- Substance Use & Dependence Basics
- Assessing for a Substance Use Problem
- Client Educational Materials
- Treatment and Training
- Referring to VA
- Online Resources
- Cool Tool
Substance Use and Dependence Basics
"When I got back, especially at first, it was impossible to turn my brain off and fall asleep
at night. Drinking was a quick and easy way to combat that, but also one that caused a lot more problems later
(Source: Make the Connection website)
8.3% of VA patients meet criteria for a Substance Abuse Disorder, other than nicotine dependence (2010). In
addition, approximately 20% of VA enrollees are current smokers.
(Source: Quality Enhancement Research Initiative, QUERI)
Indicators of Substance Misuse Include:
- Substance-related difficulties in fulfilling obligations in work, school, or home
- Using substances in hazardous situations such as driving while drinking
- Legal problems related to substance use
- Social or interpersonal problems related to the effects of using substances
Indicators of Substance Dependence Include:
- Tolerance: the ability to drink alcohol or use drugs in greater quantities over time
- Compulsive behavior: the inability to stop drinking alcohol or using drugs in spite of negative life consequences
- Withdrawal: experiencing symptoms such as feeling sick and distressed when attempting to quit drinking alcohol or using drugs
See the Make the Connection website to learn more about the signs of problematic drug or alcohol use and related problems. You may also want to visit the website to listen to Veteran stories regarding their experiences with substance use and related difficulties.
Assessing for a Substance Use Problem
There are many screening tools to assess drug and alcohol misuse. This section provides information about some widely used screening tools for alcohol, nicotine, and other drug misuse. Positive screening serves as a very valuable early warning sign that can identify potential substance use problems before they get worse. See the Online Resources section to learn about additional tools.
Screening for Alcohol Misuse
Alcohol Use Identification Test - Alcohol Consumption (AUDIT-C)
A screening tool that is widely used to assess alcohol misuse is the AUDIT-C. The AUDIT-C is a 3 item validated screening questionnaire. The AUDIT-C asks questions like "How often did you have a drink containing alcohol in the past year?" and "How many drinks did you have on a typical day when you were drinking in the past year?"
• Download the AUDIT-C and learn more about screening and providing feedback to Veterans using this measure.
• Veterans can also self-administer the Audit-C at the My HealtheVet website.
Brief scoring information for the AUDIT-C:
• A score of 4 or higher on the AUDIT-C may indicate misuse. A score of greater than 7 may indicate dependence.
• If a client scores greater than 4, further evaluation, referral and brief intervention may be warranted.
Additional information about and assessment tools for alcohol misuse can be found at the VA QUERI website.
Useful Tool for Veterans
Also, the Drinker's Check-up can be a useful tool for clients at risk of substance misuse.
Screening for Drug Abuse
Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
Veterans can self-administer a brief screen about alcohol, tobacco products, and other drugs at the VA My HealtheVet website. The ASSIST will ask questions about the Veterans experience of using substances across the lifetime and in the past three months. Based on the Veteran's answers, feedback will be given about potential risk of health and other problems related to problems with alcohol, tobacco or drugs. The results are not stored or sent anywhere.
The ASSIST and scoring information can also be found at the After Deployment website.
Self-Screening for Illicit Drug Use
Download an instructional letter and informational brochure, English / Spanish (MS Word), about self-screening.
Additional drug abuse screening information at NIDA
NIDA also provides a guide for screening for drug use in general medical settings and additional information about screening tools for drug abuse and dependence.
Screening for Nicotine Dependence
The After Deployment website provides a downloadable brief screening tool with scoring information for nicotine use.
Screening for frequently co-occurring problems
Some conditions that commonly co-occur with substance abuse and dependence include PTSD and Depression.
Assessing Addiction Problem Severity
The BAM is a 17-item measure of addiction problem severity that is designed to support measurement-based treatment in SUD specialty care settings. The BAM may be administered as a clinical interview (in-person or telephonically) or via patient self-report; and, it typically takes about 5 minutes to complete. The BAM retrospectively examines the patient's past 30-days and includes items that assess Risk factors for substance use (items 1, 2, 3, 8, 11, & 15), Protective factors that support sobriety (items 9, 10, 12, 13, 14, & 16), and drug and alcohol Use (items 4-7G). Furthermore, the BAM produces composite scores for the three aforementioned domains. A patient's clinical status may be assessed by examining individual BAM items and/or composite scores. End users are strongly encouraged to attend to the item-level data because they have direct implications for treatment planning. Additional psychometric evaluation of the composite scores is needed before they can be more extensively applied to clinical decision-making. Initial psychometric evaluation of the BAM reveals good test-retest reliability. Please contact the Philadelphia CESATE for more information: (215) 823-5800, x6181; Dominick.DePhilippis@va.gov.
• BAM Overview (PDF)
• BAM Continuous Version (PDF)
• Treatment Planning with BAM (PDF)
• Standard Drinks Conversion Chart (PDF)
• BAM Continuous Scoring Template (Excel)
• Mock BAM Scoring Template (PDF)
• BAM Scoring Template SOPs (PDF)
Client Educational Materials
Brochures, Booklets, and Handouts on Substance Misuse:
- Download a brochure to encourage Veterans to discuss and self-assess for substance misuse.
- Take a look at the handouts for clients on alcohol and other drug use on the After Deployment website. These include information on topics such as:
- Tips for drinking moderately
- How to know if there is a problem
- Substance use and combat stress
- NIDA provides a selection of booklets and fact sheets for both clients and providers.
Online Workshop for Clients:
The After Deployment website offers an online client workshop and assessments to provide more information about assessing and treatment of alcohol and other drug use.
A psychoeducational program for the client to help them to better understand whether their alcohol use is problematic and potential steps to help.
Treatment and Training
VA/DoD Guideline on SUD
The guideline describes the critical decision points in the Management of Substance Use
Disorder and provides clear and comprehensive evidence based recommendations incorporating current information
and practices for practitioners throughout the DoD and VA Health Care systems. The guideline is intended to
improve patient outcomes and local management of patients with substance use disorder. Go to the VA/DoD Clinical Practice Guidelines website for a
listing of all the Guidelines.
• SUD Full Guideline (601 KB, PDF) NEW
• SUD Summary (752 KB, PDF) NEW
VHA Mental Health Services Handbook
This Veterans Health Administration (VHA) Handbook specified the Mental Health Services that are to be
available to all enrolled Veterans and lays out minimum requirements for VHA Mental Health Services.
• VHA Handbook 1160.01 (September 11, 2008) (PDF)
VA Treatment recommendations for co-morbid SUD and PTSD
These recommendations are from a multidisciplinary workgroup. They are intended to provide
guidance to clinicians seeing clients with both Substance Use Disorders and Posttraumatic Stress Disorder.
This PDF file may be printed and used as a handout.
• Report of Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid Substance Use Disorder and PTSD (PDF)
Are there medications that can help clients cut down or abstain from
Clients who are unable or unwilling initially to consider abstinence as a goal might benefit from medications
for alcohol dependence. The NIAAA Clinician's Guide and the NIAAA COMBINE Medical
Management Treatment Manual list information and contraindications to FDA approved medications.
Medications for alcohol dependence approved by the US Food and Drug Administration (FDA) include:
• Disulfuram (Antabuse)
The NIAAA Clinician's Guide has helpful information for use of these. All three of these medications have been shown to be effective for some clients and can be managed in the primary care setting with support from a primary care-mental health team. In addition, recent trials have shown other medications to be associated with decreased drinking including:
If clients have other indications for these medications, they may also benefit from their potential effect on alcohol dependence.
Online Trainings: Learn more about Substance Use Disorders and
the VA/DoD 2012 Clinical Practice Guidelines:
This course reviews the VA/DoD 2012 clinical practice guideline recommendations for managing Substance Use
Disorders and PTSD through psychotherapy and pharmacology.
Course on Integrated Smoking Cessation and PTSD Treatment: This course provides an overview of the negative effects of smoking, particularly on Veterans with PTSD, and to help providers understand the rationale for providing tobacco cessation treatment to patients.
Referring to VA
Among the many behavioral health services available through VA is treatment for Substance Use
Disorders (SUD). VA also is an innovator in SUD treatment by supporting research and development of best
Learn More About VA Services for Veterans with Substance Use Disorders:
- VHA Programs for Veterans with Substance Use Disorders (SUD): VHA Handbook 1160.04
- OMHS Fact Sheet: VA Services for Patients with Substance Use Disorders (PDF)
- Summary of VA Treatment Programs for Substance Use Problems (PDF)
What Should I Consider When Referring?
If your client screens positive for substance misuse, they may be referred to specialized SUD treatment, behavioral medicine, or more general mental health services for further evaluation and possible treatment. In addition to individual services, Veterans can also find SUD treatment groups where they can connect with and receive support from other Veterans.
How Do I Refer?
Below are various ways to connect with VA to refer a client or to support the services your Veteran client is currently receiving:
- The VA SUD program locator can help you find a SUD program at a local VA Medical Center.
- If your Veteran client has served in Operations Enduring Freedom (OEF) or Iraqi Freedom (OIF), you may also speak with your local OEF/OIF coordinator.
- To find contact information for your local VA medical Center or Vet Center, use the VA program locator.
- You may also call VA's general information line: 1-800-827-1000.
- For referral to treatment resources and facilities other than VA, a useful resource is the Substance Abuse Mental Health Services Administration (SAMHSA) Substance Abuse Treatment Facility Locator.
National Center for PTSD: A goldmine of materials and resources about PTSD for provider and client with resources that address co-occurring PTSD and Substance Use Disorders as well.
After Deployment: Information and materials on SUD and other associated conditions for the Veteran and his/her family.
Make the Connection: Veteran stories and educational information about a variety of signs, symptoms, and conditions for your client. This site also provides direction for the Veteran about next steps to take to seek treatment or resources.
QUERI: The VA Quality Enhancement Research Initiative (QUERI) Substance Use Disorders Website provides information for clinicians and researchers.
Facts About Buprenorphine: Learn the facts about Buprenorphine for the treatment of Opioid Addiction. Buprenorphine Fact Sheet English (PDF) / Buprenorphine Fact Sheet Spanish (PDF); Buprenorphine Resource Guide (PDF) (SAMHSA Products)
Self-Help Toolkit: The 3- step Referral Method: A Product Developed by SUD QUERI, this toolkit teaches a strategy for engaging SUD clients in self-help care. The 3-Step Referral Method is an empirically validated method for referring patients to self-help programs. This step-by-step method augments standard referral practices with the addition of a few new components. The method was found to improve patient attendance and engagement in self-help programs and abstinence rates at one year. Protocol and handouts on this site.
The Rethinking Drinking Program: This is a NIAAA program addressing alcohol misuse. Includes information on alcohol misuse and provides tools such as a booklet for client's that discusses healthy drinking guidelines and self-assessment.
Searchable Assessment Libraries: These sites have many SUD and related issues assessment instruments available for download.
- Alcohol and Drug abuse Institute (ADAI) , University of Washington
- Center on Alcoholism, Substance Abuse, and Addictions (CASAA), University of New Mexico
- Addiction Research Institute, University of Texas
Alcoholics Anonymous: For meeting information, contact a local A.A. resource that provides meeting times and locations. Use this link for a list of meeting resources by state and province in the U.S. and Canada.
Veterans can self-administer a brief screen about alcohol, tobacco products, and other drugs at the VA My HealtheVet website. Enrollment in My HealtheVet can be done right on the website.
Veterans enrolled in VA can manage their health information - appointments, prescriptions, labs, blood tests and even exchange messages with their health care team.
The VA My HealtheVet website can be found at: https://www.myhealth.va.gov/.