Examining approaches to treating traumatic stress and substance use among young people

Project: COPE-A 

Lead Researcher: Professor Katherine Mills

Research has shown that experiencing trauma during childhood or adolescence is associated with a much higher risk of developing problems such as substance use disorder (SUD). Approximately one-third to one-half of people managing SUD after experiencing trauma are also managing symptoms of post-traumatic stress (PTSD) and are using the substance to treat PTSD symptoms.  

Although they may achieve a short-term reduction in symptoms, over the longer-term substance use may perpetuate the symptoms of PTSD and interfere with recovery, and a cycle can develop whereby both conditions may become mutually maintaining.

So, how do we intervene?

While exposure-based therapies are considered a gold standard for treatment of PTSD, providers expressed concerns it would lead to increased substance use to manage the intense emotions associated with therapy.  

To bridge a solution, the team, led by Professor Katherine Mills at the Matilda Centre, conducted a randomised controlled trial on a therapy that addressed both substance use AND post-traumatic stress symptoms among adults – Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure, now known as COPE.  

The trial was successful, with greater reductions in PTSD symptom severity for receiving COPE compared to those who received usual care. Close to one-half of those randomised to receive COPE no longer met criteria for PTSD, relatively to one-in-five in the control condition. Reductions in PTSD symptom severity were also associated with reductions in the severity of substance use.

With this success, and with the aim of intervening earlier, the team is adapted the program for adolescents and young people (aged 12-25 years). Known as COPE-A, the program is optimised to meet the developmental needs of young people, and another randomised controlled trial is underway to measure its effectiveness.

We joined Professor Mills to learn more about COPE-A and treating substance use and post-traumatic stress. 

This project has been part of a program of work we have been conducting over many years. Consistent with research from other parts of the world, we have found very high rates of trauma exposure and PTSD among people experiencing problems related to their alcohol or other drug use. For many experiencing these co-occurring issues, their problematic substance use comes about, at least in part, as a result of using alcohol or other drugs repeatedly to self-medicate their trauma-related symptoms and the associated distress.  

Although there are evidence-based treatments for PTSD, people experiencing problems with their substance use were traditionally denied access to these due to concerns regarding safety and effectiveness. So, with our international collaborators, we started examining whether this could be done safely and effectively by integrating evidence-based treatment for substance use and evidence-based treatment for PTSD and treating both conditions at the same time using a therapy called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). 

In our first randomised controlled trial for adults, those randomised to receive COPE in combination with treatment as usual for their substance use demonstrated significantly greater reductions in PTSD relative to those who received treatment as usual for their substance use alone. These were accompanied by significant reductions in substance use. Since then, several other trials of the COPE therapy have been conducted around the world demonstrating similar results.

It is important to note that not all integrated treatments share the same level of efficacy. There is clear evidence from systematic reviews and meta-analyses that integrated treatments that are trauma-focused are effective, but the same is not true of integrated therapies that are non-trauma-focused – that is,  therapies that do not involve revisiting traumatic memories and instead focus on coping skills.  

There are a number of advantages to treating both conditions simultaneously as they are so interrelated. From a practical perspective it also means the person receives more holistic care that is internally consistent, and they are less likely to fall between the cracks of substance use and mental health services than if they are needing to navigate providers from both separately.

I hope that this research can help to inform our knowledge as to how we can most effectively and safely treat these commonly co-occurring conditions, early in the development, and that people may have increased access to best evidence-based care if it can be delivered safely and efficaciously both in person and  via telehealth. 

COPE-A is beginning recruitment for a new trial comparing COPE-A delivered in person or via telehealth. If you are 12-25 years of age and interested in participating or a clinician interested in referring, please register your interest.