The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research

Gender differences in alcohol use disorder treatment: sociodemographic, mental health, personality, and neuropsychological factors

BACKGROUND

Rates of alcohol use increase among women, and the gender gap in alcohol use disorder (AUD) is narrowing. Earlier studies indicate that there are differences in a variety of demographic and psychological measures between men and women with AUD. Examining differences between treatment-seeking men and women to target the specific needs and effective interventions for women with AUD is thus of vital importance.

METHODS

This explorative study investigated differences in sociodemographic characteristics, psychological distress, personality functioning, and cognitive functioning between men and women seeking treatment for AUD.

RESULTS

Treatment-seeking men and women with AUD differed on a series of mental health measures, personality functioning, and cognitive functioning. Women with AUD experienced the same level of harmful drinking as men with AUD, more psychological distress, more maladaptive personality functioning, and lower general intellectual functioning.

CONCLUSIONS

The results indicate that treatment-seeking women with AUD have special needs that should be assessed and addressed in treatment. Further, there is a need for more integrated treatments targeting the high level of comorbidity experienced by women with AUD.

Expanding Treatment, Recovery, and Reentry Services for Female Offenders: Improving Outcomes through Client-Centered Interventions

This study investigated the impact of a specialized program aimed at improving substance use disorder and trauma treatment, recovery, and reentry services for adult female offenders. Trained recovery coaches delivered pretreatment interventions such as prescreening, motivational interviewing, and support-building to facilitate treatment entry and improve outcomes. Of 113 participants, 40% identified as racial/ethnic minorities, and 72% fell within the 25-45 age range. A notable 44.5% reduction in self-reported psychiatric symptoms was observed, alongside significant improvements in abstinence and trauma symptoms. Recovery capital and psychosocial functioning showed marked improvement including significant changes in employment status and housing stability and a decrease in criminal justice involvement. The results suggest that targeted, client-centered approaches can effectively improve recovery and psychosocial functioning among female offenders while reducing re-incarceration rates. These findings underscore the importance of addressing the unique needs of this population in both pre-and post-release settings to ensure equitable access to reentry services.

"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

Women with PTSD and Substance Use Disorders in a Research Treatment Study: A Comparison of those with and without the Dissociative Subtype of PTSD

Significant differences in clinical features have been reported in women with substance use disorders (SUDs) between those with the dissociative subtype of posttraumatic stress disorder (D-PTSD) compared to those without, namely more severe trauma histories, PTSD symptoms, and general psychopathology. This presentation reports on a group of 88 women with PTSD and SUD taking part in a research treatment study. All women were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and were categorized into those with (n = 23, 26%) and without (n = 65, 74%) D-PTSD. Assessments for SUDs were via the Multi-International Neuropsychiatric Inventory, Seventh Version (MINI-7). Compared to those without D-PTSD, those with D-PTSD had significantly higher CAPS-5 scores (50.5 ± 9.9 v. 39.6 ± 8.8), greater number of PTSD symptoms (16.4 ± 2.6 v. 14.2 ± 2.4), more alcohol use disorder (AUD) (65.2% v. 30.8%), and more non-cocaine stimulant use disorder (34.8% v. 12.3%). No significant differences were found for other SUDs. These women with SUDs and D-PTSD have higher degrees of PTSD severity as well as unique clinical presentations. Future research is needed to explore the significance of these findings for clinical assessment and treatment.

Adverse Childhood Experiences and Pathways to Violent Behavior for Women and Men

Childhood maltreatment is associated with risk for committing future violence, but the relationship between subgroups and biological sex is unknown. The relationship between adverse childhood experiences (ACEs), violence, and sex was examined using a nationally representative sample. Results from a latent class analysis suggested a four-class model (low adversity; moderate maltreatment with high household dysfunction; severe maltreatment with moderate household dysfunction; severe multi-type adversities). When compared to low adversity, all typology groups were at significantly higher risk to engage in violence (odds ratio > 2.10, ps < .013). The data supported a linear trajectory, meaning increased childhood trauma was associated with increased risk for violence. Although men endorsed more violent behavior, the relationship between ACEs and violence was significantly stronger among women. Prior findings identify that women are more negatively impacted by ACEs and the current findings newly identify that this extends to violent crime.

Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders

Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

INTRODUCTION

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

METHODS

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

RESULTS

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

CONCLUSIONS

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Evaluating treatments for posttraumatic stress disorder, alcohol and other drug use disorders using meta-analysis of individual patient data: Design and methodology of a virtual clinical trial

This paper describes Project Harmony, a Virtual Clinical Trial (VCT) funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to harmonize and analyze data from over 40 independent psychological, pharmacologic and/or combined pharmacological treatment studies for posttraumatic stress disorder and comorbid alcohol and other drug use disorders (PTSD/AOD). The study attends to three distinct analysis challenges: (1) variation in measurement of PTSD/AOD across studies, time, populations and reporters, (2) cross-study variation in treatment effect sizes and (3) non-randomized, cross-study variation in the classification of treatments (despite within-study randomization of treatment arms). To address these challenges, the study combines meta-analysis of individual patient data (MIPD), integrative data analysis (IDA) and propensity score weighting (PSW) to integrate raw data from these clinical trials. This protocol shows how this VCT analytic framework was used to (1) develop commensurate scale scores of PTSD and AOD severity when measures vary across studies, (2) compare the efficacy of evidence-based treatment models for PTSD/AOD, (3) test for potential mediators of treatment effects on AOD and PTSD across treatment models, and (4) explore individual- and study-level moderators to inform for whom each of the treatment models works best. The advantages of the general VCT approach are juxtaposed against the limitations of single randomized controlled trials and conventional meta-analysis.

Healthcare beliefs, health information seeking, and healthcare setting preferences among women who inject drugs by community supervision status

OBJECTIVE

Women on community supervision who inject drugs have significant unmet healthcare needs. However, it remains unclear how the intersection of community supervision and injection drug use influences healthcare experiences and service setting preferences. The present study examines whether the intersection of community supervision and injection drug use is associated with differences in women's healthcare beliefs, healthcare experiences, and service setting preferences.

METHODS

A secondary analysis was conducted on a previously collected sample of women who inject drugs recruited from a syringe exchange and social service organization for a cross-sectional survey. Participants (N = 64) were mostly White (75%), and more than a quarter were currently on probation or parole (26%).

RESULTS

Independent samples t-tests and chi-square tests revealed no significant differences on sociodemographic variables by community supervision status. There were no significant differences by community supervision status across seven indicators of healthcare confidence (ps > .05). However, results revealed significant differences in past experiences and beliefs about healthcare, health information seeking, and healthcare setting preferences by community supervision status (ps < .05), where women on community supervision less frequently sought health information and medical care outside of emergency departments.

CONCLUSIONS

Findings provide preliminary evidence about differences in the healthcare experiences and setting preferences of women who inject drugs on community supervision.

PTSD / substance use disorder comorbidity: Treatment options and public health needs

Purpose of Review

Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings.

Recent Findings

Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD.

Summary

There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.