Substance use disorders and PTSD: an exploratory study of treatment preferences among military veterans

Risk and protective factors associated with substance use among Puerto Rican youths after Hurricane María: a cross-sectional study

BACKGROUND

Identifying factors associated with post-disaster youth substance use is a crucial element of developing evidence-based prevention and intervention efforts. Hurricane María struck Puerto Rico in September of 2017 and the wide-spread impact from this disaster, including exposure to trauma, displacement, and disrupted social supports had the potential to negatively impact levels of substance use among youth across the archipelago. However, post-disaster substance use remains under-investigated in this context. The current study sought to identify risk and protective factors associated with substance use among Puerto Rican youth in the aftermath of Hurricane Maria.

METHODS

Cross-sectional, secondary data analyses were conducted using school-based survey data collected at all schools in Puerto Rico between February 1 and June 29, 2018 (5-9 months after Hurricane María). Social supports, substance use, and trauma symptoms were assessed. An ordinal regression analysis was conducted to identify student factors associated with greater likelihood of post-disaster substance use.

RESULTS

A total of 36,485 participants (50.7% female, grades 7-12), were included in an ordinal regression analysis that compared the likelihood of respondents endorsing high, low, or no substance use after Hurricane María based on reported adult social support, counselor/teacher social support, peer social support, ptsd symptomatology, and gender. Findings showed that, when compared to students that endorsed low or no substance use, those who reported having adult social support demonstrated a 58% reduction in odds (OR = 0.42, 95% CI: 0.34-0.53) of reporting high substance use after Hurricane María, while students who reported having teacher/counselor social support demonstrated a 21% reduction in odds (OR = 0.79, 95% CI: 0.69-0.89) of reporting high substance use. Additionally, those that reported having peer social support demonstrated a 31% increase in odds (OR = 1.31, 95% CI: 1.10 to 1.58) of reporting higher substance use, compared to those that reported low or no substance use.

CONCLUSIONS

While social support was generally protective, prevention efforts to build positive family and community connections may be indicated. Evidence-based school screenings of substance use and trauma may help direct intervention to those most at risk for co-occurring issues.

The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study

INTRODUCTION

Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions.

METHODS

This mixed-methods study interviewed and surveyed 10 women with current or past OUD and co-occurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD.

RESULTS

Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., trauma-focused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately.

CONCLUSIONS

Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

A Randomized Controlled Pilot Trial of Primary Care Treatment Integrating Motivation and Exposure Treatment (PC-TIME) in Veterans With PTSD and Harmful Alcohol Use

Individuals with posttraumatic stress disorder (PTSD) often engage in harmful alcohol use. These co-occurring conditions are associated with negative health consequences and disability. PTSD and harmful drinking are typically experienced as closely related-thus treatments that target both simultaneously are preferred by patients. Many individuals with PTSD and harmful alcohol use receive primary care services but encounter treatment barriers in engaging in specialty mental health and substance use services. A pilot randomized controlled trial of a brief integrated treatment for PTSD and harmful drinking versus primary care treatment as usual (PC-TAU) took place in three U.S. Department of Veterans Affairs (VA) primary care clinics. The intervention (primary care treatment integrating motivation and exposure [PC-TIME]) combines motivational interviewing to reduce alcohol use and brief prolonged exposure for PTSD delivered over five brief sessions. Participants (N = 63) were veterans with PTSD and harmful drinking. Multilevel growth curve modeling examined changes in drinking (average number of drinks per drinking day and percentage of heavy drinking days) and self-reported PTSD severity at baseline, 8, 14, and 20 weeks. Participants reported high satisfaction with PC-TIME and 70% (n = 23) completed treatment. As hypothesized, a significantly steeper decrease in self-reported PTSD severity and heavy drinking was evident for participants randomized to PC-TIME compared with PC-TAU. Contrary to expectations, no significant posttreatment differences in PTSD diagnoses were observed. PC-TIME participants were less likely to exceed National Institute for Alcoholism and Alcohol Abuse (NIAAA) guidelines for harmful alcohol use posttreatment compared with PC-TAU participants. PC-TIME is a promising brief, primary care-based treatment for individuals with co-occurring PTSD and harmful alcohol use. A full-scale randomized clinical trial is needed to fully test its effectiveness.

Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders

We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examining the Temporal Relation between Posttraumatic Stress Symptoms and Heavy Drinking among Veterans Receiving Mental Health Treatment in Primary Care

OBJECTIVE

Evidence for the use of integrated treatments targeting co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorders is steadily growing. However, limited work has evaluated the temporal association between posttraumatic stress symptoms (PTSS) and alcohol misuse over the course of integrated treatment, with no studies examining such interventions in primary care (PC). The current study examined temporal changes in PTSS and heavy drinking among individuals who received a brief treatment for co-occurring PTSD and alcohol misuse in PC (Primary Care Treatment Integrating Motivation and Exposure; PC-TIME) compared with those who received PC treatment as usual (PC-TAU).

METHOD

A total of 63 veterans (33 randomized to PC-TIME and 30 randomized to PC-TAU) presenting to PC with co-occurring PTSD and alcohol misuse were included in this study. PTSS and heavy drinking were examined at each treatment session for those in PC-TIME. Veterans in both conditions provided reports of PTSS and heavy drinking at baseline, 8-weeks (post-treatment), 14-weeks, and 20-week follow-ups.

RESULTS

Session-by-session findings for PC-TIME demonstrated that PTSS at Session 1 predicted a greater decrease in heavy drinking from Session 1 to Session 2. Moreover, heavy drinking at baseline predicted greater decreases in PTSS at 8-weeks for those in PC-TIME, whereas the reverse association was found for those randomized to PC-TAU. Additionally, heavy drinking at 8-weeks predicted decreased PTSS at 14-weeks for those randomized to PC-TAU.

CONCLUSIONS

The current study evidenced mixed support for the temporal precedence of PTSS and alcohol misuse. Relations between PTSS and heavy drinking appeared to be linked to treatment targets within PC-TIME and varied between treatment condition (PC-TIME versus PC-TAU). Notably, those with greater than average heavy drinking at the initiation of integrated treatment appeared to have greater reductions in PTSS at post-treatment. Results suggest a mutual maintenance model may best characterize the association between co-occurring PTSS and heavy drinking among treatment-seeking individuals.

Characterizing patterns of substance use in trauma exposed youth

OBJECTIVE

Previous work investigating the impact of childhood trauma on substance use and co-occurring psychiatric disorders has primarily been conducted in adults or on specific trauma types. This limits understanding of traumas impact in childhood and how different types of traumas play a role. We sought to characterize substance use in a sample of trauma-exposed youth in the context of psychiatric comorbidities.

METHOD

1152 youth from the Texas Childhood Trauma Research Network (TX-CTRN) that were exposed to at least one trauma meeting DSM-5 Criterion A were assessed for current substance use and psychiatric diagnoses. Latent class analysis was used to identify patterns of substance use. To characterize these patterns, we examined if demographics, number of trauma types experienced, or childhood psychiatric disorders predicted class membership.

RESULTS

We identified four primary patterns of substance use: Non-use (66.1%), predominantly alcohol use (19.7%), predominantly cannabis use (4.5%), and polysubstance use (9.7%). Compared to the non-users, polysubstance users tended to be older, Non-Hispanic White, have experienced more types of trauma. They were also more likely to have fulfilled diagnostic criteria for suicidality and ADHD. Comparisons among the substance using classes were more nuanced.

CONCLUSION

The findings highlight the need for universal assessments of trauma, substance misuse, and mental health symptoms in youth as the presence or absence of their co-occurrence has implications for treatment.

Psychological treatment of PTSD with comorbid substance use disorder (SUD): expert recommendations of the European Society for Traumatic Stress Studies (ESTSS)

Background: Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) are often comorbid and difficult to treat. The availability of evidence-based treatment guidelines is very limited and there is significant uncertainty about what best practice looks like.Objective: This paper describes the methodology used to develop expert recommendations for the assessment and psychological treatment of PTSD and comorbid SUD and presents the final recommendations.Methodology: A small committee of experts in the field of PTSD and SUD was formed on behalf of the European Society for Traumatic Stress Studies (ESTSS) Board. The committee developed recommendations based on a two-stage process. In the first stage a systematic review of randomised controlled trials of psychological interventions aimed at treating PTSD-SUD comorbidity was completed, and other recent relevant reviews systematic were also considered. To complement the recommendations based on systematic review, the second stage involved the review and collation of existing guidance, good practice and consensus recommendations made in methodologically rigorous clinical practice guidelines.Results: The two-stage process resulted in 9 recommendations related to assessment and 21 recommendations related to treatment planning and delivery.Conclusions: To our knowledge, this is the first attempt to provide expert recommendations based on a systematic review of the literature and through collation of guidance provided in other authoritative and reliable sources. These expert recommendations will provide helpful guidance to clinicians and service providers in both addiction and mental health settings about appropriate clinical care for those with PTSD SUD comorbidity.

Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8^TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Development and Initial Testing of a Brief, Integrated Intervention Aimed at Reducing Heavy Alcohol Use and PTSD among Military Veterans in Primary Care

There is a need for integrated treatment approaches that address heavy alcohol use and posttraumatic stress disorder (PTSD) concurrently among Veterans as interactions between heavy drinking and PTSD are frequent. Veteran engagement in specialty mental health services after referral is limited with poorer outcomes following empirically-supported, exposure-based PTSD treatments that do not explicitly address alcohol use. The current project aimed to incorporate two evidenced-based interventions: Brief Motivational Intervention (BMI) with Prolonged Exposure for Primary Care (PE-PC) for Veterans with heavy drinking and PTSD. Delphi methodology was applied to adapt an intervention protocol using subject matter expert (SME) feedback to guide the refinement of a preliminary treatment manual. The newly developed brief intervention (PC-TIME) was then tested in an open trial (n=9) to gather Veteran participant feedback to modify the treatment manual.Two rounds of SME feedback resulted in 80% agreement that manual content was "acceptable as-is" across all intervention domains. The resulting protocol is a five-session, integrated intervention with session 1 primarily focused on alcohol use reduction and sessions 2-5 consisting of narrative exposure and in-vivo exercises for PTSD symptoms with brief alcohol use check-ins. Open trial results indicated high Veteran acceptance of PC-TIME structure and content, and reductions in heavy drinking and PTSD symptoms. Preliminary data suggest PC-TIME to be a promising approach for treatment of heavy alcohol use and PTSD. A pilot randomized controlled trial is necessary to demonstrate the intervention's efficacy with Veterans in a PC setting.

Enablers and barriers to military veterans seeking help for mental health and alcohol difficulties: A systematic review of the quantitative evidence

OBJECTIVE

Research exploring the enablers and barriers that exist for military veterans seeking to address their poor mental health has produced ambiguous results. To identify the enablers and barriers correctly, this study systematically reviews the literature, including research that included alcohol and had a clearly defined veteran population.

METHODS

Six databases were searched. Inclusion criteria specified that empirical studies related to veterans that had ceased military service and were seeking help for poor mental health and/or alcohol difficulties. Critical Appraisal Skills Programme and AXIS appraisal tools were used to assess quality and bias. A narrative synthesis approach was adopted for analysis. From 2044 studies screened, 12 were included featuring 5501 participants.

RESULTS

Forty-four enablers and barriers were identified, with thirty-two being statistically significant. Post-traumatic stress disorder had the greatest number of enabler/barrier endorsements to veterans seeking help. Depression, anxiety, experience and attitudes also acted as enablers/barriers. Most studies were of fair methodological quality. Limitations included that samples were skewed towards US army veterans. Little research exists concerning those that have ceased military service.

CONCLUSIONS

Veteran help-seeking is likely enabled by poor mental health symptomology and comorbidity, which suggests veterans reach a crisis point before they seek help. Further research on alcohol misuse and attitude formation is required. The field would also benefit from alternative study designs including qualitative studies with non-US participants.

Client and staff perceptions of the integration of trauma informed care and specialist posttraumatic stress disorder treatment in residential treatment facilities for substance use: A qualitative study

INTRODUCTION

Comorbid posttraumatic stress disorder (PTSD) is prevalent among people seeking residential treatment for substance use disorders (SUD). We examined client and staff perceptions of the relationship between trauma and SUDs, and the integration of trauma-informed care (TIC) and specialist-delivered treatment for PTSD in residential alcohol and other drug (AOD) treatment facilities.

METHODS

Individual semi-structured interviews were conducted with frontline staff (n = 20) and clients (n = 18) in two residential AOD treatment facilities in Queensland, Australia. Interviews were audio recorded, transcribed and shared client and staff data was analysed using thematic analysis.

RESULTS

Major staff and client themes emerged: PTSD was perceived as an underlying cause of SUD, where AOD is used to cope with and avoid PTSD and related symptoms (Theme 1). Residential facilities were perceived to provide a safe and supportive environment for clients (Theme 2). Psychoeducation on SUD and PTSD was also highlighted to normalise experiences associated with comorbid SUD/PTSD and promote help-seeking pathways for specialist PTSD treatment. Concurrent treatment of SUD and PTSD in the residential setting was sought after and was perceived to enhance treatment outcomes (Theme 3). Staff saw the need for implementing TIC into the organisation and perceived TIC as a multi-faceted and consistent approach of service delivery.

DISCUSSION AND CONCLUSIONS

Both clients and staff perceive comorbid SUD/PTSD as a challenge in residential treatment, that may be overcome through integrating TIC and PTSD treatment in residential treatment facilitates for substance use. Organisational and practical implications are discussed.

Imaginal exposure processing during Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) therapy: Examination of linguistic markers of cohesiveness

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is an integrated, evidence-based treatment that results in significant reductions in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) severity. Emotional processing theory suggests that successful prolonged exposure-based treatments should result in more cohesive trauma narratives due to better integration and organization of trauma memory into cognitive conceptualizations of fear. Therefore, we hypothesized that language used by patients would become more cohesive over time and increased language cohesion would be related to larger reductions in PTSD and SUD outcomes. Broadly, language cohesion refers to several linguistic devices that help establish and cohere meaning throughout spoken and written discourse (e.g., increased use of transition words like "and," "then," and "but"). This was the first known study to examine changes in language related to both PTSD and SUD severity during COPE treatment. The sample included 28 military veterans with current comorbid PTSD/SUD enrolled in a larger COPE study. A text analysis program, Coh-Metrix, was used to analyze language cohesiveness. No language cohesion variables significantly changed over time. Narrativity levels significantly moderated change in PTSD outcomes, R β 2 $R_\beta ^2\;$ = 0.11. Adversative connectives significantly moderated change in SUD outcomes, R β 2 $R_\beta ^2\;$ = 0.26. The findings illuminate potential processes underlying successful COPE treatment. Less use of language conveying a narrative and more use of contrast-indicative words (e.g., but, whereas) was associated with larger reductions in PTSD and SUD outcomes during treatment. These results contribute to the extant literature on associations between trauma exposure, language, and emotional processing.

Revealing Unknown Benefits of Existing Medications to Aid the Discovery of New Treatments for Post‐Traumatic Stress Disorder

Objective

To systematically identify novel pharmacological strategies for preventing or treating post‐traumatic stress disorder (PTSD) by leveraging large‐scale analysis of real‐world observational data.

Methods

Using a self‐controlled study design, the association between 1399 medications and the incidence of PTSD across four US insurance claims databases covering commercially insured, Medicare eligible, and Medicaid patients was examined. A validated algorithm for identifying PTSD in claims data was used, and medications were identified by their RxNorm ingredient. Medications used to treat PTSD or its symptoms (e.g., antidepressants, antipsychotics) were excluded. Medications associated with ≥30% reduction in risk of PTSD in ≥2 databases were identified.

Results

A total of 137,182,179 individuals were included in the analysis. Fifteen medications met the threshold criteria for a potential protective effect on PTSD; six were categorized as “primary signals” while the remaining nine were considered “potential signals”. The primary signals include a beta blocker that has been previously studied for PTSD, and five medications used to treat attention‐deficit/hyperactivity disorder. The potential signals include four medications used to treat substance use disorders and five medications used to treat sleep disorders.

Discussion

The medications identified in this analysis provide targets for further research in studies that are designed to examine specific hypotheses regarding these medications and the incidence of PTSD. This work may aid in discovering novel therapeutic approaches to treat PTSD, wherein new and effective treatments are badly needed.

Four large US‐based administrative claims databases were used to analyze the association between all marketed prescription medications and the outcome of incident post‐traumatic stress disorder (PTSD)

Of the 1399 medications examined, there were 15 that met the strict filtering criteria for showing consistent, moderate‐to‐strong, protective effects against the outcome

Medications fell into four main classes: (1) a beta blocker (propranolol), (2) five medications used to treat attention‐deficit/hyperactivity disorder (ADHD), (3) four medications used to treat substance use disorders and (4) five medications used to treat sleep disorders

These findings identify rational starting points for future hypothesis‐driven research to explore these associations in greater detail

Epidemiology of DSM-5 alcohol use disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Alcohol use disorder (AUD) is a prevalent public health concern in the U.S. that disproportionately affects veterans relative to civilians. Given changes to the demographic composition of the veteran population and AUD diagnostic criteria in the DSM-5, updated knowledge regarding the epidemiology of DSM-5 AUD in a national sample of veterans is critical to informing the population-based burden of this disorder.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 U.S. veterans. Lifetime DSM-5 AUD (mild, moderate, severe) and past-year DSM-5 AUD were assessed using validated self-report measures, and sociodemographic, military, and psychiatric characteristics associated with lifetime and past-year AUD were evaluated.

RESULTS

Prevalences of lifetime and past-year DSM-5 AUD were 40.8% (95% confidence interval [CI]=39.2-42.3%) and 10.5% (95%CI=9.6-11.5%), respectively. Lifetime prevalences of mild, moderate, and severe AUD were 20.5%, 8.3%, and 12.0%, respectively. Veterans with lifetime AUD had elevated rates of psychiatric disorders and suicidal behavior, which generally increased as a function of AUD severity. Lifetime AUD was also associated with being younger, male, white, unmarried, retired and experiencing more adverse childhood experiences and traumas. For past-year AUD, being younger, male, white, having more adverse childhood experiences, and experiencing lifetime PTSD were significant correlates.

CONCLUSIONS

AUD is highly prevalent among U.S. veterans and associated with substantial psychopathology, including elevated odds of suicidal behaviors. Results underscore the importance of comprehensive screening and preventive efforts for AUD, and interventions that concurrently target overlapping alcohol use and psychiatric difficulties.

Posttraumatic Stress Disorder Symptoms and Coping Motives are Independently Associated with Cannabis Craving Elicited by Trauma Cues

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD), although its use can ultimately worsen PTSD outcomes. Cannabis-use coping motives may help explain the PTSD-cannabis relationship. Frequent pairing of trauma cues with substance use to cope with negative affect can lead to conditioned substance craving. For the present cue-reactivity study, we examined if PTSD symptoms were associated with cannabis craving elicited by a personalized trauma cue and explored whether coping motives mediated this hypothesized relationship; enhancement motives were included as a comparison mediator. Participants (N = 51) were trauma-exposed cannabis users who completed validated assessments on PTSD symptom severity and cannabis use motives. They were then exposed to a personalized audiovisual cue based on their own traumatic experience after which they responded to questions on a standardized measure regarding their cannabis craving. The results demonstrated that PTSD symptoms were associated with increased cannabis craving following trauma cue exposure, B = 0.43, p = .004, 95% CI [0.14, 0.72]. However, the results did not support our hypothesis of an indirect effect through general coping motives, indirect effect = .03, SE = .08, 95% CI [-.10, .21]. We found an independent main effect of general coping motives on trauma cue-elicited cannabis craving, B = 1.86, p = .002, 95% CI [0.72, 3.01]. These findings have important clinical implications suggesting that clinicians should target both PTSD symptoms and general coping motives to prevent the development of conditioned cannabis craving to trauma reminders in trauma-exposed cannabis users.

Childhood abuse, posttraumatic stress symptoms, and alcohol misuse among African-American women

The study explored associations among childhood abuse, post-traumatic stress symptoms (PTSS), and alcohol misuse in a sample of low-income African-American women (N = 172). Using bootstrapping techniques, a mediation effect was found of childhood physical and emotional abuse on alcohol misuse via PTSS symptom severity, avoidance, and hyperarousal, as well as for childhood sexual abuse on alcohol misuse via PTSS symptom severity and hyperarousal. Our results suggest that PTSS indicators, particularly symptom severity and hyperarousal, may be important mechanisms underlying the association of experiences of abuse during childhood and alcohol misuse in adulthood.

Efficacy and acceptability of interventions for co-occurring PTSD and SUD: A meta-analysis

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD.

Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders

Introduction

Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD.

Design and setting

An administrative dataset including Veterans Health Administration (VHA) users.

Participants

The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015.

Measurement

Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy.

Findings

A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment.

Conclusions

Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.

Optogenetic manipulation of the prelimbic cortex during fear memory reconsolidation alters fear extinction in a preclinical model of comorbid PTSD/AUD

RATIONALE AND OBJECTIVE

Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are disorders of learning and memory that often occur comorbidly. Exposure to trauma-related cues can increase alcohol intake in PTSD patients that are using alcohol to self-medicate. The recurrence of anxiety symptoms with subsequent alcohol use may initiate a destructive cycle where stress and alcohol exposure impair the function of the prefrontal cortex (PFC). While the incidence of these disorders has steadily increased, current therapies and treatments often lack efficacy. Thus, investigation into the underlying neurocircuitry responsible for the establishment and maintenance of these disorders is necessary to develop novel treatment targets.

METHODS

The present study examined the effects of ethanol exposure on the ability to create new learned associations around previously conditioned fear cues in a rat model. Animals were exposed to fear conditioning followed by chronic intermittent ethanol to translationally model trauma exposure followed by alcohol abuse. Optogenetics was used to inhibit the prelimbic (PrL) or infralimbic (IfL) cortex during fear memory reconsolidation, and fear behaviors were measured during subsequent extinction and spontaneous recovery tests. Results and conclusion Chronic ethanol exposure led to deficits in fear extinction learning and increased freezing during spontaneous recovery, both of which were prevented following inhibition of the PrL, but not the IfL, during memory reconsolidation. These results support the involvement of the PrL in fear learning and memory, and strongly suggest that the PrL could serve as a potential target for the treatment of the learning and memory deficits that occur following exposure to stress and alcohol.

Integrated Trauma-Focused Psychotherapy for Traumatic Stress and Substance Use: Two Adolescent Case Studies

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed.

A Narrative Literature Review of the Epidemiology, Etiology, and Treatment of Co-Occurring Panic Disorder and Opioid Use Disorder

OBJECTIVE

Panic disorder is a debilitating psychiatric disorder that often co-occurs with substance use disorders. Given the current opioid epidemic, the high reported rates of comorbid panic disorder and opioid use disorder are particularly concerning. In this narrative review, we describe the literature on panic disorder and opioid use disorder co-occurrence.

METHODS

86 studies, 26 reviews, 2 commentaries, and 5 guidelines pertaining to opioid use disorder, panic disorder, and their comorbidity were identified using all EBSCO databases, PubMed, and Google Scholar.

RESULTS

First, we review epidemiological literature on the prevalence of the comorbid condition above and beyond each disorder on its own. Additionally, we discuss the challenges that complicate the differential diagnosis of panic disorder and opioid use disorder and contribute to difficulties establishing rates of comorbidity. Second, we review three theoretical models that have been proposed to explain high rates of co-occurring panic disorder and opioid use disorder: the precipitation hypothesis, the self-medication hypothesis, and the shared vulnerability hypothesis. Third, we outline how co-occurring panic and opioid use disorder may impact treatment for each condition.

CONCLUSION

Based on findings in the field, we provide recommendations for future research as well as treatment considerations for co-occurring panic and opioid use disorders.

A Comparison of Cognitive Processing Therapy and Seeking Safety for the Treatment of Posttraumatic Stress Disorder in Veterans

To compare the outcomes of Seeking Safety (SS) and cognitive processing therapy (CPT) in veterans with PTSD in a specialty clinic of an urban VA medical center. Retrospective chart review of electronic medical records was conducted for 420 veterans with PTSD who received treatment with either CPT (n = 227) or SS (n = 193) in group setting. 1) treatment completion rate, 2) self-reported PTSD symptom severity measured by PTSD checklist (PCL), and 3) additional mental health services received within 12 months after treatment. Data were analyzed for the 160 who had both a pre and post PCL documented in their charts. The final analysis sample included n = 94 for CPT and n = 66 for SS veterans with a mean age of 49.71[SD = 14] years, 24 women [15%]; mean baseline PCL score was 68.41 [9]. Significantly more veterans completed SS treatment (SS, 59 [89%] than CPT, 47 [50%] (p = <.001). However, PCL score decreases were significantly greater for patients who completed CPT treatment than those in SS (treatment x time interaction, 9.60 vs.4.98, respectively; difference, 4.62; t₈₄ = 2.16; p = .02). The patients who received SS used significantly more mental health services of the PTSD clinical team than patients who completed CPT treatment (p = .01). The results of this study demonstrate the need for alternative approaches where dually diagnosed patients would not be delayed in their receipt of trauma-focused care - i.e., where treatment is initiated concurrently rather than sequentially to substance abuse treatment.

Quality of end-of-life care for Vietnam-era Veterans: Implications for practice and policy

BACKGROUND

In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA's response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations.

METHODS

Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between fiscal year 2013-2017. Contemporaneous comparisons were made with World War II/Korean War-era Veterans.

RESULTS

Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower.

CONCLUSIONS

Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted.

IMPLICATIONS

Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.

Problematic Use of the Internet in Subjects With Bipolar Disorder: Relationship With Posttraumatic Stress Symptoms

Background: Literature shows a high risk for problematic use of the Internet (PUI) in mood disorders, especially in bipolar disorder (BD). In subjects with BD, traumatic events and posttraumatic stress disorder (PTSD) are related to alcohol or substance use disorder, as well as to gambling disorder. However, little is known about the possible association between traumatic exposure and PUI. The present study was aimed at examining the relationship between PUI and trauma exposure, besides PTSD symptoms, in subjects with BD. Methods: A sample of 113 subjects with BD was screened to putative PUI. Furthermore, they completed the Trauma and Loss Spectrum Self-Report (TALS-SR) to assess traumatic events and posttraumatic stress symptoms. Results: Twenty-four subjects (21.2%) reported putative PUI. Subjects with putative PUI presented significantly higher scores in the TALS-SR domains Potentially Traumatic Events, Re-experiencing, Maladaptive coping, and Arousal, as well as in the TALS-SR total score. In a logistic regression model, a positive association emerged between Potentially Traumatic Events and Arousal TALS-SR domains and putative PUI. Conclusion: One in five patients with BD screened positive for PUI. A significant association between PUI and lifetime traumatic events as well as PTSD symptoms emerged, highlighting the relevance of the comorbidity between PTSD and PUI in subjects with BD.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review

INTRODUCTION

Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel.

METHODS

Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection.

RESULTS

The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies.

CONCLUSIONS

The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Treatment receipt patterns among individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders

OBJECTIVE

To determine latent classes of treatment receipt among people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) and describe each class by demographics, disease characteristics, and psychiatric diagnoses.

METHOD

Participants were National Epidemiologic Survey on Alcohol and Related Conditions-III respondents with lifetime PTSD and SUD (n = 1,349; mean age 40.3; 62.5% female; 30.9% non-White or Hispanic-White). Cross-sectional data were collected using the DSM-5 Alcohol Use Disorder and Associated Disabilities Interview Schedule. Latent class analysis was used to identify subgroups of participants with different patterns of treatment receipt.

RESULTS

Of the patients, 36% received at least 1 SUD treatment while 84% received at least 1 mental health (MH) treatment. Six latent classes were identified: no treatment (17.3%), outpatient MH (34.0%), outpatient + inpatient MH (17.9%), SUD (7.3%), SUD + outpatient MH (15.7%), and SUD + outpatient MH + inpatient MH (7.7%). The SUD treatment classes evidenced greater social instability, had higher alcohol use disorder symptom severity, and used more drug types than the non-SUD classes. Classes receiving inpatient MH treatment had a greater incidence of additional comorbid conditions and suicidal behaviors. Across all 6 classes, most respondents met diagnostic criteria for chronic PTSD (overall: 68.9%) while fewer met diagnostic criteria for chronic SUD (overall: 38.7%).

CONCLUSIONS

Most people with lifetime PTSD and SUD have sought either SUD or MH treatment or both, with substantially greater receipt of MH treatment. This comorbid group has complex clinical presentations that differ depending upon treatment subgroup, and for most, their PTSD persisted despite high rates of treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

High-dose prescribed opioids are associated with increased risk of heroin use among United States military veterans

Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.

Medical Surgical Nurse Self-perceived Competency in Posttraumatic Stress Disorder/Substance Use Disorder Veteran Care in a Non-Veterans Health Administration Setting

OBJECTIVE

This study evaluated the self-perceived readiness of medical-surgical nurses in a non-Veterans Health Administration (VHA) facility to care for veterans with posttraumatic stress disorder (PTSD) and substance use disorder (SUD).

BACKGROUND

Nurses caring for veterans with PTSD and SUD at facilities other than the VHA should be equipped with the knowledge, skills, and attitudes to provide care for this population.

METHODS

Nurses evaluated their self-perceived knowledge, skills, attitudes, experiences, and perspectives related to caring for veterans.

RESULTS

Nurses overwhelmingly indicated that they had no knowledge of the "Have you served?" campaign, and fewer than half inquired about military status when assessing patients CONCLUSION: Nurses caring for veterans in non-VHA facilities do not consistently identify veterans or assess for service-related conditions, including PTSD and SUD. Nurses report low skill levels related to identifying, addressing, and referring patients with service-related conditions.

A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders

OBJECTIVE

Recent clinical practice guidelines recommend the delivery of evidence-based psychotherapies for both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) within the same treatment episode for patients with SUD/PTSD comorbidity. This randomized clinical trial evaluated the comparative effectiveness of integrating versus phasing evidence-based psychotherapies for SUD and PTSD among veterans with co-occurring SUD/ PTSD.

METHOD

183 veterans with DSM-IV PTSD and SUD at two VA Medical Centers were randomized to one of two psychotherapies during which Motivational Enhancement Therapy [MET] for SUD and Prolonged Exposure [PE] for PTSD were either phased or integrated throughout treatment. Primary outcomes as evaluated by blinded assessors were percent days with drug use or heavy drinking and PTSD symptomology. We hypothesized integrated MET/PE (n = 95) would yield better SUD and PTSD-related outcomes at posttreatment than phased MET/PE (n = 88).

RESULTS

In intent-to-treat analyses (n=183), both treatment groups achieved clinically (d=0.46 - 1.06) and statistically significant reductions in SUD (p < 0.01) and PTSD (p < 0.01) symptomology; the time by treatment interactions were not significant. Post-hoc analyses could not confirm statistical non-inferiority; between-group effect sizes suggest a lack of clinically-meaningful differences between the two treatment approaches (d=0.08 - 0.27).

CONCLUSIONS

Our hypothesis that integrated MET/PE would result in better outcomes than phased MET/PE across a range of PTSD and SUD measures was not supported; both strategies for combining two single-disorder treatments for co-occurring SUD/PTSD yielded significant symptom reduction.

Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders?

BACKGROUND

Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD).

AIM

This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD.

METHOD

Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment.

RESULTS

At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment.

CONCLUSIONS

This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.

Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans

OBJECTIVE

A substantial amount of individuals with substance use disorders (SUD) also meet criteria for posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) is an effective, evidence-based treatment for PTSD, but there is limited data on its use among individuals with current alcohol or drug use disorders. This study evaluated the efficacy of an integrated treatment that incorporates PE (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure or COPE) among veterans.

METHOD

Military veterans (N = 81, 90.1% male) with current SUD and PTSD were randomized to 12 sessions of COPE or Relapse Prevention (RP). Primary outcomes included the Clinician Administered PTSD Scale (CAPS), PTSD Checklist-Military version (PCL-M), and the Timeline Follow-back (TLFB).

RESULTS

On average, participants attended 8 out of 12 sessions and there were no group differences in retention. Intent-to-treat analyses revealed that COPE, in comparison to RP, resulted in significantly greater reductions in CAPS (d = 1.4, p < .001) and PCL-M scores (d = 1.3, p = .01), as well as higher rates of PTSD diagnostic remission (OR = 5.3, p < .01). Both groups evidenced significant and comparable reductions in SUD severity during treatment. At 6-months follow-up, participants in COPE evidenced significantly fewer drinks per drinking day than participants in RP (p = .05).

CONCLUSIONS

This study is the first to report on the use of an integrated, exposure-based treatment for co-occurring SUD and PTSD in a veteran sample. The findings demonstrate that integrated, exposure-based treatments are feasible and effective for military veterans with SUD and PTSD. Implications for clinical practice are discussed.

Predictors of Dropout From Residential Treatment for Posttraumatic Stress Disorder Among Military Veterans

Background: Successful psychotherapy for posttraumatic stress disorder (PTSD) necessitates initial and sustained engagement. However, treatment dropout is common, with rates of 50-70% depending on the setting, type of treatment and how dropout is calculated. Dropout from residential treatment is less understood and could be impacted by participation of more symptomatic patient populations and reduced day-to-day barriers to engagement. Gaining insight into predictors of treatment dropout is critical given that individuals with greater symptoms are the most in need of successful treatments but also at higher risk of unsuccessful psychotherapy episodes. Aim: The aim of the current study was to examine predictors of treatment dropout among veterans receiving residential treatment for PTSD. Methods: The study included 3,965 veterans who initiated residential PTSD treatment within a Department of Veterans Affairs program during Fiscal Year 2015 and completed self-report measures of demographics and psychiatric symptoms at admission. Results: In our sample (N = 3,965, 86.5% male, mean age = 45.5), 27.5% did not complete the residential program (n = 1,091). Controlling for age, marital status, combat/non-combat trauma, and facility, generalized estimating equation modeling analysis indicated greater PTSD symptoms and physical functioning at admission were associated with reduced likelihood of completing the residential program. There were significant differences in trauma-focused psychotherapy received by individuals who dropped out of residential treatment and those who did not. Among veterans who dropped out, 43.6% did not get any trauma-focused psychotherapy; 22.3% got some, but less than 8 sessions; and 34.1% got at least 8 sessions; compared to 37.3%, 4.8%, and 57.9%, respectively, among program completers. Conclusion: Dropout rates from residential PTSD programs indicate that at least one in four veterans do not complete residential treatment, with more symptomatic individuals and those who do not receive trauma-focused therapy being less likely to complete.

Posttraumatic stress severity is associated with coping motives for alcohol use among in-patient and community recruited adolescents

BACKGROUND AND OBJECTIVES

A growing body of work suggests individuals with more severe post-traumatic stress symptoms (PTSS) are at higher risk for developing problematic alcohol use outcomes. Extending work from the adult literature, the present study was the first to examine the extent to which PTSS is related to drinking motives for alcohol use in both clinical and non-clinical samples of adolescents.

DESIGN

Hierarchical regression analyses were used to predict coping motives for alcohol use from PTSS, above and beyond demographic variables, alcohol use frequency, and other alcohol use motives.

METHODS

Trauma-exposed adolescents before entering treatment (Sample 1 n = 41) and recruited from the local community (Sample 2 n = 55) self-reported on PTSS and alcohol use motives.

RESULTS

PTSS positively predicted coping motives for alcohol use after controlling for age, gender, and alcohol use frequency.

CONCLUSIONS

The current study highlights the need to consider both PTSS severity, as well as underlying cognitive mechanisms (e.g., motives), to better understand the etiology of problematic alcohol use among trauma-exposed youth. Future work focused on clarifying the trajectory of alcohol use motives and problems as a function of PTSS is needed.

Exploring Demographics and Health as Predictors of Risk-Taking in UK Help-Seeking Veterans

Risk-taking amongst veterans has severe consequences, yet few studies have examined factors that may predict risk-taking in help-seeking veteran populations. This paper presents a cross-sectional study involving a random sample of 667 UK help-seeking veterans, investigating the role of demographics, mental health and physical health presentations on the propensity for risk-taking. Out of 403 (73.4%) veterans, 350 (86.8%) reported risk-taking in the past month. We found that younger age, being in a relationship, probable PTSD, common mental health difficulties and traumatic brain injury were significantly associated with risk-taking. Additionally, a direct association was found between increased risk-taking and PTSD symptom clusters, including higher hyperarousal, elevated negative alterations in mood and cognition. Our findings provide initial evidence for demographic and mental health presentations as predictors of risk-taking in help-seeking veterans. Further research and longitudinal studies are needed to facilitate valid risk assessments, and early intervention for veteran services.

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

Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort

OBJECTIVE

Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA).

METHODS

National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age.

RESULTS

Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years).

CONCLUSIONS

In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.

Development of a novel, integrated cognitive-behavioral therapy for co-occurring posttraumatic stress and substance use disorders: A pilot randomized clinical trial

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No evidence-based, 'gold standard' treatments for PTSD/SUD comorbidity are currently available. The present pilot randomized clinical trial was designed to evaluate the feasibility and preliminary efficacy of a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS), as compared to standard cognitive-behavioral treatment (CBT) for SUD. The TIPSS program integrates cognitive processing therapy with CBT for SUD for the treatment of co-occurring PTSD/SUD. Both treatment conditions are comprised of 12, 60-minute individual psychotherapy sessions, delivered twice-weekly over six weeks. Primary aims examine whether TIPSS, compared to standard CBT for SUD, reduces: (1) PTSD symptoms and (2) substance use outcomes (i.e., self-report, objective). Secondary aims examine whether (a) trauma- and substance cue reactivity and (b) distress tolerance (i.e., actual or perceived ability to withstand uncomfortable emotional or physical states) are significant mechanisms of change. The study was recently closed to new enrollment. Participants included adults with substance dependence and at least four symptoms of PTSD.

Behavioral Treatments for Alcohol Use Disorder and Post-Traumatic Stress Disorder

Alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) are highly prevalent and debilitating psychiatric conditions that commonly co-occur. Individuals with comorbid AUD and PTSD incur heightened risk for other psychiatric problems (e.g., depression and anxiety), impaired vocational and social functioning, and poor treatment outcomes. This review describes evidence-supported behavioral interventions for treating AUD alone, PTSD alone, and comorbid AUD and PTSD. Evidence-based behavioral interventions for AUD include relapse prevention, contingency management, motivational enhancement, couples therapy, 12-step facilitation, community reinforcement, and mindfulness. Evidence-based PTSD interventions include prolonged exposure therapy, cognitive processing therapy, eye movement desensitization and reprocessing, psychotherapy incorporating narrative exposure, and present-centered therapy. The differing theories behind sequential versus integrated treatment of comorbid AUD and PTSD are presented, as is evidence supporting the use of integrated treatment models. Future research on this complex, dual-diagnosis population is necessary to improve understanding of how individual characteristics, such as gender and treatment goals, affect treatment outcome.

Use of Protective Behavioral Strategies among Young Adult Veteran Marijuana Users

Young adult veterans are at risk for problematic marijuana use and associated consequences, which is partially due to their high rates of Posttraumatic Stress Disorder (PTSD), depression, and problematic substance use. Veterans tend to endorse more severe and chronic mental health symptoms compared to their civilian counterparts and they identify marijuana use as a method to cope with their symptoms. Given the prevalence of marijuana use among veterans in the community and in clinical settings, it is important to explore the factors that may help minimize harm associated with use for those that choose to use the drug. The present study sought to examine the impact of protective behavioral strategies on the relationship between mental health symptoms and marijuana use and consequences in a sample of 180 young adult veteran marijuana users. Participants were recruited via social media advertisements and completed measures of marijuana use and consequences, protective behavioral strategies, and PTSD and depression symptoms. Findings indicated that more frequent use of protective behavioral strategies was associated with less marijuana use and consequences. Participants who screened positive for PTSD or depression reported more marijuana consequences than did those not positive on these screeners. Regression analyses revealed protective strategies moderated the relationship between PTSD and marijuana consequences such that young veterans who endorsed more PTSD symptoms and infrequent use of protective strategies reported the most marijuana consequences. No moderating effects were found for the relationship between depression and marijuana consequences. Findings have clinical implications for working with young veterans.

Co-Occurring Post-Traumatic Stress Disorder and Alcohol Use Disorder in U.S. Military and Veteran Populations

Co-occurring post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are costly and consequential public health problems that negatively affect the health and well-being of U.S. military service members and veterans. The disproportionate burden of comorbid PTSD and AUD among U.S. military service members and veterans may be due to unique factors associated with military service, such as aspects of military culture, deployment, and trauma exposure. This review addresses the prevalence of co-occurring PTSD and AUD in military and veteran populations, population-specific factors that contribute to development of the comorbid conditions, and evidence-based treatments that have promise for addressing these conditions in military and veteran populations. Future directions for research and practice relevant to military and veteran populations are discussed.

Integrated, exposure-based treatment for PTSD and comorbid substance use disorders: Predictors of treatment dropout

High rates of comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have been noted in veteran populations. Fortunately, there are a number of evidence-based psychotherapies designed to address comorbid PTSD and SUD. However, treatments targeting PTSD and SUD simultaneously often report high dropout rates. To date, only one study has examined predictors of dropout from PTSD/SUD treatment. To address this gap in the literature, this study aimed to 1) examine when in the course of treatment dropout occurred, and 2) identify predictors of dropout from a concurrent treatment for PTSD and SUD. Participants were 51 male and female veterans diagnosed with current PTSD and SUD. All participants completed at least one session of a cognitive-behavioral treatment (COPE) designed to simultaneously address PTSD and SUD symptoms. Of the 51 participants, 22 (43.1%) dropped out of treatment prior to completing the full 12 session COPE protocol. Results indicated that the majority of dropout (55%) occurred after session 6, with the largest amount of dropout occurring between sessions 9 and 10. Results also indicated a marginally significant relationship between greater baseline PTSD symptom severity and premature dropout. These findings highlight inconsistencies related to timing and predictors of dropout, as well as the dearth of information noted about treatment dropout within PTSD and SUD literature. Suggestions for procedural changes, such as implementing continual symptom assessments during treatment and increasing dialog between provider and patient about dropout were made with the hopes of increasing consistency of findings and eventually reducing treatment dropout.

Integrated Treatment of PTSD and Substance Use Disorders: The Mediating Role of PTSD Improvement in the Reduction of Depression

Posttraumatic stress disorder (PTSD) represents one of the most common mental health disorders, particularly among veterans, and is associated with significant distress and impairment. This highly debilitating disorder is further complicated by common comorbid psychiatric disorders, such as substance use disorders (SUD). Individuals with PTSD and co-occurring SUD also commonly present with secondary symptoms, such as elevated depression. Little is known, however, about how these secondary symptoms are related to treatment outcome. The aim of the present study, therefore, was to examine (1) the effects of treatment of comorbid PTSD/SUD on depressive symptoms; and (2) whether this effect was mediated by changes in PTSD severity or changes in SUD severity. Participants were 81 U.S. military veterans (90.1% male) with PTSD and SUD enrolled in a randomized controlled trial examining the efficacy of an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure; n = 54) versus relapse prevention (n = 27). Results revealed significantly lower depressive symptoms at post-treatment in the COPE group, as compared to the relapse prevention group. Examination of the mechanisms associated with change in depression revealed that reduction in PTSD severity, but not substance use severity, mediated the association between the treatment group and post-treatment depression. The findings underscore the importance of treating PTSD symptoms in order to help reduce co-occurring symptoms of depression in individuals with PTSD/SUD. Clinical implications and avenues for future research are discussed.

Integrated Exposure-Based Therapy for Co-Occurring Post Traumatic Stress Disorder (PTSD) and Substance Dependence: Predictors of Change in PTSD Symptom Severity

This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.

Cannabis use among Canadian Armed Forces Veterans

Introduction: Despite rapidly changing cannabis use regulations in Canada, including health care support for Canadian Armed Forces (CAF) Veterans, the prevalence of and reasons for cannabis use in this population have not been studied. Methods: An online 28-item anonymous survey was used to examine the prevalence of cannabis use among CAF Veterans who reported undergoing treatment of PTSD ( N=120). We aimed to estimate the prevalence of cannabis use among CAF Veterans, as well as to explore the reasons for cannabis use in this population. We also examined the relationships between cannabis use and other aspects of health in CAF Veterans, namely other substance use, PTSD symptom severity, and chronic pain severity. Results: Approximately half of the respondents reported a history of cannabis use. Of these, approximately 35.5% reported beginning cannabis use before a military-related trauma, 23% reported beginning after a traumatic event, and 42% reported beginning after release. Participants stated that they used cannabis primarily for relaxation and emotional calm, and for pain management. Only 10% reported its use specifically for PTSD-related symptoms and anxiety. Chronic cannabis users (i.e., one or more years) endorsed a greater number of cannabis abuse symptoms than acute users (i.e., one time to less than three months). Cannabis users were also more likely to use both prescription and non-prescription drugs. No relationships were found between cannabis use and military-related PTSD symptom severity or pain severity. Discussion: Cannabis use, along with other substance use, is common among CAF Veterans, and the reasons for cannabis use vary greatly. Cannabis use does not appear to have an impact on PTSD- and pain-related symptom expression; however, further study is recommended.

Study design, interventions, and baseline characteristics for the Substance use and TRauma Intervention for VEterans (STRIVE) trial

While comorbidity between posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is common among veterans, there is debate regarding how to best treat individuals suffering from both conditions. Despite data supporting the effectiveness of integrated treatments that simultaneously address both disorders, due to concerns that an early focus on trauma may increase dropout and reduce the likelihood of achieving SUD-related goals, providers continue to prefer a sequential approach, where the addiction is treated first and PTSD treatment is instituted following sustained abstinence or reduced use. This project is designed to directly examine these provider concerns by evaluating the benefits and harms of an integrated versus a sequential approach to treating comorbid PTSD and SUD. This paper reviews the study's methodology, treatment approaches, and baseline participant characteristics. In this randomized clinical trial, one hundred eighty-three veterans with co-occurring PTSD and SUD have been randomized to one of two psychotherapies that include the same treatment components for SUD and PTSD (Motivational Enhancement Therapy and Prolonged Exposure respectively), but differ by whether the components are delivered sequentially or are integrated such that PTSD and SUD symptoms are addressed concurrently. We hypothesize that veterans assigned to integrated treatment will show greater improvement in PTSD and SUD symptoms than veterans assigned to sequential treatment. If this hypothesis is supported, the findings have the potential to change clinicians' beliefs and challenge long-standing practice patterns that require participation in SUD treatment prior to initiating trauma-focused therapies for PTSD.

A systematic review of technology-based interventions for co-occurring substance use and trauma symptoms

Introduction

Technology-based mental health interventions are becoming increasingly common, and several have begun to target multiple outcomes in a single intervention. Recent developments in the treatment of co-occurring posttraumatic stress disorder and substance use disorder has led to the development and testing of technology-based interventions for these disorders. The current systematic review examined technology-based interventions designed to improve mental health outcomes among patients with co-occurring trauma symptoms and substance use.

Methods

Of 601 articles reviewed, 14 included a technology-based intervention for patients with these co-occurring problems.

Results

Seven of these studies provided preliminary evidence that technology-based interventions are likely to be efficacious in reducing either trauma symptoms or substance use. The seven remaining studies demonstrated that technology-based interventions for co-occurring trauma symptoms and substance use are feasible.

Discussion

This review suggests that technology-based interventions for co-occurring trauma symptoms and substance use are feasible, but more work is needed to assess efficacy using scientifically rigorous studies.

Posttraumatic Stress Symptoms and their Relationship to Drug and Alcohol use in an International Sample of Latino Immigrants

We identify the prevalence and correlates of posttraumatic stress (PTSD) symptoms and their relationship to alcohol and substance use disorders (AUD/SUD) among Latino immigrants in two countries. A screening battery assessing PTSD symptoms (PCL-C), alcohol use (AUDIT), drug abuse (DAST), and psychological measures was administered to 562 Latino immigrants recruited in clinics. We used logistical regression analyses to evaluate the relationship between PTSD symptoms and AUD/SUD. Prevalence of elevated PTSD symptoms was high (53.7 % in Boston, 47.9 % in Madrid and, 43.8 % in Barcelona). Screening positive for psychological measures was significantly correlated to screening positive on the PCL-C (p < 0.001). Significant gender differences in risk of AUD/SUD were moderated by PTSD symptoms. Presence of any PTSD symptoms predicted problems with benzodiazepine misuse. Given the high rates of co-morbidity between PTSD symptoms and AUD/SUD, we recommend early interventions for dual pathology for Latino immigrants with trauma history.