PTSD: National Center for PTSD
Treatment of Co-Occurring PTSD and Substance Use Disorder in VA
Treatment of Co-Occurring PTSD and Substance Use Disorder in VA
- Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) often co-occur among Veterans seeking Veterans Affairs (VA) care.
- Patients with PTSD and SUD can tolerate and benefit from evidence-based trauma-focused PTSD treatment such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).
- Per VA policy, patients with PTSD and SUD should be offered evidence-based treatment for both disorders. Having one should not be a barrier to receiving treatment for the other.
- Shared decision making about treatment for co-occurring PTSD and SUD using a patient-centered collaborative approach that incorporates measurement based care (MBC) is recommended.
Prevalence and Characteristics
PTSD and SUD often co-occur. According to one national epidemiologic study, 46.4% of individuals with lifetime PTSD also met criteria for SUD (1). 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 (3). Whether these findings generalize to other cohorts is unknown.
Much information about treatment-seeking Veterans comes from VA administrative data. For example, in a study of Operations Enduring Freedom (OEF) / Iraqi Freedom (OIF) / New Dawn (OND) Veterans, 63% of those diagnosed with alcohol use disorder (AUD) or other SUD also had a diagnosis of PTSD (4). Among Veterans diagnosed with AUD and another SUD, the rate of PTSD diagnosis was 76% (4). 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% (5).
Although PTSD and SUD are each associated with functional impairment, on average, individuals who have both disorders have poorer treatment outcomes, more additional psychiatric problems, and more functional problems across multiple domains, including medical, legal, financial, and social, than those with just one disorder (6-8).
Research Regarding the Treatment of Co-Occurring PTSD and SUD
Individuals with PTSD and SUD can safely engage in and benefit from trauma-focused, cognitive behavioral psychotherapies for PTSD such as PE (9) and CPT (10). A meta-analysis suggests that patients with PTSD and SUD who received trauma-focused cognitive behavioral psychotherapy for PTSD along with SUD psychotherapy were more likely to reduce their PTSD symptoms and substance use than were patients who received SUD only treatment or treatment as usual (10). The effect sizes are small and dropout rates in the trauma-focused psychotherapies were higher than in treatment focused SUD only or treatment as usual. Therapies that were not trauma-focused and instead centered on improving coping skills were not associated with higher dropout than SUD only treatment or treatment as usual but also did not have better PTSD or SUD outcomes. For example, Seeking Safety, an integrated psychotherapy focused on improving coping skills that does not include trauma processing or exposure, has been widely implemented in VA and elsewhere, with high acceptability to patients and providers. Although early studies found support for Seeking Safety, the more rigorous randomized controlled trials in Veterans and non-Veterans suggest that it is only comparably effective to SUD treatment alone for reducing symptoms of PTSD and substance use (11,12). Thus, while there is little evidence to favor use of non-trauma-focused psychotherapies for treating co-occurring PTSD and SUD, there is emerging evidence that favors the use of trauma-focused psychotherapies either concurrently with evidence-based SUD treatment or in an integrated fashion (9,13,14). More research is needed to determine comparative effectiveness and patient acceptability of the various psychotherapy approaches for concurrent treatment of PTSD and SUD.
Several studies have found limited success with adding a selective serotonin reuptake inhibitor (SSRI) to SUD treatment as usual (15-17). Combining medication and psychotherapy is a potentially effective strategy. One recent study found that the combination of PE plus naltrexone was more effective in reducing drinking 6 months following treatment completion than either treatment was alone (18). Although acute, time-limited use of benzodiazepines alleviates symptoms of alcohol withdrawal, the authors of the 2010 VA/DoD Clinical Practice Guideline for PTSD found no evidence that ongoing benzodiazepine treatment alleviates the core symptoms of PTSD (19). There is mounting evidence of harms associated with chronic benzodiazepine use in patients with PTSD, particularly those who also have an SUD (20).
Policy and Practice Recommendations
Initial and ongoing assessment is critical to understanding the needs and progress of Veterans with PTSD and SUD. VA recently launched the Measurement Based Care (MBC) in Mental Health initiative (21). MBC is the use of patient-reported information, collected as part of routine care, to inform clinical care and shared decision making, individualize treatment, and assess progress toward recovery goals. VA’s initiative will use the PTSD Checklist for DSM-5 (PCL-5) for assessing PTSD and the Brief Addition Monitor for assessing SUD.
The 2010 VA/DoD Clinical Practice Guideline for PTSD recommends that evidence-based treatments for PTSD and SUD, including psychotherapy and medication, be available to Veterans (19). The VA Uniform Mental Health Services Handbook (22) requires that all VA Medical Centers provide access to either PE or CPT for Veterans wit PTSD. Thus, PE and/or CPT should be accessible to Veterans with PTSD and co-occurring SUD.
To ensure that SUD is not a barrier to receiving best practice treatment for specific disorders such as PTSD, the Uniform Mental Health Services Handbook (22, p. 24) states, “When PTSD or other mental health conditions co-occur with substance use disorders, evidence-based pharmacotherapy and psychosocial interventions for the other conditions need to be made available where there are no medical contraindications, with appropriate coordination of care;” and, “Substance use illness must never be a barrier for treatment of patients with other mental health conditions. Conversely, other mental disorders must never be a barrier to treating patients with substance use illnesses.”
Guidance that an SUD should not be a barrier to receiving PTSD treatment applies to residential treatment as well as outpatient. VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Programs (RRTPs) handbook (23, p. 15) states that Veterans cannot be denied admission to mental health RRTPs based on length of abstinence and that opioid replacement therapies such as buprenorphine and methadone should be available in mental health RRTPs. A number of VA RRTPs report that they treat both PTSD and SUD (24) and preliminary research suggests that co-occurring PTSD and SUD can be treated effectively in residential settings (25).
There is no single ideal type of program for the treatment of co-occurring PTSD and SUD. Rather, best practice suggests a “no wrong door policy” where Veterans are welcome to participate in treatment for PTSD and SUD regardless of the type of program through which they access treatment (e.g., primary care, behavioral health interdisciplinary program, or specialty PTSD or SUD) or the level of care through which they receive treatment (e.g., outpatient, intensive outpatient, or residential) (26). To improve access to optimal care, in 2008 VA authorized funding for an SUD 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 and provide clinical care.
Shared decision making using a patient centered, collaborative approach that includes the treatment team and the Veteran is recommended (27) to help engage and retain Veterans in care. Because there is no single level of care or evidence-based treatment that is recommended for all Veterans, using a patient centered, collaborative approach allows for tailoring of treatment to best meet each Veteran’s circumstances. MBC should be sued to assess progress and to contribute self-reported outcome data into shared decision-making. Self-reported outcome data can be invaluable in PTSD and SUD treatment for Veterans and their treatment team in assessing whether gains are being made in symptoms and/or functional status, or whether discussions of a shift in services may be warranted in order to optimize treatment outcomes.
- 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
- 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
- Seal, K. H., Cohen, G. Waldrop, A., Cohen, B. E., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan Veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116, 93-101. doi:10.1016/j.drugalcdep.2010.11.027
- J. Trafton, personal communication, April 9, 2013
- Tate, S. R., Norman, S. B., McQuaid, J. R., & Brown, S. A. (2007). Health problems of substance-dependent Veterans with and those without trauma history. Journal of Substance Abuse Treatment, 33, 25-32. doi:10.1016/j.sat.2006.11.006
- McDevitt-Murphy, M. E., Williams, J. L., Bracken, K. L., Fields, J. A., Monahan, C. J., & Murphy, J. G. (2010). PTSD symptoms, hazardous drinking, and health functioning among US OEF and OIF Veterans presenting to primary care. Journal of Traumatic Stress, 23, 108-111. doi:10.1002/jts.20482
- Stappenbeck, C. A., Hellmuth, J. C., Simpson, T., & Jacupcak, M. (2014). The effects of alcohol problems, PTSD, and combat exposure on nonphysical and physical aggression among Iraq and Afghanistan war Veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 65-72. doi:10.1037/a0031468
- Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for posttraumatic stress disorder and comorbid substance use disorder: A systemative review and meta-analysis. Clinical Psychology Review, 38, 25-38. doi:10.1016/j.cpr.2015.02.007
- Kaysen, D., Schumm, J., Pedersen, E. R., Seim, R. W., Bedard-Gilligan, M., & Chard, K. (2014). Cognitive Processing Therapy for Veterans with comorbid PTSD and alcohol use disorders. Addictive Behaviors, 39, 420-427. doi:10.1016/j.addbeh.2013.08.016
- Boden, M. T., Kimerling, R., Jacobs-Lentz, J., Bowman, D., Weaver, C., Carney, D., Walser, R., & Trafton, J. A. (2012). Seeking Safety treatment for male Veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction, 107, 578-586. doi:10.1111/j.1360-0443.2011.03658.x
- Hien, D. A., Wells, E. A., Jiang, H., Suarez-Mroales, L., Campbell, A. N. C., Cohen, L. R., Miele, G. M., Killeen, T., Brigham, G. S., Zhang, Y., Hansen, C., Hodgkins, C., Hatch0Maillette, 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
- Back, S. E., Foa, E. B., Killeen, T. K., Mills, K. L., Teesson, M., Cotton, B. D., Carroll, K. M., & Brady, K. T. (2015). Concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE): Therapist guide. New York, NY: Oxford University Press.
- 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.
- Batki, S.L., Pennington, D.L., Lasher, B., Neylan, T. C., Metzler, T., Waldrop, A., Delucche, K., & Herbst, E. (2014). Topiramate treatment of alcohol use disorder in Veterans with posttraumatic stress disorder: A randomized controlled pilot trial. Alcoholism: Clinical and Experimental Research, 38, 2169-2177. doi:10.1111/acer.12496
- Berenz, E. C., & Coffey, S. F. (2012). Treatment of co-occurring posttraumatic stress disorder and substance use disorders. Current Psychiatry Reports,14, 469-477. doi:10.1007/s11920-012-0300-0
- Petrakis, I. L., Poling, J., Levinson, C., Nich, C., Carroll, K., 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
- Foa, E. B., Yusko, D. A., McLean, C. P., Suvak, M. K., Bux, D. A., Oslin, D., O’Brien, C. P., Imms, P., Riggs, D. S., & Volpicelli, J. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD. Journal of the American Medical Association, 310, 488-495. doi:10.1001/jama.2013.8268
- Department of Veterans Affairs and Department of Defense. (2010). VA/DoD Clinical Practice Guideline for Management of Post-traumatic Stress. Washington DC: Author. Retrieved from: https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
- Park, T. W., Saitz, R., Ganoczy, D., Ilgen, M. A., & Bohnert, A. S. (2015). Benzodiazepine prescribing patterns and deaths from drug overdose among US Veterans receiving opioid analgesics: Case-cohort study. British Medical Journal, 350, h2698. doi:10.1136/bmj.h2698
- U. S. Department of Veteran Affairs (2016). Measurement Based Care (MBC) in Mental Health Initiative. Retrieved from: https://www.vapulse.net/community/focus-areas/mbc
- U.S. Department of Veteran Affairs (2008). VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics. Retrieved from: http://www.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number
- U.S. Department of Veteran Affairs. (2009). VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Programs (MH RRTP). Retrieved from: http://www.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number
- U.S. Department of Veterans Affairs. MHRRP Program Locator (2016). https://vaww.portal.va.gov/sites/OMHS/mhrrtp/default.aspx. Accessed September 6, 2016.
- Norman, S. B., Davis, B. C., Colvonen, P. J., Haller, M., Myers, U. S., Trim, R. S., Bogner, R., & Robinson, S. K. (2016). Prolonged Exposure with Veterans in a residential substance use treatment program. Cognitive and Behavioral Practice, 23, 162-172. doi:10.1016/j.cbpra.2015.08.002
- U.S. Department of Veteran Affairs. (2012). VHA Handbook 1160.04, VHA Programs for Veterans with Substance Use Disorders (SUD). Retrieved from: http://www.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number
- Department of Veterans Affairs and Department of Defense. (2015). VA/DoD Clinical Practice Guideline Management of Substance Abuse Disorder (SUD). Washington, DC: Author. Retrieved from: https://www.healthquality.va.gov/guidelines/mh/sud/index.asp