Reducing PTSD Severity May Improve
Substance Abuse Outcomes

Reducing severity of posttraumatic stress disorder (PTSD) symptoms is more likely to improve substance use outcomes, a finding that suggests that requiring patients with these comorbid disorders to be abstinent from drugs or alcohol before treating PTSD may be the wrong approach.

In a secondary analysis of data from the National Institute on Drug Abuse Clinical Trials Network, investigators at Columbia University found that reducing PTSD severity was more likely to lead to substance use improvement than vice versa.

"PTSD severity reductions were more likely to be associated with substance use improvement with minimal evidence of substance use symptoms reduction improving PTSD symptoms," the study authors, led by Denise A. Hien, PhD, write.

The study is published in the January issue of the American Journal of Psychiatry.

Safe and Effective

The trial included 353 women with comorbid PTSD and substance abuse. Patients were randomized to 12 sessions of either trauma-focused or health education group treatment.

The analysis showed that that trauma-focused treatment was the more effective approach but only among patients who were heavy substance users at baseline and who had achieved significant PTSD reductions.

“What this says to me as a standard of care point is that we do have certain treatments for PTSD and substance use disorders that have been shown to be very effective in reducing substance use but that not all treatments may be equally effective, depending upon the baseline characteristics of the individual presenting for care," Dr. Hien told Medscape Psychiatry.

The researchers found that with every unit of PTSD improvement on the Clinician-Administered PTSD Scale, the odds of being a heavy substance user at follow-up decreased by 4.6%, a finding that suggests that patients who can achieve PTSD symptom reduction are more likely to reduce their substance use and supports the hypothesis that individuals with PTSD self-medicate in an attempt to lessen their PTSD symptoms.

“Contrary to clinical fears, cognitive behavioral therapies designed for the treatment of PTSD and substance use disorder can be effective and safe for patients,” Dr. Hien said.

Time for a Change

In routine clinical practice, trauma or PTSD treatment is often deferred until the patient receives specialized addiction treatment and is abstinent from drugs and alcohol before undergoing trauma treatment. This sequencing is based on the concern that addressing trauma will worsen substance abuse.

In an accompanying editorial, Sudie E. Back, PhD, Medical University of South Carolina, Charleston, says it is time for this treatment paradigm to shift.

"The accumulating findings bring into question the common practice of requiring patients with PTSD and substance use disorders to be abstinent from alcohol or drugs before commencing trauma work. This commonly practiced treatment approach, known as the sequential model, means that patients with PTSD and a substance use disorder who present for trauma/PTSD treatment are generally referred out to first receive specialized addiction treatment," writes Dr. Back.

She adds that it is unclear how many patients " 'fall through the cracks' and either do not follow up on the addiction treatment referral or do not return to receive PTSD treatment following addiction treatment. Because patients are usually referred to a different therapist working in a different clinic with little provider cross-communication, it is likely that many are lost in this process. There has to be a better way."

Dr. Back recommends integrated treatment to address both trauma/PTSD and substance use.

"Contrary to early, largely anecdotal concerns, all of the investigations that have examined the use of integrated, cognitive behavior therapies to address PTSD and substance use disorders to date demonstrate significant reductions in both PTSD and substance use disorder outcomes. Concerns that patients who undergo trauma-focused treatment will evidence an increase in substance use, relapse, or attrition has not been borne out by the data," Dr. Back writes.

This study was supported by the National Institute on Drug Abuse. Dr. Hien and Dr. Back have disclosed no relevant financial relationships.

Am J Psychiatry . 2010;167:95-101 and 11-13.

-From Medscape Psychiatry, Medscape Medical News, “ Reducing PTSD Severity May Improve Substance Abuse Outcomes”, by Janis C. Kelly, February 12, 2010, http://www.medscape.com/viewarticle/716824 retrieved 2/16/10.

 

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