How to Treat PTSD and Alcohol Misuse

The drinking and ptsd neurokinin-1 receptor antagonist aprepitant had no effect on PTSD symptoms or alcohol craving (Kwako et al. 2015). Data from theDepartment of Veterans Affairsindicates that as many as 63 percent of veterans diagnosed with alcohol use or other substance use disorder also meet the diagnostic criteria for PTSD. While PTSD does not result solely from trauma experienced with military duty, PTSD and alcohol abuse in veterans are occurring at higher rates than in the general population. Seeking treatment for a substance use disorder and PTSD have increased at least 300 percent in recent years. Despite the significant distress, impairment, and complicated clinical course facing individuals with co-occurring SUD and PTSD, substantial gaps remain in the literature regarding effective treatment approaches.

Data Analysis

Given the research to date, it seems unlikely that one medication will be effective in treatment of both disorders given the complexity of comorbidity. As medications emerge that appear to be effective at treating one of the disorders without comorbidity (e.g., gabapentin for alcohol), testing them in comorbidity, while not especially “innovative”, is important before disseminating in “real world” populations. Because inpatient studies are expensive, other innovative strategies such as laboratory studies using stress reactivity or cue induced craving may be more efficient and cost-effective for testing novel therapies. This is an exciting field of study, which has important ramifications both for research and clinical treatment settings and hopefully investigators will be encouraged to conduct studies that can move this field forward. Overall, clinicians can be reassured that medications approved to treat one disorder can be used safely and with some efficacy in this comorbidity. Addressing both disorders, whether by using a combination of medications to treat each disorder or by combining medication with behavioral treatments seem most likely to be effective.

• In contrast, AA women were more likely than their EA counterparts to experience trauma and to develop PTSD.
• Data from theDepartment of Veterans Affairsindicates that as many as 63 percent of veterans diagnosed with alcohol use or other substance use disorder also meet the diagnostic criteria for PTSD.
• Evidence-based behavioral interventions for AUD include relapse prevention, contingency management, motivational enhancement, couples therapy, 12-step facilitation, community reinforcement, and mindfulness.
• One of the three studies clearly found that sertraline was more effective in decreasing PTSD symptoms than placebo (Hien et al. 2015) while another found a trend-level advantage of sertraline over placebo on PTSD outcomes (Brady).

Treatment For PTSD and Drinking

Despite the strengths of this meta-analytic review, this study is not without limitations. First, while review of the literature was rigorous, it is possible that some appropriate studies were missed in the data extraction phase. This includes relevant publications with missing data that could not be obtained by the authors. Because these studies could not provide missing data, it is impossible to know if they differed from the included studies in some meaningful way. Several population characteristics meaningfully influenced the indirect effect of coping.

PTSD and Alcohol: How Does Alcohol Affect PTSD Symptoms?

The available evidence suggests that medications used to treat one disorder (AUD or PTSD) can be safely used and with possible efficacy in patients with the other disorder. However, additional research on pharmacological agents based on shared neurobiology of AUD and PTSD would be useful. There has been a recent increase in studies examining the efficacy of integrated treatments that combine PE with cognitive-behavioral SUD approaches. Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) 36 is one such modality that synthesizes empirically-validated cognitive-behavioral treatment for SUD with PE.

Findings for medications that were hypothesized to treat both disorders were also contradictory. The use of medication to treat SUD and PTSD has largely focused on the treatment of either disorder alone 58. Recent findings regarding several medications to treat SUD alone, and alcohol use disorders in particular, are encouraging 59–61. However, one important remaining limitation is that the only FDA-approved medications to treat alcohol use disorders target relapse prevention only. While many medications have been investigated to treat PTSD 62, only selective serotonin reuptake inhibitors (SSRI) have received FDA approval. Across clinical trials, approximately 20–30%of patients achieve PTSD remission with SSRI treatment 63–66.

Neither of the interactions between PTSD symptom level (PMS and GMS) and number of drinks consumed were significant. Given that PTSD symptom severity data were collected longitudinally over a period of several monitoring days, it was possible to disaggregate within-person and between-person effects of PTSD symptom severity on alcohol problems (Curran & Bauer, 2011). To do so, we mean-standardized (i.e., z-scored) PTSD severity to statistically partial out effects of within-person daily PTSD symptoms opposed to overall, between-person PTSD symptoms over the entire monitoring period. Within-person PTSD severity was person-mean standardized (PMS) in order to capture the extent to which PTSD symptoms deviated from each participant’s personal mean on each day of monitoring. In other words, PMS PTSD reflects how mild/severe the participants’ PTSD symptoms were each day compared to their own personal average. We calculated between-person PTSD by grand-mean standardizing (GMS) each person’s overall PTSD scores.

Narrative exposure

• Yet avoiding the bad memories and dreams actually prolongs PTSD—avoidance makes PTSD last longer.
• As such, continued research on the development of effective screening, prevention and treatment interventions for service members and veterans is critically needed.
• Studies requiring binge drinking episodes for eligibility had smaller indirect effects compared to studies without an explicit drinking inclusion criterion.
• All moderators, excluding the harmful drinking variable (e.g., consumption, problems, hazardous drinking, heavy episodic drinking), were conducted on the pooled study correlation matrices.
• When a medication has shown efficacy in either or both of these disorders separately and common mechanisms of action have been identified, they are then considered for exploration among those with co-occurring SUD and PTSD.
• In one case study of an OEF/OIF veteran, researchers examined the effectiveness of concurrent treatment of PTSD and SUD using prolonged exposure (COPE) therapy.45 COPE involves 12, 90-minute sessions that integrate relapse prevention with prolonged exposure therapy.
• Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) 36 is one such modality that synthesizes empirically-validated cognitive-behavioral treatment for SUD with PE.

We also excluded measures of coping that assessed ‘coping through substance abuse’ more broadly since we could not be sure that the substance being used was alcohol. To examine the effects of single studies on the aggregate effect size, we used a one study removed procedure. We report the jackknife, which is the average omnibus effect size, and range of those effect sizes using this one study removed approach.

It is also clear from the moderator analyses we described that the effect of self-medication will vary widely based on multiple domains, and that there are likely to be subsets of individuals who do not drink to cope with their internal emotional states at all. For these individuals, other relevant theories such as the high-risk hypothesis or the shared vulnerability hypothesis may be more relevant. Thus, future studies may wish to take a more person-centered approach to systematically uncover different groups of individuals and the reasons that they drink.