Treatments for Co-occurring PTSD and Substance Use Disorder

Substance use disorders are common among people with PTSD
People with PTSD are likely to have one or more additional psychiatric disorders. This is called comorbidity.  A common comorbidity is misuse of substances like drugs and alcohol. Substance misuse is considered to be a substance use disorder (SUD) when the substance use leads to problems in day-to-day functioning.  A person who has PTSD is almost 2 times more likely to have a substance use disorder (SUD) than a person without PTSD (Pietrzak et al., 2011). SUDs are even more common among people who seek treatment for PTSD, and similarly, PTSD is extremely common among people seeking treatment for SUDs.
Treatment of co-occurring PTSD and SUD is an important area of study because people with this comorbidity have poorer health and well-being than people with just one of the conditions.  These individuals are more likely to have additional co-occurring disorders, poorer quality of life, lower functioning, and greater likelihood of attempting suicide.
Given the seriousness of this comorbidity, a number of investigators have developed and tested treatments for co-occurring PTSD and SUD. Here we include information on studies designed to improve both conditions. 
“I kicked my drugs. And this is all from the treatment I have been given.”
              Craig "Stu" Shipley, U.S. Marine Corps, 1964 - 1968

Psychotherapy is the most frequently tested type of treatment intervention for co-occurring PTSD and SUD

There are 23 studies of treatments for co-occurring PTSD and SUD in the PTSD-Repository.
As shown on the left, most PTSD+SUD studies (74%)  have examined psychotherapies. Among the pharmacotherapy study arms, the medications studied to treat PTSD+SUD include topiramate, naltrexone, and prazosin.
The figure on the right shows that almost half (47%) of the psychotherapy arms studied were trauma-focused. Trauma-focused psychotherapies are the most effective treatment for PTSD and have also been shown to be safe and effective to treat PTSD among people with SUDs. Select the trauma-focused (TF) or non-trauma-focused (Non-TF) slice to drill down and see the specific psychotherapies that have been tested. 

Integrated treatment for PTSD+SUD

In some cases the treatments being tested are primarily PTSD treatments with the expectation that they will also reduce the substance use.  In other cases the treatments are specifically designed to treat both disorders – these are called integrated treatments. Integrated treatments for PTSD and SUD are those that include strategies for improving both PTSD and SUD within one treatment protocol delivered by one provider. An exemplar of an integrated treatment for co-occurring PTSD+SUD is Concurrent Treatment for PTSD and Substance Use Disorder Prolonged Exposure (better known as COPE), which integrates Prolonged Exposure and cognitive-behavioral relapse prevention for SUD.
In contrast non-integrated treatments would include two treatments delivered by two different providers during the same time period (e.g., one treatment for PTSD and another for SUD) or phased treatment in which one condition is treated before the other. 
As shown here, exactly half of the PTSD+SUD study arms were integrated treatments. 

Who participates in studies of treatments for PTSD+SUD?

Substances used
Studies of PTSD+SUD have examined participants who use alcohol, drugs, or both. Most studies (n = 11) have samples in which participants used both substances. In 7 of the PTSD+SUD studies, all of the participants used alcohol. Drill down in the Drug column to see that among the studies of drug use, 4 studies had participants who all used nicotine and 1 had participants who all used drugs; these participants may or may not have been using alcohol.
Trauma type
People with PTSD+SUD are more likely to experience traumatic events than people with either condition alone.  Almost all of the PTSD+SUD studies in the PTSD-Repository were carried out with individuals who experienced a variety, rather than one type, of trauma. 
Veteran/Non-veteran status
PTSD+SUD studies were carried out with participants recruited from the community (9 studies), with many studies also conducted with military Veterans (8 studies). Some study samples were mixed, meaning that they included both community and Veteran participants.
Gender
Most PTSD+SUD studies included both men and women. This figure presents the percentage of the samples that were women. Only 4 studies had all-women samples and no studies had an all-men sample. 
How can I learn more about PTSD+SUD treatments in the PTSD-Repository?
Explore these datasets to do a deeper dive into the PTSD+SUD treatment studies. You can find the PTSD+SUD studies by filtering or sorting according to the study-level repeated variable "Treatment Focus", which is coded as PTSD or PTSD+SUD. 

Remember: 

  • PTSD and SUD often co-occur, especially among Veterans seeking Veterans Affairs (VA) care.
  • Patients with PTSD and SUD can tolerate and benefit from evidence-based trauma-focused PTSD treatment such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).
  • Patients with PTSD and SUD should be offered evidence-based treatment for both disorders. Having one should not be a barrier to receiving treatment for the other.
  • The PTSD-Repository can be used to answer many questions about treatment for co-occurring PTSD and SUD. 
For more information about problems with alcohol and drugs in the context of PTSD and how they can be treated, please see Substance Misuse - PTSD: National Center for PTSD (va.gov)