Approximately 88,000 deaths are attributable to unhealthy alcohol use each year. 1 Unhealthy alcohol use also is associated with more than 60 medical conditions and has both immediate (i.e., traffic injuries, violence, risky sexual behavior, alcohol poisoning) and long-term (i.e., neurological problems, cancer, cardiovascular disease) consequences. However, preventive care is widely recommended but uncommonly offered, and according to a report from SAMSHA's National Survey on Drug Use and Health, the majority of people who need alcohol treatment do not perceive the need for it–and/or do not receive it.
VA/HSR&D's Substance Use Disorders Quality Enhancement Research Initiative (SUD-QUERI) works to improve the detection and management of Veterans with unhealthy alcohol, tobacco, and other drug use to increase the implementation of effective prevention and treatment of SUD. As part of these efforts, SUD-QUERI is working with VA clinical partners to implement evidence-based management of unhealthy alcohol use nationwide. SUD-QUERI also established a Primary Care Work Group (PCWG) to improve the access, quality of care, and treatment outcomes for Veterans with substance abuse problems that are treated within VA primary care settings. The PCWG has been working to expand access to pharmacotherapy for alcohol use disorders, including ongoing projects that seek to enhance the implementation of pharmacotherapy into general medical and specialty care.
In addition, SUD-QUERI investigators worked with VA's Office of Quality and Performance, now the Office of Analytics and Business Intelligence, to implement evidence-based screening for the entire spectrum of unhealthy alcohol use, followed by brief intervention for those who screen positive. As a result, more than 95% of eligible Veterans now receive alcohol screening, and >75% have documented brief intervention. The VA is now a recognized leader in implementation of these preventive practices, which are recommended by the US Preventive Services Task Force and have been deemed the 3rd highest prevention priority for US adults. Because these preventive services are now covered as a standard benefit under the Affordable Care Act, the VA will likely serve as an example to other healthcare systems working to implement these services into practice.
Following are descriptions of several specific studies that highlight HSR&D and QUERI investigators' research on prevention and management of unhealthy alcohol use.
Effectiveness of Brief Alcohol Intervention Implementation
While VA has accomplished high rates of alcohol screening and brief alcohol interventions (>90% of all outpatients screened, and >75% of all screen-positive Veterans are offered brief intervention), it is unknown whether VA patients are reaping the expected benefit. This QUERI study evaluated whether documented brief alcohol intervention was associated with resolution of unhealthy drinking at follow-up screening among those Veterans who had initially screened positive. Investigators also interviewed VA providers to identify local strategies used to implement brief alcohol intervention. Findings show that among outpatients with unhealthy alcohol use, no difference in resolution at follow-up was found among those with and without documented brief alcohol intervention (48% and 47%, respectively). Results also suggest that while providers believed that addressing unhealthy alcohol use is an important part of care, they had not received adequate training regarding how to conduct screening or intervention.
Identifying VA Outpatients Who Might Not Need Annual Alcohol Screening
VA screens for unhealthy alcohol use annually, but optimal frequency is unknown. This QUERI study sought to determine whether some sub-groups of VA outpatients who screen negative on the AUDIT-C (three-item alcohol consumption questionnaire) are at such low risk for having a later positive screen that they might not need to be rescreened annually. Investigators identified 338,531 male Veterans and 853 female Veterans with at least one pair of clinical alcohol screens, in which the initial screen was negative for unhealthy alcohol use. Findings show that the probability of a positive screen at follow-up was 6% in men and 5% in women. Moreover, the number of Veterans with an initial negative alcohol screen who need to be rescreened to identify one patient with a positive screen at follow-up ranged from 3 to 159. The factors most strongly associated with remaining a negative screen at follow-up were age (older) and the initial negative AUDIT-C score. Findings suggest that decreasing the frequency of rescreening in older Veterans who have low negative AUDIT-C scores might be reasonable.
Helping Families Help Veterans with PTSD and Alcohol Abuse
Family support and encouragement represents a potentially powerful venue for engaging Veterans in needed services for PTSD and alcohol use disorders. VA-CRAFT (VA-Community Reinforcement and Family Training) is an innovative adaptation of a family training intervention that has been shown to dramatically increase treatment for substance abuse in the civilian population. This ongoing randomized controlled trial will examine the effectiveness of VA-CRAFT on Veterans' use of mental healthcare. Investigators also will look at its impact on family members' wellbeing, personal quality of life, perceived relationship quality with the Veteran, and communication about treatment seeking. Participants in this study include family members of Veterans who screen positive for PTSD and/or alcohol abuse disorders. Results from this study will provide an important first step in testing the VA-CRAFT program–a novel tool that could be widely disseminated to improve Veterans' engagement in mental healthcare.
Factors Impacting the Screening and Management of Unhealthy Alcohol Use in Women
As many as 20% to 25% of Veterans presenting to primary care screen positive for unhealthy alcohol use, with research showing that unhealthy alcohol use is increasing among women Veterans. This ongoing QUERI study seeks to identify patient, provider, and system factors that serve as facilitators or barriers to women openly discussing alcohol use with their providers, and to identify any factors that impact women's receptivity to receiving treatment for unhealthy alcohol use. Investigators interviewed both women Veterans and providers recruited from theVA Palo Alto Health Care System and the VA Greater Los Angeles Healthcare System. Preliminary findings show that the two most common reasons women fail to disclose their true level of alcohol use to providers were the negative emotions surrounding alcohol use, and women's self-appraisal of their drinking behavior. When women did disclose their alcohol use, it was most often because it was encouraged by social support, influenced by health concerns–and by concerns about the consequences of their drinking. Findings from this study will help investigators develop and/or modify existing screening and treatment approaches to enhance women's engagement in treatment for unhealthy alcohol use.
Improving Detection and Management of Unhealthy Alcohol Use among VA Inpatients
Funded through HSR&D's Nursing Research Initiative, this ongoing study includes a randomized controlled trial of a nurse-delivered alcohol brief intervention (BI) of hospitalized Veterans. Investigators will determine the impact of a nurse-led BI on alcohol consumption, readiness to change drinking behavior, and adverse consequences of alcohol use in hospitalized hazardous drinkers. This study also will examine the practical factors related to delivery of the intervention in the inpatient setting. Study results will support BI implementation, such as VA's adoption of new ORYXÂ® measures pertaining to alcohol screening, BI, referral to treatment, and follow-up for all hospitalized patients. As Chair of the VA Pittsburgh Healthcare System's implementation committee for these measures, the Principal Investigator of this study has received additional research funding from the VA Office of Nursing Services ( ONS) to conduct a formative evaluation of the measure implementation in Pittsburgh.
For general information about SUD-QUERI, please contact Janet Ekstrom, SUD-QUERI Administrative Coordinator, at Janet.Ekstrom@va.gov .
1. Centers for Disease Control and Prevention. Alcohol and Public Health. March, 2014.