High historical incidence of both Worse Outcome with both Concerning info and Evidence for SUD in Iraq War

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1 Comorbid SUD & PTSD

2 High historical incidence of both Worse Outcome with both Concerning info and Evidence for SUD in Iraq War

3 Co-Occuring Assessment & Treatment approaches Preventative treatment approaches Neurobiologic overlap b/w PTSD & SUD

4 PTSD in population 8-12% PTSD in individuals with SUD - 40%-80% SA in PTSD - 30% to 60% Studies with Veterans 46% of SUD treatment seekers had PTSD On inpatient SUD units: 58% lifetime & 38% current

5 Civil War some blame in the press for spreading drug addiction in the country WW II ETOH, Opiates Narcomania in Finland in the 50s Increased drug addiction reported in Germany in the 50s

6 Vietnam 2 stages 65 MHJ 70s highly potent heroin 1/5 troops addicted 95% were not re-addicted when out of country Raised? About what constitutes addiction Lebanon ( 73-90) Increase in Heroin, Hashish, Cocaine reported with the civilian population Gulf War I Increase in ETOH in Kuwait civilian population

7 Host Drug Exposure Environment Re: George Valliant

8 Culture Religion Customs/Traditions Family Community

9 Think Provo Utah and then think Casablanca

10 Breakdown in Culture/Religion/Family Intrusion of a competing culture Increased access to drugs and ETOH Atrocities breakdown of moral code

11 Studies of both male combat veterans and civilians with PTSD have demonstrated that alcohol abuse or dependence is the most common co-occuring disorder followed by depression and other anxiety disorders. SUD is the most common co-occuring disorder with PTSD

12 Less Improvement with Treatment Shorter time to relapse post tx Drink more on drinking days Less likely to be employed Increased medical and interpersonal problems

13

14 Established by the Army Surgeon General to assess and make recommendations to the Commanding General, Multi-National Force- Iraq Published 11/06

15 Risk Factors Combat Exposure Deployment Concerns Branch of Service Multiple Deployments Deployment Length Protective Factors NCO Leadership Officer Leadership Training Cohesion R&R Mid Tour Leave Behavioral Health Morale (Personal Status & Unit) Depression Anxiety Acute Stress (PTSD) Anger Marital Concerns Suicide Battlefield Ethics Soldier and Marine Combat & Well Being Model (Adapted from Bliese & Castro, 2003)

16

17 The PDHA does not include screening for substance abuse because access to alcohol and other substances is very limited in the war zone

18 The New York Times!

19 >1/3 of Army prosecutions are ETOH and Drug related charges. 240 out of 665 cases convicted 90% of Military sexual crimes involve ETOH NY Times March 13, 2007

20 Haiji Juice ETOH from family in the USA Red-Bull Amphetamines Hashish Prescription Drugs from local sources NY Times March 13, 2007

21 Alcohol Misuse questions: Have you used alcohol more than you meant to Predeployment - 17% Postdeployment - Army 24.5%/Marines 35% Have you felt you wanted or needed to cut down on your drinking Predeployment % Postdeployment - Army 18.2%/Marines 29.4%

22 Pentagon report 1/07

23 Rates of Heavy Drinking 5+ drinks/day: yr olds 9.7% Soldiers 9.5% Civilians yr olds Soldiers 25% Civilians 17%

24 $12.6 Million in 2005 $7.74 Million in 2007 (!) $2 million campaign ThatGuy.com

25

26 Funded in 1992 by the Dept. of Veterans Affairs. Grew out of a recognition that combat veterans with SUD were especially difficult to treat. Self-Medication of PTSD with Substances.

27 Sharon Adelson, SSPS Patrick Dulin, Ph.D. Susan Karpenko, LCSW Nancy Odell, LCSW Mark Zaslav, Ph.D. retired Psychology of Comorbid Posttraumatic Stress Disorder and Substance Abuse: Lessons from Combat Veterans Journal of Psychoactive Drugs Vol 26(4), Oct-Dec 1994

28 PTSD and SUD is a CAD: Confuses the clinical presentation Amplifies certain symptoms Irritability, sleep disturbance, isolation Diminishes certain symptoms Apathy, decreases distress

29 Two common barriers to engagement: Tuned-out style withdrawal, lack of insight, lack of curiosity externalize problems, alexithymia Dichotomous Thinking All or None Patient either I ve got PTSD or SUD Therapist sympathetic PTSD survivor or a non-sympathetic SUD addict Knowing the common neurobiology helps here

30 Dichotomous Thinking for the Therapist Abstinence versus Harm Reduction Continuum between the two Motivational Interviewing principles The sympathetic PTSD survivor and the non-sympathetic SUD addict Knowing the common neurobiology helps here

31 National Epidemiological Survey on Alcohol and Related Conditions (NESARC), Moss et al., Drug and Alcohol Dependence, n = 1,484 treatment + non treatment alcohol dependence

32 SUD Barriers to PTSD treatment: Self-Medicating symptoms Difficult to work through trauma-related material when using heavily High emotional arousal is a trigger to SUD

33 PTSD Barriers to SUD treatment: Avoidance Barriers to AA God or spiritually focused treatment Difficulty discussing their triggers to use Dichotomous thinking Treat my PTSD and I won t abuse substances Unique & special SUD due to PTSD Don t need to do the usual treatment

34 Two Phase approach Phase One: PTSD-informed SUD treatment Focus on establishing sobriety, managing triggers Working on emotional coping skills - Anger Management, Seeking Safety Phase Two: SUD-informed PTSD treatment Focus on interpersonal impact of traumatic experiences Vigilance for triggers and relapse risks

35 Two major approaches: Here & Now Emotional work Focus on affect regulation skills Improving veterans access to emotions and building healthier relationships There & Then Emotional processing Therapy Exposure based re-exposure Higher risk perhaps higher gain Some success in the literature four published approaches tighter treatment structures

36 PTSD and SUD share common neurobiology

37 Drug withdrawal Insomnia Psychomotor agitation Anxiety Autonomic hyperactivity Hand Tremor Transient Hallucinations Irritability PTSD increased arousal Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle

38 Significantly increased levels of CSF CRH Increased Norepinephrine turnover in hypothalamus, LC, hippocampus, amygdala, and cerebral cortex Stress increases CRH in the LC

39 Mesocorticolimbic system motivational system with the goal of increasing the organism s survival Hebb s Theorem nerves that fire together, wire together Dopamine bursts from drug use result in structural hijacking of the Mesocorticolimbic system Results in organism losing survival behaviors and replacing them with drug using behaviors

40 Neurohormonal environment that influence the firing of these neurons. Neuroreceptors HPA stress axis CRH and Anti-Reward system

41 Homeostasis and Allostasis Homeostatsis - maintaining a steady state A stable set point Allostasis - ability to achieve stability through change Allostatic state - state of chronic deviation of the regulatory systems from their normal state with establishment of a new set point.

42 An Allostatic adaptation to an overdriven reward system. Corticotropin Releasing Factor Part of the HPA Axis- adrenergic vigilance Source of the clinical syndrome of withdrawal, anhedonia, irritability These changes extinguish slowly (or not?)

43 Stress (including drug withdrawal) stimulate CRH release in the LC CRH activates the LC and the release of norepinephrine in the cortex Cortex norepinephrine stimulates release of CRH in the hypothalamus and amygdala

44 Positive Reinforcement Negative Reinforcement

45 The primary sign/symptom of this allostatic neurobiologic adaptation Two components to these changes: Autonomic hyperarousal Locus Ceruleus Affective changes Depressive, anhedonic, craving, feelings of not being normal, irritable

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