My Trauma - My Drugs - My World

1. My Trauma - My Drugs - My World Thomas J Kadela, LCSW, PhD Department of Veterans Affairs Marion, Illinois VA Medical Center Behavioral Medicine Thomas.Kadela@va.gov 619-993-7524 ext. 54759

2. Definitions • SUD = Substance Use Disorder • OUD = Opioid Use Disorder • PTSD = Post Traumatic Stress Disorder • FDA = Food & Drug Administration • OEF = Operation Enduring Freedom • 2001 – 2014 (Afghanistan; Al Qaeda and the Taliban) • OIF = Operation Iraqi Freedom • 2003–2011 (Iraq; Saddam Hussein)

3. Overview of Wars • Korean War (1950-1953) • Vietnam War (1964-1975) • Invasion of Panama Dec 1989 – Jan 1990 (42 days) • Persian Gulf War (Desert Shield/Desert Storm) (1990- 1991) • Global War on Terror (Oct 2001 - present) • Operation Enduring Freedom 2001 – 2014 (Afghanistan; Al Qaeda and the Taliban) • Operation Iraqi Freedom 2003–2011 (Iraq; Saddam Hussein) • Operation New Dawn (OND) 2010 - • Operation Freedom’s Sentinel (OFS) 2015 – Present (ISIL)

4. Why Use Drugs & Alcohol?

5. Had times when you ended up drinking more, or longer than you intended? • More than once wanted to cut down or stop drinking, or tried to, but couldn’t? • Spent a lot of time drinking? Or being sick or getting over the aftereffects? • Experienced craving — a strong need, or urge, to drink? • Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems? • Continued to drink even though it was causing trouble with your family or friends? • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? • Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there? In the past year, have you…

6. Survey Says… • The presence of at least 2 of these symptoms indicates an Alcohol Use Disorder (AUD) • The severity of the AUD is defined as: • Mild: The presence of 2 to 3 symptoms • Moderate: The presence of 4 to 5 symptoms • Severe: The presence of 6 or more symptoms

7. What is PTSD?

8. What would happen if… You shot up with heroin… three times a day… for 20 days?

9. Early Research • Individually caged rats had two bottles of water; regular and loaded; or • Rats individually placed in Skinner Boxes where they were hooked up to various drugs using intravenous needles implanted in their jugular veins • Rats could choose to inject themselves with the drug by pushing a lever in the cage • Both cases rats killed themselves getting high • Conclusions? Heroin, Amphetamine, Morphine, & Cocaine were irresistibly addicting; “hijack” the brain, turning it from a “normal” brain into an addicted one, with death to follow

10. Rat Park • In 1978, Canadian psychologist Bruce K. Alexander created the Rat Park Experiment • Aimed to prove a person’s mental, emotional, and psychosocial states were the greatest cause of addiction, not the drug itself • United States was seven years into the War on Drugs, the trillion-dollar federal government effort to eradicate illegal street drugs by focusing on arresting and imprisoning drug sellers and users

11. Who’s Right?

12. General Data • Past two decades - numerous attempts to reduce substance abuse yet rates continue to rise • Alcohol is the 4th leading cause of preventable death in the general US population • Alcohol-impaired driving accounts for 31% of all driving-related fatalities • Illicit drug use among Veterans is roughly equivalent to their civilian counterparts • Binge drinking in Veterans is higher than civilian population

13. General Data • Consistent with general population - alcohol and drug use are more common among male than female Veterans • Compared to civilians (51%) - Veterans (57%) are more likely to use any alcohol • High levels of combat exposure are more likely to engage in heavy (27%) and binge (55%) drinking relative to other military personnel (17% and 45%)

14. Veterans • ~11% of Veterans presenting for first-time care meet criteria for a diagnosis of SUD • Between 2005 and 2010 problematic substance use (and diagnosis) among female Veterans increased 81% • Female Veterans with SUDs, compared to female Vets w/o SUDs, have higher rates of • childhood sexual abuse • military sexual trauma • domestic violence • Women with PTSD are particularly at risk of developing substance-related problems

15. Suicide & Risky Behavior • One study of military personnel found ~30% of completed suicides were preceded by alcohol or drug use • Estimated 20% of high-risk behavior deaths were attributed to alcohol or drug overdose • Veterans aged >65 with PTSD have higher risk for a suicide attempt if they also have drinking problems or depression

16. Joe’s CommonStory • Binge drinking in high school • Alcohol use under fairly good control in early military career • Multiple deployments OEF/OIF • Returns home with PTSD and/or TBI – does not seek treatment • Rapid escalation of binge drinking • Hospitalized for alcohol detoxification with suicidal ideation

17. Sarah’s Common Story • Significant combat injury • Long-term treatment with opioids • Now addicted to opioids • Spends 3 to 4 years securing and abusing opioid pharmaceuticals from medical providers and emergency departments • Transition to IV Heroin; using for 3 to 6 months • Seeks treatment for addiction

18. SUD Comorbidity -Physical Health • Obesity, sleep disturbance, physical injury, and chronic pain • Female Veterans with an SUD diagnosis are more likely to have reproductive and urinary problems • Male Veterans with an SUD diagnosis are more likely to be diagnosed with circulatory and digestive system diseases

19. SUD Comorbidity -Mental Health • Veterans dually diagnosed with PTSD and SUDs more likely to have • additional co-occurring psychiatric and medical conditions seizures • liver disease • HIV • Schizophrenia • anxiety disorders • bipolar disorder

20. Comorbidity • Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans diagnosed with an SUD • 82%–93% diagnosed with comorbid mental health disorder • Prevalence rates of SUDs and cooccurring disorders among OEF/OIF Veterans echo findings from studies on Vietnam-era Veterans • although post-Vietnam Veterans are more likely to be dually diagnosed

21. PTSD & SUD

22. Sleepzzzzz…………..zzzzzzz…. • Some drink because they think alcohol will decrease number or intensity of dreams • Alcohol changes the quality of sleep • Avoiding bad memories and dreams actually prolongs PTSD • Drinking continues the cycle of avoidance • When you suddenly stop drinking nightmares often get worse

23. Opiates • Opioid use disorder increasing among Veterans with PTSD • Opioids were being prescribed at increasing rates to Veterans to address issues such as migraine headaches and chronic pain • From 2001 to 2009, Veterans in the VA health care system receiving an opioid prescription increased from 17% to 24% • From 2003 to 2007 the number of prescriptions written for pain medication by military physicians more than quadrupled

24. Opiates • Chronic opioid use (6 months or longer) among young Veterans in the VA health care system increased from 30% to 45% • On average, patients were prescribed two different opioids and had three different prescribers • Of these opioid prescriptions, the majority were for codeine (68%), oxycodone (47%), and hydrocodone (40%) • Veterans with PTSD-OUD engaged in significantly more healthcare services than those with PTSD alone

25. Opioids &Mental Health • Any Mental Health Diagnosis increased likelihood of receiving an opioid prescription • As compared to Veterans without a mental health diagnosis, those with PTSD: • receive higher doses of opioid medications; • are more likely to receive a simultaneous prescription for additional opioids or for a sedative hypnotic; and • are more likely to receive an early refill

26. Marijuana • Marijuana use increased over the past decade • Daily use has increased 60% in the prior decade • 2013 study found 198 million people reported using marijuana in the past month, with 81 million using almost every day • Factors associated with increased risk of marijuana use • diagnosis of PTSD • social anxiety disorder • other substance use, particularly during youth • peer substance use

27. Marijuana PTSD &Veterans • Marijuana accounts for the vast majority of illicit drug use among Veterans • 35% report marijuana use • 17% report use of illicit drugs other than marijuana • From 2002 to 2009, cannabis use disorders increased over 50% among Veterans • Several states specifically approve the use of medical marijuana for PTSD • Illinois is one 

28. Marijuana PTSD &Veterans • There is no evidence at this time that marijuana is an effective treatment for PTSD • Controlled studies have not been conducted to evaluate the safety or effectiveness of medical marijuana for PTSD • In fact, research suggests that marijuana can be harmful to individuals with PTSD

29. Marijuana Use in Veterans • When considering the subset of Veterans seen in VA health care with co-occurring PTSD and substance use disorders cannabis use disorder has been the most diagnosed SUD since 2009 • The percentage of Veterans in VA with PTSD and SUD diagnosed with cannabis use disorder increased from 130% in fiscal year (FY) 2002 to 227% in FY 2014 • As of FY 2014 there are more than 40,000 Veterans with PTSD and SUD seen in VA diagnosed with cannabis use disorder

30. Marijuana - Medical Issues • Chronic bronchitis, abnormal brain development among early adolescent initiators, and impairment in short-term memory, motor coordination and the ability to perform complex psychomotor tasks such as driving • Psychiatric problems include psychosis and impairment in cognitive ability • Quality of life can also be affected through poor life satisfaction, decreased educational attainment, and increased sexual risk-taking behavior • Chronic marijuana use also can lead to addiction, with an established and clinically significant withdrawal syndrome

31. Neurobiology of Marijuana • Marijuana use by individuals with PTSD may result in short-term reduction of PTSD symptoms • Research has consistently demonstrated that the human endocannabinoid system plays a significant role in PTSD • People with PTSD have greater availability of cannabinoid type 1 (CB1) receptors as compared to trauma-exposed or healthy controls

32. Neurobiology of Marijuana • Recent work has shown CB1 receptors may return after periods of marijuana abstinence however individuals with PTSD may have particular difficulty quitting • Data suggest continued use of marijuana among individuals with PTSD may lead to a number of negative consequences, including marijuana tolerance (via reductions in CB1 receptor density and/or efficiency) and addiction

33. Treatment

34. Medication Assisted Treatment (MAT) * • Alcohol use disorders • Disulfiram (Antabuse) • creates an unpleasant physical reaction to alcohol • Naltrexone (Revia and Vivitrol) • helps prevent relapses into alcohol • Acamprosate • reduce desire to drink alcohol • Cocaine or marijuana use disorders • None

35. Medication Assisted Treatment (MAT) • Opioid use disorders • Methadone (clinic) • Buprenorphine (office) • Naltrexone and extended-release injectable naltrexone • Methadone • tricks the brain into thinking it’s still getting the abused drug • the person is not getting high from it and feels normal, so withdrawal doesn’t occur (pregnant or breastfeeding OK) • Buprenorphine • Like methadone, buprenorphine suppresses and reduces cravings for the abused drug • Naltrexone • If a person using naltrexone relapses and uses the abused drug, naltrexone blocks the euphoric and sedative effects of the abused drug and prevents feelings of euphoria

36. MATBarriers • Only about half of private-sector treatment programs for opioid use disorder currently offer access to MAT • DO YOU? • Some stem from a misconception about how the treatments work • Stigma surrounding drug use and addiction • Some federal and state laws restricting the availability of the medications

37. MATMisconceptions • “Medications simply replace the drugs that hooked users. This just leads to more highs and a pattern of repeated use.” • Instead, the drugs work by staunching cravings and reducing or preventing withdrawal and relapse • Buprenorphine and methadone help suppress cravings • Naltrexone blocks the euphoric and sedative effects of opioids so users don't experience a high

38. Marijuana -Treatment for PTSD? • Belief marijuana can be used to treat PTSD is limited to anecdotal reports from individuals who say the drug helps with their symptoms • No randomized controlled trials for determining efficacy • Oral CBD has been shown to decrease anxiety in those with and without clinical anxiety • Led to the development and testing of CBD treatments for social anxiety but not yet for PTSD • One open trial of THC (10 participants) with PTSD showed THC was safe and well tolerated; resulted in decreases in hyperarousal symptoms

39. Emotional Regulation • Patients with both PTSD and substance abuse can have difficulty managing strong emotions • Trauma-focused therapies require patients to confront painful memories • substance use is often triggered by negative emotions • patients with poorer emotion regulation skills when starting treatment may show less response to treatment than patients with better skills

40. PTSD Psycho-therapies (Gold Standard) • Prolonged Exposure (PE) • Teaches you how to gain control by facing your negative feelings • Involves talking about your trauma and doing some things you’ve avoided • Cognitive Processing Therapy (CPT) • Teaches you to reframe negative thoughts about the trauma • Involves talking about your negative thoughts and doing short writing assignments • Eye-Movement Desensitization and Reprocessing (EMDR) * • Helps you process and make sense of your trauma • Involves calling the trauma to mind while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone)

41. Other (less efficacious) PTSD Treatments • Brief Eclectic Psychotherapy (BEP) • A therapy in which you practice relaxation skills, recall details of the traumatic memory, reframe negative thoughts about the trauma, write a letter about the traumatic event, and hold a farewell ritual to leave trauma in the past • Narrative Exposure Therapy (NET) • Developed for people who have experienced trauma from ongoing war, conflict, and organized violence You talk through stressful life events in order (from birth to the present day) and put them together into a story • Written Narrative Exposure • Involves writing about the trauma during sessions Your provider gives instructions on the writing assignment, allows you to complete the writing alone, and then returns at the end of the session to briefly discuss any reactions to the writing assignment

42. Other (less efficacious) PTSD Treatments • Stress Inoculation Training (SIT) • A cognitive-behavioral therapy that teaches skills and techniques to manage stress and reduce anxiety • Present-Centered Therapy (PCT) • Focuses on current life problems that are related to PTSD • Interpersonal Psychotherapy (IPT) • Focuses on the impact of trauma on interpersonal relationships

43. PTSD Medications • Antidepressants (SSRIs and SNRIs) • Sertraline (Zoloft) • Paroxetine (Paxil) • Fluoxetine (Prozac) • Venlafaxine (Effexor)

44. PTSD Coach • PTSD Family Coach • Mindfulness Coach • VetChange (alcohol and PTSD) • Anger and Irritability Management Skills (AIMS) • CPT Coach • PE Coach • CBT-Insomnia Coach • ACT Coach • STAIR Coach (Skills Training in Affective & Interpersonal Regulation) • Mood Coach (Behavioral Activation) • Concussion Coach • Parenting To Go • Moving Forward (Problem Solving Skills) • Stay Quit Coach (Smoking) Mobile Apps

45. Barriers in Southern Illinois • Rural Location • Of Veterans enrolled in VA health care system ~34 million are rural (41% of total) • Access to care, particularly mental health services, is problematic • Increased access via tele-mental health (TMH) improved quality of life • Feasibility and efficacy have been shown in home-based and remote locations among Veterans and civilians • Though literature directly pertaining to the delivery of TMH services for SUDs is limited, it demonstrated favorable results

46. Barriers in Southern Illinois • Underutilized Treatment • About 10% of Veterans w/ SUD receiving any type of SUD treatment had other therapy • Psychotherapy is an important part of treatment for PTSD and SUD, the majority of patients with PTSD and SUD receive treatment only for the SUD • Remains a prevailing belief SUD should be treated first, or abstinence must be achieved, before beginning treatment • Patients are not always referred to PTSD treatment after completing SUD treatment often leading to greater likelihood of relapse

47. Barriers in Southern Illinois • Stigma • Stigma associated with seeking SUD treatment • Efforts to integrate SUD care within the context of other mental health care would be helpful • Instead of having to seek care at the “addiction clinic,” Veterans could be seen at a general “mental health clinic” that would address a myriad of issues (eg, anxiety, depression, bereavement, PTSD, couples and family therapy) • Furthermore, integrating SUD care into primary care would take it another step further in reducing stigma and increasing access to care

48. References • VA/DoD Clinical Practice Guidelines • https://wwwhealthqualityvagov/guidelines/MH/sud/ • https://wwwptsdvagov/professional/articles/article-pdf/id48040pdf • https://doiorg/101016/jjanxdis201710003 • https://wwwptsdvagov/professional/co-occurring/marijuana_use_ptsd_Veteransasp • Hannah K Knudsen; Amanda J Abraham; Paul M Roman Adoption and Implementation of Medications in Addiction Treatment Programs Journal of Addiction Medicine 5(1):21-27, MAR 2011 DOI: 101097/ADM0b013e3181d41ddb PMID: 21359109 Issn Print: 1932-0620 Publication Date: 2011/03/01

49. References • Evans, K & Sullivan, J M (1995) Treating addicted survivors of trauma New York: Guilford Press • Kofoed, L, Friedman, MJ, & Peck, R (Summer 1993) Alcoholism and drug abuse in patients with PTSD Psychiatric Quarterly, 64(2), 151-171 • Matsakis, A (1992) I can't get over it: A handbook for trauma survivors Oakland, CA: New Harbinger Publications • https://wwwverywellmindcom/the-connection-between-ptsd-and-alcohol-and-drug-use-2797535 • https://wwwptsdvagov/public/problems/ptsd-alcohol-useasp • https://wwwclinicalkeycom/service/content/pdf/watermarked/1-s20-S0887618517300646pdf?locale=en_US

50. References • https://videonationalgeographiccom/video/magazine/focal-point/170822-ngm-focal-point-addiction • Report of (VA) Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid Substance Abuse and PTSD https://wwwptsdvagov/professional/pages/handouts-pdf/SUD_PTSD_Practice_Recommendpdf https://wwwncbinlmnihgov/pmc • https://journalslwwcom/journaladdictionmedicine/Abstract/2017/04000/Concurrent_Treatment_of_PTSD_and_Substance_Use9aspx • https://onlinelibrarywileycom/doi/abs/101111/acer13325 • https://onlinelibrarywileycom/doi/full/101111/acer1312