Trauma & recovery

PTSD and Substance Use Are One Problem, Not Two

The traditional advice was to get sober first and deal with the trauma later. The trial evidence does not support the sequence.

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Why they travel together

The overlap is not a coincidence and it is not a character flaw. If a memory arrives uninvited and alcohol reliably takes the edge off it, the drinking is doing something. It is a form of avoidance that works, immediately and every time, which is exactly the profile of a behaviour that becomes entrenched.

The comorbidity has been visible in the epidemiology for decades. In the National Comorbidity Survey, PTSD was found to be highly comorbid with other lifetime psychiatric disorders, substance use disorders among them (Kessler et al., 1995).

The old sequence, and the reason for it

For a long time the standard approach was sequential: stabilise the substance use, achieve a period of abstinence, and only then begin trauma work. The reasoning was straightforward. Exposure-based treatment raises distress, distress drives use, and so trauma treatment might precipitate relapse in exactly the people least able to absorb one.

It is a reasonable hypothesis. It was also, for a long time, untested.

What happened when it was tested

Mills and colleagues (2012) randomised 103 participants meeting criteria for both PTSD and substance dependence to either an integrated treatment delivering prolonged exposure alongside substance use treatment, or usual treatment for substance dependence. The integrated condition produced significantly greater reductions in PTSD symptom severity, and it did so without producing the worsening in substance use that the sequential model had predicted.

The trial did not show that integrated treatment fixes everything, and it should not be read that way. What it showed is that the specific fear underpinning the old sequence, that treating the trauma would make the substance use worse, was not borne out.

Why this matters practically

Under a strict sequential model, a person who cannot sustain abstinence is effectively barred from trauma treatment, while the untreated trauma continues to be one of the main reasons abstinence is hard to sustain. That is a closed loop, and it has kept a lot of people out of care for a long time.

The broader treatment literature supports trauma-focused approaches as more effective than non-trauma-focused ones for chronic PTSD generally (Bisson et al., 2013). Excluding people from those approaches on the basis of a hypothesis that did not survive testing is a harder position to hold than it used to be.

A caveat worth stating

Integrated does not mean unsupervised, and it does not mean the substance use is ignored while the trauma is addressed. It means both are treated as the same clinical problem, in the same room, by someone who is watching both.

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