Compared with study subjects without PTSD, those with the added disorder had better alcohol use outcomes and improvement of psychiatric symptoms when they received one or other of the active medications, reported Dr. Ismene Petrakis and associates (Biol. Psychiatry 2006;60:777-83).
Another study offers insight into integrated treatment for patients with opiate addictions. The prospective observational study found comparable reductions in drug use by patients with or without PTSD when opioid substitution was employed, even though the PTSD group had a lengthier mean history of addiction (J. Stud. Alcohol 2006;67:228-35). The PTSD subgroup used higher doses of opiate medications, but actually attended more psychosocial treatment sessions and had better treatment retention.
Motivation to Get Treatment
“I can only speculate about the difference between outcomes … but my guess is that the patients with PTSD were more sensitive to the discomfort associated with missing a dose of methadone and thus were more motivated to get to the clinic for treatment each day,” said the lead author of the study, Jodie A. Trafton, Ph.D., in an interview.
If true, the increased-distress hypothesis, also postulated by other researchers, “might suggest that maintenance therapies or very slow tapers during detoxification might be particularly helpful for patients with these comorbidities,” said Dr. Trafton, who directs the VA Program Evaluation and Resource Center, Menlo Park, Calif.
Although she is not a prescriber, Dr. Najavits advocates a medical consultation for patients with co-occurring PTSD and substance abuse, to determine whether these or other medications might be helpful during the intensive Seeking Safety program.
Because it is a difficult group to treat, strategies should aim at “giving the client as much care and support as possible,” including medication, 12-step group meetings, domestic violence counseling, parenting skills training, and HIV testing and counseling—essentially any adjunctive intervention that is relevant and scientifically sound.
“The more the better,” she said.
One challenge shared by many of the integrated therapy models is reaching potential patients who could benefit, Dr. McGovern said.
Denial is a common component of both diagnoses, and even patients who are ready to tackle one issue might be reluctant to acknowledge or address the other. PTSD, for example, might present as a sleep problem or chronic pain, either of which could prompt the writing of prescriptions with the potential of exacerbating co-occurring substance abuse.
When Dr. McGovern and associates offered free evaluations and treatments for dual diagnosis patients, they were stunned at the lack of response from the community. “We thought if we built it they would come,” he said. “We had clear recruitment challenges.”
Reaching dually diagnosed patients early, when intervention is most likely to succeed, would be aided if primary care physicians as well as psychiatrists were better trained to recognize these hidden disorders, experts agreed.
A heightened awareness and specialized training also would increase the number of providers able to treat PTSD and substance abuse.
“The hardest thing for non–substance abuse providers to do is ask and monitor for substance abuse, including urine toxicology for illicit drugs and breath alcohol [tests] as needed,” Dr. Kosten said.
His advice? “Do not avoid discussing the use of abused drugs at the first meeting with the patient. They are more than happy to discuss it, although the younger patients do not view binge alcohol as a problem and need to be convinced.”
If patients say they can quit any time, Dr. Kosten challenges them, asking whether they will stop for a week and monitoring their adherence with a breath alcohol test during a Monday morning appointment. He also asks permission to talk to a significant other about the patient's drinking.
“It is easy when you do it right from the start and do not wait to address the 'delicate issue' of substance abuse in a patient with PTSD,” he said. “They already know that it is a problem. Lots of friends and relatives have usually told them.”
Asked to offer advice to clinicians treating patients with co-occurring PTSD and substance abuse, Dr. Brady emphasized the heterogeneity of the disorders.
“No two patients look alike,” she said. “Every patient needs a careful evaluation and individualized treatment plan. The treatment provider must be flexible—ready to change treatment strategies if what they initially try doesn't work, because we [still] have a lot of uncertainties in treatment.”
Disclosures: Dr. Kosten has served on the speakers bureau for Reckitt Benkizer, maker of buprenorphine, and as a consultant to Alkermes Pharmaceuticals, maker of Vivitrol (naltrexone). Dr. Brady has received research support from GlaxoSmithKline and served as a consultant for Ovation Pharmaceuticals, now Lundbeck Inc. The other experts interviewed reported no relevant conflicts.