Data Grow to Guide Treatment of PTSD, Substance Abuse

Forty years after the end of the Vietnam War and more than a decade after the start of U.S. fighting in Iraq and Afghanistan, the health care system has collected more data than ever about post-traumatic stress disorder (PTSD) and substance use disorder related to PTSD. This data and how it affects treatment will be discussed in a workshop today.

Workshop 10, “Substance Abuse and PSTD: Chicken First or an Egg?” will be presented from 8 to 10 a.m. in the Waldorf Room on the third floor of the Hilton Chicago by Charles Marmar, MD, Chair of the Department of Psychiatry, New York University Langone Medical Center.

Among the points Dr. Marmar will discuss are how the rate of co-occurrence is high, how the two disorders are connected, how gender differences have been minimized in recent years, and how patients with the disorders should be treated.

“Each disorder increases the risk for the other,” Dr. Marmar said. “If you have PTSD from war or other life events, you are more likely to use alcohol and drugs, in part as way to cope with the pain of your traumatic stress. The commonest form of self-medication is self-initiating drug and alcohol use. Alcohol use is particularly problematic. It often takes the form of binge drinking or drinking excessively to fall asleep at night. There may be other forms abuse, such as sedatives or prescribed drugs.”

If a patient has both disorders, it is best to treat both disorders at the same time, he said.

“The data available say that by treating the PTSD you will reduce drinking days or risk of alcohol and drug use generally,” Dr. Marmar said. “But if somebody has both PTSD and alcohol or drug use, and you treat the alcohol and drug use alone and don’t treat the PTSD, it generally does not reduce the level of PTSD until you provide the effective treatment of PTSD.”

Much of the information on treating PTSD and substance abuse comes from the National Vietnam Veterans Readjustment Study conducted in 1985-86. A 25-year follow-up, the National Vietnam Veterans Longitudinal Study, was just completed, and researchers will be modeling the risk of early death in the cohort.

“We are now asking questions like ‘Does PTSD alone or alcohol or drug use alone increase the risk of premature death in the Vietnam generation?’ ‘Does the combination of PTSD and alcohol or drug use lead to an early death?’ We should have the ability from that study to compare veterans with and without alcohol or drug use in their health, and mortality and morbidity,” Dr. Marmar said. “We have a well-designed study with the ability to allow us to answer the questions about the long-term health risks of PTSD and alcohol or drug use when it’s a war.”

That data is being supplemented by data of veterans of the Afghanistan and Iraq fighting treated in the Veteran’s Administration system and more data from the general public. That data show fewer differences that used to be seen between men and women.

“Rates of binge drinking between males and females are similar, whereas in the general population, men historically have been larger binge drinkers than women,” Dr. Marmar said. “That is changing in culture if you look at college students; binge drinking may be equally high among female students, which is a generational change in culture.”

For treatment, the use of cognitive behavior therapy will be addressed, as well as using drugs such as sertraline and disulfiram, and newer drugs, including topiramate and naltrexone.

“We will talk about the overall general principles of treatment,” Dr. Marmar said. “You want to avoid drug dependence, and it is important to normalize sleep.”