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

Sequenced Treatment Effectiveness for Posttraumatic Stress (STEPS) Trial: A protocol for a pragmatic comparative effectiveness trial with baseline results

BACKGROUND

There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments.

METHOD

Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5).

RESULTS

Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline.

CONCLUSION

Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.

The impact of substance use on posttraumatic stress disorder symptoms and treatment discontinuation

This study examined the impact of ongoing substance use during posttraumatic stress disorder (PTSD) and substance use disorder (SUD) treatment on PTSD symptoms and treatment discontinuation. The study represents a secondary analysis of U.S. military veterans (N = 183) who participated in a randomized clinical trial for the treatment of both PTSD and SUD. Veterans mostly identified as Black (53.8%) or White (41.9%) and male (92.4%). Substance use, PTSD symptoms, and treatment discontinuation were measured at 4-week intervals throughout treatment. Predictors were the percentage of days with alcohol, cannabis, and other substance use (primarily cocaine and opioids) and the average number of alcoholic drinks per drinking day. Outcomes were PTSD symptoms and treatment discontinuation at concurrent and prospective assessments. Multilevel models accounted for the nested structure of the longitudinal data. Alcohol, cannabis, and other substance use did not predict PTSD symptoms or treatment discontinuation prospectively. Concurrently, we observed that as a participant's percentage of drinking days increased by 34.7% (i.e., 1 standard deviation), PTSD symptoms during the same period were 0.07 standard deviations higher (i.e., 1 point on the PCL), B = 0.03, p = .033. No other substances were related to PTSD symptoms concurrently. The findings demonstrate that PTSD symptoms improved regardless of substance use during exposure-based PTSD and SUD treatment, and treatment discontinuation was not associated with substance use. This study suggests that substance use during treatment cannot directly explain the poorer treatment outcomes observed in the literature on comorbid PTSD/SUD compared to PTSD-only populations.

A national study of clinical discussions about cannabis use among Veteran patients prescribed opioids

BACKGROUND

The Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use.

OBJECTIVE

To determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use.

DESIGN

We identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts.

SUBJECTS

Twelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients.

MAIN MEASURES

The presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use.

KEY RESULTS

Among the 12,070 patients, 65.8% (N = 7,948) had a cannabis term, whereas 34.1% (N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64-0.82].

CONCLUSIONS

One-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon.

Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data

High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.

Addressing experiences of trauma within Indigenous-focused substance use residential treatment: a systematic review and environmental scan

Indigenous individuals in Canada disproportionally experience higher rates of substance use concerns. This study examined clinical practices currently implemented with Indigenous-led residential treatment facilities to simultaneously address substance use and post-traumatic stress. A systematic review of relevant literature retrieved published approaches to address these concurrent disorders with Indigenous individuals. This review retrieved 35 sources related to trauma and substance use treatment among Indigenous individuals or communities. Among these sources, all leveraged cultural approaches as a dual treatment for trauma symptoms and substance use. Inconsistent results were reported among those sources (n = 3) who analyzed comparisons with wait-list controls or used randomized-controlled designs. Using culture-as-treatment was elaborated upon in the second goal of this study: an environmental scan of Indigenous-led treatment programs and qualitative interviews with 10 treatment center staff to understand how programs may address both substance use and traumatic symptoms among Indigenous-led substance use treatment centers across Canada. When we searched the websites of these centers, we found that approximately 38% (16 of 43) of treatment centers discussed implementing some form of treatment that addressed trauma symptoms in conjunction with primary substance use. Among the 10 staff participants, all discussed how trauma can impede client success in treatment, and ACE-specific programming is useful within their respective treatment programs. Results showed that when manualized treatments are used, they must be adapted to meet the specific needs of Indigenous communities, and culture-as-treatment is a popular approach among Indigenous-led treatment centers, particularly for addressing trauma symptoms.

A randomized clinical trial comparing Interpersonal Psychotherapy with Prolonged Exposure for the treatment of PTSD in veterans

Trauma-focused therapies are recommended as first-line treatments for posttraumatic stress disorder (PTSD), but many veterans do not complete or sufficiently respond to these treatments. Interpersonal Therapy (IPT) is a non-trauma focused approach that directly addresses the interpersonal and social impairments associated with PTSD. This two-site randomized controlled equivalence trial compared IPT with Prolonged Exposure (PE) in improving PTSD symptoms and interpersonal functioning in 109 veterans with PTSD. Secondary outcomes included functioning and quality of life. We hypothesized that IPT would be statistically equivalent to PE in reducing PTSD symptoms, and superior to PE in improving interpersonal functioning and secondary outcomes of work and social adjustment and quality of life. PTSD symptom severity decreased significantly in both treatments from pre- to post-treatment. Although IPT improved as much as PE and treatments did not differ significantly, the 95 % confidence interval for the difference between the groups did not fall completely within the margin of equivalence. IPT was not superior to PE in improvement in interpersonal functioning or on secondary outcomes. Findings from multi-level linear mixed models using longitudinal data (posttreatment, three and six month follow up) for the primary outcomes of PTSD and interpersonal functioning were consistent with the post-treatment analyses. Although statistically inconclusive in terms of equivalence, the comparable reduction in PTSD symptoms slightly favoring IPT suggests that IPT is an acceptable alternative to gold-standard trauma-focused treatments for veterans with PTSD.

Challenges and considerations for treating PTSD with medicinal cannabis: the Australian clinician's perspective

INTRODUCTION

Preclinical and experimental research have provided promising evidence that medicinal cannabis may be efficacious in the treatment of posttraumatic stress disorder (PTSD). However, implementation of medicinal cannabis into routine clinical therapies may not be straightforward.

AREAS COVERED

In this review, we describe some of the clinical, practical, and safety challenges that must be addressed for cannabis-based treatment of PTSD to be feasible in a real-world setting. These issues are especially prevalent if medicinal cannabis is to be combined with trauma-focused psychotherapy.

EXPERT OPINION

Future consideration of the clinical and practical considerations of cannabis use in PTSD therapy will be essential to both the efficacy and safety of the treatment protocols that are being developed. These issues include dose timing and titration, potential for addiction, product formulation, windows of intervention, and route of administration. In particular, exposure therapy for PTSD involves recall of intense emotions, and the interaction between cannabis use and reliving of trauma memories must be explored in terms of patient safety and impact on therapeutic outcomes.

Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders

Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.

Perspectives on the therapeutic potential of MDMA: A nation-wide exploratory survey among substance users

Background

Alcohol and other substance use disorders are commonly associated with post-traumatic stress disorder (PTSD), and the presence of these comorbidities is associated with worse treatment outcomes. Additionally, disparities in substance and PTSD prevalence have been associated with minority races and ethnicities, and minorities have been shown to be less likely to engage in treatment. Psychedelic-assisted treatments, including 3,4-methylenedioxymethamphetamine (MDMA), have shown preliminary trans-diagnostic effectiveness, however it is unknown how individuals with substance use disorders view the therapeutic potential of MDMA therapy. Previous studies have also shown that minority races and ethnicities are under-represented in the MDMA trials, leading to concerns about inequitable access to clinical treatment.

Methods

To explore demographic characteristics related to patient-level perspectives on the therapeutic potential of MDMA-assisted therapy, this study describes data from a nationwide, cross-sectional survey of 918 individuals self-reporting criteria consistent with alcohol or substance use disorders.

Results

Overall, a majority of individuals reported support for medical research of MDMA (68.1%), belief that MDMA-assisted therapy might be a useful treatment (70.1%), and willingness to try MDMA-assisted therapy if it were determined to be an appropriate treatment for them (58.8%). No race or ethnicity differences were found in support for further research or belief in effectiveness, however there were small disparities in terms of willingness to try MDMA-assisted therapy and concerns related to use of this treatment approach.

Conclusion

These results provide insights and future directions as the field of psychedelic-assisted therapy seeks to provide equitable access to clinical care and to diversify research participation.

Retention in treatment and therapeutic adherence: How are these associated with therapeutic success? An analysis using real-world data

INTRODUCTION

Treatment retention and adherence are used as outcomes in numerous randomized clinical trials and observational studies conducted in the addiction field. Although usual criteria are 3/6 months of treatment retention or number of sessions attended, there is not a methodological support for conclusions using these criteria. This study analyzed the usefulness of retention and adherence to predict therapeutic success.

METHODS

Retrospective observational study using real-world data from electronic health records of 11,907 patients in treatment diagnosed with cocaine, alcohol, cannabis and opiate use disorders or harmful use.

RESULTS

Moderate effect size relations were found between the different type of clinical discharge and months in retention (η²  = 0.12) and proportion of attendance (η²  = 0.10). No relationship was found with the number of sessions attended. Using cut-off points (i.e., 3 or 6 months in treatment or attending 6 therapy sessions) worsens the ability to predict the type of discharge.

DISCUSSIONS/CONCLUSION

Treatment retention and adherence are indicators moderately related to therapeutic success. Research using these indicators to assess the effectiveness of therapies should complement their results with other clinical indicators and quality of life measures.

An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update

Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.

The association between recreational cannabis use and posttraumatic stress disorder: A systematic review and methodological critique of the literature

BACKGROUND

Given recent changes in the legal status of cannabis, the risks and benefits associated with its use have become an important public health topic. A growing body of research has demonstrated that posttraumatic stress disorder (PTSD) and recreational cannabis use (RCU) frequently co-occur, yet findings are inconsistent (e.g., direction of effect) and methodological variability makes comparison across studies difficult.

METHODS

We conducted a comprehensive systematic review of all studies (N = 45) published before May 2020 regarding etiologic models of co-occurring RCU and PTSD, as well as provided a methodological critique to inform suggestions for future research initiatives.

RESULTS

Findings indicate that a majority of studies (n = 37) demonstrated a significant association between RCU and PTSD. Findings provide evidence for the self-medication and high-risk models posited to explain co-occurring RCU and PTSD despite variability in assessment of RCU, which includes commonly used non-standardized self-report questions.

CONCLUSION

The association between RCU and PTSD is likely bidirectional. Results inform clinicians and researchers working in the mental health and cannabis use fields how the variability in findings on the association between RCU and PTSD may be attributable, in part, to methodological issues that permeate the extant literature pertaining to RCU and PTSD.

Effects of Cannabis on PTSD Recovery: Review of the Literature and Clinical Insights

Purpose of Review

Individuals with posttraumatic stress disorder (PTSD) may use cannabis to reduce symptoms yet are also at risk for developing problematic use. This review outlines theories, summarizes recent empirical studies, and discusses clinical implications of cannabis use and PTSD recovery.

Recent Findings

Although naturalistic studies and open trials find a relationship between cannabinoids and PTSD symptom reduction, methodological limitations preclude definitive conclusions. The only randomized controlled trial to date found cannabis had no greater effect on PTSD symptoms than placebo.

Summary

Rigorous studies of the long-term impact of cannabis use on PTSD recovery are needed. Clinicians and researchers must weigh the potential therapeutic effect against the costs and risks associated with long-term cannabis use. Clinicians should consider all available PTSD treatment options, along with client level factors such as the function of cannabis use, motivation to change use, and the potential impact of cannabis on treatment engagement when making clinical recommendations.

Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.

Anxiety sensitivity and cannabis use motives among trauma-exposed young adult cannabis users

BACKGROUND AND OBJECTIVES

Anxiety sensitivity, or fear of anxious arousal, may be an important risk factor for problematic cannabis use. Specifically, anxiety sensitivity may motivate cannabis use to cope with distress, particularly among trauma-exposed individuals. The current study tested associations among anxiety sensitivity, its subdomains, and cannabis use motives in a sample of trauma-exposed cannabis users. We hypothesized elevated anxiety sensitivity, particularly cognitive concerns, would be associated with increased maladaptive coping use motives, after covarying for the number of traumas and cannabis use quantity.

METHOD

Hypotheses were tested in a cross-sectional study of trauma-exposed young adult cannabis users (N = 56) (Mage  = 20.7 years, 59% women, 73% white). Participants completed self-report measures, and a clinical interview assessing cannabis use quantity.

RESULTS

Multiple regression analyses indicated that elevated anxiety sensitivity was associated with increased cannabis use coping motives, after covarying for the number of traumas experienced and cannabis use quantity. Specifically, higher levels of anxiety sensitivity cognitive and social concerns were associated with coping motives for cannabis use.

DISCUSSION AND CONCLUSIONS

Anxiety sensitivity, particularly concerns about cognitive dyscontrol and negative social evaluations of anxious arousal, may motivate cannabis use to cope with stress among trauma-exposed cannabis users. Future research should include prospective studies with diverse samples to replicate results and determine whether intervening on anxiety sensitivity could reduce maladaptive coping motives for cannabis use.

SCIENTIFIC SIGNIFICANCE

The current study replicates prior research indicating anxiety sensitivity, particularly cognitive concerns, is associated with maladaptive cannabis use. Expanding on prior research, findings indicated anxiety sensitivity is associated with coping motives for cannabis use among trauma-exposed cannabis users.

Cannabinoid use is enhanced by stress and changes conditioned stress responses

Individuals diagnosed with post-traumatic stress disorder (PTSD) are often comorbid for substance use disorders. Cannabis is widely used by PSTD patients, and the literature is mixed on whether cannabis use ameliorates or exacerbates patient responses to stress-associated conditioned stimuli (stress-CS). We determined if cannabis use affects responsivity to stress-CS in rats receiving 2 h stress in the presence of an odor stress-CS. Three weeks after acute stress, rats self-administered cannabinoids (delta9-tetrahydrocannabinol + cannabidiol; THC + CBD) for 15 days, and the stressed males consumed more THC + CBD than sham males. We then used the stress-CS or a novel odor (stress-NS) to reinstate THC + CBD seeking. Surprisingly, the stress-NS reinstated THC + CBD seeking, an effect blocked by N-acetylcysteine. Moreover, the stress-CS inhibited THC + CBD-CS induced reinstatement. To determine if the unexpected effects of stress-NS and -CS resulted from THC + CBD altering conditioned stress, the effect of THC + CBD use on stress-NS/CS-induced coping behaviors and spine morphology was quantified. In THC + CBD-treated rats, stress-NS increased active coping (burying). Conversely, stress-CS reduced active coping and increased passive coping (immobility) and other behavioral parameters associated with stress responses, including self-grooming and defecation. Transient spine head expansion in nucleus accumbens core is necessary for cue-induced drug seeking, and THC + CBD self-administration prevented the increase in head diameter by stress-CS in control rats. These data show THC + CBD self-administration altered the salience of environmental cues, causing neutral cues to promote active behavior (drug seeking and burying) and stress-CS to switch from active to passive behavior (inhibiting drug seeking and immobilization). We hypothesize that cannabis may exacerbate conditioned stress responses.

Sex Differences across Retrospective Transitions in Posttraumatic Stress and Substance Use Disorders

Objectives: Concurrent substance use disorder (SUD) and posttraumatic stress disorder (PTSD) occur at high rates and are typically associated with poor treatment outcomes in both sexes. However, women have a propensity to cope with increased negative affect via substance use in comparison to men; thus, it is important to elucidate the sex-specific bidirectional relationships between SUD and PTSD to improve our understanding of concurrent SUD/PTSD in men and women. Methods: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-Wave 3; n = 36,309), the present study evaluated the impact of sex on the relationship between past-year SUDs (new, remitted, ongoing), including alcohol and drug use, and retrospective transitions in new vs. absent and ongoing vs. remitted diagnoses of PTSD. Additionally, the impact of sex was explored in models examining past year PTSD (new, remitted, ongoing) and retrospective transitions in new vs. absent and ongoing vs. remitted diagnosis of SUDs. Diagnostic transitions were based on retrospective reporting. Results: Results indicated that new, remitted, and ongoing SUDs increase the likelihood of new PTSD diagnoses (OR range = 2.53-8.11; p < 0.05). Among individuals with ongoing drug use disorders (DUD), there were greater odds of ongoing PTSD (OR = 2.10, p < 0.01). When examining the relationship reciprocally, new, remitted, and ongoing PTSD increased the likelihood of new SUDs (OR range = 2.50-8.22; p < 0.05), and ongoing PTSD increased the likelihood of ongoing SUD and DUD (OR = 1.40, 1.70, respectively; p < 0.05). Sex-specific analyses revealed that the relationship between PTSD and SUDs varies between sexes, particularly among women. For instance, women with new PTSD had higher odds of SUDs, and women with ongoing PTSD were almost 2.5 times more likely to have an ongoing DUD. Women with a new PTSD diagnosis were more likely to be diagnosed with a new SUD (OR = 3.27) and an ongoing DUD (OR = 3.08). Conclusions: Results indicate a bidirectional relationship between PTSD and SUD that is in many instances larger in women. Thus, illustrating potential sex-specific differences in underlying mechanisms implicated in SUD/PTSD, warranting additional research.

Prevalence and Correlates of Cannabis Use and Cannabis Use Disorder Among U.S. Veterans: Results From the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III)

OBJECTIVE

The authors sought to estimate the prevalence of past-12-month and lifetime cannabis use and cannabis use disorder among U.S. veterans; to describe demographic, substance use disorder, and psychiatric disorder correlates of nonmedical cannabis use and cannabis use disorder; and to explore differences in cannabis use and cannabis use disorder prevalence among veterans in states with and without medical marijuana laws.

METHODS

Participants were 3,119 respondents in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) who identified as U.S. veterans. Weighted prevalences were calculated. Logistic regression analyses tested associations of nonmedical cannabis use and cannabis use disorder with demographic and clinical correlates and examined whether prevalence differed by state legalization status.

RESULTS

The prevalences of any past-12-month cannabis use and cannabis use disorder were 7.3% and 1.8%, respectively. Lifetime prevalences were 32.5% and 5.7%, respectively. Past-12-month and lifetime cannabis use disorder prevalence estimates among nonmedical cannabis users were 24.4% and 17.4%, respectively. Sociodemographic correlates of nonmedical cannabis use and use disorder included younger age, male gender, being unmarried, lower income, and residing in a state with medical marijuana laws. Nonmedical cannabis use and use disorder were associated with most psychiatric and substance use disorders examined.

CONCLUSIONS

Among veterans, the odds of nonmedical cannabis use and use disorder were elevated among vulnerable subgroups, including those with lower income or psychiatric disorders and among survey participants residing in states with medical marijuana laws. The study findings highlight the need for clinical attention (e.g., screening, assessment) and ongoing monitoring among veterans in the context of increasing legalization of cannabis.

Investigating the experience of individuals with comorbid posttraumatic stress disorder and substance misuse attending a Seeking Safety group

Purpose

There is no specific recommended treatment for the co-morbid presentation of post-traumatic stress disorder (PTSD) and substance use disorder in the United Kingdom (UK). Seeking Safety (SS), a group-based treatment that targets symptoms of both disorder, has emerging evidence in the USA but lacks evidence from UK-based samples. The purpose of this study was to explore UK service users’ experience of attending SS and evaluate its impact on mental health symptomology and substance misuse.

Design/methodology/approach

A mixed method approach was used to evaluate the acceptability of SS for a small sample (n = 7) of adult users of a substance misuse service in the UK. Thematic analysis was used to explore their experiences, derived from individual semi-structured interviews. The authors also calculated the number of participants who achieved reliable and/or clinically significant change in mental health symptomology and substance misuse from data routinely collected by the service.

Findings

Seven overarching themes emerged: strengthening the foundations of the self, the evocation and management of emotions, safety and validation provided relationally, readiness and commitment, content and delivery, Seeking Safety is Not an Island and ending. Most participants with data available both before and after the group made reliable (three out of four) and clinically significant (two out of three) change for depression and anxiety symptomology; however, this was less evident for PTSD symptomology with two out of three making reliable change and one out of three making clinically significant change.

Originality/value

To the best of the authors’ knowledge, this was the first study exploring the experiences of UK attendees of a SS group as an approach to treating comorbid PTSD and substance misuse.

Anger and predictors of drop-out from PTSD treatment of veterans and first responders

BACKGROUND

Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders.

AIMS

The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD.

METHOD

Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance.

RESULTS

Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme.

CONCLUSION

These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems.

METHODS

Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations.

RESULTS

Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance.

CONCLUSION

Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.

Substance use predictors of attendance among veterans in integrated PTSD and alcohol use disorder treatment

Comorbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common, defined by greater severity and impairment than either disorder alone, and associated with poor treatment attendance. Exposure therapies are effective in treating PTSD+AUD, yet substance use is still cited as a potential contraindication for exposure. This study examined substance use-related predictors of session attendance among veterans (N = 119) randomized to receive integrated exposure therapy (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure [COPE]; Back et al., 2015) or integrated coping skills therapy (Seeking Safety [SS]; Najavits, 2002) in a clinical trial for comorbid PTSD+AUD (Norman et al., 2019). At baseline, greater percentage of heavy drinking days (β = -0.23, p = .011) and greater AUD severity per structured clinical interview for DSM-IV-TR (β = -0.21, p = .019) predicted fewer sessions across both treatments. Treatment type did not moderate the relationship between predictors and attendance, except for a trend for craving (p = .057), where greater craving predicted fewer sessions in SS (β = -0.31, p = .02) but not COPE (β = 0.14, p = .28). Percentage of abstinence days, AUD duration, and living in a controlled environment (e.g., recovery home) at the start of therapy were not associated with attendance in either treatment condition. Only a subset of substance use characteristics predicted attendance. Findings did not support the notion that alcohol use leads to lower attendance in exposure therapy compared to nonexposure therapy.

Pay for Performance and Treatment Outcome in Agonist Treatment for Opioid Use Disorder

BACKGROUND AND OBJECTIVES

Pay for performance (P4P) models have become more popular in reimbursement for medical services, including treatment for substance use disorders. However, studies have not examined whether P4P has an impact on treatment outcome in the individual in opioid agonist treatment (OAT). Thus, the present study was conducted at the individual level, rather than the programmatic level, to determine whether meeting the P4P early engagement criteria (four services in the initial 14 days of treatment and/or eight services within the initial 30 days of treatment) resulted in reduced opioid, benzodiazepine, and cocaine use.

METHODS

We performed a retrospective study of 63 patients enrolled in OAT for opioid use disorder. χ² analyses were conducted crossing P4P early engagement criteria status and urine drug screen (UDS) results for opioid, cocaine, and/or benzodiazepine use at 6 and 12 months postadmission. Methadone dosage and treatment retention were also considered. The odds ratio was used to determine the directionality of significant results.

RESULTS

Significant relationships were revealed between patients meeting 30-day P4P early engagement criteria and opioid negative UDS, and with retention in treatment at 6 and 12 months. Methadone dosage was significant at a 6-month follow-up.

DISCUSSION AND CONCLUSIONS

Since significant associations between opioid use and P4P as well as opioid use and methadone dose were revealed, findings partially supported hypothesis.

SCIENTIFIC SIGNIFICANCE

P4P and methadone dosage may have some benefit to individuals in OAT in attaining short-term abstinence from opioids. P4P may be less useful in helping individuals achieve abstinence from other substances of abuse. (Am J Addict 2020;00:00-00).

Risk and Protective Factors for PTSD in Caregivers of Adult Patients with Severe Medical Illnesses: A Systematic Review

Caregivers of severely ill individuals often struggle to adjust to new responsibilities and roles while experiencing negative psychological outcomes that include depression, anxiety and Post-Traumatic Stress Disorder (PTSD). This systematic review aims to outline potential risk and protective factors for the development of PTSD in caregivers of adult subjects affected by severe somatic, potentially life-threatening illnesses. Twenty-nine studies on caregivers of adult patients affected by severe, acute, or chronic somatic diseases have been included. Eligibility criteria included: full-text publications reporting primary, empirical data; PTSD in caregivers of adult subjects affected by severe physical illnesses; risk and/or protective factors related to PTSD; and English language. Specific sociodemographic and socioeconomic characteristics, besides the illness-related distress, familiar relationships, exposure characteristics, coping style, and support, were identified as relevant risk/protective factors for PTSD. The review limitations are the small number of studies; studies on different types of diseases; studies with same samples. It is crucial to consider factors affecting caregivers of severely ill adult patients in order to plan effective intervention strategies aimed at reducing the risk of an adverse mental health outcome and at enhancing the psychological endurance of this population.

Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment

Although some studies have demonstrated residual symptoms in patients who have participated in posttraumatic stress disorder (PTSD) treatment, no studies to date have assessed residual PTSD symptoms following treatment for comorbid alcohol use disorder (AUD) and PTSD (PTSD/AUD). We examined residual symptoms of PTSD and AUD in 73 veterans with PTSD/AUD who completed a posttreatment assessment after being randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) or Seeking Safety (SS). We used logistic regression to identify differences (a) in residual PTSD and AUD symptoms among participants randomized to COPE versus SS and (b) among those with versus without a posttreatment PTSD/AUD diagnosis within both treatment conditions. Participants randomized to SS were more likely to report persistent avoidance, inability to experience positive emotions, hypervigilance, difficulty concentrating, and difficulty sleeping, ORs = 3.74-6.21. There were no differences between COPE and SS regarding the likelihood of persistent AUD symptoms. Participants without a posttreatment PTSD diagnosis had lower conditional probabilities of most symptoms, although exaggerated startle, OR = 0.71, and irritability/aggression, OR = 0.58, were most likely to persist. Participants without a posttreatment AUD diagnosis had lower conditional probabilities of most symptoms, although withdrawal, OR = 0.21; unsuccessful quit attempts, OR = 0.04; and higher intake, OR = 0.01, were most likely to persist. Findings indicate hyperarousal may warrant additional intervention following PTSD treatment. Residual AUD symptoms may relate to the enduring nature of some AUD symptoms rather than a lack of treatment efficacy.

Clinical Data for the Use of Cannabis-Based Treatments: A Comprehensive Review of the Literature

Objective:

To compile and synthesize the available literature describing medical cannabis use across various disease states.

Data Sources:

PubMed, EBSCO, and Google Scholar searches were conducted using MeSH and/or keywords.

Study Selection and Data Extraction:

Studies were included if they described the use of cannabis-based products and medications in the treatment of a predefined list of disease states in humans and were published in English. The extraction period had no historical limit and spanned through April 2019.

Data Synthesis:

Evidence was compiled and summarized for the following medical conditions: Alzheimer disease, amyotrophic lateral sclerosis, autism, cancer and cancer-associated adverse effects, seizure disorders, human immunodeficiency virus, inflammatory bowel disease, multiple sclerosis (MS), nausea, pain, posttraumatic stress disorder, and hospice care.

Relevance to Patient Care and Clinical Practice:

Based on identified data, the most robust evidence suggests that medical cannabis may be effective in the treatment of chemotherapy-induced nausea and vomiting, seizure disorders, MS-related spasticity, and pain (excluding diabetic neuropathy). Overall, the evidence is inconsistent and generally limited by poor quality. The large variation in cannabis-based products evaluated in studies limits the ability to make direct comparisons. Regardless of the product, a gradual dose titration was utilized in most studies. Cannabis-based therapies were typically well tolerated, with the most common adverse effects being dizziness, somnolence, dry mouth, nausea, and euphoria.

Conclusions:

As more states authorize medical cannabis use, there is an increasing need for high-quality clinical evidence describing its efficacy and safety. This review is intended to serve as a reference for clinicians, so that the risks and realistic benefits of medical cannabis are better understood.

Testing Mindful Awareness as a Moderator in the Association Between HIV-Related Stress and Drug and Alcohol Use Problems Among People Living with HIV

Objectives

People living with HIV (PLWH) are disproportionately affected by stressful life events. HIV-related stress adds to general life stressors to increase health risks among this population. Stress has not only been associated with HIV progression but it is also linked to HIV transmission risk behavior (e.g., substance use). Older adults living with HIV (OALWH) experience additional age-related stress and are at increased risk for substance use. Mindfulness buffers against stress for PLWH; however, research has yet to examine mindfulness as a buffer between HIV-related stress and substance use for OALWH.

Methods

Participants were 130 OALWH (M _age = 54.65, SD = 4.20) and 74.6% were Black. The majority were male (69.2%), and nearly half identified as heterosexual (48.5%). A hierarchical linear regression examined the main and interactive effects of mindful awareness and two types of HIV-related stress (e.g., stigma and rumination) on alcohol and drug use problems.

Results

In step one of the model, we examined HIV stigma (β = .231, p = .015) and found no significant interaction with mindful awareness. In step two, HIV rumination (β = .288, p = .001) was added. We found a significant interaction (β = .196, p = .020), indicating those with low mindful awareness and high rumination reported the greatest substance use problems. Exploratory analyses revealed an indirect effect of HIV stigma on substance use through HIV rumination as well as a significant effect for second-stage moderated mediation.

Conclusions

These findings support mindful awareness as a buffer against HIV rumination for OALWH. Further, our results have important implications for the utility of mindfulness-based interventions (MBIs) with OALWH and comorbid substance use disorders.

Use of Medicinal Cannabis and Synthetic Cannabinoids in Post-Traumatic Stress Disorder (PTSD): A Systematic Review

Background and Objectives: Post-traumatic stress disorder (PTSD) is a common psychiatric disorder resulting from a traumatic event, is manifested through hyperarousal, anxiety, depressive symptoms, and sleep disturbances. Despite several therapeutic approaches being available, both pharmacological and psychological, recently a growing interest has developed in using cannabis and synthetic cannabinoids stems from their consideration as more efficient and better tolerated alternatives for the treatment of this condition. The present paper aims to evaluate the clinical and therapeutic potentials of medical cannabis and synthetic cannabinoids in treating PTSD patients. Methods: A systematic electronic search was performed, including all papers published up to May 2019, using the following keywords (((cannabis[Title/Abstract]) OR (synthetic cannabinoids [Title/Abstract])) AND ((PTSD[Title/Abstract]) OR (Posttraumatic stress disorder[Title/Abstract]))) for the topics ‘Cannabis’, ‘Synthetic Cannabinoids’, ‘PTSD’, and MESH terms, on the PubMed, Cochrane Library, and Web of Science online databases. For data gathering purposes, PRISMA guidelines were followed. Results were organized into two groups, considering cannabis and synthetic cannabinoids as different therapeutic approaches for PTSD. Results: Present data show that cannabis and synthetic cannabinoids, both acting on the endocannabinoids system, may have a potential therapeutic use for improving PTSD symptoms, e.g., reducing anxiety, modulating memory-related processes, and improving sleep. Conclusions: Even though the current literature suggests that cannabis and synthetic cannabinoids may have a role in the treatment of PTSD, there is currently limited evidence regarding their safety and efficacy. Therefore, additional research is needed in order to better understand the effectiveness and therapeutic usage of these drug classes and monitor their safety.

Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions?

In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.

Innovations in digital interventions for psychological trauma: harnessing advances in cognitive science

A range of digital psychological interventions have demonstrated a positive impact on trauma-related problems in controlled trials, but there is room for further improvements in their form, reach and impact. Most to date have been adaptions of established face-to-face treatments. In this paper, we highlight a complementary emerging route to their development, which draws on advances in cognitive science theory and research and applies them to clinical contexts. Three examples are given regarding laboratory research with potential applications to digital interventions for trauma-related mental health problems: a digital game to reduce intrusive memories of trauma, novel cognitive techniques for worry, and digitally supported mental imagery to enhance motivation for functional behavior change. Much of this research is still at an early stage, meriting a balance of optimism and caution. However, even if only a few digital applications of cognitive science constitute substantial improvements to complement current treatments, their potential for large-scale use at low unit cost may provide significant benefits across populations.