Treating alcohol disorder
- Alcohol dependence is commonly comorbid with other substance use disorders.
- Referral pathways for alcohol disorder are available via the DVA community-based AOD services panel current providers.
For the general population in Australia:
- alcohol use disorders affect 6.1% of men and 2.7% of women (WHO 2014)
- alcohol use is responsible for 4.5% of the total burden of disease and injury in (AIHW, 2019)
- alcohol use directly or indirectly resulted in over 4,000 deaths/year (ABS, 2018)
- approximately 10% Australians drink at levels that put them at risk of long-term harm (AIHW, 2010)
For the veteran poulation prevalence rates vary across cohorts and studies. For example:
- around one third of veterans are estimated to drink at risky levels (DVA)
- just under half of transitioned ADF members have experienced an alcohol use disorder in their lifetime (DVA, 2018)
- approximately 13% meet criteria for an alcohol use disorder within the last 12 months (DVA, 2018)
- an estimated 43% of Vietnam veterans experience alcohol abuse/dependence in their lifetime (O'Toole et al., 1996).
Screening and assessment
Alcohol dependence is commonly comorbid with other substance use disorders. Therefore, screening measures which assess usage of multiple substances may be useful, for example, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; WHO, 2003).
This is particularly prudent given that polydrug use (Haber et al., 2009) is associated with:
- increased risk of harm
- complex physical health problems
- complex mental health problems
- difficulties with withdrawal
People who consume excessive quantities of alcohol form a high percentage of attendees at:
- general hospitals
- general practice
- community health care centres
- other welfare services
Routine screening for alcohol consumption and associated problems is recommended. The CAGE is a screening instrument designed to identify potential alcohol abuse and dependence:
- Have you ever felt you ought to cut down on your drinking?
- Have people annoyed you by criticising your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Further assessment of alcohol problems is warranted for veterans who answer ‘yes’ to two or more of these questions.
The Alcohol Use Disorders Identification Test (AUDIT) is a freely available standardised assessment. This can be helpful in assessing severity and treatment outcomes. The AUDIT also shows:
- alcohol consumption risk levels
- guidance on the interventions appropriate to each drinking risk level
Withdrawal severity can be assessed using the Clinical Institute Withdrawal Assessment for Alcohol revised scale (CIWA-Ar).
Treatment for alcohol disorders
There are several recommended treatment options:
Interventions should be tailored both to the type of alcohol risk and to suit the veteran’s preparedness to change. Brief interventions have strong evidence for the treatment of mild to moderate alcohol problems and are a recommended approach in Australia (Haber et al., 2009). They range in duration from 5 to 30 minutes, and are typically delivered over one to four sessions.
Components of brief interventions are guided by the FLAGS process outlined below:
- Feedback the results of the alcohol assessment in non-judgemental and non-threatening manner.
- Listen carefully to the client’s reactions and concerns.
- Advise the client about degree of risk and consequences associated with their alcohol intake. Ask the client to outline the benefits and costs of continuing to drink at his or her current level.
- Goals should be set that are realistic and involve a reduction toward low-risk levels of drinking.
- Strategies to reduce consumption to safe limits should be discussed and implemented. The veteran may have already used some strategies with success. Begin with his or her suggestions, then add others, e.g. avoid drinking when in negative mood or tired, count standard drinks, avoid ‘shouts’.
Motivational interviewing (MI)
Motivational interviewing (MI) is recommended for veterans who are unsure, or ambivalent about changing their drinking behaviour. Ambivalence should be acknowledged and normalised. If possible, discrepancies between current drinking behaviour and personal beliefs and goals should be discussed. Questions to ask include:
- “What do you like about drinking? What are the things you don’t like about drinking?”
- After summarising the client’s pros and cons ask, “Where does this leave us now?”
This ‘decisional balance’ technique can assist the veteran:
- to resolve ambivalence about change
- move towards action and behaviour change
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is the treatment of choice for veterans ready to change their drinking behaviour. CBT has some general techniques applicable across a range of disorders. The specific CBT techniques for targeting alcohol use are:
- behavioural self-management - controlled drinking programs teach the veteran strategies to reduce alcohol consumption. This includes goal setting and self-monitoring
- coping skills training - teaches skills such as:
- coping with cravings
- drink refusal - to enable veterans to better cope with situations that are linked to alcohol use
- cue exposure - places veterans in the presence of cues to drinking (e.g. pub, watching sport) while not drinking and allowing the craving to fade
- relapse prevention - this includes:
- identifying internal and external relapse precipitants (e.g. feelings of low mood or fights with their partner)
- identifying available coping skills (such as drink refusal or coping with cravings)
- using the information to minimise the risk of relapse
- behavioural couples therapy - this focuses on drinking behaviour as the problem in the context of the veteran’s relationship and has been shown to be effective
Alcohol and PTSD
Trauma and alcohol-related problems are functionally related. Therefore integrated treatment of veterans with posttraumatic stress disorder (PTSD) and alcohol problems is recommended. Neither abstinence nor reduction in alcohol intake should necessarily be a prerequisite for combined treatment. Veterans can receive integrated treatment for PTSD and alcohol problems provided they:
- are not intoxicated, or
- in withdrawal during treatment sessions
Integrated treatment of PTSD and alcohol problems is challenging and requires cross-training of practitioners across traditionally separate areas of skill and knowledge. Core interventions in PTSD and alcohol treatment should include the following elements to help prepare veterans for trauma-focussed interventions recommended for the treatment of PTSD:
- crisis/safety interventions
- development of coping skills
- arousal /anxiety management techniques
- alcohol self-monitoring/self-management techniques
Psychological treatment setting and duration
Treatment setting and duration will vary depending on severity and risk factors associated with the veteran's drinking behaviour. Delivery of CBT would usually consist of one-hour sessions over 12 weeks (NICE, 2011). Although treatment duration will vary according to the veteran’s needs. Veterans with alcohol dependence or those who are acutely ill or disabled by their alcohol use will require more intensive treatments.
Veterans who are alcohol dependent or otherwise at risk of alcohol withdrawal as identified by the AUDIT should be offered alcohol withdrawal treatment. Irrespective of their intention to reduce or cease alcohol use in the longer term. Long-acting benzodiazepines such as diazepam are the preferred pharmacotherapy for alcohol withdrawal treatment. Ideally they should not be continued beyond the first one to two weeks.
Practitioners should tailor the sedative regimen to the veteran’s individual needs using an alcohol withdrawal scale. Thiamine should also be provided to all veterans undergoing alcohol withdrawal, especially when the alcohol dependence is associated with poor nutrition.
To ensure optimal safety and the likelihood of successful treatment, practitioners should consider:
- the appropriate setting for intervention (inpatient, community-based, home or outpatient)
- likely severity of alcohol withdrawal
Daily review is required when a veteran is undergoing alcohol withdrawal treatment in an outpatient or home basis. Assessing whether transfer to a higher-dependency setting is required.
Pharmacotherapies for reducing alcohol cravings such as acamprosate (e.g. Campral) or naltrexone should be routinely recommended to a veteran being treated for alcohol dependence. This increases the probability of reduced drinking or stopping altogether.
Acamprosate or naltrexone should be prescribed in combination with psychosocial relapse prevention strategies; however, the latter should not be prescribed in those who are currently opioid dependent or those who require opiate-based pain relief. These should be delivered over 3–12 months.
Antabuse has had a role as an aversive deterrent in alcohol misuse disorders and is still occasionally used. Given the range of drug interactions and serious medical adverse reactions associated with its use and the availability of safer therapeutic interventions, we advise that it be used cautiously, if at all, for veterans with more treatment resistant conditions.
The Department of Veterans' Affairs (DVA) and Open Arms – Veterans & Families Counselling offer support for veterans experiencing alcohol and other substance use disorders.
Open Arms counsellors and staff have an understanding of veteran and military culture that assists them to deliver specialised support and care to members of this community.
Veterans commonly present with comorbid disorders and complex needs that require careful treatment planning.