Impact of Cannabis Use on Treatment Outcomes among Adults Receiving Cognitive-Behavioral Treatment for PTSD and Substance Use Disorders.

Background Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD). Objectives This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans. Methods From 1992–2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms. Results Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = −0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ. Conclusion Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.

Background: To test whether an integrated prolonged exposure (PE) approach could address posttraumatic stress disorder (PTSD) symptoms effectively in individuals with co-occurring substance use disorders (SUD), we compared concurrent treatment of PTSD and SUD using PE (COPE) to relapse prevention therapy (RPT) for SUD and an active monitoring control group (AMCG). Methods: We conducted a randomized 12-week trial with participants (n = 110; 64% males; 59% African Americans) who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for full or subthreshold PTSD and SUD. Participants were randomly assigned to COPE (n = 39), RPT (n = 43), or AMCG (n = 28). Results: At the end-of-treatment, COPE and RPT demonstrated greater reduction in PTSD symptom severity relative to AMCG (COPE-AMCG = -34.06, p < 0.001; RPT-AMCG = -22.58, p = 0.002). Although the difference between COPE and RPT was not significant in the complete sample, the subset of participants with full (vs. subthreshold) PTSD demonstrated significantly greater reduction of PTSD severity in COPE relative to RPT. Both treatments were superior to AMCG in reducing the days of primary substance use (COPE-AMCG = -0.97, p = 0.01; RPT-AMCG = -2.07, p < 0.001). Relative to COPE, RPT showed significantly more improvement in SUD outcome at end-of-treatment (RPT-COPE = -1.10, p = 0.047). At 3-month follow-up, COPE and RPT maintained their treatment gains and were not significantly different in PTSD severity or days of primary substance use. Conclusion: COPE and RPT reduced PTSD and SUD severity in participants with PTSD + SUD. Findings suggest that among those with full PTSD, COPE improves PTSD symptoms more than a SUD-only treatment. The use of PE for PTSD was associated with significant decreases in PTSD symptoms without worsening of substance use.

74Distress tolerance (DT; perceived or actual ability to tolerate aversive physical or emotional states) is related to both posttraumatic stress disorder (PTSD) symptoms and substance use disorders (SUD). This investigation evaluates self-report and behavioral measures of DT as potential predictors of PTSD and SUD cognitive-behavioral therapy outcomes. Participants included 41 treatment-seeking adults (53.7% women; 73.2% African American; M age = 44.90, SD = 9.68) who met at least four symptoms of DSM-5 PTSD and DSM-IV substance dependence, assessed via structured interviews. At baseline (pre-treatment), participants completed the Distress Tolerance Scale (DTS), Mirror-Tracing Persistence Task (MTPT), Breath Holding task, and Paced Auditory Serial Addition Task. The Clinician-Administered PTSD Scale for DSM-5 severity scores and percent days of primary substance use, measured via Timeline Follow-back, were used as indicators of PTSD symptoms and substance use, respectively. Covariates included treatment condition, baseline PTSD symptom severity, and baseline substance use. Lower perceived DT at baseline (DTS total score) was associated with higher PTSD symptom severity at end-of-treatment. Lower behavioral DT at baseline (MTPT duration) was associated with higher substance use at the conclusion of treatment (i.e. proportion of number of use days to total number of days between two final treatment sessions).

BackgroundWith the Canadian government legalizing cannabis in the year 2018, the potential harms to certain populations—including those with opioid use disorder—must be investigated. Cannabis is one of the most commonly used substances by patients who are engaged in medication-assisted treatment for opioid use disorder, the effects of which are largely unknown. In this study, we examine the impact of baseline and ongoing cannabis use, and whether these are impacted differentially by gender.MethodsWe conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario, Canada. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a cannabis positive urine sample in their first month of treatment, and as a function of the proportion of cannabis-positive urine samples throughout treatment.ResultsOur cohort consisted of 644 patients, 328 of which were considered baseline cannabis users and 256 considered heavy users. Patients with baseline cannabis use and heavy cannabis use were at increased risk of dropout (38.9% and 48.1%, respectively). When evaluating these trends by gender, only female baseline users and male heavy users are at increased risk of premature dropout.InterpretationBoth baseline and heavy cannabis use are predictive of decreased treatment retention, and differences do exist between genders. With cannabis being legalized in the near future, physicians should closely monitor cannabis-using patients and provide education surrounding the potential harms of using cannabis while receiving treatment for opioid use disorder.

Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data

Substance use is common among adolescents with post-traumatic stress disorder (PTSD). We aimed to develop and study an integrated treatment for adolescents with co-occurring disorders. This is a therapy development and open pilot trial study of a manualized therapy for adolescents with post-traumatic stress, depression, and substance use that uses a combination of cognitive therapy (CT) and mindfulness. Descriptive statistics and paired sample t-tests were calculated to assess for changes in PTSD symptoms, depression, and substance use frequency from baseline to end of treatment using standardized measures and validated by urine drug screens. We also examined for safety, predictors of clinical outcomes, and treatment retention. Thirty-seven adolescents participated in the study; 62% were study completers as defined by retention for at least 6weeks of treatment. There were significant improvements in PTSD and depression symptoms from baseline to end of treatment, reflecting medium effect sizes, and which was associated with changes in trauma-associated cognitions. There was a reduction in cannabis use, which was the most commonly used substance. Preliminary results suggest feasibility, safety, and potential clinical effectiveness of an integrated therapy for adolescents with PTSD, depression, and substance use. Retention was comparable to other therapy clinical trial studies of adolescents despite the high risk for poor treatment retention and poor clinical outcomes among adolescents with PTSD and co-occurring disorders. We discuss the rationale for continued research of this mindfulness-based CT for adolescents with co-occurring disorders. Adolescents with co-occurring PTSD and substance use achieved meaningful improvement in PTSD and depression symptom severity after receiving a CT and mindfulness dual diagnosis approach. An integrated manualized therapy for dual diagnosis shows promise for reducing cannabis use in adolescents with PTSD. Changes in trauma-related cognitions have the potential to improve PTSD and depression symptoms in adolescents with substance use problems.

Objective: Many women receiving substance use treatment report histories of interpersonal violence (IV) victimization, including physical and sexual assault. IV is a risk factor for mental and behavioral health difficulties such as posttraumatic stress disorder (PTSD) and substance use disorder (SUD). Consistent with the self-medication hypothesis, PTSD may explain elevated SUD among IV survivors. Yet, few studies have investigated whether PTSD may have differential mediating effects for different substances, which has significant treatment implications. Methods: In 124 women (M age = 35.37, SD = 11.90) in substance use treatment, we examined PTSD symptoms as a mediator between IV and severity of different types of substance use, including alcohol, cannabis, cocaine, and opioid use. Participants completed self-report measures including the ASSIST, PCL-5, and LEC-5. Data were analyzed using path analysis in Mplus 8.3. Both dichotomous and continuous outcomes of problematic substance use outcomes were examined. Results: Most women (53.3%) reported problematic substance use with at least one substance, including opioids (39.7%), cocaine (13.0%), alcohol (9.6%), and cannabis (5.6%). Most (83.2%) of the sample reported at least one IV incident. On average, women reported clinically significant PTSD symptom severity. When problematic substance use was examined dichotomously, findings revealed significant indirect effects from IV exposure to opioid (β = 0.10, p = .010) and cocaine use (β = 0.07, p = .039) via elevated PTSD symptoms. There were no significant indirect effects for problematic alcohol (β = 0.03, p = .260) or cannabis use (β = 0.02, p = .562). When substance use was examined continuously, results revealed significant indirect effects from IV exposure to opioid (β = 0.09, p = .017), cocaine use (β = 0.09, p = .015), and alcohol use (β = 0.08, p = .020) via elevated PTSD symptoms. Indirect effects for cannabis use remained nonsignificant (β = 0.05, p = .100). Conclusions: IV survivors may be particularly at risk for opioid and cocaine misuse because of elevated PTSD symptoms. Treatments that integrate PTSD and SUD are needed to simultaneously target traumatic stress and substance use. Women with opioid and cocaine misuse may particularly benefit from trauma-focused exposure-based psychotherapy to reduce symptoms of PTSD, and thus, decrease opioid and cocaine misuse.

Objective A history of childhood abuse and neglect (CAN) is significantly associated with psychopathologies in adulthood, including comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Difficulties in emotion regulation (ER) might influence the association between CAN and PTSD. The aim of this study was to examine the relationship between CAN and PTSD symptom severity in women with SUD and to investigate the mediating role of general difficulties in ER and its specific dimensions. Method: We examined 320 women, with a current diagnosis of at least subsyndromal PTSD and SUD, using self-report measures of CAN, PTSD symptom severity, and ER difficulties. We conducted both simple and multiple bootstrapping-enhanced mediation analysis to investigate whether general difficulties in ER and its specific dimensions mediate the relationship between CAN and PTSD symptom severity. Results: General difficulties in ER mediated the association between CAN and PTSD symptom severity. CAN significantly predicted adult PTSD symptom severity, directly and indirectly, through ER difficulties. Difficulties engaging in goal directed behavior when distressed was the only ER dimension, which mediated the effect of CAN on PTSD symptoms. Conclusions: Our results suggest that difficulties in ER and specifically difficulties engaging in goal directed behavior when distressed might constitute an influential factor in the relationship between CAN and PTSD symptom severity in a sample of SUD patients, and highlight the importance of targeting ER as a potential treatment focus for patients with comorbid PTSD and SUD.

Hurt people who hurt people: Violence amongst individuals with comorbid substance use disorder and post traumatic stress disorder

To advance understanding of the effectiveness of evidence-based treatments for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD), research must provide a more nuanced picture of how substance use affects change in PTSD symptoms over the course of treatments and whether prolonged exposure techniques can be efficacious during active substance use. A data set that included patients with PTSD/subthreshold-PTSD and SUD treated with an exposure-based intervention provided an opportunity to conduct a secondary analysis to test how patients' substance use impacted PTSD change over treatment. We applied growth models to week-to-week PTSD symptom and substance use changes during treatment and follow-up of a randomized controlled trial of two cognitive-behavioral treatments for PTSD and SUD: Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE) and Relapse Prevention Therapy (RPT). Cross-lagged analyses were used to determine whether prior week substance use impacted subsequent PTSD symptom severity. Both treatments evidenced significant reductions in PTSD symptom severity. In the context of continued substance use, results suggest that individuals still benefit from exposure-based treatment. Results provide evidence that RPT and COPE both led to significant reductions in PTSD, providing further support that exposure-based techniques tailored for SUD can be conducted without jeopardizing PTSD or SUD outcomes. Implications for clinical decision making around treatment selection are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The impact of cannabis use on evidence-based posttraumatic stress disorder (PTSD) treatment outcomes remains inconclusive. Further, few studies to date have examined these relationships in intensive PTSD treatment settings, with existing literature being similarly inconclusive. The present study assessed the role of cannabis use frequency prior to and concurrent with treatment on self-reported PTSD and depressive symptoms in two samples of veterans undergoing distinct (3-week and 2-week) Cognitive Processing Therapy-based intensive treatment programs (ITPs; N3-week = 488; N2-week = 253). Cannabis use frequency over the past 2 weeks was self-reported by veterans. PTSD and depression symptoms were assessed before, during, and following the ITP using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and Patient Health Questionnaire-9, respectively. Linear mixed-effects models were used to analyze the effect of cannabis use frequency prior to and concurrent with treatment on PTSD and depressive symptom change over time. Individuals in the 3- and 2-week ITPs reported low rates of cannabis use prior to and concurrent with treatment. Across models, frequency of cannabis use was not significantly related to PTSD symptoms over time. Findings surrounding the impact of cannabis use on depressive symptom severity were only found in the 2-week ITP and not replicated in the 3-week ITP. Infrequent and/or recreational cannabis use frequency prior to or concurrent with treatment did not meaningfully impact intensive PTSD treatment outcomes. Findings associated with concurrent use need to be interpreted with caution due to the small subsample. Future research should explore whether more frequent cannabis use and the dosage differentially impact PTSD treatment outcomes. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

The frequent co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs) leads to manifestations of both conditions that are more severe and more resistance to treatment than single disorders. One hypothesis to explain this synergy is the impact of intrusive memories on craving which, in turn, increases the risk of relapse among patients with substance use disorders. The aim of this systematic review is to examine this possibility by assessing the impact of PTSD and its symptoms on craving among dual disorder patients. Using PRISMA criteria, four databases were comprehensively searched up to June, 2021, in order to identify all candidate studies based on broad key words. Resulting studies were then selected if they examined the impact of PTSD or PTSD symptoms on craving, and if they used standardized assessments of PTSD, SUD, and craving. Twenty-seven articles matched the selection criteria and were included in this review. PTSD was found to be significantly associated with increased craving levels among patients with alcohol, cannabis, cocaine, tobacco, and other substance use disorders. Exposition to traumatic cues among dual disorder patients was also shown to trigger craving, with an additive effect on craving intensity when exposure to substance-related cues occurred. In addition, certain studies observed a correlation between PTSD symptom severity and craving intensity. Concerning mechanisms underlying these associations, some findings suggest that negative emotional states or emotion dysregulation may play a role in eliciting craving after traumatic exposure. Moreover, these studies suggest that PTSD symptoms may, independently of emotions, act as powerful cues that trigger craving. These findings argue for the need of dual disorder treatment programs that integrate PTSD-focused approaches and emotion regulation strategies, in addition to more traditional interventions for craving management.

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) commonly cooccur following trauma, and their co-occurrence is associated with substantial costs; however, our understanding of the timing and sequencing of these posttrauma mental health conditions is limited. This study examined the trajectories of PTSD symptom severity and substance use among individuals recently exposed to a traumatic event, with a focus on the potential moderating roles of PTSD and SUD diagnoses at the final assessment. Additionally, in attempt to better understand the functional relationship between PTSD symptoms and substance use posttrauma, this study compared models reflecting the theories of self-medication, susceptibility, and mutual maintenance. Participants included 137 individuals who had experienced a traumatic event within 6 months prior to study enrollment. Participants completed four assessments over an approximate 1-year period that included clinician-administered measures for DSM-5 PTSD symptoms and SUD diagnosis and self-report measures of alcohol and drug use. Change over time in PTSD symptoms and substance use by diagnostic status were investigated using growth curve models. Temporal sequencing between PTSD symptom severity and substance use was investigated with bivariate latent difference score structural equation modeling. In line with the conceptualization of PTSD as a disorder of impeded recovery, having a diagnosis of PTSD at the final assessment moderated the trajectory of PTSD symptom severity such that symptom severity declined only among those without PTSD. In contrast, the influence of SUD appeared to be negligible. Both PTSD and SUD diagnoses were associated with initial drug use frequency. However, the relationship between alcohol use and diagnostic status did not reach statistical significance. Regarding temporal relationships between PTSD symptoms and substance use, significant and negative PTSD to change in substance use cross-lagged paths were found across most of the models, while only one significant substance use to change in PTSD severity crosslagged path emerged in the PTSD intrusion with alcohol use model. These results add to a growing body of research suggesting trauma-focused intervention is viable for individuals with PTSD/SUD. Further, examination of potential mediators and moderators of the relation between PTSD and SUD is recommended as a critical focus for future research.

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) commonly cooccur following trauma, and their co-occurrence is associated with substantial costs; however, our understanding of the timing and sequencing of these posttrauma mental health conditions is limited. This study examined the trajectories of PTSD symptom severity and substance use among individuals recently exposed to a traumatic event, with a focus on the potential moderating roles of PTSD and SUD diagnoses at the final assessment. Additionally, in attempt to better understand the functional relationship between PTSD symptoms and substance use posttrauma, this study compared models reflecting the theories of self-medication, susceptibility, and mutual maintenance. Participants included 137 individuals who had experienced a traumatic event within 6 months prior to study enrollment. Participants completed four assessments over an approximate 1-year period that included clinician-administered measures for DSM-5 PTSD symptoms and SUD diagnosis and self-report measures of alcohol and drug use. Change over time in PTSD symptoms and substance use by diagnostic status were investigated using growth curve models. Temporal sequencing between PTSD symptom severity and substance use was investigated with bivariate latent difference score structural equation modeling. In line with the conceptualization of PTSD as a disorder of impeded recovery, having a diagnosis of PTSD at the final assessment moderated the trajectory of PTSD symptom severity such that symptom severity declined only among those without PTSD. In contrast, the influence of SUD appeared to be negligible. Both PTSD and SUD diagnoses were associated with initial drug use frequency. However, the relationship between alcohol use and diagnostic status did not reach statistical significance. Regarding temporal relationships between PTSD symptoms and substance use, significant and negative PTSD to change in substance use cross-lagged paths were found across most of the models, while only one significant substance use to change in PTSD severity crosslagged path emerged in the PTSD intrusion with alcohol use model. These results add to a growing body of research suggesting trauma-focused intervention is viable for individuals with PTSD/SUD. Further, examination of potential mediators and moderators of the relation between PTSD and SUD is recommended as a critical focus for future research.

PTSD symptom severity as a predictor of cue-elicited drug craving in victims of violent crime