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
Problems with drinking or drug use may occur in response to stress, or in combination with posttraumatic stress disorder, depression, or other mental health and medical conditions.
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.
Finding Healthier Ways to Cope with Problems
Veterans discuss how they attempted to cope with stress, nightmares, and other problems by turning to alcohol or drugs. It took strength for them to seek out more effective solutions, leave behind unhealthy ways of coping, and live healthier, more fulfilling lives.
Video source: MaketheConnection.net | Alcohol or Drug Problems
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.
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 MyHealtheVet 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.
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.
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.
The Brief Addiction Monitor (BAM) is a 17-item measure of addiction problem severity that is designed to support individualized, measurement-based care (MBC) to patients with substance use disorders by providing reliable symptom monitoring in a format that yields clinically-actionable data that are not a burden to collect.
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 recovery (items 9, 10, 12, 13, 14, & 16), and drug and alcohol Use (items 4-7G). Furthermore, the BAM produces composite scores for the three domains (Risk, Protective, & Use).
A patient's clinical status may be assessed by examining individual BAM items and/or composite scores. Initial psychometric evaluation of the BAM reveals good test-retest reliability. End users are strongly encouraged to attend to the item-level data because they have direct implications for treatment planning. That is, they identify specific areas of need or resources the patient brings to bear in his/her recovery. Please contact the Philadelphia CESATE for more information: (215) 823-5800, x6181;Dominick.DePhilippis@va.gov.
Download additional information about the Brief Addiction Monitor
Client Educational Materials
Brochures, Booklets, and Handouts on Substance Misuse:
Download a brochure to encourage Veterans to discuss and self-assess for substance misuse.
NIDA provides a selection of booklets and fact sheets for both clients and providers.
Free Online Program to Help Veterans Cut Back or Stop Drinking:
VetChange.org is a free and confidential online program created for Veterans and active duty military who are concerned about their drinking.
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.
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)
Medications to help clients cut down or abstain from alcohol
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:
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 SUD and treatments
Course reviewing 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.
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 practices.
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.
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 Transition and Care Management Team.
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.
VetChange.org: A free and confidential online program created for Veterans and active duty military who are concerned about their drinking.
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.
National Institutes: National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse
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
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.
PsychArmor: This national non-profit organization is dedicated to bridging the military-civilian divide through free online education. PsychArmor has an online course focused on substance use.