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Substance Abuse and Trauma: Prevention and Treatment
Prepared by the Substance Abuse and Mental Health Services Administration
(SAMHSA) Disaster Technical Assistance Center (DTAC), ESI, under contract
with the Emergency Mental Health and Traumatic Stress Services Branch, Center
for Mental Health Services, SAMHSA.
Peer-Reviewed Journal Articles
Back, S.E., Dansky, B.S., Carroll, K.M., Foa, E.B., and Brady, K.T.
(2001). Exposure therapy in the treatment of PTSD among cocaine-dependent
individuals: Description of procedures. Journal of Substance Abuse Treatment.
21(1):35-45.
The authors describe a psychotherapy treatment, the Concurrent Treatment
of PTSD and Cocaine Dependence, for cocaine-dependent individuals with posttraumatic
stress disorder diagnoses. In vivo and imaginal exposure therapy techniques
are discussed.
Bollerud, K. (1990). A model for the treatment of trauma-related
syndromes among chemically dependent inpatient women. Journal of Substance
Abuse Treatment. 7(2):83-7.
This paper discusses an education and preliminary treatment program
for chemically dependent women who are survivors of physical and sexual violence.
Boxer, P.A. and Wild, D. (1993). Psychological distress and alcohol
use among firefighters. Scandinavian Journal of Work, Environment and Health.
19(2): 121-5.
This study investigates stressors experienced by firefighters. The
toll of significant psychological distress leads to a higher probability of
alcohol abuse.
Brady, K.T. (2001). Comorbid posttraumatic stress disorder and substance
use disorders. Psychiatric Annals. 31(5):313-319.
The literature review surveys the theoretical issues, clinical studies,
new developments, and outcomes of treatment for comorbid posttraumatic stress
disorder and substance abuse disorders.
Brady, K.T., Dansky, B.S., Back, S.E., Foa, E.B., and Carroll, K.M.
(2001). Exposure therapy in the treatment of PTSD among cocaine-dependent
individuals: Preliminary findings. Journal of Substance Abuse Treatment. 21(1):47-54.
The article discusses the preliminary findings of a psychotherapy
study to treat coexisting posttraumatic stress disorder (PTSD) and cocaine
dependence. Results indicate that exposure psychotherapy may be used safely
and effectively for individuals with concurrent PTSD and cocaine dependence.
Brady, K.T., Killeen, T.K., Brewerton, T., and Lucerini, S. (2000).
Comorbidity of psychiatric disorders and posttraumatic stress disorder. Journal
of Clinical Psychiatry. 61 Suppl (7):22-32.
Posttraumatic stress disorder (PTSD) often coexists with major depressive
disorder, perhaps the result of the under-diagnosis of PTSD when trauma histories
are unknown. In addition, trauma victims may self-medicate PTSD symptoms,
leading to substance abuse disorders.
Bremner, J.D., Innis, R.B., Southwick, S.M., Staib, L., Zoghbi, S.,
and Charney, D.S. (2000). Decreased benzodiazepine receptor binding in prefrontal
cortex in combat-related posttraumatic stress disorder. American Journal of
Psychiatry. 157(7):1120-1126.
This study examines the central benzodiazepine receptor binding in
patients with posttraumatic stress disorder to determine if humans, like animals,
exhibit a decrease in frontal cortex activity when exposed to stress. The
results reveal lower distribution volumes.
Breslau, N., Davis, G.C., and Schultz, L.R. (2003). Posttraumatic
stress disorder and the incidence of nicotine, alcohol, and other drug disorders
in persons who have experienced trauma. Archives of General Psychiatry. 60(3):289-94.
This study examines the relationship of exposure to trauma and an
increased risk for nicotine, alcohol, or drug use, independent of posttraumatic
stress disorder (PTSD). The researchers found that exposure to trauma neither
increased nor decreased the risk for chemical abuse, however, PTSD may be
a risk factor.
Brown, P.J., Stout, R.L., and Gannon-Rowley, J. (1998). Substance
use disorder-PTSD comorbidity. Patients' perceptions of symptom interplay
and treatment issues. Journal of Substance Abuse Treatment. 15(5):445-8.
Forty-two patients with posttraumatic stress disorder and substance
use disorder are interviewed regarding the coexistence of the disorders and
the most effective treatments. The paper includes discussions about treatments,
treatment deterrents, and referral criteria.
Brown, P.J. and Stout, R.L. (1996). Posttraumatic stress disorder
and substance abuse relapse among women: A pilot study. Psychology of Addictive
Behaviors. 10(2):124-28.
This study compares substance-dependent women with and without posttraumatic
stress disorder (PTSD) concerning their substance abuse after inpatient treatment.
The study found that although the rate of relapse did not significantly differ
between the two groups, women with PTSD relapsed more quickly than those without
it.
Brown, P.J., Recupero, P.R., and Stout, R. (1995). PTSD substance
abuse comorbidity and treatment utilization. Addictive Behaviors. 20(2):251-4.
In this study, approximately 25 percent of patients admitted for
detoxification at a private hospital were found to have significant posttraumatic
stress disorder symptomatology.
Brown, P.J. and Wolfe, J. (1994). Substance abuse and post-traumatic
stress disorder comorbidity. Drug and Alcohol Dependence. 35(1):51-9.
This is a literature review examining those with substance abuse
issues with and without posttraumatic stress disorder (PTSD), identifying
areas lacking in research regarding the impact of PTSD on substance abuse
treatment.
Brown, V.B., Melchior, L.A., Reback, C., and Huba, G.J. (1994). Psychological
functioning and substance abuse before and after the 1992 Los Angeles riot
in a community sample of women. Journal of Psychoactive Drugs. 26(4):431-7.
This paper assesses a community study, before and after the 1992
Los Angeles riots, reporting a lack of social supports, an environment of
high distress, and a shortage of social support from counselors following
the riots.
Cardenas, J., Williams, K., Wilson, J.P., Fanouraki, G., and Singh
A. (2003). PTSD, major depressive symptoms, and substance abuse following
September 11, 2001, in a midwestern university population. International Journal
of Emergency Mental Health. 5(1):15-28.
This report on Cleveland State University assesses the prevalence
of posttraumatic stress disorder (PTSD), major depressive disorder, and substance
abuse on the Cleveland State University campus following September 11. Several
characteristics increase the risk for PTSD, including relationship to active
duty personnel, gender, level of education, and prior history of mental health
problems.
Chilcoat, H.D., and Breslau, N. (1998). Posttraumatic stress disorder
and drug disorders. Archives of General Psychiatry. 55:913-917.
This study investigates the causal relationships between posttraumatic
stress disorder (PTSD), exposure to trauma, and drug use. Findings indicate
that drugs may be used to self-medicate PTSD symptoms.
Coffey, S.F., Saladin, M.E., Drobes, D.J., Brady, K.T., Dansky, B.S.,
and Kilpatrick, D.G. (2002). Trauma and substance cue reactivity in individuals
with comorbid posttraumatic stress disorder and cocaine or alcohol dependence.
Drug and Alcohol Dependence. 65(2):115-27.
Within the context of comorbid posttraumatic stress disorder and
substance-abusing dependent individuals, this study assesses the impact of
cue reactivity and indicates an increase of substance craving in response
to trauma memories.
Deren, S., Shedlin, M., Hamilton, T., and Hagan, H. (2002). Impact
of the September 11th attacks in New York City on drug users: A preliminary
assessment. Journal of Urban Health. 79(3):409-12.
The article surveys the habit changes of drug users in New York City
following September 11. Among a wide range of responses, researchers found
that drug users perceived an increase in drug use and a greater demand for
drug treatment.
Deykin, E.Y., and Buka, S.L. (1997). Prevalence and risk factors
for posttraumatic stress disorder among chemically dependent adolescents.
American Journal of Psychiatry. 154(6):752-757.
This study of substance dependent adolescents, age 15-19, indicates
that posttraumatic stress disorder (PTSD) rates within this population are
five times higher than previously reported, and female adolescents experience
higher PTSD rates due to a greater risk of rape than their male counterparts.
Factor, S.H., Wu, Y., Monserrate, J., Edwards, V., Cuevas, Y., Del
Vecchio, S., and Vlahov, D. (2002). Drug use frequency among street-recruited
heroin and cocaine users in Harlem and the Bronx before and after September
11, 2001. Journal of Urban Health. 79(3):404-8.
This study examines drug use frequency among Harlem and Bronx drug
users before and after September 11, reporting that drug use neither increased
nor decreased.
Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M.,
Gold, J., and Vlahov, D. (2002). Psychological sequelae of the September 11
terrorist attacks in New York City. New England Journal of Medicine. 346(13):982-987.
This study employed random-digit dialing of adults living near the
World Trade Center attacks to assess the prevalence of posttraumatic stress
disorder (PTSD) and depression in the population. Predictors and measures
of severity of PTSD primarily are exposure to the attacks and loss of a loved
one.
Jacobson, L.K., Southwick, S.M., and Kosten, T.R. (2001). Substance
use disorders in patients with posttraumatic stress disorder: a review of
the literature. American Journal of Psychiatry. 158(8):1184-1190.
This is a literature review of studies regarding the epidemiology,
clinical methods, and functional pathways of comorbid posttraumatic stress
disorder and substance abuse. Results indicate the importance of the development
of programs specifically for comorbid patients, and highlights clinical neurobiological
research.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., and Nelson, C.B.
(1995). Posttraumatic stress disorder in the National Comorbidity Survey.
Archives of General Psychiatry. 52:1048-1060.
The National Comorbidity Survey results indicate that posttraumatic
stress disorder (PTSD) is more prevalent and persistent within the national
population, and the survey supports more research to determine age of onset,
severity, and probability of PTSD for different types of trauma.
Kilpatrick, D.G., Ruggiero, K.J., Acierno, R., Saunders, B.E., Resnick,
H.S., and Best, C.L. (2003). Violence and risk of PTSD, major depression,
substance abuse/dependence, and comorbidity: Results from the national survey
of adolescents. Journal of Consulting and Clinical Psychology. 71(4):692-700.
A national household telephone survey of adolescents collected data
concerning the prevalence, coexistence, and risk-factor data for posttraumatic
stress disorder, depression, and substance abuse/dependence. The results indicate
that the risk for all of these increased with exposure to interpersonal violence.
Kozaric-Kovacic, D., Ljubin, T., and Grappe, M. (2000). Comorbidity
of posttraumatic stress disorder and alcohol dependence in displaced persons.
Croatian Medical Journal. 41(2):173-8.
A group of 368 displaced men and women were interviewed using DSM-III-R
criteria, Watson’s PTSD Questionnaire, and the CAGE Questionnaire. Research
indicates that the number of war traumas witnessed affected the presence and
severity of posttraumatic stress disorder.
Machell, D.F. (1993). Combat post-traumatic stress disorder, alcoholism,
and the police officer. Journal of Alcohol and Drug Education. 38(2):23-32.
The author discusses the psychological profile of the police officer
with alcoholism and suffering from posttraumatic stress disorder. Symptoms
and treatments are included, and the suppression of feelings through alcohol
abuse is analyzed.
Maes, M., Delmeire, L., Mylle, J., and Altamuara, C. (2001). Risk
and preventive factors of post-traumatic stress disorder (PTSD): Alcohol consumption
and intoxication prior to a traumatic event diminishes the relative risk to
develop PTSD in response to that trauma. Journal of Affective Disorders. 63(1-3):
113-121.
Utilizing the Composite International Diagnostic Interview (CIDI),
researchers studied 127 victims who had been trapped in a ballroom fire to
study risk factors and preventive strategies for posttraumatic stress disorder
(PTSD). Results suggest that PTSD can be prevented by the effects of peri-traumatic
factors, such as a sense of control or alcohol intoxication.
McFarlane, A.C. (1998). Epidemiological evidence about the relationship
between PTSD and alcohol abuse: The nature of the association. Addictive Behaviors.
23(6):813-25.
Employing the Bradford Hill criteria, this study assesses the relationship
between posttraumatic stress disorder and alcohol abuse. Results suggest a
causal relationship emphasizing the importance of public health involvement.
McKearn, J. (1988). Post-traumatic stress disorder: Implications
for the treatment of family members of alcoholics. Alcoholism Treatment Quarterly.
5(1-2):141-44.
This is a personal narrative regarding the author’s experiences as
a family member of an alcoholic. The author discusses the effect of posttraumatic
stress disorder on alcoholism treatments.
Najavits, L.M. Description of a new psychotherapy, “Seeking Safety,”
for PTSD and substance abuse. In Ouimette, P., Brown, P. (Eds.), Posttraumatic
Stress Disorder and Substance Use Disorder. In press.
This chapter gives an in-depth description of the Seeking Safety
program, including its development, treatment strategies, a review of research,
and future direction. This cognitive-behavioral therapy has become the building
block in research for the treatment of comorbidity in posttraumatic stress
disorder and substance abuse.
North, C.S., Tivis, L., McMillen, J.C., Pfefferbaum, B., Spitznagel,
E.L., Cox, J., Nixon, S., Bunch, K.P., and Smith, E.M. (2002). Psychiatric
disorders in rescue workers after the Oklahoma City bombing. American Journal
of Psychiatry. 159(5):857-9.
This is a study of psychiatric disorders in both volunteer fire personnel
and primary victims of the Oklahoma City bombing. Results indicate that posttraumatic
stress disorder was more common among the victims, and that high rates of
alcohol abuse were prevalent among the fire personnel before the disaster
and remain unchanged through the trauma and its aftermath. The researchers
suggest that the resiliency seen in firefighters may be related to their training,
preparedness, and post-disaster mental health interventions.
Op Den Velde, W., Aarts, P.G., Falger, P.R., Hovens, J.E., Van Duijn,
H., De Groen, J.H., and Van Duijn, M.A. (2002). Alcohol use, cigarette consumption
and chronic post-traumatic stress disorder. Alcohol and Alcoholism. 37(4):355-61.
A study of 147 male veterans of the Nazi occupation resistance in
Holland during World War II determined no correlation between alcohol consumption
and posttraumatic stress disorder. The authors hypothesize that substance
abuse in trauma survivors is associated with peri-traumatic patterns of coping.
Ouimette, P.C., Moos, R.H., and Finney, J.W. (2003). PTSD treatment
and 5-year remission among patients with substance use and posttraumatic stress
disorders. Journal of Consulting and Clinical Psychology. 71(2):410-4.
This study evaluated 100 male substance abuse and posttraumatic stress
disorder (SUD-PTSD) patients who attended SUD treatment with one, two, and
five-year follow-ups. Results suggest that those patients who attended treatment
for a longer duration in year one were more likely to be re-admitted into
a treatment program in year five. The researchers advise treating the comorbid
disorders simultaneously.
Ouimette, P.C., Moos, R.H., and Finney, J.W. (2000). Two-year mental
health service use and course of remission in patients with substance use
and posttraumatic stress disorders. Journal of Studies on Alcohol. 61(2):
247-53.
This study assesses the association between outpatient posttraumatic
stress disorder (PTSD) treatment and the long-term treatment of comorbid PTSD
and substance abuse patients. The findings indicate that patients who attend
more outpatient sessions with self-help group participation are more likely
to sustain remission.
Pfefferbaum, B., Vinekar, S.S., Trautman, R.P., Lensgraf, S.J., Reddy,
C., Patel, N., and Ford, A.L. (2002). The effect of loss and trauma on substance
use behavior in individuals seeking support services after the 1995 Oklahoma
City bombing. Annals of Clinical Psychiatry. 14(2):89-95.
The authors studied the effects of trauma exposure on alcohol and
substance abuse behaviors following the 1995 Oklahoma City bombing. This study
indicated that no causal relationship was found; however, a relationship exists
between posttraumatic stress and increased substance abuse behaviors in disaster
victims.
Polles, A.G. and Smith, P.O. (1995). Treatment of coexisting substance
dependence and posttraumatic stress disorder. Psychiatric Services. 46(7):
729-30.
The authors detail the clinical treatment of a physician who developed
posttraumatic stress disorder and an alcohol and opioid dependence after he
was shot and held hostage by a patient. The inpatient treatment combined behavioral
therapy and pharmacological methods with successful results.
Reijneveld, S.A., Crone, M.R., Verhulst, F.C., and Verloove-Vanhorick,
S.P. (2003). The effect of a severe disaster on the mental health of adolescents:
A controlled study. Lancet. 362(9385):691-6.
This study examines the effects of a major disaster on the substance
abuse of adolescents. Using data gathered from students in Volendam, Netherlands,
prior to and five months following a major café fire, findings revealed
that alcohol use increased for the adolescents affected by the fire, but marijuana
usage and cigarette smoking did not.
Saxon, A.J., Davis, T.M., Sloan, K.L., McKnight, K.M., McFall, M.E.,
and Kivlahan, D.R. (2001). Trauma, symptoms of posttraumatic stress disorder,
and associated problems among incarcerated veterans. Psychiatric Services.
52(7):959-964.
This study reports the coexistence of posttraumatic stress disorder
and substance abuse disorders in incarcerated veterans, and encourages the
development of comorbid treatment.
Steindl, S.R., Young, R.M., Creamer, M., and Crompton, D. (2003).
Hazardous alcohol use and treatment outcome in male combat veterans with posttraumatic
stress disorder. Journal of Traumatic Stress. 16(1):27-34.
This study assesses the relationship between alcohol dependence and
posttraumatic stress disorder (PTSD), specifically among combat veterans,
by monitoring PTSD symptoms before, during, and following group cognitive-behavioral
treatment. PTSD arousal symptoms separated the low-risk and hazardous drinkers
at follow-up, illustrating a comorbid relationship.
Stewart, S., Conrod, P.J., Samoluk, S.B., Pihl, R.O., and Dongier,
M. (2000). Posttraumatic stress disorder symptoms and situation-specific drinking
in women substance abusers. Alcoholism Treatment Quarterly. 18(3):31-47.
Researchers studied the relationship of posttraumatic stress disorder
(PTSD) and alcohol abuse among female substance abusers, determining that
PTSD symptoms are significantly correlated with the frequency of heavy drinking
related to negative situations.
Stewart, S., Pihl, R.O., Conrod, P.J., and Dongier, M. (1998). Functional
associations among trauma, PTSD, and substance-related disorders. Addictive
Behaviors. 23(6):797-812.
This review discusses research explaining potential functional pathways
between posttraumatic stress disorder and substance abuse. Optimal treatment
programs are discussed.
Stewart, S.H. (1996). Alcohol abuse in individuals exposed to trauma:
A critical review. Psychological Bulletin. 120(1):83-112.
This article discusses the relationship between posttraumatic stress
disorder, exposure to trauma, and alcohol abuse, as well as the popular theories
and risk factors regarding this relationship. The author applies these findings
to assessment and treatment and offers guidelines on future research.
Vlahov, D., Galea, S., Resnick, H., Ahern, J., Boscarino, J.A., Bucuvalas,
M., Gold, J., and Kilpatrick, D. (2002). Increased use of cigarettes, alcohol,
and marijuana among Manhattan, New York, residents after the September 11th
terrorist attacks. American Journal of Epidemiology. 155(11):988-96.
Following the September 11 attacks in Manhattan, a random-digit dial
telephone survey suggested a substantial increase in cigarette smoking, alcohol
consumption, and marijuana use in the five to eight weeks following the disaster.
Depression was more common among those who increased substance abuse, suggesting
that comorbid psychiatric conditions may increase substance use.
Volpicelli, J., Balaraman, G., Hahn, J., Wallace, H., and Bux, D.
(1999). The role of uncontrollable trauma in the development of PTSD and alcohol
addiction. Alcohol Research and Health. 23(4): 256-262.
Endorphin withdrawal following a traumatic event may cause emotional
distress and posttraumatic stress disorder (PTSD), leading to alcohol consumption
to numb the pain. This article discusses the resulting difficulties of PTSD
and alcoholism treatments.
Weiss, L., Fabri, A., McCoy, K., Coffin, P., Netherland, J., and
Finkelstein, R. (2002). A vulnerable population in a time of crisis: Drug
users and the attacks on the World Trade Center. Journal of Urban Health.
79(3):392-403.
This study assessed current and former heroin and cocaine users’
habits to monitor their drug use after September 11. Reductions in drug use
were as common as increases, and the study discusses how a wide variety of
factors may play a role.
Wilcox, J.A., Briones, D.F., and Suess, L. (1991). Substance abuse,
post-traumatic stress, and ethnicity. Journal of Psychoactive Drugs. 23(1):83-4.
This article reports the prevalence of substance abuse within the
population of combat veterans with posttraumatic stress disorder, with regard
to ethnicity and age. The study indicated that length of exposure, age, and
ethnicity of the individual do not affect the rate of substance abuse within
this population.
Zweben, J.E., Clark, H.W., and Smith, D.E. (1994). Traumatic experiences
and substance abuse: Mapping the territory. Journal of Psychoactive Drugs.
26(4):327-44.
The authors summarize the relationships between types of trauma,
addictive behaviors, and the integration of posttraumatic stress disorder
into effective treatments to determine a recovery-oriented therapy model.
The article also serves to educate mental health practitioners in treating
these disorders within the addiction treatment field.
Zywiak, W.H., Stout, R.L., Trefry, W.B., LaGrutta, J.E., Lawson,
C.C., Khan, N., Swift, R.M., and Schneider, R.J. (2003). Alcohol relapses
associated with September 11, 2001: A case report. Substance Abuse. 24(2):123-8.
This study assessed alcohol use among patients enrolled in treatment
prior to September 11, and results indicate higher usage of alcohol after
September 11. The author recommends education and outreach.
SAMHSA and Other Publications
Substance Abuse and Mental Health Services Administration (SAMHSA)
Office of Applied Studies
Overview of Findings from the 2002 National Survey on Drug Use and Health
Community Anti-Drug Coalition (CADCA)
Stress and Substance Abuse: Implications of September 11 Events
The National Center on Addiction and Substance Abuse at Columbia
University
2003 National Survey of American Attitudes on Substance Abuse VIII
The National Center on Addiction and Substance Abuse at Columbia
University
13 States, 4 Major Cities See Increased Demand for Drug and Alcohol Treatment
Since 9-11
National Center for Post-Traumatic Stress Disorder
Department of Veterans Affairs
Disasters and Substance Abuse or Dependence: Fact Sheet
National Institute on Drug Abuse
NIDA Community Drug Alert Bulletin: Stress and Substance Abuse
National Institute on Drug Abuse
Depression, PTSD, Substance Abuse Increase in Wake of September 11 Attacks
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