Do Not Disseminate Without Permission from the Author Dropout in Treatments for PTSD and Comorbid SUD ALEXANDER C. KLINE, PH.D. VA SAN DIEGO HEALTHCARE SYSTEM
Local thank you’s • Track directors Tamara Wall, Ph.D. and Scott Matthews, M.D. • Mentor Sonya Norman, Ph.D. and her lab
Treatments for PTSD+SUD • Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently co-occur (Pietrzak et al., 2011) • Increased severity, greater risk of many negative correlates (Norman et al., 2018) • PTSD treatments are effective for patients with comorbid substance use (e.g., Roberts et al., 2015) • Trauma-focused treatments regarded as first-line interventions (Hamblen et al., 2019) • There is an increasing push to provide first-line treatments for patients with PTSD and comorbid SUD (VA/DoD, 2017) • But patient retention remains a significant challenge
Impact of dropout • Dropout is problematic for number of reasons • 1. Limits effectiveness • Dropout generally a bad clinical outcome • Sufficient treatment “dose” necessary for optimal outcomes (e.g., Holmes et al., 2019) • 2. Limits reach (Becker et al., 2004; Cook et al., 2014; Osei-Bonsu et al., 2017) • Concerns regarding substance use, symptom exacerbation, and increased dropout risk have limited their implementation • Particularly relevant to exposure-based / trauma-focused therapies
Dropout research in PTSD+SUD Tx • Dropout not unique to PTSD+SUD • But often higher in these trials (Roberts et al., 2015) relative to PTSD alone (Lewis et al., 2020) and other disorders (Swift et al., 2014) • In PTSD treatment, substance use has been linked to attendance (e.g., Bedard-Gilligan et al., 2018) • Limited understanding of precise facets of use that may be linked to dropout • Chronicity? Severity? Craving? Frequency? Co-occurrence with other substances? • What should providers target? Difficult to identify patients at high risk for dropout • Patients with comorbid SUD have typically been excluded from PTSD clinical trials (Leeman et al., 2017)
Study rationale and aims • Current study used data from a recent randomized clinical trial of an integrated exposure therapy vs. integrated coping skills therapy for treatment of Veterans with comorbid PTSD+AUD (Norman et al., 2019) • Questions: • Can we identify specific SUD-related patient characteristics associated with attendance? • Are these characteristics associated with attendance differentially by treatment condition?
Current study: Method • 119 Veterans with comorbid PTSD+AUD • Average age = 41.61, SD = 12.59 • Mostly male (89.9%) • Varying index traumas, with ~60% combat-related • Integrated exposure therapy (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [ COPE ]; Back et al., 2015 ) • Integrated coping skills therapy (Seeking Safety [ SS ]; Najavits, 2002 ) • Randomized to receive 12 sessions of COPE or SS • Provided opportunity to extend up to 16 sessions • In main trial, greater reductions in PTSD symptoms in COPE compared to SS ( d = 0.41)
Current study: Method • Patients completed baseline measures: • CAPS-5 (Weathers et al., 2013) • SCID-IV-TR (First et al., 2002) • Penn Alcohol Craving Scale (PACS; Flannery et al., 1999 ) • Timeline Follow-Back (TLFB; Sobell et al., 1992 ) • SUD predictors of interest: • AUD duration (SCID) • AUD severity (SCID) • % of heavy drinking days in 90 days prior to treatment (TLFB) • % of drug use days in 90 days prior to treatment (TLFB) • % of abstinence days in 90 days prior to treatment (TLFB) • Craving (PACS)
Current study: Data analysis • Covariate checks: • Predictors of attendance from prior PTSD+SUD trials • PTSD severity, age, education, trauma type (Belleau et al., 2017; Szafranski et al., 2017; Zandberg et al., 2016) • Living arrangements (i.e., controlled environment) • Regression models with sessions attended as DV • Treatment condition in all models • Treatment interaction term entered at step 2 • Sensitivity analyses: • Excluded early responders from analyses • Recoded treatment “extenders” (i.e., attendance of 13+ sessions) as attending 12 sessions (i.e., completing treatment)
Results • Veterans attended an average of 9.13 ( SD = 4.76) sessions • Higher session attendance in SS compared to COPE, d = 0.79 • More veterans elected to extend treatment past 12 sessions in SS (44.6%) compared to COPE (20.6%), p = .009 • Covariate checks all unrelated to attendance • Trauma type • Age • Education • PTSD severity • Living arrangements
Results • Across both treatments, two baseline SUD characteristics associated with fewer attended sessions in the trial • Higher % of heavy drinking days, β = -.23, p = .011 • SCID AUD severity, , β = -.21, p = .019 • AUD duration ( p = .56), % days abstinence ( p = .57), % drug use days ( p = .83) unrelated to attendance • Treatment condition moderated relationship between craving and attendance, β = .17, p = .057 • Higher craving predicted less attendance in SS, β = -.31, p = .02 • No relationship in COPE, β = .14, p = .28 • Sensitivity analyses accounting for early treatment completers and extension past treatment completion yielded equivalent findings
Discussion • Significant differences in attendance between the two treatments, but do not appear to be explained by substance use • Several facets of baseline substance use (heavy drinking, SCID severity) were modestly associated with attendance • These relationships were not exclusive to exposure (COPE) • Greater craving associated with worse attendance in coping skills therapy (SS), but not exposure therapy (COPE) • Notable what was NOT linked to attendance: • Abstinence • Living arrangements • Drug use • AUD duration
Discussion • Limitations: • Generalizability given predominantly male veteran sample • Despite randomization, higher baseline craving in SS compared to COPE ( d = 0.45) • SS often delivered in group format or 60-min sessions, rather than 90-min individual sessions • Future steps: • Are there within-treatment signals tied to dropout? • Investigating the how and why of dropout • Are changes in session by session variables (e.g., PCL, PHQ, substance use) during treatment as predictors of dropout?
Discussion • Clinical targets for providers • Discussions with patients on how alcohol use may impact motivation or ability to attend therapy • Findings reinforce recommendations that SUD should not impede patients with PTSD+SUD from getting first-line interventions • Patients with baseline substance use likely to benefit from first- line PTSD treatments • Significant reductions in PTSD symptoms and substance use, and do not show high rates of relapse or symptom exacerbation (Hien et al., 2010; Norman et al., 2019; Roberts et al., 2015; Tripp et al., 2020; Tripp et al., in press) • SUD not a contraindication • Abstinence should not be required before beginning PTSD treatment
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