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A significant proportion of individuals with substance use disorders (SUDs) meet criteria for comorbid posttraumatic stress disorder (PTSD). This comorbidity confers a more complicated clinical presentation that carries with it formidable treatment challenges for practitioners. The current study examined sources of difficulty and gratification among clinicians (N = 423) from four national organizations who completed an anonymous questionnaire. As expected, the findings revealed that comorbid SUD/PTSD was rated as significantly more difficult to treat than either disorder alone. The most common challenges associated with treating SUD/PTSD patients included knowing how to best prioritize and integrate treatment components, patient self-destructiveness and severe symptomatology, and helping patients abstain from substance use. The findings increase understanding of SUD/PTSD treatment challenges, and may be useful for enhancing therapist training programs, supervision effectiveness, and designing optimal SUD/PTSD interventions.

We surveyed 120 patients admitted to a child and adolescent psychiatric inpatient unit regarding their cigarette smoking history, reasons for smoking, patterns of use, and psychiatric comorbidity (chart review). We administered the Social Phobia and Anxiety Inventory and the modified Fagerstrom Tolerance Questionnaire. Only six of 47 current smokers had a chart diagnosis of nicotine dependence. Logistic regression derived that the odds ratio for being a current smoker was: Caucasian race = 5.56, older age = 1.3, depressive disorders = 4.02, conduct disorder (CD) = 12.96, cannabis abuse/dependence = 24.6. Hence, cigarette smoking is highly prevalent but underdiagnosed in this population.

Neuroscientific underpinnings and pharmacotherapeutic treatments of substance use disorders are rapidly developing areas of study. In particular, there have been exciting new developments in our understanding of the involvement of excitatory amino acid neurotransmitter systems and the opiate and serotonin systems in the pathophysiology of alcohol withdrawal, alcohol dependence, and in subtypes of individuals with alcoholism. In this article, new developments in the pharmacotherapy of alcohol dependence will be reviewed. In particular, the use of anticonvulsants in alcohol withdrawal and protracted abstinence syndromes will be discussed. New data on opiate antagonists and acamprosate, an agent that exerts actions through excitatory amino acid systems in relapse prevention, will be reviewed. Finally, there will be a review of new data concerning the use of serotonin reuptake inhibitors in subtypes of alcoholism and the use of combination pharmacotherapy.

Some anticonvulsants have been shown to be as effective as some benzodiazepines for the treatment of alcohol withdrawal. Anticonvulsants may offer advantages over benzodiazepines in the outpatient treatment of alcohol withdrawal: they lack abuse potential, have minimal interactions with alcohol, and may be more effective in ameliorating psychiatric symptoms of alcohol withdrawal. Carbamazepine appears to be as effective as lorazepam and oxazepam in ameliorating the symptoms of alcohol withdrawal. In addition, a recent study indicates that carbamazepine may suppress post-withdrawal alcohol use. Divalproex may also reduce symptoms of alcohol withdrawal, based on several open-label studies. However, both carbamazepine and divalproex have limited usefulness in alcoholics with severe hepatic or hematologic complications. Newer anticonvulsants, such as gabapentin and vigabatrin, also appear to reduce alcohol withdrawal symptoms in preclinical and open-label clinical trials while lacking the toxicities of carbamazepine and divalproex. Controlled trials are underway exploring the efficacy and safety of newer anticonvulsants for the treatment of alcohol withdrawal.

To investigate differences between patients whose posttraumatic stress disorder (PTSD) preceded their cocaine dependence and vice versa, 33 patients with comorbid PTSD and cocaine dependence were divided into two groups: one in which the traum and PTSD occurred before onset of cocaine dependence (primary PTSD) and one in which the PTSD occurred after cocaine dependence was established (primary cocaine). In the primary-PTSD group, the trauma was generally childhood abuse. In the primary-cocaine group, the trauma was generally associated with the procurement and use of cocaine. In the primary PTSD group, there were significantly more women, more other Axis I diagnoses, more Cluster B and C Axis II diagnoses, and more benzodiazepine and opiate use. In the primary-cocaine group, there was a trend toward more cocaine use in the previous month. Significant clinical differences between these two groups may warrant different types of treatment or differing treatment emphasis.

The authors explored the relationship between personality disorder (PD) and cocaine use. Diagnostic interviews for PD were performed at baseline and 12 weeks (study termination) in 47 cocaine-dependent individuals entering a pharmacologic treatment trial; 68% met criteria for a PD at baseline, 51% at study termination. In comparing baseline and termination PD, 22 individuals had no change in the number of PDs, 6 had more, and 17 had fewer. The group with an increase in the number of PD diagnoses had more positive urine drug screens than either of the other groups and more cocaine use by self-report. Personality disorders appear to be common in cocaine-dependent individuals but may be affected by cocaine use and withdrawal.

The authors explored the relationship between social phobia and cocaine dependence in 158 individuals entering a pharmacologic treatment trial for cocaine dependence. Twenty-two patients met DSM-III-R criteria for social phobia. The social phobia group was compared with 22 age- and sex-matched cocaine-dependent control subjects. Those with social phobia and cocaine dependence were more likely to have additional psychiatric diagnoses and greater symptom severity, more likely to be polysubstance users, and more likely to have developed alcohol dependence at an early age. The authors discuss treatment implications of these data.

The authors explored the relationship between assault, substance use disorders, and personality disorders by interviewing 82 substance-dependent inpatients with a structured interview concerning physical and sexual assault as well as the Structured Clinical Interview for DSM-III-R, parts I and II. Sixty percent of subjects met criteria for a personality disorder. Individuals who had experienced assault (n = 43) were more likely to have all types of personality disorder diagnoses (P ⩽ 0.001). Those who reported childhood assault were more likely to have Cluster Bpersonality disorders and to meet criteria for more than two personality disorder diagnoses (P < 0.05) compared with those who reported adult assault only. Personality disorders were commonly diagnosed in this group of treatment-seeking, substance-dependent individuals. The effect of substance abuse as well as assault on the development and presentation of personality disorders is likely to be substantial.

The authors explored the relationship between sexual and physical assault and posttraumatic stress disorder (PTSD) in individuals seeking treatment for substance use disorders by giving 100 substance-dependent inpatients (50 men, 50 women) a structured interview on traumatic life events and lifetime histories of sexual and physical assault. Sixty-six percent of individuals had a history of sexual or physical assault. Half of the assault victims met DSM-III-R criteria for PTSD, whereas no one in the non-assault group met criteria for PTSD. Type of assault and specific characteristics of victims were significantly associated with psychiatric disorders. Women bad higher rates of sexual assault history, serial assault, and familial assault than men. Individuals who bad experienced childhood assault bad earlier age at onset of substance dependence than those who had not experienced childhood assault. Sexual and physical assault histories and psychopathology should be assessed in all substance-dependent individ...

To further explore the complex relationship between posttraumatic stress disorder (PISD) and substance use disorders, the authors compared 30 women with PTSD in substance abuse treatment with 25 women without PTSD in substance abuse treatment on degree of addiction severity, psychopa-thology, and aftercare compliance. Women with PTSD were more likely to have been victims of sexual and physical abuse, particularly childhood abuse. They had significantly higher scores on the Addiction Severity Index, were more likely to have comorbid affective disorder, and less likely to comply with aftercare. These results suggest that screening for victimization and PTSD among women presenting for substance abuse treatment may have important prognostic and treatment implications.

The authors studied 89 alcohol- or cocaine-dependent inpatients for comorbid Axis I or Axis II psychiatric disorders. Subjects were administered the Structured Clinical Interview for DSM-III-R (SCID) to determine Axis I diagnoses. Axis II diagnoses were determined using the SCID II self-rating questionnaire and interview. High rates of Axis I disorders were found in both groups, but the types of disorders differed between groups. Axis II disorders were also commonly found in both groups but were significantly more common in the cocaine group. The types of personality disorders differed between the alcohol and cocaine groups, with the cocaine group showing significantly more Axis II Cluster A and B diagnoses.

Gender differences in characteristics of substance use disorders may have important implications. To explore this question, the authors compared 27 women and 60 men presenting for treatment of cocaine dependence with regard to demographic and cocaine use patterns. Women had earned less in the previous year (P< 0.01) and were more likely to have been unemployed (P< 0.05). Although women began using cocaine at a later age than men, they attained regular cocaine use at the same age as men and had fewer years of total cocaine use at the time of presentation for treatment (P< 0.001). Women were more likely to initiate cocaine use with crack cocaine (P< 0.01) and reported shorter duration of abstinent periods since initiating cocaine use (P< 0.05).

Recent reports promote the efficacy of gabapentin for both anxiety and substance use disorders (SUDs).1, 2 We report on an individual with polysubstance dependence and social phobia who had decreas...

Marijuana is the most commonly abused illicit drug in the United States today.1 Anxiety may be related to continued marijuana use, as users of marijuana report that its use relieves unpleasant feel...