Contrary to past concerns, using prolonged exposure therapy to treat patients with post-traumatic stress disorder (PTSD) and comorbid alcohol dependence does not increase drinking or cravings, Penn Medicine psychiatrists report in the August 7 issue of JAMA, a theme issue on violence/human rights. In a first-of-its-kind single-blind, randomized clinical trial, researchers also found that PTSD patients treated with naltrexone for alcohol dependence drank less—and that the use of prolonged exposure therapy and naltrexone better protects PTSD patients from relapse after treatment stops.
"PTSD and alcohol dependence often go hand and hand, but evidence of effectively treating this group in tandem has been missing because many feared prolonged exposure therapy would derail alcohol treatments," said Edna B. Foa, PhD, a professor of Clinical Psychology in the department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania, and developer of prolonged exposure therapy, the type of therapy where patients face the distressing memories, situations, places, and people they have been avoiding. "It appears this is not the case, given these promising results. In fact, patients who received prolonged exposure therapy with or without naltrexone retained their low drinking level more than those who did not receive this therapy.
"This is a critical study that has implications for the hundreds of thousands of people suffering from both disorders."
Prolonged exposure therapy is thought to reduce drinking via improvement of PTSD symptoms that can lead to self-medication with alcohol. Today, 65 percent of patients with PTSD are also battling substance abuse.
For the eight-year study (2001 to 2009), 165 patients with PTSD and alcohol dependence were divided into four groups: prolonged exposure therapy plus naltrexone; prolonged exposure therapy plus placebo pill; supportive counseling plus naltrexone; and supportive counseling plus placebo. Prolonged exposure therapy was composed of 12-weekly 90-minute sessions followed by six bi-weekly sessions. (All patients received supportive counseling).
All patients in the trial had a lower percentage of drinking days and a reduction in cravings during treatment. However, those treated with naltrexone had a lower percentage of drinking days compared to those on a placebo.
In post treatment (a six-month follow up), PTSD patients with an alcohol dependence treated with prolonged exposure therapy and naltrexone had a lower rate of relapse (5.4 percent) compared to those on a placebo (13.3 percent) and received supportive counseling.
"This finding suggests that receiving prolonged exposure therapy plus naltrexone protects patients with alcohol dependence and PTSD from relapse in drinking after treatment discontinuation," the authors write.
All patients in the trial also had a reduction in PTSD symptoms, but the main effect of prolonged exposure therapy at post treatment was not significant.
This is inconsistent with a large body of evidence that prolonged exposure therapy is an effective treatment for PTSD. Such results may be explained by the fact that all patients received supportive counseling—perhaps the nonspecific factors involve in this type masked some of the unique effects of prolonged exposure therapy. Or, they posit, it may have something to do with the fact that attendance to prolonged exposure therapy session by trial participants was very low compared to other trials.
"Importantly, our findings indicated that prolonged exposure therapy was not associated with increased drinking or alcohol craving," they write. "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."
This is the first clinical trial to investigate the effects of an evidence-based medication (naltrexone) and an evidence-based therapy (prolonged exposure therapy) on PTSD patients with comorbid dependence on alcohol.
More information: JAMA. 2013;310(5):488-495