Substance use

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Diagnosis and prevalence

Alcohol and substance use disorders are significant mental health problems, affecting around one quarter of Australians over their lifetime. Tobacco and alcohol are the most commonly used substances that cause veterans harm. Given the cohort of younger veterans, it is important to note that substance use disorders are particularly common in people under 35 years. For more information on Australian veteran prevalence rates see Ikin et al. (2004) (PDF) and O’Toole et al. (1996) (PDF).

Alcohol

  • Alcohol misuse is associated with short-term harms such as accidental injury. It also has significant long-term health risks such as elevated blood pressure, liver problems, sleep difficulties, mood and anxiety problems and cognitive impairment.
  • Alcohol is a significant issue amongst veterans with about 3 in 10 drinking at risky levels.

Prevalence rates of substance use disorders vary across the different veteran populations:

  • Alcohol abuse/dependence is the most prevalent disorder amongst Australian Vietnam veterans, with a lifetime prevalence rate of 43%.  Review full article by O'Toole et al. (1996) (PDF)  .
  • About 4% of Australian veterans of the first Gulf War experienced alcohol abuse/dependence over a 12-month period.  Review full article by Ikin et al. (2004) (PDF) .
  • The 2010 Australian Defence Force (ADF) prevalence study found a 36% lifetime prevalence of alcohol use disorder amongst currently serving ADF members.  Review report by McFarlane, Hodson, Van Hooff, & Davies (2011)  (PDF) .

Other substances

  • Around one third of Australians use illicit drugs at some point in their lives.  Cannabis is the most commonly used, followed by ecstasy, amphetamines and cocaine. Misuse of prescription medication, especially pain medication, appears to be a growing problem amongst veterans.
  • Close to 3% of Australian Vietnam veterans experience other substance use problems in their lifetime.  Review full article by O'Toole et al. (1996) (PDF) .
  • Less than 1% of Australian veterans of the first Gulf War experienced drug abuse/dependence over a 12-month period.  Review full article by Ikin et al. (2004) (PDF) .
  • Co-morbid mental health problems are common, particularly depression, alcohol abuse, anxiety and PTSD.

Treatment information

Recommended treatments for alcohol use disorders

Cognitive behavioural therapy (CBT) and motivational interviewing (MI) are effective psychological interventions for reducing alcohol use. Brief interventions that include simple feedback about use, advice and goal setting are also effective.

A useful Australian resource is the Quick Reference Guide to the Treatment of Alcohol Problems.

Pharmacotherapy should be considered for all alcohol-dependent veterans following detoxification.

Recommended treatments for other substance use disorders

  • Recommended psychological treatments include motivational interviewing (MI), cognitive behavioural therapy (CBT) and behavioural couple’s therapy and family therapy.
  • To find out more about managing cannabis use disorder refer to the NCPIC Clinician’s Guide.
  • When withdrawal management is delivered, it should be considered as part of an overall management plan to prevent relapse.
 

The key components of CBT for the treatment of substance use disorders include:

  • Behavioural self-management (e.g., controlled drinking programs): this teaches the veteran strategies to reduce alcohol and drug use such as goal setting, self-monitoring and identifying high risk situations.
  • Coping skills training: this includes skills such as assertiveness, coping with cravings, and drink/drug refusal to enable veterans to better cope with substance-related situations.
  • Cue exposure: this places veterans in the presence of cues to substance use (e.g., pub, drug paraphernalia) whilst not using substances 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.

The key principles of MI are:

  • Substance use behaviour change cannot be imposed, and needs to be self-driven.
  • Matching the intervention type and delivery to the client’s readiness to change behaviours.
  • Accurate empathy assists with developing rapport and clarifying issues.
  • Seeking to draw out discrepancies between the clients goals, values and current behaviour.
  • Roll with resistance: avoid using confrontation, argument and persuasion.
  • Supporting the client’s self-efficacy –confidence in their own ability to manage.

The key components of brief interventions for the treatment of substance use disorders include:

  • Taking a harm minimisation approach: working to reduce the harms of a person’s substance use, and targeting the most harmful behaviours first.
  • Taking a motivational approach: matching the level and pace of interventions to the client’s readiness to change their substance use and associated behaviours.
  • Providing realistic feedback about a client’s behaviour and options.
  • Working with the client’s own goals, resources and skills.
  • Taking a relapse prevention approach to ensure gains made are retained, and clients are prepared to manage set-backs.

General treatment resources for alcohol and substance use disorders

Alcohol and other substance treatment panel

DVA community-based AOD services panel

  • DVA has established a panel of community-based providers to assist in treating those experiencing alcohol and other substance use disorders. These providers have been assessed against the DVA Core Service Standards for the Provision of AOD services to the Veteran Community.
  • In order to access services through these arrangements, individuals must be eligible for treatment, and referred through either a medical practitioner (for instance, a GP or psychiatrist), the Veterans and Veterans Families Counselling Service (VVCS), a hospital discharge planner or other DVA Allied Mental Health provider. For more information including how to access the panel, download the “Alcohol and Other Substance Treatment Services” factsheet from the DVA factsheet webpage.
  • You can download a list of the current providers on this panel, including their indicative service location and service offerings.

Clinical treatment guidelines

Assessment and measures

Screening questions and other instruments for substance use may indicate that further assessment is required. A screening instrument designed to identify potential alcohol abuse and dependence is the CAGE (Mayfield, McLeod, & Hall, 1974), while an adapted version, CAGE-AID, is designed to identify drug use in addition to alcohol use.

• There are several standardised assessment tools for substance use disorders that can help you develop a treatment plan, and assess symptom severity or treatment progress. For tobacco smoking, the Smoking Cessation Framework can be used as a guide to assess smoking history, past quit attempts, and readiness for change, and the Fagerstrom Test for Nicotine Dependence can be used to assess nicotine dependence. For alcohol, the AUDIT tool (PDF)  assesses alcohol use and the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989) assesses alcohol withdrawal severity. For drugs, the DAST (PDF) can be used to assess the severity of a veteran's substance use problem. 

Recommended readings and online resources

  • Mental Health Advice Book: A resource developed for clinicians who work with veterans
  • The Right Mix: is a veteran specific resource that includes information on local support contacts and tips for changing drinking behaviours.
  • DVA's free ON TRACK with The Right Mix smart phone app assists users in keeping track of the number and types of drinks they consume; the amount of money they spend and explains the impact alcohol has on their wellbeing and fitness levels.
  • Prevention Research Quarterly: provides updates on recent research in the field of substance use prevention and treatment.
  • NDARC substance fact sheets: includes information on commonly used substances in Australia.
  • Australian Drug Foundation: provides advice on community services and information around substance use. It includes:
  • Cannabis resources: includes a range of factsheets, assessment measures and videos providing information on the effects of cannabis and effective treatment
  • DVA Evidence Compass:  Summarises recent research on the prevalence of substance use in contemporary ex-serving veterans.