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Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder
Addictive Behaviors 89 (2019) 29–34
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Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder
T
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Sarah Meshberg-Cohena,b, , Anne C. Blacka,b, Jason C. DeVivaa,b, Ismene L. Petrakisa,b, Marc I. Rosena,b a b
VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States Yale University School of Medicine, Department of Psychiatry, United States
H I GH L IG H T S
treatment engagement rates at 6-months post-admission was 45.7%. • Buprenorphine half of buprenorphine-seeking Veterans carried a PTSD diagnosis. • Nearly receiving concurrent PTSD treatment had better buprenorphine retention. • Veterans Veterans were not receiving trauma treatment during buprenorphine maintenance. • Most • Veterans with a heroin use history had higher buprenorphine dropout than pill users.
A B S T R A C T
Introduction: Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. Methods: This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status. Results: Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group. Conclusions: Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.
1. Background 1.1. Epidemiology of opioid use disorder in veterans Opioid misuse is an escalating epidemic and a significant public health issue (Volkow, Frieden, Hyde, & Cha, 2014; Weiss et al., 2011), with opioid overdoses, suicides, and emergency room visits for opioid overdose related to prescription and non-prescription opioid use occurring at alarming rates (Banerjee et al., 2016; Rudd, Aleshire, Zibbell,
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& Matthew Gladden, 2016; Unick, Rosenblum, Mars, & Ciccarone, 2013). There has also been a dramatic rise in the incidence of infectious disease related to injection drug use (including hepatitis C and HIV) and in social problems related to this epidemic (Haffajee & Frank, 2018). The Center for Disease Control estimates the overall cost of this epidemic to be $78.5 billion annually (Florence, Zhou, Luo, & Xu, 2016). Military veterans are diagnosed with opioid use disorders (OUD) at higher rates than non-veterans (Gordon et al., 2007; Oliva et al., 2017). Veterans are twice as likely to die from accidental poisoning as non-
Corresponding author at: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, United States. E-mail address: [email protected] (S. Meshberg-Cohen).
https://doi.org/10.1016/j.addbeh.2018.09.010 Received 8 June 2018; Received in revised form 12 August 2018; Accepted 8 September 2018 Available online 12 September 2018 0306-4603/ Published by Elsevier Ltd.
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Seal et al., 2012). Veterans afflicted by PTSD are more likely to be impacted by opioid and other drug use disorders (Dabbs, Watkins, Fink, Eick-Cost, & Millikan, 2014; Golub & Bennett, 2013; Lan et al., 2016), making the treatment of comorbid PTSD and substance use disorders (SUD) particularly important. One recent study of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans seeking VHA services found that as many as 63% of those diagnosed with SUDs also had a PTSD diagnosis (Seal et al., 2011), and another study found that, after adjusting for demographics and military status, the odds of having a prior PTSD diagnosis were 28 times greater among service members with OUD compared to service members without OUD (Dabbs et al., 2014). Among veterans who served in the OEF/OIF conflicts, those with PTSD were more likely to receive prescription opioids for pain (Seal et al., 2012; Seal et al., 2016), exhibit prescription misuse (Banerjee et al., 2016), and experience adverse outcomes such as overdose, suicide, injuries, and illicit substance use (Banerjee et al., 2016; Seal et al., 2016). The process of re-integrating into the civilian world while coping with psychological and physical conditions may increase the likelihood that veterans will develop opioid problems (Golub & Bennett, 2013; Seal et al., 2016). PTSD may reduce the likelihood of response to buprenorphine treatment. In a large national health insurance database (n = 2947), having a comorbid psychiatric diagnosis was related to significantly poorer buprenorphine adherence (Litz & Leslie, 2017), and research has also linked childhood trauma to buprenorphine dropout, particularly when patients endorse childhood physical and emotional neglect (Kumar, Stowe, Han, & Mancino, 2016). Individuals with trauma and addiction comorbidity have been reported to have poorer health, more severe clinical profiles, and worse treatment adherence than those without traumatic experiences or PTSD symptomatology (Hien et al., 2010; Seal et al., 2016; Simpson, Lehavot, & Petrakis, 2017). While individuals with comorbid SUD and PTSD seek treatment more often than those without PTSD, their prognosis is often poor (Hien et al., 2015; Ouimette, Ahrens, Moos, & Finney, 1997; Pietrzak, Goldstein, Southwick, & Grant, 2011), particularly when trauma is left untreated (Possemato, Wade, Andersen, & Ouimette, 2010). The potential benefit of combined addiction and trauma-focused treatment for people with comorbid PTSD and addiction has been hypothesized by several groups (Back, 2010). Improvements in PTSD symptomatology are associated with better SUD results (Hien et al., 2010; Ouimette, Brown, & Najavits, 1998) and a multi-site VA database study found that among male veterans receiving inpatient SUD treatment, receipt of PTSD-focused treatment within 3 months post-discharge predicted SUD remission 5 years later (Ouimette, Moos, & Finney, 2003), while SUD outpatient care did not predict 5-year remission. Although there is a growing literature examining treatment of trauma among individuals with SUD, most studies have primarily focused on participants with either alcohol (e.g., Persson et al., 2017) or drug use disorder without specifying drug type (Norman & Hamblen, 2017; Simpson et al., 2017). There is growing consensus that trauma treatment can be provided safely in early recovery (e.g., Kaysen et al., 2014). A review of psychological interventions for comorbid PTSD and SUD by Roberts, Roberts, Jones, and Bisson (2015) found that individual trauma-focused psychotherapies were associated with higher dropout rates than the control conditions to which they were compared; however, the authors noted that this is also true of trauma-focused interventions for PTSD in general. Among the only MAT studies was an uncontrolled feasibility pilot study in which twelve Israeli women on methadone maintenance were treated with Prolonged Exposure (PE) with relatively low dropout (10 out of 12 participants completed PE) and significant reductions in PTSD and depressive symptoms (Schiff, Nacasch, Levit, Katz, & Foa, 2015). Another study found monetary incentives improved PE attendance among methadone maintenance patients, which in turn resulted in PTSD improvements, better methadone attendance, and no increased drug use (Schacht, Brooner, King, Kidorf,
veterans, with opioids frequently identified as causal agents in these accidental deaths (Bohnert, Ilgen, Galea, McCarthy, & Blow, 2011). Recent data indicate that the number of veterans diagnosed with OUD who receive VA healthcare nearly tripled from 2003 to 2017, increasing from 25,031 to 69,142 (Wyse, Gordon, Dobscha, et al., 2018). Prescription opioid misuse is significantly and independently associated with heroin initiation among veterans (Banerjee et al., 2016), and is also linked to chronic pain and posttraumatic stress disorder (PTSD), which are both more common in veteran populations than civilian populations (Golub & Bennett, 2013; Seal et al., 2016). 1.2. Opioid use disorder treatment Medication-assisted treatments (MAT), including buprenorphine or buprenorphine/naloxone, methadone, and injectable naltrexone, are the most effective treatments for OUD, and are associated with significant reductions in morbidity, mortality, and spread of infectious disease (e.g., Thomas et al., 2014; van den Brink & Haasen, 2006). Buprenorphine is a partial opioid agonist that blocks the effects of other opioids (Rosen et al., 1994), thus reducing illicit use during treatment (Thomas et al., 2014; Weiss et al., 2011). The Veterans Health Administration (VHA), which is the largest healthcare system in the country, has made the use of pharmacotherapies to treat OUD a priority, and now includes rates of those on MAT in standard measures of performance (Manhapra, Quinones, & Rosenheck, 2016; Wyse et al., 2018). While buprenorphine maintenance is a useful tool to combat the opioid epidemic, it is undermined by high dropout rates (Carroll & Weiss, 2016), with 6-month retention rarely exceeding 50%. Dropout is associated with poor outcomes (Hser et al., 2014; Pinto et al., 2010; Sordo et al., 2017) including risk of overdose, particularly in the first 30 days after discontinuation (Manhapra, Rosenheck, & Fiellin, 2017). The benefit of adding additional psychosocial treatments to MAT has varied across studies. Some studies examining patients on buprenorphine have suggested that there were no significant differences in opioid use outcomes between those receiving and those not receiving additional substance counseling, sparking controversy (Fiellin et al., 2013; Weiss et al., 2011). Brief physician management (15 mins) has been compared to extensive medication adherence and drug counseling (45 mins) among OUD participants on buprenorphine, with no differences between groups in opioid-negative urines, abstinence, or retention (Tetrault et al., 2012). Other research has shown that addictionfocused behavioral treatments did not increase positive outcomes (e.g., retention, other substance use, or opioid use) among those on buprenorphine (Ling, Hillhouse, Ang, Jenkins, & Fahey, 2013). There remains a question about whether added treatment is more effective for subgroups of patients, including those with comorbid conditions like posttraumatic stress disorder (PTSD) (Carroll & Weiss, 2016), as untreated comorbidities can impact rates of retention to OUD maintenance. Comorbid psychiatric illness is a risk factor for noncompliance (e.g., incorrect pill count, negative buprenorphine in urine screens) and dropout among veterans receiving buprenorphine for OUD (Fareed et al., 2014). 1.3. Comorbid trauma and addiction There are high rates of comorbid PTSD among those with OUD, and there are some reasons to hypothesize that trauma-focused treatment may enhance response to MAT. PTSD, which can occur following a traumatic event, is manifested by symptoms that include reexperiencing the trauma, intrusive memories associated with the event, avoidance, hyperarousal, and negative changes in mood and cognition (APA, 2013). PTSD affects approximately 8% of the general population (Blanco et al., 2013). Rates are higher in military veterans, with prevalence ranging from 11% to 30% depending on service era (Gradus, 2017; Magruder et al., 2005; Thomas et al., 2010). PTSD is one of the most prevalent mental health diagnoses treated within the VHA (e.g., 30
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2.2. Data analysis
& Peirce, 2017). Those who received PE had improvements in psychological distress, emotion regulation, and quality of life. Evidence supports addressing PTSD and SUD concurrently rather than sequentially (e.g., McCauley, Killeen, Gros, Brady, & Back, 2012), and trauma-focused interventions (versus non-trauma-focused) show superior outcomes (e.g., van Dam, Vedel, Ehring, & Emmelkamp, 2012). While VHA has been disseminating two first-line evidence-based psychotherapies (EBP) for the treatment of PTSD, including PE (Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (CPT) (Resick, Monson, & Chard, 2017), it is unclear how often these EBPs are being provided to veterans receiving buprenorphine for OUD.
Descriptive statistics were used to characterize the sample. ANOVA and chi-square analyses were used to compare the three groups (veterans with PTSD not in trauma treatment, veterans without PTSD, and veterans with PTSD in concurrent trauma treatment) on variables potentially associated with buprenorphine retention. Comparisons were made on age, gender (male versus female), marital status (married versus not), race/ethnicity (White versus other), type of opioid use (heroin versus pill-only), and service-connected disability benefits (service-connected versus not). Then, logistic regression models were used to estimate the odds of buprenorphine retention 6 months postadmission as a function of group alone, and then controlling for variables that differed significantly across groups, and those historically associated with treatment retention. The full model controlled for covariates that differed significantly between groups at baseline. The reference group in each model was PTSD-diagnosed veterans not receiving concurrent trauma treatment. All analyses evaluated statistical significance at alpha = 0.05.
1.4. Present study The proposed project examined the rate of PTSD in a VHA buprenorphine clinic, and evaluated buprenorphine maintenance retention in veterans initiating OUD treatment, while comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. The current study examined the following hypotheses: 1) Veterans with comorbid PTSD who receive concurrent trauma treatment within 3-months post-buprenorphine initiation (e.g., one of EBPs for PTSD offered in the VA [PE or CPT], and/or appointments with a provider in the PTSD treatment program) will be significantly more likely to be retained in buprenorphine maintenance (e.g., less likely to dropout) by 6-month follow-up compared to PTSD-diagnosed veterans who do not receive concurrent trauma treatment; 2) Veterans without PTSD will be significantly more likely to be retained in buprenorphine maintenance by 6-month follow-up compared to PTSD-diagnosed veterans who do not receive concurrent trauma treatment.
3. Results 3.1. Participants As shown in Table 1, most of the veterans were male (92.9%; n = 130), with an average age of 45.4 (SD = 12.7) years. Half of the sample (50.0%; n = 70) was single/never married, and the majority were White (77.1%; n = 108). Over half (n = 81; 57.9%) were receiving service-connected disability benefits for medical (n = 58; 41.4%) and/or mental health (n = 54; 38.6%) conditions. 3.2. Diagnosis and outcome
2. Method
Of the 140 records examined, 67 (47.9%) had a PTSD diagnosis. Of the 67 veterans with PTSD, only 21 (31.3%) had received concurrent trauma treatment; 8 of 21 (38.1%) received evidence-based psychotherapy for PTSD (7 received CPT and 1 received PE). As shown in Table 1, most veterans in the sample had used heroin (70.7%; n = 99), only 29.3% (n = 41) had used pills only, and many had a co-occurring SUD (e.g., 43.6% cocaine, 30.0% alcohol, 19.3% cannabis, 17.9% benzodiazepines).
2.1. Data collection This study employed a chart review of veterans enrolled in outpatient buprenorphine treatment at Veterans Affairs (VA) Connecticut Healthcare System. The study received an exemption from the Institutional Review Board at VA Connecticut. Data were gathered on consecutive referrals to outpatient buprenorphine maintenance submitted from October 1, 2015 through March 31, 2017. All new buprenorphine clinic admissions were identified via electronic consult (N = 140). Charts were systematically reviewed by the study team (including authors, S.M.C, J.C.D, and an addiction therapist) for the 6month period after the buprenorphine clinic consult was completed (i.e., initial buprenorphine appointment). Retention in buprenorphine maintenance treatment was defined as sustained treatment engagement throughout the 6-month post-admission period as evidenced by buprenorphine clinic attendance, pharmacy pickups, prescription renewals, and no note indicating treatment dropout. PTSD diagnosis was identified when the veteran's electronic medical record either had PTSD listed as a service-connected disability and/or had PTSD documented in the problem list. Individual progress notes were examined to determine whether there was any PTSD treatment (e.g., appointments with a provider in the PTSD treatment program or any engagement with one of the evidence-based psychotherapies offered in VHA [PE or CPT]) documented in the medical record within 3 months of initiating buprenorphine treatment (to allow time for trauma treatment to affect buprenorphine maintenance retention at 6 months post-admission). In addition, data on age, gender, ethnicity, type of opioid use (e.g., heroin, pills), other substance use (e.g., cocaine, cannabis, alcohol), marital status, other mental health diagnosis (e.g., major depressive disorder, schizophrenia), and service-connected status were collected.
3.3. Group comparisons on treatment-associated variables There were significant age differences between PTSD-diagnosed veterans in trauma treatment (M = 39.9; SD = 9.3), PTSD-diagnosed veterans without trauma treatment (M = 42.0; SD = 12.4), and those with no PTSD diagnosis (M = 49.1; SD = 12.6), F(2,140) = 7.4, p = .001. There were no significant differences between groups on marital status, race, other SUD, opioid type (heroin versus pills only), or gender. There was also no difference between groups on being serviceconnected for medical conditions (45.7% versus 47.6% versus 37.0%, respectively). However, PTSD-diagnosed veterans with or without trauma treatment were more likely to be service-connected for any condition (i.e., when combining medical and/or mental health conditions) compared to veterans not diagnosed with PTSD (76.1% of PTSDdiagnosed veterans without trauma treatment versus 76.2% of those who received trauma treatment versus 41.1% of non-PTSD veterans; χ2 [2,N = 140] = 17.6, p < .001); forty-two (62.7%) of the PTSD-diagnosed veterans in this study were service-connected for PTSD. 3.4. Buprenorphine retention Veterans with PTSD who received concurrent trauma treatment had the highest rate of 6-month buprenorphine retention at 90.5% (n = 19/ 21), compared to veterans not diagnosed with PTSD, of whom 46.6% 31
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Table 1 Sample descriptives: PTSD with PTSD treatment (n = 21), PTSD without PTSD treatment (n = 46), and non-PTSD (n = 73).⁎
Age (years) Gender Male Female Marital Status Married Unmarried Race White African American Hispanic/Pacific Islander Mental Health Major Depressive Disorder Bipolar Disorder (I or II) Psychotic Disorder (e.g., Schizophrenia, Schizoaffective) Anxiety Disorder (e.g. Generalized Anxiety Disorder, Panic Disorder) Service Connection Service Connection (Any) Service Connection Medical Service Connection Mental Health Substance Use Type of Opioid Pills Only Heroin Stimulant [Cocaine] Use Disorder Alcohol Use Disorder Cannabis Use Disorder Benzodiazepine Use Disorder Treatment Retention to BUP-NLX at 6 months ⁎ ⁎⁎
No PTSD M (SD)/n (%)
PTSD No treatment M (SD)/n (%)
PTSD Treatment M (SD)/n (%)
Total (N = 140) M (SD)/n (%)
49.1 (12.6)
42.04 (12.4)
39.9 (9.3)
45.4 (12.7)⁎⁎
70 (95.9%) 3 (4.1%)
43 (93.5%) 3 (6.5%)
17 (81.0%) 4 (19.0%)
130 (92.9%) 10 (7.1%)
12 (16.4%) 61 (83.6%)
6 (13.0%) 40 (87.0%)
7 (33.3%) 14 (66.7%)
25 (17.9%) 115 (82.1%)
56 (76.7%) 12 (16.4%) 5 (6.8%)
36 (78.3%) 6 (13.0%) 4 (8.7%)
16 (76.2%) 4 (19.0%) 1 (4.8%)
108 (77.1%) 22 (15.7%) 10 (7.1%)
16 (21.9%) 5 (6.8%) 3 (4.1%) 5 (6.8%)
5 6 4 1
6 2 2 1
27 (19.3%) 13 (9.3%) 9 (6.4%) 7 (5.0%)
30 (41.1%) 27 (37.0%) 10 (13.5%)
35 (76.1%) 21 (45.7%) 30 (65.2%)
16 (76.2%) 10 (47.6%) 14 (66.7%)
81 (57.9%)⁎⁎ 58 (41.4%) 54 (38.6%)⁎⁎
21 52 27 21 11 11
13 33 26 16 11 11
7 (33.3%) 14 (66.7%) 8 (38.1%) 5 (23.8%) 5 (23.8%) 3 (14.3%)
41 99 61 42 27 25
19 (90.5%)
64 (45.7%)⁎⁎
(29.7%) (70.3%) (37.0%) (28.8%) (15.1%) (15.1%)
34 (46.6%)
(10.9%) (13.0%) (8.7%) (2.2%)
(28.3%) (71.1%) (56.5%) (34.8%) (23.9%) (23.9%)
11(23.9%)
(28.6%) (9.5%) (9.5%) (4.8%)
(29.3%) (70.7%) (43.6%) (30.0%) (19.3%) (17.9%)
p < .05. p < .005.
veterans with a heroin use history, the odds of retention in buprenorphine treatment were 74% lower than for veterans using exclusively pills (OR = 0.26; p = .003). Whereas veterans with PTSD and concurrent trauma treatment continued to have significantly higher odds of buprenorphine treatment retention, controlling for other variables in the model (conditional OR = 43.36, p < .001), veterans without PTSD no longer differed significantly from the reference group (conditional OR = 2.20, p = .10). Service-connected status was not associated with treatment retention.
(n = 34/73) were retained in buprenorphine treatment, and PTSD-diagnosed veterans without trauma treatment, of whom only 11 of 46 (23.9%) were retained in buprenorphine treatment, χ2(2, N = 140) = 25.8, p < .0001. 3.5. Logistic regression models In the simple logistic regression model, regressing treatment retention on group alone, veterans with PTSD and concurrent trauma treatment and veterans without PTSD were each significantly more likely to be retained in buprenorphine treatment relative to the reference group of PTSD-diagnosed veterans without concurrent trauma treatment. Among veterans with PTSD in concurrent trauma treatment, the odds of retention were 30.23 times greater than the reference group (p < .001). Veterans without PTSD had odds of retention 2.77 times greater than the reference group (p = .02). As shown in Table 2, in the full model controlling for age (centered at the mean), service-connected status, and opioid type (heroin versus pills only), age and heroin use were significantly associated with buprenorphine treatment retention; for every increase of one year in age, the odds of retention increased by 4% (OR = 1.04, p = .013). Among
4. Discussion This retrospective chart review examined consecutive referrals to buprenorphine maintenance treatment to evaluate outcomes for those with and without comorbid PTSD, and among those with PTSD, examined buprenorphine retention between those receiving versus not receiving trauma treatment. Rates of PTSD in this study were consistent with previous research (Mills, Teesson, Ross, & Darke, 2007; Villagonzalo et al., 2011), with nearly half (47.9%) identified as having a PTSD diagnosis. PTSD-diagnosed veterans who received concurrent trauma treatment were significantly more likely to remain in buprenorphine maintenance at 6-month follow up (90.5%) compared to those without trauma treatment (23.9%). Consistent with previous studies, age and heroin use were also associated with retention in buprenorphine maintenance (Fiellin et al., 2006; Marcovitz, McHugh, Volpe, Votaw, & Connery, 2016). Overall buprenorphine treatment engagement rates at 6 months post-admission (45.7%) were similar to other research (Hser et al., 2014; Pinto et al., 2010).
Table 2 Full logistic regression of 6-month buprenorphine treatment retention. Variable
OR
95% CI
p
Age Service-Connection Status Heroin Use PTSD Diagnosis + PTSD Treatment No PTSD Diagnosis
1.04 0.95 0.26 43.36 2.20
1.01–1.08 0.39–2.29 0.11–0.64 8.10–232.06 0.86–5.70
< .05 .91 < .01 < .001 .10
4.1. Comorbid PTSD diagnosis The relatively high rate of PTSD diagnosis among veterans seeking
Veterans with PTSD not in trauma treatment as reference. 32
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treatment for OUD in this study (in a “real world” VHA clinic) is consistent with data on lifetime PTSD rates previously reported in OUDPTSD research. Mills et al. (2007) estimated a 41% rate of PTSD among OUD treatment-seeking patients using heroin in a non-veteran sample. PTSD rates among those in opioid agonist therapy range from 19.8% to 52.7% (Ecker & Hundt, 2017), with higher rates found in studies with female populations (Smith, Smith, Cercone, McKee, & Homish, 2016) and when PTSD was identified by screening instruments versus diagnosed by structured interviews (Villagonzalo et al., 2011). In comparison, data from 2014 indicate that just over 10% of all veterans served by VHA carried a diagnosis of PTSD (Harpaz-Rotem & Hoff, 2014).
5. Significance The results of this study have the potential to improve retention with buprenorphine maintenance treatment for OUD. The results support the referral to and utilization of evidence-based treatments for PTSD during OUD maintenance therapy. Increased utilization of effective therapies for PTSD could improve overall veteran functioning and possibly decrease non-compliance and/or treatment dropout among veterans seeking buprenorphine maintenance for OUD within the VHA. Acknowledgment The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (HSR&D) Project IIR 11-091 (Marc I. Rosen MD) and by Clinical Science Research & Development (CSR&D) CX001517-01A2 (Ismene L. Petrakis, MD).
4.2. Concurrent treatment outcomes Results from this study suggest that providing concurrent trauma interventions for patients seeking buprenorphine maintenance is associated with improved outcomes in retention in OUD treatment. While less than one-third (31.3%) received trauma treatment within the first 3 months of buprenorphine maintenance, those who did were significantly more likely to be engaged in buprenorphine maintenance therapy at 6-month follow-up. The odds of retention in buprenorphine maintenance were over 30 times greater among PTSD-diagnosed veterans who were receiving concurrent trauma treatment compared to their counterparts who were not receiving concurrent trauma treatment. There is still sometimes reluctance on the part of clinicians to provide trauma-focused therapy in those with SUD because of concern that exploring trauma will worsen PTSD symptoms, derail SUD treatment improvement, and perhaps lead to relapse (Back, Waldrop, & Brady, 2009). Results from this study suggest that providing traumafocused treatment was associated with improved retention and support work in other addictive disorders showing that addressing trauma during the early stages of SUD treatment can be beneficial (Hien et al., 2010; Meshberg-Cohen, Svikis, & McMahon, 2014). Despite efforts to promote use of EBPs, recent data suggested EBPs are underutilized in the VA (Sayer et al., 2017a,b); consistent with this, our study found that most OUD-PTSD veterans were not receiving an EBP for PTSD, and many were not receiving any form of trauma treatment during buprenorphine maintenance, which has implications for how veterans might be encouraged to access and engage in PTSD treatment (Watts et al., 2014; Sayer et al., 2017a,b). PTSD assessment and referral to concurrent trauma interventions should be standard components of the intake process for veterans seeking MAT for OUD. Screening for PTSD may be useful in understanding reasons for ongoing opioid use and potential for relapse and assisting with treatment referrals. Limitations of this study include the retrospective nature of the study, the use of chart review, the lack of randomization and the small sample size. Diagnosis of PTSD was determined to be present if the veteran had a service-connected rating or if the diagnosis appeared in the problem list. It is likely that this is an underreporting since PTSD was not formerly assessed for all patients. Use of structured diagnostic assessments (e.g., CAPS) would improve the confidence in the diagnosis. Because the study was observational and not randomized, it is unclear whether other factors influence referral to trauma treatment, such as active symptoms or patient request. It is also possible that veterans who remain in buprenorphine treatment had more contact with mental health providers and therefore more opportunity to engage in PTSD treatment. Furthermore, we do not have PTSD outcomes for veterans in this study, and future research should investigate trauma outcomes among those receiving concurrent PTSD-OUD treatment. It is also possible that other patient characteristics that could not be ascertained, such as educational attainment, employment status, and housing stability, could be associated with retention. Nevertheless, this research does suggest that further study on the impact of trauma-focused treatment is indicated.
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Contents lists available at ScienceDirect
Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder
T
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Sarah Meshberg-Cohena,b, , Anne C. Blacka,b, Jason C. DeVivaa,b, Ismene L. Petrakisa,b, Marc I. Rosena,b a b
VA Connecticut Healthcare System, 950 Campbell Avenue, Psychology Service/Department of Psychiatry, 116A, West Haven, CT 06516, United States Yale University School of Medicine, Department of Psychiatry, United States
H I GH L IG H T S
treatment engagement rates at 6-months post-admission was 45.7%. • Buprenorphine half of buprenorphine-seeking Veterans carried a PTSD diagnosis. • Nearly receiving concurrent PTSD treatment had better buprenorphine retention. • Veterans Veterans were not receiving trauma treatment during buprenorphine maintenance. • Most • Veterans with a heroin use history had higher buprenorphine dropout than pill users.
A B S T R A C T
Introduction: Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. Methods: This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status. Results: Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group. Conclusions: Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.
1. Background 1.1. Epidemiology of opioid use disorder in veterans Opioid misuse is an escalating epidemic and a significant public health issue (Volkow, Frieden, Hyde, & Cha, 2014; Weiss et al., 2011), with opioid overdoses, suicides, and emergency room visits for opioid overdose related to prescription and non-prescription opioid use occurring at alarming rates (Banerjee et al., 2016; Rudd, Aleshire, Zibbell,
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& Matthew Gladden, 2016; Unick, Rosenblum, Mars, & Ciccarone, 2013). There has also been a dramatic rise in the incidence of infectious disease related to injection drug use (including hepatitis C and HIV) and in social problems related to this epidemic (Haffajee & Frank, 2018). The Center for Disease Control estimates the overall cost of this epidemic to be $78.5 billion annually (Florence, Zhou, Luo, & Xu, 2016). Military veterans are diagnosed with opioid use disorders (OUD) at higher rates than non-veterans (Gordon et al., 2007; Oliva et al., 2017). Veterans are twice as likely to die from accidental poisoning as non-
Corresponding author at: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, United States. E-mail address: [email protected] (S. Meshberg-Cohen).
https://doi.org/10.1016/j.addbeh.2018.09.010 Received 8 June 2018; Received in revised form 12 August 2018; Accepted 8 September 2018 Available online 12 September 2018 0306-4603/ Published by Elsevier Ltd.
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Seal et al., 2012). Veterans afflicted by PTSD are more likely to be impacted by opioid and other drug use disorders (Dabbs, Watkins, Fink, Eick-Cost, & Millikan, 2014; Golub & Bennett, 2013; Lan et al., 2016), making the treatment of comorbid PTSD and substance use disorders (SUD) particularly important. One recent study of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans seeking VHA services found that as many as 63% of those diagnosed with SUDs also had a PTSD diagnosis (Seal et al., 2011), and another study found that, after adjusting for demographics and military status, the odds of having a prior PTSD diagnosis were 28 times greater among service members with OUD compared to service members without OUD (Dabbs et al., 2014). Among veterans who served in the OEF/OIF conflicts, those with PTSD were more likely to receive prescription opioids for pain (Seal et al., 2012; Seal et al., 2016), exhibit prescription misuse (Banerjee et al., 2016), and experience adverse outcomes such as overdose, suicide, injuries, and illicit substance use (Banerjee et al., 2016; Seal et al., 2016). The process of re-integrating into the civilian world while coping with psychological and physical conditions may increase the likelihood that veterans will develop opioid problems (Golub & Bennett, 2013; Seal et al., 2016). PTSD may reduce the likelihood of response to buprenorphine treatment. In a large national health insurance database (n = 2947), having a comorbid psychiatric diagnosis was related to significantly poorer buprenorphine adherence (Litz & Leslie, 2017), and research has also linked childhood trauma to buprenorphine dropout, particularly when patients endorse childhood physical and emotional neglect (Kumar, Stowe, Han, & Mancino, 2016). Individuals with trauma and addiction comorbidity have been reported to have poorer health, more severe clinical profiles, and worse treatment adherence than those without traumatic experiences or PTSD symptomatology (Hien et al., 2010; Seal et al., 2016; Simpson, Lehavot, & Petrakis, 2017). While individuals with comorbid SUD and PTSD seek treatment more often than those without PTSD, their prognosis is often poor (Hien et al., 2015; Ouimette, Ahrens, Moos, & Finney, 1997; Pietrzak, Goldstein, Southwick, & Grant, 2011), particularly when trauma is left untreated (Possemato, Wade, Andersen, & Ouimette, 2010). The potential benefit of combined addiction and trauma-focused treatment for people with comorbid PTSD and addiction has been hypothesized by several groups (Back, 2010). Improvements in PTSD symptomatology are associated with better SUD results (Hien et al., 2010; Ouimette, Brown, & Najavits, 1998) and a multi-site VA database study found that among male veterans receiving inpatient SUD treatment, receipt of PTSD-focused treatment within 3 months post-discharge predicted SUD remission 5 years later (Ouimette, Moos, & Finney, 2003), while SUD outpatient care did not predict 5-year remission. Although there is a growing literature examining treatment of trauma among individuals with SUD, most studies have primarily focused on participants with either alcohol (e.g., Persson et al., 2017) or drug use disorder without specifying drug type (Norman & Hamblen, 2017; Simpson et al., 2017). There is growing consensus that trauma treatment can be provided safely in early recovery (e.g., Kaysen et al., 2014). A review of psychological interventions for comorbid PTSD and SUD by Roberts, Roberts, Jones, and Bisson (2015) found that individual trauma-focused psychotherapies were associated with higher dropout rates than the control conditions to which they were compared; however, the authors noted that this is also true of trauma-focused interventions for PTSD in general. Among the only MAT studies was an uncontrolled feasibility pilot study in which twelve Israeli women on methadone maintenance were treated with Prolonged Exposure (PE) with relatively low dropout (10 out of 12 participants completed PE) and significant reductions in PTSD and depressive symptoms (Schiff, Nacasch, Levit, Katz, & Foa, 2015). Another study found monetary incentives improved PE attendance among methadone maintenance patients, which in turn resulted in PTSD improvements, better methadone attendance, and no increased drug use (Schacht, Brooner, King, Kidorf,
veterans, with opioids frequently identified as causal agents in these accidental deaths (Bohnert, Ilgen, Galea, McCarthy, & Blow, 2011). Recent data indicate that the number of veterans diagnosed with OUD who receive VA healthcare nearly tripled from 2003 to 2017, increasing from 25,031 to 69,142 (Wyse, Gordon, Dobscha, et al., 2018). Prescription opioid misuse is significantly and independently associated with heroin initiation among veterans (Banerjee et al., 2016), and is also linked to chronic pain and posttraumatic stress disorder (PTSD), which are both more common in veteran populations than civilian populations (Golub & Bennett, 2013; Seal et al., 2016). 1.2. Opioid use disorder treatment Medication-assisted treatments (MAT), including buprenorphine or buprenorphine/naloxone, methadone, and injectable naltrexone, are the most effective treatments for OUD, and are associated with significant reductions in morbidity, mortality, and spread of infectious disease (e.g., Thomas et al., 2014; van den Brink & Haasen, 2006). Buprenorphine is a partial opioid agonist that blocks the effects of other opioids (Rosen et al., 1994), thus reducing illicit use during treatment (Thomas et al., 2014; Weiss et al., 2011). The Veterans Health Administration (VHA), which is the largest healthcare system in the country, has made the use of pharmacotherapies to treat OUD a priority, and now includes rates of those on MAT in standard measures of performance (Manhapra, Quinones, & Rosenheck, 2016; Wyse et al., 2018). While buprenorphine maintenance is a useful tool to combat the opioid epidemic, it is undermined by high dropout rates (Carroll & Weiss, 2016), with 6-month retention rarely exceeding 50%. Dropout is associated with poor outcomes (Hser et al., 2014; Pinto et al., 2010; Sordo et al., 2017) including risk of overdose, particularly in the first 30 days after discontinuation (Manhapra, Rosenheck, & Fiellin, 2017). The benefit of adding additional psychosocial treatments to MAT has varied across studies. Some studies examining patients on buprenorphine have suggested that there were no significant differences in opioid use outcomes between those receiving and those not receiving additional substance counseling, sparking controversy (Fiellin et al., 2013; Weiss et al., 2011). Brief physician management (15 mins) has been compared to extensive medication adherence and drug counseling (45 mins) among OUD participants on buprenorphine, with no differences between groups in opioid-negative urines, abstinence, or retention (Tetrault et al., 2012). Other research has shown that addictionfocused behavioral treatments did not increase positive outcomes (e.g., retention, other substance use, or opioid use) among those on buprenorphine (Ling, Hillhouse, Ang, Jenkins, & Fahey, 2013). There remains a question about whether added treatment is more effective for subgroups of patients, including those with comorbid conditions like posttraumatic stress disorder (PTSD) (Carroll & Weiss, 2016), as untreated comorbidities can impact rates of retention to OUD maintenance. Comorbid psychiatric illness is a risk factor for noncompliance (e.g., incorrect pill count, negative buprenorphine in urine screens) and dropout among veterans receiving buprenorphine for OUD (Fareed et al., 2014). 1.3. Comorbid trauma and addiction There are high rates of comorbid PTSD among those with OUD, and there are some reasons to hypothesize that trauma-focused treatment may enhance response to MAT. PTSD, which can occur following a traumatic event, is manifested by symptoms that include reexperiencing the trauma, intrusive memories associated with the event, avoidance, hyperarousal, and negative changes in mood and cognition (APA, 2013). PTSD affects approximately 8% of the general population (Blanco et al., 2013). Rates are higher in military veterans, with prevalence ranging from 11% to 30% depending on service era (Gradus, 2017; Magruder et al., 2005; Thomas et al., 2010). PTSD is one of the most prevalent mental health diagnoses treated within the VHA (e.g., 30
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2.2. Data analysis
& Peirce, 2017). Those who received PE had improvements in psychological distress, emotion regulation, and quality of life. Evidence supports addressing PTSD and SUD concurrently rather than sequentially (e.g., McCauley, Killeen, Gros, Brady, & Back, 2012), and trauma-focused interventions (versus non-trauma-focused) show superior outcomes (e.g., van Dam, Vedel, Ehring, & Emmelkamp, 2012). While VHA has been disseminating two first-line evidence-based psychotherapies (EBP) for the treatment of PTSD, including PE (Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (CPT) (Resick, Monson, & Chard, 2017), it is unclear how often these EBPs are being provided to veterans receiving buprenorphine for OUD.
Descriptive statistics were used to characterize the sample. ANOVA and chi-square analyses were used to compare the three groups (veterans with PTSD not in trauma treatment, veterans without PTSD, and veterans with PTSD in concurrent trauma treatment) on variables potentially associated with buprenorphine retention. Comparisons were made on age, gender (male versus female), marital status (married versus not), race/ethnicity (White versus other), type of opioid use (heroin versus pill-only), and service-connected disability benefits (service-connected versus not). Then, logistic regression models were used to estimate the odds of buprenorphine retention 6 months postadmission as a function of group alone, and then controlling for variables that differed significantly across groups, and those historically associated with treatment retention. The full model controlled for covariates that differed significantly between groups at baseline. The reference group in each model was PTSD-diagnosed veterans not receiving concurrent trauma treatment. All analyses evaluated statistical significance at alpha = 0.05.
1.4. Present study The proposed project examined the rate of PTSD in a VHA buprenorphine clinic, and evaluated buprenorphine maintenance retention in veterans initiating OUD treatment, while comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. The current study examined the following hypotheses: 1) Veterans with comorbid PTSD who receive concurrent trauma treatment within 3-months post-buprenorphine initiation (e.g., one of EBPs for PTSD offered in the VA [PE or CPT], and/or appointments with a provider in the PTSD treatment program) will be significantly more likely to be retained in buprenorphine maintenance (e.g., less likely to dropout) by 6-month follow-up compared to PTSD-diagnosed veterans who do not receive concurrent trauma treatment; 2) Veterans without PTSD will be significantly more likely to be retained in buprenorphine maintenance by 6-month follow-up compared to PTSD-diagnosed veterans who do not receive concurrent trauma treatment.
3. Results 3.1. Participants As shown in Table 1, most of the veterans were male (92.9%; n = 130), with an average age of 45.4 (SD = 12.7) years. Half of the sample (50.0%; n = 70) was single/never married, and the majority were White (77.1%; n = 108). Over half (n = 81; 57.9%) were receiving service-connected disability benefits for medical (n = 58; 41.4%) and/or mental health (n = 54; 38.6%) conditions. 3.2. Diagnosis and outcome
2. Method
Of the 140 records examined, 67 (47.9%) had a PTSD diagnosis. Of the 67 veterans with PTSD, only 21 (31.3%) had received concurrent trauma treatment; 8 of 21 (38.1%) received evidence-based psychotherapy for PTSD (7 received CPT and 1 received PE). As shown in Table 1, most veterans in the sample had used heroin (70.7%; n = 99), only 29.3% (n = 41) had used pills only, and many had a co-occurring SUD (e.g., 43.6% cocaine, 30.0% alcohol, 19.3% cannabis, 17.9% benzodiazepines).
2.1. Data collection This study employed a chart review of veterans enrolled in outpatient buprenorphine treatment at Veterans Affairs (VA) Connecticut Healthcare System. The study received an exemption from the Institutional Review Board at VA Connecticut. Data were gathered on consecutive referrals to outpatient buprenorphine maintenance submitted from October 1, 2015 through March 31, 2017. All new buprenorphine clinic admissions were identified via electronic consult (N = 140). Charts were systematically reviewed by the study team (including authors, S.M.C, J.C.D, and an addiction therapist) for the 6month period after the buprenorphine clinic consult was completed (i.e., initial buprenorphine appointment). Retention in buprenorphine maintenance treatment was defined as sustained treatment engagement throughout the 6-month post-admission period as evidenced by buprenorphine clinic attendance, pharmacy pickups, prescription renewals, and no note indicating treatment dropout. PTSD diagnosis was identified when the veteran's electronic medical record either had PTSD listed as a service-connected disability and/or had PTSD documented in the problem list. Individual progress notes were examined to determine whether there was any PTSD treatment (e.g., appointments with a provider in the PTSD treatment program or any engagement with one of the evidence-based psychotherapies offered in VHA [PE or CPT]) documented in the medical record within 3 months of initiating buprenorphine treatment (to allow time for trauma treatment to affect buprenorphine maintenance retention at 6 months post-admission). In addition, data on age, gender, ethnicity, type of opioid use (e.g., heroin, pills), other substance use (e.g., cocaine, cannabis, alcohol), marital status, other mental health diagnosis (e.g., major depressive disorder, schizophrenia), and service-connected status were collected.
3.3. Group comparisons on treatment-associated variables There were significant age differences between PTSD-diagnosed veterans in trauma treatment (M = 39.9; SD = 9.3), PTSD-diagnosed veterans without trauma treatment (M = 42.0; SD = 12.4), and those with no PTSD diagnosis (M = 49.1; SD = 12.6), F(2,140) = 7.4, p = .001. There were no significant differences between groups on marital status, race, other SUD, opioid type (heroin versus pills only), or gender. There was also no difference between groups on being serviceconnected for medical conditions (45.7% versus 47.6% versus 37.0%, respectively). However, PTSD-diagnosed veterans with or without trauma treatment were more likely to be service-connected for any condition (i.e., when combining medical and/or mental health conditions) compared to veterans not diagnosed with PTSD (76.1% of PTSDdiagnosed veterans without trauma treatment versus 76.2% of those who received trauma treatment versus 41.1% of non-PTSD veterans; χ2 [2,N = 140] = 17.6, p < .001); forty-two (62.7%) of the PTSD-diagnosed veterans in this study were service-connected for PTSD. 3.4. Buprenorphine retention Veterans with PTSD who received concurrent trauma treatment had the highest rate of 6-month buprenorphine retention at 90.5% (n = 19/ 21), compared to veterans not diagnosed with PTSD, of whom 46.6% 31
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Table 1 Sample descriptives: PTSD with PTSD treatment (n = 21), PTSD without PTSD treatment (n = 46), and non-PTSD (n = 73).⁎
Age (years) Gender Male Female Marital Status Married Unmarried Race White African American Hispanic/Pacific Islander Mental Health Major Depressive Disorder Bipolar Disorder (I or II) Psychotic Disorder (e.g., Schizophrenia, Schizoaffective) Anxiety Disorder (e.g. Generalized Anxiety Disorder, Panic Disorder) Service Connection Service Connection (Any) Service Connection Medical Service Connection Mental Health Substance Use Type of Opioid Pills Only Heroin Stimulant [Cocaine] Use Disorder Alcohol Use Disorder Cannabis Use Disorder Benzodiazepine Use Disorder Treatment Retention to BUP-NLX at 6 months ⁎ ⁎⁎
No PTSD M (SD)/n (%)
PTSD No treatment M (SD)/n (%)
PTSD Treatment M (SD)/n (%)
Total (N = 140) M (SD)/n (%)
49.1 (12.6)
42.04 (12.4)
39.9 (9.3)
45.4 (12.7)⁎⁎
70 (95.9%) 3 (4.1%)
43 (93.5%) 3 (6.5%)
17 (81.0%) 4 (19.0%)
130 (92.9%) 10 (7.1%)
12 (16.4%) 61 (83.6%)
6 (13.0%) 40 (87.0%)
7 (33.3%) 14 (66.7%)
25 (17.9%) 115 (82.1%)
56 (76.7%) 12 (16.4%) 5 (6.8%)
36 (78.3%) 6 (13.0%) 4 (8.7%)
16 (76.2%) 4 (19.0%) 1 (4.8%)
108 (77.1%) 22 (15.7%) 10 (7.1%)
16 (21.9%) 5 (6.8%) 3 (4.1%) 5 (6.8%)
5 6 4 1
6 2 2 1
27 (19.3%) 13 (9.3%) 9 (6.4%) 7 (5.0%)
30 (41.1%) 27 (37.0%) 10 (13.5%)
35 (76.1%) 21 (45.7%) 30 (65.2%)
16 (76.2%) 10 (47.6%) 14 (66.7%)
81 (57.9%)⁎⁎ 58 (41.4%) 54 (38.6%)⁎⁎
21 52 27 21 11 11
13 33 26 16 11 11
7 (33.3%) 14 (66.7%) 8 (38.1%) 5 (23.8%) 5 (23.8%) 3 (14.3%)
41 99 61 42 27 25
19 (90.5%)
64 (45.7%)⁎⁎
(29.7%) (70.3%) (37.0%) (28.8%) (15.1%) (15.1%)
34 (46.6%)
(10.9%) (13.0%) (8.7%) (2.2%)
(28.3%) (71.1%) (56.5%) (34.8%) (23.9%) (23.9%)
11(23.9%)
(28.6%) (9.5%) (9.5%) (4.8%)
(29.3%) (70.7%) (43.6%) (30.0%) (19.3%) (17.9%)
p < .05. p < .005.
veterans with a heroin use history, the odds of retention in buprenorphine treatment were 74% lower than for veterans using exclusively pills (OR = 0.26; p = .003). Whereas veterans with PTSD and concurrent trauma treatment continued to have significantly higher odds of buprenorphine treatment retention, controlling for other variables in the model (conditional OR = 43.36, p < .001), veterans without PTSD no longer differed significantly from the reference group (conditional OR = 2.20, p = .10). Service-connected status was not associated with treatment retention.
(n = 34/73) were retained in buprenorphine treatment, and PTSD-diagnosed veterans without trauma treatment, of whom only 11 of 46 (23.9%) were retained in buprenorphine treatment, χ2(2, N = 140) = 25.8, p < .0001. 3.5. Logistic regression models In the simple logistic regression model, regressing treatment retention on group alone, veterans with PTSD and concurrent trauma treatment and veterans without PTSD were each significantly more likely to be retained in buprenorphine treatment relative to the reference group of PTSD-diagnosed veterans without concurrent trauma treatment. Among veterans with PTSD in concurrent trauma treatment, the odds of retention were 30.23 times greater than the reference group (p < .001). Veterans without PTSD had odds of retention 2.77 times greater than the reference group (p = .02). As shown in Table 2, in the full model controlling for age (centered at the mean), service-connected status, and opioid type (heroin versus pills only), age and heroin use were significantly associated with buprenorphine treatment retention; for every increase of one year in age, the odds of retention increased by 4% (OR = 1.04, p = .013). Among
4. Discussion This retrospective chart review examined consecutive referrals to buprenorphine maintenance treatment to evaluate outcomes for those with and without comorbid PTSD, and among those with PTSD, examined buprenorphine retention between those receiving versus not receiving trauma treatment. Rates of PTSD in this study were consistent with previous research (Mills, Teesson, Ross, & Darke, 2007; Villagonzalo et al., 2011), with nearly half (47.9%) identified as having a PTSD diagnosis. PTSD-diagnosed veterans who received concurrent trauma treatment were significantly more likely to remain in buprenorphine maintenance at 6-month follow up (90.5%) compared to those without trauma treatment (23.9%). Consistent with previous studies, age and heroin use were also associated with retention in buprenorphine maintenance (Fiellin et al., 2006; Marcovitz, McHugh, Volpe, Votaw, & Connery, 2016). Overall buprenorphine treatment engagement rates at 6 months post-admission (45.7%) were similar to other research (Hser et al., 2014; Pinto et al., 2010).
Table 2 Full logistic regression of 6-month buprenorphine treatment retention. Variable
OR
95% CI
p
Age Service-Connection Status Heroin Use PTSD Diagnosis + PTSD Treatment No PTSD Diagnosis
1.04 0.95 0.26 43.36 2.20
1.01–1.08 0.39–2.29 0.11–0.64 8.10–232.06 0.86–5.70
< .05 .91 < .01 < .001 .10
4.1. Comorbid PTSD diagnosis The relatively high rate of PTSD diagnosis among veterans seeking
Veterans with PTSD not in trauma treatment as reference. 32
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treatment for OUD in this study (in a “real world” VHA clinic) is consistent with data on lifetime PTSD rates previously reported in OUDPTSD research. Mills et al. (2007) estimated a 41% rate of PTSD among OUD treatment-seeking patients using heroin in a non-veteran sample. PTSD rates among those in opioid agonist therapy range from 19.8% to 52.7% (Ecker & Hundt, 2017), with higher rates found in studies with female populations (Smith, Smith, Cercone, McKee, & Homish, 2016) and when PTSD was identified by screening instruments versus diagnosed by structured interviews (Villagonzalo et al., 2011). In comparison, data from 2014 indicate that just over 10% of all veterans served by VHA carried a diagnosis of PTSD (Harpaz-Rotem & Hoff, 2014).
5. Significance The results of this study have the potential to improve retention with buprenorphine maintenance treatment for OUD. The results support the referral to and utilization of evidence-based treatments for PTSD during OUD maintenance therapy. Increased utilization of effective therapies for PTSD could improve overall veteran functioning and possibly decrease non-compliance and/or treatment dropout among veterans seeking buprenorphine maintenance for OUD within the VHA. Acknowledgment The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (HSR&D) Project IIR 11-091 (Marc I. Rosen MD) and by Clinical Science Research & Development (CSR&D) CX001517-01A2 (Ismene L. Petrakis, MD).
4.2. Concurrent treatment outcomes Results from this study suggest that providing concurrent trauma interventions for patients seeking buprenorphine maintenance is associated with improved outcomes in retention in OUD treatment. While less than one-third (31.3%) received trauma treatment within the first 3 months of buprenorphine maintenance, those who did were significantly more likely to be engaged in buprenorphine maintenance therapy at 6-month follow-up. The odds of retention in buprenorphine maintenance were over 30 times greater among PTSD-diagnosed veterans who were receiving concurrent trauma treatment compared to their counterparts who were not receiving concurrent trauma treatment. There is still sometimes reluctance on the part of clinicians to provide trauma-focused therapy in those with SUD because of concern that exploring trauma will worsen PTSD symptoms, derail SUD treatment improvement, and perhaps lead to relapse (Back, Waldrop, & Brady, 2009). Results from this study suggest that providing traumafocused treatment was associated with improved retention and support work in other addictive disorders showing that addressing trauma during the early stages of SUD treatment can be beneficial (Hien et al., 2010; Meshberg-Cohen, Svikis, & McMahon, 2014). Despite efforts to promote use of EBPs, recent data suggested EBPs are underutilized in the VA (Sayer et al., 2017a,b); consistent with this, our study found that most OUD-PTSD veterans were not receiving an EBP for PTSD, and many were not receiving any form of trauma treatment during buprenorphine maintenance, which has implications for how veterans might be encouraged to access and engage in PTSD treatment (Watts et al., 2014; Sayer et al., 2017a,b). PTSD assessment and referral to concurrent trauma interventions should be standard components of the intake process for veterans seeking MAT for OUD. Screening for PTSD may be useful in understanding reasons for ongoing opioid use and potential for relapse and assisting with treatment referrals. Limitations of this study include the retrospective nature of the study, the use of chart review, the lack of randomization and the small sample size. Diagnosis of PTSD was determined to be present if the veteran had a service-connected rating or if the diagnosis appeared in the problem list. It is likely that this is an underreporting since PTSD was not formerly assessed for all patients. Use of structured diagnostic assessments (e.g., CAPS) would improve the confidence in the diagnosis. Because the study was observational and not randomized, it is unclear whether other factors influence referral to trauma treatment, such as active symptoms or patient request. It is also possible that veterans who remain in buprenorphine treatment had more contact with mental health providers and therefore more opportunity to engage in PTSD treatment. Furthermore, we do not have PTSD outcomes for veterans in this study, and future research should investigate trauma outcomes among those receiving concurrent PTSD-OUD treatment. It is also possible that other patient characteristics that could not be ascertained, such as educational attainment, employment status, and housing stability, could be associated with retention. Nevertheless, this research does suggest that further study on the impact of trauma-focused treatment is indicated.
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