With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject:
Anka Vujanovic is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at Houston. Vujanovic leads the Trauma and Addiction Research Program in the Center for Neurobehavioral Research on Addiction. She holds a Ph.D. in clinical psychology. Her primary research interest is focused on better understanding biopsychosocial mechanisms underlying the co-occurrence of post-traumatic stress and substance use disorders, with the ultimate goal of developing more effective, evidence-based treatment programs. She is also the director of psychology services at the UT Harris County Psychiatric Center and holds appointments as adjunct assistant professor in the Department of Psychology at the University of Houston and as W.O.C. research psychologist at the Michael E. DeBakey VA Medical Center.
Editor's note: This interview has been edited for length and clarity.
Trib+Health: You're looking at the connection between PTSD and drug use in recovery. What have you seen in your recent research?
Anka Vujanovic: In our study, we are trying to develop a new treatment for people with PTSD and substance abuse disorders. PTSD and substance use very commonly co-occur. There really aren’t that many treatment options available for people that are struggling with both conditions. We’ve developed a new integrated treatment that really tries to target both PTSD and substance use together in a 12-session, individual therapy.
It is a cognitive behavioral therapy. We do some coping skills, we provide psycho-education and we do a lot of cognitive processing about their substance use and their trauma along with their PTSD symptoms.
We talk to them a lot about their thoughts and feelings related to the trauma and their substance use and we help them kind of really access their thoughts and feelings about it and do a lot of cognitive and emotional processing of the trauma and their substance use and its impact on their life.
We are comparing that treatment to cognitive behavioral therapy for substance use disorders. The comparison treatment does not contain any focus on the trauma or the PTSD per se, so that is the comparison.
Trib+Health: How widespread of an issue is this, especially here in the state?
Vujanovic: It is really significant. If you look at people with addiction, with substance use problems, typically about half of them have PTSD. When you define addiction as alcohol or drug addiction, it is about 50 percent. It is a significant co-morbidity for people.
Historically, these things were treated sequentially. So if you were identified to have PTSD and to also be struggling with addiction, typically you would be referred to work on your addiction first. When you were clean and sober, you could then engage in the PTSD treatment.
What we’ve been finding through the years is that approach really didn’t work so well because these conditions were so interwoven where people, even if they would go to residential treatment for the addiction, they would relapse so quickly if they had PTSD because the substances were really helping them to cope with their trauma symptoms. In the absence of the substances, they would relapse.
They didn’t really have a way to cope with the PTSD. You really need to help them to dampen their PTSD symptoms at the same time that you are working with them to work on their addiction. That way, if they do get clean and sober and their PTSD symptoms are dampened, they have a better chance of successfully staying off of substances.
There has been a movement toward integrated, or concurrent, treatment where you kind of target both at the same time, instead of one then the other.
Trib+Health: To clarify, this treatment doesn’t involve any medical drugs, correct?
Vujanovic: It is completely not medication. It is psychotherapy and research where we compare one type of cognitive behavioral therapy with integrated treatment to a different cognitive therapy that is just focused on substance use.
We are expecting that it will help people with both the PTSD symptoms and their substance use better than the other.
Trib+Health: How do you measure how much better one is than the other?
Vujanovic: We have clinical interviews and self-report measures of their PTSD symptoms. We also have them report weekly on their substance use, what substances they use, how much they use. We also biochemically verify substance use with urine analysis at each study appointment, which screens for all kinds of substance use, in addition to getting their self-report.
Trib+Health: For many people, PTSD is something associated with military service. Is that connection reflected at all in your research?
Vujanovic: We do have veterans in our study, but in reality trauma takes many forms. We are not selecting for the type of trauma for this study. People just need to met the criteria for PTSD, so we are seeing a lot of rape survivors. We are certainly seeing military combat trauma. We are seeing childhood sexual and physical abuse survivors, as well as community gun violence, interpersonal violence, which takes many forms. So we are seeing a lot of different types of trauma in our study.
Trib+Health: In the conversation therapy, is there a concern about people returning to a traumatic setting?
Vujanovic: None of our people so far have been in actively domestic violence situations or anything like that, but certainly if they were, we would work to address that during treatment.
We have a good portion of folks in our study that are from low income, inner city neighborhoods, where they are exposed to violence by virtue of where they live.
In a lot of ways, the first step for them to either deal with their environment better or transition to a safer community is to address their PTSD and substance use issue. In a lot of ways, it is kind of the step that would enable them to maybe make other changes. That's certainly a significant portion of the people we are seeing.
Trib+Health: Are people living in lower incomes and urban areas more prone to traumatic experiences?
Vujanovic: Not necessarily, but certainly to using illicit drugs, like crack cocaine. By virtue of your substance use and the communities you are going in to to buy the drugs and the people they are interacting with in order to purchase or use the drugs, that typically exposes people to greater levels of interpersonal violence.
Overall, trauma really affects people across socioeconomic status. Things like childhood sexual or physical abuse, domestic violence, interpersonal violence, motor vehicle accidents, things like that, they cut across all different levels of socioeconomic status.