Opinion statement
Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur. Existent evidence suggests that SUD often develops in reaction to PTSD symptoms, as individuals attempt to “self-medicate” their PTSD symptoms. Once the SUD develops, the disorders establish a bi-directional loop, with PTSD driving further substance use behaviors, and the SUD symptoms mirroring and reinforcing symptoms of PTSD. Once this bi-directional cycle is locked in, the disorders become more resistant to treatment and result in poorer prognoses and worse health outcomes versus having only one of these disorders. Traditional approaches to treatment of co-occurring PTSD and SUD have involved segregated and sequential treatment models. Normally, this involves treatments focused first on the SUD followed by a referral to different providers to address the PTSD. This traditional sequential and segregated treatment model presents several challenges to patients and treatment providers and may unintentionally contribute to the poorer prognosis observed in individuals with co-occurring PTSD-SUD. There are now state-of-the-art treatment approaches that focus on simultaneously treating PTSD and SUD. Psychotherapeutic protocols are available to simultaneously treat PTSD and SUD. Findings show that psychotherapies that simultaneously address PTSD and SUD show superior outcomes in reducing PTSD versus SUD treatment as usual. Recent studies also support the efficacy of several medications, including sertraline, naltrexone, and prazosin in treating co-occurring PTSD-SUD. Although treatments are shown to produce benefits to either reduce PTSD or improve SUD outcomes, no psychotherapeutic treatment, psychopharmacologic treatment, or combination thereof is shown to produce greater benefits versus SUD treatment as usual for simultaneously reducing both PTSD symptoms and improving SUD outcomes. The current research suggests that clinicians should consider simultaneous treatment approaches for co-occurring PTSD and SUD.
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References and Recommended Reading
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Ozer E, Best S, Lipsey T, Weiss D. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129:52–73.
Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 1991;48:216–22.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.
Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry. 2001;158:1184–90.
Jacobsen L, Southwick S, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatry. 2001;158:1184–90.
Khantzian EJ. Treating addiction as a human process. London: Jason Aronson; 1999.
Bremner JD, Southwick SM, Darnell A, Charney DS. Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse. Am J Psychiatry. 1996;153:369–75.
Scherrer JF, Xian H, Lyons MJ, et al. Posttraumatic stress disorder, combat exposure, nicotine dependence, alcohol dependence, and major depression in male twins. Compr Psychiatry. 2008;49:297–304.
Xian H, Chantarujikapong SI, Scherrer JF, et al. Genetic and environmental influences in posttraumatic stress disorder, alcohol and drug dependence in twin pairs. Drug Alcohol Depend. 2000;61:95–102.
Brown PJ, Stout RL, Mueller T. Substance use disorder and posttraumatic stress disorder comorbidity: addiction and psychiatric treatment rates. Psychol Addict Behav. 1999;13:115–22.
Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 1991;48:216–22.
Ouimette PC, Finney JW, Moos RH. Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychol Addict Behav. 1999;13:105–14. This study provides evidence for the negative prognosis that is exhibited by individuals with substance use disorders and co-occurring posttraumatic stress disorder.
Young HE, Rosen CS, Finney JW. A survey of PTSD screening and referral practices in VA addiction treatment programs. J Subst Abuse Treat. 2005;28:313–9.
Ouimette PC, Goodwin E, Brown PJ. Health and well-being of substance use disorder patients with and without PTSD. Addict Behav. 2006;31:1415–23.
Rosen CS, Chow HC, Finney JF, Greenbaum MA, Moos RH, Sheikh JI, et al. VA practice patterns and practice guidelines for treating posttraumatic stress disorder. J Trauma Stress. 2004;17:213–22.
Najavitis LM, Norman SB, Kivlahan D, Kosten TR. Improving PTSD/substance abuse treatment in the VA: a survey of providers. Am J Addict. 2010;19:257–63.
Back SE, Waldrop AE, Brady KT. Treatment challenges associated with comorbid substance use and posttraumatic stress disorder: clinician’s perspectives. Am J Addict. 2009;18:15–20.
Najavitis LM, Hien D. Helping vulnerable populations: a comprehensive review of the treatment outcome literature on substance use disorder and PTSD. J Clin Psychol In Session. 2013;69:433–79.
Roberts NP, Roberts PA, Jones N, Bisson JI. Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2015;38:25–38. This recent meta-analysis summarizes the evidence for present-centered and trauma-focused psychotherapies for addressing co-occurring substance use disorders and posttraumatic stress disorder.
Foa EB, Hembree EA, Rothbaum BO. Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences: therapist guide. New York: Oxford University Press; 2007.
Mills KL, Teeson M, Back SE, et al. Integrated exposure-based therapy for co-occuring posttraumatic stress disorder and substance dependence: a randomized controlled trial. J Am Med Assoc. 2012;308:690–9. This randomized controlled trial examined the efficacy of integrating prolonged exposure therapy with substance use psychotherapy for individuals with co-occurring substance use disorders and posttraumatic stress disorder. Findings showed greater benefits for the study treatment with regard to posttraumatic stress disorder but not substance use disorder.
Schumm JA, Monson CM, O’Farrell TJ, Gustin N, Chard KM. Couple treatment for alcohol use disorder and posttraumatic stress disorder: pilot results from military veterans and their partners. J Trauma Stress. 2015;28:247–52.
Hien DA, Levin FR, Ruglass LM, et al. Combining seeking safety with sertraline for PTSD and alcohol use disorders: a randomized control trial. J Consult Clin Psychol. 2015;83:359–69. This recent randomized clinical trial examined the efficacy of combining sertraline with Seeking Safety for individuals with co-occurring alcohol use disorder and posttraumatic stress disorder. Findings showed that the combination of Seeking Safety plus sertraline was superior to Seeking Safety plus placebo for treating posttraumatic stress disorder.
Friedman MJ, Davidson JRT, Stein DJ. Psychopharmacotherapy for adults. In: Foa EB, Keane TM, Friedman MJ, Cohen JA, editors. Effective treatments for PTSD. 2nd ed. New York: The Guilford Press; 2009. p. 245–68.
Foa EB, Yusko DA, McLean CP, et al. Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: a randomized clinical trial. J Am Med Assoc. 2013;310:488–95. This randomized controlled trial showed benefits of adding naltrexone to psychotherapy for the treatment of co-occurring alcohol use disorder and posttraumatic stress disorder.
Cahill SP, Rothbaum BO, Resick PA, Follette VM. Cognitive-behavioral therapy for adults. In: Foa EB, Keane TM, Friedman MJ, Cohen JA, editors. Effective treatments for PTSD. 2nd ed. New York: The Guilford Press; 2009. p. 139–222.
Simpson TL, Malte CA, Dietel B, et al. A pilot trial of prazosin, an alpha-I adrenergic antagonist, for comorbid alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. 2015;39:808–17.
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This material is the result of work supported with resources and the use of facilities at the Cincinnati VA Medical Center. The opinions presented in this article are those of the authors and do not represent the views of the US Department of Veterans Affairs or US Government.
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Jeremiah A. Schumm declares that he has no conflict of interest.
Whitney L. Gore declares that she has no conflict of interest.
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Schumm, J.A., Gore, W.L. Simultaneous Treatment of Co-occurring Posttraumatic Stress Disorder and Substance Use Disorder. Curr Treat Options Psych 3, 28–36 (2016). https://doi.org/10.1007/s40501-016-0071-z
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DOI: https://doi.org/10.1007/s40501-016-0071-z