Effectiveness of a substance use treatment program for veterans with chronic pain and opioid use disorder.

OBJECTIVE: Veterans suffer disproportionately from the combined adverse health impacts of chronic pain and hazardous opioid use. This evaluation involved a substance use treatment program that included medication for opioid use disorder (SATP-MOUD) in a large metro-area Veterans Health Administration (VHA). This form of treatment has become increasingly important during the opioid crisis and is among several important Department of Veteran's Affairs (VA) initiatives to improve treatment for opioid use disorder (OUD), for which chronic pain is often a comorbid condition. METHODS: We compared clinical measures related to substance use and mental health between groups who were considered either engaged or not engaged in completing treatment. The study used propensity score matching methods and Cox proportional hazards models to compare the mortality risk for treated and untreated veterans who had chronic pain with concurrent opioid use. RESULTS: We identified 1559 SATP-MOUD patients with 1 year of pre- and post-treatment follow-time. From those with chronic pain and concurrent opioid use, we matched 478 SATP-MOUD patients to 647 untreated patients. Engaged patients (at least 4 visits in the first 8 weeks of treatment) had significant improvements in Brief Addiction Monitor (BAM) scores and in PHQ-9 depression screening scores compared to those who started treatment but did not meet the engagement threshold. In Cox proportional hazards analysis, participation in SATP-MOUD was associated with a 38% lower mortality risk among veterans with chronic pain and opioid use when compared to the untreated group: (HR: 0.62, 95% CI: 0.47, 0.82). CONCLUSIONS: SATP-MOUD, as delivered in actual practice, was associated with significant improvements in depression and addiction severity scores, and was associated with reduced mortality risk for veterans with chronic pain and OUD.

Comorbid posttraumatic stress disorder and opiate addiction: a literature review.

Treatment of comorbid posttraumatic stress disorder (PTSD) and opioid dependence has been a challenge for many clinicians. There are limited evidence-based guidelines for treatment of this comorbidity. Symptoms of PTSD and opiate dependence may converge, and it is sometimes difficult to differentiate between both conditions. For example, opioid withdrawal symptoms may mimic the hypervigilance and exacerbated startle response of patients with PTSD. A common neurobiologic circuit is suggested for the pathophysiologic mechanism of this comorbidity. There is evidence that opioid substitution therapy may improve treatment outcomes for opioid addiction in patients with comorbid PTSD and opioid dependence. Evidence-based psychotherapeutic intervention is recommended for this population to improve the psychological outcome as well. Combining opioid substitution therapy with evidence-based cognitive behavioral therapy designed for individuals with comorbid PTSD and substance abuse (e.g., Seeking Safety) may improve treatment outcomes in this population. More research is needed to understand the underlying mechanisms for this comorbidity and to improve treatment response.

A controlled trial of the adjunct use of D-cycloserine to facilitate cognitive behavioral therapy outcomes in a cocaine-dependent population.

Cocaine dependence is a chronically relapsing disorder for which its predominant behavioral therapies are associated with only partial efficacy. The goal of this study was to determine if the N-methyl-d-aspartate (NMDA) glutamate receptor partial agonist and cognitive enhancer, d-cycloserine (DCS), could boost the cocaine abstinence and treatment retention goals of cognitive behavioral therapy (CBT). This study employed a placebo-controlled, randomized double-blind trial design of 44 cocaine-dependent men enrolled in a 4-week outpatient Substance Abuse Treatment Program (SATP) at the Atlanta Veteran's Administration Medical Center. Subjects received 50mg of DCS or placebo prior to four weekly sessions of a condensed version of a manual-based CBT for cocaine dependence. Cocaine abstinence and treatment retention measures represented primary outcome variables. Relative to a 12-step based treatment-as-usual, an under-dosed CBT was associated with significant improvements in drug abstinence and treatment retention at 4-weeks and for maintenance of drug abstinence after four more weeks of follow-up. The robust response to the under-dosed CBT was not enhanced by the adjunct administration of DCS at either the 4- or 8-week endpoints. This controlled clinical trial failed to demonstrate an ability of DCS to boost the relapse prevention or treatment retention goals of CBT.