1. 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

2. 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)

3.  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

4.  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

5. 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

6. 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

7. Both conditions concurrently, by the same clinician Clinic #1 Integrated Model of PTSD/SUD Treatment

8. 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

9. PTSD Improvement Results in Alcohol Use Improvement Back, Brady, Sonne & Verduin, JNMD, 2006 (N=94)

10. Alcohol Improvement Less Likely to Result in PTSD Improvement

11. (N = 35 Veterans) Back, et al., 2014

14. Overview of PTSD – Substance Use Connection PTSD Symptoms Substance Use Short Term Relief Self Medication Hypothesis (Khantzian, 1985) +

15. Overview of PTSD – Substance Use Integrated Treatment Treat PTSD + SUD Manage PTSD sx without substances Recovery from PTSD and SUD Long Term Relief

16. 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.

17. 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

18. 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)

19. 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.

20.  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

21. 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)

22. Imaginal Exposure

23. 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

24. 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

25.  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

26.  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

28. 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

29. 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

30. 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

32. BBrady et al. (2001) and Back et al. (2001): PTSD and cocaine; N=39 MMills et al. (2012): PTSD and mostly heroin; N=103; COPE + TAU vs TAU BBack et al. (ongoing): military PTSD and mostly alcohol; COPE vs RP HHien et al. (ongoing): PTSD and mostly alcohol; COPE vs RP NNorman et al. (ongoing): military PTSD; COPE vs Seeking Safety

33.  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

34. 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

35. Post-Treatment Outcomes

36. Scores Weeks Impact of Events Scale (IES)

37.  Uncontrolled study  Small sample size  Focused on cocaine dependence  High drop-out rate Considerations

38.  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

39. * Clinician Administered PTSD Scale (CAPS)

40. Using at 3 mth F/U: Treatment: 72.9% Control: 81.9% Number of SUD Dependence Criteria Met

42. 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

43. ◦ 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

44.  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

45. In Vivo Start Imaginal Start Reliable Change Index, p<.05

46. CAPS: 71 (Baseline) 42 (Session 6) 17 (Session 12) 4 (6 Mth F/U)

47. Reliable Change Index, p<.05

48.  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