PowerPoint Presentation

PTSD and Substance Use DisordersBrian E. Lozano, Ph.D.Contributing Collaborator: Sudie E. Back, Ph.D.

Medical University of South CarolinaRalph H. Johnson VA Medical Center

Lozano@musc.eduBacks@musc.edu

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ColleaguesDr. Kathleen BradyDr. Therese KilleenDr. Edna FoaDr. Colleen HanlonDr. Stacia DeSantisDr. Karen HartwellDr. Liz Santa AnaDr. Brian LozanoDr. Matt YoderDr. Kristy CenterDr. Julianne FlanaganDr. Jenna McCauleyMs. Sharon BeckerDr. Megan Moran-Santa MariaDr. Peter KalivasDr. Jacqueline McGinty

Thank youStaff/CoordinatorsMr. Frank BeylotteMs. Mary Ashley MercerMs. Emily Hartwell Dr. Elizabeth CoxMs. Wendy MuzzyMs. Alex JefferyMs. Virginia McAlisterMr. Scott HendersonMs. Amanda FederlineMs. Anjinetta JohnsonMr. Drew TeerFunding SourcesNIDA 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)

No conflicts of interest to disclose

Previous and current research funding from:National Institute on Drug AbuseDepartment of Defense J. William Fulbright Foreign Scholarship BoardDisclosure Statement3Sequential Model SUD first, then PTSDSingular Model Treat the primary disorderTreat only the SUDTreat only the PTSDParallel Model SUD and PTSD, different cliniciansIntegrated Model - SUD and PTSD, same clinician

Treatment Models4

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)N = 31 women with alcohol or drug dependence disordersPTSD and Relapse 5Untreated 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

Clinic #1Clinic #2

The Need to Treat Both PTSD and SUD 6Both conditions concurrently, by the same clinician

Clinic #1

Integrated Model of PTSD/SUD Treatment7Both 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.

Clinic #1

Integrated Model of PTSD/SUD Treatment8PTSD Improvement Results in Alcohol Use ImprovementBack, Brady, Sonne & Verduin, JNMD, 2006

(N=94)9

Alcohol Improvement Less Likely to Result in PTSD Improvement10Do you believe that your alcohol/drug use and PTSD symptoms are related?(N = 35 Veterans)Back, et al., 2014

11If your PTSD symptoms get worse,what happens to your alcohol/drug use?12Need to get data to determine the % for "don't improve" and "stay the same." Paper only has the #'s for ImproveIf your PTSD symptoms improve, what happens to your alcohol/drug use?13Need #'s for other categories.Overview of PTSD Substance Use ConnectionSelf Medication Hypothesis (Khantzian, 1985)+14Overview of PTSD Substance Use Integrated Treatment15SUD-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.16TreatmentImaginal exposureIn vivo exposureConcurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) in pressSeeking Safety (SS) - 2002Seeking Safety + Exposure Therapy-Revised (N=5) - 2005Substance Dependence PTSD Therapy (SDPT) - 1999CBT for PTSD in addiction treatment programs - 2009van Dam et al., 2012; Clinical Psych Review, 32: 202-21417

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)

COPE (Concurrent Treatment of PTSD & SUD using Prolonged Exposure)18Educate patients about the functional relationship between substance use and PTSD.Decrease SUD symptom severity, initiate and maintain abstinence.Decrease PTSD symptom severity.

Primary Goals of COPE

19Psychoeducation 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 ExposureImaginal Exposure

CBT Techniques Used To Treat PTSD20In Vivo ExercisesIn between therapy sessionsRepeated exposures Prolonged durationCommon examples:Walmart (or other crowed store)Sitting in middle of restaurant Going to a sporting eventGoing to movie theatreDriving during rush hourBeing stopped at a stop lightWatching or reading the newsGroup activities (going to AA, church,exercise class)

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Imaginal Exposure22How it works:Emotional processing, organizing the memory Habituation anxiety does not last foreverDistinguishing between memory vs. actual event, then vs. nowCognitive modifications increase sense of control, mastery, confidence

AnxietyTime Prolonged Exposure Therapy: The Wave of Anxiety23Foa 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

Empirical Support for PE24Psychoeducation 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).CBT to decrease SUD Symptoms

25Integrated 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: PsychoeducationReduce PTSD symptoms Reduce SUD symptomsSummary26COPE Session Content271Introduction: Psychoeducation, Set Goals, Therapy Contract, Breathing Retraining2PTSD: Common Reactions to Trauma SUD: Awareness of Cravings3PTSD: In Vivo Hierarchy SUD: Managing Cravings4PTSD: First Imaginal ExposureSUD: Review coping skillsSession #Session Topic

General Session Overview285PTSD: Imaginal Exposure continuedSUD: Planning for Emergencies6PTSD: Imaginal Exposure continuedSUD: Awareness of High-Risk Thoughts7PTSD: Imaginal Exposure continuedSUD: Managing High-Risk Thoughts8PTSD: Imaginal Exposure continuedSUD: Refusal SkillsSession #Session Topic

General Session Overview continued299PTSD: Imaginal Exposure continuedSUD: Seemingly Irrelevant Decisions10PTSD: Imaginal Exposure continuedSUD: Awareness of Anger11PTSD: Final Imaginal ExposureSUD: Managing Anger12Review and TerminationSession #Session Topic

General Session Overview continued30Do integrated treatments for PTSD/SUD work?

31COPE Studies to DateBrady 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 TAUBack et al. (ongoing): military PTSD and mostly alcohol; COPE vs RPHien et al. (ongoing): PTSD and mostly alcohol; COPE vs RPNorman et al. (ongoing): military PTSD; COPE vs Seeking Safety

32Preliminary, uncontrolled study N=39PTSD and cocaine dependence16 individual 90-minute sessionsAssessment at weeks 4, 8, 12, and 16, and at 6 months follow up.

Initial COPE Study33Positive Urine Drug Screen (UDS) TestsAt treatment entry = 12.8%First half of treatment = 12.2%Second half of treatment = 9.7%

Timing of AttritionThe 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(N=39) Cocaine Dependent + PTSDInitial COPE Findings34Post-Treatment Outcomes

35ScoresWeeksImpact of Events Scale (IES)

36Uncontrolled study Small sample sizeFocused on cocaine dependenceHigh drop-out rate

ConsiderationsRandomized controlled trialCOPE + TAU vs TAUN=103SUD (mostly heroin) + PTSDMajority (75%) had childhood trauma62.1% women78.6% unemployed54.2% lifetime history of suicide attempt

Mills et al., 2012

Study Aims and Design38*Clinician Administered PTSD Scale (CAPS)39Using at 3 mth F/U:Treatment: 72.9%Control: 81.9%Number of SUD Dependence Criteria Met40

COPE among Military Veterans41Total N=903 Mth Follow-UpCOPERPStudy TimelineScreening, Consent, Assessed, and RandomizedCOPE and RP Treatment Phase: 12, 90-min sessions3 Mth Follow-Up6 Mth Follow-Up6 Mth Follow-Up3 Mth Follow-Up6 Mth Follow-UpCOPE pts: Sessions 4 and 11 fMRI scan to cuesBack et al., ongoingStudy Design42Single, caucasian, 25 yr old maleUnited States Marine (gunner)Served 3 deployments in Iraq (24 months total) No history of mental health treatmentCOPE Military Pt 001

Back, Killeen, Foa et al. Am J Psychiatry 2012; 169: 688-691Index 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.

Case Details44Time-Line Follow Back Number of Standard Drinks

In Vivo StartImaginal StartReliable Change Index, p