Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans
Introduction
Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) are two of the most prevalent psychiatric disorders in the United States. In the general population, lifetime estimates are approximately 29.1% for alcohol use disorder, the most common SUD (Grant et al., 2015), and 8.3% for PTSD (Kilpatrick et al., 2013). Among military personnel and veterans, rates of SUD and PTSD are 2–4 times higher than in the general population (Hoge, 2015; Petrakis, Rosenheck, & Desai, 2011; Stein et al., 2017; Teeters, Lancaster, Brown, & Back, 2017).
Research demonstrates high rates of comorbidity between SUD and PTSD. Epidemiologic data indicate that individuals with, as compared to without, an SUD are 6.5 times more likely to have comorbid PTSD (Mills, Teeson, Ross, & Peters, 2006). Comorbid SUD/PTSD is associated with substantial psychiatric comorbidity (e.g., depression), medical problems, vocational impairment, increased violence, and poor treatment outcomes (Barrett, Teeson, & Mills, 2014; Simpson, Lehavot, & Petrakis, 2017; Stein et al., 2017).
Integrated treatments, in which both disorders are addressed concurrently, may help optimize outcomes. Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is an integrated treatment that utilizes Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) in combination with cognitive behavioral therapy for SUD. Previous studies of COPE among civilians demonstrate efficacy in reducing SUD and PTSD severity (Brady, Dansky, Back, Foa, & Carroll, 2001; Mills et al., 2012; Persson et al., 2017; Ruglass et al., 2017). Despite extensive research demonstrating the ability of PE to significantly reduce PTSD severity (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010; Resick, Williams, Suvak, Monson, & Gradus, 2012), some clinicians are reluctant to engage in exposure-based trauma work with SUD patients (Norman & Hamblen, 2017) and the vast majority of randomized controlled trials of treatments for PTSD exclude participants with SUD (Leeman et al., 2017). Accumulating evidence demonstrates, however, that PE is safe and associated with significant reductions in SUD severity, even among individuals with complex trauma histories (Foa et al., 2013, Foa et al., 2017; Mills et al., 2012; Norman et al., 2016; Peck, Schumacher, Stasiewicz, & Coffey, 2018; Persson et al., 2017; Ruglass et al., 2017). Further support is provided by recent meta-analyses and critical reviews of the literature demonstrating that exposure-based, integrated treatment results in significant improvements in SUD and PTSD (Roberts, Roberts, Jones, & Bisson, 2015; Simpson et al., 2017).
Given the sustained military operations in Afghanistan and Iraq, and the disproportionately high rates of SUD and PTSD among veterans, the current study addresses a clinically important need by evaluating, for the first time, the efficacy of COPE among military veterans. An active treatment control group was used to control for time and therapeutic attention. We hypothesized that the integrated treatment would reduce self-report and clinician-rated PTSD symptoms, as well as SUD severity (i.e., percent days using and abstinence rates) significantly more than the control group at the end of treatment (session 12).
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Participants
Participants were treatment-seeking, U.S. military veterans primarily recruited from newspaper and internet advertisements (e.g., Craigslist). Inclusion criteria included: 1) military veteran, 2) 18–65 years old, 3) met DSM-IV diagnostic criteria for current PTSD and score ≥ 50 on the DSM-IV Clinician Administered PTSD Scale (CAPS; Blake et al., 1995); and 4) met DSM-IV diagnostic criteria for current SUD and endorsed alcohol or drug use in the past 90 days. Exclusion criteria included: 1)
Baseline and clinical characteristics
Participants were mostly male with an average age of 40.4 years (see Table 1). The majority served in Operation Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn (OEF/OIF/OND), with an average of 9.8 years of military service. The average number of trauma types experienced was 8.4 (SD = 2.7) and 81.0% reported a military-related index trauma (see Table 2). The average baseline CAPS score was 79.8, indicating severe to extreme PTSD symptomatology (Weathers et al., 2001). Most
Discussion
This is the first study to evaluate the efficacy of an integrated, exposure-based treatment for co-occurring SUD and PTSD among military veterans. To date, prior studies of integrated treatments for SUD/PTSD, including prior studies of COPE, have focused on non-veteran samples. In this study, the majority of participants were OEF/OIF/OND veterans with military-related traumas. The findings from this study provide critical information to help inform clinical practice guidelines regarding the
Acknowledgement
This work was supported by funding from NIDA grants R01 DA030143 and K02 DA039229, as well as NIAAA grants T32 AA747430 and K23 AA023845.
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