Optimal Treatment of Veterans with PTSD and Comorbid Opiate Use Disorder (OUD)

创伤后应激障碍（PTSD）是退伍军人中的一种严重疾病， 从最近的冲突退伍军人。鉴于创伤后应激障碍在退伍军人中的高发病率， 退伍军人事务部（VA）和国防部（DoD）已经将PTSD的治疗作为优先事项。认知 加工疗法（CPT，CPT-C）是PTSD的标准循证疗法之一， 在VA和DoD的一个大型传播项目中， 创伤后应激障碍最近，VA DoD关于PTSD和急性应激管理的临床实践指南 Reaction（2017）指出，个体创伤治疗应该是治疗的第一线。 尽管努力推出循证疗法，但缺乏对 对患有共病的退伍军人进行干预。 有相当多的证据表明，创伤后应激障碍往往与其他物质使用障碍共病 包括阿片类药物依赖。阿片类药物使用障碍（OUD）是一种有据可查的流行病， 这对退伍军人也有很大的影响。虽然病因不明，但有可能 发生率可能部分是由于过度使用高度成瘾的处方阿片类药物导致医源性 阿片类药物依赖和成瘾性疾病的发展。最近的证据清楚地表明， 处方OUD可能导致对海洛因等街头毒品的依赖。 丁丙诺啡治疗是阿片类药物使用障碍的既定治疗方法;它是 推荐的治疗退伍军人与OUD和它的使用是导致更多的退伍军人保持 丁丙诺啡然而，在那些维持丁丙诺啡治疗的人中， 未知 这项研究的目的是测试一种标准的心理治疗创伤后应激障碍的退伍军人谁也遭受 从OUD。具体来说，这项研究将测试认知加工疗法（CPT）-C是否更有效 在治疗PTSD中，与对照组相比（个体药物咨询或IDC;接近 治疗如往常一样），在退伍军人与创伤后应激障碍和共病OUD谁是维持丁丙诺啡。 其他目标包括对阿片类药物使用的影响、治疗保留、副作用、疼痛耐受性和一般 功能 这将是一项随机、开放标签临床试验。研究分三个阶段。在第一阶段， 在诱导阶段，所有退伍军人（n=160）将开始接受2 mg丁丙诺啡治疗。丁丙诺啡的剂量 将在5-7天内增加;剂量将由临床确定。维持剂量后 丁丙诺啡是达到所有退伍军人将进入第二阶段，治疗阶段。在这个阶段，退伍军人 将被随机分配到CPT-C或标准IDC，持续12周。他们将每周接受心理治疗 也定期（每周，然后每两周，然后每月）进行丁丙诺啡管理，症状 评估和药物补充完成治疗后，退伍军人将被称为丁丙诺啡 诊所进行持续护理，并将进入研究的第三阶段，即随访。在这一阶段，他们将 在治疗完成后1个月和3个月观察。

Post-traumatic stress disorder (PTSD) is a serious disorder among Veterans and affects up to 20 % of Veterans from the recent conflicts. Given the high incidence of PTSD among Veterans, the US Department of Veterans Affairs (VA) and Department of Defense (DoD) have made the treatment of PTSD a priority. Cognitive Processing Therapy (CPT, CPT-C) is one of the standard evidence based therapies for PTSD and was rolled out nationally in a large dissemination project by the VA and the DoD as one of the gold standard treatments for PTSD. Recently the VA DoD Clinical Practice Guidelines on the Management of PTSD and Acute Stress Reaction (2017) have stated that individual trauma focused therapies should be the first line of treatment. Despite the effort in rolling out evidence based therapy, there is a lack of knowledge of the efficacy of these interventions in veterans with comorbid disorders. There is considerable evidence showing that PTSD is often comorbid with other substance use disorders including opioid dependence. Opioid use disorder (OUD) is a well-documented epidemic among the general population, and also has had a significant effect on Veterans. While the etiology is unknown, it is possible that the incidence may be in part due to the overuse of highly addictive prescription opioids leading to iatrogenic opioid dependence and the development of addictive disorders. Recent evidence has clearly shown that prescription OUD can lead to dependence on street drugs such as heroin. Buprenorphine treatment is the established treatment for those with opiate use disorders; it is the recommended treatment for Veterans with OUD and its use is leading to larger number of Veterans maintained on buprenorphine. However, the efficacy of treatments for PTSD among those maintained on buprenorphine is unknown. The objective of this study is to test a standard psychotherapy for PTSD in Veterans who also suffer from OUD. Specifically, this study will test whether Cognitive Processing Therapy (CPT)-C is more effective in treating PTSD, compared to a control group (Individual Drug Counseling or IDC; which approximates treatment as usual), among Veterans with PTSD and comorbid OUD who are maintained on buprenorphine. Other objectives include effect on opiate use, treatment retention, side effects, pain tolerance and general functioning. This will be a randomized, open-label clinical trial. The study has three phases. In Phase one, the induction phase, all Veterans (n=160) will be started on 2 mg of buprenorphine. The dose of buprenorphine will be increased over 5-7 days; dose will be clinically determined. After the maintenance dose of buprenorphine is reached all Veterans will enter Phase two, the treatment phase. During this phase Veterans will be randomly assigned to CPT-C or standard IDC for 12 weeks. They will be seen weekly for psychotherapy and also regularly (weekly, then biweekly, then monthly) for buprenorphine management, symptom evaluation, and medication refill. After completing treatment Veterans will be referred to a buprenorphine clinic for ongoing care and will enter the Third phase of the study, the follow up. During this phase they will be seen 1 month and 3 months after the completion of treatment.