Treating post-traumatic stress disorder associated with a substance use disorder

While each of the two disorders can produce severe symptoms and have deleterious repercussions on the functional and vital levels, their combination makes them more complex and aggravates them. Thus, compared with each of them, the dual pathology of PTSD-TUS is often associated with more severe clinical pictures, as evidenced by :

• A traumatic history more often marked by serious events in childhood (Khoury et al., 2010);
• A higher number of associated mental health disorders, including mood disorders, anxiety disorders and personality disorders (Sells et al., 2016; Wolitzky-Taylor, et al., 2012) ;
• Higher rates of suicidal ideation and suicide attempts (Back et al., 2019; Norman et al., 2018; Mills et al., 2012) as well as self-aggressive behavior;
• Increased violence (Barrett et al., 2014; Blanco et al., 2013; McDevitt-Murphy et al., 2010; Mills et al., 2006; Norman et al., 2018);
• A greater number of functional alterations (e.g. Hien et al., 2021)
• Greater social instability and poorer quality of life (Blakey et al., 2022; Blanco et al., 2013; Norman et al., 2018);
• A poorer response to available treatments (Simpson et al., 2020) and a higher relapse rate for TUS (Norman et al., 2007; Ouimette et al., 1997).

Moreover, PTSD is associated with greater severity ofcraving(Coffey et al., 2002; Saladin et al., 2003) and greater severity of withdrawal symptoms (Boden et al., 2013).

The dual pathology of PTSD-TUS is associated with a significant increase in early treatment interruptions.

With regard to PTSD, a landmark meta-analysis of 42 studies (Imel et al., 2013) reports an average treatment discontinuation rate of 18%. This rate may be higher in specific groups such as veterans (Myers et al., 2019).

With regard to TUS, data from the Substance Abuse and Mental Health Services Administration indicate an average therapeutic dropout rate equal to 35%, with this rate reaching 55% in certain populations (SAMHSA, 2015).

These figures increase further in the case of dual PTSD-TUS pathology. Indeed, Simpson et al. (2017) show that, among patients suffering from both disorders simultaneously, only around 50% manage to complete their treatment - whether it's based on an exposure approach, the development of coping strategies or focuses on addiction. This figure suggests an average treatment discontinuation rate of around 50%, significantly higher than that observed for the treatment of PTSD alone (18%) or SUI alone (35%).

What is noteworthy, however, is that several studies of treatment discontinuation reveal that, among patients who discontinue treatment prematurely, a significant proportion (between 36% and 68%) show clinically significant improvement or achieve a good level of functioning with regard to PTSD and/or SUD symptoms before discontinuing treatment (Szafranski et al., 2017, 2018). Thus, treatment discontinuation would not be systematically linked to a deterioration in clinical status or a lack of improvement.

The vast majority of people with the dual pathology of PTSD and TUS have only one of their disorders assessed. There may be several reasons for this.

The organization of care into separate streams: the management of PTSD and SUD is often compartmentalized between the addictology and psychiatry sectors. Each field tends to focus on its own pathology, to the detriment of assessing and treating the other disorder.

The existence of practical obstacles reported by professionals such as lack of time, limited financial resources of facilities or lack of sufficient expertise to treat the two disorders jointly (see for example Gielen et al., 2014).

The shame and guilt felt by patients, many of whom are reluctant to talk about their substance use or traumatic history, depending on the professional's field of expertise.

Despite the accumulation of knowledge over more than two decades, three erroneous beliefs still hinder the evolution of care offered to people with the dual pathology of PTSD-TUS.

Belief 1: Abstinence is essential to the effectiveness and success of PTSD treatment.

In other words, it would be necessary to treat TUS before treating PTSD.

As a result, current treatments for the dual pathology of PTSD-TUS are most often organized in a sequential and differentiated manner: TUS is first managed by a clinician who then passes on follow-up to a colleague specializing in PTSD (van Dam et al., 2012). From this perspective, access to care for PTSD is often discouraged or denied to the patient until a certain period of abstinence has been achieved - which, paradoxically, increases the risk of abandonment of care.

What's more, this organization does not reflect clinical reality. Indeed, a large proportion of people with the dual pathology PTSD-TUS use substances precisely to soothe their post-traumatic symptoms - whether to facilitate sleep, reduce nightmares, attenuate intrusive thoughts and memories, or reduce the intensity of hyperarousal symptoms (María-Ríos et al., 2020; Vujanovic et al., 2019).

In addition, several studies have evaluated the evolution of symptoms during treatment to determine whether it is really necessary to delay PTSD intervention until substance use is reduced or stopped. Their results show that improvement in PTSD symptoms is associated with a greater reduction in subsequent substance use. In contrast, the inverse relationship (substance use predicting later PTSD symptoms) is not as strong (Hien et al., 2010, 2018; Kaczkurkin et al., 2016; Tripp et al., 2021).

Belief 2: Treating PTSD and SUD at the same time would increase PTSD symptoms and hinder addiction treatment.

It would be unwise, even counterproductive, to treat PTSD and SUI at the same time. This approach would be likely to aggravate PTSD symptoms and undermine the therapeutic dynamics of addiction (Gielen et al., 2014).

This belief is now contradicted by solid scientific data. Indeed, the majority of people with a dual PTSD-USD pathology perceive their symptoms as interdependent and prefer an integrated therapeutic approach, in which both disorders are treated simultaneously (Back et al., 2015). Numerous studies also confirm the safety of these integrated treatments for both PTSD and TUS (Back et al., 2019; Norman et al., 2019; Roberts et al., 2015; Simpson et al., 2017; van Dam et al., 2012).

Thus, for example, a recent study (Tripp et al., 2021) revealed that only 15.8% of participants receiving integrated psychotherapy experienced a temporary worsening of their PTSD symptoms at the start of treatment (between sessions 3 and 5), before a noticeable improvement thereafter. This transient worsening did not vary according to whether the therapy was trauma-focused or not. In fact, a more marked exacerbation of PTSD symptoms was observed in patients treated exclusively for their SUD, compared with those benefiting from an integrated trauma-focused approach (Lancaster et al., 2020).

Belief 3: evoking traumatic memories would be detrimental to patients with the dual pathology of PTSD-TUS.

Patients suffering from SUD who are still actively using may be too vulnerable to address their traumatic memories in therapy. This could worsen their clinical condition, leading to relapse, intensification of use, exacerbation of symptoms and even an increase in suicidal risk (Becker et al., 2004).

Here again, solid scientific data contradicts these concerns. They show that the treatment of PTSD, when carried out simultaneously with that of SUI, leads to a significant reduction in the symptoms associated with both disorders (Roberts et al., 2015). Recent meta-analyses corroborate these findings (Roberts et al., 2022; Simpson et al., 2021).