Important advances in the psychosocial treatment of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) have occurred over the past two decades. Whereas before it was believed that trauma work could not be initiated until the patient was abstinent from all alcohol and drug use, ample data now show that trauma-focused treatment need not wait for a person to stop all substance use. Indeed, many patients with PTSD and SUD do not have abstinence as a treatment goal and instead want to significantly reduce their use, in line with a harm reduction approach (Lozano et al., 2015). The U.S. Department of Veterans Affairs/Department of Defense Clinical Practice Guidelines for PTSD indicate that co-occurring SUD should not prevent patients from receiving concurrent treatment with evidence-based, trauma-focused therapy for PTSD (VA & DoD, 2017).
How is trauma-focused therapy defined? The VA/DOD Clinical Practice Guidelines defines trauma-focused therapy as “any therapy that uses cognitive, emotional, or behavioral techniques to facilitate processing a traumatic experience and in which the trauma focus is a central component of the therapeutic process” (pg. 46). Trauma-focused therapy protocols are typically eight to 16 sessions in length and may include varying combinations of exposure to traumatic images or memories through imaginal or narrative exposure, exposure to avoided cues in vivo or through imagery or visualization, and cognitive restructuring techniques focused on enhancing meaning and shifting problematic appraisals that stem from the traumatic experiences.
Despite the strong evidence base and recommendations by professional agencies, some clinicians are hesitant to engage in trauma-focused work with patients who are actively using alcohol or drugs. A proportion of clinicians may believe their training is inadequate to implement trauma-focused work with SUD patients, while other clinicians may be concerned that engaging in trauma-focused therapy would lead to increased substance use or relapse (Gielen et al., 2014). Given that a substantial proportion (20%-40%) of individuals with PTSD have a co-occurring SUD (Petrakis et al., 2011; Pietrzak et al., 2011) it is crucial that trauma clinicians be informed of how substance use may play a role in PTSD and understand evidence-based treatment options available for individuals with co-occurring PTSD and SUD. Relative to individuals with either disorder alone, individuals with co-occurring PTSD and SUD are at greater risk of experiencing a range of problems, including medical comorbidities, aggression, suicidality, overdose, family/social impairment and unemployment (Blanco et al., 2013; Flanagan et al., 2014; Young et al., 2005). Further, they tend to have more complex treatment courses and need more episodes of treatment (Bowe & Rosenheck, 2015; Hawkins et al., 2012; Kaier et al., 2014).
There are numerous reasons why individuals with PTSD may use alcohol or drugs. Avoidance is a core feature of PTSD, and some individuals use substances as a method of avoiding or to “self-medicate” distressing PTSD symptoms such as intrusive memories, flashbacks and sleep impairment (Khantzian, 1985). In support of the self-medication hypothesis, exposure to trauma and the development of PTSD typically precedes the onset of SUD. Moreover, research shows that reductions in PTSD severity predict reductions in substance, but reductions in SUD severity do not necessarily predict reductions in PTSD use (Hien et al., 2010). Hence, treating the PTSD in a patient with co-occurring SUD can go a long way toward helping the patient gain more control over their substance use.
Patients with co-occurring PTSD and SUD are often treated in a sequential approach, however, with SUD-only treatment occurring first and PTSD-only treatment occurring only after the successful completion of SUD treatment. There are several limitations to the sequential approach. For example, in the sequential approach, PTSD and SUD are typically treated by separate providers at different points in time and the interplay between the two conditions may not be explicitly or effectively addressed. Importantly, many patients report that they prefer that their PTSD and SUD be targeted simultaneously—that is, they would rather work on them together at the same time (Back et al., 2006; Back et al., 2014). Given this, research on the development and evaluation of treatments to help address both PTSD and SUD simultaneously has grown substantially.
Integrated, trauma-focused treatment that targets both PTSD and SUD concurrently by one provider is feasible, well-tolerated and efficacious in significantly reducing both PTSD and SUD (Norman et al., 2019; Roberts et al., 2015; Simpson et al., 2017). There is also research to suggest that exposure-based therapy (e.g., prolonged exposure [PE]; Foa et al., 2019), which is one of the most effective types of trauma-focused treatment, has a beneficial impact among individuals with co-occurring PTSD and SUD (Back et al., 2019; Berenz et al., 2012; Coffey et al., 2016; Coffey et al., 2006; Foa et al., 2013; Peck et al., 2018). Thus, trauma-focused therapies are recommended as the most effective option for treating co-occurring PTSD and SUD.
To date, the only manualized exposure-based integrated therapy that explicitly targets both PTSD and SUD symptoms is Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure (COPE) (Back et al., 2014). This treatment consists of 12, 90-minute individual sessions that combine PE with CBT techniques for SUD (Carroll, 1998). Therapy sessions integrate PE therapy components, including both imaginal and in vivo exposure, with cognitive-behavioral skills to reduce substance use. Several randomized controlled trials have demonstrated the efficacy of COPE in reducing both PTSD and SUD severity (Back et al., 2006; Back et al., 2019; Ruglass et al., 2017). Additional research on COPE shows that distress and craving following imaginal exposures is not associated with PTSD symptom severity nor substance use assessed at the following session, and that craving in response to imaginal exposure is minimal (Jarnecke et al., 2019; Lancaster et al., 2020). Recent research among adolescents also demonstrates the feasibility, safety and preliminary efficacy of COPE in this younger age population (Schollar-Root et al., 2021). Given that most adult patients with PTSD and SUD report early-life traumas, addressing trauma and substance use earlier may help prevent the development of chronic PTSD and addiction in adulthood.
The field has made major advances in understanding the interplay between PTSD symptoms and substance use/craving (Bountress et al., 2018; Coffey et al., 2010; Possemato et al., 2015). Continued research in this area will be critical as the COVID-19 pandemic evolves because rates of SUD and overdose have increased dramatically during the pandemic, and many individuals, particularly those in marginalized communities, are at risk for experiencing traumas related to the COVID-19 pandemic (e.g., Czeisler et al., 2021; Fortuna et al., 2020; Slavova et al., 2020). Patient preferences and goals and the treatment setting will certainly play a role in helping clinicians decide which treatment modality to use with patients who have PTSD and SUD. Future work will benefit from uncovering how sex/gender, other individual differences, and cultural differences influence treatment response; developing innovative ways to improve treatment adherence and retention for individuals with co-occurring PTSD and SUD; enhancing implementation and dissemination efforts of evidence-based treatments; and addressing health disparities in treatment access and outcomes. Pharmacological and other types of augmentation strategies (e.g., technology enhancements, brain stimulation techniques) may also be useful to evaluate in future research to bolster treatment outcomes.
Additionally, alternative trauma-focused treatment options for co-occurring PTSD and SUD may be helpful to explore. For instance, there is some research examining the efficacy of cognitive processing therapy (CPT), a trauma-focused psychosocial treatment, for co-occurring PTSD and substance use with promising effects (Kaysen et al., 2014; Pearson et al., 2019). Research is currently underway to adapt and test CPT for individuals with PTSD and SUD. Even though individuals with co-occurring PTSD and SUD face significant challenges, clinicians have a growing number of therapeutic tools to engage in trauma-focused work with this population.
Author Note
Dr. Amber M. Jarnecke, is a clinical psychologist and research assistant professor in the Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina (MUSC). Dr. Sudie E. Back is a professor and director of the Addiction Sciences Division, Department of Psychiatry & Behavioral Sciences at MUSC, and a staff psychologist at the Ralph H. Johnson Veterans Affairs (VA) Medical Center in Charleston, SC.
References
Back, S. E., Brady, K. T., Jaanimagi, U., & Jackson, J. L. (2006). Cocaine dependence and PTSD: A pilot study of symptom interplay and treatment preferences. Addictive Behaviors, 31(2), 351-354. https://doi.org/10.1016/j.addbeh.2005.05.008
Back, S. E., Brady, K. T., Sonne, S. C., & Verduin, M. L. (2006). Symptom improvement in co-occurring ptsd and alcohol dependence. Journal of Nervous and Mental Disease, 194(9), 690-696. https://doi.org/10.1097/01.nmd.0000235794.12794.8a
Back, S. E., Foa, E. B., T., K., Mills, K., Teesson, M., Carroll, K., Cotton, B. D., & Brady, K. T. (2014). Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE). Therapist Manual. Oxford University Press.
Back, S. E., Killeen, T., Badour, C. L., Flanagan, J. C., Allan, N. P., Ana, E. S., Lozano, B., Korte, K. J., Foa, E. B., & Brady, K. T. (2019). Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans. Addictive Behaviors, 90, 369-377. https://doi.org/10.1016/j.addbeh.2018.11.032
Back, S. E., Killeen, T. K., Teer, A. P., Hartwell, E. E., Federline, A., Beylotte, F., & Cox, E. (2014). Substance use disorders and PTSD: An exploratory study of treatment preferences among military veterans. Addictive Behaviors, 39(2), 369-373. https://doi.org/10.1016/j.addbeh.2013.09.017
Berenz, E. C., Rowe, L., Schumacher, J. A., Stasiewicz, P. R., & Coffey, S. F. (2012). Prolonged Exposure Therapy for PTSD among individuals in a residential substance use treatment program: A case series. Professional Psychology, Research and Practice, 43(2), 154-161. https://doi.org/10.1037/a0026138
Blanco, C., Xu, Y., Brady, K., Pérez-Fuentes, G., Okuda, M., & Wang, S. (2013). Comorbidity of posttraumatic stress disorder with alcohol dependence among US adults: Results from National Epidemiological Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence, 132(3), 630-638.
Bountress, K. E., Badour, C., Flanagan, J., Gilmore, A. K., & Back, S. E. (2018). Treatment of co-occurring posttraumatic stress disorder and substance use: Does order of onset influence outcomes? Psychological Trauma: Theory, Research, Practice, and Policy, 10(6), 662-665. https://doi.org/10.1037/tra0000309
Bowe, A., & Rosenheck, R. (2015). PTSD and substance use disorder among veterans: Characteristics, service utilization and pharmacotherapy. Journal of Dual Diagnosis, 11(1), 22-32. https://doi.org/10.1080/15504263.2014.989653
Carroll, K. M. (1998). A cognitive-behavioral approach: Treating cocaine addiction (N. I. o. D. Abuse, Ed.).
Coffey, S. F., Schumacher, J. A., Nosen, E., Littlefield, A. K., Henslee, A. M., Lappen, A., & Stasiewicz, P. R. (2016). Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: A randomized controlled trial. Psychology of Addictive Behaviors, 30(7), 778-790. https://doi.org/10.1037/adb0000201
Coffey, S. F., Schumacher, J. A., Stasiewicz, P. R., Henslee, A. M., Baillie, L. E., & Landy, N. (2010). Craving and physiological reactivity to trauma and alcohol cues in posttraumatic stress disorder and alcohol dependence. Experimental and Clinical Psychopharmacology, 18(4), 340-349. https://doi.org/10.1037/a0019790
Coffey, S. F., Stasiewicz, P. R., Hughes, P. M., & Brimo, M. L. (2006). Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: Revealing mechanisms of alcohol craving in a cue reactivity paradigm. Psychology of Addictive Behaviors, 20(4), 425-435. https://doi.org/10.1037/0893-164X.20.4.425
Czeisler, M. É., Lane, R. I., Wiley, J. F., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2021). Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020. JAMA Network Open, 4(2), e2037665-e2037665. https://doi.org/10.1001/jamanetworkopen.2020.37665
Department of Veterans Affairs and Department of Defense (2017). VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington, DC.
Flanagan, J. C., Teer, A., Beylotte, F. M., Killeen, T. K., & Back, S. E. (2014). Correlates of recent and lifetime aggression among Veterans with co-occurring PTSD and substance-use disorders. Mental Health and Substance Use, 7(4), 315-328.
Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. M. (2019). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences (2 ed.). Oxford University Press.
Foa, E. B., Yusko, D. A., McLean, C. P., Suvak, M. K., Bux, D. A., Jr., Oslin, D., O'Brien, C. P., Imms, P., Riggs, D. S., & Volpicelli, J. (2013). Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. JAMA, 310(5), 488-495. https://doi.org/10.1001/jama.2013.8268
Fortuna, L. R., Tolou-Shams, M., Robles-Ramamurthy, B., & Porche, M. V. (2020). Inequity and the disproportionate impact of COVID-19 on communities of color in the United States: The need for a trauma-informed social justice response. Psychological Trauma: Theory, Research, Practice, and Policy, 12(5), 443-445. https://doi.org/10.1037/tra0000889
Gielen, N., Krumeich, A., Havermans, R. C., Smeets, F., & Jansen, A. (2014). Why clinicians do not implement integrated treatment for comorbid substance use disorder and posttraumatic stress disorder: A qualitative study. European Journal of Psychotraumatology, 5. https://doi.org/10.3402/ejpt.v5.22821
Hawkins, E. J., Malte, C. A., Baer, J. S., & Kivlahan, D. R. (2012). Prevalence, predictors, and service utilization of patients with recurrent use of Veterans Affairs substance use disorder specialty care. Journal of Substance Abuse Treatment, 43(2), 221-230. https://doi.org/10.1016/j.jsat.2011.11.002
Hien, D. A., Jiang, H., Campbell, A. N. C., Hu, M.-C., Miele, G. M., Cohen, L. R., Brigham, G. S., Capstick, C., Kulaga, A., Robinson, J., Suarez-Morales, L., & Nunes, E. V. (2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s Clinical Trials Network. The American Journal of Psychiatry, 167(1), 95-101. https://doi.org/10.1176/appi.ajp.2009.09091261
Jarnecke, A. M., Allan, N. P., Badour, C. L., Flanagan, J. C., Killeen, T. K., & Back, S. E. (2019). Substance use disorders and PTSD: Examining substance use, PTSD symptoms, and dropout following imaginal exposure. Addictive Behaviors, 90, 35-39. https://doi.org/https://doi.org/10.1016/j.addbeh.2018.10.020
Kaier, E., Possemato, K., Lantinga, L. J., Maisto, S. A., & Ouimette, P. (2014). Associations between PTSD and healthcare utilization among OEF/OIF veterans with hazardous alcohol use. Traumatology, 20(3), 142.
Kaysen, D., Schumm, J., Pedersen, E. R., Seim, R. W., Bedard-Gilligan, M., & Chard, K. (2014). Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders. Addictive Behaviors, 39(2), 420-427. https://doi.org/10.1016/j.addbeh.2013.08.016
Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142(11), 1259-1264. https://doi.org/10.1176/ajp.142.11.1259
Lancaster, C. L., Gros, D. F., Mullarkey, M. C., Badour, C. L., Killeen, T. K., Brady, K. T., & Back, S. E. (2020). Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders? Behavioural and Cognitive Psychotherapy, 48(1), 38-53. https://doi.org/10.1017/S1352465819000304
Lozano, B. E., Gros, D. F., Killeen, T., Jaconis, M., Beylotte, F. M., 3rd, Boyd, S., & Back, S. E. (2015). To reduce or abstain? Substance use goals in the treatment of veterans with substance use disorders and comorbid PTSD. American Journal on Addictions, 24(7), 578-581. https://doi.org/10.1111/ajad.12263
Mills, K. L., Teesson, M., Back, S. E., & et al. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA, 308(7), 690-699. https://doi.org/10.1001/jama.2012.9071
Norman, S. B., Trim, R., Haller, M., Davis, B. C., Myers, U. S., Colvonen, P. J., Blanes, E., Lyons, R., Siegel, E. Y., Angkaw, A. C., Norman, G. J., & Mayes, T. (2019). Efficacy of Integrated exposure therapy vs integrated coping skills therapy for comorbid posttraumatic stress disorder and alcohol use disorder: A randomized clinical trial. JAMA Psychiatry, 76(8), 791-799. https://doi.org/10.1001/jamapsychiatry.2019.0638
Pearson, C. R., Kaysen, D., Huh, D., & Bedard-Gilligan, M. (2019). Randomized control trial of culturally adapted cognitive processing therapy for ptsd substance misuse and hiv sexual risk behavior for native american women. AIDS and Behavior, 23(3), 695-706. https://doi.org/10.1007/s10461-018-02382-8
Peck, K. R., Schumacher, J. A., Stasiewicz, P. R., & Coffey, S. F. (2018). Adults with comorbid posttraumatic stress disorder, alcohol use disorder, and opioid use disorder: The effectiveness of modified prolonged exposure. Journal of Traumatic Stress, 31(3), 373-382. https://doi.org/10.1002/jts.22291
Petrakis, I. L., Rosenheck, R., & Desai, R. (2011). Substance use comorbidity among veterans with posttraumatic stress disorder and other psychiatric illness. American Journal on Addictions, 20(3), 185-189. https://doi.org/10.1111/j.1521-0391.2011.00126.x
Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25(3), 456-465. https://doi.org/10.1016/j.janxdis.2010.11.010
Possemato, K., Maisto, S. A., Wade, M., Barrie, K., McKenzie, S., Lantinga, L. J., & Ouimette, P. (2015). Ecological momentary assessment of PTSD symptoms and alcohol use in combat veterans. Psychol Addictive Behaviors, 29(4), 894-905. https://doi.org/10.1037/adb0000129
Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clinical Psychology Review, 38, 25-38. https://doi.org/10.1016/j.cpr.2015.02.007
Ruglass, L. M., Lopez-Castro, T., Papini, S., Killeen, T., Back, S. E., & Hien, D. A. (2017). Concurrent treatment with prolonged exposure for co-occurring full or subthreshold posttraumatic stress disorder and substance use disorders: A Randomized clinical trial. Psychotherapy & Psychosomatics, 86(3), 150-161. https://doi.org/10.1159/000462977
Schollar-Root, O., Cassar, J., Peach, N., Cobham, V., Milne, B., Barrett, E., Back, S., Bendall, S., Perrin, S., & Brady, K. (2021). Integrated trauma-focused psychotherapy for traumatic stress and substance use: Two adolescent case studies. Clinical Case Studies.
Simpson, T. L., Lehavot, K., & Petrakis, I. L. (2017). No wrong doors: Findings from a critical review of behavioral randomized clinical trials for individuals with co-occurring alcohol/drug problems and posttraumatic stress disorder. Alcoholism-Clinical and Experimental Research, 41(4), 681-702. https://doi.org/10.1111/acer.13325
Slavova, S., Rock, P., Bush, H. M., Quesinberry, D., & Walsh, S. L. (2020). Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug and Alcohol Dependence, 214, 108176. https://doi.org/https://doi.org/10.1016/j.drugalcdep.2020.108176
Young, H. E., Rosen, C. S., & Finney, J. W. (2005). A survey of PTSD screening and referral practices in VA addiction treatment programs. Journal of Substance Abuse Treatment, 28(4), 313-319. https://doi.org/https://doi.org/10.1016/j.jsat.2005.02.006