Treatment outcomes for veterans with PTSD and substance use: Impact of specific substances and achievement of abstinence
Introduction
Posttraumatic stress disorder (PTSD) is associated with frequent comorbid substance use disorder (SUD; McCauley et al., 2012). Clinical morbidity and treatment response have been reported to be worse among PTSD patients with comorbid SUD (McCauley et al., 2012), supporting the general assumption that concurrent substance use worsens the severity of psychiatric disorders. However, in an analysis of data from national program evaluation of Veteran Health Administration (VHA) specialized intensive PTSD treatment programs providing almost daily treatment that included PTSD focused psychotherapy and medication management for many weeks, often with a programmatic expectation of abstinence, Fontana et al. (2012) paradoxically reported that Veterans with PTSD and current SUD diagnosis (using any substance and meeting the diagnostic criteria in 30 days prior to the qualifying period for admission to treatment program) showed greater improvement in PTSD symptoms and other outcomes four months after treatment completion in comparison to Veterans with PTSD and no current SUD diagnosis. This difference in treatment effect was accounted for to a substantial extent by decreased days of substance use after treatment. In a subsequent analysis of these data focused on any marijuana use, patients who reported abstinence from marijuana 4 months following discharge showed greater improvement in PTSD symptoms and reduction in violent behavior compared to those who initiated or continued previous use of marijuana (Wilkinson et al., 2014). However, a comparison of the effects of marijuana with other addictive substances regarding PTSD outcomes was not conducted. In a single center study with similar settings, Bonn-Miller et al. (2013) showed that Veterans with PTSD and cannabis use disorder showed lesser improvement in symptoms compared to others at the completion of treatment. Prior studies have suggested that “hard” drugs like opioids (heroin) and cocaine may have more deleterious psychological effects compared to substances like marijuana in both the general population (Nutt et al., 2010) and in patents diagnosed with PTSD (Cottler et al., 1992, Goldenberg et al., 1995). These studies together raise the questions whether PTSD treatment evokes differential response depending on the specific substances used prior to the treatment episode, and how achievement of abstinence influences the outcome with different types of substance use (SU).
Hien et al. (2010a) have suggested that results of outcomes studies pertaining to PTSD and SUD are limited by the tendency to collapse SU categories due to small sample sizes, and that identifying the specific types of substances used at treatment entry may be valuable in predicting treatment response, and should, perhaps, shape treatment processes for these Veterans. In this study, we use data from the entire large national VHA program evaluation data set that formed the basis for the studies published by Fontana et al. (2012) and by Wilkinson et al. (2014) to explore differences in the PTSD and other clinical outcomes among Veterans who did not report any substance use in the 30 days prior to being admitted to specialized intensive PTSD treatment programs as compared to five groups of Veterans who reported use of a single specific addictive substance, and a final group who used three or more classes of substance. We then compare the association of abstinence after treatment for PTSD with outcomes across the seven SU groups. The particular focus of our study was on the impact of recent use and short-term changes in daily use of specific substances rather than SUD diagnoses.
Section snippets
Method
This study was approved by VACT HCS Institutional Review Board, and followed standard privacy protection protocols, especially regarding SU related data.
Baseline demographics
Veterans were of similar age across the SU categories, and overwhelmingly of male gender (Table 1). Cocaine only users had largest and sedative/hypnotic users had the lowest proportions of Veterans identifying as Blacks (risk ratio [RR] = 4.84). Veterans belonging to the cocaine only, marijuana only, and polysubstance groups were less often married and working, more often divorced and incarcerated, and earned lower income from employment. Veterans belonging to the alcohol only and
Discussion
This study of Veterans admitted from community settings to specialized intensive residential/inpatient/day treatment PTSD programs in VHA nationally, explored the differences in non-substance abuse clinical outcomes between those who did not report any substance use, five other categories of patients who reported use of a single specific addictive substance and a seventh group who reported polysubstance use in the 30 days prior to admission. We found substantial baseline differences between
Role of funding source
No funders had any role in the design of this study, the data analysis or interpretation, the writing of the manuscript, or the decision to submit for publication.
Contributors
Ajay Manhapra and Robert Rosenheck defined the research questions. Elina Stefanovics conducted the statistical analyses. Ajay Manhapra drafted the manuscript. Robert Rosenheck and Elina Stefanovics reviewed and commented on manuscript drafts.
Conflict of interests
There are no conflicts of interests for any of the authors to report.
Acknowledgements
Project supported by VA New England Mental Illness, Research, Education and Clinical Center. Ajay Manhapra supported by VA/OAA Interprofessional Advanced Fellowship in Addiction Treatment, and the Research in Addiction Medicine Scholars (RAMS) Program, R25DA033211 from the National Institute on Drug Abuse.
All authors have approved the final article.
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