A revolution is brewing in the treatment of patients with co-occurring posttraumatic stress disorder and substance use, inspired by a growing body of evidence that the disorders can be successfully addressed simultaneously.
An estimated half of returning veterans and a third of civilians with PTSD have co-occurring substance abuse, while up to 42% of people in treatment for addictions have a current diagnosis of PTSD. Yet, few programs traditionally addressed both issues simultaneously.
Patients presenting with PTSD were excluded from research studies and many treatment programs if they had an ongoing substance use problem.
Barriers blocked the route to dual treatment at substance abuse clinics as well, where clinicians were reticent to address, much less treat, PTSD.
“There's been a kind of historical trepidation to deal with PTSD when people are trying to get stabilized in a substance abuse program,” said Mark P. McGovern, Ph.D., a psychologist who serves on the psychiatry faculty at Dartmouth Medical School, Hanover, N.H.
“The thought has been, you don't want to open Pandora's box and undermine the original goal of substance use stabilization,” explained Dr. McGovern in a telephone interview. “But for many patients, Pandora's box was already open and the demons were out. They were suffering nightmares, flashbacks, [and] extreme anxiety, and until you dealt with those symptoms they were never going to stop using substances.”
Dr. Thomas Kosten, professor of psychiatry at Baylor University, Houston, and research director of the VA Substance Use Disorders Quality Enhancement Research Initiative, described a similar epiphany that occurred in the PTSD treatment community, which traditionally had insisted that patients be clean and sober before beginning therapy.
“The new veterans with PTSD cannot be effectively treated with behavioral therapies like prolonged exposure unless their binge alcohol abuse is controlled,” he said. “Otherwise any gains in therapy during the week will be lost in a weekend of binge drinking, and binge drinking occurs in half of these vets. This problem is too common to ignore.”
Lisa Najavits, Ph.D., a psychologist and professor of psychiatry at Harvard Medical School, Boston, said the “big myth” that substance abuse and PTSD had to be treated sequentially persisted throughout much of the 20th century, even as a preponderance of evidence showed that severity of symptoms was higher and PTSD and addiction treatment outcomes were poorer in dually diagnosed patients than in those with just one diagnosis.
“It has really been a mini-revolution to turn that around,” said Dr. Najavits, who developed an internationally adopted dual treatment module, Seeking Safety (www.seekingsafety.org
The payoff of integrated treatment, experts agree, has offered tantalizing suggestions and some solid evidence of enhanced outcomes for symptoms of both PTSD and substance use disorders.
Once the concept was put to the test, “we realized that a great deal of 'treatment resistance' was because individuals had two, three, or four disorders, yet we were only treating one disorder,” said Dr. Kathleen T. Brady, professor of psychiatry and director of the clinical neuroscience division at the Medical University of South Carolina, Charleston.
Dr. Najavits' 25-stage integrative model, which draws on four content areas: cognitive, behavioral, and interpersonal therapy and case management, focuses on the here and now, using practical strategies for reducing anxiety, managing relationships, and incorporating “Recovery Thinking.”
Among the findings from seven empirical studies of Seeking Safety: improvements in substance use, social adjustment, general psychiatric symptoms, suicidal thoughts and planning, depression, problem solving skills, and quality of life.
In another twist on treatment delivery possibilities, Dr. McGovern recently published preliminary results of a randomized study exploring PTSD within the context of an existing addiction treatment model in 53 patients, comparing the addition of cognitive-behavioral therapy (CBT) to individual addiction counseling (Addict. Behav. 2009;34:892-97).
The now-completed study found that while both approaches led to an improvement in substance abuse disorders, the CBT component was significantly more efficacious in reducing PTSD symptoms. Furthermore, patients randomized to receive CBT “stayed in treatment at much greater rates,” he said.
One development that has made dual treatment a reality has been the availability of “excellent medications” for addiction that can allow patients to focus on PTSD treatment, Dr. Kosten said.
Depot naltrexone, which persists for a month after injection, can assist in alcohol abstention, while buprenorphine reduces the need for opiates, covering two of the substances most abused by patients with co-occurring PTSD, he said.
At times, other medications directed at PTSD symptoms, such as the alpha adrenergic blockers prazosin or doxazosin, might be useful as well.
A randomized, controlled study by researchers at Yale University, New Haven, Conn., directly compared medications (disulfiram or naltrexone) to placebo in 254 patients being treated for alcohol dependence in a 12-week study conducted at three VA outpatient clinics.