Cognitive Behavioral Therapy for PTSD in Addiction Treatment: A Randomized Pilot Trial

The main hypothesis being tested is that a cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD) can improve treatment retention and outcomes for both posttraumatic stress and substance use disorders. The investigators have completed a Safety & Practicality Study and a Feasibility Study and both studies found that CBT for PTSD was safe and effective in reducing PTSD symptoms, improving retention, and in reducing substance use. The present study proposes to continue testing the hypotheses by evaluating and comparing the PTSD, retention and substance use outcomes resulting from CBT versus a control condition. This is termed the "Pilot Trial" phase of behavioral therapy development and requires comparing the investigational treatment (CBT) with a control treatment, within the context of addiction treatment-as-usual (intensive outpatient programs or methadone maintenance clinic settings). The results of this study will then be used to develop a RO1 grant application to NIDA to support a Stage II efficacy study (randomized controlled trial).

Our objective is to test the following specific hypotheses:

CBT for PTSD (plus addiction treatment-as-usual) vs. IAC (plus addiction treatment-as-usual): 1) Reduces PTSD symptoms; 2) Improves addiction treatment retention; and, 3) Reduces substance use and severity. A hierarchy of effects is hypothesized. The target of the CBT is PTSD symptoms, which if reduced, will favorably leverage both treatment retention and substance use, above and beyond the equivalence in type and amount of treatment in both conditions.

This study involves is a two-group repeated measures design. Within the NIDA stage model, it is a randomized, pilot trial with a matched-attention control condition. The investigators plan to examine outcomes associated with the intervention versus control condition among patients receiving outpatient addiction treatment services (intensive outpatient program or methadone maintenance program). The investigators will employ assessments at baseline, during therapy, post-therapy, and three-month follow-up. Eligible subjects will be randomly assigned to the study CBT therapy (plus addiction treatment-as-usual) or the matched attention control condition (individual addiction counseling [IAC] plus addiction treatment-as-usual), and all will be followed for the research assessments regardless of whether they drop out of treatment early (whenever possible).

Patients admitted to the participating addiction treatment programs are routinely screened for PTSD using a brief self-report survey, the PTSD Checklist (PCL). These forms are collected by clinical staff of the treatment program and scored for PTSD diagnostic criteria. Patients scoring 44 or greater on the PCL are approached by a clinic staff about potential interest in the study. If they wish to learn more about the study, the research coordinator (an on-site employee) is contacted, a suitable time arranged, and the patient engaged in the process of informed consent.