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Brian E. Lozano, Ph.D. Contributing Collaborator: Sudie E. Back, Ph.D. Medical University of South Carolina Ralph H. Johnson VA Medical Center Lozano@musc.edu Backs@musc.edu
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Colleagues Dr. Kathleen Brady Dr. Therese Killeen Dr. Edna Foa Dr. Colleen Hanlon Dr. Stacia DeSantis Dr. Karen Hartwell Dr. Liz Santa Ana Dr. Brian Lozano Dr. Matt Yoder Dr. Kristy Center Dr. Julianne Flanagan Dr. Jenna McCauley Ms. Sharon Becker Dr. Megan Moran-Santa Maria Dr. Peter Kalivas Dr. Jacqueline McGinty Staff/Coordinators Mr. Frank Beylotte Ms. Mary Ashley Mercer Ms. Emily Hartwell Dr. Elizabeth Cox Ms. Wendy Muzzy Ms. Alex Jeffery Ms. Virginia McAlister Mr. Scott Henderson Ms. Amanda Federline Ms. Anjinetta Johnson Mr. Drew Teer Funding Sources NIDA F31 DA00607 (Back) NIDA K23 DA021228 (Back) NIDA R01 DA030143 (Back) J. William Fulbright (Back) NIDA K24 DA00435 (Brady) NIH UL1RR029882 (Brady) NIDA T32 DA07288 (McGinty) DoD 803235 (Kalivas & Back) DoD 804237 (McGinty & Back)
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No conflicts of interest to disclose Previous and current research funding from: ◦ National Institute on Drug Abuse ◦ Department of Defense ◦ J. William Fulbright Foreign Scholarship Board Disclosure Statement
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Sequential Model – SUD first, then PTSD Singular Model – Treat the “primary” disorder o Treat only the SUD o Treat only the PTSD Parallel Model – SUD and PTSD, different clinicians Integrated Model - SUD and PTSD, same clinician Treatment Models
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Rates of Relapse: -With PTSD: 85% -Without PTSD: 59% (p =.12) Time to 1st Use : -With PTSD: 26.5 days -Without PTSD: 54.5 days (p =.03) (Brown et al., 1996; Psychology of Addictive Behaviors) N = 31 women with alcohol or drug dependence disorders PTSD and Relapse
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Untreated PTSD contributes to poorer treatment outcome for substance use, and vice versa. Traditionally, the standard of care = sequential model: (1) SUD treatment first, demonstrate sustained abstinence (3 to 6 months) then… (2) PTSD treatment Clinic #1 Clinic #2 The Need to Treat Both PTSD and SUD
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Both conditions concurrently, by the same clinician Clinic #1 Integrated Model of PTSD/SUD Treatment
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Both conditions concurrently, by the same clinician Driven by: o -Hypothesis that substance abuse is result of, in part, PTSD symptoms. o -Reductions in PTSD are more likely to lead to reductions in substance abuse, than the reverse. o -Patient preferences. Clinic #1 Integrated Model of PTSD/SUD Treatment
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PTSD Improvement Results in Alcohol Use Improvement Back, Brady, Sonne & Verduin, JNMD, 2006 (N=94)
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Alcohol Improvement Less Likely to Result in PTSD Improvement
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(N = 35 Veterans) Back, et al., 2014
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Overview of PTSD – Substance Use Connection PTSD Symptoms Substance Use Short Term Relief Self Medication Hypothesis (Khantzian, 1985) +
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Overview of PTSD – Substance Use Integrated Treatment Treat PTSD + SUD Manage PTSD sx without substances Recovery from PTSD and SUD Long Term Relief
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SUD-PTSD Integrated Psychotherapies Najavits (2002) - Seeking Safety. Relapse prevention + education + social skills training. Mostly group. 25 sessions. Back, Foa, Killeen, Brady et al. (in press) – COPE. Relapse prevention + in vivo exposure + imaginal exposure. Individual. 12 sessions.
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TreatmentImaginal exposure In vivo exposure Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) – in press Seeking Safety (SS) - 2002 Seeking Safety + Exposure Therapy-Revised (N=5) - 2005 Substance Dependence PTSD Therapy (SDPT) - 1999 CBT for PTSD in addiction treatment programs - 2009 van Dam et al., 2012; Clinical Psych Review, 32: 202-214
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Synthesis of 2 theory-based and empirically-validated treatments: (1) Prolonged Exposure for PTSD (Foa, Hembree, & Rothbaum, 2007) (2) Relapse Prevention for SUD (Carroll, 1998) COPE (Concurrent Treatment of PTSD & SUD using Prolonged Exposure)
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1. Educate patients about the functional relationship between substance use and PTSD. 2. Decrease SUD symptom severity, initiate and maintain abstinence. 3. Decrease PTSD symptom severity.
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Psychoeducation – education about common reactions, normalize symptoms, help understand avoidance & how it maintains PTSD symptoms. Breathing Retraining technique to decrease anxiety. Prolonged Exposure (PE): o In-Vivo Exposure o Imaginal Exposure CBT Techniques Used To Treat PTSD
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In Vivo Exercises ▶ In between therapy sessions ▶ Repeated exposures ▶ Prolonged duration ▶ Common examples: o Walmart (or other crowed store) o Sitting in middle of restaurant o Going to a sporting event o Going to movie theatre o Driving during rush hour o Being stopped at a stop light o Watching or reading the news o Group activities (going to AA, church, exercise class)
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Imaginal Exposure
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How it works: 1.Emotional processing, organizing the memory 2.Habituation – anxiety does not last forever 3.Distinguishing between memory vs. actual event, then vs. now 4.Cognitive modifications – increase sense of control, mastery, confidence Anxiety Time Prolonged Exposure Therapy: The Wave of Anxiety
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Foa et al. (1991) Foa et al. (1999) Foa et al. (2005) Marks et al. (1998) Tarrier et al. (1999) Taylor et al. (2001) Cloitre et al. (2002) Resick et al. (2003) Bryant et al. (2003) Schnurr et al. (2007) Rauch et al. (2009) Resick et al. (2012) *18% with PTSD 5-10 yrs later Empirical Support for PE
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Psychoeducation regarding relationship between substance use and PTSD sx. Effectively manage cravings and thoughts about substance use. Identify triggers for substance use - both PTSD and substance-related triggers. Learn coping skills to help prevent relapse/escalation to substances (e.g., managing anger, drug refusal skills). CBT to decrease SUD Symptoms
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Integrated treatments address both the PTSD and the SUD concurrently. COPE uses Prolonged Exposure (in vivo and imaginal) to treat PTSD, and CBT (Relapse Prevention) to treat SUD. Main Goals: ◦ Psychoeducation ◦ Reduce PTSD symptoms ◦ Reduce SUD symptoms
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1Introduction: Psychoeducation, Set Goals, Therapy Contract, Breathing Retraining 2PTSD: Common Reactions to Trauma SUD: Awareness of Cravings 3PTSD: In Vivo Hierarchy SUD: Managing Cravings 4PTSD: First Imaginal Exposure SUD: Review coping skills Session # Session Topic General Session Overview
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5PTSD: Imaginal Exposure continued SUD: Planning for Emergencies 6PTSD: Imaginal Exposure continued SUD: Awareness of High-Risk Thoughts 7PTSD: Imaginal Exposure continued SUD: Managing High-Risk Thoughts 8PTSD: Imaginal Exposure continued SUD: Refusal Skills Session #Session Topic General Session Overview continued
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9PTSD: Imaginal Exposure continued SUD: Seemingly Irrelevant Decisions 10PTSD: Imaginal Exposure continued SUD: Awareness of Anger 11PTSD: Final Imaginal Exposure SUD: Managing Anger 12Review and Termination Session # Session Topic General Session Overview continued
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BBrady et al. (2001) and Back et al. (2001): PTSD and cocaine; N=39 MMills et al. (2012): PTSD and mostly heroin; N=103; COPE + TAU vs TAU BBack et al. (ongoing): military PTSD and mostly alcohol; COPE vs RP HHien et al. (ongoing): PTSD and mostly alcohol; COPE vs RP NNorman et al. (ongoing): military PTSD; COPE vs Seeking Safety
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Preliminary, uncontrolled study N=39 PTSD and cocaine dependence 16 individual 90-minute sessions Assessment at weeks 4, 8, 12, and 16, and at 6 months follow up. Initial COPE Study
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Positive Urine Drug Screen (UDS) Tests At treatment entry = 12.8% First half of treatment = 12.2% Second half of treatment = 9.7% Timing of Attrition The majority (75%) dropped out before PE initiated (e.g., transportation or employment problems, relocation, scheduling conflicts, unstable living conditions) Brady, Dansky, Back, Foa & Carroll, 2001 (N=39) Cocaine Dependent + PTSD Initial COPE Findings
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Post-Treatment Outcomes
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Scores Weeks Impact of Events Scale (IES)
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Uncontrolled study Small sample size Focused on cocaine dependence High drop-out rate Considerations
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Randomized controlled trial COPE + TAU vs TAU N=103 SUD (mostly heroin) + PTSD Majority (75%) had childhood trauma 62.1% women 78.6% unemployed 54.2% lifetime history of suicide attempt Mills et al., 2012 Study Aims and Design
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* Clinician Administered PTSD Scale (CAPS)
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Using at 3 mth F/U: Treatment: 72.9% Control: 81.9% Number of SUD Dependence Criteria Met
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Total N=90 3 Mth Follow-Up COPE RP Study Timeline Screening, Consent, Assessed, and Randomized COPE and RP Treatment Phase: 12, 90-min sessions 3 Mth Follow-Up 6 Mth Follow-Up 3 Mth Follow-Up6 Mth Follow-Up COPE pts: Sessions 4 and 11 fMRI scan to cues Back et al., ongoing Study Design
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◦ Single, caucasian, 25 yr old male ◦ United States Marine (gunner) ◦ Served 3 deployments in Iraq (24 months total) ◦ No history of mental health treatment Back, Killeen, Foa et al. Am J Psychiatry 2012; 169: 688-691
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Index trauma: Combat related. PTSD symptoms: Frequent nightmares, intrusive thoughts, isolation/distancing, aggression, extreme difficultly driving, hyperarousal in crowded places (e.g., Walmart, movies), avoidance of thoughts and memories through alcohol. Substance use symptoms: Consuming 12.5 beers per day, 83.3% of the time (50/60 days pre study). Tx motivation: Initially did not want treatment (“military pride”) but his friend drove him to clinic. Case Details
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In Vivo Start Imaginal Start Reliable Change Index, p<.05
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CAPS: 71 (Baseline) 42 (Session 6) 17 (Session 12) 4 (6 Mth F/U)
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Reliable Change Index, p<.05
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Studies among men and women, civilian and combat-related PTSD, multiple SUD and multiple traumas show: ◦ Feasible ◦ Safe – substance use did not increase with trauma-work ◦ Effective Summary
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