PTSD and Substance Use: Treating Both Together

You do not always have to finish substance use treatment before starting effective PTSD treatment. Many people can receive care for both at the same time, with clinicians working from a shared plan. A fixed demand for months of abstinence can delay help that may be appropriate.

There is a safety distinction. Being ready for trauma therapy is different from being safe to attend a session while intoxicated, in severe withdrawal, or in an acute crisis. Those problems need assessment first. Coordinated treatment can include withdrawal care without turning it into an indefinite barrier to PTSD care.1

Do not abruptly stop heavy alcohol use if you may be at risk of withdrawal, or abruptly stop prescribed benzodiazepines. Withdrawal can be dangerous. Ask a clinician for prompt advice about a safe plan. Withdrawal seizures or severe confusion are emergencies. So are inability to stay awake or slowed breathing, which can signal overdose. Call 911.23

What matters most

• You do not always have to finish substance use treatment before starting PTSD treatment. Many people can receive both at once from a coordinated plan.
• Readiness is assessed, not counted in sober days. Intoxication, severe withdrawal, or an acute crisis needs attention first.
• Do not abruptly stop heavy alcohol use or prescribed benzodiazepines. Withdrawal can be dangerous; ask for a safe plan.
• COPE, which combines Prolonged Exposure with relapse prevention, improved PTSD more than substance-use-only care in trials. Substance use improved in both groups.
• Medicines need a clearly named job. Naltrexone, buprenorphine, and methadone treat substance use disorders; no medicine is established as a treatment for both conditions at once.

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Why the problems may become linked

Some people use alcohol or drugs to sleep, quiet memories, or feel less tense. Others had substance use problems before the traumatic event. Exposure to danger, social conditions, pain, and other mental health problems can also contribute. There is no single pathway that explains everyone.

PTSD and substance use disorders often occur together. That does not mean any alcohol use is a disorder, or that everyone who uses substances is trying to treat trauma. A substance use disorder involves a pattern of impaired control, consequences, and other clinical features. Assessment should ask about the actual pattern rather than guess a motive.1

Short-term relief can be one reason a behavior continues. The longer-term effects may then include poorer sleep, missed care, relationship strain, or more danger. Naming that pattern should lead to practical help, not blame. A person can want relief and also want to change how they seek it.

The treatment plan needs separate goals for PTSD and substance use. Less fear does not automatically mean less drinking. Fewer drinking days does not establish that PTSD has resolved.

What “treating both” can mean

Sometimes one clinician or team provides an integrated treatment. In other settings, a trauma therapist and an addiction clinician coordinate separate treatments. Either arrangement needs clear communication, with your consent, about safety, medicines, goals, and what to do when symptoms change.

One studied approach is COPE, which combines Prolonged Exposure for PTSD with relapse-prevention work. It addresses trauma memories and avoidance while also helping the person understand substance use patterns and plan responses to urges. Exposure work is planned and clinician guided. It does not mean attending sessions intoxicated or putting yourself in danger.

In a 2012 Australian trial, adults receiving COPE plus usual substance use care had greater PTSD improvement than those receiving usual substance use care alone. The substance dependence outcome did not show the same clear advantage. The trial did not find that adding exposure worsened substance dependence, but that is not a guarantee for every patient.4

A later veteran trial compared COPE with relapse-prevention treatment. PTSD outcomes favored COPE. Attendance remained a challenge: people in the study attended about eight of twelve sessions on average. That matters because a treatment can be effective in a study and still be hard to complete in daily life.5

Ask about transport, scheduling, child care, withdrawal support, and what happens after a missed visit. These are part of making treatment usable, not tests of whether a person deserves care.

Seeking Safety and relapse prevention still have roles

Seeking Safety is a present-focused approach that teaches coping and safety skills without requiring detailed work on trauma memories. Some people find its format easier to accept or find. It should be described accurately when discussing PTSD outcomes.

In a trial of veterans with PTSD and alcohol use disorder, COPE led to greater PTSD symptom improvement than Seeking Safety. Heavy drinking improved in both groups, without a clear between-group difference on that outcome. The study was mostly men, so it cannot fully represent everyone seeking care.6

A separate trial in women compared Seeking Safety with women’s health education, alongside substance use treatment. It did not find a clear advantage for Seeking Safety on the main PTSD or substance use outcomes. PTSD symptoms improved in both groups. That result does not prove that skills, support, or present-focused work are useless. It limits a claim that this particular program was better than its comparison.7

Relapse prevention can help people understand high-risk situations and respond to urges. It targets substance use and may be an important part of a plan. When PTSD remains severe, ask whether the program also offers a named PTSD treatment or can coordinate one.

What newer evidence adds

A 2022 review found that adding trauma-focused treatment to substance use care could improve PTSD outcomes, though certainty was limited and dropout was common. The evidence does not support a promise that one treatment will solve both conditions.8

Project Harmony combined individual data from many trials. Its findings supported trauma-focused approaches, including combinations with substance use medicines. But comparisons across studies are not the same as one large trial randomly assigning every treatment option. They cannot establish a single best combination for every person.9

A 2025 trial specifically enrolled women with PTSD and moderate-to-severe alcohol use disorder. Integrated exposure-based treatment improved PTSD more than relapse prevention across follow-up. Alcohol use improved without a clear treatment-group difference. This broadens the evidence beyond mostly male veteran studies while preserving the distinction between PTSD and drinking outcomes.10

Readiness should therefore be assessed, not reduced to one number of sober days. It includes consent, the ability to take part, acute medical and psychiatric needs, and a plan for substance-related risks. Abstinence may be a chosen goal. Reducing harm may also be part of care. Neither goal means ignoring dangerous withdrawal or attending treatment too impaired to participate.

Medicines need a clearly named job

Medicines for alcohol or opioid use disorder are treatments in their own right. They do not have to prove a direct PTSD benefit to be useful.

In a four-group trial that tested prolonged exposure and naltrexone alone and together, naltrexone cut drinking more than placebo. Prolonged exposure did not show a clear main advantage on PTSD symptoms in that particular trial, and it did not worsen alcohol use. The results do not mean “the combination cured both.”11

Naltrexone has important opioid-related precautions. It can precipitate withdrawal in someone with current opioid dependence, and it affects opioid pain treatment. The label lists it as contraindicated for people who are currently dependent on opioids, including those taking methadone or buprenorphine. A prescriber needs the full medication and substance history.12

Buprenorphine and methadone are established medicines for opioid use disorder. Receiving them is not a failure of sobriety, and it does not automatically exclude a person from PTSD treatment. Coordination is especially important when other sedating substances or medicines are involved.13

Topiramate has been studied for co-occurring PTSD and alcohol problems, but that use is off label.14 A small early trial suggested possible benefits and also found temporary learning and memory problems. In a larger 2025 trial, adding topiramate to Prolonged Exposure did not improve the main heavy-drinking outcome more than adding placebo. An added PTSD benefit after treatment was not sustained at later follow-up. It is not an established all-purpose medicine for both conditions.1516

Prazosin has a limited guideline role for PTSD-related nightmares17, but a trial in veterans with alcohol dependence did not establish overall PTSD, sleep, or drinking benefits. Likewise, an antidepressant may help PTSD or depression without being an effective alcohol-use treatment. Ask which outcome each medicine is intended to change.1819

Benzodiazepines and cannabis require different distinctions

The VA/DoD guideline recommends against benzodiazepines as PTSD treatment. That recommendation does not prohibit medically supervised use for alcohol withdrawal or every other indication. It also does not mean a person already taking a benzodiazepine should stop suddenly. Review ongoing use with the prescriber and addiction clinician.172

Cannabis is often described as a PTSD treatment. In a placebo-controlled study of smoked cannabis in veterans, none of the active preparations outperformed placebo on the primary PTSD symptom outcome during the initial controlled stage. The short trial does not answer every question about every cannabis product, but it does not support a broad efficacy claim.20

A 2026 review found a wider but still limited evidence base, including small trials and observational studies. It did not turn cannabis into an established PTSD treatment. The VA/DoD recommendation remains against cannabis or cannabis derivatives for PTSD. Tell the clinician what you use, including products used for sleep, so the plan reflects your risks and goals.2117

Finding coordinated care in the Inland Empire

Riverside County’s RUHS CARES line, 800-499-3008, offers behavioral health and substance use assessment and referral around the clock. San Bernardino County’s Substance Use Disorder Helpline, 800-968-2636, answers 24 hours a day for referrals and resources; the county lists free screenings and assessments Monday through Friday, 7:30 a.m. to 5 p.m. Describe both the trauma symptoms and the substance use concern.2223

Both counties participate in California’s Drug Medi-Cal Organized Delivery System. Ask about eligibility, assessment, covered services, and how PTSD treatment is coordinated. A county access number is a route to help, not a guarantee of a particular bed, therapy, or same-day appointment.24

For a suicide or mental health crisis in the United States, call or text 988, or use online chat. Call 911 for an overdose, severe withdrawal, or other immediate medical emergency.25

Frequently asked questions

Will trauma therapy make my drinking worse?

Trials of integrated exposure-based treatment did not find that adding trauma work worsened substance use, though that is not a guarantee for every person.411

Does cannabis treat PTSD?

No controlled evidence supports it. In a placebo-controlled study, no smoked cannabis preparation beat placebo, and the VA/DoD guideline recommends against cannabis for PTSD.2017

Can I get PTSD treatment while on methadone or buprenorphine?

Yes. Taking these medicines is not a failure of sobriety and does not exclude you from PTSD care. Coordination matters, especially with sedating medicines.13

What should I ask a program?

Which named PTSD treatments it provides, how it assesses withdrawal, whether PTSD care can begin while substance use care continues, and how it measures each outcome separately.1

Questions that reveal what a program actually offers

You can use these in a call or appointment:

1. Which named PTSD treatments do you provide, and who is trained to deliver them?
2. How do you assess withdrawal and decide when a person can safely take part?
3. Can PTSD care begin while substance use care continues?
4. Do you provide or coordinate medicines for alcohol or opioid use disorder?
5. What happens after a return to use or a missed session?
6. How will you measure PTSD and substance use outcomes separately?

A useful answer describes actual services and a way to adjust the plan. It should make room for safety needs without treating a setback as a reason to abandon care.

This week, ask one current clinician or program how it will address both conditions. If the answer is unclear, ask who can help build a coordinated plan.

This article is for education. It does not replace an individual assessment or treatment plan. Talk with your clinician before changing medication or treatment. Evidence, contact numbers, and U.S. guidance were checked through September 6, 2026.

Related reading on NP FADY

• How PTSD Is Treated Today: What Works, and What Order to Try It In
• The Loan Shark in the Bottle: How Alcohol Borrows Pleasure From Your Brain and Charges Interest
• No Rock Bottom Required: Every Proven Way Out of Alcohol Use Disorder, and How to Pick Yours
• Cannabis and Mental Health
• Substances & Recovery essays

References

1. VA National Center for PTSD. Treatment of co-occurring PTSD and substance use disorder in VA. https://www.ptsd.va.gov/professional/treat/cooccurring/tx_sud_va.asp

2. ASAM. Clinical practice guideline on alcohol withdrawal management. 2020. https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline

3. ASAM and partner societies. Joint clinical practice guideline on benzodiazepine tapering. 2025. https://www.asam.org/quality-care/clinical-guidelines/benzodiazepine-tapering

4. Mills KL, et al. Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: A randomized controlled trial. JAMA. 2012;308:690–699. doi:10.1001/jama.2012.9071. https://jamanetwork.com/journals/jama/fullarticle/1346186

5. Back SE, et al. Concurrent treatment of substance use disorders and PTSD using prolonged exposure: A randomized clinical trial in military veterans. Addict Behav. 2019;90:369–377. doi:10.1016/j.addbeh.2018.11.032. https://pubmed.ncbi.nlm.nih.gov/30529244/

6. Norman SB, et al. Efficacy of integrated exposure therapy vs integrated coping skills therapy for comorbid posttraumatic stress disorder and alcohol use disorder: A randomized clinical trial. JAMA Psychiatry. 2019;76(8):791–799. doi:10.1001/jamapsychiatry.2019.0638. https://pubmed.ncbi.nlm.nih.gov/31017639/

7. Hien DA, et al. Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. J Consult Clin Psychol. 2009;77:607–619. doi:10.1037/a0016227. https://pubmed.ncbi.nlm.nih.gov/19634955/

8. Roberts NP, Lotzin A, Schäfer I. A systematic review and meta-analysis of psychological interventions for comorbid post-traumatic stress disorder and substance use disorder. Eur J Psychotraumatol. 2022;13(1):2041831. doi:10.1080/20008198.2022.2041831. https://pubmed.ncbi.nlm.nih.gov/35558682/

9. Hien DA, et al. Project Harmony: A meta-analysis with individual patient data on behavioral and pharmacologic trials for comorbid posttraumatic stress and alcohol or other drug use disorders. Am J Psychiatry. 2023;180:155–166. doi:10.1176/appi.ajp.22010071. https://pubmed.ncbi.nlm.nih.gov/36475373/

10. Persson A, Axén Å, Capusan AJ, Magnusson Å, Heilig M. Concurrent treatment of posttraumatic stress disorder and alcohol use disorder in women: A randomized clinical trial. JAMA Netw Open. 2025;8(7):e2521087. doi:10.1001/jamanetworkopen.2025.21087. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2836411 Visual abstract corrected August 21, 2025.

11. Foa EB, Yusko DA, McLean CP, et al. Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: A randomized clinical trial. JAMA. 2013;310:488–495. doi:10.1001/jama.2013.8268. https://jamanetwork.com/journals/jama/fullarticle/1724275

12. DailyMed. Naltrexone hydrochloride prescribing information. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=adb7c4dc-221a-4d91-9687-0d78913a92ad

13. SAMHSA. TIP 63: Medications for opioid use disorder. 2021. https://library.samhsa.gov/product/tip-63-medications-opioid-use-disorder/pep21-02-01-002

14. DailyMed. TOPAMAX prescribing information, indications. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=21628112-0c47-11df-95b3-498d55d89593

15. Batki SL, et al. Topiramate treatment of alcohol use disorder in veterans with posttraumatic stress disorder: A randomized controlled pilot trial. Alcohol Clin Exp Res. 2014;38(8):2169–2177. doi:10.1111/acer.12496. https://pubmed.ncbi.nlm.nih.gov/25092377/

16. Norman SB, et al. A randomized clinical trial of prolonged exposure therapy with and without topiramate for comorbid PTSD and alcohol use disorder. Am J Psychiatry. 2025;182(5):452–462. doi:10.1176/appi.ajp.20240470. https://pubmed.ncbi.nlm.nih.gov/40103353/

17. VA/DoD. Clinical practice guideline for management of PTSD and acute stress disorder. 2023. https://www.healthquality.va.gov/guidelines/mh/ptsd/

18. Petrakis IL, et al. Prazosin for veterans with posttraumatic stress disorder and comorbid alcohol dependence: A clinical trial. Alcohol Clin Exp Res. 2016;40:178–186. doi:10.1111/acer.12926. https://pubmed.ncbi.nlm.nih.gov/26683790/

19. Hien DA, et al. Combining Seeking Safety with sertraline for PTSD and alcohol use disorders: A randomized controlled trial. J Consult Clin Psychol. 2015;83:359–369. doi:10.1037/a0038719. https://pubmed.ncbi.nlm.nih.gov/25622199/

20. Bonn-Miller MO, Sisley S, Riggs P, et al. The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial. PLoS One. 2021;16:e0246990. doi:10.1371/journal.pone.0246990. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246990

21. Aviram J, Belobrov R, Grinapol S, Fruchter E. Efficacy, effectiveness and safety of medical cannabis in PTSD: A scoping review. J Cannabis Res. 2026;8:89. doi:10.1186/s42238-026-00451-7. https://link.springer.com/article/10.1186/s42238-026-00451-7

22. RUHS Behavioral Health. Substance Use Prevention & Treatment Locations, with the 24/7 assessment and referral line (800-499-3008). https://www.ruhealth.org/behavioral-health/sapt/locations

23. San Bernardino County DBH. Substance use disorder and recovery services. https://wp.sbcounty.gov/dbh/sudrs/

24. DHCS. Substance use disorder county access lines. https://www.dhcs.ca.gov/individuals/substance-use-disorder-county-access-lines/

25. 988 Suicide & Crisis Lifeline. https://988lifeline.org/

If you or someone you know is in crisis

• Call 911 or go to your nearest emergency room for any life-threatening emergency.
• 988 Suicide & Crisis Lifeline — call or text 988, available 24/7. En español: marque 988 y oprima 2. Veterans: 988 and press 1, or text 838255.
• Crisis Text Line — text HOME to 741741.
• The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
• National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
• National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
• Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
• San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
• Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
• California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
• NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.