Recognition and management of alcohol misuse in OEF/OIF and other veterans in the VA: A cross-sectional study

doi:10.1016/j.drugalcdep.2009.12.025

Drug and Alcohol Dependence

Volume 109, Issues 1–3, 1 June 2010, Pages 147-153

https://doi.org/10.1016/j.drugalcdep.2009.12.025 Get rights and content

Abstract

Background

Mental health problems have been identified among soldiers serving in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF), but little is known about the prevalence and management of alcohol misuse in OEF/OIF veterans seen in the Veterans Administration health care system (VA).

Methods

We identified 12,092 veterans (n = 2009 women) 55 and younger and screened for alcohol misuse in FY2007 from a cross-sectional national sample of VA outpatients randomly selected for standardized medical record review for quality monitoring. Alcohol misuse was assessed with the Alcohol Use Disorders Identification Test Consumption questions (AUDIT-C ≥5). Based on medical record reviews, brief alcohol interventions (BI) were defined as documented (1) advice to abstain or drink within recommended limits or (2) feedback about health risks associated with drinking.

Results

Adjusted prevalence of alcohol misuse was higher in OEF/OIF men than non-OEF/OIF men [21.8% vs. 10.5%, adjusted odds ratio (AOR) = 2.37 (95% CI: 1.88–2.99)], but did not differ reliably between OEF/OIF and non-OEF/OIF women [4.7% vs. 2.9%, AOR = 1.68 (0.74–3.79)]. Adjusted rates of documented advice or feedback [31.6% vs. 34.6%, AOR = 0.87 (0.58–1.21)] and referral [24.1% vs. 28.9%, AOR = 0.78 (0.47–1.30)] were not significantly different between OEF/OIF and non-OEF/OIF men who screened positive for alcohol misuse.

Conclusion

OEF/OIF men were more likely to screen positive for alcohol misuse than non-OEF/OIF men. Overall, approximately half of those with alcohol misuse had documented BI and/or referral to alcohol treatment suggesting a need for improvement in addressing alcohol misuse in OEF/OIF and other veterans.

Introduction

Initial reports of military personnel serving in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have raised concerns about the high rates of mental health problems identified among these individuals (Hoge et al., 2004). Studies of OEF/OIF veterans using the Veterans Affairs (VA) health care system have raised similar concerns (Seal et al., 2007), but surprisingly little scientific attention has been given to the risk of alcohol misuse in this cohort of veterans.

Alcohol misuse, which includes the spectrum of unhealthy alcohol use from at-risk drinking to alcohol use disorders, is relatively common with estimates as high as 30% in primary care settings (Fiellin et al., 2000, Whitlock et al., 2004). The health consequences associated with excessive alcohol use represent a significant public health problem (Room et al., 2005). Hazardous alcohol consumption has been associated with increased mortality, morbidity and disability (Rehm et al., 2003), and is considered one of the leading causes of mortality in the United States (Mokdad et al., 2000).

Unique characteristics and military service experiences of OEF/OIF veterans potentially place them at increased risk for alcohol misuse. The risk of alcohol misuse is greater among men and individuals younger than 30 (Grant et al., 2004a, Jacobson et al., 2008). Studies of population-based surveys and clinical samples have also supported higher rates of alcohol problems among persons with anxiety, mood, or drug use disorders (Grant et al., 2004b, Jacobsen et al., 2001). In clinical samples, alcohol use disorders are ranked as the most common co-occurring disorders among men with post-traumatic stress disorder (Jacobsen et al., 2001), and a recent report has found an increased risk of new-onset hazardous drinking among OEF/OIF combat veterans (Jacobson et al., 2008).

Brief alcohol interventions (BI) reduce alcohol use and health care-related costs (Fleming et al., 2000, Fleming et al., 2002, Kaner et al., 2007, Solberg et al., 2008, Whitlock et al., 2004). BI consisting only of simple advice to drink within recommended drinking limits and as brief as 5–15 min have been shown effective (WHO Brief Intervention Study Group, 1996). Based on the relative health impact and cost effectiveness of BI, the National Commission on Prevention Priorities ranked BI 3rd among 25 clinical preventive services recommended by the US Preventive Services Task Force for the US adult population, after aspirin for heart disease prevention and tobacco counseling (Solberg et al., 2008). Despite evidence-based support and recommendations from national authorities to screen and treat the spectrum of alcohol use in primary care settings, research suggests only a minority of at-risk drinkers are managed appropriately (Calhoun et al., 2008, D’Amico et al., 2005, Milliken et al., 2007, Rose et al., 2008).

This study was designed to evaluate the recognition and management of alcohol misuse in OEF/OIF veterans enrolled in the VA health care system. First, we estimate the prevalence of documented alcohol misuse and documented rates of brief alcohol interventions, referral to alcohol treatment, and completed referral among OEF/OIF veterans. Second, we compare the prevalence of alcohol misuse and documented rates of brief alcohol interventions, referral to treatment, and completed referral to a contemporary sample of non-OEF/OIF veterans.

Section snippets

Data collection

The VA Office of Quality and Performance (OQP) contracts with an external agency to conduct monthly standardized medical record reviews of outpatient care as part of the External Peer Review Program (EPRP), and uses the data to monitor compliance on national performance measures. Medical record reviews are used to monitor brief alcohol interventions, because there are currently no reliable methods to monitor BI electronically in the VA. A sample of eligible outpatients from each facility is

Study sample

Of 16,366 outpatients randomly selected for medical record review who were 55 or younger and screened for alcohol misuse between October 1, 2006 and September 30, 2007, 12,092 (73.9%) met study criteria. The most common reasons for exclusion of potentially eligible veterans included <30 days between the alcohol screen date and medical record review date (n = 3395) and no documented AUDIT-C score in the medical record (n = 740). Reasons for study exclusion are shown separately for OEF/OIF and

Summary of findings

This study compared a national sample of OEF/OIF veterans engaged in VA care to a sample of non-OEF/OIF veterans also engaged in VA care, with regards to the prevalence of alcohol misuse and rates of documented brief intervention (BI), referral to treatment, and completed referral. The results estimate that among OEF/OIF veterans 55 or younger, the adjusted prevalence rates of alcohol misuse (AUDIT-C score ≥5) for men and women were 23% and 6%, respectively. In gender-specific analyses adjusted

Conclusion

The adjusted risk of alcohol misuse is significantly higher among OEF/OIF men than non-OEF/OIF men who are engaged in care in the VA, even after adjustment for recognized substance use and mental health disorders such as PTSD, with the risk highest among OEF/OIF men under 30. Although the low rates of BI underscore the importance of efforts currently underway in the VA to improve implementation of BI, adjusted analyses indicated that the majority of men in both groups who endorsed severe

Role of funding source

The research reported here was supported by Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. The manuscript was specifically produced with support from the Veteran Affairs’ Substance Use Disorders Quality Enhancement Research Initiative (SUB 98-000). Dr. Kivlahan and Dr. Bradley presently serve as the Clinical Coordinator and Co-Clinical Coordinator of the Substance Use Disorders Quality Enhancement Research Initiative. Supporting

Contributors

All authors contributed to the conceptualization of the manuscript. Dr. Hawkins performed statistical analyses and prepared the first draft of the manuscript. Dr. Kivlahan, Dr. Bradley and Ms. Lapham reviewed and contributed to all subsequent drafts of the manuscript. All authors have approved the final manuscript.

Conflict of interest

All of the authors report no conflict of interest.

Acknowledgements

We thank the VA Office of Quality and Performance for sharing their data for the purpose of this study, and Haili Sun for managing data collection from the VA National Patient Care Database. Preliminary data were presented at the Annual Meeting of the VA Health Services & Research Development, Baltimore, Maryland, 2008.

References (43)

A.G. Ferrier-Auerbach et al.
Predictors of alcohol use prior to deployment in National Guard Soldiers
Addict. Behav.
(2009)
B.F. Grant et al.
The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991–1992 and 2001–2002
Drug Alcohol Depend.
(2004)
R. Room et al.
Alcohol and public health
Lancet
(2005)
D.H. Au et al.
Alcohol screening scores and risk of hospitalizations for GI conditions in men
Alcohol Clin. Exp. Res.
(2007)
T.H. Bien et al.
Brief interventions for alcohol problems: a review
Addiction
(1993)
K.A. Bradley et al.
The relationship between alcohol screening questionnaires and mortality among male VA outpatients
J. Stud. Alcohol
(2001)
K.A. Bradley et al.
Two brief alcohol screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female VA patient population
Arch. Intern. Med.
(2003)
K.A. Bradley et al.
Using alcohol screening results and treatment history to assess the severity of at-risk drinking in VA primary care patients
Alcohol Clin. Exp. Res.
(2004)
K.A. Bradley et al.
AUDIT-C as a brief screen for alcohol misuse in primary care
Alcohol Clin. Exp. Res.
(2007)
K.A. Bradley et al.
Measuring performance of brief alcohol counseling in medical settings: a review of the options and lessons from the Veterans Affairs (VA) health care system
Subst. Abus.
(2007)

M.L. Burman et al.

Alcohol-related advice for VA primary care patients: who gets it, who gives it?

J. Stud. Alcohol

(2004)

K.R. Bush et al.

The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking

Arch. Intern. Med.

(1998)

P.S. Calhoun et al.

Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan

J. Clin. Psychiatry

(2008)

E.J. D’Amico et al.

Identification of and guidance for problem drinking by general medical providers

Med. Care

(2005)

D.A. Dawson et al.

Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population

Alcohol Clin. Exp. Res.

(2005)

F.K. Del Boca et al.

The validity of self-reports of alcohol consumption: state of the science and challenges for research

Addiction

(2003)

F.K. Del Boca et al.

Truth or consequences: the validity of self-report data in health services research on addictions

Addiction

(2000)

G.A. Elvy et al.

Attempted referral as intervention for problem drinking in the general hospital

Br. J. Addict.

(1988)

D.A. Fiellin et al.

Screening for alcohol problems in primary care: a systematic review

Arch. Intern. Med.

(2000)

M.F. Fleming et al.

Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings

Med. Care

(2000)

M.F. Fleming et al.

Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis

Alcohol Clin. Exp. Res.

(2002)

Cited by (84)

Alcohol consumption and dependence risk among male and female Veterans: Trajectories and predictors
2024, Drug and Alcohol Dependence
With few exceptions, previously conducted research on hazardous drinking among Veterans has employed samples in which the majority of participants identify as male. In addition, past studies have solely focused on alcohol consumption, rather than associated risk for dependence. In this study, we expanded upon the extant literature by investigating sex differences in trajectories and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans.
A national sample of 1649 Veterans (50.0% female) were recruited in a five-wave longitudinal study that followed Veterans for up to 16 years after deployment. We used growth curve modeling to investigate trajectories of change in alcohol consumption and dependence risk among men and women Veterans. We examined predictors of growth, including demographics, support and resources, psychiatric symptoms, and trauma exposure.
Among male Veterans, alcohol consumption and dependence risk remained stagnant, which is in contrast to past work using non-Veteran samples. For female Veterans, consumption exhibited initial reductions that decelerated, and dependence risk reduced at a continuous rate. PTSD diagnosis was a significant predictor of individual differences in growth for men. Psychiatric symptoms (i.e., PTSD diagnosis, probable depression diagnosis, suicidal ideation) and psychosocial functioning were significant predictors of decreasing alcohol use for women.
Results highlight important sex differences in patterns and predictors of change in alcohol consumption and dependence risk among post-9/11 Veterans. Findings are discussed in relation to screening for hazardous alcohol use and intervention strategies in this at-risk population.
Development of a mobile mindfulness smartphone app for post-traumatic stress disorder and alcohol use problems for veterans: Beta test results and study protocol for a pilot randomized controlled trial
2023, Contemporary Clinical Trials
Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly prevalent, and co-occurring among post-9/11 veterans. Mobile health (mHealth) applications, specifically those focused on mindfulness-based techniques, may be an effective avenue to intervene with veterans who cannot or will not seek care at traditional in-person settings. Thus, to address areas of improvement in mHealth for veterans, we developed Mind Guide and prepared it for testing in a pilot randomized controlled trial (RCT) with veterans.
We have completed phase 1 (treatment development) and Phase 2 (beta test) of our mobile mHealth app, Mind Guide. In this paper we describe the methods for Phase 1 as well as results for our beta test (n = 16; inclusion criteria included screen for PTSD, AUD, a post-9/11 veteran, and not currently receiving treatment) for Mind Guide as well as outline procedures for our pilot RCT of Mind Guide (Phase 3). The PTSD Checklist, self-reported alcohol use, the Perceived Stress Scale, Penn Alcohol Craving Scale, and the Emotion Regulation Questionnaire were used.
Results of our beta test of Mind Guide show promising past 30 day effects on PTSD (d = −1.12), frequency of alcohol use (d = −0.54), and alcohol problems (d = −0.44), and related mechanisms of craving (d = −0.53), perceived stress (d = −0.88), and emotion regulation (d = −1.22).
Our initial beta-test of Mind Guide shows promise for reducing PTSD and alcohol related problems among veterans. Recruitment is ongoing for our pilot RCT in which 200 veterans will be recruited and followed up for 3 months.
ClinicalTrials.gov Identifier: NCT04769986.
Rates and predictors of brief intervention for women veterans returning from recent wars: Examining gaps in service delivery for unhealthy alcohol use
2021, Journal of Substance Abuse Treatment
Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3–4; =5–7; =8–12), and the role of alcohol risk level and other factors in predicting receipt of BI.
From administrative data (2010–2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not.
While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems.
Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.
Differences in protective factors among U.S. Veterans with posttraumatic stress disorder, alcohol use disorder, and their comorbidity: Results from the National Health and Resilience in Veterans Study
2019, Drug and Alcohol Dependence
Citation Excerpt :
Probable AUD was classified as an AUDIT-C score of ≥ 5 (range = 0–12). This threshold has been utilized in a number of studies of Veteran (Chen et al., 2018; Hawkins et al., 2010) and civilian samples (Dawson et al., 2005, 2012) and found to be optimal for detecting AUD in a representative sample of US adults (Dawson et al., 2005). Cronbach’s α in the study sample was 0.77.
Comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are associated with greater clinical and functional impairments than either disorder alone, including higher rates of suicidality and reduced functioning and quality of life. Although PTSD/AUD is associated with more severe risk factors relative to either disorder alone, it is unclear whether PTSD/AUD and its related impairments are also associated with lower levels of protective factors.
We examined two composite factors of protective qualities derived from exploratory factor analyses—social connectedness (i.e., structural social support, perceived social support, secure attachment style) and protective psychosocial characteristics (i.e., resilience, purpose in life, dispositional optimism and gratitude, and community integration), in a nationally representative sample of U.S. Veterans (using data from the National Health and Resilience in Veterans Study) with PTSD alone, AUD alone, and comorbid PTSD/AUD.
Veterans with PTSD and PTSD/AUD scored significantly lower than those with AUD alone but did not differ from each other on measures of social connectedness and protective psychosocial characteristics (ps < .001). Both factors partially mediated the relationship between diagnostic status (PTSD or PTSD/AUD vs. AUD alone) and suicidal ideation (ORs = 0.58-0.62), as well as between diagnostic status and functioning/quality of life (psychosocial protective characteristics, β = 0.39; social connectedness, β = 0.16). Only protective psychosocial characteristics (OR = 0.54) emerged as a partial mediator between diagnostic status and lifetime suicide attempts.
U.S. Veterans with PTSD and PTSD/AUD score lower on measures of protective factors than Veterans with AUD. These factors may be important targets for prevention and treatment efforts.
Alcohol screening and brief intervention in a representative sample of veterans receiving primary care services
2018, Journal of Substance Abuse Treatment
Unhealthy alcohol use is common among adults, and in particular, Veterans. Routine alcohol screening followed by brief intervention is recommended and considered a prevention priority in primary care settings. While previous studies have found that Veterans enrolled in the Veteran's Health Administration (VA) receive high rates of screening and brief intervention, less than 50% of Veterans receive VA health care. No study has evaluated receipt of these services in a general sample of Veterans. Therefore, in a nationally-representative sample, we examine whether Veteran status was associated with receiving alcohol screening and brief intervention in primary care.
Using the Centers for Disease Control and Prevention's 2014 Behavioral Risk Factor Surveillance System data, we identified adults who endorsed visiting a doctor for routine checkup at least once in the past two years and responded to an optional module assessing alcohol-related care (N = 92,206; 14.1% Veterans). Multivariable logistic regression was used to assess the association between Veteran status and screening and brief intervention outcomes. We also evaluate differences in alcohol-related care across Veteran status stratified by gender. Models were adjusted for sociodemographic and clinical characteristics likely to confound the association.
Overall, Veterans were more likely than non-Veterans to be screened for alcohol quantity and heavy episodic drinking (ps < 0.05), and more likely to endorse receiving brief intervention advice about alcohol's harmful effects (p < .001). Veteran status predicted an increased likelihood of being screened and receipt of advice about alcohol's harmful effects, but did not predict the likelihood of receiving advice to reduce or abstain from drinking (AOR = 1.00, 95% C.I. [0.80–1.26]). Analyses stratified by gender indicated a similar pattern of results for males as the overall sample. Results among females indicated Veteran status predicted the likelihood of being asked about heavy episodic drinking (AOR = 1.47, 95% C.I. [1.09–1.99]) and being offered advice about the harmful effects of alcohol (AOR = 1.62, 95% C.I. [1.06–2.48]). Female Veterans were not more likely than female non-Veterans to be advised to reduce and/or abstain from drinking.
Screening about any alcohol use was common while report of screening for quantity and heavy episodic drinking occurrence and report of brief intervention were less common. Veterans were more likely than non-Veterans to report receiving recommended care, though rates of advice to reduce or abstain from drinking did not differ across groups. Persistent gaps in delivery of recommended alcohol-related care, especially for particularly vulnerable subpopulations such as women Veterans, suggest a need for quality improvement.
A psychometric evaluation of the Protective Behavioral Strategies Scale-20 among internet samples of adult drinkers
2018, Addictive Behaviors Reports
Citation Excerpt :
Second, the sample in the Cadigan et al. study was a sample of military veterans. Military veterans are more likely to be at-risk drinkers than the general adult population (e.g., Hawkins, Lapham, Kivlahan, & Bradley, 2010) and thus military veterans' PBS use may be inherently different than the general adult population. Third, Cadigan et al. (2015) used the PBSS and improvements have since been made to the Serious Harm Reduction subscale in the PBSS-20.
Protective behavioral strategies (PBS) are most commonly defined as behaviors that are used while drinking to reduce alcohol use and/or limit alcohol-related problems. Few studies have examined and quantified PBS use among non-college student populations. The purpose of the present two studies was to evaluate the psychometric properties of the Protective Behavioral Strategies Scale-20 (PBSS-20; Treloar, Martens, & McCarthy, 2015) among internet samples of adult drinkers. In the first study, we conducted an exploratory factor analysis of the PBSS-20 with a sample (n = 360) of adult drinkers who were recruited from Mechanical Turk. We then conducted a second study that recruited adult drinkers from Mechanical Turk and randomly split the data in half. With the first split-half sample (n = 339), we conducted a confirmatory factor analysis of the PBSS-20 and assessed the internal consistency and concurrent validity of the subscales. With the second split-half sample (n = 338), we tested measurement invariance across gender. The results support a three-factor structure of the PBSS-20 that is similar to what has been found among college students. However, six items were dropped and two Serious Harm Reduction items loaded best onto the Manner of Drinking factor. Furthermore, two subscales demonstrated adequate internal consistency and all three subscale were negatively associated with alcohol-related outcomes. Similar to college students, there was lack of measurement invariance across gender. We discuss the implications of the present findings in extending research on PBS to the more general population of U.S. adult drinkers.

View all citing articles on Scopus

View full text

Published by Elsevier Ireland Ltd.

Recognition and management of alcohol misuse in OEF/OIF and other veterans in the VA: A cross-sectional study

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Data collection

Study sample

Summary of findings

Conclusion

Role of funding source

Contributors

Conflict of interest

Acknowledgements

Addict. Behav.

Drug Alcohol Depend.

Lancet

Alcohol screening scores and risk of hospitalizations for GI conditions in men

Alcohol Clin. Exp. Res.

Brief interventions for alcohol problems: a review

Addiction

The relationship between alcohol screening questionnaires and mortality among male VA outpatients

J. Stud. Alcohol

Two brief alcohol screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female VA patient population

Arch. Intern. Med.

Using alcohol screening results and treatment history to assess the severity of at-risk drinking in VA primary care patients

Alcohol Clin. Exp. Res.

AUDIT-C as a brief screen for alcohol misuse in primary care

Alcohol Clin. Exp. Res.

Measuring performance of brief alcohol counseling in medical settings: a review of the options and lessons from the Veterans Affairs (VA) health care system

Subst. Abus.

Alcohol-related advice for VA primary care patients: who gets it, who gives it?

J. Stud. Alcohol

The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking

Arch. Intern. Med.

Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan

J. Clin. Psychiatry

Identification of and guidance for problem drinking by general medical providers

Med. Care

Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population

Alcohol Clin. Exp. Res.

The validity of self-reports of alcohol consumption: state of the science and challenges for research

Addiction

Truth or consequences: the validity of self-report data in health services research on addictions

Addiction

Attempted referral as intervention for problem drinking in the general hospital

Br. J. Addict.

Screening for alcohol problems in primary care: a systematic review

Arch. Intern. Med.

Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings

Med. Care

Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis

Alcohol Clin. Exp. Res.