The opioid epidemic has been called the worst drug crisis in U.S. history, with annual mortality rates reaching approximately 27,000. With less expensive pain medication easily available, physicians have tripled their prescribing rates of opioids in the last 20 years. Of significant concern is the comorbidity of opioid use disorders and other mental health issues. Studies have found that between 20 percent and 50 percent of individuals receiving treatment for opioid use disorder also meet the criteria for PTSD (Ecker & Hundt, 2017). Research has also suggested that individuals with opioid dependency and a comorbid diagnosis of PTSD have poorer treatment outcomes than those without a PTSD diagnosis (Hien et al., 2009; Read, Brown & Kahler, 2004).
The following studies examine how a simultaneous diagnosis of PTSD and opioid use disorder can complicate a person’s symptomology as well as their planned treatment strategy and its effectiveness.
In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.
Smith, K.Z., Smith, P.H., Cercone, S.A., McKee, S.A., & Homish, G.G. (2016). Past year non-medical opioid use and abuse and PTSD diagnosis: Interactions with sex and associations with symptom clusters. Addictive Behavior, 58, 167-174.
Approximately 15 percent of adults in the U.S. report having used a non-medical opioid at some point in their life. Opioids were associated with the largest increase in deaths by overdose of any illicit substance between the years 1999 and 2009. Strong relationships have been observed between nonmedical opioid use and psychiatric diagnoses, especially with PTSD. This study examined the associations between PTSD and nonmedical opioid use and explored sex differences among those associations.
The National Epidemiologic Survey on Alcohol and Related Conditions collects information on alcohol and drug use disorders from a nationally representative sample of the U.S. adult, noninstitutionalized population using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV. PTSD diagnosis was a dichotomous variable (yes/no) based on DSM-IV diagnostic criteria. DSM-IV symptoms were categorized into the four symptom clusters: intrusion, avoidance, negative cognition/mood and arousal/reactivity. Nonmedical opioid use and frequency information was gathered by questionnaire.
Comparative analysis found a strong positive association between non-medical opioid use and PTSD. A diagnosis of PTSD in the previous year correlated with a two-fold increase in rates of opioid use in women and a 52 percent increase for men. PTSD was also associated with a higher frequency of use per month for both men and women. However, only women with PTSD were positively associated with a diagnosis of opioid use disorder. Women who rated high in avoidance displayed a greater likelihood of opioid use, a higher average frequency of use, and a greater probability of a diagnosis of opioid disorder. Men who scored high in arousal/reactivity experienced similar effects. These findings suggest that the relationship between nonmedical opioid use and PTSD are mediated by different factors in men and women. Women may be motivated by a desire to avoid trauma-related stimuli and reduce negative affect, while men may be looking to cope with their alterations in arousal and reactivity including irritability and aggressive or self-destructive behaviors.
Saunders, E.C., McGovern, M.P., Lambert-Harris, C., Meier, A., McLeman, B., & Xie, H. (2015). The Impact of Addiction Medications on Treatment Outcomes for Persons with Co-Occurring PTSD and Opioid Use Disorders. American Journal of Addiction, 24(8), 722-731.
There are effective treatments that exist for both opioid use disorder and PTSD. Medication assisted treatments (MAT), including methadone, buprenorphine and naltrexone, are associated with improved retention and decreased relapse rates for the treatment of opioid use disorder. A variety of psychosocial therapies are commonly used for addressing PTSD. Up to 53 percent of MAT patients also meet the criteria for a PTSD diagnosis but the effectiveness of either treatment strategy when dealing with both disorders is unclear. This study assessed the impact of an integrated behavioral therapy plus MAT for individuals with co-occurring opioid use disorders and PTSD relative to psychosocial treatments.
126 participants that met the criteria for current opioid use disorder and for PTSD were randomized into one of three treatment conditions: Integrated Cognitive Behavioral Therapy (ICBT) plus standard care, Individual Addiction Counseling (IAC) plus standard care, or standard care alone. ICBT is an eight to 12-week manual-guided individual therapy designed to address co-occurring PTSD and substance use. IAC is an eight to 12-week manual-guided individual therapy focused on substance use problems. Standard care consisted of outpatient (IOP) treatment at a state-funded addiction treatment program that provided individual and group psychotherapy, as well as the possible provision of MAT and psychotropic medications. No differences in treatment attendance was found amongst participants in each treatment condition. Each participant was assessed for drug use and symptom severity at baseline and at a six-month follow-up using the International Neuropsychiatric Interview-6, the Self-Administered Addiction Severity Index, the Timeline Follow Back, and the Clinician Administered PTSD Scale.
This study found that while self-reported opioid use severity and frequency improved regardless of treatment condition, rates of positive urine drug screens did not change significantly from baseline to the six-month follow up. MAT and individual psychosocial therapies were not more effective than standard care in reducing frequency of opioid use as measured by urine drug screening. The combination of MAT plus ICBT was, however, associated with the lowest probability of a positive urine drug test at the six-month follow-up. With respect to PTSD symptoms, symptoms decreased significantly for all patients from baseline to six-month follow-up. No main effects were found for MAT or treatment condition, however, patients who received ICBT but not MAT as part of their standard care had the greatest reductions in PTSD symptoms. It is possible that MAT impacts the effectiveness of ICBT on the treatment of PTSD, despite it being the most effective combination for addressing opioid use disorder. As an opioid agonist, MAT drugs may prevent patients from fully processing events and symptoms due to the numbing and avoidance properties provided, preventing the process of psychosocial therapy from working effectively for reduction of PTSD symptoms.
Schacht, R.L., King, V.L., Brooner, R.K., Kidorf, M.S., & Peirce, J.M. (2017). Incentivizing Attendance to Prolonged Exposure for PTSD With Opioid Use Disorder Patients: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 85(7), 689-701.
While almost all individuals with an opioid use disorder report experiencing at least one traumatic event, existing research on exposure-based therapy for PTSD rarely includes participants with comorbid opioid use disorder. Poor attendance is a consistent limitation to providing exposure-based treatments to individuals with substance use disorders. Even in nontrauma-focused treatments, completion rates for individuals with substance use disorders are low — less than 20 percent (e.g. McGover et al., 2015, Hien et al., 2009). For exposure-based treatments the average participant with substance use disorder attends no more than 50 percent of the recommended sessions before dropping out, with completion rates barely reaching 20 percent in the affected population (Brady et al., 2001; Foa et al., 2013; Mills et al., 2012; Triffleman, 2000). Because of this, some have concluded that exposure-based therapies for PTSD are ineffective for those with substance use disorders. This study seeks to evaluate the efficacy of incentivizing treatment through contingent monetary rewards and to observe the effects of Prolonged Exposure (PE) therapy on PTSD symptoms and opioid use disorder treatment outcomes of substance use and retention.
58 participants with a current diagnosis of PTSD, an on-going methadone treatment plan, and no other medical or mental diagnoses were randomly assigned to one of two conditions: the nonincentive group and the incentive group. Participants in both groups would receive $80 for a four-hour baseline assessment and $40 each for three follow-up assessments. Assessments were gathered at baseline, at mid-treatment in week six, at the end of treatment in week 12, and three months post treatment in week 24 with the Traumatic Life Events Questionnaire, the Modified PTSD Symptom Scale–Revised, the Credibility/Expectancy Questionnaire, the Working Alliance Inventory Client Form, the adapted Barriers to Treatment Participation Scale, the Symptom Checklist-90-Revised, the Difficulties in Emotion Regulation Scale, and the Quality of Life Enjoyment and Satisfaction Questionnaire — Short Form. Participants in the incentive group only would receive vouchers for attending scheduled PE appointments. Vouchers could be exchanged for either gift cards or payment of clinic fees and varied in amount from $30 to $60 depending on the number of consecutive sessions they attended.
Results demonstrated that the incentivized participants attended far more PE sessions than did participants with no incentive. As predicted, incentivized participants showed greater improvement in PTSD symptoms. While opioid use was found to decrease in both groups, the incentivized participants maintained attendance in opioid use disorder treatment longer. Although serious adverse events like hospitalizations, suicide attempts and death were frequent, there were the same amount and types reported in both groups and were determined to be unrelated to study participation. This study confirms the effectiveness of PE therapies for PTSD and comorbid opioid use disorder and explores solutions to the confounding factor of attendance in difficult to treat populations.
Clinical implications
Even with significant experience providing treatment for PTSD, specific care and strategies may be needed for those patients also experiencing opioid use disorder. Since PTSD diagnosis is associated with greater odds of nonmedical opioid use and women with PTSD are at even greater risk for substance abuse than men, psychologists may want to screen for co-occurring substance use disorders. Additionally, the motivations for men and women to abuse opioids as a means of coping appear to be different. Women may be turning to opioids to avoid or reduce negative emotional symptoms while men may be seeking to numb or cope with heightened physiological arousal, such as increased anger, exaggerated startle response and difficulty sleeping. Determining what purpose opioid use serves in managing PTSD symptoms will inform selection of treatment strategies.
With regards to specific treatments for co-occurring PTSD and opioid use disorder, varying degrees of effectiveness have been documented. Individuals receiving medication assisted treatment for opioid use potentially experience some emotional numbing due to the agonist impact which may interfere with exposure-based therapy’s focus on fully processing traumatic emotions and events. Recognizing this potential may facilitate optimum psychotherapy strategy selection. Carefully assessing the patient’s willingness to engage in specific psychotherapy and providing supports and incentives for regular attendance is likely to increase the success of treatment.