Rural Center of Excellence on SUD Treatment
UVM CORA Co-occurring PTSD and OUD Toolkit

About This Toolkit

Introduction

Overview of Posttraumatic Stress Disorder and Opioid Use Disorder

Posttraumatic stress disorder (PTSD) is a mental health condition that can develop after a person experiences or witnesses a distressing or dangerous life event such as sexual or physical assault, an accident, or other severe events. Symptoms typically appear within three months of the event and may include repeated flashbacks, memories or dreams of the event, avoidance of people, places or activities that are reminders of the event, sleep or concentration difficulties, strong startle responses, loss of interest in former activities, and ongoing negative emotions such as fear or shame. Opioid use disorder (OUD) is a type of substance use disorder that involves a pattern of opioid (e.g., prescription opioids, heroin, fentanyl) use that is difficult to stop despite a desire to cut down or regulate use, and negatively impacts one’s physical and emotional health, relationships and daily functioning. Symptoms may also include using opioids in larger amounts or for longer than intended; spending a great deal of time obtaining, using or recovering from the effects of opioids; craving; failure to fulfill major obligations; reducing or stopping other activities; using opioids in situations where it is unsafe; opioid tolerance; and withdrawal symptoms when stopping opioid use.

Epidemiology of PTSD and OUD

It is well-established that the prevalence of PTSD is substantially higher in individuals with OUD than in the general population. In fact, almost all patients with OUD report experiencing traumatic events and up to one-third meet criteria at some point during their lives for a diagnosis of PTSD.1-3 For example, 94% of patients in Vermont’s largest opioid treatment program reported at least one clinically significant PTSD symptom, and 61% had experienced or witnessed a traumatic event in the past month alone.

OUD Treatment Outcomes

Patients with co-occurring OUD and PTSD generally experience more severe mental health and psychosocial problems than individuals with OUD alone.4 Furthermore, some individuals may use opioids and other substances to reduce the severity of PTSD symptoms.5 Although medications for OUD (MOUD; e.g., methadone, buprenorphine) are the most efficacious treatments for OUD,6 patients with co-occurring PTSD may be more likely to discontinue MOUD treatment and resume nonprescribed opioid use.7, 8 These findings highlight the importance of screening and assessing for PTSD in OUD treatment settings.

Treatments for PTSD and Limited Access in Rural Communities

Fortunately, there are well-established and effective treatments for PTSD (e.g., prolonged exposure therapy and cognitive processing therapy)9, 10 that are widely available for use. Recent research indicates that these treatments are efficacious for improving PTSD severity in individuals receiving treatment for co-occurring OUD, may be associated with better MOUD treatment retention, and do not exacerbate substance use.11-17

Unfortunately, only half of individuals with OUD and a concurrent mental health condition received past-year mental health treatment, and the strongest predictor of this unmet need was rurality.18-21 In addition, poverty, workforce shortages, and lack of reliable transportation present significant barriers to mental health treatment in rural areas.22-24 This translates to significant gaps in access to PTSD treatment among patients living in rural communities. The goal of this University of Vermont Center on Rural Addiction (UVM CORA) toolkit is to provide a number of evidence-based PTSD assessment instruments, treatment manuals, training opportunities, and educational resources to treatment providers and staff who are providing care to people with OUD in rural communities.

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  2. Mills, K. L., Teesson, M., Ross, J., & Peters, L. (2006). Trauma, PTSD, and substance use disorders: Findings from the Australian National Survey of Mental Health and Well-Being. The American Journal of Psychiatry, 163(4), 652–658.
  3. Santo, T., Jr, et al. (2022). Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis. Drug and Alcohol Dependence, 238, 109551.
  4. Meshberg-Cohen, S., et al. (2021). Treatment outcomes in individuals diagnosed with comorbid opioid use disorder and Posttraumatic stress disorder: A review. Addictive Behaviors, 122, 107026.
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  6. Mattick, R. P., et al. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. The Cochrane Database of Systematic Reviews, 2014(2), CD002207.
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  8. Schiff, M., et al. (2010). Childhood sexual abuse, PTSD, and use of heroin among female clients in Israeli methadone maintenance treatment programs. Social Work in Health Care, 49(9), 799–813.
  9. Foa, E. B., et al. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press.
  10. Resick, P. A., et al. (2024). Cognitive processing therapy for PTSD: A comprehensive therapist manual (2nd ed.). The Guilford Press.
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  14. Peck, K. R., et al. (2025). A novel prolonged exposure therapy protocol for improving therapy session attendance and PTSD symptoms among adults receiving buprenorphine or methadone treatment. Drug and Alcohol Dependence, 266, 112507.
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  18. Davis, M. M., et al. (2016). Disparities in alcohol, drug use, and mental health condition prevalence and access to care in rural, isolated, and reservation areas. The Journal of Rural Health, 32(3), 287–302.
  19. Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence, 197, 78–82.
  20. Thomas, K. C., et al. (2009). County-level estimates of mental health professional shortage in the United States. Psychiatric Services, 60(10), 1323–1328. 20
  21. Wang, P. S., et al. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 629–640.
  22. Jameson, J. P., & Blank, M. B. (2007). The role of clinical psychology in rural mental health services: Defining problems and developing solutions. Clinical Psychology: Science and Practice, 14(3), 283–298.
  23. Logan, T. K., et al. (2004). Rural and urban women’s perceptions of barriers to health, mental health, and criminal justice services. Violence and Victims, 19(1), 37–62.
  24. US Census Bureau. (2019). 2018 American community survey single-year estimates. Census.Gov.