Adaptive Interventions for Co-Occurring OUD and PTSD - PROJECT ABSTRACT Nearly half of those with opioid use disorder (OUD) experience co-occurring PTSD (co-OUD/PTSD). Among people with OUD, untreated PTSD is associated with more severe clinical profiles and higher rates of suicide attempts and drug overdoses. Exposure therapy for PTSD, delivered alongside medication for OUD improves both OUD and PTSD outcomes, but low uptake and high levels of dropout are common, resulting in sub- optimal outcomes. Reasons for poor uptake and retention include the scarcity of mental health providers resulting in long wait lists, patient avoidance, and uncertainty about the optimal timing of PTSD treatment. Interventions to increase access to and retention in trauma therapy are essential and must include primary care. Responding to both NOT-DA-23-007 and NOT-DA-23-008, this study aims to develop a scalable, equitable, and optimal adaptive treatment strategy for PTSD in patients with OUD by answering three questions: 1) Is Written Exposure Therapy (WET), an evidence-based therapy for PTSD, feasible and appropriate for delivery by community health workers? 2) What is the optimal timing of therapy for PTSD in patients with OUD? and 3) Are PTSD treatment interventions provided entirely by a collaborative care team more effective than interventions that include a referral to a licensed mental health provider? We will answer the first question by assessing the “fit” of WET for delivery by community health workers and the feasibility of different adaptive treatment strategies (R61 phase—preparation), and the latter two questions using a two- stage, Sequential Multiple Assignment Randomized Trial (SMART) design that allows us to vary the timing of when therapy is offered and by whom (R33 phase—optimization). Our study is a collaboration among RAND, the University of New Mexico, Stanford University, Boston University and the New Mexico Office of Community Health Workers. Our long-term goal is to increase access to a scalable, equitable and optimized adaptive treatment strategy for PTSD in people with OUD that improves PTSD and OUD outcomes and reduces morbidity and mortality. We also seek to shift clinical practice paradigms about what appropriate care for PTSD requires. The end-users of our research are clinicians faced with decisions about how to treat co-OUD/PTSD and policymakers searching for ways to solve the mental health workforce shortage. Our study is significant because it will equip providers with evidence-based guidance about how to address PTSD in patients with OUD at critical decision points: initial treatment and the point of non-response or symptom worsening for two synergistic and co-occurring disorders with high lethality. By testing a scalable and sustainable solution to the mental health workforce shortage—using a community health worker to deliver WET as part of a collaborative care team—it will equip policy makers with data about ways to accelerate the movement of an effective treatment for PTSD into routine use, increasing access to an effective and life-saving treatment for individuals with co-OUD/PTSD.
