Review of: Norman SB et al, Efficacy 2019;76(8):791–799

Patients with co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) have worse outcomes compared to patients with either diagnosis alone. Integrated approaches, in which both diagnoses are simultaneously addressed, are viewed as best practice. Providers, however, are often hesitant to offer prolonged exposure, an evidence-based therapy for PTSD, to dually diagnosed patients for fear that directly addressing patients’ trauma might worsen their drinking. This study is the first randomized trial to compare 2 therapies targeting both disorders: integrated prolonged exposure (I-PE) vs integrated coping skills without exposure (I-CS).

In the study, 119 veterans were randomly assigned to 12–16 sessions of either I-PE or I-CS. Subjects were primarily male (n = 107), and the majority had experienced several trauma events—both related and not related to combat. Primary outcomes were assessed for both PTSD symptom severity and percentage heavy drinking days (PHDD), which were measured via the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Timeline Followback questionnaires, respectively. Data were collected prior to treatment, post-treatment, and at 3 and 6 months following treatment.

Congruent with prior studies, PTSD severity decreased in both arms over time, and there was a significantly greater reduction in the I-PE group (p = 0.002). Regarding drinking outcomes, however, both arms were almost identical (p = 0.91). Encouragingly, regardless of whether the therapy involved exposure, PHDD dropped from approximately 50% to 20% by the end of the study, and there was a corresponding increase in days abstinent as well.

CATR’s Take
Prolonged exposure is one of the best treatments we have for PTSD, and this study helps show that it should not be withheld from patients with co-occurring AUD, especially when delivered in an integrated format that can also address alcohol use.