Substance Abuse and PTSD in the Veteran Population: Overview and Treatment

1. Substance Abuse and PTSD in the Veteran Population: Overview and Treatment Lisa T. Arciniega Ph.D. and Jennifer Klosterman Rielage Ph.D. NMVAHCS Feb. 6, 2008

2. Objectives • Background substance use disorders (SUD): assessment and treatment • Address: the relationship between substance use disorders (SUD) and posttraumatic stress disorder (PTSD) • Introduction to Seeking Safety • References / Resources for further information

3. DSM-IV TR Substance Abuse • Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period: • Failure to fulfill major role obligations at work, school or home • Recurrent use when physically hazardous Recurrent legal problems • Continued use despite recurrent social or interpersonal problems B. The symptoms have never met the criteria for Substance Dependence for this class of substance Substance Dependence • Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at anytime within a 12-month period: • Tolerance • Withdrawal • Taken in greater amounts or over longer time course than intended • Desire or unsuccessful attempts to cut down or control use • Great deal of time spent obtaining, using, or recovering from drug • Social, occupational, or recreational activities given up or reduced • Continued use despite knowledge of physical or psychological sequelae (Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV-TR), (2000). American Psychiatric Association)

4. Addiction: definition “Addiction has a specific definition: you are unable to stop when you want to , despite [being] aware of the adverse consequences. It permeates your life; you spend more and more time satisfying [your craving].” (N. Volkow, Director NIDA) “Addiction is a chronic and relapsing brain disease characterized by uncontrollable drug-seeking behavior and use. It persists even with the knowledge of negative health and social consequences. “ (S. Lukas, Mclean Hospital ) Lemonick, M. (2007). The Science of Addiction. Time (July 16,2007), 42-48.

5. Background: The State of the Art in Drug Addiction Treatment • Treatment is effective (reduces by 40-60%) • Treatment reduces undesirable consequences whether or not patients achieve complete abstinence • Mesa Grande findings:(Miller,W.R, Wilbourne, P.L. Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97(3): 265-277. 2002). brief interventions social skills training CRA, behavior contracting, behavioral marital therapy case management. Two pharmacotherapies: opiate antagonists (naltrexone, nalmefene) and acamprosate

6. SUD in Veteran Population • SUD is a significant problem in the veteran population • Data from a VHA report for 2003 showed 22% veterans with SUD diagnosis (Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series(2006)) • NMVAHCS population: CY 2007, 3500 unique veterans were treated by the SUD clinic (primary substances of use alcohol, cannabis, cocaine, stimulants, opiates)

7. Case Examples* • 20 yr old male National Guardsman who came home from Iraq and partied with his friends for 6 months. Is now interested in buckling down and going back to school. • 24 yr old female OIF/OEF veteran who had to respond to a bad convoy accident & help rescue. She has flashbacks and nightmares and feels angry all the time. She begins using alcohol to cope. • 60 yr old male veteran of the Army who met criteria for Alcohol Dependence after his TOD in Vietnam. Has been doing well but recently deployed to Iraq. *Important Note: All case examples provided have had demographic characteristics and details altered in order to protect the identity of clients.

8. Assessment: Screening Screening (Primary Clinic, ER, Specialty clinic as referral sources) • Patients should be routinely screened for SUD (MAST, DAST, CAGE, AUDIT) • Patients should be routinely screened for PTSD (TSQ, PC-PTSD) Refer for specialized treatment as needed

9. SUD Clinic Initial Assessment • Biopsychosocial assessment (MHA, ASI) • Assess for Medical / Psychiatric stability and/or intervention • (SI/HI; detox; withdrawal; anticraving medications) • Motivational Intervention emphasizing building motivation for change

10. Blocking the Cascade of Alcohol Dependence(Collins, G. et. al. (2006). Drug adjuncts for treating alcohol dependence. Cleveland Clinic Journal of Medicine, 73:7, 641-649)_ Physiological Process Drugs that May And BehaviorBlock the Cascade Desire for alcohol, Positive craving Acute drinking Naltrexone, nalmefene “Pleasure center” Dopamine release Ondansetron Chronic Drinking Central nerbous system Topiramate Hyperexcitability Withdrawal, negative craving Acamprosate During abstinence Relapse Disulfiram

11. Medications for Drug Abuse • Opioid (heroin, morphine) Addiction: Methadone and buprenorphine - medications that block the drug's effects, suppress withdrawal symptoms, and relieve craving for the drug Buprenorphine (Subutex or, in combination with naloxone, Suboxone) : This is a relatively new and important treatment medication. Development of medication and the passing of the Drug Addiction Treatment Act (DATA 2000), permitting opiate treatment in a medical setting rather than limiting it to specialized drug treatment clinics. • Ttobacco (nicotine) addiction – Chantrix and Zyban (wellbutrin) • stimulant (cocaine, methamphetamine) and cannabis (marijuana) medications are still under development.

12. Evidence Based Treatment(NIAAA COMBINE CBI Intervention) • Variety of well-supported treatment methods merged into an integrated approach. • Phase 1: motivation for change / MET feedback • Phase 2: Functional analysis, psychosocial functioning, survey of strengths and resources, SSO involvement to be used in treatment planning • Phase 3: Nine CB skill training modules (assertiveness, communication, coping with craving and urges, drink refusal and social pressure, job finding, mood management, mutual-help group facilitation, social and recreational counseling and social support for sobriety) • Phase 4: maintenance checkups • Pull-Out procedures: sobriety sampling, raising therapist’s concerns, implementing case management, handling resumed drinking, supporting medication adherence, responding to a missed appointment, telephone consultation and crisis intervention)

13. PTSD Diagnostic Criteria • Criterion A: The person has been exposed to a traumatic event in which BOTH of the following were present: • Experience/witness/confronted /w actual or threatened death or serious harm • Response included intense fear/helplessness/horror • Criterion B: Persistent Re-experience Trauma • Criterion C: Persistent Avoidance • Criterion D: Persistent Hyperarousal • Criterion E: Symptoms > 1month • Criterion F: Clinically significant distress or impairment in work, family, etc.

14. Complex Relationship between PTSD and SUD • Alcohol and drugs may be abused in an attempt to control PTSD symptoms • SUD may increase risk of development of PTSD by increasing likelihood of exposure to certain types of trauma • A third variable may be related to the development of both PTSD and SUD following a trauma exposure, e.g. poor coping skills Used with permission by R. Walser Ph.D., National Center for PTSD

15. Prevalence Rates of Veterans with SUD and PTSD • PTSD and substance abuse co-occur at a relatively high rate • Estimates of substance use disorders and PTSD • Rate among patients in SUD treatment ranges from 12%-59% 1 • 58% of veterans in SUD programs have lifetime PTSD2 • 73% of male Vietnam veterans who met diagnostic criteria for PTSD also qualified for lifetime SUD disorders3 • The odds of drug use disorders are 3 times greater in individuals with versus without PTSD4 • Presence of either disorder alone increases the risk for the development of the other5 Used with permission by R. Walser Ph.D., National Center for PTSD

16. 30% of Returnees in VA Care Receive Mental Health Diagnoses – Substance Use Disorders are among the Most Common Problems Used with permission by R. Walser Ph.D., National Center for PTSD

17. Treatment Considerations PTSD/SUD Patients • Parallel SUD / PTSD Treatment: separate but concurrent treatment in different clinics by different providers • Sequential: separate with one treatment following the other. Usual order is typically SUD treatment followed by PTSD treatment • Integrated: newer approach (Seeking Safety) Used with permission by R. Walser Ph.D., National Center for PTSD

18. Treatment Considerations PTSD/SUD Patients • PTSD, unlike other disorders, may worsen in the early stages of abstinence creating a challenging treatment environment • Exposure therapy may trigger substance abuse relapse • Aspects of 12-Step groups are difficult for some trauma patients • Powerlessness • Higher Power • Locating appropriate groups • Issues of forgiveness Used with permission by R. Walser Ph.D., National Center for PTSD

19. Treatment ConsiderationsNMVAHCS Treatment • Intensive Treatment (MITP) • Family Involvement (CRAFT) • Community Involvement (CRA) • Residential Treatment (STARR; DRRTP) • 12-step programs encouragement (AA,NA,CA) • Mindfulness • Seeking Safety

20. PTSD Symptom Model

21. Herman’s Trauma Recovery Model Step 3: Re-Integration Step 2: Mourning Step 1: Safety Herman, J. (1997). Trauma and Recovery: The aftermath of violence—from domestic abuse to political terror. Basic.

22. Seeking Safety: Basic Principles • Most urgent clinical need is to establish safety • Stop using substances • Reduce suicidal and parasuicidal behaviors • Curb risky behaviors (unprotected sex, driving fast, etc.) • End dangerous relationships • Continuous treatment of BOTH SUD & PTSD

23. Seeking Safety: Overview • Goal of treatment is safety, including replacing unsafe coping (e.g., binge drinking) with safer coping • 25 topics in cognitive, interpersonal, & behavioral realms • Importance of session format • Focus on case management

24. References: • Collins, G. et. al. (2006). Drug adjuncts for treating alcohol dependence. Cleveland Clinic Journal of Medicine, 73:7, 641-649. • American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV-TR). • Herman, J. (1997). Trauma and Recovery: The aftermath of violence—from domestic abuse to political terror. Basic. • Lemonick, M. (2007). The Science of Addiction. Time (July 16,2007), 42-48. • Marlatt, A. and Gordon (1985). Relapse Prevention Model and the Relapse Prevention Group. Seattle VAMC WATC. • Miller, W.R. et.al. (2004). Combined Behavioral Intervention Manual: A clinical research guide for therapists treating people with alcohol abuse and dependence. U.S. Department of Health and Human Services: NIH; NIAAA. • Meyers, R.J., and Smith, J.E. (1995) clinical guide to Alcohol Treatment: The Community Reinforcement Approach. New York: guilford Press, 1995. • Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People for Change. New York: guilford Press, 1991. • Miller,W.R, Wilbourne, P.L. Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97(3): 265-277. 2002 • Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford. • Principles of Drug Addiction Treatment: A Research-based Guide (NCADI publication BKD347 Additional Resources: National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov) National Institute on Drug Abuse (http://www.nida.nih.gov) National Center on PTSD (http://www.ncptsd.va.gov) National Clearinghouse on Alcohol and Drug Information (http:/www.health.gov).

25. The EndQuestions? Comments?

26. COMBINE Treatment Phase 2: • Functional analysis • a review of the client’s psychosocial functioning • survey of the client’s strengths and resources • SSO involvement • Community support involvement (12-step) • Treatment planning

27. COMBINE Treatment Phase 3: Menu of nine CB skill training modules • Assertiveness • Communication • coping with craving and urges • drink refusal and social pressure • job finding • mood management • mutual-help group facilitation • social and recreational counseling • social support for sobriety

28. NMVAHCS SUD Treatment Inpatient vs Outpatient Inpatient (Gallup, DOM, STARR, other) Outpatient MITP (Mini Intensive Treatment Program) EOP (Evening Outpatient Program) Seeking Safety Mindfulness Class Continuing Care Treatment CRAFT (Community Reinforcement and Family Training) Relapse Prevention Dual Diagnosis Gambling Program Older Veteran Program Individual Treatment Case Management Medication Management / Consultation

29. Background: Thirteen Principles of Effective Drug Addiction Treatment • No single treatment is appropriate for all individuals. • Treatment needs to be readily available. • Effective treatment attends to multiple needs of the individual, not just his or her drug use. • Treatment needs to be flexible and to provide ongoing assessments of patients’ needs. • Remaining in treatment for an adequate period of time is critical for treatment effectiveness. (For most, the threshold of significant improvement is reached at about 3 months) • Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. • Addicted or drug-abusing individuals with coexisting mental disorder should have both disorders treated in an integrated way. • Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. • Treatment does not need to be voluntary to be effective. • Possible drug use during treatment must be monitored continuously. • Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases and counseling to help patients modify or change behaviors that place them or other at risk of infection. • Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. (Principles of Drug Addiction Treatment: A Research-based Guide (NCADI publication BKD347)