PTSD: National Center for PTSD
PTSD and Substance Use Disorders in Veterans
PTSD and Substance Use Disorders in Veterans
The comorbidity of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) presents a serious challenge to many clinicians. Providers report that these patients are more difficult to treat than those with either disorder alone, leaving many clinicians unsure which treatment approach is best. It has been common practice to treat the SUD first out of concern that focusing on the trauma will cause relapse (1). However, there is growing evidence that addressing both conditions concurrently is the most effective approach.
Prevalence of substance use with PTSD
Over three-quarters of men and women with lifetime PTSD have another comorbid lifetime diagnosis (2). Often PTSD co-occurs with substance use. According to one national epidemiologic study, 46.4% of individuals with lifetime PTSD also met criteria for SUD (3). In another national epidemiologic study, 27.9% of women and 51.9% of men with lifetime PTSD also had SUD (2). Women with PTSD were 2.48 times more likely to meet criteria for alcohol abuse or dependence and 4.46 times more likely to meet criteria for drug abuse or dependence than women without PTSD. Men were 2.06 and 2.97 times more likely, respectively (2).
There are few comparable population prevalence estimates among Veterans. A substantial majority of Veterans with PTSD have met criteria for comorbid substance use at some point. The National Vietnam Veterans Readjustment Study, conducted in the 1980s, found 74% of Vietnam Veterans with PTSD had comorbid SUD (4). Whether these findings generalize to other cohorts is unknown. One might expect that the prevalence of co-occurring SUD would be higher in Veterans than civilians because some studies suggest that Veterans have poorer mental health (e.g., 5,6).
Studies of treatment-seeking samples have tended to report on current rather than lifetime diagnoses and to focus on the prevalence of PTSD in patients seeking SUD treatment. These studies show that up to half of patients seeking treatment for substance use meet criteria for current PTSD (7), but the estimates are highly variable--possibly due to heterogeneity in sample characteristics. Much information about treatment-seeking Veterans comes from VA administrative data. During the past 10 years, the number of Veterans with comorbid SUD and PTSD in VA care has increased over three-fold; in 2012, the prevalence of PTSD among Veterans receiving specialized SUD care was 32% (8).
Treating co-occurring PTSD and SUD
Several models have been proposed to account for the association between PTSD and SUD. Data most strongly support the model in which PTSD precedes the substance use and substances are used as a symptom management strategy. Then, withdrawal symptoms may trigger and exacerbate PTSD symptoms, initiating a cycle that precipitates poorer addiction outcomes (7). Therefore, it is critical that treatments address the PTSD as well as the SUD.
The revised 2010 VA/DoD Clinical Practice Guideline for the Management of PTSD provides recommendations for the management of co-occurring PTSD and SUD. The recommendation with the highest level of evidence is to offer smoking cessation treatment to patients with PTSD and nicotine dependence. There was insufficient evidence to support a preferred sequencing of treatments for PTSD or SUD. Therefore, evidence-based treatments for patients with both PTSD and SUD should be delivered concurrently with ongoing monitoring of response to treatment for both conditions.
Despite understandable enthusiasm for integrated treatments, several reviews have concluded that they may be no better than stand-alone treatments delivered concurrently (e.g., 7). For example, Seeking Safety, an integrated non-trauma focused treatment, has been widely implemented in VA and elsewhere, with high acceptability to patients and providers. Although early studies found support for Seeking Safety, the most rigorous randomized controlled trials in civilians and Veterans suggest that it is generally comparably effective to SUD treatment alone for reducing symptoms of PTSD and substance use (9,10).
A recent Australian study shows that individuals with PTSD and SUD can tolerate and benefit from an exposure-based treatment (11). COPE is a treatment that includes Prolonged Exposure for PTSD and Motivational Enhancement Therapy and Cognitive Behavioral Therapy for SUD. Civilian patients with PTSD and SUD randomized to COPE plus usual treatment had a greater reduction in PTSD than those in treatment as usual, but there were no group differences in substance use.
In the area of pharmacotherapy for co-occurring SUD and PTSD, several studies have found limited success with an SSRI in targeting comorbid disorders that increase likelihood of use or relapse (7). Another small trial found reductions in alcohol craving and PTSD symptoms with disulfiram and naltrexone (12). Although acute, time-limited use of benzodiazepines alleviates symptoms of alcohol withdrawal, the VA/DoD Guideline (2010) found no evidence that ongoing benzodiazepine treatment alleviates the core symptoms of PTSD.
To ensure that Veterans can access optimal care, in 2008 VA authorized funding for a substance use disorder specialist to augment each facility's specialty PTSD treatment services. These specialists work with PTSD specialty treatment providers to coordinate treatment planning and delivery of services. Their focus is on supporting the efforts of the treatment team in addition to providing ongoing clinical care to some patients with the co-occurring disorders.
Clinicians working with Veterans will likely need to address co-occurring PTSD and SUD. These patients may have complicated clinical presentations and poorer treatment prognoses. They can also be a challenge to treat. Although integrated treatments are intuitively appealing and can be beneficial for some, there is insufficient evidence that they are consistently effective for both disorders.
The VA/DoD Guideline (2010) recommends providing evidence-based treatment for the individual disorders concurrently. At a very minimum, patients with co-occurring PTSD and SUD do not need to wait for a substantial period of abstinence before addressing their PTSD. A growing number of studies demonstrate that these patients can tolerate trauma-focused treatment indicating that providers have a range of options to help improve the lives of patients with the co-occurring disorders.
- Back, S. E., Waldrop, A. E., & Brady, K. T. (2009). Treatment challenges associated with comorbid substance use and posttraumatic stress disorder: Clinicians' perspectives. American Journal of Addiction, 18. 15-20. doi: 10.1080/105505490802545141
- Kessler, R. C., Sonnega, A., Bromet, E. J., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. doi: 10.1001/archpsyc.1995.03950240066012
- Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456-465. doi: 10.1016/j.janxdis.2010.11.010
- Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). The National Vietnam Veterans Readjustment Study: Tables of findings and technical appendices. Brunner/Mazel. Retrieved from http://search.proquest.com/docview/42404631?accountid=28179
- Hoerster, K. D., Lehavot, K., Simpson, T., McFall, M., Reiber, G., & Nelson, K. M. (2012). Health and health behavior differences: U.S. military, Veteran, and civilian men. American Journal of Preventive Medicine, 43, 483-489. doi: 10.1016/j.amepre.2012.07.029
- Lehavot, K., Hoerster, K. D., Nelson, K. M., Jakupcak, M., & Simpson, T. L. (2012). Health indicators for military, Veteran, and civilian women. American Journal of Preventive Medicine, 42, 473-480. doi: 10.1016/j.amepre.2012.01.006
- Berenz, E. C., & Coffey, S. F. (2012). Treatment of co-occurring posttraumatic stress disorder and substance use disorder. Current Psychiatry Reports, 14, 469-477. doi: 10.1007/s11920-012-0300-0
- J. Trafton, personal communication, April 9, 2013
- Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., Walser, R., & Trafton, J. A. (2011). Seeking safety treatment for male Veterans with a substance use disorder and PTSD symptomatology. Addiction, 107, 578-586. doi: 10.1111/j.1360-0443.2011.03658.x
- Hien, D. A., Wells, E. A., Suarez-Morales, L., Campbell, A. N., Cohen, L. R., Miele, G. M., Kileen, T., Brigham, G. S., Zhang, Y., Hansen, C., Hodgkins, C., Hatch-Maillette, M., Brown, C., Kulaga, A., Kristman-Valente, A., Chu, M., Sage, R., Robinson, J. A., Liu, D., & Nunes, E. V. (2009). Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. Journal of Consulting and Clinical Psychology, 77, 607-619. doi: 10.1037/a0016227
- Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., Sannibale, C., Barrett, E. L., Merz, S., Rosenfeld, J., & Ewer, P. L. (2012) Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. Journal of the American Medical Association, 308, 690-699. doi: 10.1001/jama.2012.9071
- Petrakis, I. L., Poling, J., Levinson, C. M., Nich, C., Carroll, K. M., Ralevski, E., & Rounsaville, B. (2006). Naltrexone and disulfiram in patients with alcohol dependence and comorbid post-traumatic stress disorder. Biological Psychiatry, 60, 777-783. doi: 10.1016/j.biopsych.2006.03.074