Six-Month Treatment Outcomes of Cocaine-Dependent Patients With and Without PTSD in a Multisite National Trial

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Sex differences in cocaine self-administration by Wistar rats after predator odor exposure

Traumatic stress disorders are defined in part by persistent avoidance of trauma-related contexts. Our lab uses a preclinical model of traumatic stress using predator odor (i.e., bobcat urine) in which some but not all rats exhibit persistent avoidance of odor-paired stimuli, similar to what is seen in humans. Bobcat urine exposure increases alcohol consumption in male Avoider rats, but it has not been tested for its effects on intake of other drugs. Here, we tested the effect of bobcat urine exposure on cocaine self-administration in adult male and female Wistar rats. We did not observe any effect of bobcat urine exposure on cocaine self-administration in male or female rats. We observed that (1) female rats with long access (6 hours) to cocaine self-administer more cocaine than long-access males, (2) long-access males and females exhibit escalation of cocaine intake over time, (3) stressed rats gain less weight than unstressed rats following acute predator odor exposure, (4) baseline cocaine self-administration is predictive of subsequent cocaine self-administration. The results of this study may inform future work on predator odor effects on cocaine self-administration.

Sex differences in cocaine self-administration by Wistar rats after predator odor exposure

Traumatic stress disorders are defined in part by persistent avoidance of trauma-related contexts. Our lab uses a preclinical model of traumatic stress using predator odor (i.e., bobcat urine) in which some but not all rats exhibit persistent avoidance of odor-paired stimuli, similar to what is seen in humans. Bobcat urine exposure increases alcohol consumption in male Avoider rats, but it has not been tested for its effects on intake of other drugs. Here, we tested the effect of bobcat urine exposure on cocaine self-administration in adult male and female Wistar rats. We did not observe any effect of bobcat urine exposure on cocaine self-administration in male or female rats. We observed that (1) female rats with long access (6 hours) to cocaine self-administer more cocaine than long-access males, (2) long-access males and females exhibit escalation of cocaine intake over time, (3) stressed rats gain less weight than unstressed rats following acute predator odor exposure, (4) baseline cocaine self-administration is predictive of subsequent cocaine self-administration. The results of this study may inform future work on predator odor effects on cocaine self-administration.

Working with Trauma in the Gastroenterology Setting

Patients with gastrointestinal (GI) complaints report high rates of previous psychological trauma such as physical, emotional abuse and neglect, sexual trauma, and other traumatic experiences. History of trauma is considered a risk factor for the development of disorders of gut-brain interaction, including irritable bowel syndrome. This article discusses key points for providers in understanding how various aspects of trauma can affect patients' physical and mental health and medical interactions, as well as trauma-informed strategies providers can use to increase patient comfort, improve communication, and improve effectiveness of treatment.

Dissociable roles of the nucleus accumbens core and shell subregions in the expression and extinction of conditioned fear

The nucleus accumbens (NAc), consisting of core (NAcC) and shell (NAcS) sub-regions, has primarily been studied as a locus mediating the effects of drug reward and addiction. However, there is ample evidence that this region is also involved in regulating aversive responses, but the exact role of the NAc and its subregions in regulating associative fear processing remains unclear. Here, we investigated the specific contribution of the NAcC and NAcS in regulating both fear expression and fear extinction in C57BL/6J mice. Using Arc expression as an indicator of neuronal activity, we first show that the NAcC is specifically active only in response to an associative fear cue during an expression test. In contrast, the NAcS is specifically active during fear extinction. We next inactivated each subregion using lidocaine and demonstrated that the NAcC is necessary for fear expression, but not for extinction learning or consolidation of extinction. In contrast, we demonstrate that the NAcS is necessary for the consolidation of extinction, but not fear expression or extinction learning. Further, inactivation of mGluR1 or ERK signaling specifically in the NAcS disrupted the consolidation of extinction but had no effect on fear expression or extinction learning itself. Our data provide the first evidence for the importance of the ERK/MAPK pathway as the underlying neural mechanism facilitating extinction consolidation within the NAcS. These findings suggest that the NAc subregions play dissociable roles in regulating fear recall and the consolidation of fear extinction, and potentially implicate them as critical regions within the canonical fear circuit.

Neurochemical mechanisms and neurocircuitry underlying the contribution of stress to cocaine seeking

In individuals with substance use disorders, stress is a critical determinant of relapse susceptibility. In some cases, stressors directly trigger cocaine use. In others, stressors interact with other stimuli to promote drug seeking, thereby setting the stage for relapse. Here, we review the mechanisms and neurocircuitry that mediate stress-triggered and stress-potentiated cocaine seeking. Stressors trigger cocaine seeking by activating noradrenergic projections originating in the lateral tegmentum that innervate the bed nucleus of the stria terminalis to produce beta adrenergic receptor-dependent regulation of neurons that release corticotropin releasing factor (CRF) into the ventral tegmental area (VTA). CRF promotes the activation of VTA dopamine neurons that innervate the prelimbic prefrontal cortex resulting in D1 receptor-dependent excitation of a pathway to the nucleus accumbens core that mediates cocaine seeking. The stage-setting effects of stress require glucocorticoids, which exert rapid non-canonical effects at several sites within the mesocorticolimbic system. In the nucleus accumbens, corticosterone attenuates dopamine clearance via the organic cation transporter 3 to promote dopamine signaling. In the prelimbic cortex, corticosterone mobilizes the endocannabinoid, 2-arachidonoylglycerol (2-AG), which produces CB1 receptor-dependent reductions in inhibitory transmission, thereby increasing excitability of neurons which comprise output pathways responsible for cocaine seeking. Factors that influence the role of stress in cocaine seeking, including prior history of drug use, biological sex, chronic stress/co-morbid stress-related disorders, adolescence, social variables, and genetics are discussed. Better understanding when and how stress contributes to drug seeking should guide the development of more effective interventions, particularly for those whose drug use is stress related.

The impact of poly-traumatization on treatment outcomes in young people with substance use disorders

BACKGROUND

It is believed that clients with psychological trauma experiences have a poor prognosis with regard to treatment participation and outcomes for substance use disorders. However, knowledge on the effect of the number of trauma experiences is scarce.

METHODS

Using data from drug use disorder (DUD) treatment in Denmark, we assessed the impact of having experienced multiple potentially traumatic experiences on DUD treatment efficacy. Baseline and follow-up data from 775 young participants (mean age = 20.2 years, standard deviation = 2.6) recruited at nine treatment centers were included in analyses.

RESULTS

Analyses showed that participants who were exposed multiple trauma experiences also reported a significantly higher intake of cannabis at treatment entry, and a lower well-being score than participants who reported less types or no types of victimization experiences. During treatment, patients with multiple types of trauma experiences showed a slower rate of reduction of cannabis than patients with few or no trauma experiences. The number of trauma types was not associated with number of sessions attended or the development of well-being in treatment.

CONCLUSION

Overall, the results show that although traumatized youth in DUD treatment show up for treatment, helping them to reduce substance use during treatment is uniquely challenging.

TRIAL REGISTRATION

ISRCTN88025085 , date of registration: 29.08.2016, retrospectively registered.

Childhood trauma and post-trauma environment affect fear memory and alcohol use differently in male and female mice

BACKGROUND

Childhood trauma is associated with the development of adult mental health and substance use disorders, with females generally being more at risk. Alcohol is commonly used for coping with trauma, and alcohol use disorder (AUD) affects ∼14.4 million adult Americans annually. Research investigating sex differences in the environmental modification of anxiety and alcohol use following childhood trauma will extend our understanding of the etiology of AUD. Here, we sought to model the interacting effects of a single-episode late childhood trauma with post-trauma environment on adult alcohol use using male and female mice.

METHODS

C57Bl6/J mice (d22) exposed to predator odor (TMT) or water were reared in standard environments (SE) or environmental enrichment (EE). Mice were assessed for adolescent anxiety and conditioned fear, and for adult alcohol use in a limited access, response non-contingent, alcohol exposure paradigm.

RESULTS

A single exposure to predator odor was an effective stressor, inducing long-term sex-dependent changes in conditioned fear and alcohol behaviors that interacted with post-trauma environment. Adolescent EE females showed more conditioned freezing to the trauma-associated context. Adult EE mice consumed less total alcohol than SE mice. However, alcohol use across time differed for males and females. Exposure to a childhood stressor increased alcohol use significantly in females, but not males. EE males, but not EE females, drank less than SE counterparts.

CONCLUSIONS

Findings from this model recapitulate greater vulnerability to childhood trauma in females and support sex differences in post-trauma development of conditioned fear and alcohol use that are modified by environment.

Response-to-Treatment for Comorbid Post-Traumatic Stress and Substance Use Disorders: The Value of Combining Person- and Variable-Centered Approaches

Optimizing treatment for co-occurring post-traumatic stress disorder and substance use disorder (PTSD+SUD) is critically important. Whereas treatments have been designed that target PTSD+SUD with some success, these treatments do not benefit all. Data-driven approaches that combine person- and variable-centered methods, such as parallel process latent class growth analysis (PP-LCGA) can be used to identify response-to-treatment trajectories across both PTSD symptoms and substance use. The current study employed PP-LCGA separately in two randomized clinical trials (study 1 n = 81, Mean age = 40.4 years, SD = 10.7; study 2 n = 59, Mean age = 44.7 years, SD = 9.4) to examine PTSD symptom response and percentage of days using substances across treatment trials comparing Concurrent Treatment of PTSD and SUD using Prolonged Exposure and Relapse Prevention. Results revealed four PTSD+SUD profiles for study one and three PTSD+SUD profiles for study two. For PTSD symptoms, response trajectories could be broadly classified into treatment responders and non-responders across both studies. For substance use, response trajectories could be broadly classified into declining, moderately stable, and abstaining profiles. When considering PTSD symptoms and substance use trajectories together, profiles emerged that would have been missed had these treatment outcomes been considered separately.

Hypothalamic-pituitary-adrenal axis activity in post-traumatic stress disorder and cocaine use disorder

Post-traumatic stress disorder (PTSD) is often comorbid with cocaine use disorder (CUD), but little is known about hypothalamic-pituitary-adrenal (HPA) axis function in PTSD + CUD. Here we review the clinical and pre-clinical literature of PTSD and CUD with the goal of generating hypotheses about HPA axis activity in comorbid PTSD + CUD. Low glucocorticoid (CORT) levels immediately after trauma exposure are associated with PTSD. CORT administered within 12 h of trauma exposure reduces later PTSD symptoms. Weeks-years after trauma, meta-analyses find lower CORT levels in patients with PTSD relative to never-traumatized controls; the same is found in a pre-clinical model of PTSD. In rodents, reduced basal CORT levels are consistently found after chronic cocaine self-administration. Conversely, increased CORT levels are found in CUD patients during the first 2 weeks of cocaine abstinence. There is evidence for CORT hyper-suppression after dexamethasone, high glucocorticoid receptor (GR) number pre-trauma, and increased GR translocation to the nucleus in PTSD. Hyper-suppression of HPA axis activity after dexamethasone suggests that PTSD individuals may have increased anterior pituitary GR. Given evidence for decreased anterior pituitary GR in rats that self-administer cocaine, PTSD + CUD individuals may have normal GR density and low basal CORT levels during late abstinence. Future studies should aim to reconcile the differences in pre-clinical and clinical basal CORT levels during cocaine and assess HPA axis function in both rodent models of CUD that consider stress-susceptibility and in PTSD + CUD individuals. Although additional studies are necessary, individuals with PTSD + CUD may benefit from behavioral and psychopharmacological treatments to normalize HPA axis activity. LAY SUMMARY Post-traumatic stress disorder (PTSD) is often comorbid with cocaine use disorder (CUD), but little is known about the hypothalamic-pituitary-adrenal (HPA) axis function in PTSD + CUD. The current review provides a synthesis of available clinical and pre-clinical data on PTSD and CUD with the goal of generating hypotheses about HPA axis activity in comorbid PTSD + CUD. While this review finds ample evidence supporting aberrant HPA axis activity in both PTSD and CUD, it suggests that more research is needed to understand the unique changes HPA axis activity in PTSD + CUD, as well as the bidirectional relationship between stress-susceptibility and motivation to seek cocaine.

Changes in alcohol use, PTSD hyperarousal symptoms, and intervention dropout following veterans' use of VetChange

OBJECTIVE

Veterans of Iraq and Afghanistan conflicts report high rates of drinking, PTSD, and low rates of treatment engagement. Web interventions may help address unmet treatment need; unfortunately, little is known regarding outcomes or adherence to these interventions. In this study, we examined VetChange treatment outcomes and downstream effects of alcohol reduction on PTSD symptoms and intervention dropout rates over six months.

METHOD

Participants included 222 veterans (77.5% men, 78.3% White) between 22 and 57 (mean age = 36.02, SD = 7.19). All VetChange users completed a brief alcohol assessment and received personal feedback, then received full access to intervention content including psychoeducation; motivational and cognitive-behavioral modules for relapse prevention, goal-setting, social support, stress, anger, and sleep management; and mood and drink tracking. Veterans completed self-report measures of alcohol use and PTSD symptoms at baseline, one, three, and six months.

RESULTS

Alcohol use dropped by 43% over six months, p < .001, with the largest decrease occurring within the first month. Greater alcohol reduction in the first month predicted higher subsequent PTSD hyperarousal severity. Over half (52.3%) dropped out by month one, followed by 12.2% and 37.6% by months three and six. Hyperarousal symptoms, hypervigilance specifically, but not alcohol use predicted subsequent intervention dropout.

CONCLUSION

These results highlight the importance of attending to the association between alcohol use and PTSD symptom change in web-based interventions for veterans. The fact that hyperarousal symptoms were associated with elevated risk for intervention dropout signifies the need for online intervention refinement aimed at tailoring content to time-varying symptom presentations.

The BDNF Val66Met Polymorphism Moderates the Relationship Between Posttraumatic Stress Disorder and Trauma Script-evoked Attentional Bias to Cocaine Cues Among Patients with Cocaine Dependence

There is extensive variability in cocaine-related attentional bias (AB) following trauma script exposure among cocaine-dependent (CD) patients with posttraumatic stress disorder (PTSD). Therefore, research is needed to identify the specific PTSD-CD patients most likely to exhibit an AB to cocaine cues. A common polymorphism in brain-derived neurotrophic factor (BDNF), Val66met, is associated with risk for stimulant addiction, and thus, was examined as a moderator of the association between PTSD and cocaine-related AB following trauma script exposure in this study. Adult CD patients with (n = 17) and without (n = 28) PTSD were exposed to a personalized trauma script, followed by a visual dot-probe task assessing cocaine-related AB. Task response times were used to examine traditionally calculated AB scores, as well as trial level bias scores (TL-BS) that more accurately model the temporal dynamics of AB. PTSD-CD patients homozygous for the BDNF Val/Val genotype exhibited greater bias for attending to cocaine-related stimuli following trauma script exposure than those carrying the Met allele. The PTSD by BDNF interaction did not predict response time variability on trials for which only neutral stimuli were presented, thus increasing confidence that the observed effect is specific to cocaine-related stimuli. PTSD-CD patients homozygous for the BDNF Val/Val genotype may be at particularly high risk for negative clinical outcomes (e.g., relapse, treatment dropout) as a function of prolonged attentional engagement with cocaine cues when exposed to trauma reminders.

The influence of posttraumatic stress disorder and recurrent major depression on risk-taking propensity following trauma script exposure among patients with substance use disorders

Although evidence suggests that risk-taking among individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) may be precipitated by trauma-related emotional distress, studies have yet to examine moderators of this effect. One moderator worth investigating is recurrent major depressive disorder (MDD), given its influence on emotional responding and subsequent behavior. This study examined the moderating role of recurrent MDD in the relation of PTSD to risk-taking propensity following neutral and trauma scripts among SUD patients. Participants were 193 patients with and without current PTSD and/or recurrent MDD in residential SUD treatment. Risk-taking propensity, as assessed through the Balloon Analogue Risk Task (BART), was evaluated following a neutral script and a personalized trauma script. A significant script by PTSD by recurrent MDD interaction was found. Participants with PTSD and recurrent MDD exhibited significantly lower risk-taking following the trauma script relative to participants with PTSD but no recurrent MDD. Moreover, participants with PTSD and recurrent MDD exhibited a significantly smaller increase in risk-taking following the trauma script (relative to the neutral script) than participants with PTSD but no recurrent MDD. Participants with PTSD and recurrent MDD did not differ significantly from participants without PTSD. Results provide support for the context-dependent nature of risk-taking among PTSD-SUD patients without (vs. with) recurrent MDD. Results also highlight the importance of considering the presence of recurrent MDD in research and/or clinical work with SUD patients with PTSD.

Emotion Regulation as a Mediator between Childhood Abuse and Neglect and Posttraumatic Stress Disorder in Women with Substance Use Disorders

A history of childhood abuse and neglect (CAN) is significantly associated with psychopathologies in adulthood, including comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Difficulties in emotion regulation (ER) might influence the association between CAN and PTSD. The aim of this study was to examine the relationship between CAN and PTSD symptom severity in women with SUD and to investigate the mediating role of general difficulties in ER and its specific dimensions. Method: We examined 320 women, with a current diagnosis of at least subsyndromal PTSD and SUD, using self-report measures of CAN, PTSD symptom severity, and ER difficulties. We conducted both simple and multiple bootstrapping-enhanced mediation analysis to investigate whether general difficulties in ER and its specific dimensions mediate the relationship between CAN and PTSD symptom severity. Results: General difficulties in ER mediated the association between CAN and PTSD symptom severity. CAN significantly predicted adult PTSD symptom severity, directly and indirectly, through ER difficulties. Difficulties engaging in goal directed behavior when distressed was the only ER dimension, which mediated the effect of CAN on PTSD symptoms. Conclusions: Our results suggest that difficulties in ER and specifically difficulties engaging in goal directed behavior when distressed might constitute an influential factor in the relationship between CAN and PTSD symptom severity in a sample of SUD patients, and highlight the importance of targeting ER as a potential treatment focus for patients with comorbid PTSD and SUD.

Baseline resting heart rate variability predicts post-traumatic stress disorder treatment outcomes in adults with co-occurring substance use disorders and post-traumatic stress

Post-traumatic stress disorder (PTSD) symptoms are highly prevalent among individuals with substance use disorders (SUD), presenting a difficult-to-treat, complex comorbidity. Prognostic factors for treatment outcomes may characterize heterogeneity of the treated population and/or implicate mechanisms of action that are salient for improving treatments. High frequency heart rate variability (HF-HRV) is a suggested biomarker for emotion regulation-the ability to generate appropriate emotional responses via the influence of the parasympathetic nervous system on the heart. This initial study investigated the utility of baseline resting HF-HRV for predicting PTSD symptoms and substance use outcomes following treatment of 37 SUD participants with comorbid PTSD symptoms. Participants completed either standard cognitive- behavioral therapy (CBT) for SUD or a novel treatment of integrated post-traumatic stress and substance use that combined CBT for SUD with cognitive processing therapy for PTSD. Analyses demonstrated that higher HF-HRV predicted greater reduction in PTSD symptoms following both types of treatment. This suggests prognostic value of HF-HRV as a predictor of PTSD treatment outcomes; those with poorer autonomic emotional regulation may not respond as well to psychotherapy in general. This hypothesis-generating analysis identifies a putative biomarker that might have utility in treatment prediction.

The dissociative subtype of PTSD in women with substance use disorders: Exploring symptom and exposure profiles

The dissociative subtype of posttraumatic stress disorder (PTSD) was officially introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In accordance with this new classification, prior studies using Latent Class Analysis (LCA) empirically identified a subgroup of patients that were characterized by a high severity of dissociative symptoms. Despite the high prevalence of PTSD in patients with substance use disorders (SUD), however, no LCA studies on the dissociative subtype of PTSD exist in this population so far. Therefore, the current study aimed to identify subgroups of patients with different symptom and exposure profiles in patients with SUD and PTSD. It was assumed that one symptom and exposure profile could be identified that would be characterized by higher dissociative symptoms, higher additional psychopathology and a higher burden of childhood trauma, as compared to other subgroups. In N = 258 female patients with SUD and PTSD, clinical characteristics of dissociative symptoms, PTSD severity, borderline personality disorder (BPD), depression, childhood trauma and substance abuse were assessed. To identify symptom and exposure profiles, Latent Class Analysis was applied. A three-class solution indicated the best model fit to our data. One class was characterized by a high probability of dissociative symptoms (D-PTSD class), whereas the other two classes were characterized by lower probabilities of dissociative symptoms. The D-PTSD class encompassed 18.7% of the patients. In accordance with our hypothesis, the D-PTSD class showed higher probabilities of PTSD severity, borderline personality disorder symptoms, depressive symptoms, childhood emotional and sexual abuse, childhood emotional neglect, and drug abuse. Our results indicate that the dissociative subtype of PTSD could also be identified in a sample of female patients with SUD. Patients with SUD and PTSD characterized by the dissociative subtype showed more severe psychopathological symptoms than the remaining patients, indicating enhanced clinical needs for this vulnerable group.

A multisite randomized controlled trial of Seeking Safety vs. Relapse Prevention Training for women with co-occurring posttraumatic stress disorder and substance use disorders

Background: Co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with a more severe course and worse outcome than either disorder alone. In Europe, few treatments have been evaluated for PTSD and SUD. Seeking Safety, a manualized, integrated, cognitive-behavioural treatment, has been shown to be effective in studies in the USA. Objective: To test the efficacy of Seeking Safety plus treatment as usual (TAU) in female outpatients with PTSD and SUD compared to Relapse Prevention Training (RPT) plus TAU and TAU alone. Method: In five German study centres a total of N = 343 women were randomized into one of the three study conditions. PTSD severity (primary outcome), substance use, depression and emotion dysregulation (secondary outcomes) were assessed at baseline, post-treatment, as well as at three months and six months post-treatment. Results: Treatment participants attended M = 6.6 sessions (Seeking Safety) and M = 6.1 sessions (RPT). In an intent-to-treat analysis, Seeking Safety plus TAU, RPT plus TAU and TAU alone showed comparable decreases in PTSD severity over the course of the study. Seeking Safety plus TAU showed superior efficacy to TAU alone on depression and emotion regulation and RPT plus TAU was more effective than TAU alone on number of substance-free days and alcohol severity. Minimum-dose analyses suggest additional effects of both programmes among participants who attended at least eight group sessions. Conclusions: With respect to PTSD symptoms, a brief dose of Seeking Safety and RPT in addition to TAU was not superior to TAU alone in women with PTSD and SUD. However, Seeking Safety and RPT showed greater reductions than TAU alone in other domains of psychopathology and substance use outcomes respectively. Future studies should investigate further variables, such as what aspects of each treatment appeal to particular patients and how best to disseminate them.

Resting Heart Rate Variability: Exploring Associations With Symptom Severity in Adults With Substance Use Disorders and Posttraumatic Stress

Objective: Substance use disorders and posttraumatic stress symptoms are commonly comorbid. Previous studies have established that those with substance use disorders or posttraumatic stress disorder (PTSD) have lower high frequency-heart rate variability (HF-HRV) compared to controls, suggesting that low HF-HRV may be a biomarker of a common physiological mechanism underlying both disorders. We evaluated HF-HRV as a potential biomarker of a common underlying process by testing whether lower HF-HRV related to greater severity of substance use and PTSD symptoms in individuals with both substance use disorders and at least four symptoms of PTSD. Methods: HF-HRV was measured in 49 adults with substance use disorders and at least four symptoms of PTSD. We performed a series of regressions controlling for age to test whether low HF-HRV was associated with greater substance use disorder and PTSD symptom severity. Substance use disorder symptoms were measured by the Addiction Severity Index and PTSD symptoms were measured by the Clinician-Administered PTSD Scale and the PTSD Checklist. Results: After controlling for age, low resting HF-HRV was significantly associated with drug and alcohol symptom severity but not PTSD symptom severity. Conclusions: HF-HRV may be more sensitive to the severity of drug and alcohol use rather than PTSD. Findings may suggest that in PTSD populations, HF-HRV may primarily index comorbid substance use disorder symptoms. HF-HRV could serve as an objective measure of substance use severity and should be further investigated as a predictor of outcomes in treatment for substance use disorders.

A Randomized Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change versus Seeking Safety

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur in military veterans and other populations.

OBJECTIVE

To conduct a randomized controlled trial to compare a new past-focused treatment (Creating Change; CC), to a well-established, evidence-based present-focused treatment for PTSD/SUD (Seeking Safety; SS), on symptoms of both disorders. CC guides patients to process the past through exploration of PTSD/SUD life themes and memories whereas SS focuses on coping skills in the present.

METHODS

Fifty-two male and female veterans with current PTSD/SUD were randomized (n = 26 per treatment) and assessed at baseline, end-of-treatment and 3-month follow-up. They received 17 individual one-hour sessions.

RESULTS

Intent-to-treat analyses indicated that both conditions improved over time, with no difference between conditions, on PTSD, alcohol use, and drug use (our primary outcomes) as well as mental health symptoms, quality of life, self-efficacy, and SUD cognitions. Effect sizes were medium except for alcohol use, which was large. Change over time reflected improvement from baseline to end-of-treatment, with gains sustained at follow-up, although alcohol use showed continued improvement from end-of-treatment to follow-up. Both treatments evidenced a strong safety profile; and attendance, alliance, and treatment satisfaction were also very strong. Conclusions/importance: CC has promise as a PTSD/SUD therapy with strong public health relevance and the potential to fill important gaps in the field. We used minimal exclusionary criteria to obtain a real-world sample, which was severe-predominantly substance-dependent with chronic PTSD and additional psychiatric diagnoses. Future research is warranted, especially on nonveteran samples and treatment mechanisms of action.

Memory-Focused Cognitive Therapy for Cocaine Use Disorder: Theory, Procedures and Preliminary Evidence From an External Pilot Randomised Controlled Trial

BACKGROUND

Cocaine use disorder (CUD) is a debilitating condition with no NICE-recommended medication or specific psychosocial interventions. In the United Kingdom (UK), general counselling (treatment-as-usual; TAU) is widely delivered, but has limited effectiveness. We tested the feasibility, safety and preliminary efficacy of a novel, adjunctive psychosocial intervention for CUD, called 'memory-focused cognitive therapy' (MFCT).

METHODS

We did a two-arm, external pilot randomised controlled trial at a specialist community National Health Service addictions clinic in London, UK. 30 adults (≥18years), voluntarily seeking treatment for CUD (enrolled ≥14days; all with moderate-to-severe DSM5 CUD), were individually randomised (1:1) to a control group (ongoing TAU; 3×90min CUD cognitive conceptualisation assessments; 2×30min cocaine-related cue-induction procedures; and 3×30min research follow-ups); or to an intervention group (ongoing TAU; 3×90min cognitive conceptualisation assessments; 2×30min cocaine-related cue-induction procedures; 5×120min, one-to-one, MFCT sessions [in 1week]; and 3×60min research follow-ups and MFCT-relapse prevention). The primary outcome was the total percentage score on the frequency version of the Craving Experiences Questionnaire (CEQ-F) at 1-month follow-up after the intensive intervention week (clinical endpoint; recall period past 2weeks; higher score indicating greater craving). Secondary outcomes at the 1-month follow-up were percentage days abstinent (PDA) from cocaine, and longest period (days) of continuous abstinence (LPA) in the prior 28days. Outcomes were analysed as an unadjusted group mean difference (with Hedge's g effect size [ES]) and a 95% Confidence Interval [CI] for the primary outcome and a 90% CI for the secondary outcomes. Exploratory, multivariable linear (primary outcome) and Poisson regression models (secondary outcomes), with sex, age, months of regular cocaine use, baseline outcome score, and group estimated the effectiveness of the intervention. The trial is registered with the ISCRTN (ISRCTN16462783).

FINDINGS

Between July 15, 2015, and November 27, 2016, 58 patients were assessed for eligibility and 30 participants were randomised (14 to the control group and 16 to the intervention). With outcome data collected for all participants at the endpoint, the intervention group mean CEQ-F score (14·77; SD 21·47) was lower than the control group mean (51·75; SD 22·72); ES -1·62; 95% CI -2·45 to -0·80. MFCT was associated with more cocaine abstinence in the intervention group (PDA 85·94; SD 18·96) than the control group (PDA 54·59; SD 30·29); ES 1·19; 90% CI 0·54 to 1·84. There was also greater maximum abstinence in the intervention group (LPA 15·69; SD 10·10) than the control group (6·00; SD 7·36); ES 1·06; 90% CI 0·41 to 1·70. Exploratory, confounder-adjusted regression models for this preliminary effect supported the treatment association for reduced craving experiences (CEQ-F Coef. -28·25; 95% CI -45·15 to -11·35); more abstinence (PDA Incidence Rate Ratio [IRR] 1·56; 95% CI 1·31 to 1·88); and greater maximum abstinence (LPA IRR 2·56; 95% CI 1·96 to 3·35), although relative weak unmeasured confounding could overturn these model-adjusted exposure-outcome associations. There were four serious adverse events (among three participants). None were judged related to study procedures or interventions.

INTERPRETATION

In this first external pilot randomised controlled trial of MFCT for CUD, we have shown that the intervention and control procedures and acceptable feasible and safe, and report preliminary evidence that MFCT is associated with reduced craving and increased abstinence. These findings support progression to a substantive trial.

FUNDING SOURCE

UK National Institute for Health Research, Biomedical Research Centre.

Trauma and post-traumatic stress disorder in a drug treatment community service

Aims and method

A cross-sectional study aiming to assess the prevalence of trauma and post-traumatic stress disorder (PTSD) in a community substitution treatment sample, and to assess and compare the characteristics of traumatic experience, substance use, and psychological and social factors in those with and without PTSD. All assessments were completed during the interview which took approximately 1.5 h.

Results

The prevalence for current PTSD was 26.2% and for lifetime PTSD 42.9%. Traumatic experiences were extremely common, with two or more reported by 92.9% of the sample. The two groups differed significantly on the majority of psychological functioning and social variables, with women experiencing higher rates of PTSD and the non-PTSD group having lower rates of psychological impairment.

Clinical implications

The research supported findings from previous studies. The very high incidence of traumatic experiences has not been reported before. Training and information about trauma and PTSD for substance misuse workers are therefore necessary so that PTSD can be more easily detected and treated.

The impact of comorbid diagnoses on the course of posttraumatic stress disorder symptoms in residents of battered women's shelters

OBJECTIVE

The current investigation sought to explore the impact of the comorbidities of substance use disorder (SUD), major depressive disorder (MDD), and borderline personality disorder (BPD) on the trajectory of intimate partner violence (IPV)-related posttraumatic stress disorder (PTSD) symptoms across a 6-month follow-up period in IPV survivors who seek shelter. Research has found significant comorbidity of SUD, MDD, and BPD with PTSD (see Green et al., 2006; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Pagura et al., 2010); however, little to no research has explored these relationships in this unique population over time.

METHOD

A sample of 147 residents of battered women's shelters completed study measures at baseline, 1 week, and 3 and 6 months following shelter stay. Participants completed measures assessing for demographics, abuse, and Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision) diagnoses.

RESULTS

Results of latent growth modeling with the time-invariant covariates of SUD, MDD, and BPD yielded a significant effect of SUD (β = .002, p = .007) on the slope of IPV-related PTSD symptoms controlling for IPV victimization. Significant effects were not identified for BPD (β = .001, p > .05) or MDD (β = .002, p > .05). Results suggest IPV survivors with SUD demonstrated less improvement in PTSD symptoms over 6 months after they left shelter as compared to women without SUD.

CONCLUSION

Findings emphasize the deleterious effects of SUD, above and beyond MDD and BPD, on IPV-related PTSD and highlight the need for assessment and treatment of SUD and PTSD simultaneously in residents of battered women's shelters. Clinical Impact Statement: Findings suggest the need to go beyond standard shelter services to more effectively address and treat co-occurring SUD-PTSD in IPV survivors. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Treatment of substance use disorders: Effects on patients with higher or lower levels of PTSD symptoms

While guidelines advise integrated treatment of patients with substance use disorder (SUD) and posttraumatic stress disorder (PTSD), recent studies and reviews find no convincing evidence of different outcomes following treatment between non-trauma focused integrated programs and SUD treatment alone. In this study, we analyzed whether SUD patients with higher levels of PTSD symptoms receiving standard, non-integrated SUD treatment (N=145) differed in outcomes compared to patients with lower levels of PTSD symptoms (N=152). Patients with higher levels of PTSD symptoms showed no difference in days of substance use, but significantly more craving and psychiatric symptoms (depression, anxiety and stress) were measured at baseline. After 3 and 6months of SUD treatment, there was no difference between the groups in decreased days of substance use. After 6months of SUD treatment, depression, anxiety and stress were significantly diminished in both groups. However, those with higher levels of PTSD symptoms at the start of the SUD treatment still reported significantly higher scores on depression, anxiety and stress after 6months of SUD treatment. These findings corroborate earlier studies that SUD patients with PTSD symptoms do not necessarily have poorer addiction treatment outcomes. However, as anxiety and PTSD symptoms predict relapse, future research should note the effect of higher symptom levels on long-term SUD treatment results. Additionally, more research is needed to determine which patients need additional treatment in conjunction with or following SUD treatment.

Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction

OBJECTIVE

In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems.

METHODS

The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM).

RESULTS

No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems.

CONCLUSIONS

This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.

Treating Substance Abuse and Trauma Symptoms in Incarcerated Women: An Effectiveness Study

Incarcerated women report high rates of trauma exposure and substance use. The present study evaluated an integrated treatment program, Helping Women Recover/Beyond Trauma (HWR/BT), supplemented with additional modules on domestic violence, relapse prevention, and a 12-step program. The HWR/BT combined treatment program was compared with a matched comparison sample that did not receive the target treatment. Self-report measures were collected from 95 incarcerated women, with 56 women in the completer sample. Women in the treatment condition attended a 4-month group treatment. Results indicated statistically significant between-group differences, favoring the treatment condition, for negative posttraumatic cognitions. Pre-post, but not between-group, differences were also observed for posttraumatic stress disorder (PTSD) symptoms and substance-related self-efficacy, whereas no differences were observed for depression, dissociation, tension reduction, or anxious arousal. The present study indicates some promise for specific aspects of the treatment, although results question the overall benefit of the program over standard prison services.

Psychosocial interventions for psychostimulant misuse

BACKGROUND

Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.

OBJECTIVES

To assess the effects of psychosocial interventions for psychostimulant misuse in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.

AUTHORS' CONCLUSIONS

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.

Conditioned stress prevents cue-primed cocaine reinstatement only in stress-responsive rats

Neurobiological mechanisms underlying comorbid posttraumatic stress disorder (PTSD) and cocaine use disorder (CUD) are unknown. We aimed to develop an animal model of PTSD + CUD to examine the neurobiology underlying cocaine-seeking in the presence of PTSD comorbidity. Rats were exposed to cat urine once for 10-minutes and tested for anxiety-like behaviors one week later. Subsequently, rats underwent long-access (LgA) cocaine self-administration and extinction training. Rats were re-exposed to the trauma context and then immediately tested for cue-primed reinstatement of cocaine-seeking. Plasma and brains were collected afterwards for corticosterone assays and real-time qPCR analysis. Urine-exposed (UE; n = 23) and controls not exposed to urine (Ctrl; n = 11) did not differ in elevated plus maze behavior, but UE rats displayed significantly reduced habituation of the acoustic startle response (ASR) relative to Ctrl rats. A median split of ASR habituation scores was used to classify stress-responsive rats. UE rats (n = 10) self-administered more cocaine on Day 1 of LgA than control rats (Ctrl + Coc; n = 8). Re-exposure to the trauma context prevented cocaine reinstatement only in stress-responsive rats. Ctrl + Coc rats had lower plasma corticosterone concentrations than Ctrls, and decreased gene expression of corticotropin releasing hormone (CRH) and Glcci1 in the hippocampus. Rats that self-administered cocaine displayed greater CRH expression in the amygdala that was independent of urine exposure. While we did not find that cat urine exposure induced a PTSD-like phenotype in our rats, the present study underscores the need to separate stressed rats into cohorts based on anxiety-like behavior in order to study individual vulnerability to PTSD + CUD.

The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders

Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.

Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs

ISSUES

The high prevalence of trauma and post-traumatic stress disorder (PTSD) in individuals with substance use disorders (SUDs) presents a number of treatment challenges for community treatment providers and programs in the USA. Although several evidence-based, integrated therapies for the treatment of comorbid PTSD/SUD have been developed, rates of utilisation of such practices remain low in community treatment programs.

APPROACH

The goal of this article was to review the extant literature on common barriers that prevent adoption and implementation of integrated treatments for PTSD/SUD among substance abuse community treatment programs.

KEY FINDINGS

Organisational, provider-level and patient-level factors that drive practice decisions were discussed, including organisational philosophy of care policies, funding and resources, as well as provider and patient knowledge and attitudes related to implementation of new integrated treatments for comorbid PTSD and SUD.

IMPLICATIONS AND CONCLUSIONS

Understanding and addressing these community treatment challenges may facilitate use of evidence-based integrated treatments for comorbid PTSD and SUD.

Single prolonged stress effects on sensitization to cocaine and cocaine self-administration in rats

Posttraumatic stress disorder (PTSD) is often comorbid with substance use disorders (SUD). Single prolonged stress (SPS) is a well-validated rat model of PTSD that provides a framework to investigate drug-induced behaviors as a preclinical model of the comorbidity. We hypothesized that cocaine sensitization and self-administration would be increased following exposure to SPS. Male Sprague-Dawley rats were exposed to SPS or control treatment. After SPS, cocaine (0, 10 or 20 mg/kg, i.p.) was administered for 5 consecutive days and locomotor activity was measured. Another cohort was assessed for cocaine self-administration (0.1 or 0.32 mg/kg/i.v.) after SPS. Rats were tested for acquisition, extinction and cue-induced reinstatement behaviors. Control animals showed a dose-dependent increase in cocaine-induced locomotor activity after acute cocaine whereas SPS rats did not. Using a sub-threshold sensitization paradigm, control rats did not exhibit enhanced locomotor activity at Day 5 and therefore did not develop behavioral sensitization, as expected. However, compared to control rats on Day 5 the locomotor response to 20mg/kg repeated cocaine was greatly enhanced in SPS-treated rats, which exhibited enhanced cocaine locomotor sensitization. The effect of SPS on locomotor activity was unique in that SPS did not modify cocaine self-administration behaviors under a simple schedule of reinforcement. These data show that SPS differentially affects cocaine-mediated behaviors causing no effect to cocaine self-administration, under a simple schedule of reinforcement, but significantly augmenting cocaine locomotor sensitization. These results suggest that SPS shares common neurocircuitry with stimulant-induced plasticity, but dissociable from that underlying psychostimulant-induced reinforcement.

Assessing traumatic experiences in screening for PTSD in substance use disorder patients: what is the gain in addition to PTSD symptoms?

Traumatic experiences have been linked with substance use disorders (SUD) and may be an important factor in the perpetuation of SUD, even in the absence of posttraumatic stress disorder (PTSD) symptoms. The purpose of the current study was to examine the relationship between childhood trauma and substance use severity in 192 SUD inpatients. Childhood trauma was assessed using the Traumatic Experiences Checklist (TEC). With variables derived from this measure in addition to PTSD symptoms, two regression models were created with alcohol use or drug use severity as dependent variables. Alcohol severity was explained by PTSD symptoms as well as the age of trauma. Drug severity was explained solely by PTSD symptoms. The clinical value of assessing childhood trauma in determining the addiction severity appears to be limited in comparison with PTSD symptoms.

Drinking goal choice and outcomes in a Web-based alcohol intervention: results from VetChange

OBJECTIVES

The objectives of the paper are to describe characteristics of participants who chose moderation and abstinence drinking goals, and to examine post-treatment drinking outcomes based on patterns of goal choice during a Web-based alcohol intervention for returning U.S. Veterans.

METHOD

We conducted a descriptive secondary analysis of a subsample of 305 of 600 Veterans who participated in a clinical trial of VetChange, an 8-module, cognitive-behavioural intervention. Participants self-selected abstinence or moderation drinking goals, initially at Module 3, and weekly during subsequent modules. Alcohol use and alcohol-related problems were measured using the Alcohol Use Disorders Identification Test (AUDIT), Quick Drink Screen (QDS), and Short Inventory of Problems (SIP-2R).

RESULTS

Initial goal choices were 86.9% moderation and 13.1% abstinence. Approximately 20% of participants from each initial choice changed goals during the intervention; last goal choices were 68.6% moderation and 31.4% abstinence. Participants who initially chose moderation reported higher percent heavy drinking days at baseline; participants who initially chose abstinence were more likely to report recent substance abuse treatment and were older. Post-intervention levels of alcohol use and alcohol-related problems were significantly reduced in all goal-choice patterns (i.e., Moderation Only, Abstinence Only, Moderation to Abstinence, and Abstinence to Moderation; all measures p < 0.05 or less). Baseline drinking severity did not differentially relate to outcomes across goal-choice patterns.

CONCLUSIONS

Participants in a Web-based alcohol intervention for returning U.S. Veterans demonstrated improvements in drinking regardless of whether they chose an abstinence or moderation drinking goal, and whether the goal was maintained or changed over the course of the intervention.

How Do Females With PTSD and Substance Abuse View 12-Step Groups? An Empirical Study of Attitudes and Attendance Patterns

BACKGROUND

Self-help groups are beneficial for many people with addiction, predominantly through 12-step models. Yet obstacles to attendance also occur.

OBJECTIVES

We explored attendance patterns and attitudes toward self-help groups by 165 outpatient females with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD), the first study of its kind.

METHODS

Cross-sectional self-report data compared adults versus adolescents, and those currently attending self-help versus not attending. We also explored attendance in relation to perceptions of the PTSD/SUD relationship and symptom severity.

RESULTS

Adults reported higher attendance at self-help than adolescents, both lifetime and currently. Among current attendees, adults also attended more weekly groups than adolescents. Yet only a minority of both age cohorts attended any self-help in the past week. Adults perceived a stronger relationship between PTSD and SUD than adolescents, but both age groups gave low ratings to the fact that self-help groups do not address PTSD. That item also had low ratings by both those currently attending and not attending self-help. Analysis of those not currently attending identified additional negative attitudes toward self-help (spirituality, addiction as a life-long illness, sayings, and the fellowship). Symptom severity was not associated with attendance, but may reflect a floor effect. Finally, a surprising finding was that all-female groups were not preferred by any subsample. Conclusions/Importance. Creative solutions are needed to address obstacles to self-help among this population. Addressing trauma and PTSD, not just SUD, was valued by females we surveyed, and may be more helpful than all-female groups per se.

Psychiatric and substance-use comorbidities associated with lifetime crack cocaine use in young adults in the general population

OBJECTIVE

To assess the association between lifetime crack cocaine use and psychiatric (post-traumatic stress disorder, current depression, current dysthymia, generalized anxiety disorder, panic disorder with agoraphobia, social phobia, as well as SRQ scores and suicide risk) and substance-use disorders (tobacco, alcohol, cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogens and opioids) in youth in the general population of the city of Pelotas, RS.

METHOD

This was a cross-sectional population-based study, involving 1560 participants between 18 and 24 ears old. Lifetime substance use and abuse were investigated using the ASSIST inventory. Psychiatric comorbidities were assessed using the Mini-International Neuropsychiatric Interview and symptoms of common mental disorders were evaluated with the Self-Reported Questionnaire (SRQ).

RESULTS

The prevalence of lifetime crack cocaine use in the sample was 2.5%. Its use was associated with total SRW scores and the presence of post-traumatic stress disorder, antisocial personality disorder and suicide risk in the final regression model. Tobacco, alcohol, cannabis, cocaine, amphetamine and cocaine dependence were also associated with lifetime use of crack cocaine.

DISCUSSION

Youth with a history of crack cocaine use had a higher prevalence of psychiatric conditions such as post-traumatic stress disorder, as well as an increased risk of tobacco, alcohol, cannabis, cocaine, amphetamine and inhalant use and dependence.

Treatment outcome in substance use disorder patients with and without comorbid posttraumatic stress disorder: A systematic review

We investigated the role of comorbid posttraumatic stress disorder (CO-PTSD) in substance use disorder (DSM-IV/ICD-10 substance abuse or dependence, SUD) treatment. We conducted a systematic review of treatment outcome studies in SUD patients with and without CO-PTSD from 2000 to 2011. The N = 22 studies found differed clearly with regard to methodology and the sufficiency of provided study information, limiting their comparability. Remarkably, no consistent indication of a negative effect of CO-PTSD on the reported SUD treatment outcome was found. In addition to CO-PTSD, we point out possible further effect modifiers which need to be better understood. Finally, we emphasize the requirements for future research such as methodological standardization and a focus on long-term studies.

The feasibility and acceptability of a brief intervention for clients of substance use services experiencing symptoms of post traumatic stress disorder

BACKGROUND

Trauma exposure and post traumatic stress disorder (PTSD) are common among clients of substance use services. Existing treatments for these co-occurring conditions tend to be lengthy, treatment retention is relatively poor, and they require extensive training and clinical supervision. The aim of the present study was to conduct a preliminary examination of the feasibility and acceptability of a brief intervention for PTSD symptoms among individuals seeking substance use treatment.

METHODS

An uncontrolled open-label pilot study was conducted among 29 inpatients of a medicated detoxification unit in Sydney, Australia. All participants completed a baseline interview followed by the brief intervention. The intervention consists of a single, one-hour manualised session providing psychoeducation pertaining to common trauma reactions and symptom management. PTSD and substance use outcomes were assessed at 1-week, 1-month and 3-month post-intervention.

RESULTS

PTSD symptom severity (assessed using the Clinicians Administered PTSD Scale) decreased significantly from baseline to 1-week follow up (β -10.87, 95%CI: -19.75 to -1.99) and again between the 1-week and 3-month follow-ups (β -15.38, 95%CI: -23.20 to -7.57). Despite these reductions, the majority of participants continued to meet criteria for a diagnosis of PTSD and there was no change in participants' negative post-traumatic cognitions. Participants expressed high levels of satisfaction with the intervention.

CONCLUSIONS

Brief psychoeducation for traumatised clients attending substance use services appears to be feasible, acceptable, and may be of some benefit in reducing PTSD symptoms. However, participants continued to experience symptoms at severe levels; thus, brief intervention may best be conceptualised as a "stepping stone" to further trauma treatment.

Differences in relationship conflict, attachment, and depression in treatment-seeking veterans with hazardous substance use, PTSD, or PTSD and hazardous substance use

Veterans (N = 133) who were seeking treatment in either the Posttraumatic Stress Program or Substance Use Disorders Program at a Veterans Affairs Medical Center (VAMC) and, based on self-report of symptoms, met clinical norms for posttraumatic stress disorder (PTSD) or hazardous substance use (HSU) completed a survey related to relationship conflict behaviors, attachment styles, and depression severity. Participants were grouped into one of three categories on the basis of clinical norm criteria: PTSD only, HSU only, and PTSD + HSU. Participants completed the PTSD Checklist-Military, Experiences in Close Relationships Scale-Short Form, Center for Epidemiologic Studies-Depression scale, Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test, and Psychological Aggression and Physical Violence subscales of the Conflict Tactics Scale. Most participants were male and Caucasian. Significant differences were found between groups on depression, avoidant attachment, psychological aggression perpetration and victimization, and physical violence perpetration and victimization. Post hoc analyses revealed that the PTSD + HSU group had significantly higher levels of depression, avoidant attachment, and psychological aggression than the HSU only group. The PTSD + HSU group had significantly higher levels of physical violence than did the PTSD only group, but both groups had similar mean scores on all other variables. Potential treatment implications are discussed.

Trauma-focused treatment for posttraumatic stress disorder combined with CBT for severe substance use disorder: a randomized controlled trial

BACKGROUND

This randomized controlled trial (RCT) investigated the effectiveness of a combined treatment for co-morbid Posttraumatic Stress Disorder (PTSD) and severe Substance Use Disorder (SUD).

METHODS

Structured Writing Therapy for PTSD (SWT), an evidence-based traumafocused intervention, was added on to Treatment As Usual (TAU), consisting of an intensive cognitive behavioral inpatient or day group treatment for SUD. The outcomes of the combined treatment (TAU + SWT) were compared to TAU alone in a sample of 34 patients.

RESULTS

Results showed a general reduction of SUD symptoms for both TAU + SWT and TAU. Treatment superiority of TAU + SWT was neither confirmed by interaction effects (time x condition) for SUD or PTSD symptoms, nor by a group difference for SUD diagnostic status at post-treatment. However, planned contrasts revealed that improvements for PTSD severity over time were only significant within the TAU + SWT group. In addition, within the TAU + SWT group the remission of PTSD diagnoses after treatment was significant, which was not the case for TAU. Finally, at post-treatment a trend was noticed for between group differences for the number of PTSD diagnoses favoring TAU + SWT above TAU.

CONCLUSIONS

In sum, the current study provides preliminary evidence that adding a trauma-focused treatment on to standard SUD treatment may be beneficial.

Dropout among patients in qualified alcohol detoxification treatment: the effect of treatment motivation is moderated by Trauma Load

Background

Motivation to change has been proposed as a prerequisite for behavioral change, although empirical results are contradictory. Traumatic experiences are frequently found amongst patients in alcohol treatment, but this has not been systematically studied in terms of effects on treatment outcomes. This study aimed to clarify whether individual Trauma Load explains some of the inconsistencies between motivation to change and behavioral change.

Methods

Over the course of two months in 2009, 55 patients admitted to an alcohol detoxification unit of a psychiatric hospital were enrolled in this study. At treatment entry, we assessed lifetime Trauma Load and motivation to change. Mode of discharge was taken from patient files following therapy. We tested whether Trauma Load moderates the effect of motivation to change on dropout from alcohol detoxification using multivariate methods.

Results

55.4% dropped out of detoxification treatment, while 44.6% completed the treatment. Age, gender and days in treatment did not differ between completers and dropouts. Patients who dropped out reported more traumatic event types on average than completers. Treatment completers had higher scores in the URICA subscale Maintenance. Multivariate methods confirmed the moderator effect of Trauma Load: among participants with high Trauma Load, treatment completion was related to higher Maintenance scores at treatment entry; this was not true among patients with low Trauma Load.

Conclusions

We found evidence that the effect of motivation to change on detoxification treatment completion is moderated by Trauma Load: among patients with low Trauma Load, motivation to change is not relevant for treatment completion; among highly burdened patients, however, who a priori have a greater risk of dropping out, a high motivation to change might make the difference. This finding justifies targeted and specific interventions for highly burdened alcohol patients to increase their motivation to change.

Validation of two screening instruments for PTSD in Dutch substance use disorder inpatients

Posttraumatic stress disorder (PTSD) is highly prevalent in substance use disorder (SUD) populations. Because resources for extensive and thorough diagnostic assessment are often limited, reliable screening instruments for PTSD are needed. The aim of the current study was to test two short PTSD measures for diagnostic efficiency in predicting PTSD compared to the Clinician-Administered PTSD Scale (CAPS). The sample consisted of 197 SUD patients receiving residential substance use treatment who completed questionnaires regarding substance use and trauma-related symptoms, all abstinent from substance for 4weeks. The PTSD section of the Mini International Neuropsychiatric Interview plus (MINIplus) and the Self-Report Inventory for PTSD (SRIP) are compared to the CAPS. Results showed low sensitivity (.58) and high specificity (.91) for the PTSD section of the MINIplus. The SRIP showed high sensitivity (.80) and moderately high specificity (.73) at a cut-off score of 48. The prevalence of PTSD as measured with the CAPS was 25.4% current and 46.2% lifetime. Results indicate that the MINIplus, a short clinical interview, has insufficient quality as a screener for PTSD. The SRIP, however, is a reliable instrument in detecting PTSD in a SUD inpatient population in The Netherlands. Screening for PTSD is time efficient and increases detection of PTSD in SUD treatment settings.

The relative and unique contributions of emotion dysregulation and impulsivity to posttraumatic stress disorder among substance dependent inpatients

BACKGROUND

Despite elevated rates of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients, as well as the clinical relevance of this co-occurrence, few studies have examined psychological factors associated with a PTSD-SUD diagnosis. Two factors worth investigating are emotion dysregulation and impulsivity, both of which are associated with PTSD and SUDs. Therefore, this study examined associations between PTSD and facets of emotion dysregulation and impulsivity within a sample of trauma-exposed SUD inpatients.

METHODS

Participants were an ethnically diverse sample of 205 SUD patients in residential substance abuse treatment. Patients were administered diagnostic interviews and completed a series of questionnaires.

RESULTS

Patients with PTSD (n=58) reported significantly higher levels of negative urgency (i.e., the tendency to engage in impulsive behaviors when experiencing negative affect) and lower sensation seeking, as well as higher levels of emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior when upset, difficulties controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall emotion dysregulation emerged as a significant predictor of PTSD status, accounting for unique variance in PTSD status above and beyond facets of impulsivity (as well as other relevant covariates).

CONCLUSIONS

Results suggest that emotion dysregulation may contribute to the development, maintenance, and/or exacerbation of PTSD and highlight the potential clinical utility of targeting emotion dysregulation among SUD patients with PTSD.

Examining the interactive effect of posttraumatic stress disorder, distress tolerance, and gender on residential substance use disorder treatment retention

An extensive body of research has demonstrated that patients with a co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) diagnosis are at high risk for a wide range of negative clinical outcomes, including treatment noncompletion. However, no studies to date have explored the effect of a PTSD-SUD diagnosis on residential SUD treatment completion, as well as potential moderators of this effect. Consequently, the goal of this study was to examine the interactive effect of a PTSD diagnosis, distress tolerance (DT), and gender on residential SUD treatment retention. Participants were 214 substance-dependent patients consecutively admitted to a residential SUD treatment facility. Participants were administered diagnostic interviews, completed a laboratory-based measure of DT, and were followed throughout the course of treatment. Although no significant main effects were found, results did reveal a significant PTSD × gender × DT interaction. Post hoc analyses indicated that, among men, those with a current diagnosis of PTSD and low DT completed a significantly lower proportion of residential SUD treatment compared to all other groups. The implications of the study's findings for identifying ways to improve residential SUD treatment retention among patients with a PTSD-SUD diagnosis are discussed.

Trauma und Sucht: Implikationen für die Psychotherapie

Ziel: Die vorliegende narrative Übersichtsarbeit geht der Frage nach, welche Rolle traumatische Lebenserfahrungen und damit assoziierte Traumafolgestörungen bezüglich der Ätiologie und Pathogenese von Suchterkrankungen spielen und welche Implikationen sich daraus für die therapeutische Praxis ableiten. Ergebnisse: Die aktuelle empirische Befundlage belegt ein gehäuftes gemeinsames Auftreten von traumatischen Erfahrungen und substanzbezogenen Störungen sowie eine erhöhte Komorbidität von Posttraumatischer Belastungsstörung und Suchterkrankungen. Befunde aus Interview- und Fragebogenstudien sowie aus experimentellen Untersuchungen mit komorbiden Patienten zeigen, dass Betroffene psychotrope Substanzen als Selbstmedikation einsetzen, um ihre traumabedingte Symptomatik zu lindern. Es entsteht ein komplexes, sich gegenseitig aufrechterhaltendes Wechselspiel zwischen Traumafolge- und Suchtsymptomatik, welches die Behandlung deutlich erschwert. Schlussfolgerungen: Zur Unterbrechung dieses Wechselspiels erscheint ersten Befunden zufolge ein von Beginn an integrativer, traumafokussierter Behandlungsansatz besonders geeignet. Auch wenn diesbezüglich erste erfolgsversprechende traumakonfrontative Therapieansätze entwickelt wurden, stehen größere prospektive Untersuchungen sowie randomisiert kontrollierte Therapiestudien diesbezüglich noch aus und sollten einen Schwerpunkt zukünftiger Forschung auf diesem Gebiet bilden.

Comparison of treatment outcomes for veterans with posttraumatic stress disorder with and without comorbid substance use/dependence

Most of the attention to the treatment of patients who have comorbid Substance Use/Dependence Disorder (SUD) and Posttraumatic Stress Disorder (PTSD) has focused on SUD outcomes. This study focuses on the PTSD outcomes of comorbid patients as compared to those with PTSD only. Altogether 8599 Veterans admitted to VA specialized inpatient/residential PTSD programs were assessed for PTSD and SUD symptoms at admission and four months following discharge. Two samples were drawn sequentially in separate phases due to unexpected results in the first sample: 4966 in the first sample and 3633 in the second sample. In the first sample, dually diagnosed Veterans had significantly better PTSD outcomes than Veterans diagnosed with PTSD only. The differences could be attributed primarily to improvement in comorbid SUD symptoms. These results were replicated in the second sample. The results suggest that there may be a synergistic effect operating in the treatment of the two comorbid disorders.

Impulsive behaviors as an emotion regulation strategy: examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients

Recent investigations have demonstrated that posttraumatic stress disorder (PTSD) is associated with a range of impulsive behaviors (e.g., risky sexual behavior and antisocial behavior). The purpose of the present study was to extend extant research by exploring whether emotion dysregulation explains the association between PTSD and impulsive behaviors. Participants were an ethnically diverse sample of 206 substance use disorder (SUD) patients in residential substance abuse treatment. Results demonstrated an association between PTSD and impulsive behaviors, with SUD patients with PTSD reporting significantly more impulsive behaviors than SUD patients without PTSD (in general and when controlling for relevant covariates). Further, emotion dysregulation was found to fully mediate the relationship between PTSD and impulsive behaviors. Results highlight the relevance of emotion dysregulation to impulsive behaviors and suggest that treatments targeting emotion dysregulation may be useful in reducing impulsive behaviors among SUD patients with PTSD.

Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: a systematic review

This article gives an overview of research into psychological treatments for concurrent posttraumatic stress disorder (PTSD) and substance used disorder (SUD), with a special focus on the effectiveness of treatments addressing both disorders compared to treatments addressing one of the disorders alone. In addition, a distinction is made between trauma-focused versus non-trauma-focused therapies for concurrent PTSD and SUD. The databases Embase, Psychinfo, Medline and Web of science were searched for relevant articles. In total, seventeen studies were identified evaluating ten treatments protocols (six trauma-focused and four non-trauma-focused treatment approaches). In general, the studies showed pre-post reductions for PTSD and/or SUD symptoms. Although most treatments for concurrent PTSD and SUD did not prove to be superior to regular SUD treatments, there are some promising preliminary results suggesting that some patients might benefit from trauma-focused interventions. However, the lack of methodologically sound treatment trials makes it difficult to draw firm conclusions. Methodological limitations are discussed, along with recommendations for future research.

Reducing dropout among traumatized alcohol patients in detoxification treatment: a pilot intervention study

Dropout rates from detoxification treatment are high. We tested whether high trauma event load was related to a higher dropout from alcohol detoxification. Furthermore, we studied the feasibility and effects of a short psychoeducational tool to increase retention among traumatized alcohol in-patients. Retention and treatment length were compared between treatment as usual (TAU) and standard therapy plus a psychoeducational group intervention on alcohol drinking related to stress and trauma (PAST). Patients with high trauma load were identified with the Trauma History Questionnaire. Of the 159 in-patients treated during the study period, 66 were included in the analysis: 33 in TAU and 33 in PAST. Sociodemographic characteristics did not differ between the groups. During TAU, patients with high trauma load tended to drop out more often (p = 0.056). Among patients with high trauma load, retention level increased from 29 to 80% (p = 0.006), and among those with low trauma load from 63 to 83% (p = 0.250). Treatment length only tendentially improved among patients with lower burden (p = 0.056). The pilot study supports the idea that detoxification treatment dropout occurs more often among alcohol patients with high trauma load and that their retention can be increased by a psychoeducational group intervention.

The Use of Exposure-Based Treatment Among Individuals With PTSD and Co-occurring Substance Use Disorders: Clinical Considerations

Integrative treatments for co-occurring posttraumatic stress (PTSD) and substance use disorders have been shown to be safe and effective. Improvement in PTSD symptoms can positively impact substance use outcomes. Interventions that include exposure-based techniques, which are considered the treatment of choice for PTSD, have not been well studied in substance abusing populations. Concurrent Treatment of PTSD and Substance Use Disorders with Prolonged Exposure (COPE) is a manualized psychotherapy that combines both imaginal and in vivo exposure techniques for PTSD with cognitive behavioral techniques for substance use disorders. Preliminary studies using COPE demonstrate promise and feasibility. This article explores the clinical considerations when implementing exposure-based therapy for PTSD in substance abusing individuals.