"Nacetylcysteine when combined with group cognitive behavioral therapy CBT reduced symptoms of posttraumatic stress disorder PTSD cravings and depression significantly more than CBT alone in veterans with cooccurring PTSD and substance use disorder a particularly difficulttotreat population according to the findings of a randomized controlled pilot trial conducted by researchers at the Medical University of South Carolina MUSC and the Ralph H. Johnson VA Medical Center.  This trial is the first to use NAC as a pharmacotherapy for PTSD and a broad range of SUDs. The results were published online ahead of print on October   by the Journal of Clinical Psychiatry.  The National Center for PTSD estimates that seven to eight percent of Americans will have PTSD at some point in their life. The numbers are even worse for veterans it is estimated for example that  percent of Vietnam veterans will have experienced PTSD at some point in their life. Approximately  to  percent of veterans with PTSD also have a substance use disorder SUD.  Addiction goes along with virtually every psychiatric disorder at a higher percentage than it does in the general population said Peter W. Kalivas Ph.D. the senior author on the article and chair of the Department of Neuroscience at MUSC. People who are prone to psychiatric disorders are also prone to addiction. Currently there are no wellexplored pharmacological treatments for patients with cooccurring PTSDSUD. Although selective serotonin reuptake inhibitors have been approved by the FDA for treatment of PTSD pharmacological treatments for cooccurring PTSDSUD have yielded suboptimal results.  Groundbreaking basic science research by Kalivas has shown that levels of glutamate transporters are decreased in SUDs and that administration of the antioxidant Nacetylcysteine can help restore those levels and guard against relapse in animal models of SUD. Because evidence suggests that SUDs and PTSD share overlapping neurobiological pathways Sudie E. Back Ph.D. lead author on the article hypothesized that NAC treatment with CBT would be a novel approach to treat cooccurring PTSD and SUD. Back is a professor in the Department of Psychiatry and Behavioral Sciences at MUSC and a staff psychologist at the Ralph H. Johnson VA Medical Center. In the eightweek randomized controlled trial led by Back and Kalivas  veterans with PTSD and SUD all of whom were receiving cognitive behavioral therapy CBT for their SUD were randomized to either  mgday of NAC or placebo. The average age of the veterans was  years and many were veterans of the Vietnam War. To be included veterans had to have abstained from substance use for at least seven days. Of the veterans enrolled in the trial  completed it a very high rate for this difficulttotreat population.  Veterans in the NACtreated group showed a  reduction in PTSD symptoms compared with a  reduction in the placebo group on the ClinicalAdministered PTSD Scale CAPS which assesses trauma history and symptom severity. The threshold CAPS score for diagnosis of PTSD is .  As a group the NACtreated veterans were below diagnostic level for PTSD at the end of treatment said Back. For PTSD these are some of the best outcomes we have seen in the literature for a medication. Craving and depression were also reduced in the NACtreated group. The amount of craving was reduced by  and the frequency of craving by  in the NAC group compared with  and  in the placebo group. Craving is a key component of substance use in relapse said Back. If you have a medication that can really reduce craving that will go a long way to helping people stay clean and sober. Depression gauged using the Beck Depression Inventory was reduced  in the NAC group vs.  in the placebo group.  Veterans in the study had low rates of substance use during the trial and the study found little effect of medication on use perhaps due to the fact that all participants were receiving SUD treatment and exhibiting low levels of use. This finding could also be due to the relatively limited number of participants or to the chronic nature of the participants PTSD. This is a tough patient population with SUD to work with. said Kalivas. We have Vietnam vets that have had PTSD for  to  years. This is not an easytoturnaround population. Although these early promising findings show that NAC reduced PTSD symptoms craving and depression NAC should not be used as a monotherapy or substitute for evidencebased behavioral treatment but instead be seen as an adjunct therapy that enhances it.  We would not advocate using it instead of therapy said Back. But this could be something to help prevent relapse when used alongside a behavioral treatment.  NAC is available over the counter and does not cause side effects at the doses used in the study but it degrades quickly when stored is contraindicated in patients with asthma and can cause nausea at higher doses and so should always be obtained and administered under a physicians supervision. The next steps in Backs research are to run a longerterm trial of NAC in veterans with PTSD and SUD and to use MRS magnetic spectroscopy to better explore the effect of NAC on glutamate levels in patients with PTSD and SUD.   About MUSC Founded in  in Charleston The Medical University of South Carolina is the oldest medical school in the South. Today MUSC continues the tradition of excellence in education research and patient care. MUSC educates and trains more than  students and residents in six colleges Dental Medicine Graduate Studies Health Professions Medicine Nursing and Pharmacy and has nearly  employees including approximately  faculty members. As the largest nonfederal employer in Charleston the university and its affiliates have collective annual budgets in excess of . billion with an annual economic impact of more than . billion and annual research funding in excess of  million. MUSC operates a bed medical center which includes a nationally recognized childrens hospital the Ashley River Tower cardiovascular digestive disease and surgical oncology Hollings Cancer Center a National Cancer Institutedesignated center Level I Trauma Center Institute of Psychiatry and the states only transplant center. In  U.S. News  World Report named MUSC Health the number one hospital in South Carolina. For more information on academic programs or clinical services visit musc.edu httpmusc.edu. For more information on hospital patient services visit muschealth.org httpmuschealth.org. About the Ralph H. Johnson VA Medical Center Located in historic downtown Charleston South Carolina the Ralph H. Johnson VA Medical Center is a tertiary care teaching hospital providing the highest level quality care from cardiology to neurology to primary and mental health care for  Veterans along the South Carolina and Georgia coast. The Ralph H. Johnson VA achieved a Star rating according to VAs Strategic Analytics for Improvement and Learning Value SAIL model. The SAIL rating ranks the Charleston VA in the top  percent of VA medical centers nationwide for quality of care and efficiency. The Charleston VA is also ranked in the top th percentile according to the Healthcare Effectiveness Data and Information Set HEDIS. HEDIS is an independent review that measures performance of  percent of Americas health plans and facilities in both the public and private sector on dimensions of care and service. The Ralph H. Johnson VA Medical Center is a center of excellence for robotic surgery and orthopedics and is the first VA National TeleMental Health Hub providing care for Veterans across the U.S. The bed hospital includes six community based outpatient clinics a bed nursing home womens health and the full range of inpatient and outpatient care including medical and surgical intensive care. The VAMC provides more than  outpatient visits and approximately  inpatient stays annually. With more than  employees Charleston VA has an annual budget of  million research funding of more than  million and more than  principal investigators participating in approximately  research studies. For more information visit http"