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Post-traumatic stress disorder (PTSD) is more severe and difficult to treat when alcohol dependence is present. Most PTSD treatment studies exclude patients with alcohol use disorders, and clinicians are often encouraged not to treat PTSD until substance use is successfully addressed. In this randomized, controlled, 6-month trial, researchers tested the simultaneous efficacy of naltrexone and prolonged exposure (PE; 12 weekly sessions, then 6 biweekly sessions) in 165 patients with comorbid PTSD and alcohol dependence.
All participants received supportive counseling. The four treatment groups were pill placebo, naltrexone, PE plus pill placebo, and PE plus naltrexone. The dropout rate was 32%. All four groups showed at least 60% reduction in drinking, but naltrexone produced significantly greater reductions than placebo. PTSD symptoms also improved in all four groups, but the effect of PE was not statistically significant. However, 6 months after treatment ended, the naltrexone-plus-PE group had the smallest increase in drinking.
Foa EB et al. Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. JAMA 2013 Aug 7; 310:488. (http://dx.doi.org/10.1001/jama.2013.8268)
Comment
This study confirms the beneficial effects of naltrexone in alcohol-dependent patients and shows that reduction in drinking does not aggravate PTSD symptoms. The null effect of prolonged exposure is at variance with recent studies showing efficacy of cognitive-behavioral therapy in patients with these comorbidities. Although the small sample and dropout rate may have limited the researchers' ability to detect effects, some comorbidly ill subjects may respond better to cognitive-behavioral therapy than the more emotionally arduous PE. In any event, this study makes it clear that clinicians should seek to institute immediate treatment for both conditions, rather than initially treating only the PTSD.