Will Rutland, MD, JD, MPH. Assistant Professor and Psychiatry Clerkship Director, UAB Heersink, School of Medicine, Montgomery Regional Campus. Montgomery, AL.
Dr. Rutland, author of this educational activity, has no relevant financial relationship(s) with ineligible companies to disclose.
If you treat patients with substance use disorders (SUDs), it won’t surprise you to learn that many of them also have posttraumatic stress disorder (PTSD). Among US adults, the lifetime prevalence of PTSD is over 7%, but among your patients with SUD, that number could jump as high as 49% (Kessler RC et al, Int J Methods Psychiatr Res 2012;21(3):169–184; Gielen N et al, Eur J Psychotraumatol 2012;3:17734).
The relationship between trauma and addiction is complex and can vary widely between patients. For example, a history of trauma is associated with an increased prevalence of substance use, while conversely, patients who use substances may find themselves in dangerous situations that can lead to trauma, which in turn can cause PTSD. In this article, we’ll give you some practical advice on how to assess and treat these complicated patients.
Diagnosing PTSD in patients with SUD
Ask all patients with SUD if they have a history of trauma, which the DSM defines as exposure to actual or threatened death, serious injury, or sexual violence. Giving examples of specific traumas can be helpful, and be sure to ask whether they have witnessed violence towards others or seen a drug overdose.
For patients who do report a history of trauma, a quick screen can indicate whether to further pursue a PTSD diagnosis. You can start by asking about cardinal symptoms such as intrusive memories, nightmares, or hypervigilance. Alternatively, you can use a validated screening questionnaire like the Primary Care PTSD Screen for DSM-5 (www.tinyurl.com/2p42dxwz) or the self-report PTSD Checklist (www.tinyurl.com/any92sh8). Anybody with a history of trauma who reports experiencing symptoms consistent with PTSD, or who screens positive, warrants further diagnostic investigation.
Like all psychiatric disorders, a diagnosis of PTSD is established with a thorough psychiatric interview. In order to qualify for a diagnosis, patients who have experienced trauma must have symptoms in each of four clusters: 1) intrusive symptoms (recurrent thoughts, nightmares, dissociations, or flashbacks); 2) avoidance of memories or reminders of the traumatic event; 3) negative alterations in cognition or mood (amnesia, negative beliefs about oneself, cognitive distortions); and 4) hyperarousal (irritability, hypervigilance, exaggerated startle). These clusters can be explored in the context of either a standard psychiatric interview or a structured interview such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; www.tinyurl.com/32m2jwah). The intricacies of PTSD diagnosis are beyond the scope of this article, but there are some excellent resources that review this topic in depth (Shalev A et al, N Engl J Med 2017;376(25):2459–2469). You can find further information about complex PTSD, which arises from exposure to trauma or stress over time, in the December 2017 issue of TCPR.
Treating patients with PTSD and SUD
All the evidence indicates that if your patient presents with both PTSD and SUD, you should simply treat both conditions—maybe because the chicken-and-egg relationship between them is so difficult to untangle. Your general approach need not vary much from if you were treating each condition independently. Conventional wisdom used to suggest that a patient needed to be free of substance use before tackling trauma symptoms, but studies have not found evidence to back up this assertion.
Therapeutic approaches to PTSD
Psychotherapy is a mainstay of PTSD treatment, with trauma-based therapies such as cognitive processing therapy (CPT) and prolonged exposure (PE) having the most evidence behind them. These therapies can be effective in reducing PTSD symptoms, even for those with comorbid addiction. For example, CPT has been shown to be equally effective at reducing PTSD symptoms among veterans regardless of whether they carry an alcohol use disorder (AUD) diagnosis (Kaysen D et al, Addict Behav 2014;39(2):420–427). Similarly, PE is effective in treating PTSD in veterans with comorbid PTSD and AUD, and it might be helpful in reducing drinking as well (Back SE et al, Addict Behav 2019;90:369–377).
Does this mean we can plunge any patient with SUD headlong into trauma therapy? Not quite. Research has not found evidence that trauma therapy worsens addiction per se, but it stands to reason that stress and anxiety evoked during therapy could drive a patient to use substances. Research trials typically pair trauma therapy with some other form of substance use treatment, and many exclude patients with severe or complex presentations (Roberts NP et al, Cochrane Database Syst Rev 2016;4(4):CD010204). So, while total sobriety should not be a prerequisite for trauma therapy, it is prudent to reserve this therapy for patients who are already in SUD treatment and have adequate supports.
As a quick review, there are only two medications with FDA approval for PTSD: paroxetine and sertraline. Other serotonergic agents like fluoxetine and venlafaxine also show clinical benefit, although this use is technically off label. These established treatments should be your first-line go-tos. Evidence for other medications such as atypical antidepressants, antipsychotics, and antihypertensives is quite mixed, and they should be considered only after the serotonergic stalwarts have been given a fair trial (Charney ME et al, Harv Rev Psychiatry 2018;26(3):99–115). Other experimental treatments, like psychedelics, show promise but are not well researched enough to recommend.
Does the presence of SUD change how you should prescribe for a patient? Not really. These medications are effective for treating PTSD in patients with and without comorbid addiction, and no evidence suggests that the presence of an SUD should affect the choice of PTSD medication. Use clinical judgment in choosing the best PTSD medication for your patient, regardless of whether they have comorbid addiction.
Therapeutic approaches to SUD
Analogously, the presence of comorbid PTSD should not change the way that a patient’s addiction is treated. There is no evidence that SUD medication can worsen symptoms of PTSD, and likewise, no SUD medication has been shown to also treat PTSD. Clinicians should therefore simply pick the agent most appropriate to the SUD in question.
Accordingly, if you are treating AUD, pick naltrexone (oral or injectable), acamprosate, disulfiram, or off-label medications with high-quality clinical evidence (gabapentin, topiramate), without regard for any effect on trauma. In opioid use disorder, choose buprenorphine (with or without naloxone), methadone, or injectable naltrexone. If your patient struggles with cocaine or amphetamine use, consider off-label use of topiramate, bupropion paired with injectable naltrexone, or mirtazapine. Contingency management can be helpful if it is available. (For more on treating stimulant use disorder, see CATR May/June 2021.)
In all cases, practice brief motivational interviewing techniques to draw out your patient’s ambivalence, and consider referring to colleagues who can help with specialized therapies like cognitive behavioral therapy for SUD, motivational enhancement therapy, or—if you are lucky—contingency management.
A word on cannabis
Many areas of the country have legalized cannabis for the treatment of PTSD (34 states, several territories, and the District of Columbia, at the time of this writing). Unfortunately, these decisions were made in the absence of solid medical evidence. While some small open-label trials have reported temporary subjective symptom improvement, the long-term effects of cannabis on PTSD are not at all clear. The only randomized controlled trial to date failed to show any clinical benefit, and patients with PTSD are more likely to develop cannabis use disorder than their PTSD-free counterparts (Bedard-Gilligan M et al, Curr Addict Rep 2022;9:203–216). Moreover, some studies have found that cannabis is associated with worse PTSD symptom severity, violent behavior, and substance use (Wilkinson ST et al, J Clin Psych 2015;76(9):1174–1180).
For these reasons, you should not prescribe cannabis as a treatment for PTSD, whether it is for a patient with comorbid SUD or not. There’s a lot of misinformation out there, so be sure to explain the risks to your patients and recommend treatments that have a firm evidence base. For those patients who insist on using cannabis despite your recommendation against it, consider having them switch to strains with lower THC content and a high CBD:THC ratio, and have them avoid methods of use that utilize THC concentrates. (See CATR September/October 2022 for more on cannabis formulations.)
Addiction and PTSD are highly comorbid. The most effective approach for patients with both conditions is to treat each one simultaneously. There is no need to wait for the SUD to remit before addressing PTSD. Stick to evidence-based medication and psychotherapy treatment approaches, both of which are effective in patients with comorbid illness.
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