Vladimir Nacev, PhD, ABPP
Disclaimer: The views presented in this article are those of the author and do not reflect the views of the US Government or the Department of Defense.
Substance use, abuse, and misuse have significant health, military readiness, social and personal consequences that continue to be a major concern for the Department of Defense (DoD) (DoD Directive 101.2, 1972 and Bray, 2009). In 2009, the Department of Veterans Affairs (VA) and DoD released a revised clinical practice guideline (CPG) for the management of Substance Use Disorders (SUD) that provides evidenced-based recommendations to identify patients at risk of SUD, promote early engagement and retention of patients who can benefit from such practices and improve outcomes of patients with substance use conditions (VA/DoD CPG, 2009). This article summarizes evidence-based guidelines for screening, diagnosis and treatment of common SUD in patients seen in DoD’s general medical, mental health and SUD specialty-care settings.
Screening and Brief Intervention for Unhealthy Alcohol Use
Screening and brief intervention (SBI) is a comprehensive public-health care approach that integrates the recognition and management of unhealthy substance use in general health care settings (Polen et al., 2008). Screening for unhealthy alcohol use determines the number of drinks consumed in a typical week and the maximum number of drinks consumed on an occasion in the past year (i.e. heavy or binge drinking). Table 1 provides definitions of recommended drinking limits for men and women (NIAAA, 2005).
The primary goals of screening for unhealthy alcohol use are to identify patients who drink above the recommended limits or drink despite contraindications to alcohol use and to determine whether they are candidates for a brief alcohol intervention (BI) or referral to SUD specialty care (Kaner et.al., 2009 and Babor et al., 2007). Contraindications to any alcohol use include liver disease or hepatitis C, medical conditions potentially exacerbated or complicated by drinking (e.g., pancreatitis or congestive heart failure), medications that have adverse interactions with alcohol and pregnancy or trying to conceive. Because patients who screen positive for these contraindications are unlikely to be in treatment for their alcohol use, psychologists need to consider and provide a BI or referral to treatment.
Recommended Brief Interventions for Unhealthy Alcohol Use
The use of brief, validated screening instruments is critical to ensure both valid and effective screening (Bradley, Kivlahan, and Williams, 2009). The CPG on SUD identified the Alcohol Use Disorders Identification Test Consumption Questions (AUDIT-C) (Bush et al., 1998) and the Single-Item Alcohol Screening Questionnaire (SASQ) (Canagasaby, 2005) as valid screens for past-year unhealthy alcohol use. Psychologists need to consider a positive screen for unhealthy alcohol use if a patient’s AUDIT-C score (range from 0 to 12) is =/> 4 points for men or =/> 3 points for women or a patient reports, on the SASQ, drinking four or more (women) or five or more (men) drinks in a day in the past 12 months. Active-duty service members are required to be referred to SUD specialty care for a comprehensive evaluation if involved in an incident in which substance use is suspected to be a contributing factor. The current recommendation for annual screening is consistent with preventive screening for other disorders in DoD primary care settings and the past-year assessment window of the AUDIT-C.
An SBI for unhealthy alcohol use is patient-centered, empathetic brief counseling, lasting from several minutes to an hour and may be offered by a provider without expertise in addiction treatment (Whitlock et al., 2004). During a BI, a provider expresses concerns that the patient is drinking at unhealthy levels, gives feedback that links alcohol use and medical, social or mental health consequences and provides personalized feedback related to a patient’s specific medical concerns (e.g., hypertension, depression or anxiety, insomnia, diabetes). Providers also support the patient in choosing a drinking goal and offer a referral to SUD specialty-care, if appropriate (Rollnick et al., 2010). The unique nature about a BI is that it can be tailored to both the specific needs of a given population or health care setting or be used as a stand-alone treatment as well as for engaging those in need of more intensive treatment. Many patients may initially decline voluntary referral, but psychologist’s encouragement and support over time may improve the patient’s compliance with the referral appointment. The CPG on SUD recommends that patients be referred to SUD specialty care when: 1) they may benefit from a more comprehensive evaluation or a more intensive motivational interview about their substance use; 2) have been unsuccessful in trying to reduce their substance use on their own; 3) did respond to a BI; 4) have been diagnosed with a SUD; or 5) have returned to use after previously receiving SUD treatment.
The use of repeated BIs in general medical settings have been found to be effective for patients with alcohol-related problems who are at high risk for an alcohol use disorder and who are unwilling to accept a referral to SUD specialty care. The goal of these medical visits is to engage patients in clinical interactions that motivate a decrease in drinking without initially requiring abstinence. Repeated BIs focused on monitoring and feedback on alcohol biomarkers (Fleming, Brown, and brown, 2004; Kristenso et al., 1983; and Willenbring and Olson, 1999) or medical symptoms associated with alcohol use (Lieber et al., 2003) and adherence to medications to decrease drinking have been shown to reduce alcohol use (Anton et al., 2006).
Assessment and Diagnostic Evaluation
Successful treatment of SUD begins with a comprehensive biopsychosocial assessment and diagnosis. While the essential purpose of the assessment is to obtain information needed to accurately identify and treat SUD, it also marks the beginning of the therapeutic process. The recommended clinical interactions for a BI need to be supportive and demonstrate the patient-centered approach outlined in the CPG (VA/DoD CPG, 2009; Greenfield and Hennessy, 2008; Poston, 2010; and Miller and Rollnick, 2002).
According to the VA/DoD CPG (2009), a comprehensive biopsychosocial assessment includes:
a history of the substance use disorder, including precipitating factors and current symptoms and risks
collateral interviews with individuals who can provide insight into the patient’s substance use
ordering laboratory tests for infectious diseases
reviewing consequences of substance use
mental status examination
identification of assets, vulnerabilities and supports
patients’ perspective on current problems, treatment goals and preferences
To accomplish this, one may use a clinical interview and several independent instruments or a single, comprehensive instrument that assesses several functional domains [e.g., Addiction Severity Index] (McLellan et al., 2006). A complete evaluation is important to properly diagnose patients with SUD and develop an effective treatment plan, but for patients presumed to have less severe symptoms, the assessment needs to, at least, include screening of the above elements using a multidimensional screening instrument. In addition to formulating a diagnosis of SUD and co-occurring conditions, the results are used to also determine if patients require a behavioral or physiological stabilization and a referral to an appropriate treatment setting.
Initial Treatment Plan
A comprehensive assessment also includes a diagnostic formulation, summary of past treatment response and integrated summary of clinically relevant information. Psychologists need to consider the patients’ willingness to engage in treatment as well as the patients’ treatment goals and preferences and evaluate how their strengths, limitations and presenting problems will affect the treatment process and outcomes. To improve adherence to initial treatment priorities and outcomes, the treatment plan needs to have input from the patient (Scott and Dennis, 2009) and unit command in case of service members (US Navy OPNAV Instruction 5340.4D, 2009; US Air Force Instruction 44-121, 2011; and US Army Regulation 600-85, 2009). It may be possible to manage some patients with less severe and chronic SUD outside of specialty-care settings.
While it is recommended that the intensity of treatment needs to match the severity of the substance use problem, interventions also need to be provided in the least restrictive setting required to support their effectiveness and patient safety. If appropriate, less severe and chronic SUD may be treated in general health care settings. Although most general health care settings don’t have the staff to offer psychotherapy, physicians and medical psychologists (those trained and credentialed to prescribe psychotropic medications) can effectively provide pharmacotherapy and medical management for alcohol use disorders in these settings (VA/DoD CPG, 2009 and Anton et al., 2006). If patients’ substance use severity and co-occurring psychiatric and psychosocial problems require more intensive psychosocial interventions, SUD specialty care is typically more appropriate including referrals to health services clinical psychologists.
Perhaps no other early treatment goal is as important as facilitating patients’ engagement and retention in treatment as these factors consistently predict a successful outcome (McKay, 2009; Dale et al., 2011; Maisto et al., 2008; and Higgins, Badger, and Budney, 2008). Clinical interventions that demonstrate a non-judgmental, empathic and patient-centered approach are more likely to enhance the psychologist-patient alliance and promote opportunities to address other treatment objectives (Miller and Rollnick, 2002). Other goals include enhancing psychosocial functioning and preventing relapse to substance use and return of substance use problems.
Recommended Evidenced-based Interventions
Sometimes pharmacotherapy may be offered to patients with alcohol use disorders and opioid dependence, and coordinated with psychosocial interventions by psychologists provided in specialty care. Several systematic reviews support the efficacy of naltrexone and acamprosate (Johnson, 2010) and a recent systematic review supports the efficacy of disulfiram (Jorgensen, Pedersen, and Tonnesen, 2011). In an attempt to improve the use of these medications, efforts are underway to identify and examine patient, provider and facility-level barriers, which support pharmacotherapy for alcohol use disorders.
Due to limited resources, most specialty-care settings are unable to offer multiple psychosocial treatment options. While many psychosocial interventions are empirically supported for treatment of SUD, there is no clear evidence that any one intervention is superior or particularly effective for a specific patient’s characteristics (Miller and Wilbourne, 2002; Imel et al., 2008). Similarly, psychologists need to consider the following interventions that have been developed into published treatment manuals and evaluated in randomized trials: behavioral couples therapy, cognitive behavioral coping skills training, community reinforcement and family training (CRAFT), motivational enhancement therapy, twelve-step facilitation and contingency management/motivational incentives therapy VA/DoD CPG, 2009). Table 2 summarizes the evidence supporting these interventions and the first line and adjunctive treatment roles they serve for condition specific outcomes of SUD.
Management of Co-Occurring Medical and Psychiatric Disorders
The most common psychiatric disorder among returning veterans, from either war, with an alcohol use or drug use disorders is PTSD (63%). Engagement in SUD treatment and overall coordination of care may be improved if multiple services are provided in the most accessible setting (Saxon et al., 2006). However, referrals for behavioral health services need to be provided for conditions that cannot be managed appropriately at the initial settings for substance use treatment. Regardless, ongoing coordination of these services is essential to the overall quality of care (Forum NCSNQ, 2007).
Assess and Monitor Response to Treatment
Periodic assessment of treatment compliance, using standardized self-report and laboratory measures, is essential to evaluating patients’ progress in treatment and providing information necessary to further fine tune treatment interventions (Harding et al., 2011 and McKay, 2009). The timing of periodic assessments reflects the stage and intensity of services with reassessment occurring daily in acute inpatient settings, weekly in residential settings and new treatment episodes, followed by monthly evaluations in outpatient settings. Results of the assessments would provide a measure of a patient’s response to treatment and may be used to annotate changes to care. Improvements on measures signal that a patient is progressing as expected, whereas worsening or lack of change on measures suggests that the provider may need to evaluate the adequacy of the treatment plan, consider alternative interventions (e.g., pharmacotherapy), and consult with the patient and other members of the treatment team to identify factors that may be interfering with treatment progress.
Common indicators of treatment response include ongoing substance use, cravings, psychological distress, exposure to risky environments, stressful situations and unsupportive family and friends, side effects of medications, participation in self-help meetings and engagement in addiction specialty care. Traditional biomarkers of heavy alcohol consumption (e.g., CDT, GGT, MCV) and the new biomarker, ethyl glucuronide (EtG) , may be useful for providing objective measures of ongoing alcohol use (Litten, Bradley, and Moss, 2010).
Development of Aftercare/Recovery Plan
As patients improve, treatment teams need to collaborate with patients to plan how to achieve the remaining goals, consider reducing the intensity of SUD specialty care, and develop an aftercare plan. Transitions to less intensive levels of care requires coordinated follow up with medical or clinical psychologist involved in the patients’ care designed to monitor progress, including the risk of relapse and management of co-occurring medical and psychological conditions. Because the risk of relapse is high during early recovery, an aftercare plan needs to include a written strategy to facilitate periodic contact with treatment services in the form of individual, group or telephone contacts so to monitor the risk of relapse and the need for developing relapse prevention skills. The plan may also encourage active involvement with community support for recovery and biological monitoring of substance use and medical consequences. Service members are required to have a written, individualized aftercare plan that describes their rehabilitative responsibilities, including a quarterly evaluation of the patient’s progress conducted by a committee comprised of a substance abuse counselor/psychologist, the patient and the patient’s commanding officer (US Navy OPNAV Instruction, 2009 and US Air Force Instruction 44-121, 2011).
Barriers to Assessment and Treatment in the Military Population
Studies have identified several barriers to the initiation and completion of substance use treatment in military settings. There are limits to the confidentiality for military service personnel in SUD specialty-care as DoD policies require that a commanding officer be notified when a service member voluntarily receives services for alcohol use disorder. In addition, the commanding officer, or his representative, needs to be included as a member of the treatment team once treatment has started (DoD Directive 1010.2, 1972; US Air Force Instruction 44-121, 2011; and US Army Regulation 600-85, 2009). Additional limits of confidentiality may exist for special active duty populations such as aircrew members. A zero tolerance policy on the misuse of drugs, including prescription medications, generally represent another significant barrier for those seeking substance use treatment services (Bray and Hourani, 2007 and Kao, Schneider, and Hoffman, 2000). Service members have reported that obtaining time off from military duties to attend treatment is difficult, and deployed service members have consistently reported limited access to appropriate care (Kim et al., 2010; Joint Mental Health Advisory Team 7, 2011; and Hoge et al., 2004). Lastly, service members report concerns about the negative effect the use of psychological treatment may have on their reputation and career.
Although several barriers to care in the military population overlap with those of veterans receiving care in the VA such as stigma and logistical challenges to receiving care, there are also barriers unique to veterans treated in the VA. Much like active duty members, stigma, discomfort with help-seeking and negative beliefs about mental health care are consistently reported as important barriers to seeking psychological services (Quimette et al., 2011). Recent veterans treated in the VA have also reported concerns about not fitting in with older veterans from previous eras who remain the majority of those served.
Population-based screening and brief interventions are fundamental to the management of substance use disorders in health care settings. Patients requiring more intensive treatment services need to be referred to SUD specialty care for a comprehensive assessment of their treatment needs and the development of treatment goals. Several evidence-based pharmacotherapy and psychosocial interventions are available for the treatment of common SUD, but the importance of empathic, nonjudgmental and patient-centered clinical interactions need to remain paramount.
*Standard-sized drinks are 12-ounce beer, 5-ounce wine, or 1.5-ounce hard liquor
Vladimir Nacev, PhD, ABPP, is a program manager for psychological health at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Dr. Nacev is a published, board certified clinical psychologist and university professor who has given numerous professional presentations at national conferences. He is also a retired Navy Commander who served at the Bureau of Medicine and Surgery, Pentagon (Joint Chiefs of Staff), and Bureau of Naval Personnel.
Note: For more details and references, please review the original article published by Hawkins, E, Nacev, V, Grossbard, J, Benbow, J, and Kivlahan, D. Evidence-based Screening, Diagnosis, and Treatment of Substance Use Disorders Among Veterans and Military Service Personnel, Military Medicine, 177:829, 2012.