1
|
Petrakis IL, Meshberg-Cohen S, Nich C, Kelly MM, Claudio T, Jane JS, Pisani E, Ralevski E. Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine. Am J Addict 2024; 33:525-533. [PMID: 38624259 DOI: 10.1111/ajad.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine. METHODS This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38). RESULTS Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study. DISCUSSION AND CONCLUSIONS Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling. SCIENTIFIC SIGNIFICANCE This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.
Collapse
Affiliation(s)
- Ismene L Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sarah Meshberg-Cohen
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Charla Nich
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan M Kelly
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Psychiatry, UMass Chan Medical School, North Worcester, Massachusetts, USA
| | - Tracy Claudio
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Jane Serrita Jane
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Emily Pisani
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| |
Collapse
|
2
|
Back SE, Jarnecke AM, Norman SB, Zaur AJ, Hien DA. State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders. J Trauma Stress 2024. [PMID: 38857125 DOI: 10.1002/jts.23049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 06/12/2024]
Abstract
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.
Collapse
Affiliation(s)
- Sudie E Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
| | - Amber M Jarnecke
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego School of Medicine, San Diego, California, USA
| | - Angela J Zaur
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Denise A Hien
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, New Brunswick, New Jersey, USA
| |
Collapse
|
3
|
Meshberg-Cohen S, Cook JM, Bin-Mahfouz A, Petrakis IL. Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial. Contemp Clin Trials 2024; 139:107475. [PMID: 38365173 DOI: 10.1016/j.cct.2024.107475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/01/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.
Collapse
Affiliation(s)
- Sarah Meshberg-Cohen
- Yale University School of Medicine, Department of Psychiatry, United States of America; VA Connecticut Healthcare System, United States of America.
| | - Joan M Cook
- Yale University School of Medicine, Department of Psychiatry, United States of America
| | - Amirah Bin-Mahfouz
- Yale University School of Medicine, Department of Psychiatry, United States of America; VA Connecticut Healthcare System, United States of America
| | - Ismene L Petrakis
- Yale University School of Medicine, Department of Psychiatry, United States of America; VA Connecticut Healthcare System, United States of America
| |
Collapse
|
4
|
Hindmarch G, Meredith LS, McCullough CM, Griffin BA, Watkins KE. Interpersonal Violence and Mental Health, Drug use, and Treatment Utilization among Patients with Co-Occurring Opioid use and Mental Health Disorders. CHRONIC STRESS (THOUSAND OAKS, CALIF.) 2024; 8:24705470241279335. [PMID: 39246736 PMCID: PMC11378169 DOI: 10.1177/24705470241279335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 08/15/2024] [Indexed: 09/10/2024]
Abstract
Interpersonal violence is a common type of trauma experienced by people with opioid use disorder (OUD), especially for people with co-occurring OUD and mental illness (COD). However, little is known about demographic and clinical characteristics of individuals with COD who have experienced an interpersonal violence traumatic event compared to those who have experienced a non-violent trauma, and how experiences of interpersonal violence are associated with treatment utilization. Data presented are from a randomized clinical trial testing collaborative care for COD in primary care. Of the 797 patients enrolled in the larger study, 733 (92%) were included in this analysis because they reported a traumatic event. In this sample, 301 (41%) participants experienced a traumatic event involving interpersonal violence. Participants who experienced interpersonal violence were more likely to be younger and female. Among the 301 people who experienced interpersonal violence, 30% experienced child sexual abuse, 23% experienced physical violence, 19% experienced domestic violence, and 28% experienced sexual assault. Those who experienced physical violence were significantly less likely to be female (28.6% vs 74.2% to 88.2% in other groups). Those who reported domestic violence had significantly fewer days of drug use (4.1 days vs 9.0 to 11.5 in the other groups) and lower opioid use severity scores (mean = 13.0 vs 16.6 to 19.5 in the other groups). Multivariable regression results examining the associations between interpersonal violence experiences on treatment utilization revealed no statistically significant differences. Rates of receipt were high for medication for opioid use disorder (∼80%) in this sample while rates of mental health counseling were around 35% and rates of receiving mental health medication around 48%. These findings make an important contribution to understanding the associations between patient characteristics and traumatic experiences, and receipt of treatment for OUD and mental health problems among a sample of patients with COD. Clinical trial registration clinicalTrials.gov ID: NCT04559893.
Collapse
|
5
|
Vakkalanka JP, Lund BC, Arndt S, Field W, Charlton M, Ward MM, Carnahan RM. Therapeutic relationships between Veterans and buprenorphine providers and effects on treatment retention. Health Serv Res 2022; 57:392-402. [PMID: 34854083 PMCID: PMC8928033 DOI: 10.1111/1475-6773.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention. DATA SOURCES National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017. STUDY DESIGN Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year. DATA COLLECTION/EXTRACTION METHODS Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality. PRINCIPAL FINDINGS A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07). CONCLUSIONS Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.
Collapse
Affiliation(s)
- Jayamalathi Priyanka Vakkalanka
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIowaUSA
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Brian C. Lund
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIowaUSA
- Center for Comprehensive Access and Delivery Research and EvaluationIowa City Veterans Affairs Health Care SystemIowa CityIowaUSA
| | - Stephan Arndt
- Department of BiostatisticsUniversity of Iowa College of Public HealthIowa CityIowaUSA
- Department of PsychiatryUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - William Field
- Department of Occupational and Environmental HealthUniversity of Iowa College of Public HealthIowa CityIowaUSA
| | - Mary Charlton
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIowaUSA
| | - Marcia M. Ward
- Department of Health Management and PolicyUniversity of Iowa College of Public HealthIowa CityIowaUSA
| | - Ryan M. Carnahan
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIowaUSA
| |
Collapse
|
6
|
Meshberg-Cohen S, Ross MacLean R, Schnakenberg Martin AM, Sofuoglu M, Petrakis IL. Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review. Addict Behav 2021; 122:107026. [PMID: 34182307 DOI: 10.1016/j.addbeh.2021.107026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/26/2021] [Accepted: 06/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Opioid use disorder (OUD) is a public health emergency. Evidence suggests that posttraumatic stress disorder (PTSD) is common among individuals with OUD; however, few studies evaluate whether concurrent diagnoses affect treatment outcomes. This review examines the impact of concurrent diagnoses of OUD and PTSD on treatment outcomes. METHODS A search was performed using articles identified through June 30, 2020 in PubMed, PsycINFO, and EMBASE. Included peer-reviewed articles evaluated individuals with OUD and a PTSD diagnosis via standardized assessment and/or medical record diagnoses, and reported relationships between diagnosis and treatment outcomes and/or other psychiatric conditions. RESULTS Out of 412 articles, 17 studies met inclusion criteria for this review (from 13 databases). Articles included had a total of n = 2190 with OUD, with n = 79 non-OUD comparison participants. Studies examining individuals with OUD revealed comorbid PTSD was associated with more severe addiction, higher rates of depression, attempted suicide, and psychosocial problems. CONCLUSIONS Among individuals with OUD, presence of PTSD is associated with multiple mental health problems. The impact of PTSD on drug use is inconclusive. Although only 5 studies examined psychosocial PTSD treatment, all found PTSD-focused treatment to be effective for those with comorbid OUD. Overall, results suggest the need to better identify PTSD among those with OUD, and to develop and evaluate interventions that are brief, integrative, and easy to implement in clinical settings.
Collapse
Affiliation(s)
- Sarah Meshberg-Cohen
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, USA.
| | - R Ross MacLean
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, USA
| | - Ashley M Schnakenberg Martin
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, USA
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, USA
| | - Ismene L Petrakis
- VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, USA
| |
Collapse
|
7
|
Vakkalanka P, Lund BC, Arndt S, Field W, Charlton M, Ward MM, Carnahan RM. Association Between Buprenorphine for Opioid Use Disorder and Mortality Risk. Am J Prev Med 2021; 61:418-427. [PMID: 34023160 PMCID: PMC8384722 DOI: 10.1016/j.amepre.2021.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration-approved medication to treat opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation. METHODS This was a retrospective cohort study of Veterans receiving buprenorphine (2008-2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020. RESULTS Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8-14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates. CONCLUSIONS Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.
Collapse
Affiliation(s)
- Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Department of Emergency Medicine, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa.
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa
| | - William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, Iowa
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| |
Collapse
|
8
|
O’Connor AM, Cousins G, Durand L, Barry J, Boland F. Retention of patients in opioid substitution treatment: A systematic review. PLoS One 2020; 15:e0232086. [PMID: 32407321 PMCID: PMC7224511 DOI: 10.1371/journal.pone.0232086] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout. Methods A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided. Results 67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST. Conclusions Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.
Collapse
Affiliation(s)
- Aisling Máire O’Connor
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- * E-mail:
| | - Louise Durand
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joe Barry
- Population Health Medicine, Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
9
|
Back SE, Gray K, Santa Ana E, Jones JL, Jarnecke AM, Joseph JE, Prisciandaro J, Killeen T, Brown DG, Taimina L, Compean E, Malcolm R, Flanagan JC, Kalivas PW. N-acetylcysteine for the treatment of comorbid alcohol use disorder and posttraumatic stress disorder: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2020; 91:105961. [PMID: 32087337 PMCID: PMC7333883 DOI: 10.1016/j.cct.2020.105961] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
Alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are two prevalent psychiatric conditions in the U.S. The co-occurrence of AUD and PTSD is also common, and associated with a more severe clinical presentation and worse treatment outcomes across the biopsychosocial spectrum (e.g., social and vocational functioning, physical health) as compared to either disorder alone. Despite the high co-occurrence and negative outcomes, research on effective medications for AUD/PTSD is sparse and there is little empirical evidence to guide treatment decisions. The study described in this paper addresses this knowledge gap by testing the efficacy of N-acetylcysteine (NAC) in reducing alcohol use and PTSD symptoms. Animal studies and prior clinical research suggest a role for NAC in the treatment of substance use disorders and PTSD via glutamate modulation. NAC is a cysteine pro-drug that stimulates the cystine-glutamate exchanger, normalizes glial glutamate transporters, and restores glutamatergic tone on presynaptic receptors in reward regions of the brain. Moreover, NAC is available over-the-counter, has a long-established safety record, and does not require titration to achieve the target dose. This paper describes the rationale, study design, and methodology of a 12-week, randomized, double-blind, placebo-controlled trial of NAC (2400 mg/day) among adults with co-occurring AUD and PTSD. Functional magnetic resonance imaging (fMRI) and proton magnetic resonance spectroscopy (1H-MRS) are utilized to investigate the neural circuitry and neurochemistry underlying comorbid AUD/PTSD and identify predictors of treatment outcome. This study is designed to determine the efficacy of NAC in the treatment of co-occurring AUD/PTSD and provide new information regarding mechanisms of action implicated in co-occurring AUD/PTSD.
Collapse
Affiliation(s)
- Sudie E Back
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Kevin Gray
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Elizabeth Santa Ana
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Jennifer L Jones
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Amber M Jarnecke
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Jane E Joseph
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - James Prisciandaro
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Therese Killeen
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Delisa G Brown
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Linda Taimina
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Ebele Compean
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Robert Malcolm
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Julianne C Flanagan
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Peter W Kalivas
- Department of Neuroscience, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| |
Collapse
|
10
|
Tripp JC, Jones JL, Back SE, Norman SB. Dealing With Complexity and Comorbidity: Comorbid PTSD and Substance Use Disorders. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40501-019-00176-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|