PTSD and Substance Use Disorders

Brian E. Lozano, Ph.D.

Contributing Collaborator: Sudie E. Back, Ph.D.

Medical University of South Carolina

Ralph H. Johnson VA Medical Center

Lozano@musc.edu

Backs@musc.edu

ColleaguesDr. Kathleen BradyDr. Therese KilleenDr. Edna FoaDr. Colleen HanlonDr. Stacia DeSantisDr. Karen HartwellDr. Liz Santa AnaDr. Brian LozanoDr. Matt YoderDr. Kristy CenterDr. Julianne FlanaganDr. Jenna McCauleyMs. Sharon BeckerDr. Megan Moran-Santa MariaDr. Peter KalivasDr. Jacqueline McGinty

Thank you

Staff/CoordinatorsMr. Frank BeylotteMs. Mary Ashley MercerMs. Emily Hartwell Dr. Elizabeth CoxMs. Wendy MuzzyMs. Alex JefferyMs. Virginia McAlisterMr. Scott HendersonMs. Amanda FederlineMs. Anjinetta JohnsonMr. Drew Teer

Funding SourcesNIDA F31 DA00607 (Back)NIDA K23 DA021228 (Back)NIDA R01 DA030143 (Back)J. William Fulbright (Back)NIDA K24 DA00435 (Brady)NIH UL1RR029882 (Brady)NIDA T32 DA07288 (McGinty)DoD 803235 (Kalivas & Back)DoD 804237 (McGinty & Back)

No conflicts of interest to disclose

Previous and current research funding from:◦ National Institute on Drug Abuse◦ Department of Defense ◦ J. William Fulbright Foreign Scholarship Board

Disclosure Statement

Sequential Model – SUD first, then PTSD

Singular Model – Treat the “primary” disorderoTreat only the SUD

oTreat only the PTSD

Parallel Model – SUD and PTSD, different clinicians

Integrated Model - SUD and PTSD, same clinician

Treatment Models

Rates of Relapse:-With PTSD: 85%-Without PTSD: 59%(p = .12)

Time to 1st Use :-With PTSD: 26.5 days-Without PTSD: 54.5 days (p = .03)

(Brown et al., 1996; Psychology of Addictive Behaviors)

N = 31 women with alcohol or drug dependence disorders

PTSD and Relapse

Untreated PTSD contributes to poorer treatment outcome for substance use, and vice versa.

Traditionally, the standard of care = sequential model: (1) SUD treatment first, demonstrate sustained abstinence (3 to 6 months) then… (2) PTSD treatment

Clinic #1 Clinic #2

The Need to Treat Both PTSD and SUD

• Both conditions concurrently, by the same clinician

Clinic #1

Integrated Model of PTSD/SUD Treatment

• Both conditions concurrently, by the same clinician

• Driven by: o -Hypothesis that substance abuse is result of, in

part, PTSD symptoms.o -Reductions in PTSD are more likely to lead to

reductions in substance abuse, than the reverse.o -Patient preferences.

Clinic #1

Integrated Model of PTSD/SUD Treatment

PTSD Improvement Results in Alcohol Use Improvement

Back, Brady, Sonne & Verduin, JNMD, 2006

(N=94)

Alcohol Improvement Less Likely to Result in PTSD Improvement

94%

6% Related Unrelated

Do you believe that your alcohol/drug use and PTSD

symptoms are related?(N = 35 Veterans)

Back, et al., 2014

85%

10%5%

Increase

Stay the Same

Decrease

If your PTSD symptoms get worse,what happens to your alcohol/drug use?

62%

27%

9%

Decrease

Stay the Same

They Don't Improve

If your PTSD symptoms improve,

what happens to your alcohol/drug use?

Overview of PTSD – Substance Use Connection

PTSD Symptoms

Substance Use

Short Term Relief

Self Medication Hypothesis (Khantzian, 1985)

+

Overview of PTSD – Substance Use

Integrated Treatment

Treat PTSD +

SUD

Manage PTSD sx without

substances

Recovery from PTSD and SUD

Long Term Relief

SUD-PTSD Integrated Psychotherapies

Najavits (2002) - Seeking Safety. Relapse prevention + education + social skills training. Mostly group. 25 sessions.

Back, Foa, Killeen, Brady et al. (in press) – COPE. Relapse prevention + in vivo exposure + imaginal exposure. Individual. 12 sessions.

Treatment Imaginal exposure

In vivo exposure

Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) – in press

Seeking Safety (SS) - 2002 Seeking Safety + Exposure Therapy-Revised (N=5) - 2005

Substance Dependence PTSD Therapy (SDPT) - 1999

CBT for PTSD in addiction treatment programs - 2009

van Dam et al., 2012; Clinical Psych Review, 32: 202-214

Synthesis of 2 theory-based and empirically-validated treatments:

(1) Prolonged Exposure for PTSD (Foa, Hembree, & Rothbaum, 2007)

(2) Relapse Prevention for SUD (Carroll, 1998)

COPE (Concurrent Treatment of PTSD & SUD using Prolonged Exposure)

1. Educate patients about the functional relationship between substance use and PTSD.

2. Decrease SUD symptom severity, initiate and maintain abstinence.

3. Decrease PTSD symptom severity.

Primary Goals of COPE

Psychoeducation – education about common reactions, normalize symptoms, help understand avoidance & how it maintains PTSD symptoms.

Breathing Retraining technique to decrease anxiety.

Prolonged Exposure (PE):o In-Vivo Exposureo Imaginal Exposure

CBT Techniques Used To Treat PTSD

In Vivo Exercises

▶ In between therapy sessions▶ Repeated exposures ▶ Prolonged duration▶ Common examples:o Walmart (or other crowed store)o Sitting in middle of restaurant o Going to a sporting evento Going to movie theatreo Driving during rush houro Being stopped at a stop lighto Watching or reading the newso Group activities (going to AA, church,

exercise class)

Imaginal Exposure

How it works:1. Emotional processing, organizing the memory 2. Habituation – anxiety does not last forever3. Distinguishing between memory vs. actual event, then

vs. now4. Cognitive modifications – increase sense of

control, mastery, confidence

Anx

iety

Time

Prolonged Exposure Therapy: The Wave of Anxiety

Foa et al. (1991)Foa et al. (1999)Foa et al. (2005)Marks et al. (1998)Tarrier et al. (1999)Taylor et al. (2001)Cloitre et al. (2002)Resick et al. (2003)Bryant et al. (2003)Schnurr et al. (2007)Rauch et al. (2009)Resick et al. (2012)

*18% with PTSD 5-10 yrs later

Empirical Support for PE

Psychoeducation regarding relationship between substance use and PTSD sx.

Effectively manage cravings and thoughts about substance use.

Identify triggers for substance use - both PTSD and substance-related triggers.

Learn coping skills to help prevent relapse/escalation to substances (e.g., managing anger, drug refusal skills).

CBT to decrease SUD Symptoms

Integrated treatments address both the PTSD and the SUD concurrently.

COPE uses Prolonged Exposure (in vivo and imaginal) to treat PTSD, and CBT (Relapse Prevention) to treat SUD.

Main Goals: ◦Psychoeducation◦Reduce PTSD symptoms ◦Reduce SUD symptoms

Summary

COPE Session Content

1 Introduction: Psychoeducation, Set Goals, Therapy Contract, Breathing Retraining

2 PTSD: Common Reactions to Trauma SUD: Awareness of Cravings

3 PTSD: In Vivo Hierarchy SUD: Managing Cravings

4 PTSD: First Imaginal ExposureSUD: Review coping skills

Session # Session Topic

General Session Overview

5 PTSD: Imaginal Exposure continuedSUD: Planning for Emergencies

6 PTSD: Imaginal Exposure continuedSUD: Awareness of High-Risk Thoughts

7 PTSD: Imaginal Exposure continuedSUD: Managing High-Risk Thoughts

8 PTSD: Imaginal Exposure continuedSUD: Refusal Skills

Session # Session Topic

General Session Overview continued

9 PTSD: Imaginal Exposure continuedSUD: Seemingly Irrelevant Decisions

10 PTSD: Imaginal Exposure continuedSUD: Awareness of Anger

11 PTSD: Final Imaginal ExposureSUD: Managing Anger

12 Review and Termination

Session # Session Topic

General Session Overview continued

Do integrated treatments

for PTSD/SUD work?

COPE Studies to Date

Brady et al. (2001) and Back et al. (2001): PTSD and cocaine; N=39

Mills et al. (2012): PTSD and mostly heroin; N=103; COPE + TAU vs TAU

Back et al. (ongoing): military PTSD and mostly alcohol; COPE vs RP

Hien et al. (ongoing): PTSD and mostly alcohol; COPE vs RP

Norman et al. (ongoing): military PTSD; COPE vs Seeking Safety

Preliminary, uncontrolled study N=39 PTSD and cocaine dependence 16 individual 90-minute sessions Assessment at weeks 4, 8, 12, and 16, and

at 6 months follow up.

Initial COPE Study

Positive Urine Drug Screen (UDS) Tests At treatment entry = 12.8% First half of treatment = 12.2% Second half of treatment = 9.7%

Timing of AttritionThe majority (75%) dropped out before PE initiated (e.g., transportation or employment problems, relocation, scheduling conflicts, unstable living conditions)

Brady, Dansky, Back, Foa & Carroll, 2001

(N=39) Cocaine Dependent + PTSD

Initial COPE Findings

Post-Treatment Outcomes

Base-line

4 8 12 16 Follow Up

0

5

10

15

20

25

30

35

40

45

50

Intrusion

Avoidance

Total

Sco

res

Weeks

Impact of Events Scale (IES)

Uncontrolled study Small sample sizeFocused on cocaine dependenceHigh drop-out rate

Considerations

Randomized controlled trial COPE + TAU vs TAU N=103 SUD (mostly heroin) + PTSD Majority (75%) had childhood trauma 62.1% women 78.6% unemployed 54.2% lifetime history of suicide attempt

Mills et al., 2012

Study Aims and Design

Baseline 6 Weeks 12 Weeks 3 month F/U

25

35

45

55

65

75

85

95

Treatment

Control*

Clinician Administered PTSD Scale (CAPS)

Baseline 6 Weeks 12 Weeks 3 month F/U

0

1

2

3

4

5

TreatmentControl

Using at 3 mth F/U:Treatment:

72.9%Control: 81.9%

Number of SUD Dependence Criteria Met

COPE among Military Veterans

Total N=90

3 Mth Follow-UpCOPE

RP

Study TimelineScreening, Consent, Assessed, and Randomized

COPE and RP Treatment Phase: 12, 90-min sessions

3 Mth Follow-Up

6 Mth Follow-Up

6 Mth Follow-Up

3 Mth Follow-Up 6 Mth Follow-Up

COPE pts: Sessions 4 and 11 fMRI scan to cues Back et al., ongoing

Study Design

◦ Single, caucasian, 25 yr old male◦ United States Marine (gunner)◦ Served 3 deployments in Iraq (24 months total) ◦ No history of mental health treatment

COPE Military Pt 001

Back, Killeen, Foa et al. Am J Psychiatry 2012; 169: 688-691

Index trauma: Combat related.

PTSD symptoms: Frequent nightmares, intrusive thoughts, isolation/distancing, aggression, extreme difficultly driving, hyperarousal in crowded places (e.g., Walmart, movies), avoidance of thoughts and memories through alcohol.

Substance use symptoms: Consuming 12.5 beers per day, 83.3% of the time (50/60 days pre study).

Tx motivation: Initially did not want treatment (“military pride”) but his friend drove him to clinic.

Case Details

Time-Line Follow Back Number of Standard Drinks

In Vivo Start

Imaginal Start

Reliable Change Index, p<.05

PTSD Checklist-Military Version (PCL-M)

Reliable Change Index, p<.05

CAPS:71 (Baseline)42 (Session 6)17 (Session 12) 4 (6 Mth F/U)

Reliable Change Index, p<.05

Beck Depression Inventory (BDI)

Studies among men and women, civilian and combat-related PTSD, multiple SUD and multiple traumas show:◦Feasible◦Safe – substance use did not increase with

trauma-work◦Effective

Summary