up, with an effect of subgroup, but not treatment, on timing of response. This was the first study modeling how PTSD and AUD symptoms might cluster together in a treatment sample of veterans with PTSD/AUD. Symptom-based subgroups show promise in helping understand variability in treatment response among patients with PTSD/AUD and deserve further study.

A pilot study on ecological momentary assessment in asylum-seeking children and adolescents resettled to Germany: Investigating compliance, post-migration factors, and the relation between daily mood, sleep patterns, and mental health

Background

Asylum-seeking children and adolescents (ASCs) resettled to western countries show elevated levels of psychological distress. While research on the mental health of ASCs is increasing, less is known about their day-to-day living experiences such as their daily mood, sleep patterns, and post-migration factors. Moreover, no examination in situ, using smartphone-assisted ecological momentary assessment (EMA), has been conducted up to now among ASCs. Furthermore, we do not know if screening measures succeed in reflecting the daily mood of ASCs experienced in everyday life.

Methods

We undertook a smartphone-assisted EMA study over a two-week period with 3 measurements a day. Participants were N = 40 ASCs from 10 different countries who had resettled to Germany. They completed standardized questionnaires screening for history of trauma and clinical symptoms (post-traumatic stress symptoms, depression, and anxiety) that were carried out in interview-like settings, and they participated in the subsequent EMA where they rated mood, sleep parameters, and post-migration factors on a daily basis. Multilevel models of clinical symptoms, daily mood, and sleep parameters were computed based on a total of 680 measurements.

Results

The multiply traumatized and highly distressed participants reported different levels of discrimination, and various social activities and contacts in the EMA. The overall compliance rate was shown to be 40.5%. Higher PTSS and anxiety scores were associated with lower levels of daily mood and poorer outcomes of some sleep parameters. Depression scores were not associated with any of the variables assessed in the EMA.

Conclusions

Smartphone-assisted EMA among ASCs resettled to Germany proved to be implementable despite a rather low compliance rate. Not only do ASCs show high symptom levels, they are also affected by these symptoms in their daily lives. The results emphasize the need for concise screenings and psychological treatment for this high-risk population. Limitations include the convenient nature of the sample and the lack of a comparison group.

The Impact of Co-occurring Post-traumatic Stress Disorder and Substance Use Disorders on Craving: A Systematic Review of the Literature

The frequent co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs) leads to manifestations of both conditions that are more severe and more resistance to treatment than single disorders. One hypothesis to explain this synergy is the impact of intrusive memories on craving which, in turn, increases the risk of relapse among patients with substance use disorders. The aim of this systematic review is to examine this possibility by assessing the impact of PTSD and its symptoms on craving among dual disorder patients. Using PRISMA criteria, four databases were comprehensively searched up to June, 2021, in order to identify all candidate studies based on broad key words. Resulting studies were then selected if they examined the impact of PTSD or PTSD symptoms on craving, and if they used standardized assessments of PTSD, SUD, and craving. Twenty-seven articles matched the selection criteria and were included in this review. PTSD was found to be significantly associated with increased craving levels among patients with alcohol, cannabis, cocaine, tobacco, and other substance use disorders. Exposition to traumatic cues among dual disorder patients was also shown to trigger craving, with an additive effect on craving intensity when exposure to substance-related cues occurred. In addition, certain studies observed a correlation between PTSD symptom severity and craving intensity. Concerning mechanisms underlying these associations, some findings suggest that negative emotional states or emotion dysregulation may play a role in eliciting craving after traumatic exposure. Moreover, these studies suggest that PTSD symptoms may, independently of emotions, act as powerful cues that trigger craving. These findings argue for the need of dual disorder treatment programs that integrate PTSD-focused approaches and emotion regulation strategies, in addition to more traditional interventions for craving management.

Public implementation of a web-based program for veterans with risky alcohol use and PTSD: A RE-AIM evaluation of VetChange

BACKGROUND

Evidence-based web and mobile interventions are available for a range of mental health concerns. Little is known about how self-administered web interventions are used outside of controlled research trials, and there is a critical need to empirically examine real-world public implementation of such programs. To this end, the aim of the current study was to evaluate and describe outcomes of a nationwide public implementation of VetChange, a self-administered web intervention for veterans with problematic alcohol use and symptoms of PTSD.

METHOD

The study used the RE-AIM framework to organize outcomes along five key dimensions: reach, effectiveness, adoption, implementation, and maintenance. This naturalistic observation study included program use information for all who registered an account with VetChange during the 2-year study period and who self-identified as a returning veteran. We collected program use data automatically via normal website operation; a subset of program users provided additional self-report outcome data. The study used linear multilevel mixed modeling to evaluate changes in alcohol use and PTSD symptoms over a six-month postregistration period.

RESULTS

VetChange successfully reached a large, geographically diverse sample of returning veterans with risky drinking and PTSD symptoms. Despite variable, overall modest, rates of intervention use over time, registered users demonstrated significant improvements in drinking, PTSD, and quality of life, and participants maintained these outcomes at a six-month follow-up.

CONCLUSIONS

Given the observed low cost per acquisition, positive clinical outcomes, and the potential to produce long-term cost savings through reduced health care burden associated with chronic alcohol use disorder and PTSD, this study demonstrates how web-based interventions can provide public health benefits and reduce long-term health care costs.

Internalizing and externalizing subtypes in female patients with co-occurring post-traumatic stress disorder and substance use disorders

BACKGROUND

Research has described subtypes with more internalizing and more externalizing symptoms in samples of patients with post-traumatic stress disorder (PTSD) and samples of patients with substance use disorders (SUD).

OBJECTIVE

This study sought to examine the respective subtypes in female PTSD-SUD patients and potential relationships with substance use characteristics.

METHODS

We performed a latent class analysis (LCA) in 343 adult female participants of a multisite therapy trial on PTSD and SUD. We derived externalizing symptoms from the Assessment of DSM-IV Personality Disorders (ADP-IV) questionnaire. We assessed internalization using the Symptom Checklist-27 (SCL-27) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). We collected substance use-related information using the Addiction Severity Index-Lite (ASI-lite).

RESULTS

LCA suggested four latent classes including an externalizing (10.8%), a moderately internalizing class (31.0%), and a highly internalizing class (22.0%), as well as a class with a low severity of psychological symptoms (36.3%). Externalizing participants used more substances than any other class, while the duration of substance use did not differ between groups. Regular use started at a significantly younger age among the members of the highly internalizing subgroup compared to the moderately internalizing and low severity participants, but at an older age compared to the externalizing group members.

CONCLUSIONS

The finding of two internalizing subgroups along with an externalizing and a low severity class emphasizes the heterogeneity and complexity of populations with PTSD and SUD. This heterogeneity bears implications for research among this group of patients, but also for their treatment, especially considering our results on differences in substance use.

The neural, behavioral, and epidemiological underpinnings of comorbid alcohol use disorder and post-traumatic stress disorder

Alcohol use disorder (AUD) and (PTSD) frequently co-occur and individuals suffering from this dual diagnosis often exhibit increased symptom severity and poorer treatment outcomes than those with only one of these diseases. Although there have been significant advances in our understanding of the neurobiological mechanisms underlying each of these disorders, the neural underpinnings of the comorbid condition remain poorly understood. This chapter summarizes recent epidemiological findings on comorbid AUD and PTSD, with a focus on vulnerable populations, the temporal relationship between these disorders, and the clinical consequences associated with the dual diagnosis. We then review animal models of the comorbid condition and emerging human and non-human animal research that is beginning to identify maladaptive neural changes common to both disorders, primarily involving functional changes in brain reward and stress networks. We end by proposing a neural framework, based on the emerging field of affective valence encoding, that may better explain the epidemiological and neural findings on AUD and PTSD.

Automatic Imitation in Comorbid PTSD & Alcohol Use Disorder and Controls: an RCT of Intranasal Oxytocin

INTRODUCTION

Mimicking movements of others makes both the imitating and imitated partners feel closer. Oxytocin may increase focus on others and has been shown to increase automatic imitation in healthy controls (HC). However, this has not been replicated, and oxytocin's effects on automatic imitation have not been demonstrated in clinical populations. This study attempts to replicate effects on HC and examine effects on people with comorbid posttraumatic stress disorder and alcohol use disorder (PTSD-AUD).

METHODS

Fifty-four males with PTSD-AUD and 43 male HC received three intranasal treatment conditions (placebo, oxytocin 20 International Units (IU), and oxytocin 40 IU) in a randomized order, across three separate testing days, as part of a double-blind, crossover parent study. At 135 min post-administration, each performed the imitation-inhibition task, which quantifies automatic imitation as the congruency effect (CE). After exclusions, the final analyzed data set included 49 participants with PTSD-AUD and 38 HC.

RESULTS

In HC, oxytocin 20 IU demonstrated a statistically significant increase in CE, and 40 IU showed a trend-level increase. In PTSD-AUD, oxytocin did not significantly increase CE. Post-hoc analysis showed the PTSD-AUD group had higher CE than HC on placebo visits.

DISCUSSION

Our data suggest PTSD-AUD is associated with higher automatic imitation than HC in the absence of oxytocin administration. We successfully replicated findings that oxytocin increases automatic imitation in HC. This demonstrates an unconscious motor effect induced by oxytocin, likely relevant to more complex forms of imitative movements, which have the potential to improve social connection. We did not find a significant effect of oxytocin on automatic imitation in PTSD-AUD. Future research should examine imitation in both sexes, at peak oxytocin levels, and on increasingly complex forms of imitation.

Changes in alcohol use, PTSD hyperarousal symptoms, and intervention dropout following veterans' use of VetChange

OBJECTIVE

Veterans of Iraq and Afghanistan conflicts report high rates of drinking, PTSD, and low rates of treatment engagement. Web interventions may help address unmet treatment need; unfortunately, little is known regarding outcomes or adherence to these interventions. In this study, we examined VetChange treatment outcomes and downstream effects of alcohol reduction on PTSD symptoms and intervention dropout rates over six months.

METHOD

Participants included 222 veterans (77.5% men, 78.3% White) between 22 and 57 (mean age = 36.02, SD = 7.19). All VetChange users completed a brief alcohol assessment and received personal feedback, then received full access to intervention content including psychoeducation; motivational and cognitive-behavioral modules for relapse prevention, goal-setting, social support, stress, anger, and sleep management; and mood and drink tracking. Veterans completed self-report measures of alcohol use and PTSD symptoms at baseline, one, three, and six months.

RESULTS

Alcohol use dropped by 43% over six months, p < .001, with the largest decrease occurring within the first month. Greater alcohol reduction in the first month predicted higher subsequent PTSD hyperarousal severity. Over half (52.3%) dropped out by month one, followed by 12.2% and 37.6% by months three and six. Hyperarousal symptoms, hypervigilance specifically, but not alcohol use predicted subsequent intervention dropout.

CONCLUSION

These results highlight the importance of attending to the association between alcohol use and PTSD symptom change in web-based interventions for veterans. The fact that hyperarousal symptoms were associated with elevated risk for intervention dropout signifies the need for online intervention refinement aimed at tailoring content to time-varying symptom presentations.

PTSD relapse in Veterans of Iraq and Afghanistan: A systematic review

This systematic review examines studies published between 2003, the initial invasion of Iraq, and 2018 related to the long-term treatment outcomes for Veterans of Iraq and Afghanistan suffering from combat-related posttraumatic stress disorder (PTSD). More specifically this review attempts to estimate the rate at which Veterans experience the return of symptoms after completing treatment. The review was conducted by the authors in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The literature search identified eight eligible studies, which met the predefined inclusion criteria. Of the included studies a majority were deemed to be at a high risk of attrition bias. In addition, few studies comprehensively reported relevant relapse or recurrence related outcome statistics. The implications of the available evidence base on long-term treatment outcomes are discussed. Recommendations for future studies on relapse and recurrence of PTSD symptoms among Veterans of Iraq and Afghanistan are also presented.

Mechanisms of Shared Vulnerability to Post-traumatic Stress Disorder and Substance Use Disorders

Psychoactive substance use is a nearly universal human behavior, but a significant minority of people who use addictive substances will go on to develop an addictive disorder. Similarly, though ~90% of people experience traumatic events in their lifetime, only ~10% ever develop post-traumatic stress disorder (PTSD). Substance use disorders (SUD) and PTSD are highly comorbid, occurring in the same individual far more often than would be predicted by chance given the respective prevalence of each disorder. Some possible reasons that have been proposed for the relationship between PTSD and SUD are self-medication of anxiety with drugs or alcohol, increased exposure to traumatic events due to activities involved in acquiring illegal substances, or addictive substances altering the brain's stress response systems to make users more vulnerable to PTSD. Yet another possibility is that some people have an intrinsic vulnerability that predisposes them to both PTSD and SUD. In this review, we integrate clinical and animal data to explore these possible etiological links between SUD and PTSD, with an emphasis on interactions between dopaminergic, adrenocorticotropic, GABAergic, and glutamatergic neurobehavioral mechanisms that underlie different emotional learning styles.

Emotion Regulation as a Mediator between Childhood Abuse and Neglect and Posttraumatic Stress Disorder in Women with Substance Use Disorders

A history of childhood abuse and neglect (CAN) is significantly associated with psychopathologies in adulthood, including comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Difficulties in emotion regulation (ER) might influence the association between CAN and PTSD. The aim of this study was to examine the relationship between CAN and PTSD symptom severity in women with SUD and to investigate the mediating role of general difficulties in ER and its specific dimensions. Method: We examined 320 women, with a current diagnosis of at least subsyndromal PTSD and SUD, using self-report measures of CAN, PTSD symptom severity, and ER difficulties. We conducted both simple and multiple bootstrapping-enhanced mediation analysis to investigate whether general difficulties in ER and its specific dimensions mediate the relationship between CAN and PTSD symptom severity. Results: General difficulties in ER mediated the association between CAN and PTSD symptom severity. CAN significantly predicted adult PTSD symptom severity, directly and indirectly, through ER difficulties. Difficulties engaging in goal directed behavior when distressed was the only ER dimension, which mediated the effect of CAN on PTSD symptoms. Conclusions: Our results suggest that difficulties in ER and specifically difficulties engaging in goal directed behavior when distressed might constitute an influential factor in the relationship between CAN and PTSD symptom severity in a sample of SUD patients, and highlight the importance of targeting ER as a potential treatment focus for patients with comorbid PTSD and SUD.

The effect of pre-existing alcohol use disorder on the risk of developing posttraumatic stress disorder: results from a longitudinal national representative sample

Background: There is inconsistent evidence in the literature as to whether or not Alcohol Use Disorder (AUD) is a risk factor for Post-Traumatic Stress Disorder (PTSD).Objectives: We evaluated the risk of developing PTSD after trauma exposure in individuals with AUD. As a secondary analysis, we also tested if alcohol dependence or alcohol abuse separately increased the risk of PTSD development. We also explored the effect of AUD on exposure to various traumas.Methods: Longitudinal data was obtained from 30,180 individuals with and without AUD from National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) waves I and II. Using propensity score methods, we matched individuals with AUD (alcohol abuse and/or dependence using DSM-IV criteria) to those without AUD at baseline on demographic, familial, and clinical factors to estimate the risk of PTSD development after trauma exposure. Data were adjusted for complex survey methods.Results: Individuals with AUD had an increased risk of being exposed to various traumas between wave I and II (60.6% vs. 48.3% of controls). Among individuals exposed to trauma between the two waves (N = 14,107), AUD had no effect on subsequent PTSD development after matching and controlling for covariates (OR: 1.00; 95%CI: 0.72-1.39; p = .99). However, those with alcohol dependence only did have an effect on subsequent PTSD development (OR: 1.76; 95%CI: 1.05-2.95; p = .03).Conclusion: In individuals with alcohol dependence the experience of trauma increases the risk of developing PTSD. These findings suggest that prevention methods from PTSD after trauma exposure for individuals with alcohol dependence are needed.

Effects of Oxytocin Administration on Cue-Induced Craving in Co-occurring Alcohol Use Disorder and PTSD: A Within-Participant Randomized Clinical Trial

BACKGROUND

Individuals with alcohol use disorder (AUD) are much more likely to meet criteria for posttraumatic stress disorder (PTSD) than the general population. Compared to AUD alone, those with comorbid AUD-PTSD experience worse outcomes. Prior literature suggests that oxytocin, a hypothalamic neuropeptide, may be effective in the treatment of both AUD and PTSD when administered intranasally, although specific mechanisms remain elusive.

METHODS

Forty-seven male patients with comorbid AUD-PTSD were administered intranasal oxytocin in a randomized, double-blind, dose-ranging (20 IU, 40 IU, and matched placebo), within-participant design with study visits at least 1 week apart. A cue-induced craving paradigm was conducted using each participant's preferred alcoholic beverage versus a neutral water cue. Self-reported alcohol craving and heart rate (HR) were recorded and analyzed using linear mixed-effect models.

RESULTS

While alcohol cues significantly induced self-reported craving and increased HR compared to neutral water cues, neither dosage of oxytocin compared to placebo reduced self-reported cue-induced alcohol craving nor cue-induced changes in HR in patients with PTSD-AUD.

CONCLUSIONS

These preliminary findings suggest that oxytocin does not affect cue-induced craving. Our results contribute to an ever-growing field of research investigating the effects of intranasal oxytocin on the symptoms of substance use disorders and will help further refine methodology and streamline future inquiries in this area.

Motives for Illicit Drug Use Among Individuals With Body Dysmorphic Disorder

Drug use disorders (DUDs) are highly prevalent in body dysmorphic disorder (BDD), but motives for illicit drug use in BDD have not yet been explored. This study examined motives for drug use and clinical correlates of drug use motives in a sample of individuals with BDD and lifetime drug use, using the Drug Use Motives Questionnaire and 3 additional body image-specific drug use motives. As predicted, the Drug Use Motives Questionnaire coping motive was positively associated with attempted suicide and a lifetime DUD. All 3 body image-specific motives for drug use were also significantly associated with a lifetime DUD. In addition, they were the only variables that were significantly associated with greater severity of BDD. These results build on previous evidence suggesting that coping motives are related to problematic substance use and suicide attempts in BDD.

Review of EMDR Interventions for Individuals With Substance Use Disorder With/Without Comorbid Posttraumatic Stress Disorder

A large proportion (11%–60%) of people with posttraumatic stress disorder (PTSD) also suffer from substance use disorder (SUD). As the high cooccurrence of PTSD and SUD leads to a worsening of psychopathological severity, development and evaluation of integrated treatments become highly valuable for individuals presenting with both diagnoses. Eye movement desensitization and reprocessing (EMDR) therapy may fit these needs. This article summarized all studies that investigated EMDR treatment for SUD, to clarify whether EMDR might be a useful approach. A comprehensive Title/Abstract/Keyword search was conducted on PsycInfo, PsychArticle, PubMed, and Scopus databases. A total of 135 articles were retrieved, and 8 articles met inclusion/exclusion criteria. One RCT and one case study evaluated trauma-focused EMDR; one clinical RCT, one non-clinical RCT, one cross-over study, and one case study evaluated addiction-focused EMDR; and one quasi-experimental and one multiphase case study evaluated the combination of addiction-focused and trauma-focused EMDR. Results show that EMDR treatment consistently reduces posttraumatic symptoms, but that its effects on SUD symptoms are less evident. Although EMDR should be considered as a promising tool for this population due to its possible potential to improve SUD outcomes, further research is needed to see whether EMDR therapy, either trauma-focused or addiction-focused, is effective for SUD. We conclude with suggestions for future research and clinical practice in this area.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SE_ab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SE_c' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

The relationship between negative trauma-related cognitions and psychosocial functioning in veterans with posttraumatic stress disorder and alcohol use disorder

Background: The comorbidity of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is highly prevalent and associated with especially poor psychosocial functioning. Negative trauma-related cognitions are theoretically proposed to be associated with poor psychosocial functioning in PTSD, but few studies have examined the association between negative trauma-related cognitions and psychosocial functioning in PTSD/AUD. Evaluating this association may provide evidence of a potential treatment target for improving psychosocial functioning in PTSD/AUD. We hypothesized that negative trauma-related cognitions, including cognitions about the self, world, and self-blame, would be independently associated with poor psychosocial functioning in the following domains: vitality, psychosocial well-being, role limitations due to emotional distress, and social functioning. Methods: We examined the relationship between negative trauma-related cognitions and psychosocial functioning in 145 treatment-seeking veterans with PTSD/AUD using multiple linear regression analyses while controlling for PTSD and alcohol abuse and dependence severity. Results: Our hypotheses were partially supported. We found that negative trauma-related cognitions were uniquely associated with greater psychosocial functional impairment, independent of PTSD and alcohol abuse and dependence severity. Specifically, negative trauma-related cognitions about the self were associated with greater psychosocial functional impairment across all domains, cognitions about the world were associated with worse social functioning and psychological well-being, and self-blame was associated with impaired psychological well-being. Conclusions: Given that improvements in negative trauma-related cognitions are a mechanism of trauma-focused treatment, future studies should examine whether changes in negative trauma-related cognitions through trauma-focused treatment are associated with improved psychosocial functioning.

Veterans with PTSD and comorbid substance use disorders: Does single versus poly-substance use disorder affect treatment outcomes?

INTRODUCTION

Substance use disorders (SUD) frequently co-occur with posttraumatic stress disorder (PTSD). Little is known, however, about how individuals with a single SUD diagnosis (relating to only one substance) compare to individuals with poly-SUD diagnoses (relating to more than one substance) on substance use and PTSD treatment outcomes. To address this gap in the literature, we utilized data from a larger study investigating a 12-week integrated, exposure-based treatment (i.e., Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure, or COPE) to examine treatment outcomes by single vs. poly-SUD status.

METHOD

Participants were 54 Veterans (92.6% male, average age = 39.72) categorized as having single SUD (n = 39) or poly-SUD (n = 15). T-tests characterized group differences in baseline demographics and presenting symptomatology. Multilevel models examined differences in treatment trajectories between participants with single vs. poly-SUD.

RESULTS

Groups did not differ on baseline frequency of substance use, PTSD symptoms, or treatment retention; however, individuals with poly-SUD evidenced greater reductions in percent days using substances than individuals with a single SUD, and individuals with a single SUD had greater reductions in PTSD symptoms than individuals with poly-SUD over the course of treatment.

DISCUSSION

The findings from this exploratory study suggest that Veterans with PTSD and co-occurring poly-SUD, as compared to a single-SUD, may experience greater improvement in substance use but less improvement in PTSD symptoms during integrated treatment. Future research should identify ways to enhance treatment outcomes for individuals with poly-SUD, and to better understand mechanisms of change for this population.

Polydrug use disorders in individuals with opioid use disorder

BACKGROUND

Understanding the association of polydrug use disorders (PUD) with psychosocial and clinical factors is essential for the treatment of individuals with opioid use disorder (OUD). The aim of this study is to examine whether there is an association between childhood maltreatment, mood disorders, anxiety disorders, personality disorders, or posttraumatic stress disorder (PTSD) and PUD in individuals with OUD.

METHODS

We used data from 356 individuals with OUD in the past 12 months from a nationally representative database in the United States. PUD patients were classified into two groups: a group with additional one substance disorder (OUD + 1) and that with two or more additional substance disorders (OUD + 2). We conducted multivariate logistic regression to predict the PUD status, after adjustment for confounders including childhood maltreatment.

RESULTS

Among all individuals, 57.3% were polydrug users (n = 204) and 42.7% were not (n = 152). There was a high prevalence of childhood maltreatment in both groups, ranging from 16.1% to 59.5%, but the difference was not statistically significant. After adjustment for confounders, we found an association between past-year PTSD and OUD + 2 (odds ratio: 3.98; 95% confidence interval: 1.15-13.72; p = 0.03) but not with OUD + 1.

CONCLUSION

PTSD is highly prevalent in individuals with OUD using multiple substances and could influence PUD. We recommend screening for PTSD in cases of PUD. Future studies should evaluate the effect of PTSD treatment on PUD.

Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure

Integrated exposure-based interventions to treat substance use disorders (SUD) and posttraumatic stress disorder (PTSD) may not be widely utilized, in part, because of clinician concerns that such interventions will worsen symptomatology and lead to treatment dropout. In order to address this question, the current pilot study examined whether participants' ratings of craving and distress following imaginal exposure predicted increased substance use, PTSD severity, and treatment dropout. Participants (N = 46) were U.S. military Veterans who met criteria for current SUD and PTSD. Subjective ratings of craving and distress, and past-week substance use and PTSD symptom severity were assessed at each treatment session. Multilevel modeling tested whether lagged ratings of craving and distress predicted the following week's frequency of substance use and PTSD severity. Discrete time survival analysis, using proportional odds Cox ratio, examined whether craving and distress ratings predicted treatment dropout. The findings revealed that neither craving nor distress following imaginal exposure were associated with the following week's substance use or PTSD severity. However, participants with higher craving and distress were more likely to drop out before completing treatment. Future research is needed to develop strategies to increase treatment retention for individuals at-risk for treatment dropout and identify mechanisms that account for the association between in-session ratings of craving and distress and dropout.

Profiles of Childhood Trauma in Women With Substance Use Disorders and Comorbid Posttraumatic Stress Disorders

Background: It is increasingly becoming accepted that substance use disorders, including substance abuse and substance dependence, are closely related to childhood trauma and posttraumatic stress disorders. Among women with substance use disorders, the majority report sexual, physical or emotional abuse, or neglect. However, it is poorly understood which types of childhood trauma co-occur in women with substance use disorders and how combinations of different types and severities of childhood trauma are related to clinical characteristics. This information is important to inform treatment of substance use disorders. Aim: The first aim of this research was to investigate profiles of childhood trauma in female patients with substance use disorders and posttraumatic stress disorders. The second aim was to examine relationships between these childhood trauma profiles and addiction characteristics or current clinical symptoms. Methods: We includeda 343 treatment-seeking women with substance use disorders and comorbid posttraumatic stress disorders according to DSM-IV. Five types of childhood trauma (sexual abuse, physical abuse, emotional abuse) were measured using the Childhood Trauma Questionnaire. Addiction characteristics were assessed by using the Addiction Severity Index-lite. Current severity of clinical symptoms was determined by the Symptom-Checklist-27. Latent profile analysis was conducted to distinguish profiles of childhood trauma. Analysis of variance was applied to examine the relationship between childhood trauma profiles and addiction characteristics or severity of clinical symptoms. Results: Nine out of ten women reported at least one type of childhood abuse or neglect. Four different childhood trauma profiles could be distinguished that characterized different types and severities of childhood trauma: 'Low trauma'; 'Moderate sexual abuse and emotional abuse'; 'Severe sexual abuse and emotional abuse'; and 'Severe levels of all types of trauma'. Profiles with more severe levels of childhood trauma showed an earlier age at initiation and escalation of substance use. Furthermore, childhood trauma profiles were related to current severity of depressive symptoms, dysthymic symptoms, sociophobic symptoms, and distrust. Conclusion: In women with substance use disorders and posttraumatic stress disorders, childhood trauma profiles can inform about addiction characteristics and severity of a wide range of clinical symptoms. This information is essential to understand current treatment needs and should be systematically assessed in women with substance use disorders and trauma exposure.

A cognitive processing therapy-based treatment program for veterans diagnosed with co-occurring posttraumatic stress disorder and substance use disorder: The relationship between trauma-related cognitions and outcomes of a 6-week treatment program

Dysfunctional trauma-related cognitions are important in the emergence and maintenance of posttraumatic stress disorder (PTSD) and the modification of such cognitions is a proposed mechanism of trauma treatment. However, the authors are not aware of any research examining trauma-related cognitions as a treatment mechanism in a sample of individuals with comorbid PTSD and substance use disorder (SUD). Accordingly, the present study sought to address this gap in the literature and examined the relationship between trauma-related cognitions and treatment outcomes within a sample of seventy-two veterans diagnosed with PTSD and SUD. Veterans completed a 6-week day CPT-based treatment program that included cognitive processing therapy as a central component. Measures of trauma-related cognitions, PTSD symptoms, depressive symptoms, and trauma-cued substance craving were completed at pre- and post-treatment. As expected, trauma-related cognitions were associated with several PTSD-related variables prior to treatment. Furthermore, results of a within-subjects mediational analysis indicated that maladaptive trauma-related cognitions decreased during the treatment program and accounted for a significant portion of the variance in the reduction of PTSD and depressive symptoms at post-treatment. This study provides support for the position that attempts to modify dysfunctional trauma-related cognitions among veterans with co-occurring PTSD and SUD can lead to desirable treatment outcomes.

The impact of co-occurring opioid misuse and PTSD on response inhibition

BACKGROUND

Posttraumatic Stress Disorder (PTSD) and opioid misuse are commonly co-occurring disorders. Both disorders are associated with deficits in response inhibition; however, these associations have not considered their comorbidity. Response inhibition has not been examined in a sample with comorbid PTSD and opioid misuse. The present study examined the effect of PTSD symptom severity on response inhibition in current and past opioid misusers.

METHODS

Participants were currently (used within the last month) misusing opioids (56.6%) or in recovery (43.4%). All participants met DSM 5 criteria for PTSD. Response inhibition was measured with the stop signal task.

RESULTS

Response inhibition was associated with increased PTSD symptom severity for those in recovery but not among current users. Additionally, across both groups, there were deficits in response inhibition when withholding automatic responses for a threatening stimulus compared to a neutral stimulus.

CONCLUSIONS

PTSD Symptoms may exert a stronger effect on response inhibition among those in recovery as opposed to those who are actively using opioids.

Posttraumatic stress disorder symptoms improve after an integrated brief alcohol intervention for OEF/OIF/OND veterans

OBJECTIVE

Although brief alcohol interventions (BAIs) that incorporate personalized feedback demonstrate efficacy for reducing the frequency and quantity of alcohol consumption in veteran samples, little research has explored the influence of BAIs in reducing symptoms of posttraumatic stress disorder (PTSD). The goal of this investigation was to understand whether PTSD symptom severity and diagnostic status changed after exposure to an intervention that targeted alcohol misuse and integrated feedback on PTSD.

METHOD

Sixty-eight combat veterans (8.8% female; 27.9% African American) who screened positive for hazardous drinking were recruited from a Veterans Affairs Medical Center. Participants received a 1-session brief intervention that primarily targeted alcohol misuse but also included personalized feedback and psychoeducation on PTSD symptoms and coping. Participants were randomized to receive personalized written feedback either with or without a motivational interview.

RESULTS

A mixed-model repeated measures analysis revealed that PTSD symptom severity was significantly lower at the 6-week (M = 41.47, SD = 28.94) and 6-month (M = 35.56 SD = 26.99) follow-up appointments relative to baseline (M = 51.22, SD = 26.67), F(2, 127.24) = 38.32, p < .001. Regression analyses demonstrate that the percent change in alcohol use was related to the change in PTSD severity. Further, results indicated that a motivational-interviewing-style counseling session accompanying the feedback was not significantly more efficacious than receiving feedback only.

CONCLUSION

A brief alcohol intervention that integrates information on PTSD has the potential to reduce PTSD severity. Personalized alcohol and PTSD feedback may be useful as an opportunistic intervention for OEF/OIF veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol, cannabis, and other drug use: Engagement and outcome in PTSD treatment

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use is related to poorer outcome and increased dropout from trauma-focused treatment. Investigating PTSD and substance use can inform the intervention approaches. Exploring cannabis use in particular is especially important because rates of cannabis use have been increasing with recent legalization trends. A better understanding of how substance use is associated with treatment processes and outcome for individuals with PTSD is needed to enhance care. In this study, both lifetime diagnoses of alcohol and drug use disorders and current alcohol and drug use severity were examined in 200 men and women with chronic PTSD who received either prolonged exposure (PE) or sertraline. No lifetime or current alcohol use variables predicted dropout, adherence, or poorer outcome. However, lifetime diagnosis of both an alcohol and drug disorder (OR = 3.42) and recent cannabis use (OR = 3.38) strongly predicted higher dropout. Recent cannabis use and drug use severity predicted poorer adherence to PE (β = -.22 to -.29) but not to sertraline. Drug use severity (β = -.22) also predicted worse treatment outcome, as did lifetime diagnosis of an alcohol and drug disorder (β = -.48). Overall, patients with drug use improved with treatment but had less treatment retention, adherence, and symptom reduction. Strategies to increase engagement and retention may be indicated for these patients. Individuals who are using cannabis or other drugs may be at higher risk for not completing PTSD treatment, potentially prolonging the cycle of PTSD and substance use. (PsycINFO Database Record

Access to environmental reward mediates the relation between posttraumatic stress symptoms and alcohol problems and craving

Symptoms of posttraumatic stress (PTS) show significant comorbidity with alcohol use, but little is known about the mechanisms that might account for this comorbidity. Deficits in reward functioning have long been implicated in alcohol misuse and more recently in PTS reactions, but no study has examined whether reward deprivation may serve as a transdiagnostic risk factor for comorbid PTS-alcohol misuse. The current cross-sectional study sought to test the behavioral economic hypothesis that reward deprivation would be related to both PTS symptoms and alcohol problems, and would mediate the relation between PTS symptoms and alcohol problems in college students. We recruited a diverse sample of urban college students (N = 203, Mage = 21.5 years, SD = 5.5; 79.5% female; 56.8% White, 28.1% Black, .9% Asian, 9.8% Multiracial) who endorsed both alcohol use and PTS symptoms. Reward deprivation (lack of access to, and ability to, experience reward) was related to alcohol problems, and a lack of access to reward was related to PTS symptoms. Furthermore, reward access mediated the relation between PTS symptoms and alcohol problems and craving, after controlling for alcohol use, age, gender, and race. These data provide preliminary support for behavioral economic models of alcohol comorbidity and suggest that treatments for combined PTS and alcohol misuse should attempt to reduce barriers to accessing natural rewards. (PsycINFO Database Record

Trauma and post-traumatic stress disorder in a drug treatment community service

Aims and method

A cross-sectional study aiming to assess the prevalence of trauma and post-traumatic stress disorder (PTSD) in a community substitution treatment sample, and to assess and compare the characteristics of traumatic experience, substance use, and psychological and social factors in those with and without PTSD. All assessments were completed during the interview which took approximately 1.5 h.

Results

The prevalence for current PTSD was 26.2% and for lifetime PTSD 42.9%. Traumatic experiences were extremely common, with two or more reported by 92.9% of the sample. The two groups differed significantly on the majority of psychological functioning and social variables, with women experiencing higher rates of PTSD and the non-PTSD group having lower rates of psychological impairment.

Clinical implications

The research supported findings from previous studies. The very high incidence of traumatic experiences has not been reported before. Training and information about trauma and PTSD for substance misuse workers are therefore necessary so that PTSD can be more easily detected and treated.

Unseen scars: Cocaine patients with prior trauma evidence heightened resting state functional connectivity (RSFC) between the amygdala and limbic-striatal regions

BACKGROUND

Substance use disorder (SUD) patients with a history of trauma exhibit poorer treatment outcome, greater functional impairment and higher risk for relapse. Endorsement of prior trauma has, in several SUD populations, been linked to abnormal functional connectivity (FC) during task-based studies. We examined amygdala FC in the resting state (RS), testing for differences between cocaine patients with and without prior trauma.

METHODS

Patients with cocaine use disorder (CUD; n=34) were stabilized in an inpatient setting prior to a BOLD fMRI scan. Responses to Addiction Severity Index and the Mini-International Neuropsychiatric Interview were used to characterize the No-Trauma (n=16) and Trauma (n=18) groups. Seed-based RSFC was conducted using the right and left amygdala as regions of interest. Examination of amygdala RSFC was restricted to an a priori anatomical mask that incorporated nodes of the limbic-striatal motivational network.

RESULTS

RSFC was compared for the Trauma versus No-Trauma groups. The Trauma group evidenced greater connectivity between the amygdala and the a priori limbic-striatal mask. Peaks within the statistically significant limbic-striatal mask included the amygdala, putamen, pallidum, caudate, thalamus, insula, hippocampus/parahippocampus, and brain stem.

CONCLUSIONS

Results suggest that cocaine patients with prior trauma (versus without) have heightened communication within nodes of the motivational network, even at rest. To our knowledge, this is the first fMRI study to examine amygdala RSFC among those with CUD and trauma history. Heightened RSFC intralimbic connectivity for the Trauma group may reflect a relapse-relevant brain vulnerability and a novel treatment target for this clinically-challenging population.

Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction

OBJECTIVE

In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems.

METHODS

The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM).

RESULTS

No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems.

CONCLUSIONS

This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.

Double whammy: Adverse childhood events and pain reflect symptomology and quality of life in women in substance abuse treatment

BACKGROUND

This study examined the profiles of symptoms and health-related quality of life (QOL) of women in substance abuse treatment, comparing those with higher versus lower histories of adverse childhood events (ACE), and those with versus without current pain.

METHODS

Adult women in outpatient substance abuse treatment (n = 30) completed questionnaires (cross-sectional study) on topics including drug use, adverse childhood events (ACE), QOL, functional ability, current pain, and depression.

RESULTS

Women with pain indicated significant differences in emotional (p < 0.05), and functional ability (p < 0.01); but no significant differences were found between women with high versus low levels of ACE. Yet, radar plots of women with both current pain and high levels of ACE, versus those without, portrayed a distinctive profile indicating high levels of anxiety and depression.

CONCLUSIONS

Rather than a checklist, visual composites of symptoms experienced by women in substance abuse treatment illustrates areas of concern in the overall status of women in substance abuse treatment.

Posttraumatic Stress Disorder and Alcohol Use Disorder: A Critical Review of Pharmacologic Treatments

Treatment of alcohol use disorder (AUD) is complicated by the presence of psychiatric comorbidity including posttraumatic stress disorder (PTSD). This is a critical review of the literature to date on pharmacotherapy treatments of AUD and PTSD. A systematic literature search using PubMed MESH terms for alcohol and substance use disorders, PTSD, and treatment was undertaken to identify relevant randomized controlled trials (RCTs). The studies were independently evaluated (ILP and TLS) and those that evaluated the efficacy of a pharmacotherapy for individuals diagnosed with AUD and PTSD and were RCTs were selected. Studies were grouped in 3 categories: (i) those that evaluated first-line treatments for PTSD, (ii) those that evaluated medications to target AUD, and (iii) those that evaluated medications hypothesized to be effective in targeting alcohol consumption as well as PTSD symptoms. Nine RCTs were identified; 3 focused on medications to treat PTSD, 4 focused on AUD, and 3 to target both. One study included both a medication to treat PTSD and 1 to treat AUD so was discussed twice. All but 1 of the studies found that PTSD symptoms and drinking outcomes improved significantly over time. There is not 1 agent with clear evidence of efficacy in this comorbid group. The results for medications to treat PTSD are inconclusive because of contradictory results. There was weak evidence to support the use of medications to treat AUD among those with comorbidity with PTSD. Findings for medications that were hypothesized to treat both disorders were also contradictory. Most studies provided a combination of interventions to treat both disorders. Despite the contradictory results, this review suggests that individuals with AUD and comorbid PTSD can safely be prescribed medications used in noncomorbid populations and patients improve with treatment.

Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: A randomized controlled trial

To test whether a modified version of prolonged exposure (mPE) can effectively treat posttraumatic stress disorder (PTSD) in individuals with co-occurring PTSD and substance dependence, an efficacy trial was conducted in which substance dependent treatment-seekers with PTSD (N = 126, male = 54.0%, White = 79.4%) were randomly assigned to mPE, mPE + trauma-focused motivational enhancement session (mPE + MET-PTSD), or a health information-based control condition (HLS). All participants were multiply traumatized; the median number of reported traumas that satisfied DSM-IV Criterion A for PTSD was 8. Treatment consisted of 9-12 60-min individual therapy sessions plus substance abuse treatment-as-usual. Participants were assessed at baseline, end-of-treatment, and at 3- and 6-months posttreatment. Both the mPE and mPE + MET-PTSD conditions achieved significantly better PTSD outcome than the control condition. The mPE + MET-PTSD and mPE conditions did not differ from one another on PTSD symptoms at end of treatment, 3-, or 6-month follow-up. Substance use outcomes did not differ between groups with all groups achieving 85.7%-97.9% days abstinent at follow-up. In regard to clinically significant improvement in trauma symptoms, 75.8% of the mPE participants, 60.0% of the mPE + MET-PTSD participants, and 44.4% of the HLS participants experienced clinically significant improvement at the end-of-treatment. Results indicate mPE, with or without an MET-PTSD session, can effectively treat PTSD in patients with co-occurring PTSD and substance dependence. In addition, mPE session lengths may better suit standard clinical practice and are associated with medium effect sizes. (PsycINFO Database Record

Perceived Treatment Needs Among Women With Co-occurring Substance Use Disorders and PTSD

OBJECTIVE

Perception of need is a key factor that influences decisions to seek help and complete treatment for substance use and mental health problems. In the current study, we examine patterns of perceived treatment needs among women with co-occurring substance use disorders and posttraumatic stress disorder (PTSD) and explore how these patterns are associated with demographics, psychosocial variables, and treatment-related factors.

METHODS

Secondary data analysis of the Women and Trauma Study from the National Institute on Drug Abuse's Clinical Trial Network was conducted. The sample included 353 women with co-occurring substance use disorders and PTSD (full or subthreshold) receiving outpatient substance abuse treatment. Latent class analysis was used to examine patterns of perceived treatment need and multinomial logistic regression was used to identify characteristics associated with these patterns.

RESULTS

The sample included women between the ages of 18 and 65 (mean = 39.2, SD = 9.3) and was 46% White, 34% African American, and 21% other races/ethnicities. A three-class model representing unique perceptions of treatment needs demonstrated the best fit (Bayesian information criterion = 2101.43; entropy = 0.76; average posterior probabilities ≤ 0.82). Class one reported elevated needs in multiple areas (38%), class two reported low needs (23%), and class three reported substance use and psychological needs (40%). Living with a substance abuser, depression symptoms, recent substance use, and treatment coercion were significantly associated with membership in class 2 (OR = .28, .84, .22, and 2.32, respectively). Other race, being married, depression symptoms, recent substance use, and criminal justice involvement were associated with membership in class 3 (OR = 2.32, 2.32, .94, .42, and 1.69, respectively). Number of treatment sessions attended was not significantly associated with class membership.

CONCLUSIONS

Results provide insight into how women with co-occurring PTSD and substance use disorders view their treatment needs. While some women reported high levels of self-identified need in other areas (e.g., physical health, employment/financial support, and family or social relationships), others did not identify as having any problems (including substance use or psychological problems). Level of severity and temporal aspects of problems may be significant factors that influence women's perceived need for treatment. This clinical trial is registered at www.clinicaltrials.gov as trial #NCT00078156.

Substance use modulates stress reactivity: Behavioral and physiological outcomes

Drug addiction is a major public health concern in the United States costing taxpayers billions in health care costs, lost productivity and law enforcement. However, the availability of effective treatment options remains limited. The development of novel therapeutics will not be possible without a better understanding of the addicted brain. Studies in both clinical and preclinical models indicate that chronic drug use leads to alterations in the body and brain's response to stress. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis may shed light on the ability of stress to increase vulnerability to relapse. Further, within both the HPA axis and limbic brain regions, corticotropin-releasing factor (CRF) is critically involved in the brain's response to stress. Alterations in both central and peripheral CRF activity seen following chronic drug use provide a mechanism by which substance use can alter stress reactivity, thus mediating addictive phenotypes. While many reviews have focused on how stress alters drug-mediated changes in physiology and behavior, the goal of this review is to focus on how substance use alters responses to stress.

Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome

OBJECTIVE

The present study examined predictors and moderators of treatment response among 165 adults meeting Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD), who were randomized to 24 weeks of Naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use.

METHOD

Six domains of predictors or moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview) and AD (days drinking from the timeline follow-back interview) collected every 4 weeks throughout treatment. Multilevel modeling with the Fournier approach was used to evaluate predictors and moderators of rates of symptom improvement and posttreatment outcomes.

RESULTS

Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, White race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of AD.

CONCLUSION

These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified subgroups of PTSD-AD patients.

Pharmacologic management of comorbid post-traumatic stress disorder and addictions

BACKGROUND AND OBJECTIVES

Post-traumatic Stress Disorder (PTSD) and substance use disorders (SUD) frequently co-occur, and their combination can increase poor health outcomes as well as mortality.

METHODS

Using PUBMED and the list of references from key publications, this review article covered the epidemiology, neurobiology and pharmacotherapy of PTSD with comorbid alcohol, opiate, and cannabis use disorders. These SUD represent two with and one without FDA approved pharmacotherapies.

RESULTS

SUD is two to three times more likely among individuals with lifetime PTSD, and suicide, which is made more likely by both of these disorders, appears to be additively increased by having this comorbidity of SUD and PTSD. The shared neurobiological features of these two illnesses include amygdalar hyperactivity with hippocampal, medial prefrontal and anterior cingulate cortex dysfunction. Medications for comorbid PTSD and SUD include the PTSD treatment sertraline, often used in combination with anticonvulsants, antipsychotics, and adrenergic blockers. When PTSD is comorbid with alcohol use disorder (AUD), naltrexone, acamprosate or disulfiram may be combined with PTSD treatments. Disulfiram alone may treat both PTSD and AUD. For PTSD combined with opiate use disorder methadone or buprenorphine are most commonly used with sertraline. Marijuana use has been considered by some to be a treatment for PTSD, but no FDA treatment for this addiction is approved. Pregabalin and D-cycloserine are two innovations in pharmacotherapy for PTSD and SUD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Comorbid PTSD and SUD amplifies their lethality and treatment complexity. Although they share important neurobiology, these patients uncommonly respond to a single pharmacotherapy such as sertraline or disulfiram and more typically require medication combinations and consideration of the specific type of SUD.

A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder

BACKGROUND AND AIMS

Post-traumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of integrated cognitive-behavioral therapy (ICBT) plus standard care, individual addiction counseling plus standard care and standard care alone on substance use and PTSD symptoms.

DESIGN

Three-group, multi-site randomized controlled trial.

SETTING

Seven addiction treatment programs in Vermont and New Hampshire, USA.

PARTICIPANTS/CASES

Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n = 73), individual addiction counseling (IAC) plus SC (n = 75) or SC only (n = 73). One hundred and seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence and recovery. SC are intensive out-patient program services that include 9-12 hours of face-to-face contact per week over 2-4 days of group and individual therapies plus medication management.

MEASUREMENTS

Primary outcomes were PTSD severity and substance use severity at 6 months. Secondary outcomes were therapy retention.

FINDINGS

PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC [comparison with IAC, parameter estimate: 1.10; confidence interval (CI) = 0.17-2.04; comparison with SC, parameter estimate: 1.13; CI = 0.18-2.08] and had a greater reduction in reported drug use than SC (parameter estimate: -9.92; CI = -18.14 to -1.70). ICBT patients had better therapy continuation versus IAC (P<0.001). There were no unexpected or study-related adverse events.

CONCLUSIONS

Integrated cognitive behavioral therapy may improve drug-related outcomes in post-traumatic stress disorder sufferers with substance use disorder more than drug-focused counseling, but probably not by reducing post-traumatic stress disorder symptoms to a greater extent.

Correlates of improvement in substance abuse among dually diagnosed veterans with post-traumatic stress disorder in specialized intensive VA treatment

Substantial rates of substance use comorbidity have been observed among veterans with Post-Traumatic Stress Disorder (PTSD), highlighting the need to identify patient and program characteristics associated with improved outcomes for substance abuse. Data were drawn from 12,270 dually diagnosed veterans who sought treatment from specialized intensive Veterans Health Administration PTSD programs between 1993 and 2011. The magnitude of the improvement in Addiction Severity Index (ASI) alcohol and drug use composite scores from baseline was moderate, with effect sizes (ES) of -.269 and -.287, respectively. Multivariate analyses revealed that treatment in longer-term programs, being prescribed psychiatric medication, and planned participation in reunions were all associated with slightly improved outcomes. Reductions in substance use measures were associated with robust improvements in PTSD symptoms and violent behavior. These findings suggest not only synergistic treatment effects linking improvement in PTSD symptoms with substance use disorders among dually diagnosed veterans with PTSD, but also to reductions in violent behavior. Furthermore, the findings indicate that proper discharge planning in addition to intensity and duration of treatment for dually diagnosed veterans with severe PTSD may result in better outcomes. Further dissemination of evidence-based substance abuse treatment may benefit this population.

Integrated Cognitive Behavioral Therapy (ICBT) For PTSD and Substance Use in Iraq and Afghanistan Veterans: A Feasibility Study

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is prevalent in military Veterans and is associated with poorer outcomes than either disorder alone. The current pilot study examines the feasibility of delivering integrated cognitive behavioral therapy (ICBT) for co-occurring PTSD-SUD to Veterans who served in Iraq and Afghanistan. Our primary aims were testing the feasibility of engaging and retaining Veterans with a complex clinical presentation in a 12-week structured therapy. We focused on two feasibility outcomes: 1) acceptability; and 2) tolerability. We also examined clinically meaningful change in PTSD and depressive symptoms as a secondary aim. Over the course of the study, we recruited 12 eligible Veterans, 6 of whom completed ICBT. We encountered challenges related to engaging and retaining Veterans in treatment and discuss adaptations and refinements of ICBT or other integrated treatments for returning Veterans with co-occurring PTSD-SUD to increase feasibility with military Veterans.