Therese K. Killeen

Multisite Randomized Trial of Behavioral Interventions for Women With Co-Occurring PTSD and Substance Use Disorders

The authors compared the effectiveness of the Seeking Safety group, cognitive-behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Womens Health Education [WHE]) within the National Institute on Drug Abuses Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale-Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions.

Comorbid Substance Abuse and Posttraumatic Stress Disorder: Characteristics of Women in Treatment

To further explore the complex relationship between posttraumatic stress disorder (PISD) and substance use disorders, the authors compared 30 women with PTSD in substance abuse treatment with 25 women without PTSD in substance abuse treatment on degree of addiction severity, psychopa-thology, and aftercare compliance. Women with PTSD were more likely to have been victims of sexual and physical abuse, particularly childhood abuse. They had significantly higher scores on the Addiction Severity Index, were more likely to have comorbid affective disorder, and less likely to comply with aftercare. These results suggest that screening for victimization and PTSD among women presenting for substance abuse treatment may have important prognostic and treatment implications.

Posttraumatic stress disorder and co-occurring substance use disorders: Advances in assessment and treatment

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co-occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches - treatments that address symptoms of both PTSD and SUD concurrently -are fast becoming the preferred model for treatment. This paper reviews the prevalence, etiology and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs.

Victimization and PTSD in Individuals with Substance Use Disorders: Gender and Racial Differences

There is a paucity of studies concerning the prevalence of crime-related posttraumatic stress disorder (CR-PTSD) in individuals with substance use disorders, despite documentation of particularly high prevalence rates of sexual and physical assault in this population. A central objective of the present investigation was to assess victimization experiences and CR-PTSD among individuals receiving inpatient treatment for substance use disorders and evaluate gender and racial differences in assault characteristics CR-PTSD prevalence rates. A total of 95 inpatients (34 men and 61 women; 41 African-Americans, 52 Caucasians, and 2 other minorities) were administered a structured interview to assess substance abuse/dependence, trauma, and PTSD. Approximately 90% of the participants had a lifetime history of sexual and/or physical assault, and approximately 50% had CR-PTSD. With the exception of rape, no gender differences in assault or CR-PTSD prevalence rates were observed. Women were more likely than men to perceive their life as endangered during a rape. Men were younger than women when they experienced their first (or only) aggravated assault and were more likely to have been assaulted by a family member. No racial differences were detected for assault or PTSD, although African-American patients were significantly more likely to identify cocaine as their primary drug than Caucasian patients. Given the strikingly high rate of comorbid CR-PTSD among substance use disordered patients, exploration of the type and timing of interventions would be of clinical interest.

Comparative Profiles Of Women With Ptsd And Comorbid Cocaine Or Alcohol Dependence

This study examined differences in substance abuse severity, trauma history, posttraumatic stress disorder (PTSD) symptomatology and psychiatric comorbidity among treatment-seeking women (N=74) with PTSD and either comorbid cocaine or alcohol dependence. Women in the cocaine/PTSD group, compared with the alcohol/PTSD group, demonstrated greater occupational impairment (e.g., greater severity on the employment subscale of the Addiction Severity Index, less monthly income, fewer days worked in past month), more legal problems (e.g., greater number of months incarcerated and arrests for prostitution), and greater social impairment (e.g., fewer number of close friends, less likely to be married). Women in the alcohol/PTSD group evidenced higher rates of exposure to serious accidents, other situations involving serious injury, and other extraordinarily stressful life events. Rates of major depression and social phobia were higher among the alcohol/PTSD group than the cocaine/PTSD group. Women in the alcohol/PTSD group scored higher on the CAPS avoidance, hyperarousal, and total subscale scores. The current findings enhance our understanding of the substance-specific profiles of women with PTSD and comorbid substance use disorders and may have important implications for the design of dual-diagnosis interventions.

A placebo-controlled trial of buspirone for the treatment of marijuana dependence.

The present study investigated the potential efficacy of buspirone for treating marijuana dependence. Participants received either buspirone (maximum 60mg/day) (n=23) or matching placebo (n=27) for 12 weeks, each in conjunction with motivational interviewing. In the modified intention-to-treat analysis, the percentage of negative UDS results in the buspirone-treatment group was 18 percentage points higher than the placebo-treatment group (95% CI: -2% to 37%, p=0.071). On self-report, participants receiving buspirone reported not using marijuana 45.2% of days and participants receiving placebo reported not using 51.4% of days (p=0.55). An analysis of participants that completed the 12-week trial showed a significant difference in the percentage negative UDS (95% CI: 7-63%, p=0.014) and a trend for participants randomized to the buspirone-treatment group who completed treatment to achieve the first negative UDS result sooner than those participants treated with placebo (p=0.054). Further study with buspirone in this population may be warranted; however, strategies to enhance study retention and improve outcome measurement should be considered in future trials.

Effectiveness of naltrexone in a community treatment program

OBJECTIVE In several large, well-designed, randomized, double-blind studies, the opiate antagonist naltrexone demonstrated efficacy in the treatment of alcohol dependence. Specifically, when combined with certain psychosocial therapies, naltrexone reduces the number of drinking days, heavy drinking, and time to relapse to alcohol use in alcohol-dependent individuals. Whether this efficacy can be generalized to individuals who have alcohol use disorders and present for treatment at front-line community treatment programs has not been well established. METHODS A total of 145 patients who presented for treatment at a rural community substance abuse treatment center were randomized to receive naltrexone 50 mg daily plus usual program treatment (n = 54), placebo plus usual treatment (n = 43), or usual treatment alone (n = 48) for 12 week. A total of 133 participants had at least one follow-up visit. Primary outcome measures included percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days (four or more for women and six or more for men), and time to first heavy drinking day. Secondary measures included changes in serum biological markers (alkaline phosphatase, alanine transaminase, aspartate transaminase, and gamma-glutamyltransferase), craving, and psychosocial functioning. RESULTS In the intention-to-treat analysis, there were no between-group differences for any of the primary drinking outcomes at 12 weeks. In post hoc exploratory analyses, the entire sample of participants was divided into two new groups: (1) people who drank during the 2 weeks before the start of medication (entry drinkers) and (2) people who did not drink during this interval (entry abstainers). Entry abstainers were at an advantage at study entry in that they were significantly more likely to have an inpatient hospitalization immediately before entry into outpatient treatment. Mixed-model analysis of variance revealed a main effect for entry group at the 12-week treatment endpoint on the primary outcome measures of percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days, and time to first heavy drinking day. Participants in any of the randomized groups who were entry abstainers had significantly better improvement on all of the primary outcome measures. The abstainer groups that were randomized to placebo and usual treatment had significantly better outcomes than the entry drinkers in those perspective groups. However, for the naltrexone-treated group, entry drinkers and entry abstainers had similar improvement in drinking-related outcomes. CONCLUSIONS These data suggest that naltrexone may offer particular benefit to patients who continue to drink during the early stages of the trial as compared with those who have achieved abstinence before treatment entry.

The Impact of Trauma-Focused Group Therapy upon HIV Sexual Risk Behaviors in the NIDA Clinical Trials Network “Women and Trauma” Multi-Site Study

Women in drug treatment struggle with co-occurring problems, including trauma and post-traumatic stress disorder (PTSD), which can heighten HIV risk. This study examines the impact of two group therapy interventions on reduction of unprotected sexual occasions (USO) among women with substance use disorders (SUD) and PTSD. Participants were 346 women recruited from and receiving treatment at six community-based drug treatment programs participating in NIDA’s Clinical Trials Network. Participants were randomized to receive 12-sessions of either seeking safety (SS), a cognitive behavioral intervention for women with PTSD and SUD, or women’s health education (WHE), an attention control psychoeducational group. Participants receiving SS who were at higher sexual risk (i.e., at least 12 USO per month) significantly reduced the number of USO over 12-month follow up compared to WHE. High risk women with co-occurring PTSD and addiction may benefit from treatment addressing coping skills and trauma to reduce HIV risk.

Parental stress and child behavioral outcomes following substance abuse residential treatment Follow-up at 6 and 12 months

Residential treatment programs specifically designed for alcohol/drug-addicted women and their children have become a popular treatment modality across the United States. Outcome evaluation of these programs are beginning to show promising results. In this article, outcome data from a study of a residential substance abuse treatment program for women and young children in rural South Carolina will be presented. Data from 35 women and 23 children in the area of addiction severity, parenting and child emotional and behavioral development at 6 and 12 months following discharge from a substance abuse residential treatment program is examined. Results showed that women who completed treatment had better scores on addiction severity and parental stress, and their children had improved behavioral and emotional functioning at 6 and 12 months after discharge from the program. These results suggest that residential treatment has benefits for mothers and their children. This data adds to the growing body of evidence supporting intensive and inclusive care for certain groups of individuals with substance use disorders during critical periods.

A Placebo-Controlled Trial of Atomoxetine in Marijuana-Dependent Individuals with Attention Deficit Hyperactivity Disorder

This study evaluated the effects of atomoxetine on the symptoms of attention deficit hyperactivity disorder (ADHD) and marijuana use in marijuana-dependent adults. In conjunction with motivational interviewing, participants received either atomoxetine (n = 19) or matching placebo (n = 19) for 12 weeks. Participants randomized to atomoxetine had greater improvement in ADHD on the Clinical Global Impression-Improvement scale than participants treated with placebo. No treatment group differences in self-rated ADHD symptoms, overall Wender-Reimherr Adult Attention Deficit Disorder Scale scores, or marijuana use outcomes were noted. These results suggest that atomoxetine may improve some ADHD symptoms but does not reduce marijuana use in this population.