Roughly one-third of patients with substance use disorders (SUD) have a co-morbid diagnosis of Posttramatic Stress Disorder (PTSD). SUD patients with PTSD have greater SUD severity and patients with PTSD have higher rates of early relapse to substance use following treatment. Methods to improve the poorer SUD outcomes of this population are needed to foster recovery in patients with these prevalent co-morbidities and improve the effectiveness of VA SUD treatment programs.
To investigate whether the generally poorer substance use outcomes of male veterans with comorbid PTSD and SUD could be improved by offering a specialized treatment track, using Seeking Safety (SS). SS is a manualized, cognitive-behavioral, integrated treatment for these co-morbidities that we hypothesized would ameliorate the negative effect of PTSD on SUD treatment outcomes. Additionally, this study investigated whether this treatment track improved PTSD severity, mental health and social functioning, treatment attendance, and legal problems in SUD patients with PTSD, and explored candidate mediators of treatment effects (e.g. coping skill improvements and reduced PTSD symptoms).
This study is a randomized controlled effectiveness trial in which 96 male veterans with comborbid PTSD-SUD beginning treatment at a VA outpatient substance use disorder clinic were randomly assigned to receive SUD-focused treatment as usual (TAU) or a track for PTSD-SUD patients substituting SS based groups and case management for TAU sessions. Subjects were interviewed at baseline, 3, 6 and 12 months following treatment initiation to monitor treatment outcomes.
Patients randomized to SS showed greater reductions in drug use, but not alcohol use over time than did patients in TAU. Patients overall showed significant improvements in PTSD symptom severity and mental health functioning and reductions in legal problems and avoidance coping over the 6 month period after starting treatment, with no difference in rate of change between TAU and SS. Patients in SS attended significantly more treatment sessions, reported higher levels of treatment satisfaction, and larger increases in approach coping than patients in TAU; however, these factors were not independently associated with drug use outcomes, and thus did not mediate the effects of the SS treatment.
A SS-based track for patients with PTSD in VA outpatient SUD treatment may be useful for improving drug use outcomes, treatment attendance, treatment satisfaction and approach coping in the 6 months following treatment engagement. Because SS uses cognitive behavioral therapy methods familiar to clinicians at the majority of VA SUD treatment programs, adding a SS-based track may provide a readily implementable intervention to improve drug outcomes. A toolkit to facilitate implementation has been developed.
- Kearney LK, Smith C, Kivlahan DR, Gresen RC, Moran E, Schohn M, Trafton J, Zeiss AM. Mental health productivity monitoring in the Veterans Health Administration: Challenges and lessons learned. Psychological Services. 2018 Nov 1; 15(4):486-495.
- Zimmerman L, Lounsbury DW, Rosen CS, Kimerling R, Trafton JA, Lindley SE. Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems. Administration and policy in mental health. 2016 Nov 1; 43(6):834-849.
- Tyler Boden M, Kimerling R, Kulkarni M, Bonn-Miller MO, Weaver C, Trafton J. Coping among military veterans with PTSD in substance use disorder treatment. Journal of substance abuse treatment. 2014 Aug 1; 47(2):160-7.
- Harris AH, Oliva E, Bowe T, Humphreys KN, Kivlahan DR, Trafton JA. Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistence. Psychiatric services (Washington, D.C.). 2012 Jul 1; 63(7):679-85.
- Oliva EM, Harris AH, Trafton JA, Gordon AJ. Receipt of opioid agonist treatment in the Veterans Health Administration: facility and patient factors. Drug and Alcohol Dependence. 2012 May 1; 122(3):241-6.
- Boden MT, Kimerling R, Jacobs-Lentz J, Bowman D, Weaver C, Carney D, Walser R, Trafton JA. Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction (Abingdon, England). 2012 Mar 1; 107(3):578-86.
- Midboe AM, Cucciare MA, Trafton JA, Ketroser N, Chardos J. Implementing motivational interviewing in primary care: the role of provider characteristics. Translational behavioral medicine. 2011 Oct 28; 1(4):588-594.
- Weaver CM, Trafton JA, Walser RD, Kimerling RE. Pilot test of seeking safety treatment with male veterans. Psychiatric services (Washington, D.C.). 2007 Jul 1; 58(7):1012-3.
- Oser ML, Bucossi MM, Trafton JA, Bonn-Miller MO. Multi-method assessment of distress tolerance in relation to two objective measures of medication adherence among HIV+ individuals. Presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2012 Apr 12; New Orleans, LA.
- Bonn-Miller MO, Trafton JA. Distress tolerance and marijuana use patterns and cessation processes. In A. C. McLeish (Chair), Distress tolerance and substance use: Recent findings and treatment implications. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 13; Toronto, Canada.
- Medina JL, Mitragotri N, Bucossi M, Bonn-Miller MO, Trafton JA. Posttraumatic stress disorder and risk of poor marijuana cessation outcomes. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 13; Toronto, Canada.
- Medina JL, Smits JA, Irons JG, Trafton JA, Bonn-Miller MO. The relation between exercise intensity and coping-oriented marijuana use among a marijuana dependent sample. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 13; Toronto, Canada.
- Mitragotri N, Bucossi MM, Medina JL, Reber CA, Trafton JA, Oser ML, Bonn-Miller MO. The relation between marijuana use and HIV: Treatment adherence, symptoms, and psychological vulnerability. In A. C. McLeish (Chair), Understanding substance use among medically vulnerable populations. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 13; Toronto, Canada.
- Mok C, Christopher S, Jacobs-Lentz J, Trafton JA, Kimerling R, Weaver CM. Veterans seeking treatment for substance use and PTSD: Describing criminality and psychopathy. Presented at: American Psychology-Law Society Annual Conference; 2010 Mar 1; Vancouver, Canada.
Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
Diagnosis, Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Drug abuse, PTSD, Substance Use and Abuse