Version July 2025
INTRODUCTION —
Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) co-occur in many individuals. The co-occurrence of these disorders may alter the presentation, treatment, and outcomes of the disorders [1-3].
The complexity of these comorbidities highlights the importance of recognizing the symptoms of each disorder and treating both conditions. Effective treatment usually requires a comprehensive, patient-centered approach.
This topic reviews the epidemiology, clinical manifestations, and initial management choices specific to individuals with co-occurring PTSD and SUD. Topics addressing these disorders individually are found elsewhere.
●(See "Posttraumatic stress disorder in adults: Treatment overview".)
●(See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)
●(See "Opioid use disorder: Treatment overview".)
●(See "Substance use disorders: Clinical assessment".)
●(See "Alcohol use disorder: Treatment overview".)
●(See "Stimulant use disorder: Treatment overview".)
EPIDEMIOLOGY —
Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) frequently co-occur [4-13]. Epidemiologic survey data suggest that approximately half of patients with PTSD will develop an alcohol or drug use disorder [13]. Individuals with PTSD who are prescribed opioids are also more likely to develop an opioid use disorder than those without this diagnosis (odds ratio 3.0, 95% CI 2.4-3.7) [8]. One study of adults with lifetime trauma exposure and alcohol use suggests that the association is bidirectional; individuals with one of these disorders had increased likelihood of developing the other [12].
Military personnel, in particular, are at increased risk for both PTSD and SUDs [9,14-17].
PATHOGENESIS —
Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) share neurobiologic changes such as alterations in neurotransmitter systems (ie, the noradrenergic system) and hormone regulation pathways (ie, the hypothalamic pituitary adrenal [HPA] axis). Alterations in neurotransmitter function, and dysregulation of stress response systems may be more pronounced in individuals with comorbidity than when either disorder occurs independently.
Noradrenaline systems — Dysregulation in the noradrenaline system may play a role in comorbid SUD and PTSD as evidenced by the following observations:
●Noradrenergic activity has been linked to anxiety and negative affect during opioid withdrawal and has been associated with drug craving and relapse in individuals with cocaine use disorder [18-20].
●Alpha-1 noradrenergic receptor antagonism has been shown to prevent escalation of drug-seeking behavior in preclinical studies [21,22].
●Individuals with PTSD as compared with controls demonstrate higher 24-hour urine norepinephrine levels and higher levels of salivary alpha amylase (a biomarker associated with sympathetic nervous system arousal) upon awakening [23,24].
Alterations in the brain reward system and related structures, such as the amygdala and ventromedial prefrontal cortex, have also been observed among individuals with PTSD and SUD and may contribute to their pathogenesis [25-29].
Hypothalamic pituitary adrenal axis — Extensive research suggests that disruption in normal HPA hormonal feedback (a regulator of the stress response system) is a common physical feature of both substance use and PTSD.
Changes within the HPA axis as a result of long-term alcohol or drug use are hypothesized to contribute to an addictive phenotype [30-32]. Clinical studies of individuals with cocaine use disorder demonstrate that corticotropin releasing hormone promotes drug craving and subjective stress [27].
Studies of PTSD and HPA-axis reactivity are complex and have yielded equivocal findings [28,29,33,34]. However, the majority of studies support enhanced glucocorticoid negative feedback in patients with PTSD, suggesting a hyperactive physiologic stress system. [35-37]. The hyperactive HPA hormonal response is thought to be involved in hyperarousal that is commonly observed in patients with PTSD [38].
Further discussion of the pathogenesis of PTSD is found elsewhere. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Pathophysiology'.)
CLINICAL FEATURES —
Co-occurring substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) often manifest with several nuanced differences from the presentation of these disorders singularly.
●Symptom complexity and severity – Comorbidity is frequently associated with a more complex symptom presentation. Overlapping symptoms such as hypervigilance, trouble sleeping, irritability, and impaired concentration may lead to diagnostic confusion. Additionally, individuals with comorbid conditions often suffer from more severe symptoms than when the conditions occur independently [5].
●Increase in suicidality – Comorbid SUDs and PTSD can heighten the risk of various negative outcomes, including increased suicidal thoughts, suicide attempts, and death by suicide [15,39,40], impaired functioning, and greater likelihood of relapse [41]. (See 'Stabilize patients at immediate risk' below and "Suicidal ideation and behavior in adults".)
●Increased risk factors and reduced functioning – Comorbidity between SUD and PTSD as compared with either disorder alone, is associated with increased risk of trauma revictimization, violence, homelessness, and involvement with the legal system. These additional stressors can further exacerbate symptoms and complicate recovery efforts [5].
●Increased treatment resistance – Individuals with comorbid SUD and PTSD are often more resistant to treatment, have higher rates of treatment dropout, and experience poorer treatment outcomes compared with those with either disorder alone [42].
●Social and environmental factors – Family relationships, socioeconomic status, social support, and access to health care significantly influence the development and course of SUD and PTSD and are frequently worse in individuals with both disorders. For example, individuals with comorbid PTSD and alcohol use disorder tend to have greater exposure to childhood adversities, earlier onset of PTSD, more traumatic events, and reduced social support [43,44].
●Other psychiatric comorbidities – Individuals with both PTSD/SUD have also been shown to have higher rates of additional concurrent psychiatric disorders, such as depression.
INITIAL MANAGEMENT
Stabilize patients at immediate risk — For individuals whose severity of symptoms put them at risk for imminent self-harm, withdrawal, or overdose, we address and stabilize these issues prior to further treatment:
●Individuals at imminent risk of suicide or harm to self – Our initial focus is on the safety of the patient. In individuals with active suicidal thoughts, suicidal plan, or pervasive thoughts of self-harm, we refer for emergency psychiatric evaluation. In many cases, these individuals need hospitalization to maintain safety. Once stabilized, integrated treatment for posttraumatic stress disorder (PTSD)/substance use disorder (SUD) can be initiated. (See "Suicidal ideation and behavior in adults".)
●Individuals with high risk for life-threatening withdrawal – For individuals with alcohol or benzodiazepine physiologic dependence who are at high risk for life-threatening withdrawal, we refer for inpatient medically managed withdrawal from substances prior to further treatment for PTSD/SUD. (See "Alcohol withdrawal: Ambulatory management" and "Management of moderate and severe alcohol withdrawal syndromes" and "Benzodiazepine withdrawal".)
●Individuals at high risk of overdose – We provide individuals using substances associated with a risk of overdose (primarily opioids, benzodiazepines, and alcohol) with comprehensive education (overdose recognition, naloxone administration training) as well as harm reduction strategies (ie, avoiding mixing substances, using support networks, use of clean needles for injection drug users, pharmacotherapy to support abstinence). (See "Opioid use disorder: Treatment overview" and 'Pharmacotherapy' below and "Alcohol use disorder: Pharmacologic management".)
Integrated TF-CBT as first-line treatment — For all individuals with co-occurring SUD and PTSD, our preference for first-line treatment is with an integrated trauma-focused cognitive-behavioral therapy (TF-CBT; with or without pharmacologic management) [10]. (See 'Pharmacotherapy' below.)
Integrated TF-CBT combines evidence-based cognitive and behavioral interventions for both PTSD and co-occurring SUDs [45,46]. The components of individual programs vary but typically include:
●Education and coping skills training for both disorders
●A focus on processing the trauma using cognitive and behavioral techniques such as imaginal exposure, in vivo exposure, or cognitive restructuring
●Relapse prevention and other cognitive-behavioral therapy (CBT) techniques to treat SUD
Additionally, integrated trauma-focused programs using written exposure or cognitive processing therapy (CPT) in the treatment of co-occurring PTSD and SUDs are being developed and tested [47-49].
A meta-analyses and clinical trials support the use of TF-CBT for patients with SUD and PTSD [50-61]. From among integrated TF-CBT, our preference is concurrent treatment of PTSD and SUD using prolonged exposure (COPE).
●Concurrent treatment of PTSD and SUD using prolonged exposure (COPE) – COPE is the integrated TF-CBT with the most evidence in support of its use for individuals with PTSD and co-occurring SUD. COPE is a manualized, 12-session, individual treatment that integrates prolonged exposure (PE) therapy (imaginal and in vivo exposure) for PTSD and CBT for SUD. The format of COPE therapy is as follows:
•Sessions 1 to 2 focus on psychoeducation regarding the interrelationship between PTSD and SUD, common reactions to trauma, coping with cravings and triggers for use (both substance and trauma-related triggers), and the rationale for PE.
•Sessions 3 to 12 include in vivo exposure exercises, which are typically conducted in between sessions.
•Sessions 4 to 11 include imaginal exposure followed by processing the thoughts and feelings related to the traumatic experience.
•SUD topics are interweaved throughout the treatment; examples include awareness and management of cravings and thoughts about using, anticipating and managing high-risk situations, and effective alcohol/drug refusal skills.
Trials investigating the use of COPE in patients with PTSD and SUD have found improved outcomes on measures of PTSD severity and some measures of substance use [51,53,57,62,63]. For example, in one trial, 81 veterans with SUD and PTSD were randomly assigned to 12 sessions of treatment with COPE versus relapse prevention (RP), a manualized treatment that teaches skills to help manage cravings and avoid high-risk situations [62]. At treatment end, treatment with COPE as compared with RP led to a greater decline on measures of PTSD symptom severity (Clinician-Administered PTSD Scale mean difference: 25.6, 95% CI 11.3-49), and a greater percentage of individuals no longer met criteria for PTSD (59 versus 22 percent, respectively; odds ratio 5.3, 95% CI 1.8-15.7). Comparable reductions in SUD severity during treatment were reported while at six-month follow-up, participants in COPE evidenced fewer drinks per drinking day than those receiving RP.
Other psychotherapy as first line — When integrated trauma-focused therapy is unavailable, we use nonintegrated trauma-focused treatments (ie, PE or CPT) combined with evidence-based treatment for SUD (eg, psychotherapy or medication for SUD) [64-66]. (See "Opioid use disorder: Treatment overview" and "Alcohol use disorder: Treatment overview".)
These psychotherapies are mentioned below and discussed further elsewhere. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Types of trauma-focused therapies'.)
●Prolonged exposure (PE) therapy – PE, a single component of COPE, is a trauma-focused treatment for PTSD that appears to be effective (when combined with evidence-based treatment for SUD) in individuals with co-occurring SUDs and PTSD [54,67,68]. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Types of exposure therapy'.)
Clinicians can receive training in PE therapy through the National Center for PTSD, the STRONG STAR Training Initiative, or the Center for the Treatment and Study of Anxiety. Online training in CBT for SUDs can be found at CBT4CBT or the Beck Institute for Cognitive Behavior Therapy.
●Cognitive processing therapy (CPT) – CPT is a TF-CBT for the treatment of PTSD. CPT is typically delivered in 12 sessions. Studies examining the use of CPT among individuals with PTSD and co-occurring SUD or substance misuse show some benefit [69-73].
For example, in a randomized trial 101 participants with PTSD and alcohol use disorder were assigned to CPT versus relapse prevention therapy versus assessment only [69]. CPT led to significantly greater improvement in PTSD severity as compared with the assessment only condition. Both active treatments (CPT and relapse prevention) showed reductions in alcohol use, with relapse prevention having greater reductions in heavy drinking. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Cognitive-behavioral therapy'.)
PE and CPT have not been directly compared with COPE but have been directly compared with one another. In a trial of 916 military veterans that compared PE with CPT (using flexible dose of 10 to 14 sessions), both treatments demonstrated significant and meaningful reductions in PTSD symptoms [74]. Patients randomized to PE had statistically higher odds of treatment response, loss of PTSD diagnosis, and remission compared with those randomized to CPT, but PE had a higher dropout rate than CPT. In most cases the selection of psychotherapy is based on shared decision making, including practitioner level of comfort, patient preference and availability of treatment.
Pharmacotherapy — Our preference for pharmacologic management of individuals with co-occurring PTSD and an SUD is similar to our treatment of each of these disorders alone.
Addressing symptoms of PTSD in co-occurring disorders — We commonly initiate pharmacotherapy, typically with a selective serotonin reuptake inhibitor, to manage PTSD symptoms (eg, hyperarousal, mood changes) in patients who do not respond to TF-CBT, who prefer medication, or when symptoms are severe enough to interfere with daily life or therapy participation.
We counsel patients about possible, though extremely rare, interactions between serotonergic medications and certain substances such as 3,4-methylenedioxymethamphetamine (MDMA), opioids, cocaine, and amphetamines. Theoretically, there is an increased risk of serotonin syndrome including hyperthermia, diaphoresis, agitation, diarrhea, tremor, hyperreflexia, dilated pupils, and seizures [75]. (See "Posttraumatic stress disorder in adults: Treatment overview" and "Serotonin syndrome (serotonin toxicity)".)
Addressing SUD in co-occurring PTSD — Our preference is to manage the co-occurring SUD with pharmacotherapy as follows:
PTSD and alcohol use disorder — For individuals with alcohol use disorder with co-occurring PTSD, we recommend offering pharmacotherapy to reduce cravings and alcohol use alongside trauma-focused treatment. Our choice for initial pharmacologic management of these individuals is with naltrexone. However, if the individual’s goal of treatment is complete abstinence, we may offer disulfiram. This is especially true in individuals who have the added benefit of supervised taking of medication (eg, social support). These individuals tend to fare substantially better than controls with regards to sustained abstinence [76]. (See "Alcohol use disorder: Pharmacologic management" and 'Pharmacotherapy' below.)
Both naltrexone and disulfiram have been shown to be safe and effective in the treatment of alcohol use disorder with co-occurring PTSD [45,54,77].
●In one trial, 93 military veterans with PTSD and alcohol use disorder were randomly assigned to 12 weeks of treatment with naltrexone, disulfiram, the combination, or placebo [77]. Participants were required to be abstinent from alcohol for at least three days prior to randomization, and the goal of the study was complete abstinence from alcohol. All patients showed improvements in overall symptoms and in re-experiencing, avoidance, and hyperarousal symptoms of PTSD. Patients assigned to either naltrexone or disulfiram as compared with placebo had a greater number of consecutive days of abstinence (69 versus 76 versus 50, respectively) and lower percentage of heavy drinking days (5 versus 2 versus 10 percent, respectively).
●In a randomized trial including 165 participants with PTSD and alcohol use disorder, the efficacy of naltrexone, PE therapy, and their combination or supportive counseling were examined [54]. Participants completed outpatient medically managed withdrawal for alcohol use disorder and were required to be abstinent from alcohol for at least three days prior to beginning the treatment phase of the trial. All participants experienced a reduction in the percentage of days drinking and PTSD symptoms during the trial. However, naltrexone led to a lower percentage of days of drinking compared with placebo (5 versus 13 percent, respectively) and lower craving compared with placebo. Exploratory analyses revealed that individuals who received exposure therapy plus naltrexone were more likely to achieve a low level of PTSD symptoms at six months follow-up (70 percent) than those who received exposure therapy plus placebo (55 percent), supportive counseling plus naltrexone (44 percent), or supportive counseling plus placebo (37 percent). At six-month follow-up, while all groups had increases in the percentage of days drinking (compared with initial posttreatment assessment), the smallest increase was found for those who received exposure therapy (4 percent) compared with those who did not receive exposure therapy (16 percent).
PTSD and opioid use disorder — Our preference for the management of PTSD and co-occurring opioid use disorder is with integrated TF-CBT (eg, COPE) combined with medication management addressing the opioid use disorder. (See 'Integrated TF-CBT as first-line treatment' above.).
Our pharmacologic management of the opioid use disorder in individuals with co-occurring PTSD is similar to pharmacologic management of OUD alone and is discussed elsewhere. (See "Opioid use disorder: Pharmacologic management", section on 'Approach to treatment'.)
Individuals with opioid use disorder and PTSD are at higher risk for more severe opioid use, higher rates of depression, attempted suicide, and psychosocial difficulty [78].
PTSD and other SUD — Minimal data support specific integrated treatment in the management of PTSD with other SUDs (eg, cannabis use disorder, stimulant use disorder). We treat these disorders as we would treat each of them individually. (See "Posttraumatic stress disorder in adults: Treatment overview" and "Stimulant use disorder: Treatment overview" and "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)
Monitoring — Monitoring response to therapy in patients with comorbid PTSD and SUDs involves ongoing assessment of various factors related to both conditions. While specific criteria may vary depending on the severity and complexity of each case, as well as the individual's treatment goals, some common benchmarks for treatment response include:
●PTSD symptom severity monitoring – Initially, we evaluate treatment progress by monitoring of PTSD symptoms and substance use at weekly intervals (or at each session). Typically, we use the brief self-report measure, PTSD Checklist for DSM-5 (PCL-5), to track PTSD symptoms and monitor response to treatment. Patients can also use mobile apps (eg, the PTSD Coach or PE Coach apps) to track their symptoms. When improvement in symptoms is obtained, we typically reduce the frequency of monitoring to monthly.
●Abstinence or reduction in substance use – We review the individuals self-report of substance use at each visit. Craving levels can also be systematically tracked using simple self-report measures of craving intensity and frequency including craving diaries or logs or digital substance use tools. Diaries or digital tracking tools can also facilitate identification and correlations between PTSD symptoms and cravings.
If available, we obtain laboratory testing (ie, urine drug testing and ethyl glucuronide for alcohol use) to establish a baseline pattern of use, and then weekly or biweekly during the initial phase of treatment, and monthly or quarterly once stable improvement is noted, usually discontinuing regular testing once remission has been sustained for a year or more.
Some clinicians and patients may prefer the use of digital daily substance use tracking tools to improve accurate recall of substance use. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) website Rethinking Drinking has tools for monitoring daily alcohol use. Mobile apps are also available such as VetChange.
●Coping skill development and use – A patient’s effective use of coping strategies to manage distress and cravings should be routinely discussed, either as part of a psychotherapy treatment program, or during visits for medication management. For patients not currently engaged in psychotherapy, referrals should be offered to enhance their ability to manage cravings effectively.
●Treatment adherence – Individuals with PTSD and SUD are at higher risk for loss of follow-up. Accordingly, treatment satisfaction should be routinely asked about, and barriers to treatment adherence (ie, low motivation, side effects of medications, or logistical challenges) should be addressed. (see "Substance use disorders: Motivational interviewing"). We recommend seeing patients once or twice per week during the early phase of treatment (eg, first three months). Once significant improvements in PTSD and SUD symptoms have been achieved, frequency of sessions can decrease over time.
SUBSEQUENT TREATMENT —
Further treatment decisions are guided by response to treatment; however, our preference is to make all decisions using shared decision making.
Good response — A good response to treatment can be defined by both subjective and clinician assessment. A good response may include abstinence or significant reduction in substance use, psychologic stability, and improved functioning. Treatment response should ideally reflect patient goals of treatment with regard to each of these components. (See 'Monitoring' above.)
If a patient has fully achieved their treatment goals, it is usually recommended that they continue pharmacotherapy for at least one year (ie, until they have achieved sustained remission) and may continue pharmacotherapy indefinitely if the patient prefers.
Additionally, if good response is achieved, we typically continue psychotherapy through completion of the treatment program (eg, 12 sessions) at which point the frequency of cognitive-behavioral therapy (CBT) is typically decreased to monthly visits or booster sessions. We make this decision based on patient need and preference, continuing psychotherapy if ongoing support is needed. As psychotherapy frequency is tapered, we recommend patients consider engaging in community or self-management programs, such as Self-Management and Recovery Treatment (SMART) Recovery or Alcoholics Anonymous (AA).
Inadequate response — For individuals with inadequate response to treatment, our next step is to review and address factors that may be contributing to inadequate response such as the adherence to medication, level of motivation, length and frequency of therapy sessions, and completion of home therapy assignments (eg, practice in vivo exposure exercises).
Psychotherapy — Our next step is to consider integrated, nontrauma-focused treatment. Seeking safety is a manualized nontrauma-focused integrated CBT that provides psychoeducation and coping skills. Trials investigating seeking safety in individuals with posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have shown limited evidence of efficacy [79-82].
Options for further treatment include increasing the frequency or intensity of integrated treatment, or directly addressing other persistent symptoms (eg, insomnia, pain, family/relationship distress) with appropriate treatment. (See 'Pharmacotherapy' below.)
Emerging research suggests the written exposure therapy, a nonintegrated trauma-focused therapy, may also be beneficial for patients with PTSD/SUD, but more research is needed [10]. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Exposure-based therapies' and "Posttraumatic stress disorder in adults: Treatment overview", section on 'Management of suboptimal response'.)
Pharmacotherapy — Other agents may be useful when response to treatment is inadequate; however, limited data support these agents in the treatment of co-occurring PTSD and SUD. Therefore, our choice is based on clinical experience and patient preference.
●Topiramate – While topiramate is not specifically US Food and Drug Administration (FDA)-approved for the treatment of alcohol use disorder, it has a rising body of evidence to support its use in alcohol use disorder as well as cocaine use disorder. Further, topiramate appears to be effective in reducing alcohol consumption and craving and decreased PTSD symptom severity in veterans with PTSD and alcohol use disorder [83] .(See "Alcohol use disorder: Pharmacologic management", section on 'Topiramate'.)
●Gabapentin – Gabapentin appears to improve sleep quality, cravings, withdrawal symptoms, abstinence rates, and anxiety levels in individuals with various SUDs and is specifically considered a second-line treatment for alcohol use disorder [84-91]. Gabapentin has not been evaluated for sleep disturbances specifically associated with PTSD in a controlled trial, but a previous case series of 30 individuals showed evidence of increased sleep duration and decreased frequency of nightmares [86]. (See "Alcohol use disorder: Pharmacologic management", section on 'Second-line agents'.)
●Prazosin – Prazosin has been found to reduce sleep disruption and nightmares in some studies of patients with noncomorbid PTSD. While studies are relatively limited, a majority of previous clinical trials of prazosin in patients with co-occurring PTSD and alcohol use disorder suggest that prazosin may reduce alcohol use and cravings, although its effects on PTSD sleep impairments have not been studied in the comorbid population [92,93]. (See "Posttraumatic stress disorder in adults: Treatment overview", section on 'Additional considerations for specific populations or symptoms'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions worldwide are provided separately. (See "Society guideline links: Anxiety and anxiety disorders in adults" and "Society guideline links: Opioid use disorder and withdrawal" and "Society guideline links: Benzodiazepine use disorder and withdrawal" and "Society guideline links: Alcohol use disorders and withdrawal" and "Society guideline links: Stimulant use disorder and withdrawal" and "Society guideline links: Cannabis use disorder and withdrawal".)
SUMMARY AND RECOMMENDATIONS
●Co-occurring substance use disorders (SUD) and posttraumatic stress disorder (PTSD) – SUDs and PTSD co-occur in many individuals. The co-occurrence of these disorders may alter the presentation, treatment, and outcomes of the disorders. Effective treatment usually requires a comprehensive, patient-centered approach to treatment. (See 'Introduction' above.)
●Clinical features – Co-occurring SUD and PTSD often manifest with several nuanced differences from the presentation of these disorders singularly. (See 'Clinical Features' above.)
These include:
•Greater symptom severity and complexity
•Increased triggers and reduced overall functioning
•Increased risk of death by suicide
•Higher rates of treatment resistance
•Higher rates of additional psychiatric disorders (eg, depression)
●Initial Management
•Stabilize patients at immediate risk – For individuals whose severity of symptoms put them at risk for imminent self-harm, withdrawal, or overdose, we address and stabilize these issues prior to further treatment. (See 'Stabilize patients at immediate risk' above.)
•Integrated psychotherapy as first line for all – A comprehensive treatment approach that integrates interventions for both PTSD and SUD is preferred and appears to improve outcomes.
For individuals with co-occurring PTSD and an SUD (eg, alcohol use disorder, opioid use disorder), we suggest treatment with concurrent treatment of PTSD and SUD using prolonged exposure (COPE), rather than other types of psychotherapy (Grade 2C).
If integrated trauma-focused psychotherapy is unavailable we use nonintegrated trauma-focused treatment (such as cognitive processing therapy) combined with evidence-based treatment for SUD. (See 'Other psychotherapy as first line' above.)
•Pharmacotherapy – For patients with moderate to severe symptoms of PTSD (eg, hyperarousal, mood changes), we suggest adjunctive treatment with a selective serotonin reuptake inhibitor (SSRI) (Grade 2C). SSRIs are also an alternative to trauma-focused cognitive-behavioral therapy (TF-CBT) if patients prefer pharmacotherapy or if TF-CBT is not an option. (See 'Addressing symptoms of PTSD in co-occurring disorders' above.)
We use pharmacotherapy to address the SUD in individuals with PTSD and co-occurring alcohol use disorder or opioid use disorder. (See 'PTSD and alcohol use disorder' above and 'PTSD and opioid use disorder' above.)
Minimal data support specific integrated treatment in the management of PTSD with other SUD (eg, cannabis use disorder, stimulant use disorder). We treat these disorders as we would treatment of each of these disorders individually. (See "Stimulant use disorder: Treatment overview" and "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)
•Monitoring – A good response to treatment for comorbid PTSD and SUDs is typically defined by a combination of clinical indicators, functional improvements, and individual treatment goals. Common benchmarks for treatment response include PTSD symptom severity and diagnostic remission, significant reduction in substance use or abstinence, improved coping skills, treatment adherence, and psychologic stability. (See 'Monitoring' above.)
●Subsequent management – When response to treatment is inadequate after trials of first-line behavioral interventions and pharmacotherapy we review and address factors that may be contributing to inadequate response. Our next step is considering a trial of integrated nontrauma-focused therapy and addressing other persistent symptoms (eg, insomnia, pain, family/relationship distress) with appropriate treatment. However, limited data support these options. (See 'Subsequent treatment' above.)
