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SUDs and PTSD
Goal 4(iv). Patients with SUDs and PTSD
Approximately one-third of veterans seeking treatment for substance use disorders (SUD) meet criteria for comorbid posttraumatic stress disorder (PTSD). SUD patients with comorbid PTSD (SUD-PTSD) present with greater drug abuse severity (Clark et al., 2001), demonstrate greater trauma and drug cue-elicited drug craving (Saladin et al., 2003), and have poorer SUD treatment outcomes (Ouimette et al., 1998, Rosen et al., 2002; Najavits et al., 1997) than SUD patients without PTSD. Overdoses and liver disease related to substance use are significant causes of premature mortality among VA patients with chronic PTSD (Drescher et al., 2003). Aggression is also a significant issue for veterans with PTSD and SUD (Taft et al., 2007). Receipt of PTSD treatment is associated with improved outcomes among VA PTSD-SUD patients (Ouimette et al., 2000, 2003), although simply receiving SUD treatment (the usual practice) is not as associated with PTSD improvement (Trafton et al., 2006; Najavits et al., 2007). However, there is not yet consistent screening and referral for PTSD problems in VA addiction treatment programs (Young et al., 2005). Mental health and other providers in VA who do not specialize in SUD often feel ill-equipped to manage or treat it (Tracey et al., 2007).
Dr. Lisa Najavits from the National Center for PTSD at VA Boston (VISN 1) assumed leadership of the SUD-PTSD Task Group in September, 2006. The Task Group has been expanded and now includes 26 members. A total of 13 new members has been added and two prior members have left (related to changes in their duties). This expansion has been productive in creating a network of researchers to draw upon for projects, to expand the geographic base and types of programs represented by the Task Group, and to develop new ideas for future work. The Task Group has regularly scheduled monthly meetings and documentation of minutes of each meeting. An in-person meeting was held by the Task Group at the November 2006 International Society for Traumatic Stress Studies (ISTSS) conference, and will also be held at the 2007 ISTSS meeting.
The Task Group is developing a strategic plan to (a) implement and support ongoing evidence-based screening for PTSD among veterans in SUD treatment; (b) support improved access to effective PTSD treatment for veterans identified with comorbid SUD-PTSD, through enhanced coordination of SUD and PTSD specialty care and/or through implementation of evidence-based interventions for dual SUD-PTSD patients within VA SUD addiction treatment programs; (c) promote access to effective treatment for both deployment stress and substance use problems among OIF/OEF returnees; (d) train clinicians in evidence-based therapy for SUD/PTSD; (e) adapt evidence-based therapy for SUD/PTSD; and (f) survey VA key informants on system-level needs related to SUD/PTSD treatment. One group member, Dr. Trafton (Drs. Kimerling, Najavits, and Ouimette from the Task Group are Co-Investigators), has been actively recruiting patients for her funded study of PTSD screening and Seeking Safety as a treatment for SUD patients with comorbid PTSD. Drs. Rosen and Kimerling from the Task Group began a MIRECC-supported survey assessing rates of untreated alcohol and PTSD problems among OIF/OEF returnees entering VA care. Dr. Najavits has begun a QUERI-funded project to survey key informants in the VA regarding SUD/PTSD treatment; in addition, she has been approved for funding for an RRP on adapting Seeking Safety thearpy for SUD/PTSD for OEF/OIF veterans. Drs. Kosten and Najavits have begun a project to evaluate basic versus enhanced training for PTSD/SUD in VISN 16.
- This workgroup has validated a PTSD screening questionnaire within SUD specialty care, is evaluating integrated treatment models, is developing distance-learning for clinicians, and is identifying systems-level issues that need attention.
- Distance learning for post-deployment providers. Work Group members, led by Dr. Rosen, are continuing an RRP begun in FY07 on a formative evaluation of a distance-learning model that combines internet-based didactic materials with telephone or V-Tel coaching and supervision to help VA clinicians deliver evidence-based SUD assessment and treatment of deployment-related mental health concerns of OIF/OEF returnees. Thus far, five of 12 clinicians have been recruited and have completed interviews regarding the VIP website.
- Key informant survey. Work Group chair, Dr. Najavits, began an LIP to survey 200 VA staff regarding their opinions on system-level needs to improve treatment for SUD/PTSD. Over 100 providers have been surveyed to date.
- Adaptation of Seeking Safety for OEF/OIF. Dr. Najavits was approved for RRP funding for FY08 to adapt the Seeking Safety therapy model (designed for PTSD/substance abuse) for OEF/OIF veterans. This project involves three locations: Boston, Providence and San Diego. Findings will inform special needs of the OEF/OIF generation with regard to treatment of PTSD/substance misuse, training needs of clinicians, and systems implementation of a new model of care.
- Effectiveness of Integrated Treatment for PTSD in SUD Patients. Workgroup members Drs. Trafton and Kimerling continued their randomized trial of Seeking Safety therapy with male OEF/OIF veterans; preliminary findings indicate that the model can be successfully used without formal adaptation (Weaver et al., 2007).
- Basic versus Enhanced Training in PTSD/Substance Abuse Treatment. Drs. Kosten and Najavits are co-PIs on a project with the VISN 16 MIRECC to evaluate basic provider training versus external facilitation in the treatment of PTSD/SUD.
Progress and Accomplishments
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