Treatments for Co-occurring PTSD and Substance Use Disorder

Substance use disorders are common among people with PTSD

PTSD and substance use disorders (SUD) are highly comorbid. According to a large national epidemiologic study, 44.6% of individuals with lifetime PTSD also met criteria for an SUD (including alcohol use disorder (1). Individuals who have both disorders have poorer treatment outcomes, more additional psychiatric problems, and more functional problems across multiple domains, including medical, legal, financial, and social, than those with just one disorder (2-5).
Per VA/DoD Clinical Practice Guidelines, 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. 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 30 studies of treatments for co-occurring PTSD and SUD in the  PTSD Repository.
As shown on the left, most PTSD+SUD studies (63%)  have examined psychotherapies. Among the studies of pharmacotherapy or a combination of psychotherapy and pharmacotherapy, the medications studied include bupropion, doxazosin, naltrexone, prazosin, sertraline, topiramate, varenicline, and zonisamide.
The figure on the right shows that in the studies with a PTSD+SUD focus, just over half (56%) of the psychotherapy arms included a trauma-focused intervention. 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. The most commonly studied trauma-focused therapy is Concurrent Treatment for PTSD (COPE), an integrated treatment that combines Prolonged Exposure for PTSD with relapse prevention for SUD (3 arms). Select the trauma-focused (TF) or non-trauma-focused (Non-TF) slice of the chart 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 COPE, mentioned above.
In contrast, non-integrated treatments would include 2 treatments delivered by 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, study arms are about evenly split between integrated and non-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 = 13) have samples in which participants used both substances. In 11 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, 1 used opioids; these participants may or may not have been using alcohol.
Trauma type
People with PTSD and SUD are more likely to experience traumatic events than people with either condition alone.  Just over half of the PTSD+SUD studies in the PTSD Repository include participants who experienced a variety, rather than one type, of trauma (17 studies). 
Veteran/Non-veteran status
PTSD+SUD studies were carried out with participants recruited from the community (14 studies), with many studies also conducted with military Veterans (13 studies). Some study samples (3 studies) 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 6 studies (indicated as "1" on the pie chart) 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 is not 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 Treatment of Co-Occurring PTSD and Substance Use Disorder in Veterans Affairs.

References

  1. Simpson, T. L., Rise, P., Browne, K. C., Lehavot, K., & Kaysen, D. (2019). Clinical presentations, social functioning, and treatment receipt among individuals with comorbid life-time PTSD and alcohol use disorders versus drug use disorders: Findings from NESARC-III. Addiction, 114(6), 983-993. https://doi.org/10.1111/add.14565
  2. Blakey, S. M., Griffin, S. C., Grove, J. L., Peter, S. C., Levi, R. D., Calhoun, P. S., Elbogen E. B., Beckham, J. C. Pugh, M. J., & Kimbrel, N. A. (2022). Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between Veterans with probable posttraumatic stress disorder and alcohol use disorder. Journal of Affective Disorders, 308, 10-18. https://doi.org/10.1016/j.jad.2022.04.006
  3. McDevitt-Murphy, M. E., Williams, J. L., Bracken, K. L., Fields, J. A., Monahan, C. J., & Murphy, J. G. (2010). PTSD symptoms, hazardous drinking, and health functioning among US OEF and OIF Veterans presenting to primary care. Journal of Traumatic Stress, 23, 108-111. https://doi.org/10.1002/jts.20482
  4. Stappenbeck, C. A., Hellmuth, J. C., Simpson, T., & Jacupcak, M. (2014). The effects of alcohol problems, PTSD, and combat exposure on nonphysical and physical aggression among Iraq and Afghanistan War Veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 65-72. httpsL://doi.org/10.1037/a0031468
  5. Norman, S. B., Haller, M., Hamblen, J. L., Southwick, S. M., & Pietrzak, R. H. (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. military Veterans: Comorbidities, functioning, and suicidality. Psychology of Addictive Behaviors, 32(2), 224-229. https://doi.org/10.1037/adb0000348