Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial

A Pilot Study of Twice-Weekly Group-Based Written Exposure Therapy for Veterans in Residential Substance Use Treatment: Effects on PTSD and Depressive Symptoms

Background

Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUDs), resulting in high prevalence of PTSD among individuals in residential SUD care. However, there is limited research on integrating trauma treatment into residential SUD care settings. The aim of the present project was to conduct an initial evaluation of the effects of group-based Written Exposure Therapy (WET) on PTSD and depressive symptoms that was integrated into programming for individuals in residential SUD treatment.

Methods

Participants were 48 Veterans with comorbid PTSD-SUD from a 28-day residential SUD program at a Veterans Affairs Medical Center. Eligible participants were enrolled in 5 sessions of WET, delivered in twice-weekly in a group format. PTSD symptoms and depressive symptoms were assessed at each session with the Posttraumatic Stress Disorder Checklist, DSM-5 version (PCL-5) and the Patient Health Questionnaire (PHQ-9).

Results

Of the enrolled sample of 48 participants, 92% (n = 44) completed 3 sessions, while 56% (n = 28) completed 5 sessions. Dependent samples t-tests showed significant reductions from baseline in PTSD symptoms within-persons at both the 3-session (t(43) = 4.77, p < .001, d = .72) and 5-session mark (t(27) = 4.36, p < .001, d = .82). In addition, there were significant reductions in depressive symptoms after 3 sessions (t(38) = 3.01, p < .01, d = .48) and after 5 sessions (t(23) = 2.97, p < .01, d = .61).

Conclusion

Findings demonstrate that brief, group-delivered WET shows promise for addressing PTSD and depressive symptoms in residential SUD treatment. Results of the present evaluation could inform further efficacy testing and implementation of PTSD treatment into residential SUD settings.

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 Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

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.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Differential symptom weighting in estimating empirical thresholds for underlying PTSD severity: Toward a "platinum" standard for diagnosis?

OBJECTIVE

Symptom counts as the basis for Post-Traumatic Stress Disorder (PTSD) diagnoses in the DSM presume each symptom is equally reflective of underlying disorder severity. However, the "equal weight" assumption fails to fit PTSD symptom data when tested. The present study developed an enhanced PTSD diagnosis based on (a) a conventional PTSD diagnosis from a clinical interview and (b) an empirical classification of full PTSD that reflected the relative clinical weights of each symptom.

METHOD

Baseline structured interview data from Project Harmony (N = 2658) was used. An enhanced diagnosis for full PTSD was estimated using an empirical threshold from moderated nonlinear factor analysis (MNLFA) latent PTSD scale scores, in combination with a full conventional PTSD diagnosis based on interview data.

RESULTS

One in 4 patients in the sample had a PTSD diagnosis that was inconsistent with their empirical PTSD grouping, such that the enhanced diagnostic standard reduced the diagnostic discrepancy rate by 20%. Veterans, and in particular female Veterans, were at greatest odds for discrepancy between their underlying PTSD severity and DSM diagnosis.

CONCLUSION

Psychometric methodologies that differentially weight symptoms can complement DSM criteria and may serve as a platform for symptom prioritization for diagnoses in future editions of DSM.

A pilot test of Written Exposure Therapy for PTSD in residential substance use treatment

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUD) and can impede SUD recovery. Residential SUD treatment is a crucial opportunity to address PTSD. However, PTSD treatment is lacking in residential SUD care.

METHODS

We conducted a nonrandomized feasibility study of Written Exposure Therapy (WET), a brief, evidence-based treatment for PTSD, with patients in residential SUD treatment. We assessed attitudes towards treatment (Credibility and Expectancy Questionnaire, Barriers to Treatment Participation Scale) and mental health indicators (PTSD Checklist for DSM-5, Trauma Coping Self-Efficacy, Difficulties in Emotion Regulation-Short Form, and Brief Assessment of Recovery Capital).

RESULTS

Thirty of 49 eligible participants completed WET (61%) and 92% (n = 45) attended at least one WET session. Paired sample t-tests revealed significant posttreatment improvement across all mental health indicators, with medium to large effect sizes.

DISCUSSION AND CONCLUSIONS

Attendance and completion rates compared favorably to prior exposure-based treatment for PTSD in SUD settings. Although causality cannot be inferred without a randomized controlled trial, mental health indicators, including PTSD, improved significantly following WET.

SCIENTIFIC SIGNIFICANCE

These findings provide evidence that PTSD can be successfully treated in short-term residential care using brief exposure-based interventions, which is a crucial clinical need that has been minimally studied in the past.

A randomized controlled trial on using predictive algorithm to adapt level of psychological care for community college students: STAND triaging and adapting to level of care study protocol

BACKGROUND

There is growing interest in using personalized mental health care to treat disorders like depression and anxiety to improve treatment engagement and efficacy. This randomized controlled trial will compare a traditional symptom severity decision-making algorithm to a novel multivariate decision-making algorithm for triage to and adaptation of mental health care. The stratified levels of care include a self-guided online wellness program, coach-guided online cognitive behavioral therapy, and clinician-delivered psychotherapy with or without pharmacotherapy. The novel multivariate algorithm will be comprised of baseline (for triage and adaptation) and time-varying variables (for adaptation) in four areas: social determinants of mental health, early adversity and life stressors, predisposing, enabling, and need influences on health service use, and comprehensive mental health status. The overarching goal is to evaluate whether the multivariate algorithm improves adherence to treatment, symptoms, and functioning above and beyond the symptom-based algorithm.

METHODS/DESIGN

This trial will recruit a total of 1000 participants over the course of 5 years in the greater Los Angeles Metropolitan Area. Participants will be recruited from a highly diverse sample of community college students. For the symptom severity approach, initial triaging to level of care will be based on symptom severity, whereas for the multivariate approach, the triaging will be based on a comprehensive set of baseline measures. After the initial triaging, level of care will be adapted throughout the duration of the treatment, utilizing either symptom severity or multivariate statistical approaches. Participants will complete computerized assessments and self-report questionnaires at baseline and up to 40 weeks. The multivariate decision-making algorithm will be updated annually to improve predictive outcomes.

DISCUSSION

Results will provide a comparison on the traditional symptom severity decision-making and the novel multivariate decision-making with respect to treatment adherence, symptom improvement, and functional recovery. Moreover, the developed multivariate decision-making algorithms may be used as a template in other community college settings. Ultimately, findings will inform the practice of level of care triage and adaptation in psychological treatments, as well as the use of personalized mental health care broadly.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05591937, submitted August 2022, published October 2022.

Prolonged exposure therapy for PTSD in individuals with opioid use disorder: A randomized pilot study

OBJECTIVE

Nearly all individuals with opioid use disorder (OUD) report lifetime trauma exposure and one-third meet diagnostic criteria for posttraumatic stress disorder (PTSD). Although prolonged exposure (PE) therapy is a first-line treatment for PTSD, little is known about the effects of PE in individuals with co-occurring OUD. Furthermore, its efficacy is commonly undermined by poor therapy attendance. This pilot study evaluated the feasibility and initial efficacy of a novel PE protocol for improving PE attendance and PTSD symptoms among buprenorphine- or methadone-maintained adults with PTSD.

METHOD

Thirty participants with co-occurring PTSD and OUD were randomized to receive either: (a) continued medications for OUD (MOUD) treatment as usual (TAU), (b) Prolonged Exposure therapy (PE), or (c) PE with financial incentives delivered contingent upon PE session attendance (PE+). Primary outcomes included PE session attendance, PTSD symptom severity, and use of opioids other than prescribed MOUD.

RESULTS

PE+ participants attended significantly more therapy sessions vs. PE (87% vs. 35%; p <.0001). PTSD symptom reductions were also significantly greater in the PE+ vs. TAU group (p =.046). Participants in the two PE conditions submitted significantly fewer urine samples that tested positive for opioids than TAU participants (0% vs. 22%; p =.007).

CONCLUSIONS

These findings provide preliminary support for the efficacy of PE+ for improving PE attendance and PTSD symptoms without prompting opioid relapse in individuals with co-occurring PTSD and OUD. These promising results justify a larger scale randomized clinical trial to more rigorously evaluate this novel treatment approach.

A qualitative exploration of patients' experience of mobile telephone-delivered contingency management to promote adherence to supervised methadone

INTRODUCTION

Despite an increasing evidence base for mobile telephone-delivered contingency management (mCM), there had been no previous qualitative exploration of patients' experience of receiving mCM and the factors that might influence that experience and outcome in a UK setting. The aim of this study was to understand patients' views and experience of receiving mCM by exploring their beliefs, expectations and perceived benefits within the context of the UK's first mCM intervention.

METHODS

Qualitative interviews (N = 15) were conducted with patients undergoing opioid agonist treatment in a UK drug treatment service and receiving mCM to encourage adherence with supervised methadone as part of an existing study. Interviews were conducted at two time points and analysed using Framework to explore patients' expectations and beliefs during the early stage of the intervention (2 weeks) and their perceived benefits and experience at the end of the intervention (12 weeks).

RESULTS

The mCM was perceived as a motivator, providing validation of achievement, and involving discreet and positive interactions. Perceived benefits included enhanced methadone adherence, reduced drug use and the development of a supportive and non-judgemental connection that resembled a therapeutic alliance.

DISCUSSION AND CONCLUSIONS

The mechanisms underpinning contingency management appeared to operate in the absence of human interaction, and the mCM intervention was deemed to be meaningful, acceptable and well received by patients. These findings not only provide support for the application of mCM in this context but also offer insight into the factors that influence outcomes and should be considered in the development of future mCM interventions.

Are psychological interventions for adult PTSD more efficacious and acceptable when treatment is delivered in higher frequency? A meta-analysis of randomized controlled trials

BACKGROUND

Two systematic reviews indicated that higher treatment frequency of psychological interventions for adult PTSD may lead to higher efficacy and less dropout. Yet, a quantitative review is missing.

METHODS

We conducted a thorough systematic literature search and included trials meeting the following criteria: a) random allocation, 2) PTSD was primary treatment focus, 3) ≥ 70% interview-based PTSD rate 4) mean age ≥ 18 years, and 5) N ≥ 20. Treatment session frequency was analyzed dichotomously (< 1.5 vs. ≥ 1.5 sessions/week) and continuously (sessions per week & minutes per week).

RESULTS

A total of 160 RCTs with data from 10,556 patients were included. Analyses yielded similar treatment efficacy irrespective of treatment frequency definitions and whether differential efficacy was estimated directly via head-to-head trials or indirectly via comparisons to the same comparison group. Intense (≥ 1.5 sessions/week) vs. standard (< 1.5 sessions/week) delivery was, however, associated with significantly lower dropout rates (as a proxy for acceptability) for trauma-focused interventions (18.64% vs 11.54%, respectively, p = .024), but not for non-trauma-focused interventions.

CONCLUSIONS

We found no evidence for differential treatment efficacy of intense vs. standard psychotherapies for adult PTSD. Evidence for increased acceptability was found for intense vs. standard trauma-focused interventions.

Project Harmony: A Meta-Analysis With Individual Patient Data on Behavioral and Pharmacologic Trials for Comorbid Posttraumatic Stress and Alcohol or Other Drug Use Disorders

OBJECTIVE

Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders.

METHODS

A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up.

RESULTS

Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments.

CONCLUSIONS

The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial

OBJECTIVE

To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD.

METHOD

Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days.

RESULTS

At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days.

CONCLUSION

Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT01663337).

Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony

Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder (PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision-making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual-level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM-5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients.

Do financial incentives increase mental health treatment engagement? A meta-analysis

OBJECTIVE

Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.

METHOD

We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.

RESULTS

About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.

CONCLUSIONS

Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder

Background

The psychological treatment of comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) is clinically challenging, and outcomes are often poor.

Objective

This paper describes a systematic review and meta-analysis which sought to establish the current efficacy for a number of established psychological approaches for adults and adolescents, in comparison to interventions for SUD alone, or other active approaches, following a pre-registered protocol.

Method

This review followed PRISMA and Cochrane Collaboration guidelines. Data extraction and risk of bias judgements using Cochrane criteria were undertaken by all authors. Primary outcomes were PTSD severity and substance use post-treatment. The quality of findings was assessed using GRADE. Following a comprehensive search, conducted to 13 September 2021, 27 studies were included.

Results

We found a relatively high level of dropout across studies. In our main comparisons, we found no benefits for present-focused treatment approaches aimed at improving coping skills beyond those for SUD-only interventions. We found modest benefits for trauma-focused intervention plus SUD intervention post-treatment for PTSD (standardized mean difference (SMD) = -0.36, 95% confidence interval (CI) -0.64, -0.08), and at 6-13 months for PTSD (SMD = -0.48, 95% CI -0.81, -0.15) and alcohol use (SMD = -0.23, 95% CI -0.44, -0.02). There were no benefits for cognitive restructuring interventions as a group, but we found a modest effect for integrated cognitive behavioural therapy (ICBT) for PTSD post-treatment (SMD = -0.33, 95% CI -0.62, -0.04). There was evidence of some benefit for trauma-focused intervention over present-focused intervention for PTSD from a single study and for reduction in dropout for incentivized attendance for trauma-focused intervention from another single study. Most findings were of very low quality.

Conclusion

There is evidence that trauma-focused therapy and ICBT can improve PTSD for some individuals, but many patients do not fully engage with treatment and average treatment effects are modest.

HIGHLIGHTS

For PTSD, evidence was strongest for trauma-focused CBT-based approaches, but effects were modest.There was little evidence of any added benefit on substance use, beyond that of standard addiction treatments, for any included intervention.Dropout from treatment was high.

Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities

Individuals with psychiatric disorders often struggle to initiate and engage in treatment. Financial incentives improve treatment engagement, including treatment attendance, medication adherence, and abstinence from substance use. The U.S. Department of Veterans Affairs (VA) recently made the first large-scale, successful effort to implement incentive-based interventions in substance use disorder treatment. Health care systems, including the VA, can increase the impact of these interventions by extending them to target a range of psychiatric disorders, adapting them for specific clinical contexts, using insights from behavioral economics, and partnering with corporations to fund incentives and implement interventions.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

Examining attendance patterns across integrated therapies for posttraumatic stress disorder and alcohol use disorder

A substantial body of evidence supports the use of integrated treatments for posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Integrated trauma-focused exposure therapies reduce PTSD symptoms more than comparison treatments, including integrated coping skills therapies, but demonstrate lower attendance, raising questions regarding the relationships between attendance, outcomes, and treatment type. We aimed to examine these relationships in a RCT comparing integrated prolonged exposure (Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure, COPE; n = 58), to integrated coping skills therapy (Seeking Safety, SS; n = 52) offered in 12 sessions, with an option to extend up to four additional sessions. Participants were categorized based on number of sessions attended (0-4; 5-8; 9-12; 13-16). Multilevel modeling revealed that only when examining therapy attendance segments individually, clinical outcomes were comparable across treatments except in the 9-12 group, with COPE resulting in greater reductions in PTSD symptoms (p < 0.001), but not in alcohol use. Extending past 12 sessions was not associated with additional clinically meaningful symptom improvement for either treatment. These results suggest that attending a complete or near complete course of exposure therapy may enhance PTSD outcomes relative to non-trauma-focused therapies.

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.

Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review

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.

Addressing anhedonia to increase depression treatment engagement

Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.

Laboratory-induced stress and craving predict opioid use during follow-up among individuals with prescription opioid use disorder

BACKGROUND

Opioid use disorder (OUD) remains a public health crisis in the USA. Although stress and craving are common precipitants of substance use, no research to date has investigated the impact of laboratory-induced stress and craving on subsequent opioid use.

METHOD

Participants (N = 31) were individuals with prescription OUD who completed a human laboratory study followed by a one-month follow-up visit. Participants were randomly assigned to either a stress task (i.e., Trier Social Tress Task; TSST) or a no-stress condition, and then all participants completed an opioid cue paradigm. Measures of subjective (e.g., stress, craving), and neuroendocrine (e.g., cortisol, dehydroepiandrosterone) reactivity were assessed before and after each task. Survival and regression models tested the association between reactivity to the laboratory tasks and a) time to first opioid use and b) amount of opioid use during follow-up.

RESULTS

On average, participants first used opioids 3.65 (SD = 2.08) days following the study. Craving after the opioid cue paradigm (B = 0.44, Exp(B) = 1.55, 95 % CI [1.06, 2.28], p = .02) and after the TSST/no-stress condition plus opioid cue paradigm (B = 1.06, Exp(B) = 2.88, 95 % CI [1.70, 4.85], p < .001) predicted time to first use. Additionally, there was a significant interaction between randomization to the TSST, stress reactivity, and amount of opioids used.

CONCLUSIONS

Findings demonstrate that elevated cue-induced craving, either in the context of a stressor or not, is associated with shortened time to opioid use, whereas stress reactivity impacts the amount of opioids consumed. Preliminary findings add to the literature on stress, craving and opioid use and implicate treatment.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

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.

An Exploratory Study of the Acceptability and Feasibility of Yoga Among Women in Substance Use Disorder Recovery

Objectives: This qualitative study explored the acceptability and feasibility of yoga among women in substance use disorder (SUD) recovery. Design: Seventeen women in SUD recovery for 2 weeks or longer were recruited from nine sites in the mid-South, including a Medication-Assisted Treatment clinic in a hospital setting, prison re-entry housing, community-based peer support organizations (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), a residential SUD treatment facility, a yoga teachers' online group, and through referrals. The median age of participants was 41.5, with ages ranging from 25 to 65. We used an interpretive description approach to explore both the perceptions of women without yoga experience and the experiences of women with yoga experience to collect formative data for intervention development and implementation. The interviews were recorded and transcribed verbatim. A hybrid analysis (i.e., inductive and deductive coding) was applied to the data. Results: Women's narratives included a high prevalence of trauma exposure. Overall, women in this sample were interested in either beginning or continuing yoga. Barriers to participation included perceived lack of self-efficacy of yoga, weight, and physical injuries. Additional environmental barriers included balancing care of self with caring for others, including partners, children, and NA/AA sponsees; as well as prioritizing finances, housing, employment, and transportation. Conclusion: High prevalence of trauma exposure among women in SUD recovery necessitates careful consideration of co-occurring psychiatric disorders such as post-traumatic stress disorder, anxiety and depression and the necessary professional psychological support, as well as serious physical injuries that require modification in yoga āsana classes. As transportation and balancing care needs were salient in these data, rural SUD populations could be served with telehealth interventions that provide SUD recovery support with integrative health practices such as adjunctive yoga interventions.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

The Effects of Prolonged Exposure on Substance Use in Patients With Posttraumatic Stress Disorder and Substance Use Disorders

Despite research demonstrating the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD) in patients with co-occurring substance use disorders, there remains a strong clinical expectation that this treatment will exacerbate substance use or other psychiatric symptoms. The present study evaluated within-session and session-to-session changes in (a) craving and use of substances for a range of drug classes and (b) symptoms of PTSD and other psychiatric distress in a sample of 44 SUD patients who received prolonged exposure (PE) therapy for PTSD. Visual analog scales showed no within-session increases in craving, except for cocaine, within Session 8. Across sessions, craving scores dropped for heroin, methadone, benzodiazepines, and cocaine; no increases in craving were found. Past-week substance use reported at each session did not differ. The severity of PTSD symptoms and self-reported serious emotional problems decreased from Session 1 to subsequent sessions, with no increases or decreases in other psychiatric, social, or medical problems. Finally, PTSD severity was unrelated to substance use reported 1 or 2 weeks later. Substance use during the past week was associated with higher PTSD severity scores at the next session, B = 6.86 (SE = 2.87), p = .018, but was not associated 2 weeks later. These findings indicate that the concern that exposure therapy for PTSD will increase SUD patients' substance use or other psychiatric symptoms may be unwarranted, and, thus, SUD patients, including those who are actively using, should have access to effective treatments for PTSD, like PE.

Minority Participation in Randomized Controlled Trials for Prolonged Exposure Therapy: A Systematic Review of the Literature

Per the most recent census, non-Latinx White individuals comprise the majority of the U.S. population (76.6%); Latinx individuals make up 18.3% of the total U.S. population, followed by African Americans (13.4%) and Asians (5.9%). Given the high prevalence rates of posttraumatic stress disorder (PTSD) observed across many ethnoracial minority groups in the United States, the fact that PTSD presentation may vary across culture, and the National Institute of Health's mandates for the inclusion of women and minorities in clinical outcome research, the aim of the present systematic review was to examine minority inclusion in clinical outcome research for PTSD. Our review focused exclusively on one empirically supported treatment: prolonged exposure therapy (PE); we identified 38 studies that met the inclusion criteria. Apart from African Americans, who were overrepresented in 21 studies (inclusion rate range: 13.5%-73.9%), ethnoracial minority inclusion in RCTs examining PE was low. More specifically, across included studies that reported ethnoracial minority data, 58.9% of participants were White, 31.1% were African American, 4.9% were Latinx, 0.6% were Asian American or Pacific Islander, and 4.7% reported race as "other." Inclusion rates for ethnoracial minorities appeared to increase across time, and recruitment strategies did not appear to be associated with increased ethnoracial minority participation in RCTs for PE.

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.

Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids

Dramatic increases in the rate of opioid use disorder (OUD) during pregnancy have been paralleled by substantial increases in the number of neonates diagnosed with neonatal abstinence syndrome (NAS). Women with OUD have reliably reported high rates of unintended pregnancy and a number of studies also indicate they desire easier access to contraception. Recent statements from the Centers for Disease Control and Prevention and the American Academy of Pediatrics/American College of Obstetricians and Gynecologists have drawn increased attention to efforts to prevent unintended pregnancy and improve access to contraception among women with OUD. We briefly review a number of innovative clinical approaches in these areas, including efforts to integrate family planning services into substance use disorder (SUD) treatment and other settings that serve people with OUD and interventions that aim to make family planning a higher priority among women with OUD. Results suggest many of these approaches have led to increases in contraceptive use and may aid in efforts to reduce unintended pregnancy and improve access to contraception among women with OUD now and in the future.

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.

Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment.

METHODS

This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status.

RESULTS

Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group.

CONCLUSIONS

Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.

Adults with Comorbid Posttraumatic Stress Disorder, Alcohol Use Disorder, and Opioid Use Disorder: The Effectiveness of Modified Prolonged Exposure

Opioid use disorders (OUDs) are a growing problem in the United States. When OUDs co-occur with problematic drinking and posttraumatic stress disorder (PTSD), negative drug-related mental and physical health outcomes may be exacerbated. Thus, it is important to establish whether PTSD treatments with established efficacy for dually diagnosed individuals also demonstrate efficacy in individuals who engage in problematic drinking and concurrent opioid misuse. Adults who met DSM-IV-TR criteria for PTSD and alcohol dependence were recruited from a substance use treatment facility and were randomly assigned to receive either modified prolonged exposure (mPE) therapy for PTSD or a non-trauma-focused comparison treatment. Compared to adults in a non-OUD comparison group (n = 74), adults with OUD (n = 52) were younger, reported more cravings for alcohol, were more likely to use amphetamines and sedatives, were hospitalized more frequently for drug- and alcohol-related problems, and suffered from more severe PTSD symptomatology, depressive symptoms, and anxiety, standardized mean differences = 0.36-1.81. For participants with OUD, mPE was associated with large reductions in PTSD symptomatology, sleep disturbances, and symptoms of anxiety and depression, ds = 1.08-2.56. Moreover, participants with OUD reported decreases in alcohol cravings that were significantly greater than those reported by the non-OUD comparison group, F(1, 71.42) = 6.37, p = .014. Overall, our findings support the efficacy of mPE for PTSD among individuals who engage in problematic drinking and concurrent opioid misuse, despite severe baseline symptoms.

The relationship between trauma centrality, self-efficacy, posttraumatic stress and psychiatric co-morbidity among Syrian refugees: Is gender a moderator?

This study examined the inter-relationship between trauma centrality, self-efficacy, posttraumatic stress disorder (PTSD) and psychiatric co-morbidity among a group of Syrian refugees living in Turkey, and whether gender would moderate the mediational effect of self-efficacy on the impact of trauma centrality on distress. Seven hundred and ninety-two Syrian refugees completed the Harvard Trauma Questionnaire, General Health Questionnaire-28, Centrality of Event Scale and Generalized Self-Efficacy Scale. The results showed that 52% met the cutoff for PTSD. Trauma centrality was positively correlated with PTSD, psychiatric co-morbidity and self-efficacy. Self-efficacy was negatively correlated with PTSD only. Gender did not moderate the mediational effect of self-efficacy on the path between trauma centrality and distress outcomes. To conclude, following exposure to traumatic events, more than half reported PTSD. Perception of the future and identity construction was affected. Signs of psychological distress were evident, alongside resilience, regardless of gender.