Post Trauamatic Stress Disorder and Substance Use Disorder

*Mental health and substance use: EMCDDA session*

There is significant comorbidity of PTSD and SUD. 5 large scale national studies in the US and Australia show respondents with PTSD are 2-5 times more likely to have SUD than those without PTSD; respondents with SUD are 1.5 to 6.5 times more likely to have PTSD than those without SUD.

Comorbid PTSD-SUD is associated with substantial increased health care burden in psychiatric comorbidity (e.g., depression), medical problems, vocational impairment, increased violence, and poor treatment outcomes (Blanco 2013). Assessment of comorbid PTSD-SUD is predicated on an understanding of the trauma informed approach, whose primary principle is to avoid re-traumatizing a person.

The standard 3 phases of trauma treatment consist of: safety and stabilization (skills building) (Najavits 2002); memory processing; and reintegration (Herman 1992).  For many years, in order to prevent relapse, the two disorders were treated sequentially, not concomitantly. Early literature supporting concomitant (“integrated”) treatment (Hien 2010), utilized skills based PTSD treatment (“Seeking Safety”, “STAIR”, and Present Centered Therapy), not “processing” treatments; processing type treatments (eg prolonged exposure, EMDR, and cognitive processing therapy), are more effective than skills based, at reducing and resolving symptoms of PTSD (Norman 2019).

The earliest studied integrated processing treatment, utilized relapse prevention therapy, and prolonged exposure (COPE: Back 2014). Numerous subsequent studies support its efficacy as a treatment for PTSD, without exacerbating SUD symptoms (Hien 2018, Back 2019). Barriers remain in implementing integrated processing treatment, such as lack of adequate training, practical aspects of providing trauma treatment to patients with active SUD, and the high drop-out rate associated with prolonged exposure (Eftekhari 2020). Studies of integrated processing treatment utilizing EMDR, which has a more favorable drop out rate, have not yet been published. The experience from Weill Cornell Medical College Center for Trauma and Addiction, a program utilizing EMDR for patients with co-occurring PTSD-SUD, will be discussed.

Back, S. E.,et al. (2019). Concurrent treatment of SUD and PTSD using PE: Addictive Behaviors.

Blanco, C., et al. (2013). Comorbidity of PTSDr with alcohol dependence among US adults: Drug and Alcohol Dependence. 

Eftekhari, A., et al. (2020). Predicting treatment dropout among veterans receiving prolonged exposure. Psychological Trauma: Theory, Research, Practice, and Policy. 

Hien, D. A., et al. (2010). Do Treatment Improvements in PTSD Severity Affect Substance Use Outcomes?  American journal of psychiatry.

Najavits, L. M. (2002). Seeking safety. New York: Guilford Press

Norman, S. B., et al. (2019). Efficacy of Integrated Exposure Therapy vs Integrated Coping Skills Therapy for Comorbid PTSD & AUD. Archives of general psychiatry. 

* Mental health and substance use: EMCDDA session*