A recent publication by the ISTSS Trauma and Substance Use Disorders (SUD) SIG co-chairs (Banducci & Weiss, in press) provides recommendations for caring for patients with co-occurring PTSD-SUD during the COVID-19 pandemic. We summarize these strategies below.
Risk for (re)victimization. Self-isolation can increase risk for (re)victimization. Adult patients with PTSD-SUD may experience (re)victimization by their spouses or partners. Children who are unable to attend school, camps and daycare may be at risk for witnessing this (re)victimization or experiencing abuse themselves.
- Assess for risk of (re)victimization, including physical abuse, sexual abuse, psychological abuse, economic abuse, harassment, stalking and cyberstalking among your PTSD-SUD patients; when children are in the home, evaluate their risk of witnessing and experiencing these forms of (re)victimization.
- When there is an identified risk of (re)victimization, develop a safety plan—a personalized, practical plan that includes ways to remain safe, including how to cope with emotions, tell friends and family about the abuse and take legal action.
- Encourage PTSD-SUD patients to seek resources specific to (re)victimization, including hotlines (National Domestic Violence Hotline; 1-800-799-7233 or text LOVEIS to 22522 or go to thehotline.org), phone and digital health services, and shelters. In an emergency, call 911.
Harm reduction practices during COVID-19. COVID-19 presents unique challenges for patients who are actively using substances. It is good practice to assess current substance use behaviors and develop a plan for implementing practices to minimize the negative health, social and legal impacts associated with substance use and COVID-19 (i.e., harm reduction).
- Promote good hygiene. Recommend that your PTSD-SUD patients wash their hands with soap and water for 20 seconds (sing the “ABC Song”) after they are around other people, such as after purchasing or using substances. They should use microbial wipes, alcohol (at least 70%) or bleach before and after purchasing and handling substances and wipe down substance packages and surfaces where they prepare substances. If they are sick, they should try to stay home; if they need substances or supplies, they should seek secondary exchangers. If they have access, they should wear facemasks when around other people.
- Encourage safer substance use. Recommend that your PTSD-SUD patients minimize the sharing of substance use supplies (e.g., e-cigs, pipes, joints, syringes). If actively using, they should prepare substances themselves; thoroughly washing their hands and any surfaces they use before and after substance use with microbial wipes, alcohol (at least 70%) or bleach. They should prepare for overdose; emergency response may be slower, so they need to plan with individuals with whom they use substances, stock supplies (e.g., naloxone, breathing mask) and use smaller quantities of substances.
- Suggest stocking of supplies. Recommend that your PTSD-SUD patients get enough substance use supplies (e.g., syringes) to last two to four weeks. They should stock up on their substance of choice (weighing the legal consequences of having larger amounts of some substances or risk of overdose with larger supplies). They should have a plan to prevent disruptions in prescription medications (e.g., methadone/buprenorphine) including refills over the phone and telehealth visits. They should stock alternative drugs or over-the-counter medications that could help take the edge off if they lose access to their drug of choice.
Treatment strategies during COVID-19 for PTSD-SUD. COVID-19 presents unique challenges for continuing with PTSD-SUD treatment plans. There are a number of strategies we have found useful for increasing engagement in treatment during this public health emergency.
- Provide teletherapy services. Both video telehealth and phone sessions are good options to minimize disruptions in treatment gains. If you are providing group psychotherapy, query individual patients about their access to video or phone therapy sessions. Some PTSD-SUD patients may not have access to smartphones, WiFi or may lack data plans necessary for video appointments. Encourage patients to find a quiet, private space to participate in individual/group psychotherapy via phone/video. For groups, a thorough review of confidentiality and the limits of confidentiality is critical (e.g., not recording the session or using headphones/speakerphone, committing to protecting the confidentiality of fellow group members, noting that confidentiality cannot be guaranteed). Use structured check-in tasks and focus on topics that are simple and translate well in virtual care (e.g., techniques to manage urges and cravings).
- Groups:
- Phone groups: We have successfully used teleconferencing software for groups. Certain platforms allow the group leaders to see the names/phone numbers of the individuals calling in to group. Use of teleconferencing systems may vary, depending on the setting. Encourage group members to state their first name prior to speaking, so it is clear who is talking.
- Video conferencing groups (e.g., WebEx, VA Video Connect): Ensure all patients have access to this technology. Ensure the technology being used is secure (i.e., Zoom has been hacked). Ensure visual privacy—discuss the need to do the session in a private space, so that others are unable to view group members.
- Individual therapy:
- Video-based therapy: We have effectively conducted prolonged exposure therapy using video-based telehealth services. It is recommended that patients use the VA-based PE Coach app (available for iOS and Android devices) to record therapy sessions and complete homework assignments. This allows treatment to proceed without disruptions associated with needing to send paper-based forms for homework tracking and therapy materials. We recommend patients use two devices (one to record the sessions, one to see their provider during the video session) if possible. On Android devices, PE Coach will not continue recording the therapy session if an outgoing video or audio call is made. Multiple devices used could include: smartphones, tablets, laptop or desktop computers, devices from spouses or friends, or digital tape recorders. Carefully select the video software to ensure it protects confidentiality.
- Phone-based therapy: If patients do not have access to video technology, consider providing telephone-based therapy. Consider what can realistically be accomplished during a telephone visit including whether trauma-processing therapies are able to be effectively delivered in this context. For patients completing a course of PE, we have found it is possible to conduct imaginal exposures over the phone; for newer patients, we have delayed initiating trauma-focused treatments when video technology is not available. It may be more effective to focus on CBT for SUD skills or motivational interviewing during this time to support/maintain changes in substance use.
- Consider how restrictions around movement impact treatment: Treatment providers will need to be creative when administering treatments like PE, given that there may be items on in vivo exposure hierarchies that should not be completed during the global pandemic (i.e., sitting in a crowded restaurant). Select in vivo exposures that can be accomplished without putting patients at risk for COVID-19 (e.g., exposure to smell of perpetrator’s cologne, listening to fireworks on YouTube, using GoogleEarth to see location where trauma occurred, reading/watching news stories relevant to trauma experience). Although states have loosened social distancing requirements, it is up to providers to ensure selected in vivo homework assignments minimize the risk of exposure to COVID-19.
- Groups:
About the Trauma and Substance Use Disorders SIG
The Trauma and Substance Use Disorders (SUD) SIG was founded in 2010. It offers an international, multidisciplinary forum for discussion, networking and collaboration about clinical and research practices relevant to traumatic stress and SUD. The overarching aims of the SIG include:
- advocating for greater recognition, scholarly attention and clinical knowledge regarding the highly prevalent and difficult-to-treat occurrence of SUD among trauma-exposed populations with and without PTSD
- fostering basic, clinical, translational and implementation research efforts relevant to traumatic stress and SUD via discussion and collaboration among multidisciplinary members from various regions of the world
- advancing evidence-based clinical practices relevant to the assessment and treatment of SUD among trauma-exposed populations, concurrent PTSD and SUD, and PTSD among substance-using populations
- supporting dissemination and implementation efforts for relevant evidence-based treatments
- advancing prevention of SUD in the aftermath of trauma exposure, and prevention of PTSD among individuals with a history of SUD
The Trauma and SUD SIG is co-chaired by Dr. Anne N. Banducci and Dr. Nicole H. Weiss, alongside student co-chairs Antoine Lebeaut and Robert Lyons. Dr. Banducci is a Program Manager/Staff Psychologist/Military Sexual Trauma Coordinator at the VA Boston Healthcare System and Assistant Professor of Psychiatry at the Boston University School of Medicine. Her research has focused on exploring factors impacting symptomatology and treatment outcomes among individuals with PTSD and SUD (e.g., distress tolerance), as well as on developing and modifying existing treatments to target high-risk populations whose needs are not currently met by available treatments. Dr. Weiss is an Assistant Professor in the Department of Psychology at the University of Rhode Island and Director of the Study of Trauma, Risk-taking, Emotions, and Stress Symptoms (STRESS) Lab. Her research utilizes of ecological momentary assessment to clarify the proximal role and temporal ordering of affective processes—most notably emotion dysregulation—in PTSD symptoms and substance use over time. Antoine Lebeaut is a graduate student in the clinical psychology doctoral program at the University of Houston. His research interests include exploring transdiagnostic mechanisms, particularly anxiety sensitivity, that underlie the co-occurrence of PTSD and SUD. Robert Lyons is a graduate student in the San Diego State University/UC San Diego joint doctoral program in clinical psychology. His research focuses on functioning outcomes and mechanisms of integrated treatments for co-occurring PTSD/SUD.
The Trauma and SUD SIG is engaged in a wide range of activities that align with our mission statement. We send out monthly updates on our listserv containing a list of relevant publications to promote knowledge about advances in the field. The listserv also serves to elicit feedback regarding research ideas and discuss clinical cases and concerns. A biannual Trauma and SUD SIG Newsletter communicates SIG-related news and disseminates information regarding research, clinical practice and training in trauma and substance use. (Of note, we are always accepting commentaries on research, clinical practice or training—including from students!). Our Facebook group is a place for members to connect. Finally, we host several events at the ISTSS annual meeting, including endorsing posters and presentations and hosting a keynote speaker.
How to Join this SIG
We always welcome new members! To join this SIG:
- Log in and go to your ISTSS member profile
- Go to the SIG Choices tab and check the box next to “39 - Trauma and Substance Use Disorders”
- Scroll down and click “save”
References
Banducci, A. N. & Weiss, N. H. (in press). Caring for patients with posttraumatic stress and substance use disorders during the COVID19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy.
Resources
We have found the following websites to provide accurate, scientific, and up-to-date information about COVID-19 and how to reduce risks for providers and our clients: