Treatment of Substance Use Disorders in Veterans with Post Traumatic Stress Disorder (PTSD) - PowerPoint Presentation

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Treatment of Substance Use Disorders in Veterans with Post Traumatic Stress Disorder (PTSD)

John P. Allen, PhD, MPASenior ScientistVISN 6 MIRECCDurham, NC

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Outline of the Presentation

Context of the IssueWarzone StressorsSubstance Use Disorder and PTSD in Service Members and Veterans Treatment ConsiderationsVA Services for OEF/OIF VeteransMilitary Culture

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Scope of the Issue

As of April 6, 2012http://www.defenselink.mil/news/casualty.pdf

USA – War Fatalities

6407

USA - Wounded in Action

47784

Iraq (

OIF

) 4422 Iraq (OIF) 31923Iraq (OND) 66Iraq (OND) 301Afghanistan (OEF) 1919Afghanistan (OEF) 15560OVER 1.9 Million service members have been involved in the Global War on Terror (GWOT). 178,876 TBI’s and 1,621 amputations from 2000 through 2010 Q1

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Influx of OEF/OIF Veterans

1.9

million have served so far in

OEF

/

OIF

800,000 OEF/OIF

Veterans are now VA Eligible300,000 OEF/OIF Veterans have enrolledFormer Active DutyFormer Reserves/NG96% of OEF/OIF Veterans have been seen in outpatient care

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Mental Health Issues Among

OEF/OIF Veterans

Approximately half of OEF/OIF/OND Veterans receiving VA care have provisional mental health diagnoses. The most common of these are PTSD, affective disorders, neurotic disorders, nondependent abuse of drugs or alcohol, and alcohol dependence.

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Mental Health Problems in OEF/OIF Veterans

38% of Soldiers and 31% of Marines report psychological

symptoms.

Among the National Guard, the figure rises to 49%.

Psychological concerns are significantly higher

among those with repeated deployments.

Psychological concerns among family members of deployed and returning OEF/OIF/OND Veterans are also of concern.

Hundreds of thousands of children have experienced deployment of a parent.

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Warzone Stressors

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“In war, there are no unwounded soldiers.”

--Jose Narosky

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Understanding the Experience of OEF/OIF/OND

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There’s nothing normal about war. There’s nothing normal about seeing people losing their limbs, seeing your best friend die. There’s nothing normal about that, and that will never become normal…”

Lt. Col. Paul

Pasquina

, MD from the movie "Fighting For Life"

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Traumatic Events

in OEF/OIF

Service Members (1)

Multi-casualty incidents (suicide bombers, IEDs (improvised explosive devices), ambushes)

Seeing the aftermath of battle

Handling human remains

Friendly fire

Witnessing or being involved in situations of excessive violence

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Traumatic Events

in OEF/OIF/OND

Service Members (2)

Witnessing death/injury of close friend/favored leader

Witnessing death/injury of women and children

Feeling helpless to defend or counter-attack

Being unable to protect/save another service member or leader

Killing at close range

Killing civilians and avoidable casualties or deaths

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Exposure to traumatic warzone events(Hoge

et al., 2004)

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“The most complex

and dangerous

conflicts, the most harrowing operations, and the most deadly wars, occur in the head.”

(Anthony Swafford,

Jarhead

from PBS video

Operation Homecoming

)

Introduction

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Events that provoke terror, horror, or helplessness

Death or injury of others who are loved and with whom one identifies

Accumulation of stress from all sources over time

Events that contradict deeply held moral values and beliefs

Life threat

INTENSE OR PROLONGED STRESS

Wear & tear

Loss

Inner conflict

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Four Causes of Stress Injury

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PTSD Symptoms Overview

Symptoms of PTSD, present for at least one month, and are divided into three symptom clusters: Reexperiencing of the traumatic event, Avoidance

of trauma-relevant stimuli and numbing of general responsiveness, and

H

eightened

physiological arousal

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Exposure Contributes to RiskHoge

et al., 2006

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Millennium Cohort Study

Largest prospective military health study personnel ever21 year duration - began 2001150,000 participantsFollowed every

3 years thru post-discharge

35+ articles

published to date

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Millennium Cohort Findings

Dose Response RelationshipPTSD and Depression – The more trauma exposure – the more likely to develop problemsSubstance Use – Highest among younger Veterans and Reserve/National GuardSmoking

initiation and recidivism

Aggressive Driving

– Higher among deployed

Aggression and Domestic Violence

– higher in PTSD

Hypertension

– likely stress relatedEating problems in women with combat exposure19Slide20

Common Themes and Presenting Problems in OEF/OIF/OND Veterans

Marriage, relationship problems

Financial hardships

Endless questions from family and friends

Guilt, shame, anger

Feelings of isolation

Nightmares, sleeplessness

Lack of motivation

Forgetfulness AngerFeeling irritable, anxious, “on edge”

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Military Deployment and Substance Use Disorder (SUD)

Rate of alcohol behavioral problems doubles (25% vs 12%) before and after deployment (Wilk et al, 2010). (Among Reserve Component personnel there were twice as many new onsets

of heavy weekly drinking, binge drinking, and alcohol-related behavioral problems among deployed personnel than among their non-deployed peers (Jacobson et al, 2008).)

Post deployment military personnel with SUD problems are rarely referred for care (134 referrals/6669 positive alcohol screens on Post Deployment Health Reassessment (PDHRA) for active duty and 179/4787 for reserve component) (Milliken et al, 2007).

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Combat Exposure and SUD

Combat exposure is associated with increased rates of weekly heavy drinking, binge drinking, and alcohol-related problems. This is particularly true for personnel aged 24 or younger (Jacobson, et al, 2008).The threat of death or personal injury is most associated with post-deployment alcohol problems. This relationship is independent of the relationship of these threats to other mental health problems (

Wilk

et al, 2010).

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Considerations

in Treatment of Substance Use Disorder and PTSD

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Dynamics of SUD and PTSD in OEF/OIF Veterans (1)

25-50% co-occurrence of SUD and PTSDThe severity of SUD and PTSD tends to be greater and outcomes tend to be worse for both conditions in patients with both PTSD and SUD than

in

patients with only one of the

conditions

PTSD typically precedes

SUD

Exposure to trauma stimuli can trigger craving and substance use

Symptoms of the two conditions co-vary. Diminution of PTSD symptoms precedes reduction in alcohol use25Slide26

Dynamics of SUD and PTSD in OEF/OIF Veterans (2)

PTSD is a risk factor for SUD—Use of alcohol or drugs may reduce the anxiety component of PTSD and thus be

reinforced

Withdrawal from substances may exacerbate PTSD

symptoms

Prolonged

exposure

as a treatment for

PTSD doesn’t increase craving or substance abusePatients prefer that the two conditions be treated together26Slide27

Evidence Based Treatments for PTSD

Prolonged Exposure Therapy—Repeated verbalizations of the trauma experience to prompt reprocessing of the trauma. Training in coping skills, stress reduction strategies, cognitive restructuring, real world practice of skills (http://deploymentpsych.org/training/civilian-practice)

Cognitive Processing Therapy—Education about the PTSD symptoms, challenge and modify beliefs about the trauma event, self-monitoring of thoughts and feelings (

http

://

deploymentpsych.org/training/training-catalog/cognitive-processing-therapy-cpt-for-ptsd-in-veterans-and-military-personnel

)

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Effective Alcoholism Treatments (1)

Psychosocial interventions that are well supported by research evidence:Motivational Enhancement TherapyCognitive Behavior Therapy for Relapse PreventionCommunity Reinforcement ApproachBehavioral Couples TherapyTwelve Step Facilitation

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Effective Alcoholism Treatments (2)

Medications that can serve as alcohol treatment adjuncts:Disulfiram (Antabuse®)Naltrexone/Vivitrol®Acamprosate

Topiramate

(not approved for this indication by FDA. Research is very encouraging on efficacy, especially for Type 2 alcoholics.)

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Najavits’ Treatment

Seeking SafetySafety has highest priority in the treatment. Safety is “abstinence from all substances, reduction in self-destructive behavior, establishment of a network of supportive people, and self-protection from dangers associated with the disorders” (Najavitz

, 1998)

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Seeking Safety (2)

Designed for integrated treatment of PTSD and SUDTheme is to establish safety from substances, dangerous relationships, and extreme symptoms (e.g. suicidality)Can use in group or individual therapy sessionsCognitive behavioral approach to develop skills to cope with stress also includes psychoeducationPresent focus

Very popular in the Veterans Health Administration

Uses treatment manual and handouts

25 modules in 4 content areas :

Cognitive

Behavioral

Interpersonal

Case Management31Slide32

Seeking Safety (3)

Flexible—Use relevant modules and can vary orderStructured sessions for modules—check-in, quotation to emotionally engage clients, reflect on and comment on relevant handouts/practice skills, check-out asking what clients got out of session and what commitment they are willing to make.Positive, compassionate tone and positive interactions among clientsCan use with other treatmentsWebsite: www.seekingsafety.org

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Recommendations for Treatment of

SUD in Veterans with PTSD (Based on Findings of Subject Matter Expert Panel in November, 2009)Treatments for the two conditions should be coordinated and generally the treatments should be done simultaneously. There should be a single treatment plan.

The VA-DoD Clinical Practice Guidelines should be followed for each condition.

A community of practice for SUD-PTSD specialists should be created.

Patients should be regularly monitored to ensure that the treatment plan is responsive to their needs.

Family involvement can be very helpful to the treatment of both conditions.

The Clinical Recommendations of the Panel should be revisited/ revised on the basis of new research and the actual experiences of the SUD-PTSD specialists.

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Issues in Treating SUD in

OEF/OIF/OND Veterans (1)Assessment should include both conditions. Systematic screening for PTSD in SUD programs results in four times as many patients being diagnosed with comorbid PTSDEstablish solid working alliance.

Use term “warzone stress” rather than “combat stress.”

“Normalize” reactions of Veteran and emphasize self efficacy and hope.

Encourage relationships with other Veterans. Encourage involvement with Vet Centers

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Issues in Treating SUD in

OEF/OIF/OND Veterans (2)Distinguish developmentally-related aspects of substance abuse from risk of chronic dependence and effects.

Computerized aids to enhance SUD services.

Integrate services to address complexity of problems - combinations of SUD with traumatic brain injury, chronic pain, homelessness, PTSD, nicotine dependence, community/family readjustment.

Reduce concerns over confidentiality.

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Some Good Assessment Questions for OEF/OIF/OND Veterans

Why did you join the Army, Marine Corps, Navy, etc.? What did you hope to accomplish?

Combat tours – Number? When? Where? Military job? Duties in combat zone?

Satisfaction with training and deployment preparation

Satisfaction with leadership and equipment

How do family members feel about the military?

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Eligibility for VA Care

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Who is Eligible for VA Health Care Benefits?

Served in the Active military and discharged or released under conditions other than dishonorable

Former Reservists may be eligible if they served full-time and for operational or support (excludes training) purposes

Former National Guard members may be eligible if they were mobilized by a Federal order

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Minimum Duty Requirements

Persons enlisting in the Armed Forces after 9/7/80 or who entered on active duty after 10/16/81 are not eligible for VHA benefits unless they completed:

24 months continuous active service,

or

the full period for which they were called or ordered to active duty

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Excluded from the Minimum Duty Requirements

Minimum active duty requirements do not apply to persons discharged or released from active duty for:

Early out

Hardship

Disability that was incurred or aggravated in line of duty

or Veterans with compensable service-connected disability

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Combat Veteran (CV) Authority

Title 38, U.S.C., Section 1710(e)(1)(D) gave authority to provide hospital, medical and nursing home care to Combat Veterans despite insufficient medical evidence to conclude that the condition is attributable to such service.

Veterans who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998.

The National Defense Authorization Act of 2008 extended the period in which a combat-theater Veteran may enroll for VA health care and services to five years post discharge/release date. (

Please note that this includes Reserve and National Guard Personnel mobilized for Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND).)

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Combat Veteran Eligibility Definitions

Combat Zones Designated by an Executive Order from the President as areas in which the U.S. Armed Forces are engaging or have engaged in combat.

Hostilities

Defined as conflict in which the members of the Armed Forces are subjected to danger comparable to the danger to which members of the Armed Forces have been subjected in combat with enemy armed forces during a period of war.

“Hostile Fire or Imminent Danger Pay”

Hostile fire pay refers to pay to anyone exposed to hostile fire or mine explosion. Imminent danger pay is paid to anyone on duty outside the United States area who is subject to physical harm or imminent danger due to wartime conditions, terrorism, civil insurrection, or civil war.42Slide43

Criteria for Combat Veteran Eligibility

Must first meet the definition of a “Veteran” for VA health care benefits.Combat-theater Veterans who are ineligible to enroll for VA care are referred to a Vet Center for readjustment counseling services,

if appropriate, or to a community provider to obtain services at the Veteran's expense.

If a health care emergency exists for an ineligible Veteran, treatment is provided under VA’s humanitarian treatment authority.

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Beyond Mental Health Diagnosis

Many problems faced by returning combat Veterans and their families are not so much

clinical

as they are

functional

:

Work Stress/Unemployment

Educational/Training Needs

Housing NeedsFinancial and/or Legal Problems)Family IssuesLack of Social SupportEstrangementFamily BreakupKids in trouble44Slide45

Positive Aspects of Deployment

Foster maturity

Encourage independence

Strengthen family bonds

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Identifying/Treating Post Deployment Mental Health Problems Among New Combat Veterans and their Families OEF/OIF/OND Veterans often seek care outside DoD

/VA systems

It is estimated that 50% of those seen in

DoD

/VA may also receive part of their care in the community

Family members are also dealing with deployment-related stress and look for help in the communitySlide47

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Recommendations for Community Mental Health Care ProvidersKnow something about US military history and about our present military conflictsMilitary Culture as a major (yet often invisible) American subculture

Know the different Service Branches and respect the difference!

Know something about

DoD

and VA

Services, Best practices, Access, Benefits

Ask each patient if he/she has ever served in the Armed Forces or is close to someone who hasSlide48

Examples of VA

Services Relevant for OEF/OIF Veterans

PTSD Treatment Teams

SUD-PTSD Specialist

Military Sexual Trauma

Homelessness Services

Veterans Justice Outreach Program

Vet Centers

Suicide Prevention ProgramDeployment Health ClinicsOEF/OIF Coordinators48Slide49

Frequency of VHA Mental Health Screenings

At-risk drinking (annual)Post-traumatic stress disorder (every year for first five years and once every five years thereafter)Depression (annual)Suicide risk (if depression screen is positive)Military sexual trauma (once)

Traumatic brain injury (once)

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VHA Care Access Points

(As of November 3, 2010)

153 medical centers--At least one in each state, Puerto Rico and the District of Columbia

951 ambulatory care/community-based outpatient clinics

47 residential rehabilitation treatment programs

271 Veterans Centers

Suicide Prevention Hotline:

1-800-273-TALK50Slide51

Key Aspects of VHA Mental Health Care Services

Recovery OrientationEvidence-Based Practices and TreatmentsContinuum of CareIntegration of Mental Health Services with Each Other and with Physical Health Care Services

Role of Principal Mental Health Care Provider

Maximal Access to Care

Continuing Care

Measurement-Based Outcome Indicators

Automated Treatment Adjuncts

(e.g.

MyHealtheVet)51Slide52

Prevalence of SUD / PTSD Diagnoses in Veteran Patients in FY 2010

In FY2010, 5,536,526 patients were seen in VA. Around 7% of these are OEF/OIF Veterans. 465,262 Veterans (8.4 %) were diagnosed with SUD. Of these 28% also had PTSD.553,045 Veterans (10 %) were diagnosed with PTSD. Of these 23% also had SUD.Slide53

Treatment Services Offered by VA SUD Programs at VA Facilities FY08-FY10 (N=140)

Treatment Service

FY 2008 % of Facilities

FY2010

% of Facilities

% Increase

OEF/OIF-specific groups or services

39%

50%

11%

Seeking Safety

58%

71%

13%

Pharmacotherapy and psychosocial intervention for PTSD and SUD

76%

78%

2% Slide54

Availability of Evidence-Based SUD Psychotherapy Treatment within General Mental Health Clinics at VHA Facilities (N=140)

Therapy Modalities

% of Facilities

Cognitive Behavioral Therapy for Relapse Prevention

57%

12-Step Facilitation

33%

Contingency Management

14%

Seeking Safety

53%

Behavioral Couples/Family Therapy

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Public Health Model (1)

Most war fighters/Veterans will

not

develop a mental illness but all war fighters/Veterans and their families face important readjustment issues

This population-based approach is less about making diagnoses than about helping individuals and families retain a healthy balance despite the stress of deployment

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Public Health Model (2)

Incorporates the Recovery Model and other principles of the President’s New Freedom Commission on Mental Health

There is a difference between having a problem and being disabled

The public health approach requires a progressively engaging, phase-appropriate integration of services

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Public Health Model (3)

This program must:

Be driven by the needs of the Service Member/Veteran and his/her family rather than by

DoD

and VA traditions

Meet prospective users where they live rather than wait for them to find their way to the right mix of our services

Increase access and reduce stigma

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Offers

each state its own pageIncludes VA facilities and Vet Centers

Over 1500 providers nationally

Over 1200 providers in NC including 96 of 100 NC counties

A model for further populating the National Resource Directory on a state-by-state

basis

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http://www.ptsd.va.gov/professional/ptsd101/course-modules/af-am-vets.asp

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