State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders.

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) co-occur at high rates, with research showing that up to nearly 60% of individuals with PTSD also suffer from an alcohol and/or drug use disorder. PTSD/SUD is complex; associated with adverse health, social, and economic outcomes; and can be challenging to treat. Over the past decade, the landscape of treatment research addressing PTSD/SUD has significantly expanded. Ongoing efforts aimed at developing and evaluating novel treatments for PTSD/SUD, encompassing both psychotherapy and pharmacotherapy approaches, are steadily advancing. As such, this State of the Science paper reviews the literature on the latest scientific advances in treating PTSD/SUD. Clinical practice guidelines for the treatment of PTSD/SUD are discussed, along with evidence-based psychotherapies and emerging interventions. Rigorously conducted clinical trials demonstrate that individual, manualized, trauma-focused treatments are the most efficacious psychotherapies to use among individuals with PTSD/SUD. Moreover, patients do not need to be abstinent to initiate or benefit from evidence-based PTSD treatment. To date, no medications have been established for this comorbidity. We highlight ongoing research on novel treatments for PTSD/SUD, such as new forms of integrated trauma-focused psychotherapies, pharmacological augmentation strategies, and technology-based enhancements. Finally, promising future directions for the field are discussed.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD. METHODS: Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021. RESULTS: The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently. CONCLUSIONS: The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

Clinician perspectives on technology-enhanced in vivo exposures during prolonged exposure therapy for PTSD.

OBJECTIVE: To investigate clinicians' perceptions regarding the use of mobile technology tools during prolonged exposure (PE) therapy to allow for monitoring and enhancing in-vivo exposures (IVEs). METHODS: Clinicians with training in PE therapy (N = 32; average of 9 years of practice) completed surveys asking about their perspectives on the utility of virtually attending IVEs with patients while simultaneously having access to real-time subjective and physiological data (i.e., heart rate, galvanic skin conductance) to guide exposure exercises and assure optimal stimulus engagement. RESULTS: Findings showed clinicians to have a favorable view of applying technology devices and systems to enhance IVEs of PE therapy. Most clinicians (93.8%) believed that real-time monitoring of IVEs-particularly monitoring patients' subjective distress and completion of and duration of time in the IVE-would be useful and significantly enhance PE therapy. CONCLUSION: The positive perceptions toward integrating technology into IVEs in this study have important implications for the development and implementation of technology-enhanced PE therapy. A mobile technology system that incorporates real-time indicators of engagement (i.e., both subjective and physiological) during IVEs and allows clinicians to review recordings of, or virtually accompany, patients during IVEs has the potential to innovate and transform PE and other exposure-based treatments. Clinicians also believed that technology-enhanced IVEs may help reduce early termination from PE.

Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment.

OBJECTIVE: Concurrent Treatment of Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (i.e., COPE) is an efficacious, integrated, psychotherapy that attends to PTSD and substance use disorders simultaneously. No study has examined how therapeutic alliance functions during the provision of COPE and how this compares to non-integrated treatments, such as relapse prevention (RP) for substance use disorders. Understanding the role of alliance in COPE versus RP could inform treatment refinement and ways to enhance treatment outcomes. METHODS: Participants (N = 55 veterans) were randomized to 12, individual, weekly sessions of COPE or RP in a randomized clinical trial. Piecewise linear mixed effect models examined how mid-treatment (1) patient-rated alliance, (2) therapist-rated alliance, and (3) the convergence between patient- and therapist-rated alliance as measured by a difference score predicted reductions in PTSD symptoms and substance use across treatment and follow-up periods. RESULTS: Both patient- and therapist-rated alliance predicted reductions in PTSD symptoms in COPE. Higher patient-rated alliance predicted lower percent days using substances in RP. Difference score models showed higher patient-rated alliance relative to therapist-rated alliance scores predicted symptom reductions in COPE whereas higher therapist-rated alliance scores relative to patient-rated alliance scores predicted symptom reductions in RP. DISCUSSION: Preliminary findings show a unique relationship between the rater of the alliance and treatment modalities. Patient-rated alliance may be important in trauma-focused, integrated treatments whereas therapist-rated alliance may be more important in skills-focused, substance use interventions.

Motives for prescription opioid use: The role of alexithymia and distress tolerance.

BACKGROUND AND OBJECTIVES: Prescription opioid (PO) use disorder is a national public health crisis. Distress tolerance and alexithymia are two separate but related components of emotion regulation that are known to impact substance use disorders. No studies to date, however, have examined the role of distress tolerance and alexithymia in PO use disorder. Thus, the current study examined the association between distress tolerance, alexithymia, and specific motivations for PO use. METHODS: Participants were non-treatment-seeking individuals with current PO use disorder (N = 81; average age = 35.0). Assessments included the Distress Tolerance Scale, Toronto Alexithymia Scale, and the Inventory of Drug Taking Situations. RESULTS: The findings indicate that distress tolerance mediated the association between alexithymia and PO use in negative situations. Specifically, distress tolerance mediated the association between alexithymia and unpleasant emotions, testing personal control, and conflict with others. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The results provide novel information regarding emotional states that may contribute to PO use and are malleable intervention targets. Additionally, this study adds to existing literature exploring the relationship between distress tolerance and substance use and is the first to expand upon the connection between alexithymia and distress tolerance in an opioid-using population. Implications for clinical practice and future research are discussed.

Imaginal exposure processing during Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) therapy: Examination of linguistic markers of cohesiveness.

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is an integrated, evidence-based treatment that results in significant reductions in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) severity. Emotional processing theory suggests that successful prolonged exposure-based treatments should result in more cohesive trauma narratives due to better integration and organization of trauma memory into cognitive conceptualizations of fear. Therefore, we hypothesized that language used by patients would become more cohesive over time and increased language cohesion would be related to larger reductions in PTSD and SUD outcomes. Broadly, language cohesion refers to several linguistic devices that help establish and cohere meaning throughout spoken and written discourse (e.g., increased use of transition words like "and," "then," and "but"). This was the first known study to examine changes in language related to both PTSD and SUD severity during COPE treatment. The sample included 28 military veterans with current comorbid PTSD/SUD enrolled in a larger COPE study. A text analysis program, Coh-Metrix, was used to analyze language cohesiveness. No language cohesion variables significantly changed over time. Narrativity levels significantly moderated change in PTSD outcomes, R ß 2 $R_\beta ^2\;$ = 0.11. Adversative connectives significantly moderated change in SUD outcomes, R ß 2 $R_\beta ^2\;$ = 0.26. The findings illuminate potential processes underlying successful COPE treatment. Less use of language conveying a narrative and more use of contrast-indicative words (e.g., but, whereas) was associated with larger reductions in PTSD and SUD outcomes during treatment. These results contribute to the extant literature on associations between trauma exposure, language, and emotional processing.

Temporal dynamics of symptom change among veterans receiving an integrated treatment for posttraumatic stress disorder and substance use disorders.

The present study examined temporal patterns of symptom change during treatment for comorbid posttraumatic stress disorders (PTSD) and substance use disorders (SUDs). We hypothesized that PTSD symptom severity would predict subsequent-session substance use and that this association would be particularly strong among patients who received an integrated treatment versus SUD-only treatment. Participants were 81 United States military veterans with current PTSD and an SUD who were enrolled in a 12-week, randomized controlled trial examining the efficacy of an integrated treatment called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) compared with cognitive behavioral relapse prevention therapy (RP). Lagged multilevel models indicated that PTSD symptom improvement did not significantly predict the likelihood of next-session substance use (likelihood of use: B = 0.03, SE = 0.02, p = .141; percentage of days using B = -0.02, SE = 0.01, p = .172. Neither substance use, B = 1.53, SE = 1.79, p = .391, nor frequency of use, B = 0.26, SE = 0.50, p = .612, predicted next-session PTSD symptom severity in either treatment condition. Stronger associations between PTSD symptoms and next-session substance use were expected given the self-medication hypothesis. Additional research is needed to better understand the temporal dynamics of symptom change as well as the specific mediators and mechanisms underlying symptom change.

The Impact of COVID-19 on Psychotherapy Participation Among Individuals With Posttraumatic Stress Disorder Enrolled in Treatment Research.

The onset of the COVID-19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in-person to telemental health. In the present study, we explored the impact of the pandemic on individuals' ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the association between the impact of COVID-19 impact on health and financial well-being and psychotherapy participation. Participants (N = 161, 63.2% male, Mage = 42.7 years) were United States military veterans (n = 108), active duty military personnel (n = 12), and civilians (n = 6), who were participating in one of nine PTSD treatment trials. The results indicate a predominately negative COVID-19 impact on therapy participation, although some participants (26.1%) found attending therapy sessions through telehealth to be easier than in-person therapy. Most participants (66.7%) reported that completing in vivo exposure homework became harder during the pandemic. Moreover, the impact of the pandemic on PTSD symptom severity and daily stress were each associated with increased difficulty with aspects of therapy participation. The findings highlight the unique challenges to engaging in PTSD treatment during the pandemic as well as a negative impact on daily stress and PTSD severity, both of which were related to treatment engagement difficulties.

Estimating posttraumatic stress disorder severity in the presence of differential item functioning across populations, comorbidities, and interview measures: Introduction to Project Harmony.

Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder (PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision-making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual-level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM-5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients.

The Drug Abuse Research Training (DART) Program for Psychiatry Residents and Summer Fellows: 15-Year Outcomes.

OBJECTIVE: To increase the number of physician-scientists in research, the Drug Abuse Research Training (DART) program at the Medical University of South Carolina offers a 2-year research track for psychiatry residents and a 10-week summer fellowship for students. The goal of this study was to examine program outcomes and alumni diversity levels over DART's 15-year history. METHODS: To date, 215 trainees (44 residents, 171 summer fellows) have completed the program. An anonymous online survey was sent to the 143 program alumni with valid contact information. Survey data included demographic characteristics, post-program research involvement, and self-reported barriers to continued research engagement. RESULTS: Overall survey completion response was 83.5% (N = 122). The alumni included 59.0% women, and 36.1% of respondents identified as a member of a minority racial/ethnic group. Following program completion, 77.0% of the alumni reported continued research involvement. More than half of the alumni reported scientific publications (57.4%) and conference presentations (63.1%) since completing DART. Among respondents who did not subsequently engage in research, the most common modifiable barriers included difficulty finding a mentor, self-perceived deficits in statistical skills and research methodology, and overall lack of confidence in research ability. CONCLUSIONS: Over the past 15 years, the DART program has established a diverse research training program that now spans the educational spectrum from undergraduate to residency training. Future program goals include additional training to address self-reported modifiable research barriers. This program provides a model for other training programs designed to cultivate research interests and promote the diversity of clinical researchers.

Ethnoracial differences in treatment-seeking veterans with substance use disorders and co-occurring PTSD: Presenting characteristics and response to integrated exposure-based treatment.

OBJECTIVE: Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) frequently co-occur. While previous research has examined ethnoracial differences among individuals with either SUD or PTSD, little research to date has focused on individuals with co-occurring SUD/PTSD. The current study addresses this gap in the literature. METHOD: Participants were 79 military veterans (91% male; 38% African American [AA] and 62% White) with current SUD/PTSD who were randomized to receive Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) or Relapse Prevention (RP). Primary outcomes included substance use and self-reported and clinician-rated PTSD symptoms. RESULTS: At baseline, AA participants were significantly older, reported greater substance and alcohol use, and tended to report higher PTSD severity than White participants. AA participants evidenced greater decreases in substance and alcohol use during treatment, but greater increases in substance and alcohol use during follow-up as compared to White participants. All participants decreased alcohol consumption during treatment; however, AA participants in the COPE condition and White participants in the RP condition evidenced the steepest decreases in average number of drinks per drinking day (DDD) during treatment. Additionally, White participants receiving RP reported greater increases in DDD during follow-up compared to AA participants. CONCLUSION: Overall, integrated treatment for co-occurring SUD/PTSD was effective for both AA and White participants; however, some important differences emerged by ethnoracial group. Findings suggest that greater attention to race and ethnicity is warranted to better understand the needs of diverse patients with SUD/PTSD and to optimize treatment outcomes.

Craving Moderates the Effects of Intranasal Oxytocin on Anger in Response to Social Stress Among Veterans With Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorder.

PURPOSE/BACKGROUND: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur among US military veterans. Oxytocin may have therapeutic value in treating both conditions. The potential for oxytocin to augment affective features common to PTSD and AUD, such as anger, is relevant to inform emerging treatments. METHODS/PROCEDURES: We examined the influence of intranasally administered oxytocin on connections between alcohol craving and stress-induced anger in a sample of 73 veterans (91.3% men) with co-occurring PTSD and AUD. Participants self-administered oxytocin (40 IU) or placebo (saline) 45 minutes before completing the Trier Social Stress Task (TSST). Self-reports of alcohol craving and anger were assessed pre- and post-TSST using a modified visual analog scale. Multiple regression analysis, including main effects for group, baseline craving, and their interaction, was used to predict post-TSST anger. FINDINGS/RESULTS: A marginally significant interaction was observed, suggesting a positive association between baseline craving and anger for those in the oxytocin group (B = 0.65, P = 0.01). Among those reporting low craving, participants in the oxytocin group reported significantly lower post-TSST anger than those in the placebo group. IMPLICATIONS/CONCLUSIONS: The current study is among the first to examine relevant psychosocial moderators that may influence the effects of oxytocin among veterans with comorbid PTSD and AUD. Although oxytocin attenuated ratings of anger after a stress task among those with low baseline craving, findings suggest that oxytocin may not be as effective at reducing anger, a highly salient factor in PTSD, for individuals experiencing high levels of craving. Findings are consistent with the social salience hypothesis and suggest that individual differences in alcohol craving should be considered when evaluating oxytocin as a potential treatment for individuals with comorbid PTSD and AUD.

Treatment Goals and Alcohol Use Outcomes in Veterans With Comorbid Alcohol Dependence and Posttraumatic Stress Disorder.

BACKGROUND AND OBJECTIVES: Previous research demonstrates the utility of goals in attaining improved drinking outcomes. Considerably less is known about the association between substance use goals and outcomes among persons with comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD). This secondary analysis examined the association between alcohol use outcomes and participants' treatment entry substance use goals to either abstain or reduce substance use in the context of treatment for comorbid SUD/PTSD. METHODS: Participants (N = 39) were treatment-seeking veterans with current alcohol dependence and PTSD. Participants completed self-report and clinician-rated measures of substance use and PTSD as part of a larger randomized controlled trial. RESULTS: Participants in both goal groups (abstain; reduce) achieved significant reductions in the likelihood of drinking and the likelihood of exceeding low-risk drinking levels. The primary analysis did not identify significant differences in outcome between goal groups; however, the exploratory analysis revealed that participants with reduced use goals were more likely to drink and more likely to exceed low-risk drinking levels. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The findings suggest a moderately strong association between substance use goal and drinking outcome in the current study. Although the findings did not unequivocally support abstinence as a superior treatment goal, they offer a preliminary indication that abstinence may be an overall lower-risk option. These findings expand consideration of the utility of substance use goals and suggest that clinicians should invite consideration of abstinence but may need not limit integrated treatment for SUD/PTSD based on strict adherence to abstinence, particularly if low-risk use goals are targeted. (Am J Addict 2021;30:131-137).

Putting the Patient Back in Clinical Significance: Moderated Nonlinear Factor Analysis for Estimating Clinically Significant Change in Treatment for Posttraumatic Stress Disorder.

The present study introduced a modernized approach to Jacobson and Truax's (1991) methods of estimating treatment effects on individual-level (a) movement from the clinical to the normative range and (b) reliable change on posttraumatic stress disorder (PTSD) severity. Participants were 450 trauma-exposed women (M age = 39.2 years, SD = 8.9, range: 18-65 years) who presented to seven geographically diverse community mental health and substance use treatment centers. Data from 53 of these women, none of whom met the criteria for full or subthreshold PTSD, were used to establish the normative range. Using moderated nonlinear factor analysis (MNLFA) scale scoring, which weights symptoms by their clinical relevance, a significantly larger proportion of participants moved into the normative range for PTSD severity scores and/or exhibited reliable changes after treatment compared to the same individuals' movement when using symptom counts. Further, approximately 24% of the participants showed discrepant judgments on reliable change indices (RCI) between MNLFA scores and symptom counts, likely due to the false assumption that the standard error of measurement is equal for all levels of underlying PTSD severity when estimating RCIs with symptom counts. An MNLFA approach to estimating underlying PTSD severity can provide clinically meaningful information about individual-level change without the de facto assumption that PTSD symptoms have equivalent weight. Study implications are discussed with regard to a joint emphasis on (a) measurement models that highlight differential symptom weighting and (b) treatment-arm differences in individual-level outcomes rather than the current overemphasis of treatment-arm differences on group-averaged trajectories.

A multi-centre, double-blind, 12-week, randomized, placebo-controlled trial to assess the efficacy of adjunctive N-Acetylcysteine for treatment-resistant PTSD: a study protocol.

BACKGROUND: Most patients with Posttraumatic Stress Disorder (PTSD) suffer residual symptoms following first-line treatment. Oxidative stress has been implicated in the pathophysiology of PTSD. N-acetylcysteine (NAC) is a precursor of the brain's primary antioxidant, glutathione, and may diminish oxidative cellular damage. An 8-week pilot study of NAC in veterans with PTSD found that symptoms were significantly reduced in the NAC group compared to placebo. This study aims to confirm these findings with a larger sample in a double-blind, placebo-controlled trial to further explore the efficacy of NAC as an adjunctive therapy in treatment-resistant PTSD. METHODS: A multicentre, randomised, double-blind, placebo-controlled trial for adult patients who still meet criteria for PTSD following first-line treatment. The intervention comprises either NAC as a fixed dose regime of 2.7 g/day (900 mg three times daily) administered orally for 12 weeks, or placebo. Standard care for PTSD will continue in addition, including other pharmacotherapies. Detailed clinical data will be collected at randomisation and weeks 4, 8, 12, 16, and 64 post-randomisation, with self-report measures completed weekly from baseline to 16 weeks and at 64 weeks post-randomisation. Blood-based biomarkers will be collected at baseline and 12 weeks to assess the mechanism of effect. The primary outcome measure will be change in Clinician-Administered PTSD Scale for DSM-5 at 12 weeks compared with baseline. Secondary outcomes will be change in quality of life, depression, anxiety, substance use and craving, and somatic symptoms. With 126 completed participants (63 per arm), the study is powered at 80% to detect a true difference in the primary outcome measure using a two-tailed analysis with alpha = 0.05, beta = 0.2. DISCUSSION: This is the first multicentre, double blind, randomised, placebo-controlled trial of adjunctive NAC for treatment-resistant PTSD. NAC has an established safety profile, is readily available and easy to administer, and has a favourable tolerability profile, therefore making it an attractive adjunctive therapy. Inclusion of blood analyses to assess potential target engagement biomarkers of oxidative stress and neuroinflammation may help gauge the biological mechanisms of effect of NAC. TRIAL REGISTRATION: ACTRN12618001784202, retrospectively registered 31/10/2018, URL: http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376004 .

Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders?

BACKGROUND: Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD). AIM: This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD. METHOD: Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment. RESULTS: At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment. CONCLUSIONS: This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.

Heterogeneity of treatment dropout: PTSD, depression, and alcohol use disorder reductions in PTSD and AUD/SUD treatment noncompleters.

Treatment dropout is often assumed to be due to worsening or lack of symptom improvement, despite minimal research examining symptom change among treatment dropouts. Thus, the present study examined symptom change in veterans who discontinued evidence-based treatment for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Participants were veterans who completed at least one session of a 12-session Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) for comorbid PTSD/AUD. The study analyses investigated the 43% of the sample (n = 22) that did not complete the full 12-session protocol and were therefore considered treatment dropouts. Symptom changes in PTSD, AUD, and depression were examined among dropouts using two methods: (a) clinically significant change criteria and (b) good end-state criteria. Results indicated that a significant proportion of treatment dropouts displayed clinically significant improvement and/or met good end-state criteria for PTSD (40-59%), AUD (66%), and depression (45-68%) prior to dropping out. The results revealed that participants who displayed symptom improvement attended more treatment sessions and completed more imaginal exposures than participants who did not experience significant improvement. Together, the findings add to a growing body of literature suggesting that a large proportion of treatment dropouts may actually improve. Although preliminary, the findings challenge the notion that treatment dropout is always associated with negative outcomes.

Concurrent Treatment with Prolonged Exposure for Co-Occurring Full or Subthreshold Posttraumatic Stress Disorder and Substance Use Disorders: A Randomized Clinical Trial.

BACKGROUND: To test whether an integrated prolonged exposure (PE) approach could address posttraumatic stress disorder (PTSD) symptoms effectively in individuals with co-occurring substance use disorders (SUD), we compared concurrent treatment of PTSD and SUD using PE (COPE) to relapse prevention therapy (RPT) for SUD and an active monitoring control group (AMCG). METHODS: We conducted a randomized 12-week trial with participants (n = 110; 64% males; 59% African Americans) who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for full or subthreshold PTSD and SUD. Participants were randomly assigned to COPE (n = 39), RPT (n = 43), or AMCG (n = 28). RESULTS: At the end-of-treatment, COPE and RPT demonstrated greater reduction in PTSD symptom severity relative to AMCG (COPE-AMCG = -34.06, p < 0.001; RPT-AMCG = -22.58, p = 0.002). Although the difference between COPE and RPT was not significant in the complete sample, the subset of participants with full (vs. subthreshold) PTSD demonstrated significantly greater reduction of PTSD severity in COPE relative to RPT. Both treatments were superior to AMCG in reducing the days of primary substance use (COPE-AMCG = -0.97, p = 0.01; RPT-AMCG = -2.07, p < 0.001). Relative to COPE, RPT showed significantly more improvement in SUD outcome at end-of-treatment (RPT-COPE = -1.10, p = 0.047). At 3-month follow-up, COPE and RPT maintained their treatment gains and were not significantly different in PTSD severity or days of primary substance use. CONCLUSION: COPE and RPT reduced PTSD and SUD severity in participants with PTSD + SUD. Findings suggest that among those with full PTSD, COPE improves PTSD symptoms more than a SUD-only treatment. The use of PE for PTSD was associated with significant decreases in PTSD symptoms without worsening of substance use.

The influence of traumatic brain injury on treatment outcomes of Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in veterans.

BACKGROUND: The co-occurrence of posttraumatic stress disorder (PTSD), substance use disorders (SUD), and traumatic brain injury (TBI) in veterans of Operations Enduring/Iraqi Freedom and New Dawn has received much attention in the literature. Although hypotheses have been presented and disseminated that TBI history will negatively influence treatment response, little data exist to support these claims. The present study investigates the influence of TBI history on response to COPE (Concurrent Treatment of PTSD and SUD Using Prolonged Exposure), a 12-session, integrated psychotherapy designed to address co-occurring PTSD and SUD. METHOD: Participants were 51 veterans with current PTSD and SUD enrolled in a clinical trial examining COPE. Assessments of PTSD symptoms, substance use, and depression were collected at baseline and each treatment session. A TBI measure was used to dichotomize veterans into groups with and without a history of TBI (ns=30 and 21, respectively). RESULTS: Participants with and without TBI history demonstrated significant improvements in PTSD and depression symptoms during the course of treatment. However, participants with TBI history experienced less improvement relative to participants without TBI history. CONCLUSIONS: The present findings suggest that, although patients with a TBI history respond to treatment, their response to treatment was less so than that observed in patients without a TBI history. As such, identification, symptom monitoring, and treatment practices may require alteration and further special consideration in individuals with PTSD, SUD and TBI.

Concurrent treatment of PTSD and alcohol use disorder via telehealth in a female Iraq veteran.

BACKGROUND AND OBJECTIVES: A growing literature provides evidence for the use of integrated treatments (e.g., Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure; COPE); however, no known studies have applied COPE via telehealth. METHOD: COPE was delivered via telehealth to treat one black female veteran with combat trauma and alcohol use disorder. RESULTS: The patient demonstrated significant reductions in alcohol consumption and PTSD and depressive symptoms. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Although preliminary, findings demonstrate that integrated treatment via telehealth is feasible and effective, and may be useful for female veterans reluctant to seek services at male-dominated VAMCs. (Am J Addict 2017;26:112-114).