The Lifelong Quest for Sobriety… The Ultimate Hero’s Journey – Part 64

Guest blogger and long-time Council friend, Bob W. presents Part 64 of a series dealing with Alcoholism and Addiction from a Mystical, Mythological Perspective, reflecting Bob’s scholarly work as a Ph.D. in mythological studies.

In the 1999 movie, The Matrix, a group of rebels are fighting a desperate war against a machine that has enslaved humanity in a sophisticated virtual reality system.  Laurence Fishburne is Morpheus, the leader of the rebels, and he has recruited Neo, played by Keanu Reeves and Trinity, played by Carrie-Anne Moss as his archetypal warriors.  The operatives of The Matrix have been unbeatable, led by Agent Smith, played by Hugo Weaving, such that most rebel warriors have little chance in head-to-head battles with the machine.

But Neo and Trinity have developed and honed their skills. A series of confrontations toward the end of the movie have Neo and Trinity performing incredible athletic feats to avoiding being hit by a barrage of bullets and simultaneously firing back in explosive bursts.  In one scene, Neo contorts his body to impossible extremes as the bullets fly by in slow motion.

A friend of mine, in a meeting one day, commented on this scene as reminiscent, to him, of how, in our continuing growth in recovery, we learn such adroitness, we develop evasive moves to avoid letting the pitfalls of life destroy us as they once had.  What a spectacular vision it created for me.  How often in our diseased states and even in early sobriety did we let everyday mishaps and normal challenges penetrate our fragile exterior and drive us to difficult ends.

Some of us, like me, may have reacted to minor mishaps with near explosive rage.  Maybe family members pushed long-set psychic buttons with idle remarks; maybe a friend or acquaintance made a snide comment that stirred some long forgotten pain; or maybe some external unrelated event had a similar effect. 

Our recovery demands that we learn to deal with these events.  As we work the program with sponsors and with fellow recovering heroes we learn to let these events, these triggers, to slide off or around us much as Neo dodged the Matrix’s bullets.  The image is powerful…we just need to learn the intricate evasive moves for ourselves, using the tools we hear over and over again from all our Fellows.

Where to start?

A road map to recovery options for those struggling with addiction

By Lori Fiester, Clinical Director for the Center for Recovering Families at The Council on Recovery

While the Council on Recovery is a known place to start when looking for help with alcohol or drug abuse, the average person who struggles with substance use issues does not know what is involved in treatment, much less recovery. It does not simply begin with the desire to do things differently…

Many people begin with decreasing their use of the identified substance, or stop completely.  While some can be successful with either measure, most who have abused substances for a long period of time have withdrawal symptoms. Those who have heavily used or have a genetic predisposition need more assistance. Millions of people have a crossed the doorway to 12-step meetings, have a sponsor and have worked the steps and been successful. And then there are those who need more support. 

When thinking about treatment, it’s important that the client be served in the least restrictive environment, but safety has to be the priority. The least restrictive measure involves individual therapy/counseling.  This modality can work but it needs to be supplemented with regular 12-step group attendance, utilizing sponsorship and working the steps.

Fiester (left) is the head of The Council’s Center for Recovering Families, Houston’s premier outpatient provider of treatment for alcoholism, substance abuse, and mental health disorders.

The next level of care is Intensive Outpatient Program (IOP). This type of program offers approximately 10 hours of treatment to the individual that includes individual and group therapy, psychoeducation, and skills group, spread out between three to four days a week. This allows the person to work and sleep at home, but a good portion of their time is dedicated to therapy. Most IOP’s last six to eight weeks.

Partial Hospitalization (PHP) is the next level in care.  This option consists of being treated for up to five hours a day for five days, and then going home early evening. This service includes much of what IOP does, but is even more intense, adding five to ten hours per week, and can last several weeks.

Residential care is when the person enters a hospital-type setting in which they have about 20 hours of dedicated treatment services. They can stay there anywhere from 28 to 90 days. Many people who enter this type of care often need detoxification, which includes medical stabilization and a doctor to oversee the person’s withdrawal from the substance.

There are many avenues to consider when thinking about getting sober.  The Council can help with an assessment that can diagnose and give recommendations of what to do next. The continuum of care has many opportunities for someone to stay sober. Research indicates that the longer a person is in treatment services, the less risk they have for relapse.  If you or anyone you know is in need to start their journey to recovery today, start here – (713) 914-0556.

‘Sesame Street’ Addresses Impact of Addiction on Children

This guest post is written by Kierstin Collins, Clinical Manager of Children and Adolescent Services at The Council

Earlier this month, Sesame Workshop, the nonprofit educational organization behind Sesame Street, broadcast an initiative to support children and families affected by parental addiction. The newest Muppet to join the Sesame Street group, Karli, is featured in the initiative, whose mom is dealing with addiction. In the new content released, long time characters like Elmo and Abby Cadabby learn what Karli is experiencing and help support her. Resources released through the Sesame Street in Communities program, including videos, articles, and activities, broadcast the words children need to hear most: “You are not alone. You will be taken care of. Addiction is a sickness and, as with any sickness, people need help to get better.” And most importantly: “It’s not your fault.”

Ten-year-old Salia Woodbury, whose parents are in recovery, poses with “Sesame Street” character Karli. The show recently explained that the puppet is in foster care because her mother is battling addiction. (Flynn Larsen/Sesame Workshop/AP)

In a press release this month Sesame Workshop, shared the motivation behind their efforts saying, “In the United States, there are 5.7 million children under age 11, or one in eight children, living in households with a parent who has a substance abuse disorder—a number that doesn’t include the countless children not living with a parent due to separation or divorce, incarceration, or death as a result of their addiction. One in three of these children will enter foster care due to parental addiction, a number that has grown by more than 50% in the past decade. The trauma of parental addiction can have lasting impacts on a child’s health and wellbeing, but children can be incredibly resilient; the effects of traumatic experiences can be mitigated with the right support from caring adults like the parents, caregivers, and providers this initiative targets.”

The Council on Recovery recognizes that Houston is not immune to these jarring statistics and aims to meet the needs of this special population. The Council has a long history of educating the community about the disease of addiction to break down the stigma and misunderstanding around this complicated family problem.

With the understanding that addiction is a family disease, The Council addresses all those who are touched by addiction, including youth who are at high risk of developing a substance use problem. Children from families of addiction are more likely to use and use problematically at a young age due to both genetic and environmental factors. To address this cycle of addiction, The Council provides services tailored to the developmental needs of youth. In the Kids Camp at The Council program, kids age 7 to 12 participate in three days of games, activities, and group work to gain education, prevention, and support. Kids in the program learn through their experience that addiction is not their fault, they are not alone, their job is to be a kid, and how to take care of themselves. Parents work alongside children to learn age-appropriate language around addiction and how to communicate about hard feelings, problems, and secrets.

As the rate of substance abuse grows in our community, the population of children who are impacted grows alongside it. You know a child who needs us. To interrupt the cycle of addiction and provide hope in the face of addiction, call 713-914-0556 or visit us online at councilonrecovery.org where you can learn more about Kids Camp and other youth services offered at The Council.

Grateful Client Gives Back

This guest post is written and graciously shared by Janel, a grateful client who found recovery through The Council

Seven years ago I was trapped living a nightmare with no way out. My addiction took me to the darkest place imaginable. I was literally battling for my soul. I could not stop using. I eventually gave up and tried to take my own life. It was the only way I thought I could find peace. Waking up in Ben Taub’s ICU after my liver shut down, I realized that God had another plan for me. I had been given a second chance at life.

Forced to seek help, The Council on Recovery started me on my new journey. They found me a bed at a treatment center where I spent almost 3 months coming out of my fog of addiction. While there I met one of The Council’s recovery coaches who told me about a longer term treatment program, where I spent fifteen additional months. During that time, I learned so much about myself and how to overcome my addiction. I learned how to be a lady and live life with a purpose. I would not be where I am today if it hadn’t been for The Council guiding me in the right direction. Their resources are what saved my life. The work they do in the recovery community is vital. Most addicts don’t know how to stop. They do not know how to get help. That’s what The Council is for.

Last year I found a way to give back and help The Council. I used my story and my first-ever marathon to help raise more than $3,000 for this powerful organization. The marathon was about pushing myself to do something I once saw as impossible. It was meant to inspire others and – of course – bring as much attention to The Council as possible.

People need to know there is a solution. They need to know where to reach out when they are ready. I am living proof that recovery is possible. Today, I am 7 years clean and sober and I am a productive member of society. I have put myself through school, received my Bachelors degree in Human Services, and now manage a successful staffing agency. I have run a marathon and am now training for my first Ironman. Seven years ago my addiction almost killed me, but today I live free with no limits to be and do whatever I want to. And it all began at The Council. They showed me how to break the chains that bound me. They gave me hope. 

Janel ran the Chevron Houston Marathon as her first-ever marathon and used the opportunity to help raise more than $3,000 for The Council on Recovery

How useful is abstinence alone in understanding the effectiveness of SUD treatment?

The following article was recently published on the research page of the Recovery Research Institute website. It reports that abstinence from alcohol and other drugs is commonly perceived as a defining feature of recovery and has been widely used as a marker by which to evaluate the success of substance use disorder (SUD) treatment. Efforts have been made to define recovery more broadly by incorporating indices of functioning and well-being, but even within such broader definitions, achieving abstinence (as opposed to drinking at low-risk levels) is noted as an important milestone. This research presents three-year outcomes of persons who participated in outpatient treatment for alcohol use disorder, where treatment outcomes are defined in terms of both alcohol use and functioning.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

A focus on abstinence in defining recovery from an alcohol or other substance use problem has a long history in the field of addiction. More recently, however, efforts have been made to broaden the definition of recovery so as to align more closely with the variety of actions one can take toward health and wellness for those with substance use disorder. This broadening of the definition has largely focused on incorporating indices of functioning and well-being, which, of course, are of great relevance to individuals with SUD, both inside and outside the treatment context. When it comes to substance use, however, most definitions of recovery continue to focus on abstinence rather than also considering drinking patterns that do not result in a re-occurrence of substance use disorder symptoms or other harms. Clinically as well, patients are often advised to choose abstinence as their treatment goal. Increasingly, however, it is being questioned if abstinence is a necessary treatment goal for all persons with substance use disorder. To shed further light on this issue, Witkiewitz and colleagues looked at the outcomes of 806 alcohol use disorder outpatients over the course of three years after they started alcohol use disorder outpatient treatment.  

HOW WAS THIS STUDY CONDUCTED?

This study was a secondary data analysis of the well-characterized and frequently analyzed dataset stemming from Project MATCH, a multi-site project conducted in the 1990s in the United States. This analysis used a subsample of these study participants who were followed for up to three years following the initial Project MATCH treatments.  In this subsample, 952 individuals with alcohol use disorder were randomized to receive one of three individually-delivered outpatient treatments (i.e., cognitive behavioral therapymotivational enhancement therapy, or Twelve-Step facilitation). Of these, 806 (85%) provided data on their drinking during the three years following treatment and were included in analyses. Assessments were conducted prior to treatment, during the 12 weeks of treatment, immediately following treatment, and 6, 12, and 36 months after treatment end. In addition to reporting on their drinking and negative consequences they experienced due to their drinking, participants also provided information on their experiences during the past 30 days, using four yes/no items (“employed,” experienced “serious depression,” “trouble understanding, concentrating, or remembering,” “serious anxiety or tension”), and completed several items measuring to what degree they engaged in problematic social behaviors and to what degree they felt satisfaction with their life.   

Witkiewitz and colleagues then conducted two types of analyses. First, they simply defined three groups of participants in terms of their drinking based on cut-off values of public health interest and described their outcomes over time. The three groups they defined were abstainers, low-risk drinkers (i.e. non-abstinent individuals with no heavy drinking days) and heavy drinkers. A heavy drinking day was defined using nationally-defined standards as consuming four or more drinks in a day for women, or five or more drinks in a day for men. Then, they used an exploratory technique called “latent profile analysis” to identify groups of patients based on their reports of alcohol consumption and life functioning (i.e., as described above) over the three years following entry into outpatient treatment. 

WHAT DID THIS STUDY FIND?

When outcomes were defined by public health relevant cut-off values, low-risk drinkers were not significantly different from abstainers (i.e., differences were not greater than could be explained by chance alone) on almost all non-drinking outcomes, with one exception: abstainers were significantly unhappier with life. This may because these individuals tended to have the heaviest drinking and most severe problems prior to treatment and these individuals’ lives can continue to be detrimentally affected for many years even after remission has been achieved.  

In defining groups that emerged by considering participants’ data over time, Witkiewitz and colleagues identified four profiles: 

Figure 1. Four drinking categories identified by researchers.

By far the largest group is ‘high-functioning infrequent non-heavy drinking’ (51.2%), which is good news in and of itself. Among these, only 49% were completely abstinent from alcohol, demonstrating that both abstainers and individuals who experienced at least some low-level re-exposure to alcohol were able to achieve high-functioning. Of note, all of these patients were able to refrain from heavy drinking.   

For the remaining three groups, whether or not someone remained abstinent was also not a very informative datapoint: a third of these participants were high–functioning despite at least some heavy drinking. Note also that achieving infrequent drinking or abstinence did not guarantee higher functioning: roughly 25% of those achieving infrequent drinking had very poor functioning (i.e., the ‘low-functioning infrequent heavy drinking’ group, which comprises 25% of all participants who were able to refrain from occasional or frequent heavy drinking). Of note, this group also seemed to be worse off at the beginning of the study, as they reported higher levels of depression, tension, and difficulties concentrating at the onset of the study, suggesting that this group was struggling to overcome greater psychosocial challenges than the other groups.    

More generally, the study also made observations about how baseline characteristics of patients related to outcomes three years later: 

  • Higher functioning: Patients who at baseline were found to have better mental health, greater purpose in life, and social support from family and friends were more likely to be high–functioning three years after treatment. 
  • More frequent heavy drinking: Patients who at baseline had more high-risk social networks that actually supported continuing to consume alcohol were more likely to engage in frequent heavy drinking three years after treatment.  
  • Achieving high-functioning heavy drinking: Patients who had lower alcohol dependence severity at baseline were more likely to achieve high-functioning despite at least some heavy drinking. Note that high-functioning patients who engaged in occasional heavy drinking were more likely to be White, and at study entry drank fewer drinks per drinking day and experienced fewer consequences due to their drinking than those high-functioning patients who engaged in infrequent non-heavy drinking. 

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

The findings from this secondary data analysis project of a large, multi-site trial delivering outpatient treatment (in the 1990s) to more than 800 alcohol use disorder outpatients lend further weight to recent calls reconsider how the effectiveness of SUD treatments ought best to be measured. It builds on a previous report from the same research group that has highlighted the shortcoming of existing Food and Drug Administration guidance to use heavy drinking as indicative of treatment “failure,” as it fails to acknowledge substantial psychosocial improvements made by individuals who continue to occasionally drink heavily post-treatment. As Witkiewitz and colleagues argue, patient variability (i.e., heterogeneity) has long been acknowledged as an important factor to consider; it may now also be time to acknowledge that there is considerable variability in how some individuals may function following treatment for alcohol use disorder. That said, whereas it is becoming clearer that abstinence is a relatively uninformative indicator of treatment success, engaging in heavy drinking in and of itself confers harm, given that alcohol is a known Group 1 carcinogen – it has the potential to cause cancer. It is also a major cause of liver disease. Thus, while it is possible to engage in heavy drinking occasionally and still function at a high level, such toxicity–related risks need also to be considered. For this reason, perhaps other characterizations of alcohol consumption may be more informative, such as staying within national “low-risk” drinking guidelines. Drinking guidelines, such as those of the American Cancer Society, seek to prevent not only alcohol use disorder, but also the harms posed by both toxicity from alcohol, and recommend that women and men should drink no more than one and two drinks per day respectively, to limit harm due to alcohol’s toxicity-related effects. Beyond broadening our perspective of how alcohol consumption should be considered in terms of defining treatment “success,” the results of this study raise additional intriguing questions surrounding the broad definition of “recovery” that most agree should encompass both indices of functioning and a range of alcohol use indices.  

Also of note, roughly half of those who are low-functioning after outpatient treatment show vulnerability to intermittent alcohol exposure, and continue to struggle psychosocially, underscoring the importance of continuing care that can help address these challenges over the longer term. LIMITATIONS

BOTTOM LINE

This new analysis of a large, multi-site trial with more than 800 alcohol use disorder outpatients showed that some individuals who engage in at least some occasional heavy drinking following treatment may function as well as those who are mostly abstinent with respect to psychosocial functioning, employment, life satisfaction, and mental health. Such individuals tend to have lower addiction severity and fewer alcohol-related consequences prior to treatment, suggesting a more favorable prognosis overall.  

  • For individuals and families seeking recoveryAn incidental finding of this study, but good news that deserves highlighting nevertheless, is the finding that more than half of the alcohol use disorder outpatients examined in this study had a positive outcome for at least 3 years following treatment, both in terms of drinking (i.e., no heavy drinking days) and functioning (i.e., low probability of reporting problematic social behaviors, unemployment, other drug use, or life dissatisfaction). This positive finding is in line with other recent findings highlighting that roughly half of the people seeking to recover from a substance use problem need only two recovery attempts.     
  • For treatment professionals and treatment systemsThis paper provides further empirical support to move beyond a reliance on abstinence as the ultimate indicator of treatment success, and instead to move towards a broader range of drinking as well as psychosocial functioning. See our previous Bulletin article on broader definitions of recovery. Patients with higher addiction severity at treatment entry are less likely to achieve high-functioning with occasional heavy drinking. Moving beyond abstinence as the indicator of treatment success may help decrease barriers to treatment–seeking amongst those who do not wish to abstain from alcohol entirely but may otherwise welcome support in achieving low-risk drinking and higher functioning.   
  • For scientists: The present study, as well as similar reports, are based on older datasets, and thus replication in more modern-day datasets would help clarify if observed findings generalize to present day alcohol use disorder treatment contexts and recovery supports. Note also that “functioning” may be defined in a number of ways, but in the present study was limited to the indices used in Project MATCH. As Witkiewitz and colleagues highlight, further research should examine the role and impact of heretofore understudied correlates in this context, such as cognitive functioning/executive control, medical health and chronic pain, and misuse of prescription drugs.  
  • For policy makersAn increasing body of research points to the downfalls of relying on abstinence as a marker of alcohol use disorder treatment success. Far beyond being a simple matter of treatment goal preference of a substantial number of treatment seekers, current evidence, including this paper, suggests that alcohol consumption by itself does not necessarily equate to “treatment failure.” Guidance used to evaluate alcohol use disorder treatment, including FDA regulations, may need to be updated in light of this emerging evidence, with perhaps measures of diagnostic remission status and/or drinking within the national low-risk drinking guidelines being the optimal outcomes.  

CITATIONS

Witkiewitz, K., Wilson, A. D., Pearson, M. R., Montes, K. S., Kirouac, M., Roos, C. R., . . . Maisto, S. A. (2018). Profiles of recovery from alcohol use disorder at three years following treatment: Can the definition of recovery be extended to include high functioning heavy drinkers? Addiction, 114(1), 69-80. doi:10.1111/add.14403 

Individuals can get help for alcohol use and PTSD at the same time: A movement toward integrated treatment approaches

The following article was recently published on the research page of the Recovery Research Institute website. The study indicates that individuals with post-traumatic stress disorder (PTSD) are at increased risk of having co-occurring alcohol use disorder. However, it is not known whether the first-line treatment for PTSD (i.e., prolonged exposure therapy) is also effective in reducing problematic drinking. This study replicated prior findings suggesting prolonged exposure therapy is superior in treating PTSD symptoms, but was not more effective in reducing heavy drinking days than an intervention intended primarily to increase coping skills. However, findings from this study do challenge the notion that alcohol use disorder may be a barrier to receiving gold-standard treatment for PTSD. 

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Individuals with PTSD are more likely to have an alcohol use disorder than individuals in the general population. One representative survey of adults in the United States found individuals with PTSD were 1.2 times as likely to have an alcohol use disorder in their lifetime than those without PTSDPTSD is also associated with a more problematic course of alcohol useincluding greater difficulty quitting, briefer abstinence periods, and more associated medical, legal, and psychological consequences. These disparities in alcohol use outcomes in individuals with PTSD underscore the need to identify treatments that are effective in treating both symptoms of PTSD as well as problematic alcohol use. To address this need, Norman and colleagues studied the immediate, 3-month, and 6-month outcomes among 119 adult veterans with co-occurring PTSD and alcohol use disorder who received one of two competing treatment approaches. The table below outlines key components of each treatment approach. The first treatment, called Concurrent Treatment for PTSD and Substance Use Disorder Using Prolonged Exposure, or “COPE,” was integrated with prolonged exposure therapy that involves 1) helping individuals gradually approach trauma-related memories, feelings, and situations, and 2) relapse prevention for alcohol use disorder using cognitive and behavioral therapeutic techniques. The second tested treatment, called Seeking Safety (an empirically-supported treatment for co-occurring PTSD and substance use disorder), was a present-focused coping intervention that aimed to teach individuals skills to cope with both symptoms of PTSD and alcohol use disorder. The ultimate goal of this research study was to determine which treatment modality was most effective in supporting the recovery of individuals living with both PTSD and alcohol use disorder. 

Figure 1. Chart comparing the features of both the COPE and Seeking Safety treatment approaches, including general timeframe of treatment, and specific therapy techniques.

HOW WAS THIS STUDY CONDUCTED?

Study authors examined 119 adult veterans (90% male, average age of 41 years, 66% White) with current symptoms of PTSD who were receiving care at the San Diego Department of Veterans Affairs (VA). While individuals were encouraged to avoid other treatment for their PTSD, they were able to receive standard mental health treatment at the VA while participating in this study. For example, 65% were taking psychotropic medication during the study. Participants also needed to have current alcohol use disorder, at least 20 days of heavy alcohol use (see below for heavy drinking definition) in the past three months, and a stated desire to quit or cut back on alcohol use. Participants were randomly assigned to receive either 12-16 90-minute sessions of COPE (i.e., integrated prolonged exposure therapy) or Seeking Safety (i.e., coping skills–focused therapy). Sessions were administered preferably once to twice per week on consecutive weeks, but could span across a 6-month period of time. 

Participants completed assessments of PTSD symptoms and problematic drinking behavior after treatment and at 3- and 6-months posttreatment, and these assessments were administered by study staff who were not aware of (i.e., “blinded” to) the treatment received.The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was the primary measure used to quantify PTSD symptoms and diagnosis, with scores >=12 suggestive of a PTSD diagnosis (range: 0-80). Frequency and quantity of alcohol use were ascertained via a calendar-based interview (i.e., Timeline Follow-Back), which was used to deduce A) the percent of heavy drinking days defined as the number of days in which 5 or more drinks for men or 4 or more drinks for women were consumed since the last assessment, and B) percent days abstinent for alcohol. A breathalyzer was administered to any participant who appeared intoxicated. 

WHAT DID THIS STUDY FIND?

PTSD symptoms declined more in veterans who received integrated prolonged exposure therapy compared to the present-focused coping intervention.

PTSD symptoms improved over time regardless of therapy assignment; however, the COPE group improved more than did the Seeking Safety group. Immediately after treatment, over 20% of individuals went from having a PTSD diagnosis to no longer meeting criteria for the condition (“remission”), compared to only 7% in the present-focused coping intervention. The advantage for the COPE group became slightly weakened over time but was nevertheless maintained; the greater PTSD symptom gains for the COPE group were still present 6 months after completing treatment.

Figure 2.

Drinking outcomes improved similarly across treatment groups.

All participants showed reductions in the percent of heavy drinking days over time, though the extent of decrease was similar in those who received integrated prolonged exposure and the present-focused coping intervention. Findings were similar – both groups displayed similarly improved drinking – when the outcome was percent days abstinent as well.

Figure 3.

Figure 4.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study is responsive to the urgent need to identify treatments that are effective in mitigating both symptoms of PTSD and alcohol use disorder, the co-occurrence of which is both highly common and linked with greater negative outcomes compared to either disorder alone. Findings from this study build upon a robust literature suggesting that prolonged exposure therapy is the gold standard for mitigating PTSD symptoms. Importantly, this study demonstrates that prolonged exposure therapy is effective even among individuals with an active alcohol use disorder. This study, plus a growing body of literature, challenges a commonly held belief that individuals with alcohol use disorder cannot tolerate exposure-based approaches, addressing the notion of alcohol use disorder as a potential barrier to receiving widely–supported, evidence–based therapy for PTSD.

Contrary to the authors’ hypotheses, however, prolonged exposure therapy was no more effective in reducing problematic alcohol use than the present-focused coping intervention. The fact that this PTSD reduction benefit did not translate into lower problematic alcohol use suggests that, whereas some PTSD patients may have initially drunk (and still drink) alcohol to help “medicate” the distress caused by PTSD, for many others, the alcohol use may persist fairly independently of PTSD. Although group differences were not found with regard to drinking use, it is notable that both groups showed significant reductions in drinking over time, suggesting that simultaneous treatment for alcohol use disorder can be integrated into the framework of PTSD treatment without interfering with the treatment of PTSD itself. Future studies are needed to determine which PTSD treatment modalities may have the most beneficial impact on drinking behaviors. Some findings from other groups provide promising preliminary support for approaches that involve teaching individuals to challenge and modify maladaptive beliefs (cognitive processing therapy and cognitive behavioral therapy) and guided eye movements with the goal of diminishing negative feelings associated with traumatic events (eye movement desensitization and reprocessing therapy).LIMITATIONS

BOTTOM LINE

  • For individuals and families seeking recoveryThis study demonstrated that the simultaneous attention to both PTSD symptoms and alcohol use disorder is possible, and attention to both disorders in an integrated treatment approach is linked with improved functioning. Therefore, patients with both conditions should feel empowered to have both PTSD symptoms and problematic drinking behavior as treatment targets that can be addressed in tandem rather than in parallel. This is comparable to other studies that find integrated approaches to be successful in cases of co-occurring substance use and other neuropsychiatric disorders such as depression and ADHD
  • For treatment professionals and treatment systemsPatients with PTSD and alcohol use disorder benefitted from integrated treatment approaches. Findings suggest that individuals with comorbid PTSD and alcohol use disorder should not be excluded from receiving front-line PTSD treatment on account of their untreated alcohol use. Rather, alcohol use should be identified as a core treatment target and addressed in tandem with PTSD. Further work is needed, though, to determine the most effective treatment modality for addressing problematic alcohol use in the context of PTSD.  
  • For scientists: Findings point to the efficacy of prolonged exposure therapy, even in the presence of co-occurring alcohol use, in mitigating symptoms of PTSD. While findings suggest a reduction in heavy drinking days, this effect was not specific to the therapeutic approach of prolonged exposure therapy. This finding does not align with “self-medication” as a maintaining condition for alcohol use disorder, at least for some. While more work is needed to determine the most effective approach for reducing alcohol use among PTSD patients, this study represents an important first step in decreasing barriers to access to empirically-validated and integrated treatments. Additionally, while prolonged exposure therapy is commonly viewed as a gold standard approach for trauma treatment, retention particularly in real-world settings is often low. Co-occurring substance use has been found to be one patient factor robustly associated with dropout. Therefore, future studies aimed at enhancing engagement and retention, especially among patients with co-occurring disorders, is critical for the widespread dissemination of this approach. 
  • For policy makersFindings lend preliminary support for the efficacy of integrated treatment approaches, which runs contrary to the outdated, yet still pervasively present notion, that substance use disorders need to be fully remitted prior to the treatment of co-occurring other mental health concerns (e.g., PTSD, depression, anxiety disorders). Integrated treatment approaches that allow for substance use disorders and other mental health disorders to be addressed simultaneously will undoubtedly decrease barriers to treatment access for the large proportion of patients seeking recovery from multiple conditions. Therefore, it is imperative that clinician trainees and all patient-facing staff in mental health facilities receive proper education and training in issues related to substance use disorders. Such training may involve early identification of problematic substance use and management of acute signs of overdose. Additionally, as demonstrated in this study, it remains unknown which integrated treatments are optimally effective in treating substance use disorders in the context of PTSD and other co-occurring mental health conditions. Therefore, the field would benefit from continued funding to support research on novel treatment development and evaluation.  

CITATIONS

Norman, S. B., Trim, R., Haller, M., Davis, B. C., Myers, U. S., . . . Mayes, T. (2019). Efficacy of integrated exposure therapy vs integrated coping skills therapy for comorbid posttraumatic stress disorder and alcohol use disorder: A randomized clinical trial. JAMA Psychiatry, (Epub ahead of print). doi: 10.1001/jamapsychiatry.2019.0638 

The Council on Recovery is the leader in providing a wide range of prevention and education resources aimed reducing alcohol use, especially among adolescents and young adults. We also offer therapeutic counseling and an intensive outpatient treatment program (IOP) for those affected by alcoholism. For more information, please call 713-942-4100 or contact us online.