Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder

SPECIAL REPORT: COMORBIDITIES PART 2

The experience of trauma is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.¹ The most prevalent comorbid disorders among adults with serious mental illness (SMI) are substance use disorders (SUDs).² Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for posttraumatic stress disorder (PTSD).³ Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as psychiatric comorbidities is inadequate to capture the range of symptoms and impairments of this diverse patient population.² Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.

Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate trauma-informed care (TIC) in both SUD and psychiatric settings,^4,5 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the COVID-19 pandemic,⁶ the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.

Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.⁷ Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.⁸ As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.

Integrate TIC and Substance Use Care

There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.¹ Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about patient trauma.⁵ Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.⁴ Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.

Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased PTSD symptom severity is related to substance craving.⁹ Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.

Recognize Trauma as a Primary Pathway to Substance Use

For decades, the pervasive narrative around substance use was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.¹⁰ Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.¹⁰ Conversely, marijuana use has been associated with reductions in opioid use in states with medical cannabis use.¹¹

Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.¹² There is clearly an association between experiences of trauma and substance use, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.⁹ Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.¹³

One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.² ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.²

As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.¹⁴ Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that substance use may have been the only accessible and available coping tool at that time.

When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and recovery.

Partner With Patients Across Multiple Pathways to Recovery

Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.

Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.¹⁵ Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.¹⁶ In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and harm reduction are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.¹⁷

Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.

Approach With Unconditional Positive Regard

When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an art to facilitating an informative interview. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.

Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.

Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.¹⁸ There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.

Engage in Ongoing Knowledge and Skill Development

A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.¹⁸ Formal educational opportunities including fellowships in addiction psychiatry, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.¹⁹ All health care providers practicing clinically are required to participate in continuing education. Due to the opioid epidemic, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.

There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,²⁰ which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.

Concluding Thoughts

As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.

Mrs Robinson is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham. Ms Apicelli serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work. Dr Nolte is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.

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