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.

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.

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.

Pretreatment Posttraumatic Stress Disorder Symptom Network Metrics Predict the Strength of the Association Between Node Change and Network Change During Treatment.

Network analysis has been increasingly applied in an effort to understand complex interactions among symptoms in posttraumatic stress disorder (PTSD). Although methods that initially focused on identifying central symptoms in cross-sectional networks have been extended to longitudinal data that can reveal the relative roles of acute symptoms in the emergence of the PTSD syndrome, the association between network metrics and symptom change during treatment have yet to be explored in PTSD. To address this gap, we estimated pretreatment PTSD symptom networks in a sample of patients from a multisite clinical trial for women with full or subthreshold PTSD and substance use. We tested the hypothesis that node metrics calculated in the pretreatment network would be predictive of the strength of the association between a symptom's change and the change in the severity of all other symptoms through the course of treatment. A symptom node's strength and predictability in the pretreatment network were each strongly correlated with the association between that symptom's change and overall change across the symptom network, r(15) = .79, p < .001 and r(15) = .75, p < .001, respectively, whereas a symptom's mean severity at pretreatment was not, r(15) = .27, p = .292. These findings suggest that a node's centrality prior to treatment engagement is a predictor of its association with overall symptom change throughout the treatment process.

Exploring gender differences among treatment-seekers who use opioids versus alcohol and other drugs.

Identifying clinical differences between opioid users (OU) and alcohol and other drug users (AOD) may help to tailor treatment to OU, particularly among the majority of OU who are not on opioid agonist treatments. Given the dearth of research on these differences, this study explored gender differences in demographic and clinical characteristics between OU and AOD. Participants (N = 506) were from a multisite, randomized controlled clinical trial of an Internet-delivered psychosocial intervention conducted in 2010-2011. Logistic regression models explored differences in demographic and clinical characteristics by substance use category within and between women and men. Women OU were more likely to be younger, White, employed, benzodiazepine users, and less likely to have children or use cocaine and cannabis than women AOD. Men OU, compared to men AOD, were more likely to be younger, White, younger at first abuse/dependence, benzodiazepine users, and reported greater psychological distress, but were less likely to be involved in criminal justice or use stimulants. Interactions by gender and substance use were also detected for age of first abuse/dependence, employment, and criminal justice involvement. These findings provide a nuanced understanding of gender differences within substance use groups to inform providers for OU seeking treatment.

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.

Asian Women's Action for Resilience and Empowerment Intervention: Stage I Pilot Study.

This study describes the development and pilot test of Asian Women's Action for Resilience and Empowerment (AWARE), a culturally informed group psychotherapy intervention designed to reduce depressive symptoms, suicidality, substance use, and HIV and sexual risk behaviors among 1.5 and second generation Asian American (AA) women. To participate, AA women had to meet the criteria for posttraumatic stress disorder (PTSD) or have a history of exposure to interpersonal violence (IPV) as determined using the Clinician-Administered PTSD Scale (CAPS) and Traumatic Life Events Questionnaire (TLEQ). This article also presents the preliminary feasibility and acceptability of AWARE from its Stage I pilot study of nine Chinese, Korean, and Vietnamese American women. To foster holistic treatment, AWARE was developed based on original research findings from Stage 0 and integrated theoretical models including fractured identity theory, empowerment theory, cognitive behavioral therapy (CBT), mindfulness-based techniques, and the AIDS Risk Reduction Model (ARRM). The development of AWARE was an iterative process informed by participant feedback, which led to frequent intervention modifications for a future randomized controlled trial (RCT) in Stage II. A qualitative analysis of participant feedback informed the following modifications: further exploration of feelings, improvements in technology delivery, learning and practicing coping skills, more specific cultural tailoring related to sexual health, decreased number of sessions and increased time per session. Findings provide support for the acceptability and feasibility of AWARE as "culturally informed" for AA young women with IPV histories, high-risk behaviors, and mental health issues.

Racial differences in adherence and response to combined treatment for full and subthreshold post-traumatic stress disorder and alcohol use disorders: A secondary analysis.

We conducted a secondary data analysis to examine whether there were racial differences in adherence and treatment outcomes for participants with co-occurring full and subthreshold post-traumatic stress disorder (PTSD) and alcohol/substance use disorders (A/SUD) who were treated with Seeking Safety (a cognitive-behavioral therapy) and sertraline or Seeking Safety and placebo as part of a clinical trial. Bivarate analyses examined the association between race and adherence, and generalized estimating equations assessed whether race moderated the effect of combination treatment on PTSD and alcohol use outcomes. Except for education, there were no statistically significant racial differences in baseline demographic and psychiatric characteristics. African Americans and Caucasians were equally adherent in number of psychotherapy and medication sessions attended and medication compliance. After controlling for baseline demographics and psychiatric symptoms, however, a race by treatment condition interaction emerged suggesting that African Americans who received the Seeking Safety and sertraline treatment had significantly lower PTSD symptom severity posttreatment and at six months follow-up compared to their counterparts who received Seeking Safety and placebo. No differential effect of treatment condition was found for Caucasians. Moreover, results indicated that a diagnosis of major depressive disorder negatively impacted PTSD symptom recovery for African American participants but not for Caucasians. In conclusion, no differences emerged between African Americans and Caucasians in adherence to combination treatments for PTSD and A/SUD. Findings also suggest assessment and treatment of MDD among African Americans may improve treatment outcomes. More research is needed to determine whether the differential response to Seeking Safety and sertraline among African Americans compared to Caucasians can be replicated.

Exploring the relationship between eating disorder symptoms and substance use severity in women with comorbid PTSD and substance use disorders.

BACKGROUND: Eating disorders (ED) and substance use disorders (SUD) commonly co-occur, especially in conjunction with posttraumatic stress disorder (PTSD), yet little is known about ED and ED symptoms in women presenting to addiction treatment programs. OBJECTIVE: We examined the association between ED symptoms and substance use frequency and severity in a sample of women with a DSM IV diagnosis of current SUD and PTSD enrolled in SUD treatment. METHOD: Participants were 122 women from four substance abuse treatment sites who participated in a multi-site clinical trial through the National Institute of Drug Abuse Clinical Trials Network (NIDA CTN). The Eating Disorder Examination-Questionnaire (EDE-Q), the Clinician's Administered PTSD Scale (CAPS) and the Addiction Severity Index (ASI) were administered at baseline and correlational analyses were performed. Variables that significantly correlated with EDE-Q total and subscale scores were entered into a linear regression analysis. RESULTS: Scores on the EDE-Q Global scale, as well as the Eating Concern, Weight Concern and Shape Concern subscales of the EDE-Q were significantly associated with Caucasian race/ethnicity, past 30 day opiate use, higher ASI Psychiatric Subscale score and lower ASI Employment Subscale score. CONCLUSION: Although exploratory, these findings suggest that there may be a relationship between addiction severity, use of certain drugs of abuse and eating disorder symptoms, particularly those involving weight and shape concerns in women with comorbid PTSD and SUD.

At the crossroads: the intersection of substance use disorders, anxiety disorders, and posttraumatic stress disorder.

The co-occurrence of substance use disorders with anxiety disorders and/or posttraumatic stress disorder has been widely documented and when compared to each disorder alone, consistently linked to increased risk for a host of negative outcomes including greater impairment, poorer treatment response, and higher rates of symptom relapse. This article focuses on recent advances in the understanding and effective treatment of this common and highly complex comorbidity. Prevalence and epidemiological data are introduced, followed by a review of contemporary models of etiology and associative pathways. Conceptualizations of effective treatment approaches are discussed alongside evidence from the past decade of clinical research trials. Highlighted are ongoing questions regarding the benefit of sequential, parallel, and integrated approaches and the necessity of further investigation into the mechanisms underlying treatment efficacy. Lastly, recent contributions from neuroscience research are offered as a promising bridge for the development and testing of novel, interdisciplinary treatment approaches.

Associations between post-traumatic stress symptoms, stimulant use, and treatment outcomes: a secondary analysis of NIDA's Women and Trauma study.

BACKGROUND AND OBJECTIVES: To examine the associations between post-traumatic stress disorder (PTSD) symptoms, stimulant use, and treatment outcomes among dually diagnosed women. METHODS: Participants were 141 women who participated in a multisite clinical trial of group treatments for PTSD and addictions. RESULTS: Generalized linear models indicated Seeking Safety (SS; a cognitive-behavioral intervention) was significantly more effective than Women's Health Education (WHE; a control group intervention) in reducing stimulant use at follow-up among women who were heavy stimulant users at pre-treatment and who showed improvements in PTSD symptoms. There were no significant differences between the interventions among women who were light stimulant users at treatment entry. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: These findings suggest that integrated treatment of co-occurring PTSD and addictions may be more effective than general health education approaches for heavy stimulant users. Assessment of frequency of stimulant use among individuals with PTSD symptoms may inform treatment selection for this population.

Indirect effects of 12-session seeking safety on substance use outcomes: overall and attendance class-specific effects.

OBJECTIVES: This study examined in- and post-treatment mediation effects of a 12-session dose of Seeking Safety (SS)-an integrative cognitive behavioral treatment for comorbid PTSD and SUDs-on alcohol and cocaine outcomes in comparison to Women's Health Education (WHE) in a seven-site randomized controlled effectiveness trial. METHODS: Women (n = 353) enrolled in outpatient substance abuse treatment, who had experienced multiple traumas in childhood and/or adulthood and who had comorbid PTSD, were randomly assigned to receive SS or WHE delivered in open enrollment groups for 12 sessions in 6 weeks (unlike the full 25-topic SS protocol). Data were analyzed under two forms of longitudinal mediation analysis, each accounting for changes over time in group membership and group context, respectively. RESULTS: Women in SS, compared to WHE, showed significantly steeper decreases in PTSD frequency and severity, which in turn, showed significant impact in reducing both cocaine and alcohol use. This pattern was strongest for those who completed most of the treatment sessions, which was the majority of patients in the trial; these patterns only emerged during the in-treatment phase. CONCLUSIONS: Use of an integrated approach to PTSD/SUD such as SS can be helpful to more rapidly reduce PTSD, which consequently reduce SUD symptoms, particularly for those who attend most of the available treatment sessions. SCIENTIFIC SIGNIFICANCE: This is one of the first studies to illustrate such effects in treating comorbid PTSD and SUD in the context of a highly impaired population delivered by community-based providers. (Am J Addict 2014;23:218-225).

Changes in sleep disruption in the treatment of co-occurring posttraumatic stress disorder and substance use disorders.

Sleep disruption appears not only to reflect a symptom of posttraumatic stress disorder (PTSD), but also a unique vulnerability for its development and maintenance. Studies examining the impact of psychosocial treatments for PTSD on sleep symptoms are few and no studies to date of which we are aware have examined this question in samples with co-occurring substance use disorders. The current study is a secondary analysis of a large clinical trial comparing 2 psychological treatments for co-occurring PTSD and substance use disorders. Women (N = 353) completed measures of PTSD at baseline, end of treatment, and 3-, 6-, and 12-month follow-ups. Results indicated that the prevalence of insomnia, but not nightmares, decreased during treatment, and that 63.8% of participants reported at least 1 clinical-level sleep symptom at the end of treatment. Improvement in sleep symptoms during treatment was associated with better overall PTSD outcomes over time, χ(2) (1) = 33.81, p < .001. These results extend the existing literature to suggest that residual sleep disruption following PTSD treatment is common in women with co-occurring PTSD and substance use disorders. Research on the benefits of adding sleep-specific intervention for those with residual sleep disruption in this population may be a promising future direction.

Racial/ethnic match and treatment outcomes for women with PTSD and substance use disorders receiving community-based treatment.

This study examined the relationship between racial/ethnic match and treatment outcomes for 224 women who participated in a clinical trial of group treatments for posttraumatic stress disorder (PTSD) and substance use disorders. Generalized estimating equations were used to examine the effect of client-therapist racial/ethnic match on outcomes. Results revealed racial/ethnic match was not significantly associated with session attendance. There was a significant three-way interaction between client race/ethnicity, baseline level of PTSD symptoms, and racial/ethnic match on PTSD outcomes. White clients, with severe PTSD symptoms at baseline, who attended treatment groups where they were matched with their therapist, had greater reductions in PTSD symptoms at follow-up than their counterparts who were racially/ethnically mismatched with their group therapist. Racial/ethnic match did not confer additional benefits for Black clients in terms of PTSD outcomes. Racial/ethnic match interacted with baseline substance use to differentially influence substance use outcomes at follow-up for all women. Clinical implications are discussed.

Functional Domains of Substance Use and their Implications to Trauma: A Systematic Review of Neuroimaging Studies.

Substance use disorder (SUD) is a significant health problem, and trauma exposure is a known risk factor for the escalation of substance use. However, the shared neural mechanisms through which trauma is associated with substance use are still unknown. Therefore, we systematically review neuroimaging studies focusing on three domains that may contribute to the overlapping mechanisms of SUD and trauma-reward salience, negative emotionality, and inhibition. Using PRISMA guidelines, we identified 45 studies utilizing tasks measuring these domains in alcohol, tobacco, and cannabis use groups. Greater reward, lesser regulation of inhibitory processes, and mixed findings of negative emotionality processes in individuals who use substances versus controls were found. Specifically, greater orbitofrontal cortex, ventral tegmental area, striatum, amygdala, and hippocampal activation was found in response to reward-related tasks, and reduced activation was found in the inferior frontal gyrus and hippocampus in response to inhibition-related tasks. Importantly, no studies in trauma-exposed individuals met our review criteria. Future studies examining the role of trauma-related factors are needed, and more studies should explore inhibition- and negative-emotionality domains in individuals who use substances to uncover clinically significant alterations in these domains that place an individual at greater risk for developing a SUD.

The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study.

INTRODUCTION: Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions. METHODS: This mixed-methods study interviewed and surveyed 10 women with current or past OUD and co-occurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD. RESULTS: Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., trauma-focused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately. CONCLUSIONS: Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders.

We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = -0.30), AOD-focused psychotherapy (SMD = -0.29), and other control psychotherapies (SMD = -0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = -0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = -0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = -0.53), placebo medication (SMD = -0.50), and trauma-focused psychotherapy + placebo medication (SMD = -0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data.

High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.

Alcohol, cannabis, and nicotine use have distinct associations with COVID-19 pandemic-related experiences: An exploratory Bayesian network analysis across two timepoints.

BACKGROUND: Substance use trends during the COVID-19 pandemic have been extensively documented. However, relatively less is known about the associations between pandemic-related experiences and substance use. METHOD: In July 2020 and January 2021, a broad U.S. community sample (N = 1123) completed online assessments of past month alcohol, cannabis, and nicotine use and the 92-item Epidemic-Pandemic Impacts Inventory, a multidimensional measure of pandemic-related experiences. We examined links between substance use frequency, and pandemic impact on emotional, physical, economic, and other key domains, using Bayesian Gaussian graphical networks in which edges represent significant associations between variables (referred to as nodes). Bayesian network comparison approaches were used to assess the evidence of stability (or change) in associations between the two timepoints. RESULTS: After controlling for all other nodes in the network, multiple significant edges connecting substance use nodes and pandemic-experience nodes were observed across both time points, including positive- (r range 0.07-0.23) and negative-associations (r range -0.25 to -0.11). Alcohol was positively associated with social and emotional pandemic impacts and negatively associated with economic impacts. Nicotine was positively associated with economic impact and negatively associated with social impact. Cannabis was positively associated with emotional impact. Network comparison suggested these associations were stable across the two timepoints. CONCLUSION: Alcohol, nicotine, and cannabis use had unique associations to a few specific domains among a broad range of pandemic-related experiences. Given the cross-sectional nature of these analyses with observational data, further investigation is needed to identify potential causal links.

Project Harmony: A Meta-Analysis With Individual Patient Data on Behavioral and Pharmacologic Trials for Comorbid Posttraumatic Stress and Alcohol or Other Drug Use Disorders.

OBJECTIVE: Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders. METHODS: A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up. RESULTS: Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments. CONCLUSIONS: The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.