Review of: Lake EP et al, Am J Addict 2019;28(2):86–91

For many years, the mainstay of treatment for PTSD has been the SSRI class of medications, but many of our patients still suffer crippling symptoms despite optimal antidepressant medication dosing. PTSD is often accompanied by opioid misuse, sometimes in an effort to self-treat the hyperarousal and hypervigilance related to PTSD. So, can treatments like buprenorphine/naloxone that target opioid receptors also have an effect on PTSD symptoms?

This retrospective study looked at three groups of patients with PTSD treated at VA medical centers over a six-year period—those receiving SSRIs, buprenorphine/naloxone, and full-agonist opioids. Patients could only have been receiving one of these medications during the study period. A total of 2,015 patients were identified, out of which 55 patients were selected for each group after applying the inclusion criteria and then using a random number generator. The subjects were mostly white (76.4%) and male (88.5%), with an average age of 43. PTSD symptoms were assessed using either the PTSD Checklist for Clinicians (PCL-C) or the VA Primary Care PTSD Screen (PC-PTSD)—the PCL-C scores were converted to the PC-PTSD scale for the analysis. This new standardized score was a 4-point scale, with 1 being minimal and 4 being maximal symptoms. A score of 3+ is considered a “positive” screening for PTSD. The primary outcome was the most recent standardized PTSD rating scale score, with a secondary outcome of change in score from initial to most recent assessment.

The buprenorphine group had the best final standardized PTSD score, significantly lower than the SSRI group (2.473 vs 3.164, p = 0.048). There was no significant difference between the final scores of the SSRI vs full-agonist opioid groups or between the buprenorphine vs full-agonist opioid groups. For the change from initial to final standardized PTSD score, the buprenorphine group also did the best, with significantly greater change in scores compared to the SSRI group (p = 0.026), and again no differences were found in the other two group comparisons.

CATR’s Take
The results are interesting but should be taken with a grain of salt. This study was set up as a retrospective chart review, not a prospective efficacy study. The time intervals for rating scale assessments weren’t standardized, there was no standard length of treatment, and the study did not control for confounding factors such as age, comorbid conditions, or concurrent psychotherapy. At most, this gives us more confidence in using buprenorphine/naloxone when treating comorbid PTSD and opioid use disorder, but randomized controlled trials are needed to establish efficacy.