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NAC for Treating Comorbid PTSD and SUD (DoD-NAC)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02911285
Recruitment Status : Completed
First Posted : September 22, 2016
Last Update Posted : January 18, 2020
United States Department of Defense
Institute for Translational Neuroscience
Information provided by (Responsible Party):
Medical University of South Carolina

Brief Summary:
As a result of sustained operations in Afghanistan and Iraq, there are an increasing number of U.S. military Veterans with substance use disorders and comorbid posttraumatic stress disorder (PTSD). If left untreated, individuals with substance use disorders and PTSD are at increased risk for developing other mental health problems (e.g., depression, anxiety), suicidal ideation and attempts, medical problems, reduced resiliency and military readiness, vocational problems, and family/social impairment. This study will determine the benefits of N-acetylcysteine (NAC) in treating alcohol use disorder and comorbid post-traumatic stress disorder (PTSD) among military Veterans.

Condition or disease Intervention/treatment Phase
Posttraumatic Stress Disorder (PTSD) Alcohol Use Disorder (AUD) Substance Use Disorder (SUD) Drug: N-acetylcysteine Drug: Placebo Behavioral: Cognitive behavioral therapy Phase 2

Detailed Description:
As a result of sustained operations in Afghanistan and Iraq, there are an increasing number of U.S. military Veterans with substance use disorders and comorbid posttraumatic stress disorder (PTSD). While mental health services are in place for U.S. service members, substantial gaps in the treatment of co-occurring substance use disorders and PTSD exist and there is little scientific evidence available to guide the provision of care. Treatment for comorbid substance use disorders and PTSD, especially pharmacologic treatment, is largely ineffective and short-lived. While there have been numerous studies focused largely on dopaminergic mechanisms of reward, they have not led to the development of adequate treatments for comorbid substance use disorders and PTSD. Animal models demonstrate that (a) acute stress and chronic use of addictive substances reduce the capacity of glia to remove the neurotransmitter glutamate, and (b) this impairment as well as relapse can be prevented or reversed by N-acetylcysteine (NAC). Further, human studies indicate that NAC is associated with reduced craving and substance use. Based on this, the investigators conducted a Proof of Principle (PoP) study which was the first to examine the use of NAC for the treatment of PTSD, with or without comorbid addiction. In this randomized, controlled double-blind pilot study the investigators showed that Veterans with substance use disorders (81.5% alcohol use disorder) and PTSD who were treated with 2400mg NAC for 8 weeks demonstrated significant reduction in PTSD severity and craving. Moreover, reductions in PTSD and substance-related symptomatology were sustained at 1-month follow-up. However, to extend and confirm its clinical utility in the military/Veteran context, it is important to know whether NAC reduces severity of alcohol use disorder (AUD), the most common addiction among Veterans and military service members, and the mechanisms underlying therapeutic response. Based on promising data from the PoP project, the proposed Extend-and-Confirm (EC) study will determine the efficacy of NAC in reducing AUD and comorbid PTSD in Veterans (N=90). Further, new aims include the application of functional magnetic resonance imaging (fMRI) and proton magnetic resonance spectroscopy (1H-MRS) to investigate the pathophysiology of AUD/PTSD, as well as prognostic indicators of treatment outcome. These aims extend the Future Plans proposed in the original PoP study and provide an opportunity for collaboration among clinical and preclinical investigators at the Ralph H. Johnson Veterans Affairs (VA) Medical Center and the Medical University of South Carolina (MUSC) to solve this critical health problem in the military context. In the proposed EC study, the investigators will (1) employ a randomized, double-blind, between-groups experimental design that will consist of 8 weeks of treatment with NAC (2400mg) or placebo medication, and follow-up assessment at 1-, 3-, and 6-months post treatment; (2) use standardized, repeated dependent measures to rigorously assess AUD severity and PTSD symptomatology during treatment and follow-up; (3) collect biologic measures of alcohol use; (4) measure impairment in associated areas of functioning (e.g., depression, sleep, suicidality, risky sexual behaviors, family/social functioning); and (5) employ advanced neuroimaging techniques before and after treatment among a subset of enrolled subjects. This proposal is directly responsive to the missions of the Institute for Translational Neuroscience (ITN), and the US Army/Department of Defense (DoD) in that it seeks to accelerate the development of new, medication-based treatments to mitigate the impact of AUD and comorbid psychological conditions, such as PTSD, in the military/Veteran context. The findings of this study will provide critically needed empirical evidence to help inform practice guidelines and better serve the needs of U.S. service members, Veterans and their families.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 90 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
Official Title: Glial Regulators for Treating Comorbid Posttraumatic Stress Disorder and Substance Use Disorders
Actual Study Start Date : October 2016
Actual Primary Completion Date : August 5, 2019
Actual Study Completion Date : November 4, 2019

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: NAC/CBT
Participants will receive N-acetylcysteine (NAC) and Cognitive Behavioral Therapy (CBT) for 8 weeks.
Drug: N-acetylcysteine
1200mg bid (2400mg/day)
Other Name: NAC

Behavioral: Cognitive behavioral therapy
CBT for AUD/SUD, one hour/once a week
Other Name: CBT

Placebo Comparator: Placebo/CBT
Participants will receive placebo pills and CBT for 8 weeks.
Drug: Placebo
Placebo pills bid

Behavioral: Cognitive behavioral therapy
CBT for AUD/SUD, one hour/once a week
Other Name: CBT

Primary Outcome Measures :
  1. Reduction in AUD severity [ Time Frame: Following 8 weeks of treatment ]
    Total number of standard drinks consumed

  2. Reduction in PTSD severity [ Time Frame: Following 8 weeks of treatment ]
    Clinician Administered PTSD Scale (CAPS-5) score

  3. Reduction of AUD severity [ Time Frame: Following 8 weeks of treatment ]
    fMRI scans of prefrontal cortex-amygdala at rest and in response to cues

  4. Reduction in Alcohol craving [ Time Frame: Following 8 weeks of treatment ]
    Obsessive Compulsive Drinking Scale (OCDS) Total Score

Secondary Outcome Measures :
  1. Alcohol Use Timeline Follow Back (TLFB) [ Time Frame: Following 8 weeks of treatment ]

  2. PTSD symptoms [ Time Frame: Following 8 weeks of treatment ]
    PTSD Checklist (PCL-5)

  3. Alcohol Use [ Time Frame: Following 8 weeks of treatment ]
    Ethyl Glucuronide (EtG)

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years to 75 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Male or female, any race or ethnicity, age 18 to 75 years old.
  • U.S. military Veteran, including National Guard and Reservists.
  • Able to comprehend English.
  • Meet Diagnostic and Statistical Manual (DSM-5) criteria for current alcohol use disorder (AUD) and/or substance use disorder (SUD).
  • Meet DSM-5 criteria for current PTSD or subthreshold PTSD. Subjects may also meet criteria for a mood disorder (except bipolar affective disorder, see Exclusion Criteria) or other anxiety disorders (e.g., panic disorder, agoraphobia, social phobia, generalized anxiety disorder). The inclusion of subjects with affective and other anxiety disorders is essential because of the marked frequency of the co-existence of mood and other anxiety disorders among patients with PTSD (Brady et al., 2000; Kessler et al., 2005).
  • Subjects taking psychotropic medications will be required to be maintained on a stable dose for at least four weeks before treatment initiation. This is because initiation or change of medications during the course of the trial may interfere with interpretation of results.
  • Must consent to random assignment to N-acetylcysteine (NAC) or placebo.
  • Must consent to complete all treatment and follow-up visits.

Exclusion Criteria:

  • Subjects meeting DSM-5 criteria for a history of or current psychotic or bipolar affective disorders, as the study protocol may be therapeutically insufficient.
  • Subjects with a current eating disorder (bulimia, anorexia nervosa) or with dissociative identity disorder, as they are likely to require specific time-intensive psychotherapy.
  • Subjects experiencing significant withdrawal symptoms, as evidence by a score of 10 or above on the Clinical Institute Withdrawal Assessment of Alcohol (CIWA).These subjects will be referred for clinical detoxification and may be re-assessed for study eligibility after medically supervised detoxification has been completed.
  • Individuals considered an immediate suicide risk based on the Columbia Suicide Severity Rating Scale (C-SSRS) or who are likely to require hospitalization during the course of the study.
  • Women who are pregnant, nursing or not practicing an effective form of birth control.
  • Asthma or any clinically significant medical condition that in the opinion of the investigators would adversely affect safety or study participation.
  • Use of carbamazepine, phenytoin, nitrous oxide, methotrexate, 6 azauridine triacetate, or nitroglycerin within the last 14 days or any other medication felt to have a hazardous interaction if taken with NAC.
  • History of childhood or adult seizures of any cause.
  • MRI exclusions: Claustrophobia; tattoos above the shoulders; permanent eyeliner or permanent artificial eyebrows; cardiac pacemaker; metal fragments in eye, skin, or body, including shrapnel; heart valve replacement; brain clips; venous umbrella; being a sheet-metal worker or welder; lifetime history of aneurysm surgery; intracranial bypass, renal, or aortic clips; prosthetic devices such as middle ear, eye, joint, or penile implants; joint replacements; non-removable hearing aid, neurostimulator, or insulin pump; shunts/stents; metal mesh/coil implants; metal plate/pin/screws/wires; or any other metal implants. Note that individuals who meet inclusion/exclusion criteria for the medication component of the study but not the MRI portion (e.g., excluded due to metal implants) will still be eligible to enroll in and complete the medication/treatment phase.
  • Subjects on maintenance anxiolytic, antidepressant, or mood stabilizing medications which have been initiated during the past four weeks. If it is determined, based on clinical criteria, that a subject needs to be started on maintenance medications for anxiety, mood or psychotic symptoms during the course of the study, they will be discontinued from the treatment trial.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02911285

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United States, South Carolina
Medical University of South Carolina
Charleston, South Carolina, United States, 29401
Ralph H Johnson VA Medical Center
Charleston, South Carolina, United States, 29401
Sponsors and Collaborators
Medical University of South Carolina
United States Department of Defense
Institute for Translational Neuroscience
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Principal Investigator: Sudie Back, Ph.D. Medical University of South Carolina

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Responsible Party: Medical University of South Carolina Identifier: NCT02911285    
Other Study ID Numbers: Pro00052757
First Posted: September 22, 2016    Key Record Dates
Last Update Posted: January 18, 2020
Last Verified: January 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No
Keywords provided by Medical University of South Carolina:
Post Traumatic Stress Disorder
Additional relevant MeSH terms:
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Substance-Related Disorders
Stress Disorders, Traumatic
Stress Disorders, Post-Traumatic
Pathologic Processes
Trauma and Stressor Related Disorders
Mental Disorders
Alcohol-Related Disorders
Chemically-Induced Disorders
Antiviral Agents
Anti-Infective Agents
Respiratory System Agents
Free Radical Scavengers
Molecular Mechanisms of Pharmacological Action
Protective Agents
Physiological Effects of Drugs