Homeyra Lalavi

AwareCare, Australia

Title: Must Abstinence Come First? Current Evidence on Concurrent Trauma-Focused Treatment for Co-Occurring PTSD and Substance Use Disorders

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Biography

Homeyra Lalavi is an AHPRA-registered psychologist based in Sydney, Australia, with postgraduate qualifications in psychology, counselling and psychotherapy. She works primarily with adults across private practice, community mental health and telehealth settings. Her clinical interests include trauma, anxiety, OCD, grief, emotional regulation and co-occurring mental health difficulties. Her practice is trauma-informed and draws on evidence-based approaches including CBT, ACT and DBT. She is particularly interested in translating research findings into practical, person-centred psychological care.

Abstract

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) frequently co-occur. Trauma-focused PTSD treatment has historically been delayed until abstinence is achieved or SUD treatment is completed, partly because of concerns that trauma processing may worsen substance use or relapse risk. This focused narrative review examines whether abstinence is necessary before initiating trauma-focused PTSD treatment in adults with co-occurring PTSD and SUD, and separately considers evidence on simultaneous versus sequential treatment. The review prioritises current clinical guidelines, systematic reviews and meta-analyses, individual-patient-data analyses, and key randomised controlled trials, with attention to PTSD severity, substance use, treatment completion, safety, timing, and patient preference. Preliminary evidence does not support abstinence as a routine prerequisite for evidence-based PTSD treatment. Trauma-focused treatment delivered alongside SUD care can reduce PTSD symptoms without clear evidence of worsening substance use. Meta-analytic findings suggest PTSD benefits are more consistent than additional SUD benefits, while treatment dropout remains a challenge. Project Harmony (36 studies; N=4,046) supports trauma-focused approaches, particularly when combined with SUD pharmacotherapy. A 2026 randomised trial of 209 patients found no significant differences in PTSD severity between simultaneous and sequential treatment at 6- and 9-month follow-up; simultaneous treatment produced greater improvement at 3 months and was preferred by most participants. Overall, current evidence challenges routine delay of trauma-focused PTSD treatment until abstinence is achieved and supports individualised decisions about treatment timing.