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Akiba CF, Patel SV, Wenger LD, Morgan-Lopez A, Zarkin GA, Orme S, Davidson PJ, Kral AH, Lambdin BH. Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial. Implement Sci 2023; 18:33. [PMID: 37537665 PMCID: PMC10398915 DOI: 10.1186/s13012-023-01288-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically. METHODS We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness. DISCUSSION This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.
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Affiliation(s)
- Christopher F Akiba
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA.
| | - Sheila V Patel
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Lynn D Wenger
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Antonio Morgan-Lopez
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Gary A Zarkin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Stephen Orme
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, UCSD, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Alex H Kral
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Barrot H Lambdin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
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Hien DA, Morgan-López AA, Saavedra LM, Ruglass LM, Ye A, López-Castro T, Fitzpatrick S, Killeen TK, Norman SB, Ebrahimi CT, Back SE. 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. Am J Psychiatry 2023; 180:155-166. [PMID: 36475373 PMCID: PMC10016363 DOI: 10.1176/appi.ajp.22010071] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Denise A Hien
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Antonio A Morgan-López
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Lissette M Saavedra
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Lesia M Ruglass
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Ai Ye
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Teresa López-Castro
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Skye Fitzpatrick
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Therese K Killeen
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Sonya B Norman
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Chantel T Ebrahimi
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
| | - Sudie E Back
- Center of Alcohol and Substance Use Studies, Rutgers University-New Brunswick, Piscataway, N.J. (Hien, Ruglass, Ebrahimi); Department of Psychology, City College of New York, New York (Ruglass, López-Castro); L.L. Thurstone Psychometric Laboratory, Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill (Ye); Department of Psychology, York University, Toronto (Fitzpatrick); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, and Ralph H. Johnson VA Medical Center, Charleston (Killeen, Back); Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System (Norman);Department of Psychology, New School, New York (Ebrahimi)
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Killeen TK, Wen CC, Neelon B, Baker N. Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders. Subst Use Misuse 2023; 58:500-511. [PMID: 36705433 DOI: 10.1080/10826084.2023.2170183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.
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Affiliation(s)
- Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chun-Che Wen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathanial Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Morgan-López AA, McDaniel HL, Bradshaw CP, Saavedra LM, Lochman JE, Kaihoi CA, Powell NP, Qu L, Yaros AC. Design and methodology for an integrative data analysis of coping power: Direct and indirect effects on adolescent suicidality. Contemp Clin Trials 2022; 115:106705. [PMID: 35176503 PMCID: PMC9018598 DOI: 10.1016/j.cct.2022.106705] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 01/02/2023]
Abstract
As suicide rates have risen in the last decade, there has been greater emphasis on targeting early risk conditions for suicidality among youth and adolescents as a form of suicide "inoculation". Two particular needs that have been raised in this nascent literature are a) the dearth of examination of early intervention effects on distal suicide risk that target externalizing behaviors and b) the need to harmonize multiple existing intervention datasets for greater precision in modeling intervention effects on low base rate outcomes such as suicidal behaviors. This project, entitled "Integrative Data Analysis of Coping Power (CP): Effects on Adolescent Suicidality", funded by the National Institute of Mental Health (NIMH), will harmonize and analyze data from 11 randomized controlled trials of CP (total individual-level N = 3183, total school-level N = 189). CP is an empirically-supported, child- and family-focused preventive intervention that focuses on reducing externalizing more broadly among youth who exhibit early aggression, which makes it ideally suited to targeting externalizing pathways to suicidality. The project utilizes three measurement and data analysis frameworks that have emerged across multiple independent disciplines: integrative data analysis (IDA), random treatment effects multilevel modeling (RTE-MLM), and propensity score weighting (PSW). If successful, the project will a) provide initial evidence that CP would have gender-specific indirect effects on suicidality through reductions in externalizing for boys and reductions in internalizing for girls and b) identify optimal conditions under which CP is delivered (e.g., groups, individuals, online) across participants on reductions in suicidality and other key intermediate endpoints.
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Affiliation(s)
- Antonio A Morgan-López
- RTI International, Community Health Research Division, Research Triangle Park, NC, United States of America.
| | - Heather L McDaniel
- School of Education and Human Development, University of Virginia, Charlottesville, VA, United States of America
| | - Catherine P Bradshaw
- School of Education and Human Development, University of Virginia, Charlottesville, VA, United States of America
| | - Lissette M Saavedra
- RTI International, Community Health Research Division, Research Triangle Park, NC, United States of America
| | - John E Lochman
- Center for Youth Development and Intervention, University of Alabama, Tuscaloosa, AL, United States of America
| | - Chelsea A Kaihoi
- School of Education and Human Development, University of Virginia, Charlottesville, VA, United States of America
| | - Nicole P Powell
- Center for Youth Development and Intervention, University of Alabama, Tuscaloosa, AL, United States of America
| | - Lixin Qu
- Center for Youth Development and Intervention, University of Alabama, Tuscaloosa, AL, United States of America
| | - Anna C Yaros
- RTI International, Community Health Research Division, Research Triangle Park, NC, United States of America
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Increasing knowledge about recovery-related life domains among pregnant and parenting women in comprehensive substance use disorder treatment: The Art of Addiction Recovery Program. Drug Alcohol Depend 2022; 232:109252. [PMID: 35032855 PMCID: PMC8885977 DOI: 10.1016/j.drugalcdep.2021.109252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Group treatments designed specifically for pregnant and parenting women with substance use disorders are lacking. This study provides a preliminary assessment of the Art of Addiction Recovery Program, a manualized group treatment imbedded within a comprehensive substance use disorder treatment program for pregnant and parenting women. METHODS The Program consists of 14 sessions, each focusing on a different topic, including health, social relationships, the recovery process, well-being, and introspection. Each session includes both the presentation of information by a facilitator, group discussions guided by the facilitator, and a creative project. A single-group pretest-posttest design provides an initial evaluation of the Art of Addiction Recovery Program. RESULTS Participants were 51 women with an average age of 28.7 (SD = 5.0) with most (69%) having a primary opioid use disorder and 82% reporting tobacco use. Significant (ps < 0.001) pre- to post-session increases in session-specific knowledge occurred for all 14 sessions with a measure of multivariate association indicating that these changes were substantial. Ratings of learning and effectiveness were generally high, with 19/28 means at 3.7 or above (maximum score = 4). CONCLUSIONS Findings suggest that The Art of Addiction Recovery Program was effective in conveying knowledge about substance use and recovery, and that participants increased their knowledge and generally strongly agreed that the sessions provided high levels of learning and were highly effective. The Art of Addiction Recovery Program provides an option for those seeking a manual-based group treatment program as an aid in the treatment process for this subpopulation.
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Molina G, Whittaker A. Treatment of post-traumatic stress disorder and substance use disorder in adults with a history of adverse childhood experiences: A systematic review of psychological interventions. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100028. [PMID: 36845903 PMCID: PMC9948894 DOI: 10.1016/j.dadr.2022.100028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/12/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022]
Abstract
Background Adverse childhood experiences (ACEs) have long-term effects on adult health, including unresolved trauma and substance use disorder (SUD). There are hypotheses of a mediating role of emotion regulation. This systematic literature review and narrative synthesis assessed the effectiveness of psychological interventions on emotion regulation, PTSD and SUD symptoms. Methods Searches were conducted using the Cochrane Handbook for Systematic Reviews methodology. Eligible studies were randomised controlled trials (RCTs) and quasi-experimental psychological interventions published between 2009 and 2019. Study characteristics, results and methodological quality were systematically analysed. Results Thirteen studies, including nine RCTs, were selected. Integrated SUD and PTSD treatments consisted of Seeking Safety, exposure-based treatment, Trauma Recovery and Empowerment Model, and integrated cognitive behavioural therapy. Two studies reported emotion regulation. Five studies found a small to medium positive effect size of psychological interventions on PTSD outcomes. Two studies had a small positive effect size on SUD outcomes and two a small negative effect size. Attrition was high across most studies. Characteristics likely to affect the applicability of the review were described. Conclusion The review found some evidence of a small inconsistent positive effect of psychological interventions on PTSD outcomes, and no evidence of effect on SUD outcomes. The range of theoretical models was narrow. Overall quality was low with high clinical heterogeneity and missing key information, particularly on emotion regulation, an important transdiagnostic feature. Further research is required to establish interventions that can treat these multiple conditions with a focus on effectiveness, acceptability, and implementation in real life clinical practice.
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Key Words
- ACEs, adverse childhood experiences
- AEs, adverse events
- ATREM, Attachment-informed TREM
- CBT, Cognitive–Behavioural Therapy
- CI, confidence intervals
- CPTSD, complex PTSD
- DERS, Difficulties in Emotion Regulation Scale
- EMDR, eye movement desensitisation and reprocessing
- ER, emotion regulation
- FSP, family and social problems
- ICBT, Integrated CBT
- M, mean
- OR, odds ratio
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PTSD, post-traumatic stress disorder
- RCT, randomised control trial
- SD, standard deviation
- SS, Seeking Safety
- SUD, substance use disorder
- SWiM, Synthesis Without Meta-Analysis
- TREM, Trauma Recovery and Empowerment Model
- adverse childhood experiences
- emotion regulation
- posttraumatic stress disorder
- psychological interventions
- substance use disorder
- systematic review
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Affiliation(s)
- Genevieve Molina
- CeGIDD, Pôle Santé Publique et Médecine Sociale, CHU Toulouse, Hôpital La Grave, TSA 60033, 31059 Toulouse Cedex 9, France
- Corresponding author.
| | - Anne Whittaker
- NMAHP Research Unit, Faculty of Health Sciences and Sport, Pathfoot Building, University of Stirling, FK9 4LA, Stirling, Scotland, UK
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Hien D, Kropp F, Wells EA, Campbell A, Hatch-Maillette M, Hodgkins C, Killeen T, Lopez-Castro T, Morgan-Lopez A, Ruglass LM, Saavedra L, Nunes EV. The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research. J Subst Abuse Treat 2021; 112S:12-17. [PMID: 32220405 DOI: 10.1016/j.jsat.2020.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/02/2020] [Accepted: 02/08/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Denise Hien
- Center of Alcohol & Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick, Piscataway, NJ, United States of America.
| | - Frankie Kropp
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, United States of America
| | - Elizabeth A Wells
- School of Social Work, University of Washington, Seattle, WA, United States of America
| | - Aimee Campbell
- Department of Psychiatry, Columbia University Irving Medical Center and Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, United States of America
| | - Mary Hatch-Maillette
- University of Washington Alcohol & Drug Abuse Institute, Department of Psychiatry & Behavioral Sciences, Seattle, WA, United States of America
| | | | - Therese Killeen
- Medical University of South Carolina, Charleston, SC, United States of America
| | - Teresa Lopez-Castro
- Psychology Department, The City College of New York, New York, NY, United States of America
| | - Antonio Morgan-Lopez
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States of America
| | - Lesia M Ruglass
- Center of Alcohol & Substance Use Studies, Graduate School of Applied and Professional Psychology, Rutgers University-New Brunswick, Piscataway, NJ, United States of America
| | - Lissette Saavedra
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, United States of America
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Irving Medical Center and Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, United States of America
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Saavedra LM, Morgan-López AA, Hien DA, López-Castro T, Ruglass LM, Back SE, Fitzpatrick S, Norman SB, Killeen TK, Ebrahimi CT, Hamblen J. Evaluating treatments for posttraumatic stress disorder, alcohol and other drug use disorders using meta-analysis of individual patient data: Design and methodology of a virtual clinical trial. Contemp Clin Trials 2021; 107:106479. [PMID: 34157418 DOI: 10.1016/j.cct.2021.106479] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022]
Abstract
This paper describes Project Harmony, a Virtual Clinical Trial (VCT) funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to harmonize and analyze data from over 40 independent psychological, pharmacologic and/or combined pharmacological treatment studies for posttraumatic stress disorder and comorbid alcohol and other drug use disorders (PTSD/AOD). The study attends to three distinct analysis challenges: (1) variation in measurement of PTSD/AOD across studies, time, populations and reporters, (2) cross-study variation in treatment effect sizes and (3) non-randomized, cross-study variation in the classification of treatments (despite within-study randomization of treatment arms). To address these challenges, the study combines meta-analysis of individual patient data (MIPD), integrative data analysis (IDA) and propensity score weighting (PSW) to integrate raw data from these clinical trials. This protocol shows how this VCT analytic framework was used to (1) develop commensurate scale scores of PTSD and AOD severity when measures vary across studies, (2) compare the efficacy of evidence-based treatment models for PTSD/AOD, (3) test for potential mediators of treatment effects on AOD and PTSD across treatment models, and (4) explore individual- and study-level moderators to inform for whom each of the treatment models works best. The advantages of the general VCT approach are juxtaposed against the limitations of single randomized controlled trials and conventional meta-analysis.
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Affiliation(s)
| | | | - Denise A Hien
- Center of Alcohol Studies, Rutgers University-New Brunswick, USA
| | | | | | | | | | - Sonya B Norman
- National Center for PTSD, White River Junction, VT, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, USA
| | | | | | - Jessica Hamblen
- National Center for PTSD, White River Junction, VT, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Luteijn I, VanDerNagel JEL, van Duijvenbode N, de Haan HA, Poelen EAP, Didden R. Post-traumatic stress disorder and substance use disorder in individuals with mild intellectual disability or borderline intellectual functioning: A review of treatment studies. RESEARCH IN DEVELOPMENTAL DISABILITIES 2020; 105:103753. [PMID: 32763655 DOI: 10.1016/j.ridd.2020.103753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/07/2020] [Accepted: 07/25/2020] [Indexed: 06/11/2023]
Abstract
Individuals with mild intellectual disability or borderline intellectual functioning (MID-BIF; IQ 50-85) are at high risk for developing post-traumatic stress disorder (PTSD) and substance use disorders (SUD). In individuals without MID-BIF, Seeking Safety (SeSa) is found to be effective in treating PTSD and SUD simultaneously. However, little is known about integrated treatment of PTSD and SUD in individuals with MID-BIF. This review aims to provide an overview of studies about this type of triple psychopathology, as well as PTSD or SUD in individuals with MID-BIF (i.e. dual diagnosis). No studies were found on integrated treatment of PTSD and SUD in individuals with MID-BIF. Thirty-two studies were found on treatment of either PTSD (mostly Eye Movement Desensitization and Reprocessing and cognitive behavior therapy) or SUD (mostly cognitive behavior therapy and mindfulness) in individuals with MID-BIF. Only 9.4 % of these studies mentioned the co-morbidity of PTSD and SUD. Suggestions for adapting treatment to individuals with MID-BIF were provided on communication, structure, non-verbal elements, network, coping skills, therapeutic relationship and use of suitable and reliable instruments to measure treatment progress. More research is needed on the effectivity of EMDR or Imaginary Exposure (IE) combined with SUD treatment (CBT and mindfulness), and on the adaption of SeSa tot individuals with MID-BIF, as well as on this type of triple psychopathology in general.
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Affiliation(s)
- Ilse Luteijn
- Tactus Verslavingszorg, P.O. Box 154, 7400 AD, Deventer, the Netherlands.
| | - Joanneke E L VanDerNagel
- Tactus Verslavingszorg, P.O. Box 154, 7400 AD, Deventer, the Netherlands; Radboud Universiteit Nijmegen, Nijmegen Institute for Scientist-Practitioners in Addiction, P.O Box 6909, 6503 GK Nijmegen, the Netherlands; Aveleijn, Grotestraat 260, 7622 GW Borne, the Netherlands; University of Twente, Faculty of Electrical Engineering, Mathematics, & Computer Science, Human Media Interaction, Drienerlolaan 5, 7522 NB Enschede, the Netherlands
| | - Neomi van Duijvenbode
- Tactus Verslavingszorg, P.O. Box 154, 7400 AD, Deventer, the Netherlands; Trajectum, Hanzeallee 2, 8017 KZ Zwolle, the Netherlands
| | - Hein A de Haan
- Tactus Verslavingszorg, P.O. Box 154, 7400 AD, Deventer, the Netherlands; Radboud Universiteit Nijmegen, Nijmegen Institute for Scientist-Practitioners in Addiction, P.O Box 6909, 6503 GK Nijmegen, the Netherlands
| | - Evelien A P Poelen
- Pluryn, Research & Development, Industrieweg 50, 6541 TW, Nijmegen, the Netherlands; Behavioral Science Institute, Radboud University, P.O. Box 9104, 6500 HE, Nijmegen, the Netherlands
| | - Robert Didden
- Trajectum, Hanzeallee 2, 8017 KZ Zwolle, the Netherlands; Behavioral Science Institute, Radboud University, P.O. Box 9104, 6500 HE, Nijmegen, the Netherlands
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Crisanti AS, Murray-Krezan C, Reno J, Killough C. Effectiveness of Peer-Delivered Trauma Treatment in a Rural Community: A Randomized Non-inferiority Trial. Community Ment Health J 2019; 55:1125-1134. [PMID: 31338716 PMCID: PMC6744517 DOI: 10.1007/s10597-019-00443-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/25/2019] [Indexed: 11/26/2022]
Abstract
This randomized controlled non-inferiority trial explored the effectiveness of Seeking Safety (SS) delivered by peer providers compared to its delivery by licensed behavioral health clinicians. The study enrolled 291 adults with PTSD and/or substance use disorders. Data were collected at 3 and 6-months post start of treatment. With respect to long-term outcomes, at 6 months PTSD symptoms decreased by 5.1 points [95% CI (- 9.0, - 1.1)] and by 4.9 points [95% CI (- 8.6, - 1.1)] and coping skills increased by 5.5 points [95% CI (0.4, 10.6)] and by 5.6 points [95% CI (0.8, 10.4)], in the peer- and clinician-led groups, respectively. This study demonstrated non-inferiority of peer-delivered SS compared to clinician-delivered SS for reducing PTSD symptoms and similar outcomes for both groups with respect to coping skills. A confirmatory study on the effectiveness of peer-delivered trauma-specific services is warranted, especially given the potential for increasing access to such treatment in underserved rural communities.
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Affiliation(s)
- Annette S Crisanti
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, MSC 09 5030, Albuquerque, NM, 87131, USA.
| | | | - Jessica Reno
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, MSC 09 5030, Albuquerque, NM, 87131, USA
| | - Cynthia Killough
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, MSC 09 5030, Albuquerque, NM, 87131, USA
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Bailey K, Trevillion K, Gilchrist G. What works for whom and why: A narrative systematic review of interventions for reducing post-traumatic stress disorder and problematic substance use among women with experiences of interpersonal violence. J Subst Abuse Treat 2019; 99:88-103. [DOI: 10.1016/j.jsat.2018.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022]
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Murphy TM, Dispenza F, Chang CY, Elston N, Rumsey A, Sinclair M, Curtis-Davidson R. Enhancing the Seeking Safety group intervention with trauma-sensitive yoga practice: A program evaluation. Complement Ther Clin Pract 2019; 35:308-315. [PMID: 31003675 DOI: 10.1016/j.ctcp.2019.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 02/11/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this article is to report the results of a qualitative Utilization Focused Program Evaluation on the integration of the Seeking Safety manualized group counseling intervention with Trauma-Sensitive (TS) yoga practice at a community mental health agency. To date, there has been no evaluation of Seeking Safety and TS yoga as complementary therapies. METHOD AND MATERIALS Qualitative data were generated from key informant interviews and focus groups, then coded and analyzed for theme and content. RESULTS Analysis of data indicate that, in this specific setting, the combination of Seeking Safety and TS Yoga was perceived by clients and clinicians as an effective complementary intervention strategy. CONCLUSION The results of this qualitative evaluation are specific to the agency utilizing the interventions. By integrating Seeking Safety with TS yoga many of the inherent weaknesses of the two individual approaches were moderated.
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Affiliation(s)
- Thomas M Murphy
- Department of Counseling, The College of Saint Rose, United States.
| | - Franco Dispenza
- Department of Counseling & Psychological Services, Georgia State University, United States.
| | - Catherine Y Chang
- Department of Counseling & Psychological Services, Georgia State University, United States.
| | - Nikki Elston
- Department of Counseling, Wake Forrest University, United States.
| | - Amanda Rumsey
- Department of Education & Human Development, Clemson University, United States.
| | - Moneta Sinclair
- Positive Impact Health Centers - Decatur, GA, United States.
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Sugarman DE, Reilly ME, Greenfield SF. Treatment Outcomes for Women with Substance Use Disorders: a Critical Review of the Literature (2010–2016). CURRENT ADDICTION REPORTS 2017. [DOI: 10.1007/s40429-017-0172-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. Sex and gender differences in substance use disorders. Clin Psychol Rev 2017; 66:12-23. [PMID: 29174306 DOI: 10.1016/j.cpr.2017.10.012] [Citation(s) in RCA: 472] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Abstract
The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.
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Affiliation(s)
- R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States.
| | - Victoria R Votaw
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States
| | - Dawn E Sugarman
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
| | - Shelly F Greenfield
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
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Schacht RL, Brooner RK, King VL, Kidorf MS, Peirce JM. Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial. J Consult Clin Psychol 2017; 85:689-701. [PMID: 28414485 DOI: 10.1037/ccp0000208] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes. METHOD Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization. RESULTS Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use. CONCLUSIONS Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record
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Affiliation(s)
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Van L King
- Department of Psychiatry, University of Texas Health Science Center at San Antonio
| | - Michael S Kidorf
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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Roberts NP, Roberts PA, Jones N, Bisson JI. Psychological therapies for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database Syst Rev 2016; 4:CD010204. [PMID: 27040448 PMCID: PMC8782594 DOI: 10.1002/14651858.cd010204.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective. OBJECTIVES To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles. SELECTION CRITERIA Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias. AUTHORS' CONCLUSIONS We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.
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Affiliation(s)
- Neil P Roberts
- Cardiff University School of MedicineInstitute of Psychological Medicine and Clinical NeurosciencesHadyn Ellis BuildingMaindy RoadCardiffUKCF24 4HQ
- Cardiff and Vale University Health BoardPsychology and Counselling DirecorateCardiffUK
| | - Pamela A Roberts
- Cardiff and Vale University Health BoardPsychology and Counselling DirecorateCardiffUK
- Cardiff and Vale University Health BoardCommunity Addiction ServiceCardiffUK
| | - Neil Jones
- Cardiff and Vale University Health BoardCommunity Addiction ServiceCardiffUK
| | - Jonathan I Bisson
- Cardiff University School of MedicineInstitute of Psychological Medicine and Clinical NeurosciencesHadyn Ellis BuildingMaindy RoadCardiffUKCF24 4HQ
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Effect of traumatic event reexposure and PTSD on substance use disorder treatment response. Drug Alcohol Depend 2016; 158:126-31. [PMID: 26652898 PMCID: PMC4698104 DOI: 10.1016/j.drugalcdep.2015.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND A remarkably high rate of traumatic event reexposure has been demonstrated in community-based substance users which negatively impacts their substance use disorder (SUD). The rate and effect of such reexposure in treatment is unknown. Despite increasing evidence that a diagnosis of posttraumatic stress disorder (PTSD) has little influence on long-term SUD treatment outcomes, it is possible that PTSD symptom fluctuations could have effects. METHODS This prospective longitudinal study examined the rate and effect of traumatic event reexposure and PTSD symptoms in 169 male and female methadone maintenance patients with a comorbid psychiatric disorder who were participating in a parent study. Traumatic events and PTSD symptoms were tested for association with drug use, treatment interruption, and counseling adherence in the same month, one month later, and two months later. RESULTS Approximately 18% of patients were reexposed to a traumatic event each month during the 12-month study. Reexposure was associated with about twice the risk of treatment interruption in the same month and one month later. Every 10% increase in PTSD symptom severity was associated with a 36% increased risk of treatment interruption two months later. No effects were seen on drug use or counseling adherence. CONCLUSIONS SUD patients have a relatively high rate of traumatic event reexposure. Both traumatic events and PTSD symptoms are associated with increased risk of treatment interruption, resulting in SUD patients leaving treatment at precisely the time they could benefit from treatment support.
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Hien DA, Campbell ANC, Ruglass LM, Saavedra L, Mathews AG, Kiriakos G, Morgan-Lopez A. Maximizing Effectiveness Trials in PTSD and SUD Through Secondary Analysis: Benefits and Limitations Using the National Institute on Drug Abuse Clinical Trials Network "Women and Trauma" Study as a Case Example. J Subst Abuse Treat 2015; 56:23-33. [PMID: 25907849 PMCID: PMC4519371 DOI: 10.1016/j.jsat.2015.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/31/2015] [Accepted: 04/06/2015] [Indexed: 12/31/2022]
Abstract
Recent federal legislation and a renewed focus on integrative care models underscore the need for economical, effective, and science-based behavioral health care treatment. As such, maximizing the impact and reach of treatment research is of great concern. Behavioral health issues, including the frequent co-occurrence of substance use disorders (SUD) and posttraumatic stress disorder (PTSD), are often complex, with a myriad of factors contributing to the success of interventions. Although treatment guides for comorbid SUD/PTSD exist, most patients continue to suffer symptoms following the prescribed treatment course. Further, the study of efficacious treatments has been hampered by methodological challenges (e.g., overreliance on "superiority" designs (i.e., designs structured to test whether or not one treatment statistically surpasses another in terms of effect sizes) and short term interventions). Secondary analyses of randomized controlled clinical trials offer potential benefits to enhance understanding of findings and increase the personalization of treatment. This paper offers a description of the limits of randomized controlled trials as related to SUD/PTSD populations, highlights the benefits and potential pitfalls of secondary analytic techniques, and uses a case example of one of the largest effectiveness trials of behavioral treatment for co-occurring SUD/PTSD conducted within the National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) and producing 19 publications. The paper concludes with implications of this secondary analytic approach to improve addiction researchers' ability to identify best practices for community-based treatment of these disorders. Innovative methods are needed to maximize the benefits of clinical studies and better support SUD/PTSD treatment options for both specialty and non-specialty healthcare settings. Moving forward, planning for and description of secondary analyses in randomized trials should be given equal consideration and care to the primary outcome analysis.
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Affiliation(s)
- Denise A Hien
- Gordon F. Derner Institute of Advanced Psychological Studies, Adelphi University; Department of Psychiatry, Columbia University College of Physicians and Surgeons, and New York State Psychiatric Institute.
| | - Aimee N C Campbell
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, and New York State Psychiatric Institute
| | - Lesia M Ruglass
- Department of Psychology, The City College of New York, The City University of New York
| | - Lissette Saavedra
- Division of Social Policy, Health, and Economics Research, RTI International, Research Triangle Park, NC
| | | | | | - Antonio Morgan-Lopez
- Division of Social Policy, Health, and Economics Research, RTI International, Research Triangle Park, NC
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Hien DA, Levin FR, Ruglass LM, López-Castro T, Papini S, Hu MC, Cohen LR, Herron A. Combining seeking safety with sertraline for PTSD and alcohol use disorders: A randomized controlled trial. J Consult Clin Psychol 2015; 83:359-69. [PMID: 25622199 DOI: 10.1037/a0038719] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The current study marks the first randomized controlled trial to test the benefit of combining Seeking Safety (SS), a present-focused cognitive-behavioral therapy for co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD), with sertraline, a front-line medication for PTSD shown to also impact drinking outcomes. METHOD Sixty-nine participants (81% female; 59% African American) with primarily childhood sexual (46%) and physical (39%) trauma exposure, and drug dependence in addition to AUD were randomized to receive a partial-dose (12 sessions) of SS with either sertraline (n = 32; M = 7 sessions) or placebo (n = 37; M = 6 sessions). Assessments conducted at baseline, end-of-treatment, 6- and 12-months posttreatment measured PTSD and AUD symptom severity. RESULTS Both groups demonstrated significant improvement in PTSD symptoms. The SS plus sertraline group exhibited a significantly greater reduction in PTSD symptoms than the SS plus placebo group at end-of-treatment (M difference = -16.15, p = .04, d = 0.83), which was sustained at 6- and 12-month follow-up (M difference = -13.81, p = .04, d = 0.71, and M difference = -12.72, p = .05, d = 0.65, respectively). Both SS groups improved significantly on AUD severity at all posttreatment time points with no significant differences between SS plus sertraline and SS plus placebo. CONCLUSION Results support the combining of a cognitive-behavioral therapy and sertraline for PTSD/AUD. Clinically significant reductions in both PTSD and AUD severity were achieved and sustained through 12-months follow-up, Moreover, greater mean improvement in PTSD symptoms was observed across all follow-up assessments in the SS plus sertraline group. (PsycINFO Database Record
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Affiliation(s)
| | | | | | | | | | - Mei-Chen Hu
- Department of Psychiatry, Columbia University College of Physicians and Surgeons
| | | | - Abigail Herron
- Department of Psychiatry, Columbia University College of Physicians and Surgeons
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Ruglass LM, Lopez-Castro T, Cheref S, Papini S, Hien DA. At the crossroads: the intersection of substance use disorders, anxiety disorders, and posttraumatic stress disorder. Curr Psychiatry Rep 2014; 16:505. [PMID: 25224608 DOI: 10.1007/s11920-014-0505-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The co-occurrence of substance use disorders with anxiety disorders and/or posttraumatic stress disorder has been widely documented and when compared to each disorder alone, consistently linked to increased risk for a host of negative outcomes including greater impairment, poorer treatment response, and higher rates of symptom relapse. This article focuses on recent advances in the understanding and effective treatment of this common and highly complex comorbidity. Prevalence and epidemiological data are introduced, followed by a review of contemporary models of etiology and associative pathways. Conceptualizations of effective treatment approaches are discussed alongside evidence from the past decade of clinical research trials. Highlighted are ongoing questions regarding the benefit of sequential, parallel, and integrated approaches and the necessity of further investigation into the mechanisms underlying treatment efficacy. Lastly, recent contributions from neuroscience research are offered as a promising bridge for the development and testing of novel, interdisciplinary treatment approaches.
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Affiliation(s)
- Lesia M Ruglass
- Department of Psychology, The City College of New York, 160 Convent Avenue, NAC Building, Rm 7/120, New York, NY, 10031, USA,
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