Yale Psychiatry Grand Rounds: September 29, 2023
September 29, 2023Innovations in Research for Treatments of PTSD and Substance Use Disorders: The Next Decade in Combined Pharmacotherapy and Behavioral Approaches
Speaker: Denise Hien, PhD, Distinguished Professor; Helen E. Chaney Endowed Chair in Alcohol Studies; Vice Provost of Research; Director, Center of Alcohol and Substance Use Studies, Rutgers-New Brunswick
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Transcript
- 00:00Here to be here
- 00:03and I'm just letting everyone know.
- 00:05I'm pipelining in from my private
- 00:07practice office in New York City where
- 00:10I maintain a very small practice.
- 00:12And despite the the various other
- 00:14things that I spend my time doing.
- 00:17Because I, you know, and I say that
- 00:19because I'm a clinician obviously,
- 00:20as well as a scientist and very pleased to
- 00:25be able to talk to you today about the,
- 00:29you know, sort of the state of science
- 00:33in our field and you know where
- 00:36where I think the field is going,
- 00:38hopefully the signal will hold.
- 00:41We're in the midst of a giant rainstorm,
- 00:44which I think is affecting you guys as well.
- 00:46But we just had a flash flood warning.
- 00:49So I'm going to share my screen now
- 00:52and spend some time talking about the
- 00:55landscape and then hopefully we'll have
- 00:58some time for some questions and discussion.
- 01:01So let's see.
- 01:04Are you guys seeing my presentation now?
- 01:07Yes, yes. OK, fantastic.
- 01:09I'm just going to get you
- 01:12out of my way a little bit.
- 01:13And then will take it away.
- 01:16So I've spent the bulk
- 01:18of my career as is mini,
- 01:20you know introduced it doing clinical
- 01:23multi single site and multi site trials.
- 01:26The single site trials I spent most
- 01:29of my career in New York City,
- 01:31working with agencies and
- 01:33communities in Harlem and Fort
- 01:36Washington and Upper Manhattan,
- 01:38mostly minoritized populations and
- 01:40testing different types of interventions,
- 01:44both behavioral and also combined
- 01:48pharmacotherapy interventions to
- 01:50address trauma, post traumatic stress,
- 01:53and substance use disorder.
- 01:54So the bulk of what I'm talking about
- 01:57kind of comes from my experiences here,
- 02:00although I have moved into the sphere
- 02:02of data science and using big data,
- 02:05which in our field you know constitutes
- 02:09pooling together clinical trials
- 02:11that are usually somewhere between
- 02:1350 and 100 participants per trial.
- 02:17So the big data allows us to look
- 02:20at sample sizes of like 4500 and
- 02:23and going up into the future.
- 02:25So I'll be talking about that
- 02:27as I think a promising Ave.
- 02:29for the future in before I get fully started.
- 02:34First of all,
- 02:35want to do a small land acknowledgement,
- 02:38just that where I am in New Jersey
- 02:41and also in New York City where we
- 02:43do our scholarship and research,
- 02:45it stands on the land that is ancestral
- 02:48territory of the Lenape peoples.
- 02:50And we pay respect to indigenous
- 02:53peoples throughout this diaspora,
- 02:55past, present and future,
- 02:57honoring all those who've been historically
- 03:00and systematically disenfranchised
- 03:02And acknowledge that New York,
- 03:04New Jersey and the United States
- 03:07was founded upon exclusions and
- 03:08erasures of indigenous peoples.
- 03:10And that's the disclosure that
- 03:11I would like to make.
- 03:13I have no other disclosures other than
- 03:16my my career long funding with the
- 03:20the National Institutes of Health.
- 03:23So just to bring us right to the our,
- 03:25our who we work with and what you
- 03:29know what it feels like for patients,
- 03:31for individuals with lived experience
- 03:34who have both traumatic stress related
- 03:37problems and also substance use problems.
- 03:40I know it ravages my life.
- 03:43But when I'm high I don't have to feel it.
- 03:45The trauma in my body, in my soul.
- 03:49I can disappear a few hours,
- 03:51a few days, a few weeks,
- 03:53a break from those relentless memories.
- 03:56Well, at least I'll know exactly how
- 03:58I will feel when I use substances,
- 04:01good, bad or ugly.
- 04:03Otherwise,
- 04:04I'm all over the place.
- 04:05These are some of the sentiments
- 04:08of individuals who we strive
- 04:11to help with their conditions.
- 04:14And I'm very happy to say as as a
- 04:18starting point that we have a lot
- 04:21of answers that we didn't have.
- 04:23You know,
- 04:23in over the decades of all of us who've
- 04:26been and doing research in this these areas,
- 04:29it's really led to a groundswell of
- 04:32knowledge that I'm going to share with you.
- 04:35You know sort of the big picture of what do
- 04:37we know in terms of comorbidity and
- 04:39consequences, what do we know in terms
- 04:42of the science of integrated PTSD&SUD
- 04:45care and then how do we apply it
- 04:48in integrated treatment frameworks.
- 04:50And really the challenge for all of
- 04:52us who are are continuing to work
- 04:55in this field is dissemination,
- 04:57dissemination, adoption, dissemination.
- 04:58Because even though we know a lot,
- 05:02there is still a gap and a barrier
- 05:05between what we do know as from our
- 05:07science and from our clinical trials and
- 05:10what is being practiced in the community.
- 05:12Even though we do know a lot more.
- 05:15And you know from your agencies and working
- 05:18with agencies the concepts of trauma,
- 05:19informed care and the importance of
- 05:21doing work in these spaces and bringing
- 05:24together people with substance use
- 05:26and mental health issues broadly.
- 05:28But we still have a lot of,
- 05:32a lot of room to still do work and
- 05:37understand more about dissemination
- 05:38and implementation.
- 05:39So first,
- 05:40what do we know about the scope
- 05:42of the problem And this is a slide
- 05:44that everyone has seen that speaks
- 05:46to opioid overdose deaths,
- 05:48which is one way that we have,
- 05:50you know, come to understand this,
- 05:52the significance of the problem
- 05:55of addiction in our country.
- 05:58And these numbers,
- 05:59you know are now upwards of 100,000
- 06:02deaths per year through due to opioids,
- 06:06prescription drugs, synthetics, fentanyl.
- 06:07It's really shifted over to fentanyl
- 06:10and now other other substances.
- 06:13But you know,
- 06:16we and and as a nation we've come to
- 06:19some understanding of the importance of,
- 06:21you know,
- 06:22D stigmatizing addiction as as the
- 06:25rates of deaths of white young men
- 06:29actually were rising most dramatically.
- 06:31And I think really tapped the
- 06:35nation's understanding in a way
- 06:37that the substance use, you know,
- 06:40criminalization of substance use and
- 06:42problems that have faced our black
- 06:45and brown communities, you know,
- 06:47have been going on for decades.
- 06:48You know as since the Rockefeller
- 06:50laws were in place, you know,
- 06:52prior to Nixon,
- 06:53you know,
- 06:53so it's been going on for a long time.
- 06:56But it I still think it's good
- 06:57that we have more recognition about
- 06:59the importance of addiction and
- 07:01and facing addiction.
- 07:03And just to show that in
- 07:06in the curves that we see,
- 07:08there's sort of it's there's a coming
- 07:10down in terms of opioid overdose deaths.
- 07:13It's still a steep increase
- 07:16for for white populations.
- 07:18But what we see is that the
- 07:21rise for individuals,
- 07:24you know from Latinx and African American
- 07:27backgrounds continues to steeply increase.
- 07:30And with the fentanyl and also cocaine
- 07:33combinations that have really been lethal,
- 07:37this is not a problem that we've cracked
- 07:39the code on and we still need to do
- 07:42much more and really be focusing in
- 07:45on our our black and brown communities.
- 07:48So more broadly,
- 07:49however,
- 07:50than mortality,
- 07:51we also need to understand more
- 07:55about the epidemiology of substance
- 07:58use in its relationship to other
- 08:00mental health conditions.
- 08:02M5 allows us to have a more
- 08:04of a continuum
- 08:05model when we think about how substance
- 08:08use what role it plays in the lives of
- 08:11individuals in our country, for example.
- 08:14And so we have a more continuous model
- 08:16that has helped us look at categories
- 08:18of impaired control, social problems,
- 08:21risky use and physical dependence.
- 08:24And we also can think about levels of
- 08:27severity of use from at risk all the
- 08:30way up through severe severe addiction.
- 08:33And this continuum model has helped us
- 08:36to re to understand how many people in
- 08:39our country are affected by substance
- 08:42use of all kinds and we include
- 08:44alcohol here and illicit drug use,
- 08:47cannabis use disorders down the line.
- 08:50But you see that we're,
- 08:51we're dealing with 40 million people who,
- 08:57you know are part of our our,
- 08:59our pool of individuals who are
- 09:02struggling with substance use
- 09:05at some level of of harmfulness.
- 09:08And I show this even though
- 09:10it's a little bit old,
- 09:11older with a different definition
- 09:14of substance use.
- 09:15So it's a much lower number from 2016,
- 09:18but basically to show the disparity
- 09:20between those who are struggling with
- 09:23substance use problems and those are
- 09:25actually receiving any kind of care,
- 09:28which is a small fraction.
- 09:31And that continues to this day,
- 09:34including medications for opioid use
- 09:37treatment and other kinds of treatment.
- 09:39And and it still remains true
- 09:41that people don't seek treatment.
- 09:42A lot of people don't seek treatment
- 09:45because they're not ready to stop
- 09:47using a lot of barriers that
- 09:49have to do with access to care.
- 09:53And then stigma is another huge,
- 09:56huge area that we need to do
- 09:58better to sort of help, you know,
- 10:01encourage people to seek treatment.
- 10:03Because we do have a lot of
- 10:05treatments that actually work,
- 10:07whether they're from a medication point of
- 10:09view or from behavioral or combination,
- 10:11which I'm going to tell you about.
- 10:13So people,
- 10:14another reason that people don't
- 10:16seek or receive adequate care is that
- 10:20people who have comorbidities often
- 10:22don't get the care that they need.
- 10:24So those who live with a mental illness,
- 10:26for example,
- 10:27are at a much higher likelihood of using
- 10:30drugs and alcohol than those who don't.
- 10:33So here this is,
- 10:36you know 50% of those with SMI and
- 10:3940% of those with acute mental
- 10:43illness disorders have used illicit
- 10:45drugs in the past year compared to
- 10:48only 17% of adults 18 years of age
- 10:51or older with no mental illness.
- 10:53So this is recent.
- 10:55And so the,
- 10:57the main point to get across the big
- 10:59elephant in the room that unfortunately
- 11:01continues to be you know plague ourselves.
- 11:04Our systems,
- 11:05our systems of care are not set
- 11:07up to address comorbidity,
- 11:09but comorbidity is the norm,
- 11:12not the exception.
- 11:14And so we need to really get
- 11:17that through to you know,
- 11:20in terms of our thinking in order
- 11:22to really be able to address
- 11:24our nation's problem.
- 11:25So for example, even in,
- 11:27you know,
- 11:28the big rollout of medications
- 11:30for opioid use disorders,
- 11:33most of the people that have
- 11:35opioid use disorders also have severe
- 11:38trauma and trauma related conditions
- 11:40and depression and other mental health
- 11:42conditions and as well as physical problems.
- 11:46But our our care systems are really not
- 11:48set up to deliver these kinds of things.
- 11:51So if we can deliver medications,
- 11:53which is really lifesaving and very
- 11:56important, don't get me wrong.
- 11:58But we still have to figure out how
- 12:01to get mental health interventions
- 12:03that work into these populations and
- 12:05also how to work with those 50% of
- 12:09people who aren't ready to get help.
- 12:11And so I just was heard a talk from one
- 12:14of our postdocs at Columbia University,
- 12:16Manesh Gopal Dus,
- 12:17who does work on adherence and looks at,
- 12:21looked at one of the CTN Xbox
- 12:23studies and looked at adherence to
- 12:26opioid use treatment in the study.
- 12:31And basically, you know,
- 12:32people were adherent early on
- 12:34and then over the course of time
- 12:36became less and less adherent.
- 12:38And those only those who actually got
- 12:42stayed with some types of medications.
- 12:46The the rates of other treatments
- 12:49increased dramatically.
- 12:49And I suspect that those other treatments
- 12:52were some of the behavioral other
- 12:55interventions for mental health conditions
- 12:57that may have helped them along the way.
- 12:59But we we we don't have a
- 13:01magic bullet at this point.
- 13:03And so we need to kind of
- 13:05have all hands on deck.
- 13:07The other thing I will just mention
- 13:09that we learn from the pandemic,
- 13:11all of us learned in real time
- 13:13is that there was this collision
- 13:15And so we all know about the
- 13:18inequalities and access to care for
- 13:21for COVID related health conditions.
- 13:26We also were dealing with the
- 13:29epidemic of opioid,
- 13:31of the opioid epidemic and we were
- 13:34all aware of the epidemic of racism
- 13:37with George Floyd's killing and others
- 13:40that you know brought our attention.
- 13:42So we've talked about the idea that these
- 13:46were really a condition of syndemic,
- 13:49which is the collision of multiple epidemics.
- 13:52And I,
- 13:53you know,
- 13:54we've argued that traumatic stress
- 13:56really forms one of the core elements
- 13:59that we hear a lot of people now
- 14:01talking about social determinants of
- 14:03health influencing the likelihood
- 14:04that people are going to get
- 14:06the kind of care that they need.
- 14:08And certainly when we think of
- 14:10social determinants of stress,
- 14:11we also have to recognize that trauma
- 14:14goes part and parcel with with those
- 14:17social determinants like lack of,
- 14:19you know, access to healthcare,
- 14:21housing,
- 14:22poverty,
- 14:22nutrition and all those things that
- 14:26people who are of color and also come
- 14:28from lower socioeconomic circumstances are,
- 14:32are dealing with and facing.
- 14:34So turning our attention to one of
- 14:36the bigger trauma related conditions
- 14:38that many of you here I know are very
- 14:41interested in and it contributed
- 14:43greatly to the science of this is
- 14:46one of the problem Post traumatic
- 14:49stress affects 8 million people
- 14:51in the United States.
- 14:53I'm not going to go into all
- 14:54of the criterion risk factors,
- 14:56but we know that you know social
- 14:59determinants are are some of them and
- 15:02also you know the predisposition and
- 15:05I'll talk a little bit about some of
- 15:08the pathways to addiction that overlap
- 15:09for those with PTSD and substance use.
- 15:12But we also know that more women than men
- 15:16develop PTSD when exposed to a trauma Puma.
- 15:19But still it cost.
- 15:21It exacts a huge toll on our economy and
- 15:27the kinds of symptoms we're talking about.
- 15:30You know, when we think about, you know,
- 15:32certainly the hallmark symptoms of
- 15:34PTSD are being haunted by memories of
- 15:38and triggers of the traumatic event.
- 15:41We also see intrusion symptoms and
- 15:45particularly avoidance symptoms that can
- 15:48include and often do include the use of
- 15:52substances as well as the HPA access,
- 15:55arousal and guilt feelings and
- 15:58cognitive and dissociative symptoms.
- 16:00So it's a it's a pick.
- 16:02It's a real mix of of diagnosis
- 16:06and what we are are symptoms that
- 16:08people are struggling with.
- 16:10But often I think it's important to
- 16:13mention people who have PTSD or trauma
- 16:15don't necessarily think that they do.
- 16:17So part of our interventions,
- 16:20many of our interventions focus
- 16:22on providing identification and
- 16:24psychoeducation around the problem.
- 16:27And the fact that these disparate
- 16:29symptoms that are very dysregulating
- 16:31for a person actually constitutes
- 16:34something that is a a common
- 16:37reaction to an uncommon event.
- 16:39So even though many people
- 16:42could develop PTSD,
- 16:44most people are quite resilient and don't.
- 16:47But for those who do, we we,
- 16:50we know that there are,
- 16:52you know,
- 16:53the the likelihood of them developing
- 16:55more than one condition is actually
- 16:58again more common than not.
- 17:00And so some of the numbers that
- 17:03you know well are and it doesn't
- 17:06matter what kind of study you do,
- 17:08whether it's an epidemiologic study
- 17:10like the epidemiologic catchment area
- 17:12or knees arc or that you guys you
- 17:16know obviously know very well or it
- 17:19is clinical trials in communities
- 17:22or its community assessments in
- 17:24addiction related facilities or
- 17:26assessments in mental health facilities.
- 17:30No matter which way you scratch it,
- 17:32you know,
- 17:33basically we know that the two
- 17:35conditions Co occur and are ubiquitous.
- 17:38And so here are some of the numbers.
- 17:41And we know that six people that
- 17:43have PTSD are 6 times more likely
- 17:46to develop alcohol use disorders,
- 17:482 1/2 times more likely to develop
- 17:50a substance use disorder.
- 17:52And here you see for men,
- 17:5460% are likely to have at least more
- 17:58than three cooccurring diagnoses
- 18:00and similarly not not quite as
- 18:03a high rates for women.
- 18:05But.
- 18:05So when we're working with
- 18:07someone with either trauma,
- 18:09PTSD or substance use,
- 18:11we can know that they're likely
- 18:14more likely than not may have the
- 18:16cooccurring condition and then
- 18:18they may also struck be struggling
- 18:21with another depression mood
- 18:22disorder or an anxiety disorder.
- 18:24So how we understand the relationship
- 18:28between PTSD and substance use,
- 18:30We've made a lot of gains in that regard.
- 18:33And the two most common ways we
- 18:36think about the relationship
- 18:37are self medication model,
- 18:40which is the idea that substance
- 18:42use is used to
- 18:43manage the PTSD symptoms.
- 18:45So like the avoidance symptoms,
- 18:46the hyper arousal, the nightmares,
- 18:49people may use particular substances
- 18:51to help tamp down those symptoms.
- 18:54The high risk model is the idea of
- 18:57susceptibility that you know if
- 18:59you're a substance user you may be
- 19:01for whatever various of reasons
- 19:03more likely to be traumatized.
- 19:05Let's say you you're are doing high risk
- 19:07things and you're in in the company
- 19:09of others who are doing harvesting.
- 19:11So you then may be victimized either
- 19:15related to drug related crime or you
- 19:19know assaults and things like that and
- 19:22that would then lead you to develop PTSD.
- 19:24The studies that have really attempted
- 19:27to look at comparisons between the self
- 19:30medication model and susceptibility
- 19:33models largely continue to come
- 19:35back to self medication as the most
- 19:39likely the most common pathway.
- 19:42But what we do know is that there
- 19:45is a convergent, rich,
- 19:47multidisciplinary literature that
- 19:50describes cross sensitization of
- 19:52stress and reward neural pathways
- 19:55that promote and then maintain the
- 19:58relationship between PTSD and Sud.
- 20:00The role that early life adversity
- 20:03and the dysregulation of HBA access
- 20:06and dopaminergic systems that
- 20:09predisposes individuals to internalizing
- 20:12and externalizing disorders and
- 20:15behavioral styles.
- 20:16And personalities that are shared
- 20:18between the two disorders and not to
- 20:21mention G wash studies that indicate
- 20:25that polymorphisms are kindling for
- 20:28the relationship between PTSD&SUD.
- 20:30And there have been a couple of
- 20:33great review papers that you know
- 20:35kind of cover the sort of pathway
- 20:39pathways that we can understand.
- 20:40But the bottom line is this is
- 20:43these are complicated problems,
- 20:44they require all hands on deck and
- 20:47there's room for everyone doing.
- 20:49You know,
- 20:50you can find some piece of yourself in,
- 20:52in many of these explanatory pathways.
- 20:54And this is true for other you know,
- 20:56conditions,
- 20:57mental health conditions that we're
- 20:58trying to study and understand more about.
- 21:01But it's certainly true for for
- 21:04this comorbidity.
- 21:05And so regardless of the, you know,
- 21:08you know, the explanatory pathways,
- 21:10what we do know is that people
- 21:13that have both have more severe
- 21:15psychiatric problems.
- 21:16They are of course less likely to seek help.
- 21:19They have higher dropout rates.
- 21:22When they do seek help,
- 21:25they probably have less access to
- 21:27care because of the barriers between
- 21:30our separated funding structures
- 21:32and and and the way that our our
- 21:35programs are set up and thus are
- 21:38at increased rates of relapse.
- 21:41And finally and to close off the
- 21:44epidemiology kind of section of this talk,
- 21:48you know it's often the case that
- 21:50people with substance use present
- 21:52with the most complex trauma profile.
- 21:54So the I CD10 and 11 have have
- 21:59complex trauma in it.
- 22:00Our system DSM55 do does not but
- 22:04regardless because of all the
- 22:06dysregulation and other symptoms that
- 22:09I've described our our clients also
- 22:13have complicated lives with ongoing trauma.
- 22:18There's interpersonal trauma IPVI.
- 22:20Know that that at Yale
- 22:22you have many folks here,
- 22:24Kate Walsh,
- 22:25Tammy Sullivan and their their
- 22:27teams that have been working for
- 22:30decades on trying to address
- 22:33IPV, specifically in relation
- 22:35to substance use disorder,
- 22:38difficulties in relationships
- 22:40and trust impairments and emotion
- 22:43regulation and dissociative disorders
- 22:46that kind of complicate the picture
- 22:49and make it a challenge to treat.
- 22:52Nonetheless, I'm here to tell
- 22:54you the good news that all of our
- 22:58efforts have not been in vain and
- 23:00over decades we actually have a
- 23:03robust science in of of integrated
- 23:07PTSD Sud care that I'm going to do
- 23:11my best to summarize you know for
- 23:14us in the next section of the talk.
- 23:17I will say that we,
- 23:19we are all familiar with the concept
- 23:23of trauma informed care which sort
- 23:26of speaks to making agencies and
- 23:29providers and institutions recognize
- 23:31that many of the clients who come to
- 23:35us for whatever different reasons in
- 23:38in through through many different
- 23:40doors come to us with trauma.
- 23:43And that the way that we organize
- 23:46our program, our programming,
- 23:48the way that we present ourselves
- 23:50to our clients as as caregivers,
- 23:53you know should have recognition of that.
- 23:56Whether it's how your waiting room
- 23:59looks or how the the consulting
- 24:01room looks or how you approach,
- 24:04you know how you train your staff.
- 24:06Because also you know particularly
- 24:08now with a peer driven system that
- 24:11we have for delivering a lot of
- 24:13the first line care for people
- 24:16with substance use disorders.
- 24:18We're talking about people
- 24:19who have lived experience,
- 24:20who also have their own trauma
- 24:23histories and backgrounds and
- 24:25so being mindful of how they are
- 24:28potentially being re traumatized and
- 24:30also need support is very important.
- 24:33What I'm going to be talking about
- 24:35is not that but actually the evidence
- 24:38based and treatment development
- 24:40that we've done over over time.
- 24:43So when, you know,
- 24:44I first started in the field in
- 24:47the late 90s and early 2000s,
- 24:51the concept of phase based
- 24:54approaches for PTSD was key.
- 24:56For those of you who may not have read,
- 25:01you know, Judith Herman's book,
- 25:03I I still recommend it as a kind
- 25:07of encyclopedia of of understanding
- 25:09you know trauma and it and and the
- 25:13way that we can think about
- 25:14conceptualizing the care.
- 25:16And so she emphasized a stage
- 25:19model that first you would work
- 25:21on stabilization and these kinds
- 25:23of skills would do,
- 25:24would be involved in psychoeducation.
- 25:26As I spoke about skills training,
- 25:30affect regulation, distress tolerance,
- 25:33the processoriented second phase is
- 25:36really the delving into the trauma more
- 25:39specifically and that involves the
- 25:42trauma focused treatment approaches
- 25:45such as prolonged exposure in which you
- 25:48are working in a manualized fashion
- 25:52very systematically to desensitize
- 25:54the individual through you know sort
- 25:57of exposure to the traumatic memory
- 26:00and then working on a bottom up,
- 26:04you know allowing the person to experience
- 26:06the fear and to live through it.
- 26:09And I didn't realize in a systematic
- 26:13fashion that their their symptoms
- 26:16can reduce through fear habituation
- 26:18and that exposure based approach or
- 26:22cognitive treatments that are more
- 26:24top down that focus on addressing
- 26:27like cognitive processing therapy.
- 26:29That this meanie Petrakis has
- 26:31employed a great deal and to great
- 26:34success in her interventions that
- 26:36are pharmacotherapy combinations.
- 26:38But where you're addressing the
- 26:41cognitive distortions that come
- 26:44from PTSD and helping the person to
- 26:48reexamine their assumptions and work
- 26:50towards managing the trauma that way.
- 26:52But it's a very active and trauma,
- 26:55you know in both cases people are
- 26:58identifying their specific traumas
- 26:59and delving into them very deeply.
- 27:02And then we also have somatosensory
- 27:05approaches where people are doing
- 27:08EMDR and other kinds of, you know,
- 27:12somatosensory approaches that help to
- 27:15address trauma on a physical level.
- 27:17And so these these process the idea
- 27:20had been early on that we would do
- 27:23stabilization first and processing next,
- 27:26but that the assumption was that
- 27:29with PTSD and substance use that
- 27:32sequential care was necessary and
- 27:34that you couldn't start working
- 27:36on trauma until the person was
- 27:39abstinent from their substance use.
- 27:42And so that's how our systems
- 27:44have been set up.
- 27:45And even though there have been some changes,
- 27:48we're still sort of tackling the fact that
- 27:51there are structural barriers to doing
- 27:54what I'm going to talk about in a moment,
- 27:56which is the idea of integrated care.
- 27:59And more and more,
- 28:00our science has really showed us that
- 28:03the siloed care is quite harmful.
- 28:05So sending a patient over,
- 28:07you know, like OK,
- 28:08sorry,
- 28:08you can't get any treatment for your
- 28:11PTSD until you go to this substance
- 28:13use treatment facility that has
- 28:15an absence based model and you
- 28:16have to get clean first before you
- 28:19can start addressing any of those
- 28:21other mental health conditions.
- 28:23Well,
- 28:23it doesn't make sense if the mental
- 28:27health condition is a driver of
- 28:29the substance used to expect that
- 28:32the patient can heal themselves
- 28:34before you've actually helped to to
- 28:36deal with the underlying problem.
- 28:38So we do know that the siloed
- 28:42approaches do not have not worked
- 28:44as well and patients tend to drop
- 28:46out of treatment and don't, don't,
- 28:48you know, complete their care.
- 28:50And what we don't now know is that
- 28:53concurrent PTSD care is safe and effective.
- 28:56So patients can't are not as fragile
- 28:59as we thought them to be And in
- 29:02fact the first treatment model
- 29:04that many of us started working on
- 29:06early on and and you know and it
- 29:08made perfect sense that we would
- 29:10employ a skill based model first.
- 29:13The Seeking Safety model is a 24 session
- 29:16skills based model that integrates and
- 29:20talks about PTSD and substance use,
- 29:23you know,
- 29:23in sessions.
- 29:24At the same time,
- 29:27there's a lot of sessions on relapse
- 29:29prevention that are incorporated.
- 29:31There's sessions on psychoeducation
- 29:33about PTSD and the symptoms.
- 29:35There's sessions on safety.
- 29:37It's organized around helping
- 29:38the patient to focus on safety.
- 29:41It it's turned out to be a very
- 29:44adoptable intervention that's feasible.
- 29:46You can train people so that they
- 29:49even now there's an app peer peer
- 29:51individuals have been trained to
- 29:53be able to deliver seeking safety
- 29:55and it's been well tolerated.
- 29:58So patients like it.
- 30:01So that was very good for us to get started
- 30:04in the field to really show that yes,
- 30:06you don't have to wait to treat
- 30:08the trauma and here are some
- 30:10approaches that can be used and
- 30:12delivered safely and without harm.
- 30:14What we have found over the
- 30:17last really decade is very clear
- 30:21evidence that treating trauma with
- 30:24a trauma focused intervention.
- 30:27So that's stage two model that I was
- 30:30talking about is also safe and tolerable
- 30:33and effective for people with substance use.
- 30:36So that's a new sort of
- 30:39relatively newer finding.
- 30:40And so those those are what we call
- 30:43trauma focused interventions and the
- 30:45most commonly tested one has been the
- 30:48COPE treatment which is an integrated
- 30:51treatment that focuses on some relapse
- 30:54prevention as well as as well as you
- 30:58know a prolonged exposure cognitive
- 31:01processing therapy is another trauma
- 31:03focused treatment that has been used.
- 31:05EMDR has been used effectively and and
- 31:10basically we have one you know more
- 31:12recent clinical trial that was done by
- 31:15Sonia Norman and her colleagues with
- 31:18veterans that was published in JAMA
- 31:21Psychiatry right before the pandemic
- 31:24really showing superiority of the of
- 31:27of in a headtohead comparison between
- 31:30cope and seeking safety treatment.
- 31:34So suggesting that that although
- 31:39you know the the more stabilization
- 31:42focused treatments seem to do
- 31:44no harm and may do some good.
- 31:46We're seeing stronger outcomes and I'll
- 31:49be showing you some more data that
- 31:52helps helps us to pretty confidently
- 31:54say that it's important to think
- 31:57about the the COPE interventions
- 31:58and then one of our trials.
- 32:01So, you know,
- 32:01should we wait to treat PTSD for those
- 32:05who have PTSD said absolutely not.
- 32:09And we can.
- 32:10We we know that that these treatments
- 32:12are tolerable,
- 32:13safe and effective.
- 32:14And what we see is that if we treat PTSD,
- 32:18we see greater substance use improvement.
- 32:23And that is coming from now there
- 32:27are four or five systematic reviews
- 32:30that pretty rigorously and and
- 32:34definitively are showing that greater
- 32:38PTSD reduction is also associated with
- 32:41greater substance use improvements.
- 32:44And the opposite is less true.
- 32:47And I'll show you one of our
- 32:50trials where we compared COPE,
- 32:52which is a prolonged exposure,
- 32:54trauma focused treatment for people
- 32:56with substance use disorders
- 32:57to relapse prevention.
- 32:59This was done in New York City with
- 33:02individuals who basically entered our trial.
- 33:05We're not receiving any other care.
- 33:07So pretty severe PTSD histories
- 33:10and substance use problems.
- 33:13And So what you see here just to
- 33:15Orient you to the slide is horizontal
- 33:17axis is the weeks of treatment,
- 33:19vertical is the PTSD symptoms severity.
- 33:23And we broke out the groups by how much use,
- 33:27how much they were using during
- 33:29the course of treatment.
- 33:30And this is just one example and
- 33:32I know it's media has also worked
- 33:35on using these clinical trials to
- 33:37do cross lagged analyses to try to
- 33:39look in real time as what's going
- 33:41on with the person's substance use
- 33:44while they're receiving treatment
- 33:46in relation to their PTSD symptoms
- 33:50as they are going through treatment
- 33:52and then over the course of time.
- 33:54And so here we see the end of treatment.
- 33:57So after 12 weeks of treatment,
- 33:59we see one month follow up,
- 34:01two months and three months in this
- 34:03in this trial And the Gray box are
- 34:07all those who end up through the
- 34:10course of treatment entering into the
- 34:13clinically significant change group.
- 34:16So like significant reductions in
- 34:18their PTSD to a level that we would,
- 34:21it's not just a change in severity
- 34:23but it's a clinically significant.
- 34:25So we see everybody's getting
- 34:27better over the course of time,
- 34:29but those that make it into the Gray box
- 34:32of what we want to see by the end of
- 34:35treatment and then over the course of time,
- 34:38the two curves to look at.
- 34:41So the blue are the people that received
- 34:44relapse prevention as the comparator
- 34:45and the orange and red are those that
- 34:48received the trauma focus treatment.
- 34:50And what we see is that for those who
- 34:53received relapse prevention who were
- 34:55the very frequent substance users,
- 34:57so they were using four times a week
- 35:00or more during the course of the
- 35:03trial their symptoms if they received
- 35:05the not you know the comparison
- 35:07treatment of relapse prevention,
- 35:09they don't get into the clinically
- 35:12significant change realm in
- 35:14terms of their PTSD.
- 35:15Those that were actively using.
- 35:17So the yellow bar that were actively
- 35:20using to a level of four times a
- 35:24week or more when they received the,
- 35:26the the prolonged exposure trauma
- 35:29focused treatment you see they make
- 35:31it into the clinically significant
- 35:33change box over the course of the
- 35:36study and their followup period.
- 35:37So what does that tell us?
- 35:39That tells us that that our patients
- 35:43are not as fragile as we would
- 35:45think that the people and that
- 35:47the people that are using the most
- 35:50actually benefit more from the trauma
- 35:53focused intervention than from a
- 35:56psychoeducational or or control treatment.
- 35:58So then moving along to the
- 36:04pharmacotherapy story,
- 36:05which we know a lot about,
- 36:08thanks to Doctor Petrakis and
- 36:12others who have really been working
- 36:15in this space in a way, you know,
- 36:19consistently over decades.
- 36:21There are a number of treatments,
- 36:22medications that we have to target
- 36:25both alcohol or substance use
- 36:28disorders alone with PTSD agents
- 36:32that target both And then agents
- 36:34that focus on craving aversive,
- 36:37you know,
- 36:38agents like disulforam and agents
- 36:41that target withdrawal.
- 36:43And So what we know thus far and I
- 36:46think I I did one trial that was a
- 36:50combined medication we use sertraline
- 36:52and and and seeking safety for
- 36:55individuals with alcohol use disorders.
- 36:57And I swore I'll never do another
- 37:01pharmacotherapy trial because of how
- 37:02hard it is to do, how long it takes,
- 37:05how how hard it is to engage patients,
- 37:08to keep them in treatment,
- 37:09all these things.
- 37:10And so I think these numbers
- 37:12are probably higher now,
- 37:13but some of the systematic
- 37:15reviews that have been done
- 37:17really show us not so much which
- 37:21interventions are superior,
- 37:22but rather the fact that we can
- 37:25see significant reductions in both
- 37:28PTSD and alcohol use disorders.
- 37:30There's no evidence against using
- 37:33medications in non comorbid populations
- 37:36and but yet we don't fully know
- 37:39what are the best practices yet for
- 37:43these kinds of medications that have
- 37:46been applied for both PTSD and a
- 37:49UD individually and then together.
- 37:53However, I do have more.
- 37:55So stay, you know,
- 37:57hold off the judgment because we we
- 37:59have more to say on that when I get
- 38:02to our our data science project.
- 38:04But largely, you know,
- 38:05we do know things that I can tell
- 38:08you happily that we can say okay.
- 38:10Now we we do have ideas about
- 38:13signals for how to treat PTST and
- 38:16Sud both with medications and also
- 38:19with behavioral interventions.
- 38:21But in fact doing this work for anyone
- 38:24who spent their time doing it's really hard.
- 38:27It takes forever.
- 38:28Our effect sizes are small.
- 38:31We see most impacts directly
- 38:33in the PTSD domain.
- 38:36We have high rates of attrition
- 38:39in our studies.
- 38:40Like I said before,
- 38:42we have spotty uptake of evidence
- 38:44based treatments and we are.
- 38:46It's very hard to examine to
- 38:48go beyond just like compare the
- 38:50treatment and the comparator.
- 38:51We don't get to say who does these,
- 38:53who do these treatments work best
- 38:55for and also how do they work?
- 38:57Like what are the mechanisms?
- 38:58Because our ends are just too small.
- 39:01So, you know,
- 39:03our latest solution to this problem
- 39:06has been to to use data science
- 39:08as a means to help us move the
- 39:11drive the field forward.
- 39:12And so I'm going to tell you
- 39:14spend a little bit of time talking
- 39:16about Project Harmony,
- 39:17which was mentioned earlier,
- 39:19which is an integrative data analysis
- 39:22where we managed to pool together.
- 39:25We acquired 42 studies agnostic
- 39:29to treatment type.
- 39:31And you'll see what I mean when
- 39:33I show you the the variety of
- 39:35treatments that we pooled in.
- 39:37But we we identified using a set
- 39:40of inclusion criteria any study in
- 39:42the world that we could get our
- 39:45hands on that attempt to a treat
- 39:48PTSD and substance use disorders
- 39:51in adults that had measures of
- 39:54both PTSD&SUD outcomes and that
- 39:56had evidence that the treatments
- 39:58were being delivered in fidelity,
- 40:00with fidelity.
- 40:01And this was regardless of
- 40:04treatment type and also you know
- 40:09other other characteristics.
- 40:10And we we acquired a pool
- 40:13of over 4500 participants.
- 40:15This was a.
- 40:17And all hands on deck and I'm
- 40:19going to show you our team from,
- 40:21you know, City College,
- 40:23Columbia University,
- 40:24Rutgers University,
- 40:25Medical University of South Carolina,
- 40:28Yale University,
- 40:29University of South Wales,
- 40:32University of Washington,
- 40:35Stanford University and
- 40:37University of Toronto.
- 40:38These are our team members and our
- 40:41Scientific Advisory Board members
- 40:43who shared their data with us
- 40:46as well as and Antonio Morgan.
- 40:48Lopez was the MPI on this project.
- 40:51He's at RTI International with
- 40:53me and did all the elegant quant
- 40:57work on the project.
- 40:58This is just, I can't spend time on this,
- 41:01but these are our international
- 41:03consortium that we call our cast
- 41:06and all of these individuals
- 41:08shared their data sets with us.
- 41:10And when I say shared their data,
- 41:12I mean they gave us their data sets.
- 41:14So we were able to do things with the
- 41:17data and I'll just show you about that.
- 41:20But first we brought together the
- 41:22international group and one of the
- 41:24things we needed to do given that
- 41:26we were agnostic to treatment type
- 41:28was we had to categorize treatment.
- 41:31So we had the international group,
- 41:34they were involved with us.
- 41:35We had several meetings,
- 41:37consensus meetings and we did surveys
- 41:40but we we identified and categorized
- 41:44treatments into trauma focused like the
- 41:47ones you know the stage two treatments
- 41:49that we were talking about and non
- 41:51trauma focused which were treatments
- 41:53like a seeking safety treatment that
- 41:55didn't target the trauma but may have
- 42:00been an integrated treatment for traumatics,
- 42:04PTSD and Sud.
- 42:05And we also so we had
- 42:07behavioral interventions,
- 42:09we had integrated behavioral where
- 42:11they tried to address both PTSD and
- 42:14substance use in the same treatment we
- 42:16had combined so integrated plus meds,
- 42:18we had meds alone.
- 42:20So targeting either the alcohol
- 42:22or substance use outcome,
- 42:25the PTSD outcome or both.
- 42:29And then we also had a variety
- 42:31of controls because when you're
- 42:32doing comparative effectiveness,
- 42:34you need to be able to classify
- 42:36the treatment so that you're
- 42:38kind of reducing the number of,
- 42:40you know,
- 42:41kind of degrees of freedom or
- 42:45increasing the degrees of freedom,
- 42:47but you are also comparing it to
- 42:51the same comparator.
- 42:52So we classified the control
- 42:56groups as psychotherapy that was
- 42:58targeting a alcohol or drug use only,
- 43:02psychotherapy controls that were really
- 43:05treatment as usual and then placebo
- 43:09controls which was medication placebo.
- 43:13And so by doing that we end up with
- 43:15about with eight classes that were
- 43:18comparing to 1 comparator which would
- 43:21either be treatment as usual or placebo.
- 43:24And so you know one of the things
- 43:27that we did with Project Harmony
- 43:29was a traditional systematic review
- 43:31and we did a network meta analysis.
- 43:34And so that's taking, you know,
- 43:35a typical traditional meta analysis is
- 43:37when you go in to the published data
- 43:40and you look at what's out there and you,
- 43:44you know extract effect sizes from
- 43:47that data and then you examine
- 43:50the effects of the treatments
- 43:52and you and you come up with a,
- 43:53you know,
- 43:54some kind of an idea about what's
- 43:56what's going.
- 43:57And so we did the a traditional
- 44:00systematic review from the literature.
- 44:03This is not the pooled analysis yet,
- 44:05which I'll show you in a moment.
- 44:07But we then did a a network meta
- 44:10analysis to kind of characterize
- 44:13the state of science and to
- 44:15look at PTSD and a UOD outcomes.
- 44:18And out of you know 1000,
- 44:21you know hits that we got,
- 44:23we we sifted through 700 trials that
- 44:27met our criteria and in the end we
- 44:31identified 39 trials with two
- 44:34subnetworks of the this network I'm
- 44:38showing you above is the behavioral
- 44:40interventions compared to a psychotherapy
- 44:43control like a treatment as usual.
- 44:47And then there was another step
- 44:49network of the medication trials that
- 44:52were compared to placebo and what we
- 44:55found in this network meta analysis
- 44:57which is about to be published in
- 45:00psychological bulletin like today,
- 45:03tomorrow who knows it's it's coming
- 45:05out very shortly is that the for
- 45:10PTSD the integrated trauma focus.
- 45:13So again those trauma focused interventions
- 45:17did significantly better compared to
- 45:19the treatment as usual controls than
- 45:22any of the other other classifications.
- 45:25And for the medications,
- 45:28we saw that alcohol targeting
- 45:32medications with or without trauma
- 45:35focused treatment appeared to be
- 45:39superior to placebo interventions
- 45:41in this network meta analysis.
- 45:45So it's giving us an indication
- 45:48of yes trauma focused and yes,
- 45:51our alcohol targeting medications and
- 45:53that's a direct effect on alcohol outcome.
- 45:57So in this network meta and then to go
- 46:01into the Project Harmony piece where
- 46:04we did an integrative data analysis
- 46:07with the individual patient data that
- 46:10we got from all of these trials over
- 46:13the world that was recently published.
- 46:16And you can get more of the the
- 46:18fine finer details from the American
- 46:21Journal of Psychiatry and in February.
- 46:23But basically,
- 46:23and I don't have time to go into all of it,
- 46:26but we did a bunch of fancy analyses
- 46:29that kind of what I like to say is
- 46:32this virtual clinical trial basically
- 46:34does like on your iPhone where you
- 46:37have a photograph and then you go
- 46:39into edit on the photo and there's a
- 46:41little magic wand and you press the
- 46:43wand and the photo just looks better.
- 46:45It like makes it pop.
- 46:48That's what I think of as this,
- 46:50this type of analysis where we did
- 46:52a variety of things.
- 46:53We did propensity score weighting to
- 46:57sort of the equivalent of covariates in
- 47:00a single trial to address measurement
- 47:03inequalities and other issues
- 47:06with across all of these trials.
- 47:08Because remember,
- 47:09we're pooling all these trials,
- 47:12we have to harmonize the measures and
- 47:15do we did modified nonlinear factor
- 47:18analysis to create harmonization so
- 47:20we could look at the same outcomes.
- 47:22The outcomes were PTSD,
- 47:25alcohol use and substance drug use.
- 47:28So those were our outcome measures.
- 47:30We harmonize all across all studies.
- 47:33So in one study it might have
- 47:35used timeline follow back to look
- 47:36at substance use outcomes.
- 47:38In another study they might have
- 47:39used the ASI or some other metric
- 47:42and we you have to kind of harmonize
- 47:44it so you can compare across.
- 47:46We categorize like I told you
- 47:49before and we structured time.
- 47:50So we were looking at post treatment
- 47:53which is 3 months post treatment
- 47:55and 12 month which was estimated
- 47:57because of course some trials might
- 47:59have looked at six month outcomes,
- 48:01others might have looked at one
- 48:02week outcomes,
- 48:03others might have looked at
- 48:04one year outcomes.
- 48:05And so we did analysis to structure the time
- 48:09and what we ended up finding was very
- 48:12good news and the good news overall was
- 48:15that all of the intervention classes,
- 48:18patients got better.
- 48:19So we like to say there are no wrong doors.
- 48:22You can apply these variety of
- 48:25interventions and everyone got better,
- 48:28but some doors are better than others.
- 48:30So people got better with some
- 48:33of the trauma focused integrated,
- 48:37I'm sorry non trauma focused
- 48:40integrated models whoops,
- 48:41but but as you can see here it
- 48:47wasn't statistically significant.
- 48:48So, so the seeking safety model was a non
- 48:54was an integrated but non trauma focused.
- 48:57We don't see significant impacts
- 48:59compared to treatment as usual,
- 49:01whereas the big winner was drum roll
- 49:06trauma focused interventions with
- 49:08alcohol targeting medications and
- 49:10what you can see here are very large
- 49:13effect sizes for those interventions.
- 49:15So we might not have seen that in any
- 49:17of the individual clinical trials like
- 49:19all of the ones that this mini has been
- 49:22working on and working on where you
- 49:25might not have seen the impacts also
- 49:27because she was comparing to placebo Med,
- 49:31placebo Med also does pretty
- 49:34well on PTSD for example.
- 49:37And but what we're seeing is direct
- 49:40effects on the alcohol outcomes and
- 49:43then you know you know the it's so the
- 49:46winners are the trauma focused whether
- 49:48they're integrated or they're not
- 49:50integrated and alcohol targeting meds.
- 49:52So it's sort of expands on the lit review
- 49:55network meta analysis that I showed you.
- 49:58So we're but we're taking
- 49:59this data and we're we're,
- 50:02we're sort of able to examine it.
- 50:04And so this just gives you a
- 50:06taste of what we're finding.
- 50:08And then we are also doing moderator
- 50:11mediator analysis as we speak.
- 50:13The one thing that you see you might take a
- 50:16note of is that in terms of drug outcomes,
- 50:18we're not seeing a lot of direct impacts
- 50:21on drug from either any of the kinds
- 50:23of interventions on drug directly.
- 50:25And what we do expect to be able
- 50:28to talk about more is that that
- 50:31indirect effect of if you target the
- 50:34trauma you will see impacts like
- 50:36downstream on the drug effects.
- 50:40And why it is that we are able to
- 50:42see the impact on alcohol more
- 50:44directly for the first time here
- 50:47with this analysis at Versus Drugs.
- 50:49I'll leave it to,
- 50:50you know maybe we can talk about
- 50:52that during the Q&A.
- 50:53But so that that sort of gets us to,
- 50:56I'm going to spend the last few
- 50:58moments before we have time for
- 51:01chat to talk about as clinicians
- 51:03okay what's the take away.
- 51:04So I mean the take away from
- 51:06the treat my science,
- 51:08you know the science of our
- 51:10interventions is good news.
- 51:11We have a lot of things that we can
- 51:14do and now we have to try to start,
- 51:17you know,
- 51:18doing them more more systematically
- 51:20and enabling places that may not have
- 51:23access to care to do these interventions.
- 51:26So I was in Australia giving a
- 51:28talk to a
- 51:29bunch of, you know, addiction medicine
- 51:33professionals recently and you know,
- 51:36they were like our system is so
- 51:39separated that how do we bring these
- 51:42interventions to to our, our population.
- 51:46And so I encourage them to get
- 51:49creative because not, you know,
- 51:51and and because we know the answer,
- 51:53we know that these
- 51:54interventions actually work.
- 51:55So now we have to start
- 51:57really pushing them out.
- 51:59So how do we apply an integrated framework?
- 52:02Well, these are some of the questions from
- 52:04a clinician perspective that we need to
- 52:06start thinking about and trying to answer.
- 52:09What does success look like?
- 52:10Like, Is it really abstinence or is
- 52:14it really diminishment of symptoms?
- 52:16Probably not.
- 52:17If you're thinking about your client,
- 52:19you want quality of life.
- 52:20You want to think about other
- 52:23types of outcomes.
- 52:24What if the person still using do?
- 52:26Can we call it a win if someone goes
- 52:29shifts from being a daily opioid
- 52:32user to a nightly cannabis smoker?
- 52:36Is that a good thing?
- 52:39You know, how do we make those judgments?
- 52:41How do you match for your client
- 52:44the right kind of therapy for them?
- 52:47And what do you do if your
- 52:49patient starts getting worse?
- 52:50How do you handle that and how
- 52:53do we understand differences by,
- 52:56you know,
- 52:58social determinants and other
- 53:00individual characteristics?
- 53:01How do we incorporate cultural variations
- 53:04and how we deliver our treatments?
- 53:07So what we basically advocate for
- 53:09is what I call an integrative
- 53:11treatment framework where we you
- 53:13know it's it's it's good treatment.
- 53:15So this is nothing new to anyone
- 53:17who's a provider is like we want
- 53:19a comprehensive assessment so
- 53:20we know what we're dealing with.
- 53:22Obviously we want to use
- 53:26those destigmatizing,
- 53:27motivational interviewing and harm
- 53:29reduction techniques to understand
- 53:31that not you know what might be
- 53:33abstinence model might be great
- 53:35for one patient and really and not
- 53:37a good model for another patient.
- 53:39So really matching and having
- 53:42kindness and care and a sense
- 53:45of positivity for our clients.
- 53:48Harm reduction therapy is one
- 53:50example that we can use,
- 53:52but there are many other approaches
- 53:54motivational interviewing we
- 53:56want to think about engaging our
- 53:58clients and therapeutic alliance.
- 54:00So you know,
- 54:02understanding that patients may not
- 54:04seek treatment or stay in treatment
- 54:06or use treatment in the same way and
- 54:08that doesn't mean that they should
- 54:10be denied treatments of these ideas
- 54:11that like 3 strikes and you're out
- 54:14because our clients don't attend
- 54:16sessions for lots of different
- 54:19reasons due to those emotional
- 54:21dysregulation and other factors.
- 54:23But you know,
- 54:24there's a lot of things that
- 54:25we need to do and that we can
- 54:27help support our clients.
- 54:29So a lot of these treatments if
- 54:31even if you don't have trauma
- 54:33focused training at your agency yet,
- 54:36there's a lot of treatments for
- 54:39dysregulation that can be used to
- 54:41help address traumatic stress in our
- 54:44clients and help with treatment processing.
- 54:47So again,
- 54:48treatment planning,
- 54:50coordinated care,
- 54:51working together across disciplines
- 54:54and promoting stability,
- 54:56these are all just like really good
- 54:58principles of treatment planning that we
- 54:59should apply in working with our clients.
- 55:01So to sum it up, people with PTSD stutter,
- 55:07highly comorbid and undertreated
- 55:12integrated care is safe and efficacious.
- 55:15I feel confident in saying that
- 55:18and optical optimal care should be
- 55:21individualized and you know as I just
- 55:24said involves having a client centered
- 55:27approach and and incorporating A harm
- 55:30reduction model doing comprehensive
- 55:32assessment that's collaborative and
- 55:35then using evidence based particularly
- 55:39combined treatments will lead our
- 55:43clients down a very positive path.
- 55:46Before I end, I just want to express
- 55:49appreciation to all of my colleagues
- 55:51that over 101,000 participants in
- 55:53the clinical trials that have helped
- 55:56us gain the knowledge that we have.
- 55:59You know my institutions,
- 56:01Rutgers, Columbia University,
- 56:02City College of New York,
- 56:05and you for being such good listeners and
- 56:09hopefully engaging with me in conversation.
- 56:12And then I'm going to end with some words.
- 56:15I like to end with the words of one of
- 56:19our clients who was is a woman from
- 56:23a disadvantaged background who was a,
- 56:26you know,
- 56:27receiving treatment in one of our
- 56:29treatment programs here in New York City,
- 56:31The Women's Health Project at
- 56:33Saint Luke's Roosevelt.
- 56:34Now it's Mount Sinai.
- 56:35I
- 56:37forget what the full name is but hospital
- 56:41and she was someone who had a very
- 56:46challenging background multiple you know
- 56:49cocaine and opioid use disorder disorder.
- 56:54You know profile sexual abuse ongoing
- 56:58victimization and this was her poem.
- 57:02Multi trauma survivor heals
- 57:04to find wedded bliss.
- 57:06Healing universe applauds.
- 57:09You are next. I'm a new house.
- 57:12I've come out of thick,
- 57:14tough hide swearing by the rock I
- 57:17rubbed against to be tender again.
- 57:20To able to receive and give love for
- 57:23my most vulnerable, healed self.
- 57:26Appreciating freshly discovered
- 57:28beauty from its fearless depths.
- 57:31Of honesty.
- 57:32Feeling peace out of the gratitude
- 57:34of being accepted as is by the
- 57:38universe myself and the reflection
- 57:40in the eyes that behold me.
- 57:43I believed it for me.
- 57:46Believe it for you.
- 57:49Thank you.