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Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) frequently occur together, but little is known about why this association exists and what the optimal treatment options are for patients with both conditions.
The “self-medication hypothesis” suggests that individuals with PTSD use substances in an effort to cope with chronic trauma-related symptoms, making SUD more likely.
Given how often PTSD and SUDs occur together, Telsie A. Davis, PhD, of the Atlanta Veterans Administration and Medical Center in Georgia, and colleagues evaluated whether substance use would exacerbate or alleviate the alterations seen in PTSD.2
“The key results indicated that chronic substance abuse canceled out some of the physiological effects observed in PTSD. Specifically, exaggerated fear responses to threatening signals were attenuated in individuals with chronic SUD,” said coauthor, Tanja Jovanovic, PhD, of Emory University School of Medicine in Atlanta, Georgia.
“However, another psychophysiological measure that is deficient in PTSD, an impaired ability to respond differently to threatening compared to non-threatening signals, was not alleviated in SUD.”
This means that those who have both PTSD and SUD may be less afraid of danger, and may also having difficulty telling the difference between dangerous and safe situations, Jovanovic explained. “This may lead to increased engagement in high risk behavior.”
Additional evidence suggests that certain SUDs may be more prevalent in PTSD than others. Patients entering treatment for prescription opioid use problems had a significantly increased risk of co-occurring PTSD compared with other SUDs, in a study recently published in the American Journal of Drug and Alcohol Abuse.1
“Providers should be aware of the high prevalence rates of comorbid prescription opioid use problems and PTSD,” said study researcher, Andrea L. Meier, MS, of Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire.
Treatment Challenges
Patients with both PTSD and SUD are living with two separate and equally debilitating conditions that interact with each other, causing more severe psychological and biological problems than are found among individuals with just one of these disorders.
This makes it important to treat both disorders together and at the same time, but there are two issues that make this challenging.
“First, in the U.S. mental health system, treatment for PTSD and SUD remain largely separate,” said Davis. “And second, there are several evidence-based treatments for either PTSD or SUD, but integrated, evidence-based treatments for both PTSD and SUD are still in development.”
Limited Pharmacotherapy Options
Currently, there are several pharmacotherapy options for PTSD symptoms — including medications used to alleviate or reduce nightmares, anxiety, concentration, and sleep difficulties — and several relapse-preventing medications for SUD.
Although these pharmacotherapies are effective for the treatment of PTSD and SUD alone, there are no proven medications that treat both conditions.
In a review of recent advances in pharmacological treatments, Mehmet Sofuoglu, MD, PhD of Yale University in New Haven, Connecticut, and colleagues highlighted the potential of norepinephrine and glutamate/GABA targets for the treatment of PTSD and SUD in preliminary studies.
In their analysis they identified several promising noradrenergic medications including prazosin, guanfacine, and atomoxetine. Glutamate/GABA medications that could yield benefits include topiramate, memantine, acamprosate, N-acetylcysteine, and ketamine. However, the safety and efficacy of these medications in humans need to be tested in randomized controlled clinical trials.3
“Future studies also need to address how these medication treatments can be optimally combined with behavioral treatments,” Sofuoglu and colleagues wrote. “Such studies will provide better guidance for the clinical management of patients with PTSD and SUD.”
Behavioral Models
Psychological therapy is an important component of addressing both PTSD and SUD, and involves maintaining a patient’s safety and exploring the reasons for both conditions.
Currently, a widely accepted counseling model called Seeking Safety helps patients with both disorders learn coping skills and increase stabilization.
However, a remaining challenge is to figure out if and when a patient should move into intense trauma narrative to explore feelings and memories connected with trauma.
Lisa Najavits, PhD, of Boston University School of Medicine, and colleagues evaluated a new past-focused behavioral therapy approach, referred to as Creating Change, which identifies a patient’s readiness to explore the past and is designed to address PTSD and SUD at the same time.
Initial results from a pilot study published in the American Journal of Addictions have been positive in terms of efficacy and safety. The researchers noted improvements in PTSD and trauma-related symptoms, as well as in broader psychopathological symptoms such as paranoia, obsessive symptoms and interpersonal sensitivity that play roles in alcohol and drug problems.4
“Creating Change appears to have a promising effect in combination with Seeking Safety. The two models can be used together. Seeking Safety is well known and widely used. Creating Change offers the next step for moving onto the next piece of work,” said Najavits.
Conclusions
Combinations of pharmacologic and nonpharmacologic strategies are likely the most effective for addressing both PTSD and SUD.
“The limitation of drug therapy alone is that when patients stop taking the medication, their symptoms often come flooding back. I always recommend that patients receive evidence-based behavioral interventions in addition to medication,” said Meier.
References
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Davis TA, Jovanovic T, et al. Substance use attenuates physiological responses associated with PTSD among individuals with co-morbid PTSD and SUDs. J Psychol Psychother. 2013; S7: 1-7.
