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PTSD and Substance Use Disorders

PTSD and Substance Use Disorders. Brian E. Lozano, Ph.D. Contributing Collaborator: Sudie E. Back, Ph.D . Medical University of South Carolina Ralph H. Johnson VA Medical Center Lozano@musc.edu Backs@musc.edu. Thank you. Staff/Coordinators Mr . Frank Beylotte Ms . Mary Ashley Mercer

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PTSD and Substance Use Disorders

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  1. PTSD and Substance Use Disorders Brian E. Lozano, Ph.D. Contributing Collaborator: Sudie E. Back, Ph.D. Medical University of South Carolina Ralph H. Johnson VA Medical Center Lozano@musc.edu Backs@musc.edu

  2. Thank you Staff/Coordinators Mr. Frank Beylotte Ms. Mary Ashley Mercer Ms. Emily Hartwell Dr. Elizabeth Cox Ms. Wendy Muzzy Ms. Alex Jeffery Ms. Virginia McAlister Mr. Scott Henderson Ms. Amanda Federline Ms. Anjinetta Johnson Mr. Drew Teer Colleagues Dr. Kathleen Brady Dr. Therese Killeen Dr. Edna Foa Dr. Colleen Hanlon Dr. Stacia DeSantis Dr. Karen Hartwell Dr. Liz Santa Ana Dr. Brian Lozano Dr. Matt Yoder Dr. Kristy Center Dr. Julianne Flanagan Dr. Jenna McCauley Ms. Sharon Becker Dr. Megan Moran-Santa Maria Dr. Peter Kalivas Dr. Jacqueline McGinty Funding Sources NIDA F31 DA00607 (Back) NIDA K23 DA021228 (Back) NIDA R01 DA030143 (Back) J. William Fulbright (Back) NIDA K24 DA00435 (Brady) NIH UL1RR029882 (Brady) NIDA T32 DA07288 (McGinty) DoD 803235(Kalivas & Back) DoD 804237 (McGinty & Back)

  3. Disclosure Statement • No conflicts of interest to disclose • Previous and current research funding from: • National Institute on Drug Abuse • Department of Defense • J. William Fulbright Foreign Scholarship Board

  4. Treatment Models • Sequential Model – SUD first, then PTSD • Singular Model – Treat the “primary” disorder • Treat only the SUD • Treat only the PTSD • Parallel Model – SUD and PTSD, different clinicians • Integrated Model - SUD and PTSD, same clinician

  5. PTSD and Relapse N = 31 women with alcohol or drug dependence disorders Rates of Relapse: -With PTSD: 85% -Without PTSD: 59% (p = .12) Time to 1st Use : -With PTSD: 26.5 days -Without PTSD: 54.5 days (p = .03) (Brown et al., 1996; Psychology of Addictive Behaviors)

  6. Untreated PTSD contributes to poorer treatment outcome for substance use, and vice versa. Traditionally, the standard of care = sequential model: (1) SUD treatment first, demonstrate sustained abstinence (3 to 6 months) then… (2) PTSD treatment The Need to Treat Both PTSD and SUD Clinic #2 Clinic #1

  7. Both conditions concurrently, by the same clinician Integrated Model of PTSD/SUD Treatment Clinic #1

  8. Both conditions concurrently, by the same clinician Driven by: -Hypothesis that substance abuse is result of, in part, PTSD symptoms. -Reductions in PTSD are more likely to lead to reductions in substance abuse, than the reverse. -Patient preferences. Integrated Model of PTSD/SUD Treatment Clinic #1

  9. PTSD Improvement Results in Alcohol Use Improvement (N=94) Back, Brady, Sonne & Verduin, JNMD, 2006

  10. Alcohol Improvement Less Likely to Result in PTSD Improvement

  11. Do you believe that your alcohol/drug use and PTSD symptoms are related? (N = 35 Veterans) Back, et al., 2014

  12. If your PTSD symptoms get worse,what happens to your alcohol/drug use?

  13. If your PTSD symptoms improve,what happens to your alcohol/drug use?

  14. Overview of PTSD – Substance Use Connection + Self Medication Hypothesis (Khantzian, 1985)

  15. Overview of PTSD – Substance Use Integrated Treatment

  16. SUD-PTSD Integrated Psychotherapies Najavits (2002) - Seeking Safety. Relapse prevention + education + social skills training. Mostly group. 25 sessions. Back, Foa, Killeen, Brady et al. (in press) – COPE.Relapse prevention + in vivo exposure + imaginal exposure. Individual. 12 sessions.

  17. van Dam et al., 2012; Clinical Psych Review, 32: 202-214

  18. COPE (Concurrent Treatment of PTSD & SUD using Prolonged Exposure) • Synthesis of 2 theory-based and empirically-validated treatments: • (1) Prolonged Exposure for PTSD (Foa, Hembree, & Rothbaum, 2007) • (2) Relapse Prevention for SUD • (Carroll, 1998)

  19. Primary Goals of COPE • Educatepatients about the functional relationship between substance use and PTSD. • Decrease SUD symptom severity, initiate and maintain abstinence. • Decrease PTSDsymptom severity.

  20. CBT Techniques Used To Treat PTSD • Psychoeducation – education about common reactions, normalize symptoms, help understand avoidance & how it maintains PTSD symptoms. • Breathing Retraining technique to decrease anxiety. • Prolonged Exposure (PE): • In-Vivo Exposure • Imaginal Exposure

  21. In Vivo Exercises • In between therapy sessions • Repeated exposures • Prolonged duration • Common examples: • Walmart (or other crowed store) • Sitting in middle of restaurant • Going to a sporting event • Going to movie theatre • Driving during rush hour • Being stopped at a stop light • Watching or reading the news • Group activities (going to AA, church, • exercise class)

  22. Imaginal Exposure

  23. Prolonged Exposure Therapy: The Wave of Anxiety Anxiety Time How it works: • Emotional processing, organizing the memory • Habituation – anxiety does not last forever • Distinguishing between memory vs. actual event, then vs. now • Cognitive modifications – increase sense of control, mastery, confidence

  24. Empirical Support for PE Foa et al. (1991) Foa et al. (1999) Foa et al. (2005) Marks et al. (1998) Tarrier et al. (1999) Taylor et al. (2001) Cloitre et al. (2002) Resick et al. (2003) Bryant et al. (2003) Schnurr et al. (2007) Rauch et al. (2009) Resick et al. (2012) *18% with PTSD 5-10 yrs later

  25. CBT to decrease SUD Symptoms • Psychoeducation regarding relationship between substance use and PTSD sx. • Effectively manage cravings and thoughts about substance use. • Identify triggers for substance use - both PTSD and substance-related triggers. • Learn coping skills to help prevent relapse/escalation to substances (e.g., managing anger, drug refusal skills).

  26. Summary • Integrated treatments address both the PTSD and the SUD concurrently. • COPE uses Prolonged Exposure (in vivo and imaginal) to treat PTSD, and CBT (Relapse Prevention) to treat SUD. • Main Goals: • Psychoeducation • Reduce PTSD symptoms • Reduce SUD symptoms

  27. COPE Session Content

  28. General Session Overview Session # Session Topic

  29. General Session Overview continued Session # Session Topic

  30. General Session Overview continued Session Topic Session #

  31. Do integrated treatments for PTSD/SUD work?

  32. COPE Studies to Date • Brady et al. (2001) and Back et al. (2001): PTSD and cocaine; N=39 • Mills et al. (2012): PTSD and mostly heroin; N=103; COPE + TAU vs TAU • Back et al. (ongoing): military PTSD and mostly alcohol; COPE vs RP • Hien et al. (ongoing): PTSD and mostly alcohol; COPE vs RP • Norman et al. (ongoing): military PTSD; COPE vs Seeking Safety

  33. Initial COPE Study • Preliminary, uncontrolled study • N=39 • PTSD and cocaine dependence • 16 individual 90-minute sessions • Assessment at weeks 4, 8, 12, and 16, and at 6 months follow up.

  34. Positive Urine Drug Screen (UDS) Tests At treatment entry = 12.8% First half of treatment = 12.2% Second half of treatment = 9.7% Initial COPE Findings (N=39) Cocaine Dependent + PTSD Timing of Attrition • The majority (75%) dropped out before PE initiated (e.g., transportation or employment problems, relocation, scheduling conflicts, unstable living conditions) Brady, Dansky, Back, Foa & Carroll, 2001

  35. Post-Treatment Outcomes

  36. Impact of Events Scale (IES) Scores Weeks

  37. Considerations • Uncontrolled study • Small sample size • Focused on cocaine dependence • High drop-out rate

  38. Study Aims and Design • Randomized controlled trial • COPE + TAU vs TAU • N=103 • SUD (mostly heroin) + PTSD • Majority (75%) had childhood trauma • 62.1% women • 78.6% unemployed • 54.2% lifetime history of suicide attempt Mills et al., 2012

  39. Clinician Administered PTSD Scale (CAPS) *

  40. Number of SUD Dependence Criteria Met Using at 3 mth F/U: Treatment: 72.9% Control: 81.9%

  41. COPE among Military Veterans

  42. Study Design 6 Mth Follow-Up COPE 3 Mth Follow-Up Total N=90 3 Mth Follow-Up 6 Mth Follow-Up RP Study Timeline COPE and RP Treatment Phase: 12, 90-min sessions Screening, Consent, Assessed, and Randomized 3 Mth Follow-Up 6 Mth Follow-Up COPE pts: Sessions 4 and 11 fMRI scan to cues Back et al., ongoing

  43. COPE Military Pt 001 • Single, caucasian, 25 yr old male • United States Marine (gunner) • Served 3 deployments in Iraq (24 months total) • No history of mental health treatment Back, Killeen, Foa et al. Am J Psychiatry2012; 169: 688-691

  44. Case Details • Index trauma: Combat related. • PTSD symptoms: Frequent nightmares, intrusive thoughts, isolation/distancing, aggression, extreme difficultly driving, hyperarousal in crowded places (e.g., Walmart, movies), avoidance of thoughts and memories through alcohol. • Substance use symptoms: Consuming 12.5 beers per day, 83.3% of the time (50/60 days pre study). • Tx motivation: Initially did not want treatment (“military pride”) but his friend drove him to clinic.

  45. Time-Line Follow Back Number of Standard Drinks Imaginal Start In Vivo Start Reliable Change Index, p<.05

  46. PTSD Checklist-Military Version (PCL-M) CAPS: 71 (Baseline) 42 (Session 6) 17 (Session 12) 4 (6 Mth F/U) Reliable Change Index, p<.05

  47. Beck Depression Inventory (BDI) Reliable Change Index, p<.05

  48. Summary • Studies among men and women, civilian and combat-related PTSD, multiple SUD and multiple traumas show: • Feasible • Safe – substance use did not increase with trauma-work • Effective

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