Substance use and related disorders among persons exposed to the 9/11 terrorist attacks: Essentials for screening and intervention

Abstract

A growing body of research supports the association between direct exposure to the September 11, 2001, terrorist attacks, increased rates of alcohol and substance use and elevated risk of subsequent diagnosis with trauma-related and substance use disorders. Posttraumatic stress disorder (PTSD) is the most diagnosed psychiatric illness in individuals who witnessed the 9/11 attacks or participated in disaster response efforts, and substance use disorders (SUDs) are highly comorbid with PTSD. The presence of both conditions poses challenges for clinical management and highlights the importance of screening and offering intervention to this at-risk population. This paper provides background on substance use, SUDs, and co-occurring PTSD in trauma exposed populations, describes best practices for identifying harmful substance use, the role of psychotherapy and medication for addiction treatment (MAT), and recommendations for management of co-occurring SUD and PTSD.

Keywords:

• 9/11 substance use disorders
• comorbid PTSD and SUD
• disaster exposure and substance use
• September 11 terrorist attack
• World Trade Center
• WTC alcohol use disorder

Introduction

The September 11, 2001 (9/11) terrorist attacks were unprecedented in scope and magnitude, exposing hundreds of thousands of individuals to environmental toxins and horrific events. Large areas of lower Manhattan were destroyed, and community residents, students, and local workers (“survivors”) were displaced from their homes and schools, lost jobs, or lived in the disaster aftermath. Many rescue, recovery, restoration, clean-up workers and volunteers (“responders”) worked long hours under perilous conditions, often engaging in disturbing tasks outside of their usual scope of work such as recovering bodies and handling human remains.¹ For many individuals, this exposure continued for months following 9/11 and resulted in or exacerbated psychiatric disorders including post-traumatic stress disorder (PTSD), depression, anxiety, alcohol use disorder (AUD) and other substance use disorders.² Health consequences of 9/11 exposure were often accompanied or followed by psychosocial stressors including unemployment,³ loss of medical benefits, loss of community cohesion, family conflict, and ruptured relationships.⁴

The World Trade Center Health Program (WTCHP) is a limited federal health program that provides no-cost medical monitoring and treatment for WTC exposure-related health conditions to those directly affected by the 9/11 attacks (https://www.cdc.gov/wtc/about.html). Patients who present with conditions that do not meet criteria for program enrollment (e.g., non-WTC related occupational conditions or injuries) are offered case management services and appropriate referrals.

This paper focuses on best practices for screening for alcohol and other substance use, and management of AUD and other SUDs in populations with trauma exposure. It emphasizes alcohol use and AUD, as alcohol is the most used substance reported among the responders and survivors enrolled in the WTCHP. It reviews medications for addiction treatment (MAT) for both alcohol and opioid use disorders, and briefly discusses approaches to manage PTSD, the most prevalent 9/11-related psychiatric condition, when co-occurring with AUD or SUDs. This is one in a series of papers to promote the practice of high quality, evidence-based medicine when evaluating and treating persons who were directly exposed to the September 11th terrorist attacks (see⁵ for details). Tobacco use disorder and treatment strategies for smoking cessation are addressed in a separate paper in this series.⁵

Substance use and co-occurring conditions in disaster exposed populations

Increase in substance use among individuals following human-made or natural disasters^6,7 or terrorism⁸ is well documented, suggesting that exposure to traumatic stressors may be a risk factor for subsequent diagnosis of SUD.⁹ One theory proposed to explain this association is that some people use the psychopharmacological effect of substances to mitigate or self-medicate symptoms resulting from trauma.¹⁰ PTSD, increased alcohol use, and SUDs often co-occur in trauma-exposed populations; according to one national epidemiologic study, 46.4% of individuals diagnosed with PTSD at some point in life also met criteria for SUD.¹¹ Patients with co-existing PTSD and SUD tend to have more severe symptoms and are more refractory to treatment than those with a single diagnosis.¹² In addition, individuals with SUDs and comorbid conditions have more medical, financial, and social problems, contributing to more complex presentations, greater functional impairment, and worse treatment outcomes.⁴

Although research examining the effect of exposure to the 9/11 disaster on substance use behaviors and diagnosis with SUDs is limited, several papers have reported increased rates of substance use and related disorders in 9/11 responders and survivors. Early studies among Manhattan residents in the months following the 9/11 attacks documented an increase in cigarette, alcohol, and marijuana use.^13–15 Later studies observed persistent patterns of increased substance use in some individuals; even fifteen years post 9/11, a substantial number of exposed persons reported using alcohol to self-medicate PTSD symptoms.¹⁶

Studies among enrollees of the World Trade Center (WTC) Health Registry, a cohort of individuals directly exposed to the 9/11 disaster in New York City, found a strong association between witnessing traumatic events, diagnosis of PTSD, and alcohol or substance use-related hospitalizations.^17,18 Welch and colleagues¹⁹ found increased prevalence, and intensity of binge drinking and PTSD among highly exposed responders more than a decade post-9/11. In that study, binge drinking was reported by 24.7% of 9/11 responders; this was significantly higher than national and local estimates (17.1% in the U.S. and 17.9% in NYC responders). Further, alcohol and drug related mortality was significantly elevated for WTC Health Registry enrollees who were rescue or recovery workers, had 9/11-related probable PTSD, or sustained an injury on 9/11.²⁰ These findings, together with the persistence of PTSD symptoms within the WTC trauma-exposed cohort,² highlight the need for ongoing SUD screening to identify individuals who may benefit from treatment to address both psychiatric illness and SUD.

Screening for alcohol and other substance use

The disease burden of harmful alcohol and other substance use is high and poses an ongoing challenge to population health.²¹ Individuals with harmful drinking patterns are at elevated risk for multiple alcohol-related medical complications^22,23 and suicide:^24,25 a meta-analysis of prospective-cohort studies²⁶ found that alcohol use increased the probability of suicidal ideation, attempts, and suicide mortality up to 65%. Although AUD is highly prevalent, it often goes unrecognized and untreated,²⁷ highlighting the vital role of primary care physicians and other specialists in identifying substance use.

The US Preventive Services Task Force (USPSTF) and American Society for Addiction Medicine (ASAM) recommend screening for unhealthy alcohol use in primary care settings in adults 18 years or older and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.^28,29 For patients in general medical and mental healthcare settings, the³⁰ recommends periodically screening for unhealthy alcohol use using the three-item Alcohol Use Disorders Identification Test Consumption (AUDIT-C).³¹ ASAM recommends the Single Item Screening Questions (SISQs), which have been validated for both alcohol and substance use.³² Because relapse is common, repeated screening is recommended.

Link for the AUDIT screening tool: https://nida.nih.gov/sites/default/files/audit.pdf

Link for SISQs for both alcohol and other substances:

https://www.sbirt.care/pdfs/tools/Pre-Screen-Annual%20Screen.PDF.

When a history of trauma exposure is elicited, use of a standard self-report measure such as the PTSD Checklist for Civilians (PCL-C) is recommended to assist with screening: https://www.ptsd.va.gov/professional/assessment/documents/APCLC.pdf.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes SUD as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.” Criteria for diagnosing other substance use disorders, such as opioid or marijuana use disorders, are similar. AUD is characterized by alcohol use resulting in clinically significant impairment or distress over a 12-month period, resulting in two or more of eleven criteria which focus on: impaired control; social impairments; risky use; and neuroadaptation (tolerance or withdrawal). Severity is determined by the number of criteria met.

More information on diagnosis of AUD and other SUDs, including the full diagnostic criteria, is provided in the reference section.^33–36

Treatment

Effective treatment for SUDs includes a combination of pharmacologic, psychotherapeutic, and psychosocial interventions. A growing evidence base^28,37 supports the ability of primary care physicians to effectively use the screening, brief intervention, and referral to treatment (SBIRT) model to manage AUD and SUD. While patients with mild SUD can be appropriately treated in primary care settings, those with more severe or complex presentations (e.g., elderly patients with co-occurring conditions) may require early specialist consultation or an integrated care approach.³⁷ CPGs^34,38 support the use of MAT for AUD and the use of psychotherapy and psychosocial strategies for co-occurring AUD or SUD. These include cognitive behavioral therapy, motivational enhancement therapy, 12-step facilitation, behavioral couples’ therapy, and peer linkage to promote active involvement in mutual help group programs. Collaboration between physicians and other providers, communication with family members, and use of community resources is critical to optimizing care and reducing the risk of relapse.

For patients diagnosed with alcohol or substance use disorder, withdrawal management and further treatment may occur in either the outpatient or inpatient setting. For alcohol or benzodiazepine withdrawal, patients in severe withdrawal and/or who have risk factors for severe withdrawal such as older age, high medical or psychiatric comorbidity, history of withdrawal seizures or withdrawal delirium, management of withdrawal in either highly supervised outpatient setting or inpatient setting may be necessary.^34,36

When considering a placement setting for treatment of alcohol or substance use disorder after withdrawal management, ASAM recommends consideration of six dimensions. These include risk for acute intoxication/withdrawal; co-occurring medical illness/complications; co-occurring psychiatric or cognitive disorders/complications; readiness to change; relapse, continued use or problems potential; and recovery and living environment.^28,36

For relapse prevention, psychological and psychosocial strategies and medications for addiction treatment may be considered. CPGs recommend medications specifically for AUD (such as intramuscular (IM) or oral naltrexone, acamprosate, or topiramate) and for opioid use disorder (IM naltrexone, buprenorphine, or methadone).^28,34,35 While the evidence base demonstrates that MAT is effective when abstinence is the treatment goal, reduced use and harm reduction may be more achievable for many patients and may still result in improvement of the SUD, co-morbid mental health conditions, and quality of life.^28,36,38,39

Treatment of co-occurring PTSD and SUD

Populations directly exposed to trauma, including many individuals who witnessed the 9/11 attacks or participated in disaster response efforts, are at increased risk of developing both PTSD and SUDs.^17,18 When these conditions co-occur, clinical management is more complicated, and treatment is less successful compared to outcomes for either condition alone. Despite concerns by some practitioners that using some psychotherapies designed to treat PTSD (e.g., cognitive processing therapy, exposure therapy) might increase substance use behavior, studies have found no evidence to support this.⁴⁰ Recent studies found positive outcomes for integrated treatment, that is, approaches where psychosocial and pharmacological interventions for PTSD and SUD are delivered simultaneously rather than sequentially.⁴¹ Growing evidence suggests that interventions that integrate exposure-based PTSD treatment and behavioral treatment for SUD may result in improvements in both substance use and PTSD symptoms.^36,42 A systematic review of psychological interventions for comorbid PTSD and SUD⁴⁰ found evidence that trauma-focused interventions delivered alongside treatment for SUD led to greater improvements in PTSD symptom severity when compared to interventions focused only on SUD. Likewise, psychosocial, psychological and medication treatments for addiction disorders may be used safely in patients receiving psychotherapy^43,44 or pharmacotherapy⁴⁵ for PTSD. VA/DoD guidelines for management of PTSD specifically advise against excluding patients with co-occurring SUD from first-line, trauma-focused therapies for PTSD (Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017 - VA/DoD Clinical Practice Guidelines).

The following clinical practice guidelines for SUD/AUD treatment are recommended:¹

1. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorder:³⁸

2. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management³⁴ The pocket guide is a useful office reference for assisting with point of care decisions. ASAM Pocket Guidelines and Patient Guide - Alcohol Withdrawal Management: (guidelinecentral.com) http://eguideline.guidelinecentral.com/i/1254278-alcohol-withdrawal-management/0?

The ASAM Principles of Addiction Medicine²⁸ is a useful source on SBIRT for alcohol and other substances, and for medical treatment and psychosocial/psychotherapy of AUD and SUD.

Program coverage

The WTCHP is a limited federal health program that provides no-cost medical monitoring and treatment for certified WTC exposure-related health conditions to those directly affected by the 9/11 attacks in New York, the Pentagon, and Shanksville, Pennsylvania. To receive certification, a WTCHP physician must attest that 9/11 exposures were substantially likely to have been a significant factor in aggravating, contributing to, or causing the enrolled WTC member’s condition. For additional information specific to mental health coverage and resources, refer to the WTCHP Mental Health Resource Webpage www.cdc.gov/wtc/mentalhealth.html.

Conclusion

PTSD, the most diagnosed psychiatric illness among persons with direct exposure to psychological trauma on 9/11 and its aftermath, is highly comorbid with various SUDs, leading to increased clinical complexity and worse treatment outcomes for both conditions. The persistence of these conditions many years after September 11th highlights the need for ongoing screening to identify persons who may benefit from treatment. Primary care physicians and other primary care providers serve a key role in providing AUD and SUD screening, brief intervention, and referral to treatment. CPGs support the use of medications, psychotherapy, and psychosocial strategies for SUD. For co-occurring PTSD and SUDs, integrated treatment may result in greater improvements in both substance use and PTSD symptoms.

Disclaimer

The contents of this article are the sole responsibility of the authors and do not necessarily represent the official views of, nor an endorsement, by the National Institute for Occupational Safety and Health (NIOSH), the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (CDC/HHS), or the U.S. Government.

Institutional review board (IRB) review

This activity did not involve human subjects and therefore did not require IRB review.

Acknowledgements

The authors would like to thank all the 9/11 responders and survivors who participate in the World Trade Center Health Program, their families, the communities who support them, and the physicians and other healthcare providers committed to caring for them.

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

This work was funded in part by the National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (CDC/HHS). Dr. Lowe is supported by CDC/NIOSH Contract 75D30122C15516.

Notes

1 Practice guidelines suggested in this paper were identified from the ECRI (Emergency Care Research Institute) Guidelines Trust (https://guidelines.ecri.org/), a compendium of CPGs that meet prespecified inclusion criteria (for details on selection criteria, see 5).