Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs

Stress Exposure and PTSD in a Cross-Sectional Residential Substance Use Treatment Sample

BACKGROUND

Aim 1 of this cross-sectional, observational study with people in residential treatment for substance use disorders (SUDs) was to document stress exposure. Aim 2 was to assess potential sociodemographic and health differences based on probable posttraumatic stress disorder (PTSD) status. Aim 3 was to assess relative contributions of Diagnostic and Statistical Manual (DSM)-congruent versus DSM-incongruent stressors (Criterion A vs non-Criterion A) to mental and physical health. We hypothesized that both types of stressors would significantly contribute to impairment across indicators and that DSM-congruent stressor exposure would be more strongly associated with impairment than DSM-incongruent exposure.

METHODS

We assessed exposure to DSM-congruent traumatic stressors and DSM-incongruent life stressors, PTSD and depressive symptoms, emotion regulation difficulties, substance use recovery capital, and physical/mental health-related quality of life among 136 people in residential SUD treatment who were 64% men, 36% women; 49% white, 41% Black, 11% multiracial/another race; 18% lesbian, gay, or bisexual (LGB+); mean age = 39.82 (standard deviation = 12.24) years.

RESULTS

Participants reported experiencing a mean of 9.76 (SD = 6.11) DSM-congruent events. Those with probable PTSD were younger and more likely to be LGB+ than those without probable PTSD (P < .05). Experiencing higher numbers of DSM-congruent events was associated with more severe PTSD and depressive symptoms, emotion regulation difficulties, and lower physical health-related quality of life (P < .05). DSM-incongruent stressor exposure was not independently associated with any indicators. Recovery capital was not associated with either type of stress exposure.

CONCLUSIONS

Stressful event exposure among people in residential SUD treatment is very high. Those who are younger or LGB+ in residential SUD treatment may be at greater risk of developing PTSD. DSM-congruent stressors are more consistently associated with mental health indicators than are DSM-incongruent stressors. Prioritizing treatment targets and identifying implementable treatment strategies can be challenging with this complex population.

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.

Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care

BACKGROUND

Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City.

METHODS

Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31.

RESULTS

Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment.

CONCLUSIONS

Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.

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.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD.

METHODS

Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021.

RESULTS

The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently.

CONCLUSIONS

The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

Monotonic Association of Increasing Past-Year Substance Use Disorder across a Four-Level Trauma Post-Traumatic Stress Disorder (PTSD) Hierarchy in a Nationwide Sample

OBJECTIVE

There is limited information on the differences in the association of substance use disorders (SUD) with four clinically relevant hierarchical groups based on trauma exposure and its consequences (1-no trauma; 2-trauma but no PTSD; 3-remitted PTSD; and 4-current PTSD).

METHODS

Among adults enrolled in a large nationally representative survey, the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC III), we compared differences in SUD prevalence between each of the hierarchical trauma group and the prior group adjusting for potentially confounding factors.

RESULTS

Unadjusted results show that each increase in the hierarchy was associated with a greater likelihood of SUD diagnoses, even after adjusting for potentially confounding variables. However, after adjusting for covariates, comparison of adults with past to those with current PTSD showed persistence of SUD indicators.

CONCLUSION

SUD prevalence increased substantially with trauma exposure even without PTSD and monotonically increased further with past and current PTSD, respectively, illustrating the differential effect of the clinical consequences of trauma.

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 retrospective chart review of trauma-related documentation in an Australian substance use treatment service

INTRODUCTION

Trauma exposure among clients of substance use treatment services is almost universal and rates of trauma-related symptoms are correspondingly high. This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation of trauma-related comorbidities and their treatment in a substance use treatment setting.

METHODS

A retrospective chart review was conducted on a sample of 300 patient records in a public substance use treatment setting. Rates of documentation of trauma-related events, symptoms and treatment, along with variables influencing the documentation of these issues, were examined.

RESULTS

Trauma-related documentation was present in 45.3% of records. There were documented trauma-related symptoms in 15.3% of records, although treatment activities addressing trauma were only present in 2.3% of records. Being female (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.42, 4.69), having prior mental health treatment (OR 1.82, 95% CI 1.05, 1.12) and having more treatment sessions (OR 1.08, 95% CI = 1.05, 1.12) increased the odds of trauma-related documentation being present, while being in the first episode of treatment (OR 0.49, 95% CI = 0.28, 0.84) decreased the odds.

DISCUSSION AND CONCLUSIONS

This study highlights significant under documentation of trauma-related comorbidities in substance-use treatment. There is limited evidence of consideration of trauma-related symptoms or diagnoses, and trauma-related comorbidities are rarely included in treatment planning activities. The lack of documented trauma-related information has important clinical and medico-legal implications for patients, and provides evidence to suggest a lack of integration of treatment for trauma-related disorders in substance use settings.

Trauma-Integrated Mindfulness-Based Relapse Prevention for Women with Comorbid Post-Traumatic Stress Disorder and Substance Use Disorder: A Cluster Randomized Controlled Feasibility and Acceptability Trial

Background: Comorbid post-traumatic stress disorder and substance use disorder (PTSD-SUD) among women receiving substance use treatment are common. Few evidence-based interventions target PTSD-SUD, however, fewer are gender responsive. Mindfulness-based relapse prevention (MBRP) has shown effectiveness for women with SUD, although it does not explicitly target PTSD. Integration of trauma-focused and gender-responsive treatments into MBRP may address the limited availability of PTSD-SUD interventions for women. This study assessed feasibility and acceptability of trauma-integrated MBRP (TI-MBRP). Methods: A single-blind computer-generated cluster-randomized design was employed in which women with PTSD-SUD (N = 83) received either TI-MBRP (k = 5) or MBRP (k = 5). Measures of PTSD symptom severity and craving were administered at pre-, post-, 1-, 3-, 6-, 9-, and 12-month follow-up and assessed at the individual level. Results: TI-MBRP demonstrated acceptability among participants; however, attrition was high (64%) at 12-month follow-up. Reductions in PTSD were greater in the MBRP than in the TI-MBRP group at postcourse and 1-month follow-up, and there were significant reductions in PTSD severity and craving over the 12-month period in both conditions. Conclusions: Integrating trauma- and gender-focused interventions into MBRP was feasible and acceptable. MBRP alone may be effective in reducing both PTSD and SUD symptoms in women with PTSD-SUD; however, confirmatory studies are warranted. Clinical Trial Registration Number: NCT03505749.

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.

Exploring the Role of Traumatic Event Exposure in Tobacco Dependence Treatment Outcomes Among African Americans

African Americans are more likely to die from tobacco-related diseases and less likely to quit smoking than their white counterparts. Evidence of greater prevalence of posttraumatic stress disorder (PTSD) among African Americans underscores the importance of studying the effects of traumatic event exposure on tobacco dependence treatment outcomes in this group. In this secondary analysis of data from a previously completed randomized control trial, we examined the effects of traumatic event exposure (e.g., serious accident) on tobacco dependence treatment outcomes, as well its moderating effects on the effectiveness of an adapted smoking cessation treatment, in a sample (n = 169) of African American smokers in New York City. Traumatic event exposure did not have a significant impact on tobacco treatment outcomes and did not moderate the relationship between treatment type and outcomes in this sample. While results may be driven by unique sample characteristics, they may also indicate that an average level of traumatic event exposure does not significantly impact tobacco treatment outcomes among African Americans. Future research should examine the effects of higher levels of traumatic event exposure on treatment outcomes, as well as investigating the factors underlying trauma-exposed individuals' difficulties with reducing/quitting smoking in a larger, more diverse African American sample.

Patient-Centered Telehealth Solution for Observed Urine Collections in Substance Use Disorder Care Delivery During COVID-19 and Beyond

Patients with substance use disorder (SUD) rely upon urine drug testing to support treatment adherence and to mitigate relapse. Before the onset of coronavirus 2019 (COVID-19), the logistical challenges of randomized observed collections for urine drug testing for the patient were significant. During COVID-19, these barriers were often insurmountable. Since SUD patients represent a population at a higher risk for complications from COVID-19, an alternative strategy to support COVID-19 testing was urgently needed. We designed and deployed a telehealth-based solution in which patients could use mobile devices to connect with trained collection professionals to perform observed urine collections, often referred to a UA (urinalysis). The solution was designed with patient-centered best practices for telehealth, stigma prevention, trauma-informed, empathy and compassion, and to remove barriers to access to care. This approach demonstrated high patient satisfaction scores thereby proving that it is possible to provide urine collection services in the patient's home via a telehealth technology, while still upholding SUD testing integrity best practices. This study lays the path for a more patient-centered way to support this population.

The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research

INTRODUCTION

The "Women and Trauma" Study (WTS) conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN-0015) resulted in research publications, presentations, and a train-the-trainer workshop to support dissemination efforts for skills-based trauma treatment in substance use community treatment. Twelve years after its completion, this paper aims to examine whether and how the WTS contributed to knowledge in the field of trauma and addictions and inspired community treatment programs (CTPs) to train staff to identify and provide trauma-related services.

METHOD

We present findings from two different analyses that explored longer term study impacts on treatment and dissemination: (1) a post-study site survey covering 4 domains from 4/7 programs that participated in delivering the WTS to evaluate their perceptions of study impact on their treatment community; and (2) an analysis of citations of its publications to determine impact on the scientific community.

RESULTS

Surveys from responding sites indicated that participation in the study significantly increased their agencies'' awareness of the need to take a focused approach to treating trauma issues in this population. Specifically, these sites increased their commitment to using skills-based trauma treatment with the study's target population of female patients with SUD and trauma histories, as well as expanding it to other groups affected by trauma. Citation analysis revealed that according to the Web of Science, as of August 2019, the number of citations of 24 CTN-0015 articles, ranged from 1 to 135 (Mean = 20, SD = 33; Median = 6). Four of the most influential are discussed.

CONCLUSIONS

This manuscript provides original information about the contributions of the WTS study, demonstrating how the study contributed to serving women with trauma in community substance use treatment.

Trauma and post-traumatic stress disorder in patients treated for opioid use disorder: findings from a 12-month cohort study

BACKGROUND

Exposure to traumatic events is both a risk factor for substance use and an adverse outcome of substance use disorders. Identifying and managing post-traumatic stress disorder (PTSD) in patients with addiction requires attention.

AIMS

To examine the lifetime prevalence of traumatic events and past-month prevalence of PSTD in patients treated for opioid use disorder, and explore the association between trauma, PTSD and treatment outcomes.

METHOD

Participants (n = 674) receiving methadone treatment in 20 community clinics across Ontario, Canada, were administered the Mini-International Neuropsychiatric Interview to identify self-reported traumatic events and PTSD. Drug use was measured for 12 months by urine drug screens.

RESULTS

Eleven per cent of participants met past-month criteria for PTSD (n = 72), and 48% reported history of traumatic events with no current PTSD (n = 323). Participants with PTSD were more likely to be female (odds ratio 2.13, 95% CI 1.20-3.76) and less likely to be employed (odds ratio 0.31, 95% CI 0.16-0.61) or married (odds ratio 0.51, 95% CI 0.26-0.90) than those with no trauma history. Antidepressants (39 v. 24%) and benzodiazepines (36 v. 18%) were differentially prescribed to patients with and without PTSD. Length of time in treatment and opioid use were not associated with trauma; however, suicidal ideation was more common in PTSD (odds ratio 2.29, 95% CI 1.04-5.01).

CONCLUSIONS

Trauma and PTSD are prevalent among patients with opioid use disorder, and consideration of trauma symptoms and associated characteristics is warranted. Patients with and without comorbid PTSD differ clinically and psychosocially, highlighting the relevance of integrating addiction and mental health services for this population.

Childhood maltreatment, psychiatric symptoms, and suicidal thoughts among adolescents receiving substance use treatment services

INTRODUCTION

Childhood maltreatment experiences are associated with future suicidal thoughts and suicide attempts, yet the roles of specific psychiatric symptoms mediating this relation remain to be clarified. To clarify these relations, we tested a model incorporating multiple forms of childhood maltreatment (sexual abuse, physical punishment, emotional neglect), past year psychiatric disorder symptoms during adolescence (anxiety, mood, and conduct disorders) and recent suicidal thoughts.

METHODS

We administered structured interviews to 394 adolescents receiving outpatient substance use treatment services in the Southeastern United States (280 males; Mage = 16.33; SDage = 1.15). Structural equation models (SEMs) were used to evaluate the degree to which relations between childhood maltreatment and suicidal thoughts were mediated by specific past-year psychiatric symptoms.

RESULTS

Mood disorder symptoms significantly mediated the relation between neglect/negative home environment and suicidal thoughts. This path of influence did not vary by gender.

CONCLUSIONS

Childhood maltreatment and subsequent psychopathology influence suicidal thoughts among adolescents receiving substance use treatment services. The findings of the present study have implications for the adaptation and delivery of substance use treatment services to adolescents to enhance treatment engagement and outcomes.

A gender comparative analysis of post-traumatic stress disorder among a community-based cohort of people who use drugs in Vancouver, Canada

BACKGROUND

While exposure to traumatic events and subsequent post-traumatic stress disorder (PTSD) are common among people who use drugs (PWUD), little is known about gender-based differences associated with PTSD in this population. We explore gender-based differences in factors associated with a probable PTSD diagnosis in a cohort of PWUD from Vancouver, Canada.

METHODS

Data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two community-recruited cohorts of PWUD. Participants were administered the PTSD Checklist for DSM-5. Multivariable logistic regression was used to investigate social-structural factors and substance use patterns and behaviours associated with a probable PTSD diagnosis, stratified by self-identified gender. PTSD symptom clusters and brief descriptions of the worst traumatic event experienced were also reported.

RESULTS

Between December 2016 and December 2018, of 797 eligible participants, 295 (37.0%) identified as women. PTSD was more commonly reported in women compared to men (53.2% vs. 31.5%, p < 0.001). In multivariable analysis involving men, no correlates were associated with PTSD. In multivariable analysis involving women, PTSD was positively associated with exposure to violence (AOR: 3.66; 95%CI: 1.14-11.72), daily stimulant use (AOR: 2.32; 95%CI: 1.32-4.08) and heavy alcohol use (AOR: 3.84; 95%CI: 1.84-8.00), and negatively associated with being in a stable relationship (AOR: 0.46; 95%CI: 0.25-0.84).

CONCLUSIONS

Gender-based differences in PTSD diagnosis among a cohort of PWUD point to the need to develop gender-focused and trauma-informed health and social services to meet the immediate needs of PWUD living with PTSD.

"Now We Are Seeing the Tides Wash In": Trauma and the Opioid Epidemic in Rural Appalachian Ohio

Background: Ohio's opioid epidemic continues to progress, severely affecting its rural Appalachian counties-areas marked by high mortality rates, widespread economic challenges, and a history of extreme opioid overprescribing. Substance use may be particularly prevalent in the region due to interactions between community and interpersonal trauma. Purpose/Objectives: We conducted qualitative interviews to explore the local context of the epidemic and the contributing role of trauma. Methods: Two interviewers conducted in-depth interviews (n = 34) with stakeholders in three rural Appalachian counties, including healthcare and substance use treatment professionals, law enforcement officials, and judicial officials. Semi-structured interview guides focused on the social, economic, and historical context of the opioid epidemic, perceived causes and effects of the epidemic, and ideas for addressing the challenge. Results: Stakeholders revealed three pervasive forms of trauma related to the epidemic in their communities: environmental/community trauma (including economic and historical distress), physical/sexual trauma, and emotional trauma. Traumas interact with one another and with substance use in a self-perpetuating cycle. Although stakeholders in all groups discussed trauma from all three categories, their interpretation and proposed solutions differed, leading to a fragmented epidemic response. Participants also discussed the potential of finding hope and community through efforts to address trauma and substance use. Conclusions: Findings lend support to the cyclical relationship between trauma and substance use, as well as the importance of environmental and community trauma as drivers of the opioid epidemic. Community-level and trauma-informed interventions are needed to increase stakeholder consensus around treatment and prevention strategies, as well as to strengthen community organization networks and support community resilience. Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1887248.

Montreal Cross-Training Program: The contribution of positional clarification activities to help bridge fragmented prevention and treatment services for co-occurring disorders

Co-occurring disorders in mental health and addiction present a high prevalence, but services available to prevent and treat them are often fragmented. Cross-training activities have been used to help minimise breaks in service continuity. This study assesses to what extent positional clarification (a specific type of cross-training activity) can help bridge fragmented services for co-occurring disorders by providing information and promoting interactions to help professionals better orient and treat their clientele. A total of 2,107 participations were recorded for 11 positional clarification events taking place within the Montreal Cross-Training Program for mental health and substance use disorders between 2010 and 2016. The Kirkpatrick four-level training evaluation model was used to evaluate these activities. Evaluation questionnaires (n = 1,650) and interviews with a convenience sample of 32 participants were analysed using descriptive statistics and thematic analysis. More than three-quarters of participants reported that the activity met their expectations and was relevant to their practice. Respondents also reported receiving useful information to better orient their clientele, discovering new resources, learning about the functioning of other resources, identifying members of other networks who could orient them when needed, and learning more about the theme of the activity and the different mechanisms for collaboration among the related services. Among those who participated in more than one positional clarification event, roughly three-quarters reported that they were able to call upon new resources at least once as a result of their participation, and were able to establish referrals towards resources that were unknown or less familiar to them prior to their participation. Results suggest that the programme meets its service integration objectives and that positional clarification events can lead to changes that can help facilitate the integration of fragmented services by improving participants' knowledge of specific themes and available resources to better orient and treat their clientele.

Perspectives on trauma and the design of a technology-based trauma-informed intervention for women receiving medications for addiction treatment in community-based settings

BACKGROUND

Despite national calls to develop gender-specific interventions for women with opioid use disorder (OUD) with co-occurring trauma and post-traumatic stress disorder (PTSD) symptoms, there remains a dearth of research on what modalities or treatment components would be most feasible for this population. This study interviewed women with OUD receiving medication assisted treatment and addiction treatment providers to explore (a) experiences of barriers to receiving trauma treatment, and (b) both the perceptions and desired design of a prospective technology-delivered, trauma-informed treatment for women with OUD.

METHODS

Women with lifetime OUD (n = 11) and providers (n = 5) at two community substance use clinics completed semi-structured interviews. Interviews were transcribed, coded, and analyzed in NVivo v11 using a grounded theory approach. Women also completed a demographic form and clinical measures.

RESULTS

Clients were primarily women with children reporting histories of multiple trauma exposures, high PTSD symptoms, and polysubstance use. Two themes emerged among clients and one among providers regarding barriers to trauma treatment. Regarding the feasibility and desired attributes of a technology-based intervention, six themes emerged among clients and providers, respectively.

CONCLUSIONS

Themes suggest a high interest by clients and providers for a technology-delivered, trauma informed treatment available by smartphone. Utilizing technology as an adjunct to care, without reducing face-to-face therapy, was important to both clients and providers.

Service provider perspectives on treating adolescents with co-occurring PTSD and substance use: challenges and rewards

Purpose

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur (PTSD+SUD). The onset of these disorders often occurs during adolescence. There is limited understanding of the perspectives of service providers working with this population. The purpose of this paper is to identify the practices, attitudes, experiences and training needs of Australian service providers treating adolescents with PTSD+SUD.

Design/methodology/approach

Service providers in Australia were invited to complete an anonymous online survey regarding their experiences working with adolescents who have PTSD+SUD. Ninety participants completed the 48-item survey that comprised multiple choice and open-ended questions.

Findings

Service providers estimated that up to 60 per cent of their adolescent clients with PTSD also have SUD. They identified case management, engaging with caregivers and difficult client emotions as specific challenges associated with working with this population. Despite this, providers rated treating PTSD+SUD as highly gratifying for reasons such as teaching new coping skills, developing expertise and assisting clients to achieve their goals. There were mixed perspectives on how to best treat adolescents with PTSD+SUD, and all participants identified a need for evidence-based resources specific to this population.

Originality/value

This is the first survey of Australian service providers working with adolescents who experience PTSD+SUD. The findings improve our understanding of the challenges and rewards associated with working with this population, and provide valuable information that can enhance clinical training and guide the development of new treatment approaches for this common and debilitating comorbidity.

Substance Use and Maxillofacial Trauma: A Comprehensive Patient Profile

PURPOSE

Maxillofacial trauma confers an increased risk of long-term clinical sequelae with a substantial economic burden on the health care system. Substance use has long been correlated with an increased risk of trauma, yet to date, a comprehensive profile of substance users incurring facial fractures has not been established. We aimed to establish patterns and trends of substance use and specific substances in the setting of maxillofacial trauma.

PATIENTS AND METHODS

A retrospective chart review was conducted at our institution examining patients with maxillofacial fractures from 2016 to 2017. Information on age, gender, race, urine drug screen status, setting of presentation, mechanism of injury, trauma history, and injury severity was collected and examined for associations with particular substances.

RESULTS

We included 388 patients for analysis. Patients with positive urine drug screen results were significantly more likely to be men, present in an urban setting, incur poly-facial trauma, and have a history of facial trauma. In addition, alcohol use correlated significantly with injury severity in the context of polytrauma. Living in an urban setting and using phencyclidine were both significantly associated with a history of maxillofacial trauma.

CONCLUSIONS

Patients with comorbid maxillofacial trauma and substance use exhibit particular patterns in presentation and history. Establishing a profile for these patients allows for the development of prevention and rehabilitation programs.

A Simplified Risk Scoring System to Predict Mortality in Cardiovascular Intensive Care Unit

Background

Cardiovascular intensive care unit (CICU) is an area with high mortality rates globally. The prediction of inpatients mortality risk at CICU needs a simplified scoring systems. Hence, this study aims to analyze the predictors for in-hospital mortality of patients whom hospitalized at CICU of Sardjito General Hospital Yogyakarta and to create a mortality risk score based on the results of this analysis.

Methods

Data were obtained from SCIENCE (Sardjito Cardiovascular Intensive Care) registry. Outcomes of 595 consecutive patients (mean age 59.92 ± 13.0 years) from January to November 2017 were recorded retrospectively. Demography, risk factor, comorbidities, laboratory result and other examinations were analyzed by multivariate logistic regression to create two models of scoring system (probability and cut-off model) to predict in-hospital mortality of any cause.

Results

A total of 595 subjects were included in this research; death was found in 55 patients (9.2%). Multiple logistic regression analysis showed some variables that became independent predictor of mortality, i.e. age ≥ 60 years, pneumonia, the use of ventilator machine, and increased of serum glutamate-pyruvate transaminase level, an increased of creatinine level and an ejection fraction < 40%. Receiver operating characteristic (ROC) curve analysis showed a cut-off model scoring system with score 3 to 9 predicting mortality compared to score 0 - 2. This model yielded sensitivity of 80% and specificity 74%. While the probability scoring system (score 0 to 9) showed that the higher the score, the higher the mortality probability (e.g. the mortality of patient with score 2 is 5.27%; while the mortality of patient with score 8 is 87.5%).

Conclusions

Scoring system derived from this study can be used to predict the in-hospital mortality of patients whom hospitalized in our CICU and show a favorable sensitivity and specificity result.

Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington

Background: Clinic-imposed barriers can impede access to medication for opioid use disorder (MOUD). We evaluated a low-barrier buprenorphine program that is co-located with a syringe services program (SSP) in Seattle, Washington, USA. Methods: We analyzed medical record data corresponding to patients who enrolled into the buprenorphine program in its first year of operation. We used descriptive statistics and tests of association to longitudinally evaluate retention, cumulative number of days buprenorphine was prescribed, and toxicology results. Results: Demand for buprenorphine among SSP clients initially surpassed programmatic capacity. Of the 146 enrolled patients, the majority (82%) were unstably housed. Patients were prescribed buprenorphine for a median of 47 days (interquartile range [IQR] = 8-147) in the 180 days following enrollment. Between the first and sixth visits, the percentage of toxicology tests that was positive for buprenorphine significantly increased (33% to 96%, P < .0001) and other opioids significantly decreased (90% to 41%, P < .0001) and plateaued thereafter. Toxicology test results for stimulants, benzodiazepines, and barbiturates did not significantly change. Conclusions: SSP served as an effective point of entry for a low-barrier MOUD program. A large proportion of enrolled patients demonstrated sustained retention and reductions in opioid use, despite housing instability and polysubstance use.

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

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

An Evaluation of Practitioner's Experience of Service Users Seeking Community Detoxification from Benzodiazepines

A recent report in Ireland identified that two-thirds of poisoning deaths involved poly drug use with an average of four different drugs involved. Of these, benzodiazepines were the most common drug group involved. Concern has been expressed regarding high levels of benzodiazepine prescriptions globally. Community-based detoxification programs are required, but detoxification is complex with associated high risks, such as overdose. This study utilized a survey to gather the experiences of a range of drug workers in addiction settings in the southern region of Ireland who are tasked with the management of supporting service users who wish to detoxify from benzodiazepines. The purpose of this study is to identify the issues highlighted in the data and consequently inform policy development, service delivery, future training, and pathways to support service users (SUs). Findings indicate that, while practitioners had high levels of confidence in managing community-based detoxes, levels of knowledge of schedules, contraindications, access to support, and appropriate referral pathways were limited. Barriers to supporting detoxes emerged, emphasizing the importance of multidisciplinary and interagency care planning. Changing trends in drug use led participants to indicate a need for pharmacology training and development of specific local protocols.

The Role of Context in the Implementation of Trauma-Focused Treatments: Effectiveness Research and Implementation in Higher and Lower Income Settings

In recent years, the implementation of trauma-focused treatments has expanded across settings that vary widely in the availability of resources, infrastructure, and personnel. The present review aims to inform researchers, policy makers, trainers, and administrators about this diverse range of research. Taking a global health perspective, this review of effectiveness trials and implementation studies compares strategies used in high-income countries to those in low- and medium-income countries. A primary difference between studies in high-income and low- and medium-income countries is the relative emphasis placed on fidelity or adaptation. Adaptations used in low- and medium-income countries might offer useful ideas for increasing the portability, impact, and accessibility of evidence-based interventions in high-income countries.

Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs

BACKGROUND

Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID.

METHODS

Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use.

RESULTS

Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05).

CONCLUSIONS

A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.

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

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