Many active-duty service members and military veterans struggle with substance use. Some start using substances during their military service; others start using them after they’ve transitioned out of service. The National Institute on Drug Abuse estimates that 25% of active-duty service members and 10% of veterans have a substance use disorder (SUD). To help you better serve this population, we’ll review substance use treatment programs for veterans and active-duty members.
Substance use among active military and veterans
To understand the need for substance use treatment programs for veterans and active-duty members, we first need to understand the rate of substance use among these populations.
Some studies suggest a low prevalence rate of substance use disorders among active-duty service members. However, it’s hard to determine the true prevalence of substance use among this population, primarily due to difficulties around data collection. First, active-duty service members may not self-report substance use due to fears of retaliation or dishonorable discharge. Second, survey questions used to determine the prevalence of substance use frequently change, making it difficult to compare results and spot trends.
Despite these difficulties, NIDA estimates that more active-duty service members have a substance use disorder than the general population.
As with active-duty service members, the prevalence of SUDs is difficult to determine among military veterans. Veterans who go to the VHA for veteran support services are screened annually for alcohol use. Currently, there is no required annual screening for other substances. However, screening tools are available for providers to use.
Screening and assessments for substance use disorders
There are a variety of substance use screening tools that providers can use. In this section, we’ll review three popular choices for screening tools and some best practices around assessments.
Remember, a screening tool is used to determine whether further assessment is needed. Screening tools do not provide enough information to make a diagnosis of a substance use disorder.
Screening tools for SUDs
Brief Addiction Monitor (BAM)
The Brief Addiction Monitor (BAM) is a screening tool that asks about an individual’s substance use and provides information on their risk factors for ongoing use and protective factors for recovery. Most government-sponsored veteran support services use this screening tool to measure the level of care, mental health counseling, etc., that a person needs.
Additionally, the BAM is used to measure how well the person is doing in substance use disorder treatment. In 2017, a Brief Addiction Monitor (BAM-R) was released, however, there is limited evidence on how effective it is.
Substance Abuse Screening (ASSIST)
The Substance Abuse Screening (ASSIST) is a screening tool that asks about alcohol, tobacco, and other substances. The tool asks about someone’s experience using substances across their lifetime as well as in the past three months.
ASSIST comes with four sets of questions that mental health providers can use to determine if an individual is affected by any co-occurring disorders, such as post-traumatic stress disorder (PTSD), if anyone in their life has expressed concern, and if they’ve used, or felt an urge to use, substances in the past several months.
Studies of the ASSIST methodology have found that it is a reliable and effective means of screening for a person’s need for substance use disorder treatment.
Alcohol Use Screening Identification Test (AUDIT-C)
The Alcohol Use Screening Identification Test (AUDIT-C) is a screening tool that focuses on alcohol use. This screening tool is usually done annually at VA hospitals.
AUDIT-C is a 10-question assessment to gauge an individual’s standard alcohol consumption. Each answer choice is assigned a point value. Practitioners can then use their client’s score to determine if SUD treatment is necessary and, if so, which therapies would work best for their client.
AUDIT-C questionnaire:
| Question | Answer choices and point values |
| How often do you have a drink containing alcohol? | (0) Never [Skip to Qs 9-10]; (1) Monthly or less; (2) 2 to 4 times a month; (3) 2 to 3 times a week; (4) 4 or more times a week |
| How many drinks containing alcohol do you have on a typical day when you are drinking? | (0) 1 or 2; (1) 3 or 4; (2) 5 or 6; (3) 7, 8, or 9; (4) 10 or more |
| How often do you have six or more drinks on one occasion? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily; Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0 |
| How often during the last year have you found that you were not able to stop drinking once you had started? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily |
| How often during the last year have you failed to do what was normally expected from you because of drinking? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily |
| How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily |
| How often during the last year have you had a feeling of guilt or remorse after drinking? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily |
| How often during the last year have you been unable to remember what happened the night before because you had been drinking? | (0) Never; (1) Less than monthly; (2) Monthly; (3) Weekly; (4) Daily or almost daily |
| Have you or someone else been injured as a result of your drinking? | (0) No; (2) Yes, but not in the last year; (4) Yes, during the last year; |
| Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? | (0) No; (2) Yes, but not in the last year; (4) Yes, during the last year; |
Assessments
If a substance use screening tool is positive, or a provider wants to get a better understanding of someone’s substance use, an assessment is recommended. Agencies may have a preferred assessment form that they use. Some insurance companies require specific questions to be asked on an assessment form.
If a provider knows that they are seeing an active-duty service member or a veteran, they should add additional questions about the person’s military service and trauma history. As mentioned previously, understanding a person’s experiences in the military is essential to providing person-centered care.
Substance use treatment programs for veterans and active-duty members
After you have completed an assessment for SUDs and understand your client’s needs, consider one of the following evidence-based treatment modalities.
Cognitive behavioral coping skills training
Cognitive-behavioral coping skills training works with clients to modify their thoughts and behaviors related to substance use and other parts of their lives affected by substance use. They learn how to track their thinking and behavior in order to identify any emotional or behavioral consequences brought on by these thoughts and actions. Once clients have pinpointed the behavioral patterns they want to change, providers can show them techniques to modify harmful thoughts and behaviors.
Additionally, in this model, providers help their clients strengthen coping skills, improve their mood and interpersonal functioning, and enhance their social support. In cognitive-behavioral coping skills training, clients are encouraged to practice skills outside of sessions, including scheduled activities, self-monitoring, and recording their challenging thoughts and responses. Studies have found that these types of cognitive-behavioral coping skills are an effective strategy for preventing relapse to substance use.
Contingency management
Contingency management is an effective behavioral intervention for substance use. Based on the behavioral principles of reinforcement, the goal is to reward specific behavioral goals related to recovery. Rewards are made contingent on measurable objectives (e.g., negative drug screens), treatment adherence, or progress toward treatment goals.
Rewards can be monetary or nonmonetary, such as providing clients with vouchers that can be exchanged for goods or services. The frequency and expense of reinforcement vary, which affects the overall implementation costs. Because contingency management does not work to find and address the root causes of an individual’s substance use disorder, but helps to reinforce positive behavior change, experts recommend using it as a complementary method with other interventions.
Motivational enhancement therapy
Motivational enhancement therapy uses principles of motivational interviewing to increase the client’s understanding of their ambivalence to change, increase their commitment to change, and enhance their self-efficacy. Although it is a relatively short treatment (typically four sessions), motivational enhancement therapy has proven effective in decreasing substance use.
Motivational enhancement therapy is a structured intervention that focuses on client assessments and encourages the client’s feedback. The provider advocates for the client’s commitment to change and collaborates with them on developing an individualized change plan. Significant others are encouraged to attend at least one session. This intervention may be especially helpful with clients who display low readiness or increased anger.
12-Step Facilitation
Twelve-step facilitation supports individuals’ continuous abstinence and remission from substance use. This intervention is delivered over 12 sessions in which the provider actively encourages the client to engage in 12-step meetings and supports the client through the first four steps of the support program. Each session is divided into three parts.
- The provider reviews relevant events of the last week with the client and discusses the homework assignment from the last session.
- The provider provides psychoeducation related to the 12 steps.
- The provider assigns the client a new homework assignment and develops a plan for the client to engage in recovery-oriented activities.
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