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In this study, crack/cocaine-dependent (CD) and non-drug-using matched control (MC) participants were presented with hypothetical immediate and delayed rewards, with 16 delay conditions ranging from 5 min to 25 years. All participants were presented with hypothetical monetary rewards; however, the CD group was also presented with hypothetical crack/cocaine rewards. The objective value of the rewards ranged from $1 to $1,000. Hyperbolic discounting functions provided a good fit of the data. The CD group discounted monetary rewards at a higher rate than the MC group did, and the CD group discounted crack/cocaine rewards at a higher rate than it did monetary rewards. Moreover, scores on self-report measures indicated greater impulsivity in the CD group when compared with the MC group.

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RAUMATIC STRESS IS A SIGNIFIcant public health problem 1 that frequently results in a distinctive pattern of persistent and disabling psychological and physiological symptoms. 2,3 Once thought to be primarily limited to soldiers in combat, posttraumatic stress disorder (PTSD) is now recognized in civilians, including those who have experienced natural disasters, physical and sexual assault, fire, motor vehicle and other serious trauma, as well as those who have witnessed inflicted injury or death. Exposure to a traumatic event is common, estimated in the range of 5% to 35% annually, with a lifetime exposure to 1 or more traumatic events occurring in more than 50% of the US population. 1 The clinical presentation of PTSD is characterized by moderate-to-severe symptoms in 3 separate domains: reexperiencing (intrusive thoughts, nightmares, flashbacks, images, or memories), emotional numbing and avoidance (flattened affect or detachment, loss of interest and motivation, and avoidance of any activity, place, person, or topic associated with the trauma); and Author Affiliations and Financial Disclosures are listed at the end of this article.

Context There is concern that exposure therapy, an evidence-based cognitivebehavioral treatment for posttraumatic stress disorder (PTSD), may be inappropriate because of risk of relapse for patients with co-occurring substance dependence.Objective To determine whether an integrated treatment for PTSD and substance dependence, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), can achieve greater reductions in PTSD and substance dependence symptom severity compared with usual treatment for substance dependence.Design, Setting, and Participants Randomized controlled trial enrolling 103 participants who met DSM-IV-TR criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009 in Sydney, Australia; outcomes were assessed at 9 months postbaseline, with interim measures collected at 6 weeks and 3 months postbaseline.Interventions Participants were randomized to receive COPE plus usual treatment (n=55) or usual treatment alone (control) (n=48). COPE consists of 13 individual 90minute sessions (ie, 19.5 hours) with a clinical psychologist. Main Outcome MeasuresChange in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale (CAPS; scale range, 0-240) and change in severity of substance dependence as measured by the number of dependence criteria met according to the Composite International Diagnostic Interview version 3.0 (CIDI; range, 0-7), from baseline to 9-month follow-up. A change of 15 points on the CAPS scale and 1 dependence criterion on the CIDI were considered clinically significant. ResultsFrom baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group (mean difference, −38.24 [95% CI, −47.93 to −28.54]) and the control group (mean difference, −22.14 [95% CI, −30.33 to −13.95]); however,thetreatmentgroupdemonstratedasignificantlygreaterreductioninPTSDsymptom severity (mean difference, −16.09 [95% CI, −29.00 to −3.19]). No significant between-group difference was found in relation to improvement in severity of substance dependence (0.43 vs 0.52; incidence rate ratio, 0.85 [95% CI, 0.60 to 1.21), nor were there any significant between-group differences in relation to changes in substance use, depression, or anxiety. ConclusionAmong patients with PTSD and substance dependence, the combined use of COPE plus usual treatment, compared with usual treatment alone, resulted in improvement in PTSD symptom severity without an increase in severity of substance dependence.