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 (6-9).
In This Article
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 (10) and CPT (11). 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 (11). 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. In some studies, participants received trauma-focused therapy concurrently with SUD psychotherapy (e.g., 12) while in other studies, trauma-focused PTSD treatment and SUD psychotherapy were integrated into a single intervention. For example, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) integrates Prolonged Exposure therapy for PTSD with relapse prevention for SUD. Studies of COPE with Veteran and non-Veteran samples have shown COPE to outperform treatment as usual and relapse prevention for PTSD symptom reduction (13,14).
The same meta-analysis found that 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 (15-17).
A recent randomized clinical trial with Veterans directly compared COPE and Seeking Safety and found that COPE was associated with greater PTSD symptom reduction and greater likelihood of PTSD remission than Seeking Safety (18). Thus, while there is little evidence to favor use of non-trauma-focused psychotherapies for treating co-occurring PTSD and SUD, there is evidence that favors the use of trauma-focused psychotherapies either concurrently with evidence-based SUD treatment or in an integrated fashion (9,19,20). 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 (21-23). 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 (24).
Although acute, time-limited use of benzodiazepines alleviates symptoms of alcohol withdrawal, the authors of the 2017 VA/DoD Clinical Practice Guideline for PTSD found no evidence that ongoing benzodiazepine treatment alleviates the core symptoms of PTSD (25). There is mounting evidence of harms associated with chronic benzodiazepine use in patients with PTSD, particularly those who also have an SUD (26).
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 (27). 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 2017 VA/DoD Clinical Practice Guideline for PTSD recommends that evidence-based treatments for PTSD and SUD, including psychotherapy and medication, be available to Veterans and that having one disorder not preclude Veterans from getting evidence-based treatment for the other disorder (25). The VA Uniform Mental Health Services Handbook (28) 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 (28, 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.” Furthermore, “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 (29, 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 (30) and preliminary research suggests that co-occurring PTSD and SUD can be treated effectively in residential settings (31).
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) (32). 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 (33) 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. Measurement based care (MBC) should be used 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.
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