Treating Post-Traumatic Stress Disorder and Co-Occurring Substance Use Disorder

August 18, 2026

Takeaway: Developed by an HSR researcher and colleagues, COPE was officially recognized by the American Psychological Association as a first-line treatment for co-occurring PTSD and substance use disorders (SUDs) in the 2025 Clinical Practice Guideline for PTSD. HSR researchers then developed COPEweb-a web-based training protocol and innovative delivery system to strengthen providers' treatment of Veterans with co-occurring PTSD and SUD. COPEweb may be particularly useful for providers in rural clinic settings where mental healthcare training is less accessible.

Background

Post-traumatic stress disorder (PTSD) and substance use disorders (SUD) often co-occur. According to a large national epidemiologic study, nearly half of individuals with lifetime PTSD also met criteria for SUD, which may include alcohol use disorder (AUD) or drug use disorders (e.g., cannabis use disorder, opioid use disorder). Many individuals use more than one substance. Moreover, individuals with comorbid PTSD and drug use disorders have greater social and psychiatric impairment than those with PTSD and AUD, and may require different types and intensity of intervention (Simpson, et al, 2019).

Co-occurring PTSD and SUD are common among Veterans. For example, 63% of Afghanistan and Iraq War Veterans who received a SUD diagnosis also met criteria for PTSD, and Veterans with a diagnosis of SUD were 3-4 times more likely to have a co-occurring PTSD diagnosis .Clinical practice guidelines recommend trauma-focused integrated treatment as a first-line treatment for Veterans with co-occurring PTSD and SUD.

Concurrent Treatment of PTSD and SUDs Using Prolonged Exposure

Sudie Back, PhD, and colleagues developed the Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE)-an evidence-based, integrated, trauma-focused treatment that VA has identified as a gold standard of behavioral healthcare. Randomized controlled trials among Veterans have demonstrated COPE's efficacy in significantly reducing the severity of both PTSD symptoms and substance use (including alcohol and drug use).

COPE is an integrated cognitive behavioral psychotherapy developed for patients struggling with both PTSD and alcohol or drug misuse. To address both disorders concurrently, COPE combines two evidence-based treatments: prolonged exposure and cognitive behavioral therapy (CBT).

In addition, COPE was officially recognized by the American Psychological Association as a first-line treatment for co-occurring PTSD and SUD in the 2025 Clinical Practice Guideline for PTSD. However, there is a critical shortage of clinicians trained to deliver COPE despite a poll of VA PTSD-SUD Specialists that found 97% want COPE training. The poll also found that 99% of clinicians would use web-based training for COPE, if available.

COPEweb

A web-based resource for providers is ideal in many ways, as it can be rapidly disseminated, is easily accessible, and provides a significant amount of information in a standardized way. Currently, Dr. Back is working on COPEweb-a web-based training program to strengthen providers' delivery of COPE to treat Veterans with PTSD/SUD. COPEweb may be particularly useful for providers in rural clinic settings where mental health training is less accessible.

COPEweb also has the potential to serve a novel role in disaster planning to ensure mental healthcare providers are equipped to address the anticipated post-pandemic needs of Veterans, particularly given the rise in post-traumatic stress and alcohol/drug use that was seen during the COVID pandemic.

Implications

In collaboration with the investigators' operations partners, VA leadership, and Evidence-based Practice (EBP) Coordinators, COPEweb will be rapidly disseminated to mental health providers to increase the adoption of evidence-based treatment for PTSD-SUD and to improve the quality of mental healthcare for Veterans and the nation.

Investigator

Sudie Back, PhD, is a core investigator with HSR's Health Equity and Rural Outreach Innovation Center (HEROIC); she is also a staff psychologist at the Ralph H. Johnson VA Medical Center, and she is a Professor in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina.

Partners

VA National Center for PTSD, Drs. Sonya Norman and Jessica Hamblem; and the STRONG STAR Training Initiative, UT Health, San Antonio, TX, Ms. Brooke Fina.

Citation

Back S, Jarnecke A, Norman S, et al. State of the science: Treatment of comorbid posttraumatic stress disorder and substance use disorders. Journal of Traumatic Stress. December 2024;37(6):803-813.

Back S, Killeen T, Badour C, et al. Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military Veterans. Addictive Behaviors. March 2019;90:369-377.