Characterizing and Comparing Evidence-Based Psychotherapy Utilization Among Veterans with Co-occurring PTSD and Substance Use Disorder.

Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain.

BACKGROUND: Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse. OBJECTIVE: The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse. DESIGN: A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain. PARTICIPANTS: Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans. MAIN MEASURES: Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse. KEY RESULTS: Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c = - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' = - 0.147, p = 0.007). CONCLUSIONS: Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

PTSD Symptom Clusters and Craving Differs by Primary Drug of Choice.

Objective: Research has demonstrated a cyclical relationship between posttraumatic stress disorder (PTSD) and substance use disorder. Identifying factors that link PTSD symptom clusters and substance use disorder may illuminate mechanisms underlying the PTSD-substance use disorder relationship, better informing interventions that target this comorbidity. The current study of individuals enrolled in an outpatient aftercare chemical dependency program in King County, Washington, assessed whether overall PTSD symptoms and specific PTSD symptom clusters predicted craving depending on individuals identified primary drug of choice (DOC). Methods: Participants eligible for the parent study were at least 18 years of age, fluent in English, medically cleared from substance withdrawal, and able to participate in treatment sessions and agreed to random assignment. Random assignment to either a mindfulness-based relapse prevention group, a standard relapse prevention group, or a treatment as usual group was conducted on a computer randomization program. A secondary analysis of baseline data was employed in the current study to determine which of the PTSD symptom clusters (avoidance, hyperarousal, and intrusion) predicted substance craving. Results: Covarying for severity of dependence, results suggest that overall PTSD scores predicted craving in participants who identified alcohol, stimulants, and opiates as their primary DOC. Further, avoidance-related PTSD symptoms alone predicted a significant proportion of the variability in craving in stimulant users, and hyperarousal symptoms alone predicted a significant proportion of the variability in craving in alcohol users. No specific PTSD cluster significantly predicted a proportion of the variability in craving in marijuana or opiates users. Conclusions: Findings suggest that craving may play a role in maintaining the relationship between specific PTSD symptom clusters and substance use disorder, and the nature of this relationship may differ by primary DOC. The clinical trial on which this secondary analysis of data was conducted is registered as NCT01159535 at www.clinicaltrials.gov.The original trial from which data for this study was drawn was supported by the National Institutes of Health [NIH/NIDA 5 R01 DA025764-02].

Randomized controlled trials of mind-body interventions for posttraumatic stress disorder: a systematic review.

Mind-body interventions (MBIs) include mindfulness-based interventions (MiBIs), meditation- and mantra-based interventions (MMIs), and movement-based interventions (MoBIs). These approaches have demonstrated preliminary efficacy in improving posttraumatic stress disorder (PTSD) symptoms. However, previous systematic reviews and meta-analyses have noted that this area of research is limited by inadequate comparator conditions, heterogeneity of measurement, and absence of objective outcome measures. For these reasons, an updated review of the highest-quality evidence available is warranted. We used the Agency for Healthcare Research and Quality (AHRQ)-funded evidence tables for the PTSD-Repository to identify relevant studies and assess the risk of bias as follows: The search was conducted between June 2018 and June 2022, and databases included PTSDpubs (formerly PILOTS), Ovid® MEDLINE®, Cochrane CENTRAL, Embase®, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), SCOPUS, and PsycINFO®. Twenty-six randomized controlled trials met our inclusion criteria. After identifying studies and retrieving risk of bias information from the PTSD-Repository evidence tables, we extracted additional data and synthesized the evidence. The strength of evidence was rated as low for MiBIs and MMIs, largely due to contradicting results, inconsistent use of active versus passive comparators, and high risk of bias. The strength of evidence for MoBIs was rated as moderate due to individual studies consistently favoring the intervention and a relatively large number of studies and participants. Of the 26 included studies, only two included objective outcome measures. Implications for future MBI research and clinical applications for treating PTSD are discussed.

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

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

Formal mindfulness practice predicts reductions in PTSD symptom severity following a mindfulness-based intervention for women with co-occurring PTSD and substance use disorder.

BACKGROUND: Women with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) experience systemic barriers that place them in danger of poorer treatment outcomes. Some mindfulness-based interventions (MBIs) have demonstrated efficacy in reducing PTSD and SUD symptoms. Mindfulness practice is a core component of MBIs, thought to elicit and maintain positive behavioral change; however, no research to our knowledge has assessed the role of mindfulness practice on sustained treatment gains among women with co-occurring PTSD-SUD. Such research is necessary to better inform MBIs for dually diagnosed women. METHODS: This secondary analysis assessed whether post-intervention formal and informal mindfulness practice predicted reductions in PTSD symptoms and substance craving 6 months following an 8-session mindfulness-based relapse prevention intervention for women diagnosed with co-occurring PTSD-SUD (N = 23). Data were derived from a pilot randomized controlled trial evaluating the feasibility and preliminary efficacy of a trauma-integrated mindfulness-based relapse prevention program for women with co-occurring PTSD-SUD. RESULTS: Greater duration of formal mindfulness practice (i.e., minutes per practice) predicted reduced total PTSD symptoms ([Formula: see text] = - .670, p < .00), trauma-related avoidance ([Formula: see text] = - .564, p = .01), arousal and reactivity ([Formula: see text] = - .530, p = .02), and negative cognitions and mood ([Formula: see text] = - .780, p < .01) six months following treatment. Informal practice did not predict any outcomes. CONCLUSIONS: This research highlights the potential role of formal mindfulness practice in sustaining reductions in PTSD symptoms over time among women with co-occurring PTSD-SUD. Further study of strategies to promote ongoing formal mindfulness practice in this population following a MBI are warranted. Trial registration The parent trial was registered with ClinicalTrials.gov (Identifier: NCT03505749).

The Role of Pretreatment Expectancy on Substance Use Outcomes in Women Mandated to Mindfulness-Based Relapse Prevention.

Background: More than one-third of justice-involved individuals meet the criteria for substance use disorder (SUD). Many studies show that treatment expectancy predicts longitudinal SUD outcomes; however, results are inconsistent, and the role of treatment expectancy on SUD outcomes for individuals mandated to a mindfulness-based intervention (MBI) is unknown. Mindfulness-based relapse prevention (MBRP) has shown efficacy with justice-involved populations; however, enrollment in MBRP is typically voluntary. The current study assessed whether pretreatment expectancy predicted SUD- and affect-related outcomes in a sample of women (n = 54) mandated to MBRP as part of their residential SUD programming. Method: The authors employed a quasiexperimental design and administered measures at pre-, mid-, and postcourse. Results: Following mandatory participation in MBRP, significant reductions in craving and substance use were observed. However, contrary to hypotheses, higher pretreatment expectancy predicted greater substance dependence at postcourse. Conclusions: Positive treatment expectancy within the context of an MBI was not related to favorable posttreatment outcomes; in fact, it was related to higher postcourse substance dependence. This suggests that MBIs may be suitable for mandated individuals who may not have voluntarily chosen to participate in such an intervention, and thus may have lower expectancy for the treatment. This finding needs to be replicated in a larger sample to warrant a firmer conclusion.

Mindfulness-Based Relapse Prevention for Methadone Maintenance: A Feasibility Trial.

OBJECTIVES: As rates of opiate misuse rise in the United States, so do significant associated health and financial consequences to afflicted individuals, their families, and society at large. Methadone maintenance therapy (MMT) is one evidence-based approach to treating opiate addiction, yet supplemental psychosocial treatment to support this approach is lacking. Mindfulness-based relapse prevention (MBRP) has shown to be efficacious in various substance use populations, but has yet to be assessed with MMT clients. DESIGN: The current mixed methods study was designed to inform protocol adaptation for MMT clients and to evaluate the feasibility, acceptability, and preliminary efficacy of MBRP for this population. SUBJECTS: The sample consisted of adults (N = 15) recruited from a methadone clinic to participate in a 6-week MBRP course. OUTCOME MEASURES: Data from focus groups and course satisfaction surveys supported feasibility and acceptability of the intervention. Self-report outcome measures included depression, anxiety, craving, symptoms of post-traumatic stress, and experiential avoidance, and were assessed at baseline and postcourse. RESULTS: Mean scores on all primary outcomes changed in the expected direction at postcourse, and baseline to postcourse changes in depression, craving, and trauma symptoms reached statistical significance. CONCLUSIONS: Results from this initial pilot trial support feasibility and acceptability, and provide preliminary data on outcomes for future trials of mindfulness-based approaches within the MMT community.