A program of cognitive-behavioral therapy combined with substance abuse treatment decreased the symptoms of posttraumatic stress disorder but had little effect on drug use.

That finding, however, can be construed as a positive, Katherine L. Mills, Ph.D., and her colleagues reported in the Aug. 15 issue of JAMA.

“It’s important to note that most participants randomized to receive [the dual therapy] continued to use substances throughout the study,” wrote Dr. Mills and her coauthors. “These findings challenge the widely held view that patients need to be abstinent before any trauma work, let alone prolonged exposure therapy, is commenced.”

Courtesy The University of New South Wales

Dr. Katherine L. Mills
The study randomized 103 patients with concurrent PTSD and substance abuse to one of two arms: a dual treatment of cognitive-behavioral therapy plus substance abuse treatment, or substance abuse treatment alone, said Dr. Mills of the Australian National Drug and Alcohol Research Centre, Sydney (JAMA 2012;308:690-9).

The active arm employed the Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) program, which consists of 13 90-minute sessions. Components included motivational enhancement and cognitive-behavioral therapy for substance abuse, education about the interaction of PTSD and substance abuse, in vivo and imaginary exposure, and a final session in which patients constructed an after-care plan.

Usual treatment was the patient’s choice of counseling, inpatient detoxification, residential rehabilitation, and pharmacotherapies. All of the participants were offered 9 months to complete their treatment program.

The patients were a mean of 33 years old. Most (77%) were unemployed, and 35% had been in prison. The most commonly abused drug was heroin, followed by marijuana, amphetamines, benzodiazepines, alcohol, cocaine, opiates, and hallucinogens. Most (93%) had undergone prior substance abuse treatment.

All had experienced multiple traumas, including physical assault (92%), being threatened or held captive (89%), witnessing injury or death (77%), sexual assault (78%), accident or disaster (66%), torture (24%), or combat (2%).

The mean age at first trauma was 8 years. About half of the group had experienced a childhood sexual assault; half also had attempted suicide at least once.

There were compliance problems for the group randomized to dual therapy, the investigators noted. Only 10 patients attended all 13 of the sessions.

By the end of the 9-month follow-up period, both groups had experienced significant reductions in PTSD symptom severity, although the intervention group had significantly greater improvements than did the control group.

Most of the patients continued to use substances at the end of the follow-up period (82% active, 73% control); there was no significant between-group difference. Both groups experienced significant decreases in drug abuse severity, but again, this was not significantly different between the groups. Both groups also experienced similar, significant decreases in anxiety and depression, without a between-group difference.

Seven patients attempted suicide during the study – two from the treatment group and five from the control group. “Although it is possible that these attempts were related to participation in the study, all seven individuals … elected to remain involved with the study,” Dr. Mills and her associates noted.

The investigators also suggested that the final outcomes might actually improve with time. “It’s important to note that studies examining the temporal sequencing of changes in PTSD and substance dependent symptoms have shown that improvements in PTSD symptoms are associated with subsequent improvements in substance dependence, but the reciprocal relationship is not observed,” they wrote. “These findings highlight the importance of treating PTSD to improve substance dependence outcomes for individuals with this comorbidity.”

The study was funded by the Australian National Health and Medical Research Council. Neither Dr. Mills nor any coauthor had any relevant financial disclosures.

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Unraveling the Knot of PTSD and Drug Abuse

This study is the first published randomized controlled trial to assess the efficacy of prolonged cognitive-behavioral therapy for PTSD and comorbid substance abuse, Lisa M. Najavits, Ph.D., wrote in an accompanying editorial (JAMA 2012;308:714-6).

Although the study was well designed, its results highlight this clinically thorny presentation, she said. “The majority of patients still had PTSD and moderate depression, and nearly half still had evidence of substance dependence, despite receiving treatment and close monitoring in this trial and, for 65% of the patients, other treatments for PTSD prior to this trial.”

Allowing a 9-month compliance period was probably an ill-advised aspect of the study, resulting in “a lack of consistent timing for end-of-treatment outcome assessment. … Even with the time extension, the dropout rate was considered high by the investigators, with patients attending a median of only 5 of 13 sessions,” she said.

The trial’s limited results highlight the need for more research, Dr. Najavits said. In light of its ambiguous results, “exposure-based therapy for co-occurring PTSD and substance abuse cannot be widely recommended based on the results of this trial alone.”

Dr. Najavits is professor of psychiatry at Boston University, a lecturer at Harvard Medical School, a clinical psychologist at the Veterans Affairs Boston Healthcare System, and clinical associate at McLean Hospital in Belmont, Mass. She had no financial disclosures.