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Utah Addiction Center University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108

Utah

The

Non-profit Organization

Addiction Center

U.S. POSTAGE PAID Salt Lake City, Utah Permit No. 1529

Volume 2 Issue 10

February 2010

Report

Dedicated to research, clinical training, and education in chemical addiction

Contact Us University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108 Phone: (801) 581-8216 Fax: (801) 587-7858 E-mail: abbie.paxman@hsc.utah.edu Internet: http://uuhsc.utah.edu/uac/

A Message from the Director

Post-Traumatic Stress Disorder and Substance Abuse

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powerful connection exists between extreme emotional experiences and resultant dysfunctions and substance abuse disorders. An appreciation for this co-morbidity and its causes, as well as its consequences, is essential for effective prevention and treatment of drug addiction/dependence for many people. Of particular importance Glen W. Hanson, Ph.D, D.D.S is the role of stress and its various expressions. Relevant to this UAC Newsletter is that form of stress disorder known as PTSD or post-traumatic stress disorder. Â While most people have experienced traumatic events either acutely or chronically, the expression of PTSD is limited to ~5-10% of the population with greater expression in females.

The Utah Addiction Center is based in the office of the University of Utah Senior Vice President for Health Sciences INSTITUTIONAL ADVISORY BOARD

A. Lorris Betz, M.D., Ph.D. Louis H. Callister, J.D. Edward B. Clark, M.D. M. David Rudd, PhD, ABPP Patrick Fleming, LSAC, MPA Raymond Gesteland, Ph.D. Jay Graves Ph.D. John R. Hoidal, M.D. Glen W. Hanson Ph.D, D.D.S, Maureen Keefe, RN, Ph.D Jannah Mather, Ph.D. Chris Ireland, Ph.D. John McDonnell, Ph.D. Barbara N. Sullivan, Ph.D. Ross VanVranken, ACSW Kim Wirthlin, MPA

Although some experts would argue that these estimates are low, it is still clear that a significant portion of our population has been severely traumatized emotionally and is vulnerable to complications of PTSD, such as drug abuse. This problem has become especially critical in our country and community due to the emotional and physical trauma associated with warfare, such as that encountered by our U.S. troops (associated with both regular and reserve units) participating in military activities in the Middle East. This issue of the UAC Newsletter includes outstanding articles written by local experts in the field of PTSD and drug abuse to explain the linkages and help readers appreciate the need for developing effective strategies to address the problems of these co-morbidities.

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Today’s Returning Military Veterans: Current Practices and Ongoing Research

Substance Abuse Among Troops, Veterans, and Their Families

Steve Allen, Lindsay Carpenter, Patricia Gullberg, Taylor Plumb, Jennifer Romesser, Edyta Skarbeck, Jennifer Steele, Chris Stock

NIDA Notes Director’s Perspective Vol. 22, No. 5 (November 2009) By NIDA Director, NORA D. VOLKOW, M.D.

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ilitary experts are concerned that the wars in Iraq and Afghanistan may be precipitating a rise in problems related to substance use and abuse among the military personnel who have been deployed to those fronts. NIDA has joined forces with the Department of Defense, Department of Veterans Affairs, and other Federal agencies in a campaign to assess and find solutions to this threat to the health and well-being of our service men and women, veterans, and their families.

hatever your thoughts are about the VA Health Care System, they are probably out of date. Many people consider the VA as a place where “old soldiers go to die.” In fact, the VA has changed significantly in the last 10 years. By any standard, the VA is frequently ranked as the leading health care system in the nation. (Business Week 2006). In addition, the VA is a leader in many areas of mental health treatment including substance abuse and PTSD. In the area of chronic mental illness, the VA is among the participants in evolving the “Recovery Model.” The Recovery Model emphasizes veterans returning to their highest level of functioning, often to include “mentoring” other veterans in peer-to-peer programs.

Demographic factors and the military’s unique organizational structures, culture, and experiences contribute to service members’ overall high prevalence of smoking and binge drinking and low prevalence of illicit substance abuse, when compared with civilian rates. The patterns of tobacco use illustrate the impact that war can have on substance use: Tobacco use is about 50 percent higher among the Nation’s active duty military personnel and veterans than in the civilian population. Yet studies reported at a recent NIDAcosponsored meeting indicate that smoking rates are an additional 50 percent higher among personnel who have served in war zones.

The current wars in Iraq, “Operation Iraqi Freedom (OIF),” and Afghanistan, “Operation Enduring Freedom (OEF),” have presented significant challenges in caring for veterans. In Utah, many of the deployed service members are National Guard members called to serve from their families and careers. Approximately 12,000 Utahns have served in OEF/OIF. They range in age from about 19 to about 60, with an average age of about 37. Many service members have served multiple tours with the expectation of likely re-deployment in the future. Many service members deal with a range of post-deployment consequences, including readjustment issues, employment, substance abuse, suicide, Post-Traumatic Stress Disorder (PTSD), chronic pain, military sexual trauma and mild traumatic brain injury.

Combat exposure appears to be a primary mediator of the impact of war deployment on substance abuse rates. In one study, one in four veterans of Iraq and Afghanistan reported symptoms of a mental or cognitive disorder; one in six reported symptoms of post-traumatic stress disorder (PTSD). These disorders are strongly associated with substance abuse and dependence, as are other problems experienced by returning military personnel, including sleep disturbances, traumatic brain injury, and violence in relationships.

Responding to the needs of OEF/OIF service members has further changed the VA. Drawing on hard won lessons from treatment of soldiers from past conflicts, the VA is now engaged in considerable community outreach, including collaborations with the National Guard to attract service members to their earned benefits. The Salt Lake VA recently opened a specialty clinic devoted to providing comprehensive care of OEF/OIF veterans including primary care and mental health treatment. The OEF/ OIF clinic also provides aggressive outreach to veterans to attract them to VA services. The VA is also actively involved in outreach to homeless veterans, providing interventions to veterans in the justice system and suicide prevention. Other innovations in the VA are providing mental health services in a primary care setting and training police and corrections officers about mental health issues.

NIDA research has established effective principles for preventing and treating substance abuse and co-occurring problems and has proven the efficacy of a variety of interventions. This knowledge may provide a basis for reducing substance abuse and its consequences among the military. Modifications may be required, however. Ways will have to be found, for example, to counter some service members’ reluctance to seek treatment, which may reflect a cultural emphasis on showing strength rather than needs, or perhaps worries about potential disciplinary consequences. We will need to learn how factors associated with deployment affect service members’ risks for substance abuse and their recovery pathways. The high rates of co-occurring PTSD and substance abuse among those who have directly experienced combat have put a premium on research to develop stronger responses to these difficult problems. NIDA and its coalition partners have issued a call for research on the epidemiology, causes, prevention, and treatment of substance use and abuse and co-occurring problems among service members, veterans, and their families (RFA-DA-10-001 and RFA-DA-10-002). In this and other efforts, NIDA is working with military and mental health specialists to help those who have served the Nation.

In this article we will briefly review some of the recent developments in the VA Health Care system in caring for veterans, particularly for PTSD, mild traumatic brain injury and substance abuse.

The Utah Addiction Center Report

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Meet the New Members of the Utah Addiction Center Advisory Board: M. David Rudd, PhD, ABPP

What is Posttraumatic Stress Disorder (PTSD)?

PTSD first appeared in the DSM-III (APA, 1980) primarily in response to pathology developing because of combat experiences of Vietnam veterans, as well as sexual assaults, and natural disasters. This definition was expanded in subsequent editions to include pathology resulting from events that were witnessed or heard about. Currently, the DSM-IV-TR (APA, 2000) stipulates two conditions necessary for defining an event as traumatic. The first, Criterion A1, states that the event involved “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” The subjective nature of experiencing a trauma is captured by Criterion A2, which states that experiencing the event must have involved “intense fear, helplessness, or horror.” Therefore, by definition, a potentially traumatic experience must have occurred in order to meet criteria for a diagnosis of PTSD. Although it is theoretically possible that in some cases a person may exhibit PTSD-like symptoms without a potentially traumatic event, these instances appear to be rare.

M. David Rudd is Dean of the College of Social and Behavioral Sciences at the University of Utah (Effective August 2009). His undergraduate degree is from Princeton University. He completed his doctoral training at the University of Texas-Austin and completed a post-doctoral fellowship in cognitive therapy at the Beck Institute in Philadelphia under the direction of Aaron T. Beck. He is a Diplomate of the American Board of Professional Psychology and a Fellow of three professional societies, including the American Psychological Association (Division 12 and Division 29), the International Association of Suicide Research, and the Academy of Cognitive Therapy (a founding fellow). He was recently elected a Distinguished Practitioner and Scholar of the National Academies of Practice in Psychology. In addition to his clinical work, Dr. Rudd is an active researcher with over 170 publications. He has authored several books, including Treating Suicidal Behavior (2001, Guilford, 2nd printing in 2004) and Suicide Science: Expanding the Boundaries (2001, Kluwer Academic Publishers), The Assessment Post-Traumatic Stress Disorder is the and Management of Suicidality: A Pocket Guide (Professional Resource Press, 2006) and the recently Primary Suicide Risk Factor For Veterans released The Interpersonal Theory of Suicide (with Researchers working with Iraq and Afghanistan Joiner, VanOrden, & Witte) from the American war veterans have found that post-traumatic Psychological Association Press. stress disorder, the current most common mental disorder among veterans returning from His research has been recognized with awards service in the Middle East, is associated with an both national and international. He has served as increased risk for thoughts of suicide. a consultant to many organizations nationally and Results of the study indicated that veterans who internationally, including the United States Air Force, screened positive for PTSD were four times more likely to report suicide-related thoughts relative the U.S. Army, the Department of Defense and the Beijing Suicide Prevention and Research Center. to veterans without the disorder. The research, published in the Journal of Traumatic Stress, Dr. Rudd serves on a number of editorial boards, establishes PTSD as a risk factor for thoughts of suicide in Iraq and Afghanistan war veterans. is past Chair of the Texas State Board of Examiners of Psychologists, past President of the Texas This holds true, even after accounting for other psychiatric disorder diagnoses, such as substance Psychological Association, past President of Division abuse and depression. Veterans who screened 12 Section VII of the American Psychological positive for PTSD and two or more comorbid Association, past Past-President of the American mental disorders were significantly more likely Association of Suicidology, a previous members of to experience thoughts of suicide relative to the APA Council of Representatives, and currently veterans with PTSD alone. serves as vice-president of the PDV Foundation. Dr. Rudd has twice testified before the U.S. Congress on from Science Daily issues related to veterans and suicide.

Did You Know?

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Traumatic sequelae are clustered into three additional criteria: reexperiencing, avoidance of stimuli that remind one of the event and numbing of general responsiveness, and hyperarousal. Reexperiencing includes having flashbacks, nightmares, and intrusive thoughts about the traumatic event. Persistent avoidance and numbing include avoiding people, places and activities that are reminders of the event as well as a diminished capacity to feel emotions in general. Hyperarousal includes hypervigilance and having an increased startle reaction such as to loud noises. Who is affected by PTSD?

Approximately 90% of the population will experience at least one potentially traumatic event as defined by the DSM-IV-TR criteria for PTSD sometime in their lives (Breslau & Kessler, 2001). Despite this almost universal exposure rate, the lifetime prevalence rate of PTSD is about 5-6% in men and 12-14% in women (Breslau, 2001; Kessler, Sonnega, & Bromet, 1995). One possible explanation for the relatively low rate of PTSD is that the DSM definition excludes some events that are commonly considered traumatic. For example, instances of child sexual abuse (CSA) in which the child is groomed over time may not involve experiences of fear, helplessness, or horror (Veldhuis & Freyd, 1999). Expanding the definition to include additional cases of CSA would likely raise the overall number of cases of PTSD. Despite the higher prevalence of PTSD among women, men consistently report higher overall rates of exposure to traumatic events (Breslau, 2001; Norris et al., 2002), which has led some to suggest an inherent vulnerability among women (Breslau et al., 1997). However, a closer examination of the types of events reveals that men tend to report more instances of accidents, physical assaults, and combat trauma than women whereas women are more likely to experience sexual assault (Norris et al., 2002). Among all traumas, sexual trauma is associated with one of the highest rates of PTSD. Research has found that sexual assault at least partially accounts for the gender difference in rates of PTSD.

The Utah Addiction Center Report

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Meet the New Members of the Utah Addiction Center Advisory Board: John McDonnell, PhD

How is PTSD treated?

This is an exciting time in mental health care! Decades of research and evaluation have produced psychotherapies that are shown to be effective, or “evidence-based,” for particular conditions. The Institute of Medicine has concluded that Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are the most effective treatments available for PTSD. The Department of Veterans Affairs (VA) is actively training clinicians and offering these evidencebased treatments to veterans.

Dr. McDonnell joined the faculty in the Department of Special Education in 1984. His research is focused on curriculum and instruction, transition programs, and inclusive education for students with intellectual and developmental disabilities. He has published a number of journal articles, book chapters, and books in these areas. During his tenure at the University, Dr. McDonnell has obtained over twelve million dollars in federal and state grants and contracts to support his research and personnel training activities.

Both CPT and PE have established protocols and are VIRTUAL IRAQ - Army Col. Michael J. Roy, left, who oversees delivered in approximately 12 weekly sessions. CPT the exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator that focuses on the strong connection between thoughts represents a new form of Post Traumatic Stress Disorder and emotions. Individuals with PTSD are likely to treatment with Army Sgt. Lenearo Ashford, Technical Services experience disruptions in their thoughts about safety, Branch, Uniformed Services University, on Sept. 16, 2008, in Washington, D.C. Defense Dept. photo by John J. Kruzel trust, power/control, esteem and intimacy. CPT uses cognitive techniques to assist clients in working through their problematic, trauma-related thoughts. PE includes in-vivo (or real world) and imaginal exercises. During in-vivo exposure, clients systematically engage in a hierarchy of activities that they have been avoiding because of their trauma. Imaginal exposure consists of clients repeatedly reviewing the details of their traumatic experience, in order to emotionally process the event and achieve habituation.

He serves on the editorial boards of several of the top journals in special education including Exceptional Children, Intellectual and Developmental Disabilities, Education and Training in Developmental Disabilities, and Research for Persons with Severe Disabilities. He is an avid fly fisherman and loves camping, hiking, and exploring the wilds of Utah and the intermountain area.

What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?

Mild Traumatic Brain injury

Mild traumatic brain injury (TBI), also known as concussion is the most common form of brain injury in both the civilian population as well as the military population. Research suggests that between 10-20% of OEF/OIF service members may have sustained a concussion while deployed (Hoge et al., 2008; Schneiderman, et al, 2008). Concussions can occur from close range blasts, falls, motor vehicle accidents or blows to the head. Following concussion it is normal to develop post concussive symptomology which can be physical, cognitive and emotional in nature (Alves et al., 1986):

According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.

• Physical: headache, nausea, dizziness, problems with sleep, noise and light sensitivity

PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.

• Cognitive: symptoms: problems with attention, memory and slower thinking • Emotional symptoms: irritability, anxiety, depression

What can I do to begin the healing process? There are some positive steps that you can take right away to begin healing. Here are some suggestions: • Recognize your loss. • Establish safety for yourself. • Respect the way you feel and your right to feel that way. • Talk about your feelings with those you trust. • Connect with other survivors of violence, many of whom experience similar difficulties. • Do not be afraid to seek professional help. • Try to recognize triggers that may take you back to the memory and fear of your trauma. • Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there. • Take care of yourself—exercise, eat right, and take a deep breath when you feel tense. • Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions. • Do not abandon hope—believe that healing can and will take place.

Research has repeatedly demonstrated that the majority of individuals who sustain a TBI completely recover in the days to weeks to months after the incident with no longstanding problems (Mittenberg, 1996; Belanger et al, 2005; McCrea, 2008; Schretlen & Shapiro, 2003; Ivins et al., 2009). Unfortunately, a small percentage of individuals may remain symptomatic longer than expected. Risk factors that enhance vulnerability to experiencing persistent problems include: • A history of multiple concussions • A prior history of brain injury • Significant stress during the recovery period • Co-morbid mental health problems such as post traumatic stress disorder, anxiety, depression, sleep disorders, chronic pain or substance use. The SLC VA Health Care system is designated as a Polytrauma Level III site for evaluation and treatment of veterans with TBI. The focus of treatment is intensive outpatient services for service members with TBI. All returning service members who come to the VA are screened for possible The Utah Addiction Center Report

from SAMHSA

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Meet the New Members of the Utah Addiction Center Advisory Board: Chris Ireland, PhD

TBI. Those that screen positive are assessed by a multidisciplinary team consisting up of physiatrists, neuropsychologists, social workers, speech and language pathologists, audiologists, and physical therapists. The Polytrauma team maintains regular contact with those service members diagnosed with TBI and provides treatment, education, and support for these service members and their families. Treatment and support activities include rehabilitation therapies, mental health, a TBI support group, and family social functions several times a year. The VA is also involved in outreach services to educate healthcare providers and members of the community about TBI and resources throughout the state of Utah.

Dr. Chris M. Ireland joined the faculty of the University of Utah as an Assistant Professor of Medicinal Chemistry in 1983. He served as Professor and Chair of the Department of Medicinal Chemistry from 1992-99 and his current appointment is Professor and Interim Dean, College of Pharmacy. He is also an Adjunct Professor of Chemistry. During his 26 years on the faculty he has established himself as a world leader in the field of natural product drug discovery.

Substance Abuse treatment and research

Reflecting the importance of substance abuse and mental health issues for veterans after deployment, the VA has devoted considerable resources into treatment and research. For instance, each VA has designated clinicians specializing in treatment of both PTSD and substance abuse. At the Salt Lake City VA, several approaches are utilized for treating substance abuse, including a harmreduction paradigm, “Seeking Safety”, for veterans suffering from illness where risky behavior is evident such as PTSD, TBI or substance abuse.

Dr. Ireland’s research program has focused on the discovery of antitumor agents from natural product sources including marine invertebrate animals, tropical plants and fungi. He and his co-workers have published more than 160 peer reviewed research articles, eight book chapters and five patents. His research accomplishments and international reputation have been acknowledged in the form of numerous invitations to speak at national and international symposia on natural products research and cancer chemotherapeutics.

Seeking Safety is a presentfocused, structured Domains (cognitive, behavioral, interpersonal, (14) Creating Meaning (cognitive) psychotherapy or a combination) are listed in parentheses. (15) Community Resources treatment for (1) Introduction to treatment / Case (interpersonal) management people with the (16) Setting Boundaries in Relationships (2) Safety (combination) dual diagnosis of (interpersonal) PTSD and Substance (3) PTSD: Taking Back Your Power (17) Discovery (cognitive) (cognitive) Use Disorders. The (18) Getting Others to Support Your (4) Detaching from Emotional Pain: Recovery (interpersonal) format includes 25 Grounding (behavioral) topics focused on (19) Coping with Triggers (behavioral) (5) When Substances Control You coping skills relevant (20) Respecting Your Time (behavioral) (cognitive) to both disorders. (21) Healthy Relationships (6) Asking for Help (interpersonal) Seeking Safety can (interpersonal) (7) Taking Good Care of Yourself be utilized in a (22) Self-Nurturing (behavioral) (behavioral) group or class setting (23) Healing from Anger (interpersonal) (8) Compassion (cognitive) or individually. (24) The Life Choices Game (9) Red and Green Flags (behavioral) The topics are (combination) (10) Honesty (interpersonal) independent of (25) Termination (11) Recovery Thinking (cognitive) one another, thus allowing maximum (12) Integrating the Split Self (cognitive) flexibility for (13) Commitment (behavioral) clinicians and clients in choosing the order of presentation. The topics are designed to teach people how to maintain safety while dealing with symptoms related to PTSD and substance abuse.

Seeking Safety treatment topics

He has served as Chair of the Marine Natural Products Gordon Conference, as Chair of the organizing committee of two of the most successful American Society of Pharmacognosy annual meetings (Park City 1987, San Diego 1993), as President of the American Society of Pharmacognosy, and Chairman of the Board of the American Society of Pharmacognosy Foundation. Dr. Ireland has received additional recognition by serving on a number of review panels at NIH including the Bioorganic and Natural Products NIH study section and most recently as a member of the National Cancer Institutes Board of Scientific Counselors. He is an Alfred P. Sloan Fellow, a 2008 short term Fellow of the Japan Society for the Promotion of Science, and an Honorary Research Fellow of the Queensland Museum Biodiversity Program. His awards include an NIH Career Development Award, the 2006 University of Utah Inaugural Distinguished Graduate Mentor Award, the 2006 University of Utah, College of Pharmacy Distinguished Teaching Award, the 2007 University of Utah Distinguished Scholarly & Creative Research Award, the 10th Webster Sibilsky Award for Contributions to the Field of Medicinal Chemistry and the 2007 Utah Governor’s Medal for Science and Technology. During his tenure at the University he has been awarded over 23 million dollars in investigator initiated research funding from a variety of agencies including the National Institutes of Health, the United States Department of Commerce, the Petroleum Research Fund and the Alfred P. Sloan Foundation. Dr. Ireland is the Principal Investigator of a $5.9M National Cooperative Drug Discovery Group consortium funded by the NCI to discover new cancer drugs from unique natural products sources, and the Co-PI of a $3.5M International Cooperative Biodiversity Group consortium funded by the Fogerty International Center to discover new HIV, Malaria and TB drugs from plants in Papua New Guinea.

The Utah Addiction Center Report

The five central ideas of Seeking Safety are: 1) safety is the priority of first-stage treatment; 2) integrated treatment for trauma and substance use disorders is very effective; 3) a focus on ideals helps to inspire participants to change; 4) content areas use strategies of cognitive, behavioral, interpersonal and case management treatments; 5) various processes are emphasized for the therapist, such as building therapeutic alliances, using coping skills, giving clients control, modeling positive behavior and asking for patient feedback. Safety is an umbrella term which signifies discontinuing psychoactive substance abuse, reducing suicidal ideation and behavior, minimizing exposure to HIV risk, letting go of dangerous relationships, gaining control over dangerous symptoms, and stopping self-harm behaviors. The focus is on client potential rather than pathology. 8

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An exciting developing treatment option for veterans coping with co-occurring PTSD and substance use disorders is MindfulnessBased Relapse Prevention (MBRP). MBRP is an innovative 8-week psycho-educational program specifically created for individuals in recovery from substance use and designed to help prevent future relapse. MBRP uses empirically supported interventions from Dr. Alan Marlatt’s Relapse Prevention Therapy (RPT), Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR), and MindfulnessBased Cognitive Therapy (MBCT). The MBRP curriculum integrates mindfulness meditation practices with cognitive-behavioral strategies to support individual’s ability to regulate negative affect and promote lifestyle changes for a healthy life of recovery. The MBRP program teaches effective skills to support management of negative emotional states, including hyper-arousal symptoms, manage urges and cravings, and cultivate better self-understanding and acceptance. MBRP participants are typically expected to engage in group discussions and follow-up home assignments, ultimately developing both formal and informal mindfulness practice.

at the VA to treat PTSD, this study is one of the first that will provide an objective measure of the effectiveness of antipsychotics on reducing anxiety and depression, inhibiting aggression and reducing sleep disturbances in the veteran population (Krystal et al, 2005). This study is in the final phases of data collection and the results have not yet been analyzed or published. Prazosin is another medication that has been widely used in an off-label manner to treat nightmares and sleep disturbance in people suffering from PTSD. The VA’s research team is set to participate in a new VA sponsored trial: CSP #563, Prazosin and Combat Trauma (PACT). This study aims to evaluate prazosin, another medication that is used widely for its clinical lore as a suppressor of combat related nightmares. Enrollment in this study is set to begin in early 2010. The research arm of the VA’s Substance Abuse Department recently completed CSP#1025, Topiramate for Methamphetamine Dependence. This study was sponsored by the National Institute on Drug Abuse and conducted with multiple other research clinics from around the country. Although the medication tested, topiramate, did not show to be strongly effective at improving the disease of methamphetamine dependence the study also examined the genomics of this disorder. The genetics samples provided by subjects throughout the 12 weeks of the study have allowed scientists to learn new information about how medications can affect gene expression during recovery from methamphetamine dependence. Genes expressed are involved in critical areas of neurotransmission and effect areas of cognition including thinking, emotions, memory, learning and new behavior acquisition. These investigations into gene expression have opened up a new area for not only targeting medications for the treatment of substance use disorders but also identifying which individuals who are most likely to respond to or who are least likely to experience side effects from a particular medication.

Although this is an stimulating time to be involved in treatment or therapy at the VA there are still many areas where growth is necessary to provide the best possible care and improve veterans’ quality of life. There continue to be gaps in adequate pharmacotherapies for patients suffering from PTSD or substance abuse. This is evident by the lack of medications approved by the FDA to treat PTSD or substance abuse issues. In studies published by Brady, Davidson, Marshall, Tucker, et.al as cited in Raskind & Peskind, 2009, we know the only drugs to have gained FDA approval for PTSD are the SSRI antidepressants sertraline and paroxetine, based on large industry sponsored multicenter trials in samples of participants with almost exclusively civilian (non-veterans, non-combat) trauma PTSD. Although it appears that the SSRIs as a class are effective in civilian PTSD, the magnitude of SSRI effects has been small to moderate in these civilian trauma studies. Furthermore, in U.S. military veterans with PTSD, a multicenter sertraline PTSD study was negative and two placebo-controlled fluoxetine SSRI trials for PTSD in United States veterans also were negative (Raskind & Peskind, 2009).

An additional project in the substance abuse research clinic includes VA Cooperative Study #1026 with the National Institute on Drug Abuse. CSP#1026 evaluates the medication modafinil for treating methamphetamine dependence. This study is in the final weeks of data collection and will be going through statistical analysis in early 2010. This is another multi-site clinical trial that investigated a medication to help methamphetamine addicts quit using. Results from data analysis are expected to be published by fall 2010. On the horizon, come more collaborative efforts with the National Institute on Drug Abuse where the VA’s research team has again been invited to enroll civilians and veterans alike to help determine if bupropion is effective in helping methamphetamine addicts reduce use or achieve abstinence.

Mental Health Research at the VA

These Cooperative Studies research trials are unique because they not only offer research opportunities for veterans but they are also open to the community (civilians). This is an additional research resource for the community that may provide more options to clients whose choices for care may be limited to that provided by the Salt Lake County Substance Abuse System. These clinical research trials support the desire to find evidence based treatments and in addition offer a Cognitive Behavioral Component utilizing the Matrix Model and provide motivational support for enrolled research participants.

The Salt Lake VA Health Care System provides support for ongoing research in treatments for PTSD and substance abuse. There are both local investigator initiated as well and nationally directed research efforts to seek out and evaluate effective treatments taking place at the George E Wahlen VA Medical Center. Current and previous research projects within the clinical mental health sector at the Salt Lake City VA include research focused on treatments for alcohol, cocaine, methamphetamine and opiate dependence as well as for PTSD. Investigators at the George E Wahlen VA Medical Center include Chris Stock, PharmD; Steve Allen, PhD; Jennifer Romesser, PsyD; Gavin West, MD; Caroline Merveille, MD; Current Cooperative Studies at Paul Carlson, MD; and study coordinators Lindsay the Salt Lake VA Carpenter and Marni Greenwell. • Risperidone Treatment for Military This research team recently completed enrolling Service Related Chronic Post-Traumatic patients in the study: VA Cooperative Study#540, Stress Disorder Risperidone Treatment for Military Service Related • Prazosin and Combat Trauma (PACT) Chronic Post-Traumatic Stress Disorder. This is a • Topiramate for Methamphetamine multi-site clinical trial that is being conducted at VA Dependence sites across the country. The study is designed to test • Modafinil for Treating Methamphetamine risperidone to determine if it is effective in reducing combat related PTSD for the veteran community. Dependence Although risperidone has been widely used off-label

At a Glance

The Utah Addiction Center Report

In summary, “This is not your Father’s VA.” There are many exciting new treatments and pharmacotherapies on the horizon, especially in the areas of PTSD and substance abuse. The VA offers a broad variety of treatments and a greater understanding for the complex needs of our veterans have when they return home from the battlefield. Our hope at the VA is to improve the quality of life for the veterans who have served for us. To care for him who shall have borne the battle and for his widow, and his orphan (Abraham Lincoln). This article is a collaboration of the PCT and Mental Health Research Teams at the VA Salt Lake City Health Care System. References are available upon request. 6

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An exciting developing treatment option for veterans coping with co-occurring PTSD and substance use disorders is MindfulnessBased Relapse Prevention (MBRP). MBRP is an innovative 8-week psycho-educational program specifically created for individuals in recovery from substance use and designed to help prevent future relapse. MBRP uses empirically supported interventions from Dr. Alan Marlatt’s Relapse Prevention Therapy (RPT), Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR), and MindfulnessBased Cognitive Therapy (MBCT). The MBRP curriculum integrates mindfulness meditation practices with cognitive-behavioral strategies to support individual’s ability to regulate negative affect and promote lifestyle changes for a healthy life of recovery. The MBRP program teaches effective skills to support management of negative emotional states, including hyper-arousal symptoms, manage urges and cravings, and cultivate better self-understanding and acceptance. MBRP participants are typically expected to engage in group discussions and follow-up home assignments, ultimately developing both formal and informal mindfulness practice.

at the VA to treat PTSD, this study is one of the first that will provide an objective measure of the effectiveness of antipsychotics on reducing anxiety and depression, inhibiting aggression and reducing sleep disturbances in the veteran population (Krystal et al, 2005). This study is in the final phases of data collection and the results have not yet been analyzed or published. Prazosin is another medication that has been widely used in an off-label manner to treat nightmares and sleep disturbance in people suffering from PTSD. The VA’s research team is set to participate in a new VA sponsored trial: CSP #563, Prazosin and Combat Trauma (PACT). This study aims to evaluate prazosin, another medication that is used widely for its clinical lore as a suppressor of combat related nightmares. Enrollment in this study is set to begin in early 2010. The research arm of the VA’s Substance Abuse Department recently completed CSP#1025, Topiramate for Methamphetamine Dependence. This study was sponsored by the National Institute on Drug Abuse and conducted with multiple other research clinics from around the country. Although the medication tested, topiramate, did not show to be strongly effective at improving the disease of methamphetamine dependence the study also examined the genomics of this disorder. The genetics samples provided by subjects throughout the 12 weeks of the study have allowed scientists to learn new information about how medications can affect gene expression during recovery from methamphetamine dependence. Genes expressed are involved in critical areas of neurotransmission and effect areas of cognition including thinking, emotions, memory, learning and new behavior acquisition. These investigations into gene expression have opened up a new area for not only targeting medications for the treatment of substance use disorders but also identifying which individuals who are most likely to respond to or who are least likely to experience side effects from a particular medication.

Although this is an stimulating time to be involved in treatment or therapy at the VA there are still many areas where growth is necessary to provide the best possible care and improve veterans’ quality of life. There continue to be gaps in adequate pharmacotherapies for patients suffering from PTSD or substance abuse. This is evident by the lack of medications approved by the FDA to treat PTSD or substance abuse issues. In studies published by Brady, Davidson, Marshall, Tucker, et.al as cited in Raskind & Peskind, 2009, we know the only drugs to have gained FDA approval for PTSD are the SSRI antidepressants sertraline and paroxetine, based on large industry sponsored multicenter trials in samples of participants with almost exclusively civilian (non-veterans, non-combat) trauma PTSD. Although it appears that the SSRIs as a class are effective in civilian PTSD, the magnitude of SSRI effects has been small to moderate in these civilian trauma studies. Furthermore, in U.S. military veterans with PTSD, a multicenter sertraline PTSD study was negative and two placebo-controlled fluoxetine SSRI trials for PTSD in United States veterans also were negative (Raskind & Peskind, 2009).

An additional project in the substance abuse research clinic includes VA Cooperative Study #1026 with the National Institute on Drug Abuse. CSP#1026 evaluates the medication modafinil for treating methamphetamine dependence. This study is in the final weeks of data collection and will be going through statistical analysis in early 2010. This is another multi-site clinical trial that investigated a medication to help methamphetamine addicts quit using. Results from data analysis are expected to be published by fall 2010. On the horizon, come more collaborative efforts with the National Institute on Drug Abuse where the VA’s research team has again been invited to enroll civilians and veterans alike to help determine if bupropion is effective in helping methamphetamine addicts reduce use or achieve abstinence.

Mental Health Research at the VA

These Cooperative Studies research trials are unique because they not only offer research opportunities for veterans but they are also open to the community (civilians). This is an additional research resource for the community that may provide more options to clients whose choices for care may be limited to that provided by the Salt Lake County Substance Abuse System. These clinical research trials support the desire to find evidence based treatments and in addition offer a Cognitive Behavioral Component utilizing the Matrix Model and provide motivational support for enrolled research participants.

The Salt Lake VA Health Care System provides support for ongoing research in treatments for PTSD and substance abuse. There are both local investigator initiated as well and nationally directed research efforts to seek out and evaluate effective treatments taking place at the George E Wahlen VA Medical Center. Current and previous research projects within the clinical mental health sector at the Salt Lake City VA include research focused on treatments for alcohol, cocaine, methamphetamine and opiate dependence as well as for PTSD. Investigators at the George E Wahlen VA Medical Center include Chris Stock, PharmD; Steve Allen, PhD; Jennifer Romesser, PsyD; Gavin West, MD; Caroline Merveille, MD; Current Cooperative Studies at Paul Carlson, MD; and study coordinators Lindsay the Salt Lake VA Carpenter and Marni Greenwell. • Risperidone Treatment for Military This research team recently completed enrolling Service Related Chronic Post-Traumatic patients in the study: VA Cooperative Study#540, Stress Disorder Risperidone Treatment for Military Service Related • Prazosin and Combat Trauma (PACT) Chronic Post-Traumatic Stress Disorder. This is a • Topiramate for Methamphetamine multi-site clinical trial that is being conducted at VA Dependence sites across the country. The study is designed to test • Modafinil for Treating Methamphetamine risperidone to determine if it is effective in reducing combat related PTSD for the veteran community. Dependence Although risperidone has been widely used off-label

At a Glance

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In summary, “This is not your Father’s VA.” There are many exciting new treatments and pharmacotherapies on the horizon, especially in the areas of PTSD and substance abuse. The VA offers a broad variety of treatments and a greater understanding for the complex needs of our veterans have when they return home from the battlefield. Our hope at the VA is to improve the quality of life for the veterans who have served for us. To care for him who shall have borne the battle and for his widow, and his orphan (Abraham Lincoln). This article is a collaboration of the PCT and Mental Health Research Teams at the VA Salt Lake City Health Care System. References are available upon request. 6

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Meet the New Members of the Utah Addiction Center Advisory Board: Chris Ireland, PhD

TBI. Those that screen positive are assessed by a multidisciplinary team consisting up of physiatrists, neuropsychologists, social workers, speech and language pathologists, audiologists, and physical therapists. The Polytrauma team maintains regular contact with those service members diagnosed with TBI and provides treatment, education, and support for these service members and their families. Treatment and support activities include rehabilitation therapies, mental health, a TBI support group, and family social functions several times a year. The VA is also involved in outreach services to educate healthcare providers and members of the community about TBI and resources throughout the state of Utah.

Dr. Chris M. Ireland joined the faculty of the University of Utah as an Assistant Professor of Medicinal Chemistry in 1983. He served as Professor and Chair of the Department of Medicinal Chemistry from 1992-99 and his current appointment is Professor and Interim Dean, College of Pharmacy. He is also an Adjunct Professor of Chemistry. During his 26 years on the faculty he has established himself as a world leader in the field of natural product drug discovery.

Substance Abuse treatment and research

Reflecting the importance of substance abuse and mental health issues for veterans after deployment, the VA has devoted considerable resources into treatment and research. For instance, each VA has designated clinicians specializing in treatment of both PTSD and substance abuse. At the Salt Lake City VA, several approaches are utilized for treating substance abuse, including a harmreduction paradigm, “Seeking Safety”, for veterans suffering from illness where risky behavior is evident such as PTSD, TBI or substance abuse.

Dr. Ireland’s research program has focused on the discovery of antitumor agents from natural product sources including marine invertebrate animals, tropical plants and fungi. He and his co-workers have published more than 160 peer reviewed research articles, eight book chapters and five patents. His research accomplishments and international reputation have been acknowledged in the form of numerous invitations to speak at national and international symposia on natural products research and cancer chemotherapeutics.

Seeking Safety is a presentfocused, structured Domains (cognitive, behavioral, interpersonal, (14) Creating Meaning (cognitive) psychotherapy or a combination) are listed in parentheses. (15) Community Resources treatment for (1) Introduction to treatment / Case (interpersonal) management people with the (16) Setting Boundaries in Relationships (2) Safety (combination) dual diagnosis of (interpersonal) PTSD and Substance (3) PTSD: Taking Back Your Power (17) Discovery (cognitive) (cognitive) Use Disorders. The (18) Getting Others to Support Your (4) Detaching from Emotional Pain: Recovery (interpersonal) format includes 25 Grounding (behavioral) topics focused on (19) Coping with Triggers (behavioral) (5) When Substances Control You coping skills relevant (20) Respecting Your Time (behavioral) (cognitive) to both disorders. (21) Healthy Relationships (6) Asking for Help (interpersonal) Seeking Safety can (interpersonal) (7) Taking Good Care of Yourself be utilized in a (22) Self-Nurturing (behavioral) (behavioral) group or class setting (23) Healing from Anger (interpersonal) (8) Compassion (cognitive) or individually. (24) The Life Choices Game (9) Red and Green Flags (behavioral) The topics are (combination) (10) Honesty (interpersonal) independent of (25) Termination (11) Recovery Thinking (cognitive) one another, thus allowing maximum (12) Integrating the Split Self (cognitive) flexibility for (13) Commitment (behavioral) clinicians and clients in choosing the order of presentation. The topics are designed to teach people how to maintain safety while dealing with symptoms related to PTSD and substance abuse.

Seeking Safety treatment topics

He has served as Chair of the Marine Natural Products Gordon Conference, as Chair of the organizing committee of two of the most successful American Society of Pharmacognosy annual meetings (Park City 1987, San Diego 1993), as President of the American Society of Pharmacognosy, and Chairman of the Board of the American Society of Pharmacognosy Foundation. Dr. Ireland has received additional recognition by serving on a number of review panels at NIH including the Bioorganic and Natural Products NIH study section and most recently as a member of the National Cancer Institutes Board of Scientific Counselors. He is an Alfred P. Sloan Fellow, a 2008 short term Fellow of the Japan Society for the Promotion of Science, and an Honorary Research Fellow of the Queensland Museum Biodiversity Program. His awards include an NIH Career Development Award, the 2006 University of Utah Inaugural Distinguished Graduate Mentor Award, the 2006 University of Utah, College of Pharmacy Distinguished Teaching Award, the 2007 University of Utah Distinguished Scholarly & Creative Research Award, the 10th Webster Sibilsky Award for Contributions to the Field of Medicinal Chemistry and the 2007 Utah Governor’s Medal for Science and Technology. During his tenure at the University he has been awarded over 23 million dollars in investigator initiated research funding from a variety of agencies including the National Institutes of Health, the United States Department of Commerce, the Petroleum Research Fund and the Alfred P. Sloan Foundation. Dr. Ireland is the Principal Investigator of a $5.9M National Cooperative Drug Discovery Group consortium funded by the NCI to discover new cancer drugs from unique natural products sources, and the Co-PI of a $3.5M International Cooperative Biodiversity Group consortium funded by the Fogerty International Center to discover new HIV, Malaria and TB drugs from plants in Papua New Guinea.

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The five central ideas of Seeking Safety are: 1) safety is the priority of first-stage treatment; 2) integrated treatment for trauma and substance use disorders is very effective; 3) a focus on ideals helps to inspire participants to change; 4) content areas use strategies of cognitive, behavioral, interpersonal and case management treatments; 5) various processes are emphasized for the therapist, such as building therapeutic alliances, using coping skills, giving clients control, modeling positive behavior and asking for patient feedback. Safety is an umbrella term which signifies discontinuing psychoactive substance abuse, reducing suicidal ideation and behavior, minimizing exposure to HIV risk, letting go of dangerous relationships, gaining control over dangerous symptoms, and stopping self-harm behaviors. The focus is on client potential rather than pathology. 8

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Meet the New Members of the Utah Addiction Center Advisory Board: John McDonnell, PhD

How is PTSD treated?

This is an exciting time in mental health care! Decades of research and evaluation have produced psychotherapies that are shown to be effective, or “evidence-based,” for particular conditions. The Institute of Medicine has concluded that Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are the most effective treatments available for PTSD. The Department of Veterans Affairs (VA) is actively training clinicians and offering these evidencebased treatments to veterans.

Dr. McDonnell joined the faculty in the Department of Special Education in 1984. His research is focused on curriculum and instruction, transition programs, and inclusive education for students with intellectual and developmental disabilities. He has published a number of journal articles, book chapters, and books in these areas. During his tenure at the University, Dr. McDonnell has obtained over twelve million dollars in federal and state grants and contracts to support his research and personnel training activities.

Both CPT and PE have established protocols and are VIRTUAL IRAQ - Army Col. Michael J. Roy, left, who oversees delivered in approximately 12 weekly sessions. CPT the exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator that focuses on the strong connection between thoughts represents a new form of Post Traumatic Stress Disorder and emotions. Individuals with PTSD are likely to treatment with Army Sgt. Lenearo Ashford, Technical Services experience disruptions in their thoughts about safety, Branch, Uniformed Services University, on Sept. 16, 2008, in Washington, D.C. Defense Dept. photo by John J. Kruzel trust, power/control, esteem and intimacy. CPT uses cognitive techniques to assist clients in working through their problematic, trauma-related thoughts. PE includes in-vivo (or real world) and imaginal exercises. During in-vivo exposure, clients systematically engage in a hierarchy of activities that they have been avoiding because of their trauma. Imaginal exposure consists of clients repeatedly reviewing the details of their traumatic experience, in order to emotionally process the event and achieve habituation.

He serves on the editorial boards of several of the top journals in special education including Exceptional Children, Intellectual and Developmental Disabilities, Education and Training in Developmental Disabilities, and Research for Persons with Severe Disabilities. He is an avid fly fisherman and loves camping, hiking, and exploring the wilds of Utah and the intermountain area.

What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?

Mild Traumatic Brain injury

Mild traumatic brain injury (TBI), also known as concussion is the most common form of brain injury in both the civilian population as well as the military population. Research suggests that between 10-20% of OEF/OIF service members may have sustained a concussion while deployed (Hoge et al., 2008; Schneiderman, et al, 2008). Concussions can occur from close range blasts, falls, motor vehicle accidents or blows to the head. Following concussion it is normal to develop post concussive symptomology which can be physical, cognitive and emotional in nature (Alves et al., 1986):

According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.

• Physical: headache, nausea, dizziness, problems with sleep, noise and light sensitivity

PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.

• Cognitive: symptoms: problems with attention, memory and slower thinking • Emotional symptoms: irritability, anxiety, depression

What can I do to begin the healing process? There are some positive steps that you can take right away to begin healing. Here are some suggestions: • Recognize your loss. • Establish safety for yourself. • Respect the way you feel and your right to feel that way. • Talk about your feelings with those you trust. • Connect with other survivors of violence, many of whom experience similar difficulties. • Do not be afraid to seek professional help. • Try to recognize triggers that may take you back to the memory and fear of your trauma. • Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there. • Take care of yourself—exercise, eat right, and take a deep breath when you feel tense. • Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions. • Do not abandon hope—believe that healing can and will take place.

Research has repeatedly demonstrated that the majority of individuals who sustain a TBI completely recover in the days to weeks to months after the incident with no longstanding problems (Mittenberg, 1996; Belanger et al, 2005; McCrea, 2008; Schretlen & Shapiro, 2003; Ivins et al., 2009). Unfortunately, a small percentage of individuals may remain symptomatic longer than expected. Risk factors that enhance vulnerability to experiencing persistent problems include: • A history of multiple concussions • A prior history of brain injury • Significant stress during the recovery period • Co-morbid mental health problems such as post traumatic stress disorder, anxiety, depression, sleep disorders, chronic pain or substance use. The SLC VA Health Care system is designated as a Polytrauma Level III site for evaluation and treatment of veterans with TBI. The focus of treatment is intensive outpatient services for service members with TBI. All returning service members who come to the VA are screened for possible The Utah Addiction Center Report

from SAMHSA

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Meet the New Members of the Utah Addiction Center Advisory Board: M. David Rudd, PhD, ABPP

What is Posttraumatic Stress Disorder (PTSD)?

PTSD first appeared in the DSM-III (APA, 1980) primarily in response to pathology developing because of combat experiences of Vietnam veterans, as well as sexual assaults, and natural disasters. This definition was expanded in subsequent editions to include pathology resulting from events that were witnessed or heard about. Currently, the DSM-IV-TR (APA, 2000) stipulates two conditions necessary for defining an event as traumatic. The first, Criterion A1, states that the event involved “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” The subjective nature of experiencing a trauma is captured by Criterion A2, which states that experiencing the event must have involved “intense fear, helplessness, or horror.” Therefore, by definition, a potentially traumatic experience must have occurred in order to meet criteria for a diagnosis of PTSD. Although it is theoretically possible that in some cases a person may exhibit PTSD-like symptoms without a potentially traumatic event, these instances appear to be rare.

M. David Rudd is Dean of the College of Social and Behavioral Sciences at the University of Utah (Effective August 2009). His undergraduate degree is from Princeton University. He completed his doctoral training at the University of Texas-Austin and completed a post-doctoral fellowship in cognitive therapy at the Beck Institute in Philadelphia under the direction of Aaron T. Beck. He is a Diplomate of the American Board of Professional Psychology and a Fellow of three professional societies, including the American Psychological Association (Division 12 and Division 29), the International Association of Suicide Research, and the Academy of Cognitive Therapy (a founding fellow). He was recently elected a Distinguished Practitioner and Scholar of the National Academies of Practice in Psychology. In addition to his clinical work, Dr. Rudd is an active researcher with over 170 publications. He has authored several books, including Treating Suicidal Behavior (2001, Guilford, 2nd printing in 2004) and Suicide Science: Expanding the Boundaries (2001, Kluwer Academic Publishers), The Assessment Post-Traumatic Stress Disorder is the and Management of Suicidality: A Pocket Guide (Professional Resource Press, 2006) and the recently Primary Suicide Risk Factor For Veterans released The Interpersonal Theory of Suicide (with Researchers working with Iraq and Afghanistan Joiner, VanOrden, & Witte) from the American war veterans have found that post-traumatic Psychological Association Press. stress disorder, the current most common mental disorder among veterans returning from His research has been recognized with awards service in the Middle East, is associated with an both national and international. He has served as increased risk for thoughts of suicide. a consultant to many organizations nationally and Results of the study indicated that veterans who internationally, including the United States Air Force, screened positive for PTSD were four times more likely to report suicide-related thoughts relative the U.S. Army, the Department of Defense and the Beijing Suicide Prevention and Research Center. to veterans without the disorder. The research, published in the Journal of Traumatic Stress, Dr. Rudd serves on a number of editorial boards, establishes PTSD as a risk factor for thoughts of suicide in Iraq and Afghanistan war veterans. is past Chair of the Texas State Board of Examiners of Psychologists, past President of the Texas This holds true, even after accounting for other psychiatric disorder diagnoses, such as substance Psychological Association, past President of Division abuse and depression. Veterans who screened 12 Section VII of the American Psychological positive for PTSD and two or more comorbid Association, past Past-President of the American mental disorders were significantly more likely Association of Suicidology, a previous members of to experience thoughts of suicide relative to the APA Council of Representatives, and currently veterans with PTSD alone. serves as vice-president of the PDV Foundation. Dr. Rudd has twice testified before the U.S. Congress on from Science Daily issues related to veterans and suicide.

Did You Know?

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Traumatic sequelae are clustered into three additional criteria: reexperiencing, avoidance of stimuli that remind one of the event and numbing of general responsiveness, and hyperarousal. Reexperiencing includes having flashbacks, nightmares, and intrusive thoughts about the traumatic event. Persistent avoidance and numbing include avoiding people, places and activities that are reminders of the event as well as a diminished capacity to feel emotions in general. Hyperarousal includes hypervigilance and having an increased startle reaction such as to loud noises. Who is affected by PTSD?

Approximately 90% of the population will experience at least one potentially traumatic event as defined by the DSM-IV-TR criteria for PTSD sometime in their lives (Breslau & Kessler, 2001). Despite this almost universal exposure rate, the lifetime prevalence rate of PTSD is about 5-6% in men and 12-14% in women (Breslau, 2001; Kessler, Sonnega, & Bromet, 1995). One possible explanation for the relatively low rate of PTSD is that the DSM definition excludes some events that are commonly considered traumatic. For example, instances of child sexual abuse (CSA) in which the child is groomed over time may not involve experiences of fear, helplessness, or horror (Veldhuis & Freyd, 1999). Expanding the definition to include additional cases of CSA would likely raise the overall number of cases of PTSD. Despite the higher prevalence of PTSD among women, men consistently report higher overall rates of exposure to traumatic events (Breslau, 2001; Norris et al., 2002), which has led some to suggest an inherent vulnerability among women (Breslau et al., 1997). However, a closer examination of the types of events reveals that men tend to report more instances of accidents, physical assaults, and combat trauma than women whereas women are more likely to experience sexual assault (Norris et al., 2002). Among all traumas, sexual trauma is associated with one of the highest rates of PTSD. Research has found that sexual assault at least partially accounts for the gender difference in rates of PTSD.

The Utah Addiction Center Report

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Today’s Returning Military Veterans: Current Practices and Ongoing Research

Substance Abuse Among Troops, Veterans, and Their Families

Steve Allen, Lindsay Carpenter, Patricia Gullberg, Taylor Plumb, Jennifer Romesser, Edyta Skarbeck, Jennifer Steele, Chris Stock

NIDA Notes Director’s Perspective Vol. 22, No. 5 (November 2009) By NIDA Director, NORA D. VOLKOW, M.D.

M

W

ilitary experts are concerned that the wars in Iraq and Afghanistan may be precipitating a rise in problems related to substance use and abuse among the military personnel who have been deployed to those fronts. NIDA has joined forces with the Department of Defense, Department of Veterans Affairs, and other Federal agencies in a campaign to assess and find solutions to this threat to the health and well-being of our service men and women, veterans, and their families.

hatever your thoughts are about the VA Health Care System, they are probably out of date. Many people consider the VA as a place where “old soldiers go to die.” In fact, the VA has changed significantly in the last 10 years. By any standard, the VA is frequently ranked as the leading health care system in the nation. (Business Week 2006). In addition, the VA is a leader in many areas of mental health treatment including substance abuse and PTSD. In the area of chronic mental illness, the VA is among the participants in evolving the “Recovery Model.” The Recovery Model emphasizes veterans returning to their highest level of functioning, often to include “mentoring” other veterans in peer-to-peer programs.

Demographic factors and the military’s unique organizational structures, culture, and experiences contribute to service members’ overall high prevalence of smoking and binge drinking and low prevalence of illicit substance abuse, when compared with civilian rates. The patterns of tobacco use illustrate the impact that war can have on substance use: Tobacco use is about 50 percent higher among the Nation’s active duty military personnel and veterans than in the civilian population. Yet studies reported at a recent NIDAcosponsored meeting indicate that smoking rates are an additional 50 percent higher among personnel who have served in war zones.

The current wars in Iraq, “Operation Iraqi Freedom (OIF),” and Afghanistan, “Operation Enduring Freedom (OEF),” have presented significant challenges in caring for veterans. In Utah, many of the deployed service members are National Guard members called to serve from their families and careers. Approximately 12,000 Utahns have served in OEF/OIF. They range in age from about 19 to about 60, with an average age of about 37. Many service members have served multiple tours with the expectation of likely re-deployment in the future. Many service members deal with a range of post-deployment consequences, including readjustment issues, employment, substance abuse, suicide, Post-Traumatic Stress Disorder (PTSD), chronic pain, military sexual trauma and mild traumatic brain injury.

Combat exposure appears to be a primary mediator of the impact of war deployment on substance abuse rates. In one study, one in four veterans of Iraq and Afghanistan reported symptoms of a mental or cognitive disorder; one in six reported symptoms of post-traumatic stress disorder (PTSD). These disorders are strongly associated with substance abuse and dependence, as are other problems experienced by returning military personnel, including sleep disturbances, traumatic brain injury, and violence in relationships.

Responding to the needs of OEF/OIF service members has further changed the VA. Drawing on hard won lessons from treatment of soldiers from past conflicts, the VA is now engaged in considerable community outreach, including collaborations with the National Guard to attract service members to their earned benefits. The Salt Lake VA recently opened a specialty clinic devoted to providing comprehensive care of OEF/OIF veterans including primary care and mental health treatment. The OEF/ OIF clinic also provides aggressive outreach to veterans to attract them to VA services. The VA is also actively involved in outreach to homeless veterans, providing interventions to veterans in the justice system and suicide prevention. Other innovations in the VA are providing mental health services in a primary care setting and training police and corrections officers about mental health issues.

NIDA research has established effective principles for preventing and treating substance abuse and co-occurring problems and has proven the efficacy of a variety of interventions. This knowledge may provide a basis for reducing substance abuse and its consequences among the military. Modifications may be required, however. Ways will have to be found, for example, to counter some service members’ reluctance to seek treatment, which may reflect a cultural emphasis on showing strength rather than needs, or perhaps worries about potential disciplinary consequences. We will need to learn how factors associated with deployment affect service members’ risks for substance abuse and their recovery pathways. The high rates of co-occurring PTSD and substance abuse among those who have directly experienced combat have put a premium on research to develop stronger responses to these difficult problems. NIDA and its coalition partners have issued a call for research on the epidemiology, causes, prevention, and treatment of substance use and abuse and co-occurring problems among service members, veterans, and their families (RFA-DA-10-001 and RFA-DA-10-002). In this and other efforts, NIDA is working with military and mental health specialists to help those who have served the Nation.

In this article we will briefly review some of the recent developments in the VA Health Care system in caring for veterans, particularly for PTSD, mild traumatic brain injury and substance abuse.

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Utah Addiction Center University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108

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Addiction Center

U.S. POSTAGE PAID Salt Lake City, Utah Permit No. 1529

Volume 2 Issue 10

February 2010

Report

Dedicated to research, clinical training, and education in chemical addiction

Contact Us University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108 Phone: (801) 581-8216 Fax: (801) 587-7858 E-mail: abbie.paxman@hsc.utah.edu Internet: http://uuhsc.utah.edu/uac/

A Message from the Director

Post-Traumatic Stress Disorder and Substance Abuse

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powerful connection exists between extreme emotional experiences and resultant dysfunctions and substance abuse disorders. An appreciation for this co-morbidity and its causes, as well as its consequences, is essential for effective prevention and treatment of drug addiction/dependence for many people. Of particular importance Glen W. Hanson, Ph.D, D.D.S is the role of stress and its various expressions. Relevant to this UAC Newsletter is that form of stress disorder known as PTSD or post-traumatic stress disorder. Â While most people have experienced traumatic events either acutely or chronically, the expression of PTSD is limited to ~5-10% of the population with greater expression in females.

The Utah Addiction Center is based in the office of the University of Utah Senior Vice President for Health Sciences INSTITUTIONAL ADVISORY BOARD

A. Lorris Betz, M.D., Ph.D. Louis H. Callister, J.D. Edward B. Clark, M.D. M. David Rudd, PhD, ABPP Patrick Fleming, LSAC, MPA Raymond Gesteland, Ph.D. Jay Graves Ph.D. John R. Hoidal, M.D. Glen W. Hanson Ph.D, D.D.S, Maureen Keefe, RN, Ph.D Jannah Mather, Ph.D. Chris Ireland, Ph.D. John McDonnell, Ph.D. Barbara N. Sullivan, Ph.D. Ross VanVranken, ACSW Kim Wirthlin, MPA

Although some experts would argue that these estimates are low, it is still clear that a significant portion of our population has been severely traumatized emotionally and is vulnerable to complications of PTSD, such as drug abuse. This problem has become especially critical in our country and community due to the emotional and physical trauma associated with warfare, such as that encountered by our U.S. troops (associated with both regular and reserve units) participating in military activities in the Middle East. This issue of the UAC Newsletter includes outstanding articles written by local experts in the field of PTSD and drug abuse to explain the linkages and help readers appreciate the need for developing effective strategies to address the problems of these co-morbidities.

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PTSD & Substance Abuse  

Whatever your thoughts are about the VA Health Care System, they are probably out of date. Manypeople consider the VA as a place where “old...

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