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Exposure treatment for PTSD did not affect substance dependence

Patients who received an integrated treatment for posttraumatic stress disorder and substance dependence, besides usual treatment, experienced improvement in PTSD symptom severity compared with patients who received usual treatment only, according to study results published in The Journal of the American Medical Association.

The researchers said there have been concerns that the evidence-based cognitive-behavioral treatment (CBT) of exposure therapy — the “gold standard treatment” for PTSD — may be inappropriate for patients who are at risk of relapse with co-occurring substance dependence.

“Based on early case reports, it was widely believed that the intense emotions elicited during prolonged exposure therapy could place individuals at increased risk for relapse,” the researchers wrote.

Katherine L. Mills, PhD, of the University of New South Wales in Sydney, Australia, and colleagues conducted a randomized controlled trial enrolling 103 participants who met DSM-IV criteria for both PTSD and substance dependence. Participants received either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) plus usual treatment for substance dependence (n=55), or usual treatment only (n=48).

COPE is an intervention consisting of 13 individual, 90-minute sessions of motivational enhancement, CBT for substance use, psychoeducation, in vivo exposure, imaginal exposure and cognitive therapy for PTSD. The final session in COPE was focused on providing a review of the treatment, creating an after-care plan and termination of therapy. Participants enrolled in usual treatment only were at liberty to access any type of substance use treatment currently available in the community, including outpatient counseling, inpatient or outpatient detoxification, residential rehabilitation and pharmacotherapy.

Outcomes were assessed at 6 weeks and again at 3 and 9 months post-baseline. PTSD symptom severity was measured using the Clinician-Administered PTSD Scale, and substance dependence was measured by the number of dependence criteria participants met according to the Composite International Diagnostic Interview Version 3.0.

At the 9-month follow-up, Mills and colleagues observed significant reductions in PTSD symptom severity in the COPE treatment group (95% CI, –47.93 to –28.54) and the control group (95% CI, –30.33 to –13.95), but the COPE group experienced a significantly greater reduction in PTSD symptom severity (95% CI, –29 to –3.19). There was no significant difference in improvement related to the severity of substance dependence between the two groups (incidence rate ratio=0.85; 95% CI, 0.60-1.21), and there were no significant differences related to changes in substance use, depression or anxiety.

Mills and colleagues said most participants randomly assigned to COPE plus usual treatment continued to use substances throughout the study period.

“Contrary to popular belief, participants randomized to receive the exposure-based intervention did not demonstrate poorer substance use outcomes relative to those randomized to receive usual treatment only,” the researchers wrote. “The complex trauma, substance use, and psychiatric presentations commonly found among individuals with PTSD and substance dependence should not be a deterrent to providing trauma-focused treatment.”

Disclosure: The study was supported by an Australian National Health and Medical Research Council project grant. See the study for a full list of financial disclosures.