Treatment for PTSD does not appear to increase risk of drinking among individuals with alcohol dependence and PTSD

In a trial that included patients with alcohol dependence and posttraumatic stress disorder (PTSD), treatment with the drug naltrexone resulted in a decrease in the percentage of days drinking while use of the PTSD treatment, prolonged exposure therapy, was not associated with increased drinking or alcohol craving, according to a study in the August 7 issue of JAMA, a theme issue on violence/human rights.

"Alcohol dependence and PTSD are highly comorbid [co-existing], yet little is known about how best to treat this large, highly dysfunctional, and distressed population. Even though studies of treatments for alcohol dependence do not exclude patients with PTSD, symptoms of PTSD are not targeted with these treatments," according to background information in the article. "In addition, there is a concern that prolonged exposure therapy for PTSD may exacerbate alcohol use."

Edna B. Foa, Ph.D., of the University of Pennsylvania, Philadelphia, and colleagues compared the efficacy of naltrexone, which is an evidence-based treatment for alcohol dependence, and prolonged exposure therapy, which is an evidence-based treatment for PTSD, separately and in combination, along with supportive counseling. Prolonged exposure therapy is hypothesized to reduce drinking via amelioration (improvement) of PTSD symptoms that can lead to self-medication with alcohol. The randomized trial included 165 participants with PTSD and alcohol dependence. Participant enrollment began in February 2001 and ended in June 2009. Data collection was completed in August 2010. Participants were randomly assigned to (1) prolonged exposure therapy plus naltrexone, (2) prolonged exposure therapy plus pill placebo, (3) supportive counseling plus naltrexone, or (4) supportive counseling plus pill placebo. Prolonged exposure therapy was composed of 12 weekly 90-minute sessions followed by 6 biweekly sessions. All participants received supportive counseling. Independent evaluations occurred prior to treatment (week 0), at posttreatment (week 24), and at 6 months after treatment discontinuation (week 52).

The researchers found reductions in percentage of days drinking (PDD) in all groups during treatment. At posttreatment, patients receiving naltrexone had lower PDD (average, 5.4 percent) than patients receiving placebo (average, 13.3 percent). All groups also showed reductions in alcohol craving during treatment. "A significant main effect of naltrexone emerged at posttreatment such that the 2 naltrexone groups had less alcohol craving than the 2 placebo groups."

All 4 groups showed reductions in PTSD symptoms during the treatment period, but the main effect of prolonged exposure therapy at posttreatment was not significant.

"Six months after the end of treatment, participants in all 4 groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases," the authors write.

"Importantly, our findings indicated that prolonged exposure therapy was not associated with increased drinking or alcohol craving, a concern that has been voiced by some investigators. In fact, reduction in PTSD severity and drinking was evident for all 4 treatment groups. This finding contradicts the common view that trauma-focused therapy is contraindicated for individuals with alcohol dependence and PTSD, because it may exacerbate PTSD symptoms and thereby lead to increased alcohol use."

"... our trial demonstrates that (l) patients with comorbid alcohol dependence and PTSD benefit from naltrexone treatment; (2) prolonged exposure therapy is not associated with exacerbation of alcohol dependence; and (3) combined treatment with naltrexone and prolonged exposure therapy may decrease the rate of relapse of alcohol dependence for up to 6 months after treatment discontinuation," the researchers conclude.

Editorial: Treatment of Comorbid Substance Dependence and Posttraumatic Stress Disorder

Katherine Mills, Ph.D., of the University of New South Wales, Sydney, Australia, comments on the findings of this study in an accompanying editorial.

Mills notes, "Consistent with the theory that patients with PTSD use substances to self-medicate their symptoms, patients frequently report that their PTSD symptoms are exacerbated [made worse] in the absence of substance use ... As a consequence, patients in this population group have not received the care they need."

"... the study by Foa and colleagues is a timely contribution to the literature regarding the treatment of comorbid alcohol dependence and PTSD. The study provides evidence regarding the treatment of this commonly occurring comorbidity and provides hope that the gap in treatment provision for this population may begin to narrow."