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PTSD Treatment, Drinking Risk Among Those With Alcohol Dependence

In a trial that included patients with alcohol dependence and 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 The Journal of the American Medical Association.

“Alcohol dependence and PTSD are highly comorbid, 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, PhD, 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 six 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%) than patients receiving placebo (average, 13.3%). All groups also showed reductions in alcohol craving during treatment. “A significant main effect of naltrexone emerged at posttreatment such that the two naltrexone groups had less alcohol craving than the two placebo groups.”

All four 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 four groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases,” the authors wrote.

“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 four 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 concluded.

— Source: American Medical Association