Prolonged exposure therapy for PTSD in individuals with opioid use disorder: A randomized pilot study

•PTSD is prevalent and associated with adverse consequences in individuals with OUD.•Incentivizes increased attendance to PE sessions for individuals with OUD and PTSD.•PE+ was associated with greater reductions in PTSD symptoms than TAU.•PE did not prompt opioid relapse in individuals with OUD and PTSD. Nearly all individuals with opioid use disorder (OUD) report lifetime trauma exposure and one-third meet diagnostic criteria for posttraumatic stress disorder (PTSD). Although prolonged exposure (PE) therapy is a first-line treatment for PTSD, little is known about the effects of PE in individuals with co-occurring OUD. Furthermore, its efficacy is commonly undermined by poor therapy attendance. This pilot study evaluated the feasibility and initial efficacy of a novel PE protocol for improving PE attendance and PTSD symptoms among buprenorphine- or methadone-maintained adults with PTSD. Thirty participants with co-occurring PTSD and OUD were randomized to receive either: (a) continued medications for OUD (MOUD) treatment as usual (TAU), (b) Prolonged Exposure therapy (PE), or (c) PE with financial incentives delivered contingent upon PE session attendance (PE+). Primary outcomes included PE session attendance, PTSD symptom severity, and use of opioids other than prescribed MOUD. PE+ participants attended significantly more therapy sessions vs. PE (87% vs. 35%; p