Medical Marijuana, PTSD, and VA?

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OneNeuroDoctor

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I am seeing a number of individuals for evaluations and therapy with a PTSD diagnosis established by another provider. Since medical marijuana isn't approved in my state, some are driving to an adjoining state to get physician prescribed medical marijuana. Some are veterans and others are individuals with a childhood and adult victims of abuse history.

Recently, I did an evaluation for a veteran who indicated his physician is prescribing medical marijuana for PTSD. I questioned him about this as part of the evaluation and he did not provide additional information, so it was unclear if this was actually truthful information.

Does anyone else working with PTSD have any knowledge of medical marijuana treatment for PTSD? It seems many claiming to have PTSD read out what appears to be a "shopping list" memorized out of the DSM of PTSD symptoms. My knowledge from training is people with genuine PTSD are very hesitant to verbally discuss symptoms of PTSD. I wonder if people could mimic PTSD for secondary gain of getting medical marijuana?

Since Marijuana is legal in Colorado and Washington, a physician prescription is not necessary. My guess is a VA physician would not be allowed to prescribe marijuana in the VA System, but would this prevent them from recommending Marijuana\Cannabis in states where it's legal?

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I am seeing a number of individuals for evaluations and therapy with a PTSD diagnosis established with a different provider. They are driving to an adjoining state on a monthly to every three months basis to get physician prescribed medical marijuana. Many are Veterans or individuals with a childhood and adult victims of abuse history.

Recently, I did an evaluation for a Veteran who indicated his physician is prescribing medical marijuana for PTSD. I questioned him about this as part of the evaluation and he did not provide additional information, so it was unclear if this was actually truthful information.

Does anyone else working with PTSD have any knowledge of medical marijuana treatment for PTSD? It seems many claiming to have PTSD read out what appears to be a memorized list out of the DSM of PTSD symptoms and my knowledge from training is people with genuine PTSD are very hesitant to verbally discuss symptoms of PTSD.

People perceive all kinds of things to be helpful. It doesn't mean they objectively are of benefit for the condition in general, or for any actual healing or remission.

I'm sure Marijuana helps people with PTSD sleep. But again, see above.
 
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The research is mixed on how helpful it is. Some think it even makes symptoms worse in the long term. I think of it as a form of avoidance, though, and avoidance is always the enemy in PTSD treatment.
 
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The research is mixed on how helpful it is. Some think it even makes symptoms worse in the long term. I think of it as a form of avoidance, though, and avoidance is always the enemy in PTSD treatment.
It really bothers me how avoidance is often portrayed as the best way to treat PSTD by lay people, when it in fact the symptoms worse (see: mandatory trigger warnings, etc)
 
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The VA hospitals are federal property. MJ is not federally legal, even where legal in a state. Physicians in the VA cannot prescribe marijuana. They can't even prescribe things not in the VA formulary. Not too mention, MJ is not an EBT for PTSD, very poor evidence at this point.
 
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Is this true in the 23 states were medical marijuana is approved? I was aware of medical marijuana for chemotherapy patients, but this is the first time I've heard of it being prescribed for PTSD.

It's common for patient to claim their marijuana use seems to help with moods, anxiety, anger, sleep impairment, and pain.

It seems that some of the people I am seeing with a prior PTSD diagnosis have personality disorder traits preferring medications over psychotherapy.

From my experience, individuals with authentic PTSD do well with psychotherapy using prolonged exposure methods without medication interventions. These individuals are reluctant to openly talk about their PTSD symptoms and it takes time to develop rapport and trust.

For me, when a patient has more knowledge about PTSD than I do with an expectation of medication intervention and expecting that they are owed benefits or money from the government, I tend to see red flags.

I can see individuals faking PTSD with the expectation of receiving medical marijuana.
 
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MJ has been passed around as a "medication" for mental health conditions for years, nothing new here. Still no good evidence for it being helpful in mood and anxiety disorders. As for individuals faking PTSD for receiving MJ, are you surprised? People fake more for less all the time.
 
MJ has been passed around as a "medication" for mental health conditions for years, nothing new here. Still no good evidence for it being helpful in mood and anxiety disorders. As for individuals faking PTSD for receiving MJ, are you surprised? People fake more for less all the time.

Everytime my wife goes to Chilli's, it her birthday. Brownies might be relevant here.
 
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The research is mixed on how helpful it is. Some think it even makes symptoms worse in the long term. I think of it as a form of avoidance, though, and avoidance is always the enemy in PTSD treatment.

This is currently how I view it (i.e., MJ and its relation to both PTSD and anxiety) as well, until I see good evidence to the contrary. I don't know that I see how it'd be much different than using alcohol or benzodiazepines in that respect, at least RE: the immediate "beneficial" effects.
 
Having done a fair amount of addictions work, I remain eternally amused at the number of folks out there who won't take any sort of medication because its "bad" and "I don't want to rely on that kinda stuff" but see no issues with marijuana.

I'm extremely pro-legalization since I think the laws have done more harm than good. I maintain the culture surrounding its use (in part because of its schedule 1 status) is a MUCH bigger problem than the drug itself. Of course, the same could actually be said about most drugs, but that's a more controversial stance....
 
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CESATE (Center of Excellence in Substance Abuse Treatment and Education) at the Seattle VA has a presentation that I've seen about why they think marijuana for PTSD is not particularly helpful. One reason is that the withdrawal symptoms mimic or would likely exacerbate PTSD symptoms. I'll try to dig up the Power Point when I have time.

I know that anecdotally vets report that MJ is helpful for sleep, but I wonder if it's actually poorer quality sleep. Sort of like alcohol--the sleep is not only worse, but IIRC it keeps you in REM longer so you're more prone to nightmares.
 
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I can't recommend anything that does not have an evidence base and I really stay away from recommending any type of medication - legal or illegal or recreational or prescribed and leave that to physicians. I have a few patients who use medical marijuana and the side effects can be problematic. Weight gain, memory problems, rebound anxiety, decreased motivation. I have one patient who has been abstinent from medical marijuana for a couple of months now and overall function has improved significantly. I discuss pros and cons of use with patients for all medications, assign them to research for themselves, and help them to make the best informed decisions.
 
Yale published a study last year which demonstrated that PTSD populations using marijuana suffered worse outcomes than abstainers including symptom severity, and violent behaviors (n=2,000+). Other case studies and rodent models demonstrate efficacy. Good luck having a pt accept that.
 
Yale published a study last year which demonstrated that PTSD populations using marijuana suffered worse outcomes than abstainers including symptom severity, and violent behaviors (n=2,000+). Other case studies and rodent models demonstrate efficacy. Good luck having a pt accept that.
Thanks for the info. I will talk about this study when talking with patients with PTSD. Here is the source http://www.ncbi.nlm.nih.gov/pubmed/26455669
 
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Yale published a study last year which demonstrated that PTSD populations using marijuana suffered worse outcomes than abstainers including symptom severity, and violent behaviors (n=2,000+). Other case studies and rodent models demonstrate efficacy. Good luck having a pt accept that.
I didn't know that rodents smoked pot, but it looks like it has the same effect:
mZo9xT6.jpg
 
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Maybe somewhat relevant but the protocol at our VA is to get the patient into substance use treatment WAY before any type of EBT for PTSD is attempted. The Seeking Safety group is always popular here. It is great (and facilitates tx in so many ways) when your patient is honest with you about their substance use, but I feel it is still always necessary to discuss the risks of substance use in a motivational interviewing kind-of-way. And I second the notion that VAs are federal facilities that do not condone medical MJ for treatment. So, yes, OneNeuroDoctor, VA docs would not be able to recommend medical MJ for treatment (on the books).

smalltownpsych...there needs to be a meme made out of that picture with the caption "Duuudddeee.....those trails were rough"
 
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Maybe somewhat relevant but the protocol at our VA is to get the patient into substance use treatment WAY before any type of EBT for PTSD is attempted. The Seeking Safety group is always popular here. It is great (and facilitates tx in so many ways) when your patient is honest with you about their substance use, but I feel it is still always necessary to discuss the risks of substance use in a motivational interviewing kind-of-way. And I second the notion that VAs are federal facilities that do not condone medical MJ for treatment. So, yes, OneNeuroDoctor, VA docs would not be able to recommend medical MJ for treatment (on the books).

smalltownpsych...there needs to be a meme made out of that picture with the caption "Duuudddeee.....those trails were rough"
The evidence increasingly suggests your VA protocol is wrong. You should treat both and if one had to be first, it should be PTSD treatment. Treating PTSD sx reduces substance use on average, and this has been shown with SS. I'll edit when I have a chance to post an article.
 
The evidence increasingly suggests your VA protocol is wrong. You should treat both and if one had to be first, it should be PTSD treatment. Treating PTSD sx reduces substance use on average, and this has been shown with SS. I'll edit when I have a chance to post an article.

That's what I've seen in the lit as well. The substance use is often a coping mechanism. Need to give someone better coping mechanisms/reduce distressing symptoms before they can really kick the habit. Although, I haven't reviewed the newest lit on PTSD tx, so I am admittedly slightly behind that area. Looking forward to the posting of the data.
 
The evidence increasingly suggests your VA protocol is wrong. You should treat both and if one had to be first, it should be PTSD treatment. Treating PTSD sx reduces substance use on average, and this has been shown with SS. I'll edit when I have a chance to post an article.
Both have to be treated and the research is pretty clear on that; however, if a patient who meets criteria for substance dependence does not reduce or eliminate substance use, then the PTSD treatment will likely have little effect and patient will get worse. How can it be very effective when they won't even show up for appointments if they are still using?

Another important point about concurrent treatment is that the exposure needs to be carefully mediated with substance abusers in early stages of abstinence because they have more limited coping than they let on to.
 
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That's what I've seen in the lit as well. The substance use is often a coping mechanism. Need to give someone better coping mechanisms/reduce distressing symptoms before they can really kick the habit. Although, I haven't reviewed the newest lit on PTSD tx, so I am admittedly slightly behind that area. Looking forward to the posting of the data.
This is the one that I was thinking of - had read it last year.

http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09091261

I've still got to look at some of the more recent reviews but I keep seeing studies like this. The idea of having to get clean before you can address psychological symptoms really represents an antiquated view that wasn't really data-driven to begin with when people developed PTSD interventions. Plus, it excludes about half of your PTSD population.
 
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Both have to be treated and the research is pretty clear on that; however, if a patient who meets criteria for substance dependence does not reduce or eliminate substance use, then the PTSD treatment will likely have little effect and patient will get worse. How can it be very effective when they won't even show up for appointments if they are still using?

Another important point about concurrent treatment is that the exposure needs to be carefully mediated with substance abusers in early stages of abstinence because they have more limited coping than they let on to.
The idea of integrated or concurrent treatment does need to be handled carefully. But we also have to look at the data on a condition by condition basis. With PTSD, it is one of those cases where the self-medication hypothesis actually seems to hold up for a lot of clients. Sure patients are more vulnerable during early abstinence. Does that mean they can't benefit from PTSD treatment?

Also - APA suggests not to identify people by their condition (people with substance use disorder instead of " substance abusers") - just a random pet peeve I always see.
 
The idea of integrated or concurrent treatment does need to be handled carefully. But we also have to look at the data on a condition by condition basis. With PTSD, it is one of those cases where the self-medication hypothesis actually seems to hold up for a lot of clients. Sure patients are more vulnerable during early abstinence. Does that mean they can't benefit from PTSD treatment?

Also - APA suggests not to identify people by their condition (people with substance use disorder instead of " substance abusers") - just a random pet peeve I always see.
Much of what I have seen in the community is poor treatment of the PTSD and a focus on treating that with constantly changing medications and a lack of progressive exposure therapy which lends itself to patients using their continued distress as an excuse to continue using.

I agree with not using language that way and avoid it for most mental disorders, but I do tend to be more comfortable myself with using terms like addict or alcoholic since many in recovery tend to self-identify using those terms.
 
The evidence increasingly suggests your VA protocol is wrong. You should treat both and if one had to be first, it should be PTSD treatment. Treating PTSD sx reduces substance use on average, and this has been shown with SS. I'll edit when I have a chance to post an article.

Thanks for the article. I will give it a read.

We do treat both, but for us, PTSD is not always first (maybe there are other cases that I am not privy to but, generally speaking...stabilization from substance use dx is key...unless the therapist and patient agree that they can proceed with the full-course of treatment). Well, remember I said EBTs for PTSD. In my experience (and what I have observed with others), the patients were not turned away but did not begin full course of say PE or CPT with active substance use....too unstable and those treatments would send them straight to the inpatient unit (and do not pass GO). And for this reason...Seeking Safety (either before or after treatment remains a popular group).

We could analyze behavioral avoidance....if you are masking your avoidance with EtOH, then that is not going to help anyone when it is time for prolonged exposure therapy, right?

I'd be interested in what @cara susanna thinks about this.

Edit:
The idea of having to get clean before you can address psychological symptoms really represents an antiquated view that wasn't really data-driven to begin with when people developed PTSD interventions. Plus, it excludes about half of your PTSD population.

Nuances of language lead to errors in communication. I did not intend to imply that the patient must get clean (that is a tall order for many)....the patient must be "stabilized," and since the operational definition for patient stabilization may tend to differ from patient to patient, clinician to clinician...this indicates that the patient must adhere/agree to the treatment guidelines before tx begins.

P.S. My SDN paranoia is kicking in so I may edit out some stuff later.
 
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Maybe somewhat relevant but the protocol at our VA is to get the patient into substance use treatment WAY before any type of EBT for PTSD is attempted. The Seeking Safety group is always popular here. It is great (and facilitates tx in so many ways) when your patient is honest with you about their substance use, but I feel it is still always necessary to discuss the risks of substance use in a motivational interviewing kind-of-way. And I second the notion that VAs are federal facilities that do not condone medical MJ for treatment. So, yes, OneNeuroDoctor, VA docs would not be able to recommend medical MJ for treatment (on the books).

smalltownpsych...there needs to be a meme made out of that picture with the caption "Duuudddeee.....those trails were rough"

This may be cultural, because that ideology has been long done away with here, and was one of the rationales for the development of MHRRTPs and DOMs in the VA system.
 
This may be cultural, because that ideology has been long done away with here, and was one of the rationales for the development of MHRRTPs and DOMs in the VA system.

I dunno. At my VISN, we have a lot of ground-breaking research going on so I am surprised that what I am observing seems like standard practice and it is not in line with current research. My guess that our VISN's protocol is not wrong, but perhaps my perception of what is going on...

If there's an appropriate segue, maybe I'll bring it up and see what folks say (after I read the article).
 
I agree with not using language that way and avoid it for most mental disorders, but I do tend to be more comfortable myself with using terms like addict or alcoholic since many in recovery tend to self-identify using those terms.
I think it is a dangerous assumption personally. The 12-step community encourages this and a lot of them do, sure, but not everyone fits into that mode of treatment or responds well to it. I wouldn't go around calling them that myself (or referring to them in general that way), as it has the potential to be stigmatizing depending on the client (and definitely when referring to a collective group). I try not to be too casual about this out of respect for clients, and that has served me well.

Bill White has an interesting article out there too about using the term "abuse" as totally inaccurate and laden with moral-model thinking. It is becoming less of a problem now that term is not in the DSM system anymore.
 
I dunno. At my VISN, we have a lot of ground-breaking research going on so I am surprised that what I am observing seems like standard practice and it is not in line with current research. My guess that our VISN's protocol is not wrong, but perhaps my perception of what is going on...

If there's an appropriate segue, maybe I'll bring it up and see what folks say (after I read the article).
Here is another article - this is a commentary on the earlier article I posted.

http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09111602

I think it lays out the rationale for why earlier ways of thinking about comorbid PTSD-SUD treatment are problematic, and why we need to be thinking about things differently. I know this is a little bit of a tangent but figured I would try to follow-up my earlier post.

Here is a key quote: "Contrary to early, largely anecdotal concerns, all of the investigations that have examined the use of integrated, cognitive behavior therapies to address PTSD and substance use disorders to date demonstrate significant reductions in both PTSD and substance use disorder outcomes. Concerns that patients who undergo trauma-focused treatment will evidence an increase in substance use, relapse, or attrition has not been borne out by the data."
 
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I think it is a dangerous assumption personally. The 12-step community encourages this and a lot of them do, sure, but not everyone fits into that mode of treatment or responds well to it. I wouldn't go around calling them that myself (or referring to them in general that way), as it has the potential to be stigmatizing depending on the client (and definitely when referring to a collective group). I try not to be too casual about this out of respect for clients, and that has served me well.

Bill White has an interesting article out there too about using the term "abuse" as totally inaccurate and laden with moral-model thinking. It is becoming less of a problem now that term is not in the DSM system anymore.
I actually tend to follow the patients lead on the language to use. I never liked substance abuse as a term myself, but my DSM-IV indoctrination leaks out at times.
 
Here is another article - this is a commentary on the earlier article I posted.

http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09111602

I think it lays out the rationale for why earlier ways of thinking about comorbid PTSD-SUD treatment are problematic, and why we need to be thinking about things differently. I know this is a little bit of a tangent but figured I would try to follow-up my earlier post.

Exert from abovementioned article that details the dilemma entirely:

"The accumulating findings bring into question the common practice of requiring patients with PTSD and substance use disorders to be abstinent from alcohol or drugs before commencing trauma work. This commonly practiced treatment approach, known as the sequential model, means that patients with PTSD and a substance use disorder who present for trauma/PTSD treatment are generally referred out to first receive specialized addiction treatment. Any trauma/PTSD work is deferred, often based on the concern that addressing trauma will lead to an exacerbation in substance use or risk for relapse. Thus, patients are required to demonstrate some length of abstinence (e.g., 6 months) from drugs and alcohol before their trauma/PTSD is addressed. It is unclear how many patients "fall through the cracks" and either do not follow up on the addiction treatment referral or do not return to receive PTSD treatment following addiction treatment. Because patients are usually referred to a different therapist working in a different clinic with little provider cross-communication, it is likely that many are lost in this process. There has to be a better way."

As I mentioned, I improperly suggested (or maybe it was assumed) that the patient needs to abstain from drugs and EtOH for a period of time prior to the start of trauma-focused therapy. This is not entirely true, in my experience. Abstinence is not always required, but the issue of substance use must be addressed and together, the patient/clinician, decide whether to proceed with TFP...also, TFP is time-limited so then the patient becomes tied to two clinics (which is problematic as article suggests), with one clinic (substance recovery services) being available to offer long-term support, where PTSD clinics may not. And, anecdotally, I have experienced patients opting to go to substance recovery services first, then referred back to the PTSD clinic (but not the other way around). But, most importantly, these patients are given the option: Ongoing substance use + active PTSD tx, OR Active substance use tx + delayed PTSD tx. And if the former is chosen, the type of substance is significant....I'm seen many continue to use MJ and EtOH in TFP, but not heroin or severe EtOH use.
 
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I actually tend to follow the patients lead on the language to use. I never liked substance abuse as a term myself, but my DSM-IV indoctrination leaks out at times.
If a patient wants to be called that that is fine with me. I just never assume it is okay going into it. It can be an interesting discussion in terms of how patients view themselves and how the language that we use impacts our perception. I've had some great discussions about this with patients before.
 
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As I mentioned, I improperly suggested (or maybe it was assumed) that the patient needs to abstain from drugs and EtOH for a period of time prior to the start of trauma-focused therapy. This is not entirely true, in my experience. Abstinence is not always required, but the issue of substance use must be addressed and together, the patient/clinician, decide whether to proceed with TFP...also, TFP is time-limited so then the patient becomes tied to two clinics (which is problematic as article suggests), with one clinic (substance recovery services) being available to offer long-term support, where PTSD clinics may not. And, anecdotally, I have experienced patients opting to go to substance recovery services first, then referred back to the PTSD clinic (but not the other way around). But, most importantly, these patients are given the option: Ongoing substance use + active PTSD tx, OR Active substance use tx + delayed PTSD tx. And if the former is chosen, the type of substance is significant....I'm seen many continue to use MJ and EtOH in TFP, but not heroin or severe EtOH use.
This is why integrated treatment is so important to develop and begin to study more with RCTs. Trying to operationalize the degree to which abstinence or treatment compliance or lack of use for some substances vs. others is terribly messy with a complex (and heterogenous) population. Best to be able to focus on their complex problems and their interactions. From what I've seen so far, engaging in an EBT even with people actively using still can be efficacious. I haven't seen any data suggesting any real iatrogenic effects that clinicians have used as a rationale for using active substance use as an exclusion criterion.

I still want to see more RCTs for integrated treatment for comorbid conditions. But we have to start somewhere and the serial treatment concept is not always holding up.
 
This is why integrated treatment is so important to develop and begin to study more with RCTs. Trying to operationalize the degree to which abstinence or treatment compliance or lack of use for some substances vs. others is terribly messy with a complex (and heterogenous) population. Best to be able to focus on their complex problems and their interactions. From what I've seen so far, engaging in an EBT even with people actively using still can be efficacious. I haven't seen any data suggesting any real iatrogenic effects that clinicians have used as a rationale for using active substance use as an exclusion criterion.

I still want to see more RCTs for integrated treatment for comorbid conditions. But we have to start somewhere and the serial treatment concept is not always holding up.

The SUDTP here has psychologist dedicated to PTSD assessment and treatment (EBTs only, pretty much) both for individuals in the residential level of care and for those in the outpatient level of care. Our PCT specialty clinic/providers of course inquire about substance use, but ive never heard that being used a reason to decline EBT treatment for PTSD on their end.
 
The SUDTP here has psychologist dedicated to PTSD assessment and treatment (EBTs only, pretty much) both for individuals in the residential level of care and for those in the outpatient level of care. Our PCT specialty clinic/providers of course inquire about substance use, but ive never heard that being used a reason to decline EBT treatment for PTSD on their end.
Oh of course, I am sure that a lot of places are aware of this and implementing it appropriately - my comment was pointed towards the example earlier in the thread. But I know that there are some clinics that are not well-informed and continue to exclude people for using substances. It reflects a larger problem, in my opinion, of there being a significant number of psychologists that are just not very educated regarding substance use, what the culture of that population is like, etc. Moreover, a lot of psychologists don't seem to understand the various subcultures that exist within the population and just lump them into one category. It is an area of weakness in the training of your modal psychologist, in my opinion.

It is unrealistic to expect total abstinence or to just shut everything down when there is a relapse. I've seen some pretty awful stigma towards people with SUDs among psychologists as well - not everywhere but it is more common than I'm comfortable with. We're learning to do some interventions better (evidence-based application of MI and not just half-assed "I use MI principles", effective use of relapse prevention techniques to reduce the number and severity of relapses, BCT, etc...) but as with a lot of interventions, some psychologists do not implement them properly. Calling all implementation scientists - fix this!
 
Goodness. It'll be awhile before I can read all those. I have comments on the first article you shared, but may peruse those others before I reply again, Pragma. Bottom line: The VA offered folks the same Tx (seeking safety) as the experimental Tx (in the first article)...as a first option for stablization if the person did not chose to go to Substance Recovery clinic first. So we are on target with other protocols. I'm curious about the CPT /PE articles b/c that is where I could see ongoing substance use as being the most worrisome.

To what erg923 said: Mine as well. There are psychiatrist-psychologist-social work-teams who specialize in coborbid PTSD/Substance use within the PTSD clinic, as well as the Substance Recovery clinic.
 
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There are actually studies where they've done PE on substance use inpatient units, which demonstrated success. Generally the rules I've seen are that current SUD is okay as long as 1) they aren't high during session 2) they aren't high while completing homework.
 
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The consistent finding is that PE/CPT/other EBTs are fine for people with an active SUD based on limited trials to date. They benefit as much as those with just PTSD and also seem to have good SUD outcomes. In fact, some of the studies suggest that reduced PTSD sx is the mechanism of change in SUD sx, although that is harder to determine at this point.

Considering one of those RCTs is by Foa and published in JAMA and concludes outpatient PE is kosher for current AUD, I'm feeling confident that this is the direction we are moving in. In fact, PE predicted better long term postreatment AUD outcomes while not performing better than comparison conditions on PTSD symptoms.
 
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I haven't seen these patients who were refused treatment because of active substance abuse. My experience has been the opposite with clinicians rarely addressing substance abuse especially when it comes to medications. The reality is when my patients are able to get to latter stages of change with substance use, the prognosis is bright. When they are in earlier stages it often feels futile because most continue to get worse. Of course, we don't have any programs for either treatment within our community so what the big city VA programs are doing is less generalizable to us.
 
I haven't seen these patients who were refused treatment because of active substance abuse. My experience has been the opposite with clinicians rarely addressing substance abuse especially when it comes to medications. The reality is when my patients are able to get to latter stages of change with substance use, the prognosis is bright. When they are in earlier stages it often feels futile because most continue to get worse. Of course, we don't have any programs for either treatment within our community so what the big city VA programs are doing is less generalizable to us.
Well the data I've seen do support that abstinence does obviously augment PTSD treatment outcomes - for instance, the DAD paper I referenced above supports that notion across all different types of substance use that is comorbid with PTSD in a huge sample.

I do see people with active SUD excluded from PTSD treatment. Not just at VAs. What a number of those studies above show you though is that your assertions earlier...
Both have to be treated and the research is pretty clear on that; however, if a patient who meets criteria for substance dependence does not reduce or eliminate substance use, then the PTSD treatment will likely have little effect and patient will get worse. How can it be very effective when they won't even show up for appointments if they are still using?

Another important point about concurrent treatment is that the exposure needs to be carefully mediated with substance abusers in early stages of abstinence because they have more limited coping than they let on to.
...are not supported. The data say the opposite. Treat the PTSD even if there is an active SUD. What you alluded to with regard to iatrogenic effects are not supported by the data, the idea that they won't show up is not supported by the data, and the idea that treatment will have little effect is not supported by the data.

I guess that is the main point I am trying to make here. The popular assumptions people make regarding this population are simply not supported. These studies also reflect community samples, women, etc., and not just typical VA populations.

I am just as big of a believer in tailoring interventions based on where someone is at with regard to the transtheoretical model of change. But we have to think beyond just those factors - just because someone is in precontemplation or contemplation does not mean that PTSD treatment won't be effective. Moreover, the population is so heterogeneous that just considering their level of motivation is not sufficient when making a decision about when to initiate PTSD treatment.

That model fits pretty well when you only frame of reference is abstinence-only treatment goals, but it can be applied flexibly to the wide range of different types of people and use patterns that constitute this population.
 
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I am not framing it as abstinence only and never said that. I treat patients with active substance abuse every day both in my office and in the ER. The studies are not likely to be capturing the patients that I am referring to who are coming in and out of our ER and are in the first stage of change - denial and severe substance use. If we can get them into a program, great, then we can treat it all, but what I see are missed appointments with myself and inconsistent appointments with medication prescriber. In other words, I can't treat anything if they are at the bar and not my office.

I think that is what Cheetah is saying too. I imagine there are programs with limited resources who are excluding patients in active substance use and I would support their ability to make those choices. However, I personally believe that it is actually better to make those decisions based on more objective behavioral criteria as opposed to just diagnosis. At my last job, I used to be in charge of deciding who to admit to a residential treatment program and who to exclude. We didn't exclude either PTSD or substance abuse nor cared initially which stage of change they were in so long as they agreed to be there. We did treat both as they are obviously intertwined and we also met the patient right where they were at in that process.

I completely agree with flexibility in this area, but I think that we neglect one of the most important aspects of these treatment studies and that is that they have strict treatment protocols, aka rules. Too often, the real world translation, takes findings like that and ends up with a chaotic poorly implemented treatment without firm guidelines.
 
Some of why I am engaging in this dialogue is that we are starting a substance abuse treatment program at my current job and I am on the oversight committee. The underlying and unyielding to research belief here is that confrontation is effective. :arghh:
 
Here recently I am seeing people claiming to have been on medications and therapy for PTSD with negative outcome until they started using marijuana. Could their expectation that marijuana works for reducing PTSD be due to expectancy effect?
 
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My dad was an alcoholic, but I believe that his major issue was really bad anxiety. He still had to be functional, so his way of numbing himself and being more social and functional was to drink so much that he wouldn't care (about what others thought, etc) He stopped drinking maybe 10yrs back once he sort of just got to a point where he didn't care what others thought. (I think that comes with age..people at some point just realize that it's sort of dumb to waste your time stressing out)
 
The self-medication hypothesis. Very popular philosophy amongst professionals. Doesn't jibe with what the recovering addicts always tell me. They say that even when they had psychological problems, which we all know many or even most do, the basic underlying reason for them was that they wanted to get high and that they would use the problems as a justification to continued use.
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Here recently I am seeing people claiming to have been on medications and therapy for PTSD with negative outcome until they started using marijuana. Could their expectation that marijuana works for reducing PTSD be due to Placebo effect?

Marijuana works fast. SSRI/SNRIs- 4-6 weeks. PE=increase nightmares and anxiety for first few sessions/weeks. Homework is well, homework (work).

Marijuana side effect profile is limited, or at least not immediately noticeable or adverse.

Getting "high" is probably an extra bonus in all this.
 
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Here recently I am seeing people claiming to have been on medications and therapy for PTSD with negative outcome until they started using marijuana. Could their expectation that marijuana works for reducing PTSD be due to Placebo effect?
Marijuana is not a placebo. I'm pretty sure that most people use it because it makes them feel better. Probably not as effective in PTSD as ETOH, but some people tolerate it better and if it makes them feel better, then it works.
 
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