There are several reasons why it is important for MOUD providers to assess patients for a history of traumatic experiences and PTSD.

1. Buprenorphine and methadone treatment providers may be the first or only point of contact with the healthcare system for individuals with co-occurring OUD and PTSD. Most individuals with co-occurring OUD and PTSD do not receive treatment for their trauma/PTSD symptoms.¹ MOUD providers can be an important first point of access to mental healthcare. Empirically supported brief screening measures for PTSD, such as the PTSD Checklist for DSM-5 (see below in Measures), may be a worthwhile addition to assessment in MOUD treatment settings as it has demonstrated utility for identifying a potential PTSD diagnosis, provides information on trauma-related symptoms, and takes only a few moments to complete.
2. Traumatic experiences and PTSD are common among individuals with OUD. Ninety percent of adults with OUD have experienced at least one trauma in their lifetime. The most commonly experienced traumas include sexual assault, physical assault, and witnessing the injury or death of someone else (e.g., opioid overdose). Further, 18.1% of individuals with OUD currently meet the criteria for PTSD, compared to only 1.2% in the general population.²
3. PTSD affects health and healthcare utilization. The co-occurrence of PTSD and OUD is associated with more severe substance dependence, higher rates of depression, attempted suicide, and psychosocial problems.³ PTSD is also comorbid with a range of physical health conditions (e.g., arterial, musculoskeletal, gastrointestinal, dermatologic, autoimmune, and cerebrovascular).⁴ These psychiatric, psychosocial, and physical health burdens are likely to impact MOUD treatment retention and outcomes. Furthermore, given these greater health burdens, individuals with PTSD are more likely to utilize healthcare services.⁵
4. PTSD is underrecognized in healthcare settings. Most patients with PTSD are not properly evaluated and are not offered education, counseling or referrals for mental health evaluation or treatment.⁶ Additionally, many patients avoid talking about their trauma due to uncomfortable emotions associated with this discussion or feelings of guilt or shame, making it even less likely that patients will spontaneously share their trauma experiences or related symptoms with providers unless they are specifically asked about it. Screening measures for traumatic experiences or PTSD can be completed in as little as 5-10 minutes and may provide a valuable opportunity for intervention.

Do you want to assess traumatic experiences, PTSD symptoms or PTSD diagnosis?

The purpose of a trauma experience measure such as the LEC-5 is to identify what traumatic events an individual has experienced.

In contrast, the other PTSD measures (above) may be used to determine whether the person has PTSD symptoms related to one of the identified traumatic events, the severity of symptoms, or whether the person has a diagnosis of PTSD. We have provided a range of measures. Some are broad enough to include symptoms other than those related to PTSD (e.g., PC-PTSD-5, PDS-5, PCL-5). However, we have also provided PTSD measures that are more focused on the PTSD symptoms needed to make a diagnosis using the DSM-5 (e.g., PSSI-5, CAPS-5). Broad measures may be used as screeners to make a determination whether a patient would benefit from more thorough and focused measures.

How much time can you allocate to assessment?

The provided assessment measures differ in length and format of administration. For example, the PCL-5 is a brief self-report measure that provides a single rating for each item, whereas the CAPS-5 is a structured interview with detailed inquiries about each symptom and interviewer ratings regarding the validity of reports.

Although structured interviews require more interviewer training and administration time, they result in a more comprehensive and reliable assessment of PTSD.

What is your goal?

There is no single “best” trauma or PTSD symptom measure. The right measure depends on your goal. If you want a quick screen, we recommend self-report measures (PC-PTSD-5, PDS-5, PCL-5). However, if you are a mental health provider and your aim is to provide a DSM diagnosis, you may want to use a structured clinical interview that assesses for frequency and severity of symptoms (PSSI-5, CAPS-5). Before deciding on a measure, you may need to consider the time and training required to administer the measure, whether you need to assess symptoms related to a single traumatic event or multiple traumatic events (or to assess symptoms when the trauma history is unknown), and whether the measure needs to correspond to DSM criteria for PTSD.

For making a diagnosis of PTSD rather than simply assessing PTSD symptoms, structured interviews will generally yield more valid results than other types of measures. However, it is worth noting that the validity of a structured interview will be greatly affected by the level of training of the interviewer. If interviewers are not familiar with mental health disorders, clinical assessment, and traumatic stress, and are not trained in the administration of the particular structured interview being used, results of the interview may be invalid. Brief scales and self-report measures cannot be used to establish a diagnosis of PTSD because there is too much chance for error in responses.

MOUD providers can increase the chances of improved health outcomes for their patients by following these steps:

1. Screen for PTSD

MOUD providers can use a screening questionnaire to ask about trauma-related symptoms. You can ask the patient to complete the screening questionnaire prior to their appointment. Completed screens can be collected and reviewed by the provider prior to the appointment.

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen that was designed to identify individuals with probable PTSD in primary care settings and may be particularly well-suited for identifying PTSD in MOUD treatment settings.

Respondents screening positive should be referred for further assessment, preferably with a structured interview such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). If a clinical interview is not possible due to time and personnel requirements, it is recommended that additional, validated self-report measures are used such as the PTSD Checklist for DSM-5 (PCL-5) or Posttraumatic Diagnostic Scale (PDS-5).

2. Discuss the results with the patient

Here are a few general tips offered by the US Department of Veterans Affairs:

• Communicate results to the patient in a private and confidential location.
• Show empathy, interest, and concern by telling the patient you are glad that they shared their symptoms.
• Normalize screening and let the patient know that trauma-related experiences can impact their physical and mental health. For example, “I ask my patients these questions because we know that trauma can impact health and opioid use disorder treatment.” Or, “It’s helpful to know if your sleep is disrupted because of trauma-related nightmares, or if certain parts of OUD treatment are difficult because of trauma-related experiences.”
• Note that unless you have mental health training and will be the person to evaluate or treat the patient, it is not advisable to ask for a detailed account of the trauma or to challenge the patient’s report in any way.

For patients who screen positive for PTSD, the following suggestions are provided by the Veteran’s Administration for facilitating further discussion:

• Extend appreciation for the patient’s willingness to share their trauma-related distress with you. “Thank you for letting me know that you are struggling with some trauma-related symptoms.”
• Provide feedback: “The results of your screen suggest you may have PTSD.”
• Acknowledge any reported distress: “I’m sorry you have had such terrible nightmares.”
• Don’t make assumptions about the meaning or impact of traumatic events for an individual; your assumptions may be inconsistent with the patient’s feelings and experience.
• Determine if the reported symptoms are disruptive to the patient’s life: “How have these thoughts, memories, or feelings affected your life? Have they interfered with your relationships? Your work? How about with recreation or your enjoyment of activities?”
• Ascertain whether traumatic events are ongoing in a patient’s life. If so, it is critical that you determine whether the patient needs an immediate referral for social work or crisis services. You might ask: “Are any of these dangerous or life-threatening experiences still continuing in your life now?” If ongoing family violence or safety concerns are suspected, it is imperative that their safety be prioritized and the focus of treatment. The patient should be told the limits of confidentiality for medical or mental health professionals, who are mandated to report suspected abuse of children and dependent adults. Discussion of possible abuse should take place in the absence of the suspected perpetrator. The goal is to develop a safety plan that increases rather than decreases the safety of the patient and their loved ones.

For patients who screen negative for PTSD, it is important to normalize their results to determine if additional assessment is needed:

• Normalize a negative screen: “Despite traumatic events in your past, the results of your screen suggest that you are not experiencing posttraumatic stress disorder. This is often the case–most people do not develop PTSD after a traumatic event, even though they may have some PTSD symptoms.”
• If additional assessment is needed, try to facilitate a warm handoff to a mental health provider. Make sure the patient has the name and number of the mental health provider.

3. Provide a referral

After reviewing the questionnaire results and discussing with the patient, the provider can decide whether the patient may benefit from further evaluation or treatment. Referrals can be made to mental health or behavioral specialists in primary care, or to general mental health or PTSD specialty clinics.

In many rural communities, mental health workforce shortages create barriers to evidence-based PTSD treatment access. However, the adoption of telehealth has increased access to healthcare services. In addition to insurance company provider lists and broad therapist directories (e.g., Psychology Today), the organizations listed below provide rosters that may be helpful for identifying a therapist, counselor, or mental health professional in your geographic area:

Providers Specializing in Evidence-Based Treatment of PTSD

• University of Pennsylvania Perelman School of Medicine Center for Treatment and Study of Anxiety (CTSA) – Provides a list of CTSA-certified prolonged exposure (PE) therapists by state
• Emory University School of Medicine Department of Psychiatry and Behavioral Sciences – Provides a nationwide directory of PE providers trained by Emory University’s Prolonged Exposure Consultant Training Program
• The official website for Cognitive Processing Therapy (CPT) – Provides a roster of mental health providers who have met the requirements to be a CPT Provider.

Mental Health Providers

• VA’s National Center for PTSD – Find a Therapist – Provides assistance with finding a therapist, counselor or other mental health provider who can help with recovery from trauma and PTSD.
• The International Society for Traumatic Stress Studies – Provides a directory of clinicians, counselors, and mental health professionals that makes it easy to find a provider who specializes in trauma or PTSD in your local area.
• Association for Behavioral and Cognitive Therapies – Provides a find-a-therapist service that provides access to therapists who are trained in cognitive and behavioral therapy techniques.
• American Psychological Association – Their psychologist locator tool provides a list of licensed mental health providers that is searchable by zip code, city, or state.
• Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Provider Locator – Provides a resource for identifying treatment facilities for mental and substance use disorders.

Email us at cora.ptsd@uvm.edu for help identifying treatment providers in your area.

• When providing a referral, explain why the screening results led you to recommend further evaluation and/or treatment. For example: “Screening positive does not mean that you have PTSD, it means that you might have PTSD and that it would be a good idea to meet with a mental health professional for follow up. Here is a list of providers who may take your insurance.”
• Provide the patient with the written contact information of a mental health professional, or a list of them, if available. (If needed, please refer to the lists of providers above.)
• Let the patient know that there are effective treatments for PTSD and that they have options. For example: “Although additional assessment is needed to determine if you have PTSD, I want you to know there are a number of available PTSD treatments that have been shown to significantly reduce symptoms and other trauma-related problems, like difficulties with functioning or relationships. The most effective treatments are trauma-focused talk therapies but there are other talk therapies and medications that have also been shown to work.”
• Encourage the patient to ask questions when they speak with a potential provider. For example:
  • Does the provider have experience treating people who have experienced trauma?
  • Does the provider have experience delivering evidence-based therapy for PTSD, such as Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE)?
  • What type(s) of insurance does the provider accept and what will you have to pay (out-of-pocket costs) for care?
• If the patient does not want a referral, you can still provide educational resources.  

4. Provide educational materials

Educational materials can be provided to all patients who are experiencing trauma-related difficulties. Below are some materials that may be helpful.

• For basic information and education about PTSD, NIMH, APA and VA resources are available.
• For information about PTSD that is specific to women, Office on Women’s Health Resources are available.
• For patients considering PTSD treatment, the following VA resources present user-friendly and easy-to-understand tools for learning about treatment options and identifying treatment preferences: VA PTSD Treatment Decision Aid, PTSD Treatment Basics, and Aboutface VA.
• Additional information for patients and families is available from the National Center for PTSD: Understanding PTSD: A Guide for Family and Friends.
• For patients who are interested in self-management strategies in conjunction with professional treatment, the following apps may be helpful:
  • PE Coach
  • CPT Coach
  • PTSD Coach

5. Follow up with the patient

At the patient’s next visit, it is important to ask whether they followed through with the referral for PTSD evaluation or treatment. If the patient did follow through, offer ample praise and ask if the referral was perceived as helpful. If the patient did not follow through with the referral and is still in need of care, try to learn what the obstacles were to obtaining care. Offer to provide additional assistance if possible to help them engage in care.

Consider frequent brief follow-ups on the topic. Regular check-ins with patients about their current functioning as well as follow-ups on referrals are important for keeping patients involved in their own recovery process.

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