David Yusko, PsyD & Emily Malcoun, PhD

Transcription

1 David Yusko, PsyD & Emily Malcoun, PhD

2 Introduce the history, prevalence, and complications this unique comorbidity introduces to clinical practice Discuss two clinical trials that illustrate potential evidence based treatment options for this population Review the components of concurrent treatment models that integrate evidenced practices for PTSD (prolonged exposure therapy) & SUD. Answer questions and have discussion

3 Studies indicate that 30-60% of patients presenting for alcohol use treatment also meet diagnostic criteria for PTSD (Brown et al., 1995; Chilcoat & Menard, 2003; Kessler et al., 2005). Similarly, men with PTSD are twice as likely to have an Alcohol Use Disorders (AUD). (Kessler et al., 1995) Women with PTSD are 2.5 times more likely to have an AUD (Kessler et al., 1995).

4 PTSD patients present to treatment drinking more at baseline, experience more consequences, and drink/use drugs more during and after treatment (Ouimette et al & 1999). PTSD patients were less likely to enter remission after treatment (Hien et al. 2000). PTSD patients may relapse more quickly (Brown et al. 1996). These data suggest a failure in treatment to address this unique comorbidity.

5 Agency Patients Screened To Date Number of patients experienced a trauma To Date Number of patients with probable PTSD To Date NHS 1,830 1,257 (68.7%) 954 (52.1%) JJPI 1,673 1,112 (66.5%) 715 (42.7%) The Consortium 1, (72.0%) 656 (56.7%) Chances (73.5%) 240 (39.8%) Hall Mercer (40.1%) 323 (36.7%) Gaudenzia 1, (29.9%) 410 (24.5%) NET 2, (40.1%) 570 (24.7%) Family Center (80.9%) 95 (42.2%) My Sister s Place (88.0%) 28 (56.0%) Caton Village (71.8%) 21 (53.8%) Total 10,434 5,677 (54.4%) 4,012 (38.5%)

6 Self-medication --> alcohol used to relieve PTSD symptoms Alcohol use interferes with natural trauma recovery process Using alcohol leaves the individual more vulnerable to a traumatic experience Combined model: PTSD + alcohol use develop independently; later, PTSD symptoms maintain alcohol use & vice versa Studies suggest PTSD often plays a causal role in the etiology of SUD after which a cycle of maintenance ensues (Chilcoat & Breslau, 1998).

7 RCT s for either disorder have typically ruled out the other as a typical exclusion criteria 12 Step model suggests that up to one year of recovery is necessary before addressing trauma. Mental health treatment programs often require a period of sobriety before addressing trauma. Addiction treatment programs often cite negative affect as the number one reason for relapse and therefore trauma is not addressed in treatment for addiction. Consequently, patients with SUD do not receive treatment for PTSD and vice versa

8 Present-focused counseling model to help people attain safety from trauma and/or substance abuse Group or individually based 12 to 25 weeks 25 topic areas e.g. Taking Back Your Power, When Substances Control You, Asking for Help, Setting Boundaries in Relationships, Getting Others to Support Your Recovery, Healthy Relationships, etc. Has solid evidence for effectively engaging clients to discuss the impact of trauma on SUD development/maintenance

9 Hien et al. (2009) 353 women with SUD+PTSD were randomized to 12 sessions of either SS+TAU or a Women s Health Education program + TAU. While all participants experienced reductions in SUD +PTSD symptoms; SS = WHE as an adjunctive treatment to standard SUD treatment on all outcomes (CAPS, PDS, 7 day abstinence rate, & % days substance use).

10 Hien et al. (2004) randomly assigned 107 SUD+PTSD women to SS (n=41), relapse prevention (n=34), or TAU (n=32). SS = RP >TAU in reducing both substance use and PTSD at post tx and 6 month f/u At 9 month f/u SS = RP > TAU on PTSD; while RP > SS = TAU on substance use outcomes

11 Average Number of Treatment Sessions Seeking Safety Group Individual PE Seeking Safety Group 8.4 Individual PE

12 PDS-5 Score Pre-PDS Post-PDS Seeking Safety Group Individual PE

13 BDI Score Seeking Safety Group 20 Individual PE Pre-BDI Post-BDI

14 It is possible to effectively deliver combined, concurrently delivered treatments for SUD and PTSD with positive outcomes and certainly without harmful effects. There is evidence suggesting that PTSD symptom change mediates the change in alcohol use but decreases in alcohol use do not appear to mediate change in PTSD (Back et al. 2006). Maintained PTSD improvement may be associated with subsequent substance use improvement (Hien et al. 2010). SS appears very effective at engaging clients and keeping them connected to treatment while not necessarily being an evidenced based treatment for PTSD

15 This Study has been funded by the National Institute on Alcohol Abuse and Alcoholism RO1 AA012428

16 Prolonged Exposure (PE) No Exposure (No-PE) Naltrexone (NAL) PE + NAL (N = 40) Completers = 23 No-PE + NAL (N = 42) Completers = 33 Placebo (PBO) PE + PBO (N = 42) Completers = 26 No-PE + PBO (N = 43) Completers = 29 * Chi square revealed no significant differences in attrition between treatment conditions, (χ 2 (3) = 3.99, p = 0.26).

17 Counseling: alcohol counseling that consisted of 30-minute sessions administered by the study nurse. All participants received Counseling at every treatment visit. Naltrexone: goal of 100mg per day for 24 weeks Prolonged Exposure: 12 weekly PE sessions followed by 6 biweekly sessions

18 Targets of counseling were allowed to be any need identified with the exception of trauma related material. This allowed for tremendous flexibility in its application: increased adherence to medication; access to medical care; housing needs; incorporated 12-step and CBT interventions for AD; relationship concerns; crisis management; etc. In addition to the medication, this is a strong adjunctive counseling component to the overall treatment and allowed the PE therapists to remain focused on addressing PTSD concerns.

19 PTSD Severity Foa et al., 2013 Study Week

20 %DD Naltx + PE Placebo + PE Naltx no PE Placebo No PE Foa et al., 2013 Study Week

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22 PE + NAL 70 PE + PLA 55 Counseling + NAL 44 Counseling + PLA 37 P =.02

23 Both NAL conditions result in substantive reductions in drinking days. However without PE, drinking gains are eroded, whereas with PE drinking gains are maintained. Combined treatment of NAL and PE appears to have performed better overall. There is no indication that treatment involving confrontation of trauma memories and trauma reminders will lead to increased alcohol use or increased cravings.

24 13 session therapy focused on psychoeducation, motivational enhancement, CBT for SUD, in vivo exposure, imaginal exposure, and cognitive therapy for PTSD Has solid evidence for more effectively reducing PTSD symptoms and similar efficacy for reducing SUD to TAU

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26 PTSD & substance use disorders, including alcohol dependence, (SUD) are two of the most common health problems experienced among OEF/OIF veterans The most commonly used strategy is sequential treatment, where the addiction is treated first followed by PTSD treatment. An alternative, but untested, strategy is to conduct integrated treatment that addresses both disorders simultaneously by the same therapist This strategy is not only theoretically the most promising but has been reported as the preferred method by patients

27 Effectiveness trial Multisite Philadelphia VAMC, coordinating site Minneapolis VAMC Sample size = 200 (100/group)

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29 Completion of VA brief motivational interviewing assessment and feedback tool - generates Personal Feedback Report (PFR) Integrated treatment rationale Identify index trauma Breathing retraining Introduce diary cards (use, craving)

30 Your Weekly Alcohol Use This section provides information based on what you told us about how much you are drinking in a typical week. You reported an average of 12 drink(s) per week. Based on your self-report, we estimate that in the last year you drank: * 43% of all days * A total of 624 drinks

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32 Review diary cards Feedback from PFR Common reactions to trauma In vivo exposure (start hierarchy)

33 Review diary cards Go over in vivo homework Address any substance use and related motivational issues Introduce and start imaginal exposure

34 Review homework (diary cards, breathing, in vivo, listen to audiotape) Address any substance use and related motivational issues Complete imaginal exposure in session Note: Start hot spots procedure in Session 5

35 Both treatment conditions demonstrated clinically meaningful reductions in PTSD and SUD symptoms However, there were no statistically significant differences between integrated or sequential treatment on any measured outcomes Participant drop out remains a critical problem Given the lack of preferential treatment design, the preference of the client should be seriously considered when treatment planning

36 Efficacy and Effectiveness of Prolonged Exposure

37 Chronic PTSD: EX therapy only Ex therapy + SIT and/or CR Acute PTSD or ASD EX only Ex therapy + SIT and/or CR 23 studies 26 studies 2 study 5 studies

38 The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD (chapter 4, p. 97) Reference: Institute of Medicine (IOM): Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

39 Time Point PTSD Outcome General Distress Outcome Post-treatment g = 1.08 g = 0.77 Follow-up g = 0.68 g = 0.41 The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures.

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41 Is the patient an appropriate candidate for PE? PE is a treatment for chronic PTSD, not a treatment for trauma The focus of imaginal exposure should be a traumatic event (i.e., not a general problem such as relationship difficulties ) The patient needs to have a memory of the traumatic event(s) that they can narrate fragmented memories with few details are OK as long as the patient can visualize and describe the trauma experience.

42 Factors that prevent successful implementation of PE: current imminent threat of suicidal or homicidal behavior serious self-injurious behavior active psychosis high risk of being assaulted (e.g., living with domestic violence). presence of other primary disorders, such as severe panic disorder with agoraphobia; severe depression that renders the patient incapable of engaging in treatment; unaddressed substance use Treatment and stabilization of these primary problems should take place before beginning PE - except for substance use which can be addressed concurrently.

43 Imaginal exposure Prolonged Exposure for PTSD: Treatment Procedures Processing of the revisiting experience Repeated in vivo exposure Psychoeducation: Education about common reactions to trauma; breathing training Treatment was designed to initially consist of 8-15 weekly 90- minute sessions but may include as many as 20 sessions if improvement is occurring.

44 The two primary procedures are: Imaginal exposure: repeated revising, recounting, and processing of the traumatic event. The imaginal encounter enhances the emotional processing of the trauma memories and helps attain a realistic perspective on the trauma In-vivo exposure: repeated confrontation with safe situations, activities, and places that are avoided because they are trauma reminders. These encounters reduces trauma-related distress and enables the client to realize that the avoided situations are not dangerous Both procedures results in changes of negative cognitions associated with PTSD: I am utterly incompetent and the world is utterly dangerous

45 Session 1 Overview of the program: Rationale for Prolonged exposure Gathering trauma-relevant information Breathing training Homework: practice breathing retraining listen to audio recording of session

46 Discussion of Common reactions to trauma Rationale for in-vivo exposure Generating a list of avoided situations and constructing and arranging them according to anticipated distress associated with them Homework: Initial in vivo exposure assignments listen to session audiotape one time breathing training

47 Presenting the rationale for imaginal exposure Imaginal revisiting and recounting of the trauma memory for ~ 45 minutes Process imaginal exposure Homework: In vivo exposure daily Listen to tape of imaginal exposure daily; listening to the rest of the session once Breathing

48 Homework review Imaginal exposure to trauma memory about min. Focus on hot spots progressively Process imaginal exposure with client about min. Homework: In vivo exposure daily Listen to tape of imaginal exposure daily; listen to the rest of the session once Breathing practice

49 Homework review Imaginal exposure to entire trauma memory aproximately min Process imaginal exposure with client and discuss how perception of trauma has changed Review changes in SUDs ratings of in vivo exposure with client Evaluate the usefulness of the procedures and what the client learned in treatment Home work: Continue to apply everything you learned in therapy!

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51 Lessons Learned As We Conducted Prolonged Exposure In This Comorbid Population

52 The Impact of Comorbidity Compared to AUD-only and PTSD-only, patients with AUD+PTSD: had less education were more likely to be unemployed were less likely to live with a partner had lower income drank more per dinking episode were more depressed (Drapkin, Yusko, Yasinski, Oslin, Hembree, & Foa,2011)

53 Treatment Retention As suggested, these patients demonstrated greater psychopathology and psychosocial impairment at intake. Often, patients were homeless, had gone without any medical care for a long time; had no phone, physical address or addresses; or these contacts changed frequently; which often created tremendous challenges to keeping patients engaged with treatment. We quickly learned that the goal of two treatment sessions/week - one for counseling and another for PE - wouldn t work. As a result, keeping these clients connected to treatment was some of our most time intensive work - establishing rapport, creating a warm and welcoming treatment environment, offering novel treatment to provide hope, individual focus

54 Importance of Facilitating Therapeutic Alliance These patients have likely been through multiple treatment failures and are quite skeptical of a treatment being accepting of the problems they bring Acknowledge client s courage in coming for treatment Communicate understanding of the client s symptoms Validate client s experience in empathic and non-judgmental manner May be the first time revisiting the trauma narrative, your reaction is important Work collaboratively Incorporate the client s judgment about pace and targets of therapy

55 If initial assessment determined it is appropriate to treat PTSD concurrently with alcohol use, maintain the focus of the PTSD sessions with periodic reassessment of other problems. Clients with chronic PTSD and alcohol dependence are more often likely to face multiple life stressors; crises during treatment are the norm. Self-destructive impulse control problems (e.g., alcohol binges, substance abuse, risky behaviors) need to be monitored regularly all clinicians working with the patient.

56 If a crisis arises without imminent risk: Remind client that adhering to PTSD treatment is the best help you can give to address PTSD, substance use, and other associated symptoms Clearly state support for the client s desire to recover from PTSD/substance use; applaud healthy coping and homework effort If appropriate, externalize crises as related to PTSD -- predict that these situations will improve as PTSD/SUD improves The overall aim is to provide emotional support through the crisis, yet keep PTSD as the major focus

57 The jury is still out so Consult and use the current SAMSHA or VA/DoD clinical practice guidelines for PTSD and SUD. Clinical judgment will continue to be needed in deciding which specific treatments to implement, for which patients, and under which treatment conditions. In general, treatments for patients with both PTSD and SUD can be effectively delivered concurrently.

58 Use effective first-stage treatment strategies, such as use of Motivational Interviewing principles and Seeking Safety to facilitate engagement. Systematic treatment response monitoring (e.g., Brief Addiction Monitor [BAM], PTSD Checklist [PCL]) is essential to continuously obtaining evaluation on the effectiveness of recommended treatments for patients with co-occurring PTSD and SUD.

59 Like one of our participants said, This works but you have to work with it. All data indicate that concurrent treatment of PTSD and alcohol/substance use disorders should be developing as the new standard of care. While more research is still needed on the topic, it appears that combining evidenced based treatments for both disorders is more likely to provide better treatment outcomes. Our biggest challenge may be spreading the word and figuring out how to incorporate a concurrent treatment into systems that are often separate from one another - mental health from substance abuse.