What is Acudetox, and why has The Council decided to offer it?

By Lori Fiester, Clinical Director of the Center for Recovering Families

I have been in the social work field for approximately 32 years and have seen trends come and go in substance abuse treatment settings. Treatment for substance abuse was primarily geared to the 12 Steps when I first entered the field, along with licensed chemical dependency counselors. Today we have a plethora of providers that give a vast array of therapeutic interventions that can assist those seeking help. Recently, I stumbled upon an opportunity to learn another intervention that can assist people who want to get sober, are sober, or are in sustained recovery, called Acudetox.

Acudetox is a five-point acupuncture protocol specifically designed for those struggling with substance use issues. The acupuncture needles are gently placed in the ear at specific points. This helps balance the body’s energy and assists the healing process. It is referred to in Eastern medicine as a yin tonification, restoring calm inner qualities like serenity. This process is best done in a group setting lasting from 30-45 minutes and is non-verbal with minimal interaction from the facilitator.

Acudetox has shown to decrease cravings for alcohol and drugs, withdrawal symptoms, relapse episodes, anxiety, insomnia and agitation.  Even more exciting, the effects can be immediate. There are usually no side-effects and the intervention is inexpensive.  Clients report relaxation, stress and craving reduction, mental clarity, an increased sense of wellbeing and more energy.  Programs have reported more successful completions and less client discharge against medical advice, along with higher client satisfaction improvement.

This seemed too good to be true, so off I went to get trained in Acudetox. As a result, I’m a firm believer that this intervention can assist anyone in the process of recovery. While practicing the protocol, I experienced immediate relaxation myself and noticed later that my mindless eating wasn’t as mindless. As I practiced on friends and colleagues, they reported decreased blood pressure, better sleep and more concentration. Even those who chose not to have the intervention in the group setting experienced a meditative state. As a therapist, it’s an interesting shift from talk therapy to inserting needles, but I see the value as clients become more aware of their body and their thoughts, and are able to settle more quickly to begin their work.   

The Council is offering Acudetox to clients in The Center for Recovering Families’ Intensive Outpatient Program, and is also now offering appointments open to the general public.  Click here for more information on Acudetox or to register for a session.

What is CBD and How is it Different from Marijuana?

Clinical Director for the Center for Recovering Families Lori Fiester answers your burning questions about CBD.

If you’ve driven around town lately, you might have seen all the CBD shops that have burst on the scene, or may have seen ads on your favorite social media site selling CBD oils and other such related items.

This surge recently came about due to hemp being legalized in 2018. There seems to be a lot of confusion about that too, especially when you realize that hemp and marijuana come from the cannabis plant. The difference between hemp and marijuana is that hemp can only contain 3% of Tetrahydrocannabinol (THC). Past that percentage, it’s considered marijuana, which is illegal in Texas. While I see the effects of recreational marijuana abuse in my work, I had limited understanding about the what the differences between the substance were, the legalities, and was Cannabidiol (CBD) just another silver bullet. So I thought I’d dip my big toe in the river.

The Science of CBD

First of all, THC and CBD are chemically the same! Twenty-one carbon atoms, 30 hydrogen atoms and two oxygen atoms. The difference is in a single atom structure. And that single-atom difference is about feeling the psychoactive effects of the substance or not.

There are about 85 known cannabinoids found in the Cannabis plant, which include THC and CBD. A cannabinoid is a compound that interacts within the network of receptors in the Endocannabinoid System (ECS), which assist to maintain vital functions within the body. There are two receptors in the body called CB1 and CB2. CB1 is found in parts of the brain that is responsible for mental and physiological processes such as memory, cognition, emotion and motor skills. CB2 is found throughout the central nervous system and the immune system.

While both CBD and THC bind to the CB2, they interact with the CB1 receptors differently.  THC binds to the CB1 receptors that signals the brain to feel pleasure or ‘high’ feeling. CBD doesn’t bind directly to the CB1 and even its presence will negate the effects of the THC on the brain, meaning you won’t feel high. 

Use and Effects

CBD has been linked to assisting with pain, epilepsy, multiple sclerosis (MS), Parkinson’s, and inflammation, just to name a few. CBD is not regulated by the FDA and there have been no long term studies. There are no known side effects except in drug to drug interaction, i.e. medication.

THC is psychoactive which gives the ‘high,’ and its effects can include relaxation, altered senses, fatigue, hunger and reduced aggression.  Long term effects include addiction, impaired thinking and reasoning, a reduced ability to plan and organize, altered decision making, reduced control over impulses and correlates with significant abnormalities in the heart and brain.

Medical THC has been seen to help with the side effects of chemotherapy, MS, HIV/AIDS, spinal injury, nausea/vomiting, chronic pain, inflammation and digestive issues.

Marijuana is illegal in Texas although many states have legalized it for both recreation and medically.  Medical cannabis is legal in Texas in very limited situations. The Texas Compassionate Use Act came into law in 2015 allowing those affected with epilepsy, MS, Parkinson’s and Lou Gehrig’s disease have access to cannabis oil with less than 5% THC.

The Bottom Line is…

While CBD and THC come from the same plant, one is legal in Texas and one is not. It appears that CBD can have positive effects on a person’s health, it is not a psychoactive drug, there are no known side effects, and due to the changes in the law, it is readily available.  However, with that being said, there are no guidelines for manufacturing the substance, and there are no long term studies on the effects from taking the substance. I stress the issue of manufacturing due to the serious illness and even deaths we have seen from vaping when this delivery system was off-brand/market and often involving marijuana.

Marijuana is still illegal in Texas, it is a psychoactive and addictive drug and there are many side effects from its use. 

To make an appointment for a clinical assessment, or if you have any questions about how we can help you or a loved one struggling with substance abuse, call 713-914-0556 or contact us online.

If your campus, workplace or community would benefit from a presentation, contact us at 281-200-9273 or comm_education@councilonrecovery.org.

The Link Between Childhood Trauma and Addiction

For decades, the professional approach to addiction has been shifting away from shaming and blaming, and toward the belief that addiction is a normal and common biological response to adversity experienced in childhood. The popularization of this game-changing perspective is credited to Dr. Daniel Sumrok, director of the Center for Addiction Sciences at the University of Tennessee Health Science Center’s College of Medicine, who began his crusade to change the narrative around addiction after treating Vietnam veterans with PTSD in the early 1980s.

Adverse Childhood Experiences (ACEs) affect long-term health, and can include physical, emotional, and sexual abuse; physical and emotional neglect; living with a family member who’s addicted to substances; depression and other mental illnesses; parental divorce or separation; incarceration or deportation of a family member; racism; involvement in the foster care system, and more. Clinicians like Dr. Sumrok administer an ACE assessment upon meeting a patient for the first time, and for good reason.

According to ACE studies, about 64% of people have at least one ACE, which can double to quadruple the likelihood of using drugs or alcohol, particularly at an early age. Having an ACE score of 4 nearly doubles the risk of heart disease and lung cancer and increases the likelihood of becoming an alcoholic by 700%. People with a score of 5 or higher are seven to 10 times more likely to use illegal drugs and become addicted. Furthermore, these studies show that it doesn’t matter what type of trauma the patient experienced. Different combinations of ACEs produce the same statistical health consequences.

Considering potential childhood trauma is necessary for addressing one’s addiction.

This requisite has fortunately also normalized the concept of addiction as “ritualized compulsive comfort-seeking” – it’s something one adopts as a coping behavior because they weren’t provided with a healthy alternative when they were young. This approach is not only supported by psychological research, it’s also the compassionate route to treating clients with substance abuse problems. Rather than labeling someone as an addict and punishing them for their behavior, clinicians like those at The Council find it’s kinder and more productive to address ACEs with their clients, and to help them seek comfort in other behaviors. Since its inception, the staff at the Center for Recovering Families is dedicated to helping their clients by looking at their trauma when appropriate and providing the necessary skills to deal with their feelings.

For more information about ACEs, read here. To calculate your ACE score, click here.

For questions about The Council’s assessment and treatment options, or if you or a loved one needs help, call (713) 914-0556 or contact us here.

CDC Reports High Tobacco Use Among Youth in 2019

The Center for Disease Control released a report earlier this month on tobacco product use among middle and high school students in public and private schools across America, reminding The Council on Recovery that although we’ve made great strides in the past decade, we still have much work to do in the coming years in our fight to reduce substance use and abuse by minors.

The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, self-administered survey of U.S. middle school and high school students attending public and private schools that uses a representative sample to estimate how many youths are using tobacco, and what factors contribute to this number, such as type of tobacco product, exposure to tobacco marketing, perceptions of harm, and more. Here are its major findings:

Over half of all U.S. high school students (53.3 %, around 8 million) have used a tobacco product.

Almost a third of high school students (31.2%) reported they were currently using tobacco products. E-cigarettes were the most commonly used tobacco product among high schoolers, with 27.5% reporting they had used one in the past 30 days.

A fourth of all U.S. middle school students (24.3%, around 2.9 million) reported using a tobacco product.

About 12.5% of middle school students reported they were currently using tobacco products. E-cigarettes were also the most commonly used tobacco product with middle schoolers, with 10.5% reported using them.

E-cigarettes remain a major public health concern.

The prevalence of cigarette smoking among students was the lowest ever recorded by the study since 1999. This is no cause to celebrate, however, as this is due to the emergence and popularization of e-cigarettes, which have been recorded as the most popular tobacco product among youths since 2014. In 2017-2018, the use of e-cigarettes increased by 77.8%, prompting the U.S. Surgeon General to declare e-cigarette use a national epidemic last December. This 2019 report reports even higher e-cigarette usage, but takes into consideration changes to the survey itself that could have affected outcomes.

This survey acts as a reminder to The Council that there is still much work to be done in middle schools and high schools across the major Houston area. Through the CHOICES program, The Council will continue to meet schools where they are at to help students and their families resist the seductive appeals of e-cigarette and other tobacco product marketing, and learn the risks and consequences of substance use at such an early age.

“Longitudinal studies have shown that youth vapers are four times more likely to smoke combustible cigarettes than non-vapers,” says Patrick Hagler, CHOICES counselor. “CHOICES can help by educating teens and parents about the real consequences of vaping.”

The Council on Recovery and Prevention Resource Center 6 have also teamed up to host a Houston Vaping Summit on February 21, 2020, with the goal to educate local school administrations (as well as healthcare, law enforcement, mental health professionals, and parents) on vaping and to equip them with the tools they need to respond promptly and effectively.

In positive news, the federal government has raised the legal age for purchasing tobacco products to 21, effective in the summer of 2020.

For more information on the National Youth Tobacco Survey, click here.

If your teen or child needs our help, call (713) 914-4100. For information on how to create a CHOICES program at your school, please contact (281) 200-9272.

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.