Adults with Comorbid Posttraumatic Stress Disorder, Alcohol Use Disorder, and Opioid Use Disorder: The Effectiveness of Modified Prolonged Exposure

Abstract

Opioid use disorders (OUDs) are a growing problem in the United States. When OUDs co-occur with problematic drinking and posttraumatic stress disorder (PTSD), negative drug-related mental and physical health outcomes may be exacerbated. Thus, it is important to establish whether PTSD treatments with established efficacy for dually diagnosed individuals also demonstrate efficacy in individuals who engage in problematic drinking and concurrent opioid misuse. Adults who met DSM-IV-TR criteria for PTSD and alcohol dependence were recruited from a substance use treatment facility and were randomly assigned to receive either modified prolonged exposure (mPE) therapy for PTSD or a non-trauma-focused comparison treatment. Compared to adults in a non-OUD comparison group (n = 74), adults with OUD (n = 52) were younger, reported more cravings for alcohol, were more likely to use amphetamines and sedatives, were hospitalized more frequently for drug- and alcohol-related problems, and suffered from more severe PTSD symptomatology, depressive symptoms, and anxiety, standardized mean differences = 0.36-1.81. For participants with OUD, mPE was associated with large reductions in PTSD symptomatology, sleep disturbances, and symptoms of anxiety and depression, ds = 1.08-2.56. Moreover, participants with OUD reported decreases in alcohol cravings that were significantly greater than those reported by the non-OUD comparison group, F(1, 71.42) = 6.37, p = .014. Overall, our findings support the efficacy of mPE for PTSD among individuals who engage in problematic drinking and concurrent opioid misuse, despite severe baseline symptoms.

Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans

“…Reductions in SUD observed in the current study were similar to findings from previous studies of COPE in civilians (Mills et al, 2012;Ruglass et al, 2017) and comparable to findings observed in randomized controlled trials of SUD-only patients (Anton et al, 2006;Dutra et al, 2008). The findings from this study converge with those of previous investigations (Coffey et al, 2006;Foa et al, 2013;Mills et al, 2012;Norman et al, 2016;Peck et al, 2018;Persson et al, 2017;Ruglass et al, 2017) and show that PE delivered in the context of an integrated or comprehensive SUD treatment is beneficial, even among individuals who continue to use substances. The findings also highlight that there is room for improvement, particularly with regard to SUD outcomes, and suggest that the addition of pharmacotherapies or other interventions to further reduce craving and substance use may be benefit some patients with SUD/PTSD.…”

“…The majority of available COPE sessions (73.7%) and RP sessions (61.7%) were attended. Completion rates and attendance in this study were similar to or higher than previous studies of non-exposure based, integrated treatments (Hien et al, 2009;Myers, Browne, & Norman, 2015;Najavits et al, 2018) as well as exposure-based, integrated treatments (Coffey et al, 2016;Foa et al, 2013;Mills et al, 2012;Peck et al, 2018;Ruglass et al, 2017;Schacht et al, 2017). Improvements in retention observed in the current study may be due, in part, to modifications made to the treatment protocol.…”

“…Despite extensive research demonstrating the ability of PE to significantly reduce PTSD severity (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010), some clinicians are reluctant to engage in exposure-based trauma work with SUD patients (Norman & Hamblen, 2017). Accumulating evidence demonstrates, however, that PE is safe and associated with significant reductions in SUD severity, even among individuals with complex trauma histories (Foa et al, 2013(Foa et al, , 2017Mills et al, 2012;Norman et al, 2016;Peck et al, 2018;Persson et al, 2017;Ruglass et al, 2017). Further support is provided by recent metaanalyses and critical reviews of the literature demonstrating that exposure-based, integrated treatment results in significant improvements in SUD and PTSD (Roberts, Roberts, Jones, & Bisson, 2015;Simpson et al, 2017).…”

Did the War on Terror Ignite an Opioid Epidemic?

“…Finally, prior medical research suggests that the risk of opioid abuse may be exacerbated by PTSD (Peck et al 2018). We empirically confirm this suggestion in Appendix Table 6, where we show that PTSD substantially increases the adverse effects of combat.…”

Multiple diagnoses in the context of parallel epidemics: methamphetamine, opioid use disorder and psychiatric conditions

“…A parallel area of study has examined the connections between OUD and MHCs, which has similarly revealed substantial overlap among these conditions. Depression, anxiety and ASPD rank among the most commonly observed (Santo et al , 2022), but there is also evidence suggesting post-traumatic stress disorder (PTSD) may be more common among people diagnosed with OUD relative to those who do not have a similar condition (Peck et al , 2018).…”