Note: This content is derived from the 2021 VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders. For the latest clinical practice guideline for this condition, visit https://www.healthquality.va.gov/HEALTHQUALITY/index.asp.
In the military, alcohol misuse can impact mission readiness and productivity, as well as service members’ physical and mental health. The Department of Defense regularly tracks alcohol use in the military. Findings from the 2018 Department of Defense Health Related Behaviors Survey of Active Duty Military Personnel indicated that 34 percent of service members were engaged in binge drinking (consuming five or more drinks on the same occasion for men and four or more drinks on the same occasion for women), 9.8 percent drank heavily (binge drinking on at least one or two days a week), and 6.2 percent experienced one or more serious consequences from drinking. The percentage of both binge drinking and heavy drinking was highest in the Marine Corps, and lowest in the Air Force.
The 2021 VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders provides guidance relating to screening for alcohol misuse and recommended treatment options. Providers should also stay apprised of the latest DOD policy guidance on substance misuse. The Psychological Health Center of Excellence has created substance use disorder clinical support tools for providers, patients, and families based on the guidance in the clinical practice guideline.
Screening for Alcohol Misuse
According to the 2021 VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders, screening should be conducted periodically for patients in general medical and mental healthcare settings using the three-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) or Single Item Alcohol Screening Questionnaire (SASQ).
- The AUDIT-C was developed by the World Health Organization. It is a brief alcohol screen that can help identify patients who engage in hazardous drinking or have active alcohol use disorders.
- The SASQ is a single-item screen that is often easier to integrate into clinical interviews as primary care providers may be unlikely to recall response options and scoring for the AUDIT-C.
A Positive Screen
A screening for unhealthy alcohol use is considered positive if an individual obtains:
- An AUDIT-C score of greater than or equal to five points.
- A positive score on the SASQ (if individuals report drinking four or more drinks on an occasion (women) or five or more drinks (men) on an occasion in the past year).
Patients without documented alcohol use disorder who screen positive for unhealthy alcohol use should be provided a single initial brief intervention regarding alcohol-related risks and advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly consumption.
Screening, Brief Intervention, and Referral to Treatment
SAMHSA’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for individuals with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers and other community settings provide opportunities for early intervention with people at risk for substance misuse before more severe consequences occur.
The SBIRT process consists of the following elements:
Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.
Co-occurring Disorders with Alcohol Misuse
Some individuals with alcohol misuse have co-occurring psychosocial problems that affect their likelihood of establishing and maintaining good clinical outcomes and improved functional status; therefore, it is best to provide integrated care for all conditions in a single setting when possible, and if not, managed collaboratively. Several mental health conditions, such as bipolar disorders, schizophrenia, and antisocial personality disorder are associated with increased rate of alcohol use disorder. Anxiety and depressive disorders may also correlate with alcohol use disorder.
Individuals with alcohol and substance use disorders may also have co-occurring physical conditions. Drinking alcohol at levels above weekly or daily limits can damage the heart, interfere with brain communication pathways, lead to liver inflammation and other liver problems, weaken the immune system, and increase the risk of developing mouth, throat, esophagus, liver and breast cancer, according to the NIH's National Institute on Alcohol Abuse and Alcoholism.
Treatment for Alcohol Misuse
According to the 2021 VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders , patients who screen positive for unhealthy alcohol use, but do not have a diagnosed alcohol use disorder (AUD), should be provided a single initial brief intervention regarding alcohol-related risks and the advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly alcohol consumption.
Overall Treatment Considerations
Department of Defense Instruction 1010.04 Problematic Substance Use and Gambling Disorder outlines procedures for problematic substance use and gambling disorder prevention, identification, diagnosis, and treatment for DOW military personnel, eligible beneficiaries of the MHS, and DOW civilian personnel. Providers within the Defense Health Agency should consult DOD Instruction 1010.04, other relevant-DOD policies, and individual service level policies for overall guidance and procedural requirements. Further, providers should consult the evidence-based treatment recommendations in the VA/DOD substance use disorder clinical practice guideline along with individual patient needs and characteristics, to include patient preferences and provider competencies, when making treatment decisions.
Per the clinical practice guideline, providers should offer referral for specialty AUD care for patients if they are diagnosed with an AUD that may benefit from additional evaluation of their alcohol use and related problems, or are willing to engage in specialty care. There are many factors that help to determine the appropriate level of care for AUD treatment, such as patient preference, patient motivation, patient willingness, and available resources. There is no clear evidence to support using a standardized assessment to determine initial intensity and setting of AUD care rather than the clinical judgment of trained providers.
For patients with AUD in early recovery or following relapse, providers should promote active involvement in group mutual help programs using a systematic approach such as peer linkage, network support, or 12-step facilitation. Patients in intensive outpatient or residential treatment should be offered ongoing systematic relapse prevention efforts or recovery support individualized on the basis of treatment response. Patients who do not respond to treatment or relapse should not be automatically discharged from treatment.
Recommended Treatment Options
Psychosocial interventions and pharmacotherapy treatment options are recommended for patients with alcohol use disorders. Providers should consider patient preference as well as their own competencies when selecting which intervention to offer.
Psychosocial Interventions
The following psychosocial interventions are recommended per the VA/DOD substance use disorders clinical practice guideline.
- Cognitive behavioral therapy focuses on teaching patients to modify both thinking and behavior related to alcohol use, as well as to change other areas of life functionally related to alcohol use. Treatment incorporates techniques such as structured practice outside of session, including scheduled activities, self-monitoring, thought recording and challenging, and interpersonal skills practice.
- Community reinforcement approach is a comprehensive cognitive-behavioral intervention that focuses on environmental contingencies that impact and influence a patient’s behavior through increasing positive reinforcement, learning new coping behaviors, and involving significant others in the recovery process.
- Motivational enhancement therapy uses principles of motivational interviewing to heighten awareness of ambivalence about change, promote commitment to change, and enhance self-efficacy through a structured intervention based on systematic assessment with personalized feedback.
- 12-step Facilitation aims to increase the patient’s active involvement in Alcoholics Anonymous or other 12-step-based group mutual help resources delivered as 12 sessions of individual therapy in which a provider encourages engagement with AA and walks a patient through the first steps of AA.
- Behavioral couples therapy focuses both on reducing alcohol use in the identified patient and on improving overall marital satisfaction for both partners using a series of behavioral assignments to increase positive feelings, shared activities, and constructive communication.
Pharmacotherapy
For patients with moderate to severe alcohol use disorder, there are several pharmacotherapy treatments recommended, to include the following medications:
- Acamprosate
- Disulfiram
- Naltrexone — oral or extended release
- Topiramate
For patients for whom first-line pharmacotherapy is inappropriate or ineffective, there is some evidence to support offering gabapentin as an alternative pharmacotherapy. For more information regarding pharmacotherapy, refer to the VA/DOD substance use disorders clinical practice guideline or consult with a medical provider.
Medications for the Treatment of Alcohol Use Disorder is a brochure that can be provided to patients to explain alcohol use disorder and recommended treatments.
DOD Policy Guidance on Substance Misuse
- DODI 1010.04 Problematic Substance Use and Gambling Disorder — Establishes policies, assigns responsibilities, and prescribes procedures for problematic substance use and gambling disorder prevention, identification, diagnosis, and treatment for DOW military personnel, eligible beneficiaries of the MHS, and DOW civilian personnel
Programs
Mental Health Care
Service-specific Guidance
Air Force
Army
- AR 600-85 The Army Substance Abuse Program — Governs the Army Substance Abuse Program and identifies Army policy on alcohol and other drug abuse, and identifies assigned responsibilities for implementing the program
Coast Guard
- M1000.4 Military Separations — This Commandant Change Notice publishes a change to Military Separations, COMDTINST M1000.4C
- M1000.10B Military Substance Abuse and Behavioral Addiction Program — This Manual establishes Coast Guard policy concerning administration of military drug and alcohol policies. It also establishes performance and discipline standards for drug and alcohol incidents and provides standards by which these incidents will be properly adjudicated.
- Commandant Instructions 6200.1E CG Health Promotion Manual — This Manual establishes policy, assigns responsibilities, and provides guidelines regarding physical fitness, nutrition, stress management, weight management, health risk reduction, substance abuse prevention, and unit health promotion program planning. It clarifies the roles and responsibilities of Commandant (CG-1111), the Health, Safety, and Work-Life Service Center, Substance Abuse Prevention Specialists, the Substance Abuse Prevention Program Supervisor, Command Drug and Alcohol Representatives, Culinary Specialists, and Health Services personnel
- M6320.5 CG Substance Abuse Prevention and Treatment — This Manual establishes policy, assigns responsibilities, and provides guidelines on substance abuse prevention, treatment, and unit health promotion program planning. It clarifies the roles and responsibilities of Commandant (CG-1111), the Health, Safety, and Work-Life Service Center, Substance Abuse Prevention Specialists, the Substance Abuse Prevention Program Supervisor, Command Drug and Alcohol Representatives, and Health Services personnel.
Marine Corps
Navy