What is the recommended treatment for military service members with post-traumatic stress disorder (PTSD) linked to substance use disorder (SUD) after discharge?

Treatment of PTSD with Co-occurring Substance Use Disorder in Discharged Military Service Members

For military veterans with PTSD and substance use disorder, integrated concurrent treatment using trauma-focused psychotherapy (specifically Prolonged Exposure, Cognitive Processing Therapy, or Eye Movement Desensitization and Reprocessing) combined with pharmacotherapy (paroxetine, sertraline, or venlafaxine) is the recommended approach, with psychotherapy prioritized over medication when both are available. 1, 2

Treatment Algorithm

First-Line Approach: Integrated Trauma-Focused Psychotherapy

• Initiate trauma-focused psychotherapy as the primary treatment modality rather than pharmacotherapy alone, using one of three strongly recommended manualized approaches: 1, 2

  • Prolonged Exposure (PE)
  • Cognitive Processing Therapy (CPT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

• Use integrated concurrent treatment protocols that address both PTSD and SUD simultaneously rather than sequential treatment, as this approach shows superior outcomes in military veterans 3, 4

• The COPE protocol (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure) demonstrated large effect sizes (d = 1.4 for PTSD symptoms) and significantly higher PTSD remission rates (OR = 5.3) compared to relapse prevention alone in veterans 3

Pharmacotherapy Augmentation

• Add paroxetine, sertraline, or venlafaxine as first-line medications when pharmacotherapy is indicated, as these are the only medications specifically recommended by VA/DoD guidelines for PTSD treatment in veterans 1, 2, 5

• These SSRIs/SNRIs have demonstrated efficacy in reducing PTSD symptoms and improving quality of life in the veteran population 2

• Lower PTSD symptom severity at treatment completion correlates with reduced substance use at follow-up, supporting the self-medication model and importance of aggressive PTSD treatment 6

Critical Contraindications

• Absolutely avoid benzodiazepines for PTSD treatment despite their common use in acute alcohol withdrawal management 1, 2

• Do not recommend cannabis or cannabis-derived products for PTSD treatment in this population 1, 2

Treatment Format and Delivery

Intensive Outpatient Programs

• Two-week intensive outpatient programs with concurrent PTSD/SUD treatment show high completion rates and significant symptom reduction in post-9/11 veterans, with benefits maintained at 3-month follow-up 6

• Typical attendance averages 8 out of 12 sessions with no difference in retention between integrated trauma-focused treatment and standard relapse prevention 3

Telehealth Options

• Utilize secure video teleconferencing to deliver recommended psychotherapy when validated for telehealth use or when in-person options are unavailable 1, 2

Substance Use Management During PTSD Treatment

Alcohol Use Disorder Specifics

• For veterans requiring medical detoxification from alcohol, use symptom-triggered benzodiazepine protocols with CIWA-Ar monitoring during the acute withdrawal phase only 5

• Initiate acamprosate (666mg three times daily) once withdrawal symptoms resolve to maintain abstinence, as this shows the strongest evidence for maintaining alcohol abstinence 5

• Begin trauma-focused psychotherapy once medically stable, not waiting for extended sobriety periods 5

Addressing Trauma-Related Nightmares

• Consider Imagery Rehearsal Therapy (IRT) or Exposure, Relaxation, and Rescripting Therapy (ERRT) specifically for trauma-related nightmares that commonly co-occur with substance use 5

Evidence Supporting Integrated Treatment

Veteran Preferences and Perceptions

• 94.3% of veterans with co-occurring PTSD and SUD perceive a direct relationship between their conditions 4

• 85.3% report PTSD symptom exacerbation leads to increased substance use, while 61.8% report PTSD improvement leads to decreased substance use 4

• Approximately 66% of veterans prefer integrated treatment approaches over sequential treatment 4

Mechanism of Action

• Modification of dysfunctional trauma-related cognitions during CPT-based treatment accounts for significant variance in reduction of both PTSD and depressive symptoms in veterans with co-occurring SUD 7

• This cognitive mechanism appears to function similarly in dual-diagnosis populations as in PTSD-only populations 7

Common Pitfalls to Avoid

Sequential Treatment Trap

• Do not delay PTSD treatment until substance use is fully controlled, as historical sequential approaches show inferior outcomes compared to integrated concurrent treatment 8, 4

• The outdated concern that trauma-focused therapy will worsen substance use is not supported by evidence; both conditions improve with integrated treatment 3

Medication Mismanagement

• Avoid prescribing benzodiazepines for ongoing PTSD management despite their use in acute alcohol withdrawal, as they are contraindicated for PTSD treatment and carry addiction risk 1, 2

• Do not substitute cannabis products for evidence-based pharmacotherapy despite veteran interest, as these are explicitly not recommended 1, 2

Treatment Intensity

• Standard once-weekly outpatient therapy may be insufficient; consider intensive outpatient formats (multiple sessions per week over 2-6 weeks) for this high-acuity population 6, 7

Monitoring and Follow-up

• PTSD symptom severity at treatment completion predicts subsequent substance use, making aggressive PTSD symptom reduction a priority for preventing relapse 6

• Both PTSD symptoms and substance use should show improvement during concurrent treatment; lack of improvement in either domain warrants treatment modification 3

• At 6-month follow-up, integrated trauma-focused treatment shows sustained benefits including fewer drinks per drinking day compared to SUD-focused treatment alone 3