Treating alcohol and substance misuse
Substance use disorders represent a significant mental health problem, affecting around one quarter of Australians over their lifetime (Australian Bureau of Statistics, 2007).
About substance use disorders
Tobacco and alcohol are the most commonly used substances that cause veterans harm. However, prescription medication and illicit substance misuse also have a significant impact. Given the cohort of younger veterans returning from recent conflicts and peacekeeping operations, it is worth keeping in mind that substance use disorders are particularly common in those aged under 35 years.
Substance misuse may be a primary problem or it may be symptomatic of other mental health problems affecting the veteran. Veterans may begin to use substances to reduce anxiety and insomnia (e.g. alcohol) or improve dysphoric states (e.g. stimulants or opiates). Veterans often find the concept of ‘self-medication’ a useful, non-judgemental way of understanding their substance misuse. Nevertheless, both short-term and long-term harm associated with substance misuse is often profound. It is common for veterans to present with comorbid problems such as depression, anxiety, PTSD and substance misuse disorders. The presence of substance misuse is often a prominent barrier to engagement in and response to the treatment of other conditions.
Substance misuse amongst veterans
Prevalence rates of substance use disorders vary across the different veteran populations. For example:
- Around one third of veterans are estimated to drink at risky levels (Department of Veterans' Affairs), while approximately one in ten Australians drink at levels that put them at risk of long-term harm (Australian Institute of Health and Welfare, 2010).
- Alcohol abuse/dependence is the most prevalent disorder amongst Vietnam veterans, with a lifetime prevalence rate of 43 per cent. Close to three per cent experience substance use problems in their lifetime (O'Toole et al., 1996).
- Four per cent of first Gulf War veterans experienced alcohol abuse/dependence and less than one per cent drug abuse/dependence over a 12-month period (Ikin et al., 2004).
- The 2010 Australian Defence Force (ADF) prevalence study found a 36 per cent lifetime prevalence of alcohol use disorder amongst currently serving ADF members (Hodson, McFarlane, Van Hooff, & Davies, 2011).
- In 2010, 15 per cent of Australians over the age of 14 were daily smokers, down from 24 per cent in 1991 (Australian Institute of Health and Welfare, 2011). There is some evidence to suggest that smoking is more prevalent among veterans than in the general community, particularly among younger veterans, although rates differ across the three branches of military service, and across different deployments (Barton et al., 2010). As in the general population, smoking rates appear to be on the decline among veterans.
- The growing rate of misuse of prescription medication, particularly pain medication, among veterans may be reflective of a general increase in prescription medication abuse in the community. Use of illicit drugs is also relatively common, with around one third of Australians using illicit drugs at some point in their lives (Australian Institute of Health and Welfare, 2011).
- The rate of cannabis use in veterans, including Vietnam veterans, is often underestimated by practitioners. Cannabis is the most commonly used illicit substance in the general population, followed by ecstasy, amphetamines and cocaine (Australian Institute of Health and Welfare, 2011).
A harm minimisation (or harm reduction) framework informs the treatment of most substance use problems and is the basis of the National Drug Strategy. This approach focuses on reducing the health and lifestyle related harms of continued substance misuse. For example, a harm minimisation approach to a person injecting heroin may involve referral to a safe injecting house to reduce the health harms associated with injecting, as well as receiving education and pharmacological treatment. This framework is not recommended for smoking.
Screening and assessment
People who consume excessive quantities of alcohol form a high percentage of attendees at general hospitals, general practice, community health care centres and 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 and can be helpful in assessing severity and treatment outcomes. The AUDIT also shows alcohol consumption risk levels and provides 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).
Assessing mental health provides an opportunity to assess and address smoking, and for the person to consider changes in their smoking habits. The following questions from the Royal Australian College of General Practitioner guidelines (2011) can be used to identify the veteran's level of motivation to cease smoking:
- How do you feel about your smoking at the moment?
- Are you ready to stop smoking now?
The Smoking Cessation Framework can be used as a guide to further assess the veteran's smoking history, past quit attempts, and readiness for change. Most smokers will shift across stages of readiness, from not thinking about quitting, contemplation, planning, taking action to stop smoking, and reconsideration following relapses.
If the veteran is considering quitting, it is important to assess his or her level of nicotine dependence, as this will predict withdrawal and inform treatment planning. Signs of nicotine dependence include smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and history of withdrawal symptoms in previous quit attempts. A useful tool is the Fagerstrom Test for Nicotine Dependence.
Illicit and prescribed substances
The CAGE questions adapted to include drugs (CAGE-AID) is a screening instrument designed to identify potential substance abuse and dependence, and asks the following questions. When thinking about drug use, including illegal drug use and the use of prescription drugs other than as prescribed:
- Have you ever felt you ought to cut down on your drug use?
- Have people annoyed you by criticising your drug use?
- Have you ever felt bad or guilty about your drug use?
- Have you ever used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Veterans who answer ‘yes’ to two or more of these questions should be assessed further for substance use problems.
The Drug Abuse Screening Test (DAST-20) can assist in assessing the severity of the veteran’s substance use problem.
Comorbid mental health problems are common with veterans who misuse illicit or prescription drugs. Depression, alcohol abuse, anxiety and PTSD commonly co-occur with substance abuse. Also, substance use and suicidal thoughts or behaviour are often related. Therefore, where substance use problems are present, screening for risk of harm to self or others is recommended. Assessment of injecting behaviour to determine health risks is also advised.
Open Arms clinicians can access screening tools from our clinical practice software, VERA online.
Treatment for alcohol disorders
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, Lintzeris, Proude, & Lopatko, 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) 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, and move towards action and behaviour change. Cognitive behavioural therapy (CBT) is the treatment of choice for veterans ready to change their drinking behaviour. Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting alcohol use are:
- Behavioural self-management (i.e. controlled drinking programs) – this teaches the veteran strategies to reduce alcohol consumption, such as goal setting and self-monitoring.
- Coping skills training – this teaches skills such as assertiveness, coping with cravings, and drink refusal to enable veterans to better cope with situations that are linked to alcohol use.
- Cue exposure – this type of exposure places veterans in the presence of cues to drinking (e.g. pub, watching sport) whilst 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), and using the information to minimise the risk of relapse.
Behavioural couples therapy has been shown to be effective and focuses on drinking behaviour as the problem in the context of the veteran’s relationship.
Alcohol and PTSD
As trauma and alcohol-related problems are functionally related, 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 (National Institute for Health and Care Excellence, 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, whether or not they intend to reduce or cease their use of alcohol in the longer term. Long-acting benzodiazepines such as diazepam are the preferred pharmacotherapy for alcohol withdrawal treatment, but ideally 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) and the likely severity of alcohol withdrawal. When veterans are undergoing alcohol withdrawal treatment on an outpatient or home basis, they should be reviewed daily by their practitioner to assess whether transfer to a higher-dependency setting is indicated.
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, to increase the probability of reduced drinking or stopping altogether. Acamprosate or naltrexone should be prescribed in combination with psychosocial relapse prevention strategies. 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
Treatment of smoking
As smoking is a major contributor to premature death and illness, veterans should be encouraged to quit by their mental health practitioner, even when they may not be principally presenting for that problem. It is also important to incorporate smoking cessation in a veteran’s overall treatment, as continued smoking is likely to contribute to poor mental health through raised anxiety, sleep disturbance, irritability and labile mood. However, there is evidence to suggest that repeatedly advising smokers to quit can damage the practitioner-client relationship, so it is important to develop strong rapport and ask permission before discussing the veteran’s smoking.
The interventions used for helping veterans to quit smoking will vary on the veteran's assessed readiness to quit. However, for all veterans who smoke, including those who are not ready to quit, providing advice and support is recommended. For veterans who are thinking about quitting, are unsure about quitting, or are ready to quit, a combination of pharmacotherapy, provision of self-management resources, as well as brief counselling are recommended.
Psychological interventions should be adjusted according to the veteran’s motivation to change.
- Not ready to quit – Veterans who are not ready to quit do not require formal psychological intervention, but should be provided with education on the benefits of quitting and the effects of passive smoking, and followed up with later.
- Unsure about quitting – Motivational interviewing can help to resolve ambivalence about smoking and prepare the veteran for change. Ambivalence should be acknowledged and discrepancies between the veteran’s smoking behaviour and personal beliefs and goals should be discussed. Questions to ask include:
- “What do you like about smoking? What are the things you don’t like about smoking?”
- 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, and move towards action and behaviour change. Motivational interviewing can also help resolve ambivalence about alcohol and other unhelpful behaviours such as problem gambling.
- Ready to quit – Individual or group counselling that uses cognitive behavioural therapy-based strategies is recommended for veterans who are ready to quit smoking. Key components of treatment include:
- Assistance to identify high-risk smoking situations, and develop problem-solving strategies to deal with those situations.
- Strategies and skills to cope with cravings, for example ‘The 4Ds’ (delay, deep breathe, drink water, do something).
- Encouragement for the veteran to utilise his or her social supports, e.g. family, friends and/or other veterans.
Psychoeducation and self-management strategies
Veterans who are considering quitting or are ready to quit may benefit from the following advice and information before undergoing targeted treatment. Encourage the veteran to:
- Discuss the impact of smoking, and provide information about harms related to smoking.
- Go through reading material on how to quit smoking, and the health consequences of smoking (available from http://www.quitnow.gov.au/ and the relevant state-based ‘Quit’ website).
- Select a quit date, ideally within the next two weeks. Arrange follow-up appointments about one week and one month after quit date.
- Use the Quitline services (13 7848).
- Utilise his or her social supports, e.g. family, friends and/or other veterans.
Pharmacological interventions are central to effective smoking cessation treatments, especially for veterans smoking more than 10 cigarettes each day. Treatment usually lasts between 7 and 12 weeks. Slow-release nicotine replacement therapy (NRT) by means of a transdermal patch is the preferred pharmacological intervention, as quick-release preparations such as gum or lozenges can contribute to nicotine dependence. The sustained mode of release also counters a withdrawal syndrome. Over time, NRT is reduced at a gradual rate that the person finds tolerable without resuming smoking.
Veterans experiencing episodic cravings may benefit from a ‘top-up dose’ of quick-release NRT, but should be monitored to ensure that use does not become habitual. Note that resumption of smoking at the same time as using NRT may lead to nicotine toxicity with harmful effects on physical and mental health.
In cases of severe nicotine dependence or a history of failure of cessation with slow-release NRT, bupropion (e.g. Zyban) or varenicline (e.g. Champix) may be added to slow-release NRT to reduce cravings and increase treatment effectiveness.
Treatment of illicit and prescribed substances
Talking to a veteran, together with the veteran’s family, about his or her substance use is the start of treatment. A number of psychological interventions have been found to be effective in the treatment of substance use disorders. The choice of treatment will depend on the substance being used, the severity of dependence, and veteran and practitioner preferences. Recommended treatments include:
- Motivational interviewing (MI) – Veterans with problematic or risky substance use, or those who are unsure or ambivalent about changing their substance use behaviour, may benefit from MI. Ambivalence should be acknowledged and normalised. Thisay involve providing the veteran with information about reducing the risks associated with substance use, normalising ambivalence, and discussing discrepancies between current substance use behaviour and personal beliefs and goals. Questions to ask include:
- “What do you like about your substance use? What are the things you don’t like about it?”
- After summarising the pros and cons about substance use identified by the veteran, ask about his or her intention to change in a non-directive manner (e.g. “Where does this leave us now?”).
This 'decisional balance' technique can assist the veteran to resolve ambivalence about change, and move towards action and behaviour change.
- Cognitive behavioural therapy (CBT) – Some evidence suggests that CBT can be particularly effective. Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting substance use are:
- Behavioural self-management – This teaches the veteran strategies to reduce drug use such as self-monitoring and identifying high risk situations.
- Coping skills training – This training includes skills such as assertiveness and coping with cravings, to enable veterans to cope better with situations that are linked to drug use.
- Cue exposure – This exposure approach places veteran in the pre, drug paraphernalia, other people using drugs) whilst not using and observing the craving fade.
- Behavioural couples therapy (BCT) and family therapy (FT) – This approach recognises that family members often play a crucial role in the origin and maintenance of addictive behaviour. BCT and FT have demonstrated effectiveness in treating substance use problems, however there is limited research to identify which drugs these therapies are particularly effective for. Key aims of BCT and FT include:
- eliminating drug abuse
- engaging the family’s support for the client’s efforts to change their behaviour
- restructuring patterns of couple and family interactions in ways conducive to long-term, stable abstinence.
CBT treatment elements for cannabis dependence
There is emerging evidence that CBT is an effective treatment for cannabis dependence, especially when used with motivational enhancement techniques (Buckner & Carroll, 2010; McRae, Budney, & Brady, 2003). Specific CBT techniques for targeting cannabis use are:
- Identifying and learning about external (others using, cravings, relationships) and internal triggers (negative emotional states, unpleasant thoughts).
- Developing problem-solving skills to manage triggers such as drug refusal, coping with craving, avoiding 'high risk' environments, and managing relationships.
- Developing cognitive strategies such as recognising automatic thoughts and thought management.
- Developing assertiveness and refusal skills.
- Managing negative mood states with, for example, relaxation exercises.
Contingency management and twelve-step programs
- Contingency management and twelve-step programs are other approaches used for substance use disorders. However, each has its limitations.
- Contingency management (CM) involves the use of incentives, such as vouchers and prizes, to encourage reduced substance use. Evidence indicates that CM is effective for promoting abstinence during and after treatment for a wide range of substance use disorders (Prendergast, Podus, Finney, Greenwell, & Roll, 2006). However, this approach is not widely used because it is resource and labour intensive, so may be best suited to settings such as forensic monitoring and treatment.
- Twelve-step programs, such as Alcoholics Anonymous and Narcotics Anonymous, are peer-based group programs aimed to help members achieve and maintain abstinence. Alcoholics Anonymous is readily available and cost effective, and there is sufficient, but not strong, evidence to suggest that long-term participation can be effective for some people (Australian Government Department of Health and Ageing, 2009).
Psychological treatment setting and duration
Psychological interventions may be delivered in either an individual or a group format, with the duration of treatment tailored to the veteran’s needs. The choice of treatment setting will depend on the severity of the veteran’s substance use problem. Residential programs or therapeutic communities (TC) may be considered for severe dependency, polysubstance use and significant comorbid issues. There is, however, limited evidence for the long-term benefits of these programs and their capacity to prevent relapse following treatment completion.
Pharmacological treatment of a substance use disorder will depend on the substance being used and whether the overall goal of pharmacotherapy is replacement/substitution or symptom management. Appropriate pharmacotherapy for the mental health consequences of long-term substance misuse is likely to have advantages in preventing relapse behaviour. An example of this type of intervention is treating depression and anxiety following psycho-stimulant cessation with selective serotonin reuptake inhibitors (SSRIs).
In general, substitution pharmacotherapy is more likely to be suitable for veterans misusing opioids, (including illicit drugs such as heroin, and prescription analgesics such as OxyContin), and for those misusing minor tranquilisers such benzodiazepines. A number of options for the pharmacological management of dependence on other drugs (e.g. cannabis, cocaine) are currently being investigated. However, at present there is insufficient evidence to support recommendations on which regimens are likely to be the most effective. Therefore, we will focus here on the treatment of opioid dependence.
Physical withdrawal from opioids can be managed by methadone or buprenorphine, with some evidence suggesting that the latter is associated with briefer periods of withdrawal. Both these medications can be used as long-term maintenance (opiate substitution) pharmacotherapy. Naltrexone can assist in the treatment of opioid dependence (particularly relapse prevention) by blocking the euphoric effects of opioids, thereby removing the ‘reward’ of drug use. Buprenorphine (a partial opiate agonist) has a similar effect, and also acts as a disincentive to opiate use. Note however that veterans must be assessed for recency of opiate use before commencing naltrexone or buprenorphine treatment.
Where pharmacotherapy is considered necessary for the treatment of substance use, it should be adjunctive to, or followed by one or more of the psychological interventions described above in order to maximise the likelihood of full recovery. For example, while pharmacotherapy may treat the veteran’s physical dependence on the drug or concomitant mood disorders, it is unlikely to address broader psychosocial issues surrounding the veteran’s drug use, such as diminished problem solving skills, relationship breakdown, unemployment, or engagement in criminal activity. In the case of naltrexone, the treatment itself has no beneficial effect on the user’s mood, and so there is no immediate incentive to engage. Therefore, concurrent psychological intervention is particularly important in maintaining treatment compliance.
Clinical judgement is essential in determining whether a withdrawal plan is necessary, as a diagnosis of substance abuse or dependence will not necessarily require a withdrawal management plan. For example, users of substances with lower levels of physical dependence, such as cannabis, are unlikely to require a withdrawal management plan.
Withdrawal management may be conducted in home-based, community residential, or inpatient hospital settings; the choice of setting will be determined by the predicted severity of (or potential medical complications associated with) withdrawal. Where possible, participation in community-based withdrawal programs is recommended as these provide the veteran with ongoing professional support and advice while allowing him or her to begin practicing coping skills and other withdrawal management strategies in everyday life. Inpatient withdrawal programs may be required for polysubstance users or veterans with significant medical, psychiatric, or social problems that will make it difficult to engage in community-based programs.
Pharmacotherapy may have a particular role to play in managing the physical withdrawal from the substance of dependence, but should be considered as part of an overall treatment plan for the veteran’s substance dependence, including both pharmacological and psychological interventions. In developing treatment plans, all stages of treatment should be considered and the continued involvement of the primary practitioner established. This allows a smooth transition from withdrawal to the maintenance phases of treatment and increases the likelihood of recovery. Research shows that clients who participate in withdrawal programs without a post-withdrawal plan are more likely to return to pre-withdrawal levels of substance use.
- Open Arms - Veterans & Families Counselling is available 24 hours on 1800 011 046.
- Psychiatrist: for specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists online.
- A treatment plan should be developed collaboratively with the veteran and his or her family, and coordinated across service providers.
- Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans.
- Given the central role of pharmacological interventions in smoking cessation, veterans should be encouraged to stay in regular contact with their GP or pharmacist.
- Guidelines for the treatment of alcohol problems (2009)
- Supporting Smoking Cessation: A Guide for Health Professionals (2011)
- Cochrane reviews of tabacco addiction
- Management of cannabis use disorder and related issues: A clinician’s guide (2009)
- Ministerial Drug and Alcohol Forum (MDAF)
- The Right Mix website
- Department of Health drinking guidelines and self-management strategies
- The Quit website
- Quitline (13 78 48)
- Australian Drug Foundation
- National Cannabis Prevention and Information Centre
A panel of community-based providers assist in treating alcohol and other substance use disorders.
Alcohol use is so common in Australia that alcohol misuse is often the subject of jokes. This masks the seriousness of the problem. Slight changes to alcohol use can significantly improve your health and wellbeing.
The sooner you quit smoking, the better. Even smokers who quit at 60 can reduce their chance of getting cancer and other diseases.