Implementing trauma-focused integrated treatment for women with PTSD and substance use disorder in Australia

Background: Trauma and addiction frequently co-occur. About 1 in 2 people in addiction treatment settings have symptoms of post-traumatic stress disorder (PTSD), yet integrated treatment is not routinely available. Although gold standard psychological approaches, such as COPE (Concurrent Treatment of PTSD and substance use with Prolonged Exposure), are demonstrated to be safe and efficacious, their translation into routine practice has been limited in Australia. This study presents data from a pilot clinic for women with PTSD and substance use disorder at Turning Point, Melbourne, the first trauma-focused integrated service in the state, with the aim of sharing reflections relevant to clinical practice and broader program implementation of this important treatment innovation.

Methods: Evaluation of a clinical program, incorporating data from women accessing care from November 2020 to Nov 2023. Data collected included background demographics (age, postcode, employment and accommodation status, caregiving status), substance use (primary drug of concern, AUDIT and DUDIT, Alcohol Use Disorder Identification Test, Drug Use Disorders Identification Test), trauma history (Life Events Checklist for DSM-5), and symptoms of trauma-related mental health disorders including PTSD and complex PTSD (PCL-5, International Trauma Questionnaire). Statistical analyses included descriptive characterisation of the sample and analyses of trauma symptoms by primary drug of concern. This study received quality assurance approval from the Eastern Health Human Research Ethics Committee.

Results: The majority of clients accessing the service had not had previous treatments for trauma. The most common drug of concern in this group was alcohol, followed by methamphetamine. Most women accessing this clinic had experienced multiple trauma exposures, in childhood and in adulthood. Most women had symptoms that met criteria for complex PTSD (80%), rather than PTSD.
Implementation challenges within routine care included capacity building of referrers and clinical teams in assessment of trauma and PTSD, as well as building clinician capability and confidence in delivery of prolonged exposure treatment. Similar to other trauma-focused prolonged exposure programs, this study identified significant drop-out from treatment at key points in the program, and faced challenges in retention.

Conclusions: This was the first clinic to provide integrated trauma-focused treatment for PTSD and substance use disorder in a routine care, public setting in this region. Evaluation of the program provided key learnings for our team, and for referrers and substance use treatment providers, in relation to assessment of trauma, readiness for trauma-focused care, and gaps in capacity and capability. Clinically, women appeared to derive benefits from the COPE program, including reductions in PTSD and substance use, despite a diverse range of presentations, symptom profiles and rates of retention in treatment.