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There are high rates of trauma exposure and posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). The process of re-integrating into the civilian world while coping with psychological and physical conditions may increase the likelihood that veterans will develop substance problems.1,2 Comorbid PTSD contributes to poor SUD treatment outcomes and is associated with worse overall mental and physical health, including high rates of suicide and higher rates of relapse to alcohol and drugs.2,3 Individuals with this comorbidity are also likely to have greater addiction severity, greater rates of interpersonal problems, a lower motivation for treatment, multimorbidity and worse treatment adherence than those without comorbid PTSD or traumatic experiences.2,3 While addiction programs traditionally do not address PTSD, there is increasing evidence that trauma treatments not only treat PTSD but may even improve SUD treatment retentionand substance use outcomes among those with comorbidity. Given the high co-occurrence of SUD and PTSD among veterans seeking care within the U.S. Department of Veterans Affairs (VA), U.S. Veterans Health Administration (VHA) policy has recommended that evidence-based treatment be provided for both disorders concurrently.5

Although there are effective evidence-based psychotherapies (EBPs) for PTSD,only a small percentage of veterans receive an adequate dose of EBPs due to low treatment engagement and high dropout.Furthermore, veterans with SUD are usually treated in SUD specialty clinics, where staff may not be trained in trauma and therefore may not even offer PTSD treatment.For example, among N=140 veterans admitted to a U.S. VA buprenorphine clinic, 47.9% (n=67) had a PTSD diagnosis but only 31.3% (n=21) were referred to PTSD treatment; among those engaged in PTSD treatment, 90.5% were still on buprenorphine at six months compared to only 23.9% of those without PTSD treatment (p<.0001).In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in treatment than the reference group (p<.001).In light of this, it is imperative that we find PTSD interventions that veterans can engage in during SUD treatment that can also be easily disseminated by addiction providers who might not necessarily specialize in PTSD.

Written exposure therapy (WET) is a brief, evidence-based trauma-focused written narrative exposure treatment. WET has several characteristics that make it ideal for dissemination and implementation within SUD clinics. It can be delivered in five sessions, can be easily provided with minimal therapist training requirements, has high patient satisfaction and lower dropout compared to other PTSD treatments.9,10 A recent clinical trial also found that WET was as efficacious as 12 full sessions of a ‘first-line’ EBP (Cognitive Processing Therapy) for PTSD.WET thus appears an effective and cost-efficient treatment and may be ideally suited for clinical settings that might not have the PTSD expertise found in PTSD specialty clinics.

Emerging evidence also suggests that WET may address this difficult-to-treat comorbidity. In a preliminary study, women in residential SUD treatment (N=149) who were randomized to a written exposure paradigm11 had greater reductions in posttraumatic symptom severity and depression compared to controls (p<.05).12 Of the 149 participants, 141 (94.6%) completed all writing sessions. Altogether, these results suggest WET may be an ideal intervention for administration in a busy outpatient SUD clinic.

Building upon this promising data, we conducted a small pilot study examining the feasibility of WET for veterans with SUD and comorbid PTSD. SUD treatment-seeking veterans (N=12) with comorbid PTSD were randomized to WET plus treatment as usual (TAU) or TAU augmented by a neutral writing condition. This data is unpublished, but we found that WET was feasible and acceptable; veterans reported high satisfaction using a standardized Client Satisfaction Questionnaire (range 8-32) (WET: M=24.8 versus TAU: M=21.3). WET was also associated with greater improvements in PTSD symptoms (mean PCL-5 decrease of 8.7 to 11.3 points) versus TAU (mean decrease of 2.4 points) and fewer days of substance use (past 30 days at baseline [WET: M=10.0 days; TAU: M=6.3 days] that decreased by follow-up [WET: M=2.3 days; TAU: M=5.0 days]). Overall, WET was viewed as an acceptable and feasible intervention to administer within the context of a busy outpatient SUD clinic. An ongoing larger clinical trial is planned to evaluate the efficacy of WET among veterans seeking SUD specialty care who present with comorbid PTSD.

Research on WET within comorbid populations with PTSD and active SUD is an emerging area, and the available evidence strongly suggests that individuals with primary SUD/PTSD could benefit from this brief intervention. In fact, Leeman and colleagues (2017) examined 156 randomized controlled trials and found that while most studies excluded participants with SUD, among those that included SUD patients there were no reported increases in substance use, nor variations in PTSD retention or outcome effects, when SUD participants were included.13 Integrated treatment approaches addressing SUD and PTSD simultaneously may be clinically optimal14 and WET can be easily incorporated into a busy SUD program.

About the Authors

Sarah Meshberg-Cohen, PhD, is a clinical psychologist, serves as clinic director of the VA Connecticut’s Outpatient Addiction Recovery Service (OARS), and is an assistant professor in the department of psychiatry at Yale School of Medicine. Dr. Meshberg-Cohen has dedicated her work to exploring, developing and enhancing evidence-based treatments targeting the unique experiences of individuals presenting with co-occurring substance use disorders (SUD) and posttraumatic stress disorder (PTSD). She recently submitted a randomized clinical trial within a SUD specialty clinic designed to evaluate whether WET enhances standard treatment for veterans engaging in SUD treatment who present with comorbid PTSD.

Noah Wolkowicz, PhD, is currently a postdoctoral fellow in the Mental Illness Treatment, Research, and Clinical Center (MIRECC) program at VA Connecticut Healthcare System/Yale School of Medicine. His research examines the interplay of dynamic risk factors (e.g., stress, craving) in initiating and maintaining alcohol and substance use.

Ismene Petrakis, MD, currently serves as the director of the Mental Health Service Line at VA Connecticut Healthcare System and is a professor of psychiatry at Yale University School of Medicine. Dr. Petrakis’ research focuses on understanding and developing treatments for substance use disorders (SUD) particularly in those with psychiatric comorbidity, most notably posttraumatic stress disorder (PTSD), and understanding the underlying neurobiology of alcohol use disorders. 


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