RISE: Rapid Recovery Through Integrated Substance Use Treatment and Written Exposure for PTSD

Summary

Veterans with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) experience significant impairment and worse treatment outcomes compared to those with either condition alone, including higher rates of psychiatric hospitalization, relapse, and suicide risk. Unfortunately, integrated treatment options for PTSD-SUD remain extremely limited despite strong Veteran preference for integrated care over sequential or concurrent models. The only current integrated, evidence-based treatment aligned with VA/DoD clinical guidelines, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), requires 12 weekly 90-minute sessions and is associated with a 43-46% dropout rate, with most dropout occurring after six or more sessions. The high treatment burden and dropout rate indicate a critical need to develop a brief, effective, integrated intervention for Veterans with PTSD-SUD. Written Exposure Therapy (WET) is an evidence-based treatment for PTSD requiring only five 60-minute sessions, with substantially lower dropout than other trauma-focused therapies. The investigators have developed a treatment targeting PTSD and comorbid SUD called RISE (Rapid Recovery through Integrated Substance Use Treatment and Written Exposure for PTSD), that integrates WET with core components of Cognitive Behavioral Therapy for Substance Use Disorder (CBT-SUD), including functional analysis, urge and craving management, cognitive restructuring, refusal skills, and relapse prevention. By combining these two evidence-based treatments, RISE is designed to reduce treatment burden and dropout relative to existing integrated approaches while addressing both conditions concurrently. The primary goal of this study is to evaluate the feasibility and acceptability of RISE relative to CBT-SUD alone among Veterans with PTSD-SUD. Proposed is a randomized, two-arm pilot clinical trial in which 30 Veterans with PTSD-SUD will be randomized 2:1 to either 1) RISE, an integrated six-session treatment combining WET and CBT-SUD, or 2) CBT-SUD alone, delivered in a matched six-session, 90-minute format. Specific aims include: AIM 1) To evaluate the feasibility of RISE, including recruitment, session attendance, and treatment completion rates; AIM 2) To evaluate the acceptability of RISE using the Client Satisfaction Questionnaire-8; and an EXPLORATORY AIM) To generate preliminary estimates of change in PTSD and substance use symptom severity to inform a future fully-powered non-inferiority trial. If found feasible and acceptable, RISE has the potential to significantly expand access to integrated, guideline-concordant care for Veterans with PTSD-SUD while reducing treatment burden and improving long-term PTSD and SUD outcomes.