A few years ago, while visiting a substance abuse treatment program, I was discussing treatment protocols with the Clinic Director. A case was brought up in which the woman patient clearly had a history of traumatic abuse. When I asked how the program addressed these issues, the Director replied, “Oh we leave that stuff alone. We only have a few weeks to get them on track and delving too deeply is just going to bring up stuff we don’t have the time to deal with.” I swallowed, and asked, “So then… how is she going to tell her story?” The conversation was interrupted at the time, so I didn’t get an answer to my question, but the conversation alerted me to how hesitant some agencies are to deal with the combined problems of trauma and substance abuse. Yet in certain populations, including the chemically dependent and especially addicted women, the prevalence of significant trauma history and affects is so high that one could almost make the presumption it exists and then rule it out, rather than presume it is not present. Of course, trauma does not equate to PTSD, but there is clearly a relationship between Substance Abuse Disorders (SUD) and trauma, including PTSD. Among those diagnosed with PTSD, the co-existence of SUD is pervasive.
In a study of 5,338 veterans seeking treatment within the DVA specialized outpatient PTSD programs, 44% met criteria for alcohol abuse/dependence and 22% for drug abuse/dependence (MayoClinic.com, ‘08).
In certain studies, 60-80% of treatment-seeking Vietnam combat veterans with PTSD also met the criteria for current alcohol and/or drug abuse, and one study even found 91% of an inpatient sample meeting the lifetime criteria for substance use disorders (Meissler, A.W., ‘96). In a large survey of people from communities across the United States, it was found that 34.5% of men who had PTSD at some point in their lifetime also had a problem with drug abuse or dependence during their lifetime. Similar rates (26.9%) were found for women who had PTSD at some point in their lifetime. There were greater gender differences in the case of alcohol abuse or dependence, but prevalence was always high.
It may seem obvious that a causal relationship of some type exists, but there is no unanimity in regard to what that relationship is. Clearly there is a complex interplay between these disorders and their etiology. Some theories include:
Self-Medication – This idea suggests that persons suffering from the symptoms of post-traumatic stress will tend to use chemicals, either alcohol or other drugs, to ease those symptoms. An example would be use of the depressant alcohol, to decrease symptoms of increased arousal. Studies of Manhattan residents following the events of September 11, 2001 show significant increases in use of alcohol and other drugs. In some studies, PTSD has been associated with a fourfold increased risk of drug abuse and dependence (Chilcoat HD, Breslau N, ’98). Several studies that looked at etiology found that trauma and/or PTSD tend to predate the onset of Substance Abuse Disorders, though some other research finds increased SUD more in PTSD than trauma alone (Lippincott, et.al., 2008).
Biochemical Shared Traits – This idea suggests that there are components of personality or biochemistry that are shared by those with symptoms of post-traumatic stress disorder and substance use disorders. For instance, research into corticotrophin release factor suggests that this peptide triggers biological responses implicated in the pathophysiology of both disorders. Research suggests an overlap between neuro-circuits that respond to drugs and those that respond to stress (Piazza, P.V. ‘98). Going further, there is some research suggesting a genetic predisposition may come into play and influence these disorders. Mice that lack a receptor for CRF have impaired stress responses and express less anxiety-related behavior (Smith, et al,’98).
“In both people and animals, stress leads to an increase in the brain levels of…corticotrophin releasing factor (CRF). The increased CRF levels in turn triggers a cascade of biological responses.…Research has implicated this cascade in the pathophysiology of both substance use disorders and Posttraumatic Stress Disorder (PTSD)” (Jacobsen, 2001).
Developed Vulnerability – Persons subjected to prolonged stress or demonstrating symptoms of PTSD have poorly regulated hormonal responses that do not return to normal when the stress is past. Some theorists posit that abuse of drugs and alcohol not only put some persons at a higher risk of experiencing traumatic situations, but also reduces their ability to develop healthy coping mechanisms when those situations occur. Patients with substance abuse disorders tend to suffer from more severe PTSD symptoms than those without SUDs (NIDA, ‘02, ‘06) and substance abusers with PTSD experience higher levels of subjective distress and other problems than substance abusers without PTSD (Ouimette et al., 1996).
What Are the Treatment Options?
There is evidence of successful treatment effects for both medication and behavioral therapy. Certain anti-anxiety (e.g. buspar) and antidepressant drugs (e.g. sertraline) have shown themselves to be useful in ameliorating symptoms, though primarily as an adjunct to behavioral treatment.
Although there are some limitations to its use, Cognitive Behavioral Therapy shows general effectiveness. There may be contraindications for use in some severe states but using the techniques and tools of CBT within a more inclusive treatment strategy seems benign, and indeed helpful in many cases. There is some evidence supporting exposure therapy when knowledgeable screening identifies appropriate subjects, though the research was primarily with cocaine abusers.
A specific treatment model for Chemical Dependency and Trauma “Seeking Safety”, a 25-session course of treatment developed by Lisa Najavits’, PhD, which includes a patient workbook. This model has shown successful outcomes and has the advantage of being able to be incorporated as an element within traditional CD treatment programs.
“Transcend” is a model developed by Donovan, Padin-Rivera, and Kowaliw primarily for combat related SUD and PTSD. That has two phases, the first of which includes partial hospitalization.
Dr. Elisa Triffleman has developed an intervention with more general application that consists of a two-stage intensive format, where the client meets with the clinician twice weekly for five months.
Isn’t it risky to deal with two such potent problems at once? Historically, substance abuse treatment agencies had a “hands-off” policy on dealing with past trauma. As the conversation I described earlier demonstrates, this is a common belief in the CD Treatment community. The folk culture of recovery seems to support delaying the work of deeper issues until there is a solid base of recovery, and this idea was easily adopted by a treatment community that had few resources to tackle more pervasive issues in the short time allotted to SUD treatment. In truth, one of the challenges of treatment is that abstinence often results in increased PTSD symptoms and treatment of PTSD may result in increased use of substances as a coping device for the consequent emotional reactions generated as a part of the treatment. It is not surprising that the belief about separate treatment has become institutionalized.
“One patient who I talked to said that she had to lie to be able to get adequate treatment for both disorders. She was told when she went to a PTSD treatment program that she couldn’t have substance abuse or she wouldn’t be able to get treatment–she had to be clean first. And it’s a message a lot of people have heard” (Lisa Najavits, PhD). However, there is general consensus among researchers and experts that PTSD and SUD should be treated simultaneously, with as much integration as possible given the current state of regulations and separate systems. This understanding needs to inform new models. Cross-silo collaboration between mental health and addiction systems is needed. As in the case of other co-occurring psychiatric and substance abuse disorders, integrative treatment is preferred. Thus, intensive treatment modalities such as partial hospitalization or intensive day treatment programs may be incorporated into the course of treatment, especially when used in early phases of treatment to improve outcomes. Intensive case management may also prove to be a key to better results.
Clearly, understanding and development of treatment options for co-occurring PTSD and SUD are in the early stages. One welcome change is the increased understanding that people undergoing chemical dependency treatment are also ready and able to address issues of trauma. They too, need to tell their story. “Patients in treatment for substance abuse want to talk about their traumas. It is no longer a question of whether to treat PTSD in substance abusers, but how to do it best” (Elisa Triffleman, MD).
Dr. Barry Hawkins, PhD, LMHC, CASAC, CATSM, is Director of Chemical Dependency Services for the Orange County Department of Mental Health. He is also Coordinator of the Orange County Mental Health Team for Disaster and Community Response, is Board Certified in Acute Traumatic Stress Management and is a Diplomate of the National Center for Crisis Management.
