Exposure to war-zone stress confers significant risk for a broad range of detrimental mental health effects, in particular posttraumatic stress disorder (PTSD) and substance use disorders (SUDs). Among Veterans from the most recent conflicts, Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq, approximately 15–17% suffer from PTSD (1–4) and up to 24% demonstrate alcohol misuse (5–6). Furthermore, OEF/OIF Veterans with, as compared to without, PTSD are more than twice as likely to have an alcohol use disorder (3).
Despite the relative frequency of PTSD and comorbid SUDs, empirical evidence needed to guide treatment is sparse. Historically, the standard of care has been the sequential model in which the SUD is treated first and trauma work deferred until the patient achieves some length of sustained abstinence (e.g., 6 months). This deferment is based primarily on the concern that trauma work will lead to substance use exacerbation. Contrary to these early, largely anecdotal concerns, a burgeoning literature examining integrative models, in which both disorders are simultaneously addressed, documents significant improvement in substance use severity, PTSD symptomatology and global functioning outcomes (7–8). Compelling evidence is also provided by studies investigating the temporal course of improvement in symptoms. These studies show that patients who achieve improvement in PTSD are significantly more likely to show subsequent improvement in substance use, but the reciprocal relationship is less robust, with only minimal evidence that improvement in substance use yields improvement in PTSD (9–10). Taken together, the accumulating data highlight the critical need to address PTSD in order to optimize treatment for PTSD/SUD patients.
In response to this need, a cognitive-behavioral treatment that represents a synthesis of theory-based and empirically-validated treatments for PTSD (11) and substance use disorders (12) was designed. COPE (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure) consists of 12, individual, 90-minute sessions that integrate relapse prevention for substance use with Prolonged Exposure (PE) for PTSD. The substance use treatment component is designed to help patients identify triggers (e.g., environmental, emotional) and high-risk situations for substance use, and effectively manage cravings through a variety of techniques (e.g., stimulus control, decision delay, cognitive restructuring). Patients are taught a technique called “Urge Surfing,” which encourages patients to sit with the craving, and observe the natural rise and fall of the urge to use substances. Urge Surfing is synergistic with exposure-based techniques and teaches patients that cravings, like anxiety, do not last forever and that they are capable of ‘riding out the wave’ of both anxiety and cravings. In addition, COPE teaches patients skills to manage anger, a symptom of PTSD and a frequent trigger for relapse for SUDs (6). The PTSD treatment component is designed to normalize common reactions to trauma, and reduce PTSD symptoms via in-vivo and imaginal exposure. In-vivo exposure involves having patients repeatedly confront safe, but anxiogenic situations that serve as trauma reminders and are avoided. Imaginal exposure involves having patients repeatedly revisit the memory of the traumatic event to help organize the memory, gain new perspective, decrease emotional reactivity to the memory, and enhance self competence. Based on promising preliminary findings demonstrating the feasibility, safety and efficacy of COPE among civilian samples (8, 13), we applied COPE to a U.S. Marine returning from Iraq. The following measures were used for diagnostic assessment and to monitor progress: Mini International Neuropsychiatric Interview (MINI; 14) assessed psychiatric diagnoses, Clinician Administered PTSD Scale (CAPS; 15) assessed PTSD diagnosis and symptoms, PTSD Checklist-Military (PCL-M; 16) monitored weekly PTSD severity, Beck Depression Inventory (BDI-II; 17) assessed weekly depressive symptoms, Timeline Follow-Back (TLFB; 18) monitored self-report daily use of substances, urine drug screens (UDS) assessed illicit drug use, and breathalyzer tests assessed recent alcohol use. An independent assessor conducted the MINI, CAPS and TLFB.