Spotlight on Alcohol Use Disorders Research
Throughout human history, people have consumed alcohol in some form—as a daily beverage, at celebrations and social gatherings, and for its power to induce relaxation or decrease stress. In the age before widespread, effective water treatment, brewed beverages containing alcohol—such as mead and cider—were often safer to drink than water. However, alcohol has a powerful, physiological effect on the human body, and for many people, can become the basis for addiction or alcohol use disorder (AUD). The National Institutes of Alcohol Abuse and Alcoholism (NIAAA) define AUD as “chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using.” [i]
According to NIAAA, an estimated 15 million people in the United States have AUD. Approximately 5.8 percent or 14.4 million adults in the United States ages 18 and older had AUD in 2018. This includes 9.2 million men and 5.3 million women. Adolescents can be diagnosed with AUD as well, and in 2018, an estimated 401,000 adolescents ages 12–17 had AUD. [ii]
Alcohol use disorders are also commonly associated with co-occurring mental illness. According to the National Institutes of Mental Health, 7.9 million adults in the U.S. had both a substance use disorder and another mental illness, and more than half were men (4.1 million).[iii] This has particular importance for Veterans, the majority of whom are male. In VA, it is estimated that in the wars in Iraq and Afghanistan, about 1 in 10 returning Veterans seen in the VA healthcare system have a problem with alcohol or other drugs. Further, Veterans with co-occurring post-traumatic stress disorder (PTSD) and alcohol problems also tend to binge drink more often than their counterparts who do not experience PTSD.[iv]
Within VA, research plays a key role in understanding those factors that contribute to alcohol use disorders and that support Veterans in maintaining healthy behaviors. Investigators with VA’s Health Services Research and Development Service (VA HSR&D) conduct a wide variety of research that focuses on alcohol use and misuse—ranging from delivery of services for addiction treatment to diagnosing and treating co-occurring mental health challenges. In addition to individual studies, VA HSR&D also funds the Center of Innovation for Mental Healthcare and Outcomes Research, which focuses on research to improve access to and engagement in evidence-based mental health and substance use disorder treatment. In addition, investigators with VA’s Quality Enhancement Research Initiative developed a toolkit for assessing and addressing alcohol misuse. The following are just a few of the ongoing and recently concluded studies focused on supporting Veterans with AUD and managing the impact of alcohol use on health.
© iStock/Tero Vesalainen
Implications for Care
For Veterans using VA care, the emergency department (ED) is an important portal for entry into the VA healthcare system--particularly for Veterans experiencing hazardous or harmful drinking. This study is one of the first attempts to directly test the impact of peer-delivered alcohol interventions and mentorship to link with and engage patients in VA primary and specialty care through the ED. Investigators expect that results will show the intervention to have a potentially significant, positive impact on Veterans and on the VA system. For Veterans with more serious alcohol problems, linkage to primary and specialty care may reduce ED visits and improve their mental and physical health outcomes. For the VA system-wide, the intervention may result in more appropriate allocation of resources.
The study will address the following questions:
- What is the efficacy of a peer-delivered alcohol intervention and mentorship to facilitate reduction in hazardous drinking?
- What is the impact of a peer-delivered alcohol intervention?
- What is the impact of mentorship on linkage to primary care or, if needed, specialty alcohol treatment services?
- What aspects of a peer-delivered intervention influence change?
- What are the barriers and facilitators of implementation through qualitative interviews.
About the Study
This randomized clinical trial will compare a brief Alcohol Peer Mentorship intervention starting in the ED—combined with six strengths-based booster sessions—to the enhanced usual care of Brief Advice. The Peer Mentorship intervention includes a Veteran Peer research assistant who will contact the study participant once in the ED upon enrollment, and up to six times after enrollment over the course of two months. Participants in the Brief Advice group will be offered standard VA care practices when a patient endorses hazardous drinking behaviors; they will receive a resource pamphlet on alcohol and other health issues.
Investigators will enroll approximately 450 Veterans with hazardous drinking behaviors who received care in the VA Ann Arbor Medical Center ED to the Alcohol Peer-Mentor intervention (n=225) or the Brief Advice comparison group (n=225). Patient assessments regarding alcohol use, healthcare utilization, and other mental health and wellness factors will occur at baseline, 3-, 6-, and 12-months following enrollment. Interviews with a subset of Veterans, peers, clinicians, and clinical leaders will be conducted to assess potential barriers and facilitators to the implementation of this approach in VA emergency departments.
There are no findings at this time.
Frederic Blow, PhD, MA, is an investigator with HSR&D’s Center for Clinical Management Research at the VA Ann Arbor Healthcare System.
Implications for Care
This ongoing evaluation of the Drinking Options: Motivate, Shared Decisions, Telemonitor (DO-MoST) project has produced a decision aid that provides a bridge between medical-surgical treatment and alcohol use disorder (AUD) treatment. Decision aids have been used successfully in a number of contexts, but never with medical-AUD inpatients. VHA Mental Health Services and Medical Service are committed to directly addressing the dangerous, costly pattern of Veterans obtaining medical-surgical services but not receiving the AUD treatment they need. DO-MoST is well-positioned to support that goal.
- Can a decision aid be effectively adapted and implemented with AUD patients in non-VA primary care settings?
- What is the effectiveness of DO-MoST at two VA facilities (Ann Arbor and Palo Alto) designated as study sites?
- When compared to patients in usual care, will patients in the DO-MoST intervention be more likely to: 1) utilize AUD help, 2) have fewer heavy drinking days and better medical outcomes, and 3) have fewer and more delayed acute care episodes (ED visits, rehospitalizations)?
- Will an evaluation to inform the wider implementation of DO-MoST provide guidance for VA facilities' broader adoption of DO-MoST in the future? Will that adoption extend to possible adaptation for diverse subpopulations of Veterans, such as patients with mental health diagnoses (e.g., PTSD)?
About the Study
In this study, investigators are evaluating the DO-MoST intervention as a potential solution to the critical need for evidence-based strategies to improve Veterans' AUD and medical outcomes. DO-MoST entails the use of motivational interviewing and a decision aid during medical visits to facilitate informed choices about post-medical treatment drinking options and resources for help to change drinking patterns. If desired, patients may also receive post-stay telephone calls for continued motivation and behavioral decision support.
Investigators have completed assessments of several study questions and have successfully adapted a decision aid to be appropriate for Veterans with AUDs in medical-surgical settings. Enrollment has begun for participants in the randomized controlled trial portion of the investigation.
Christine Timko, PhD, is an investigator with HSR&D’s Center for Innovation to Implementation at the VA Palo Alto Healthcare System, and Mark Ilgen, PhD, is an investigator with HSR&D’s Center for Clinical Management Research at the VA Ann Arbor Healthcare System.
© iStock/Chainarong Prasertthai
Implications for Care
Data from this pilot study show that a mobile-based application, paired with peer support, increases the value and accessibility of evidence-based care for Veterans treated in VA primary care settings who engage in hazardous levels of drinking but rarely seek treatment. Investigators suggest that a larger, more comprehensive investigation will likely increase the evidence-base of this alcohol innovation in VA primary care.
How best can a smartphone application for hazardous drinking ("Step Away") be adapted to meet the needs of Veteran primary care patients? What is the best way to integrate use of such an app with support from a VA Peer Support Specialist?
About the Study
Hazardous drinking poses a significant public health problem and is a critical issue in the lives of a large population of Veterans. Of Veterans seen in VA Primary Care, 15-30% are identified as hazardous drinkers; however, due to a number of barriers such as time constraints on providers and behavioral costs to patients (e.g., traveling to VA for regular treatment sessions), the vast majority of these Veterans go untreated. Smartphone technology and the development of specialized applications ("apps") can overcome these barriers by extending care for hazardous drinking beyond the onsite appointment through prescribing a self-directed, evidence-based treatment application.
The first aim of the project was to use the Method for Program Adaptation through Community Engagement model to modify a mobile application ("Step Away") for Veterans engaged in hazardous drinking. Investigators recruited 12 Veterans, and 11 peer specialists. A majority of the Veterans who used the Step Away mobile app for 10 days reported that the app helped them reduce the amount they drink or how often they drink.
A majority of Veterans also reported that they were likely to continue using the mobile app even after completion of the study. Participants suggested the following improvements to the app:
- Including rewards for reaching drinking goals, as well as the ability to track progress towards these goals;
- Increasing accessibility to some features; and
- Adding Veteran testimonials and more Veteran-specific activities.
Based on this feedback, the app was redesigned, and a new Veteran-specific version of the app (“Stand Down: Think Before You Drink”) was launched for the second aim of the study.
The second aim was to conduct a field test of the app with added peer support, in order to evaluate if this approach is acceptable to patients and useful in terms of improving drinking outcomes among VA Primary Care patients who engage in hazardous drinking. Results for this aim are still pending.
Daniel Blonigen, PhD, is an investigator with HSR&D’s Center for Innovation to Implementation at the VA Palo Alto Healthcare System.
Implications for Care
Study findings suggest that nonfatal overdose is relatively common among Veterans who have experienced homelessness. Overdoses involving alcohol were more common than any specific drug. Data indicate that improving access to addiction treatment for Veterans who are experiencing homelessness or who are recently housed—especially for those who have experienced or witnessed overdose—could help to protect this population.
How common is nonfatal overdose among Veterans who have experienced homelessness, and what are the risk factors and substances involved in overdoses?’
About the Study
This survey study was conducted from November 15, 2017 to October 1, 2018 via mailed surveys with telephone follow-up for non-respondents. Eligible participants were selected from the records of 26 VA Medical Centers (VAMCs) and included Veterans, who had received primary care at one of these VAMCs and had a history of experiencing homelessness. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020.
Of the 5,766 Veterans surveyed nationwide who had experienced homelessness, 7.4% reported an overdose in the previous three years; of those Veterans with an overdose (n=379), alcohol was the most commonly involved substance.
Riggs KR, Hoge AE, DeRussy AJ, et al. Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness. JAMA Netw Open. 2020;3(3):e201190. doi:10.1001/jamanetworkopen.2020.1190
[i] National Institutes of Health National Institute for Alcohol Abuse and Alcoholism website. Overview on Alcohol Consumption. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders
[iii] National Institutes of Health National Institute for Mental Health. Substance Use Disorders and Mental Health Overview. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health/index.shtml
[iv] Department of Veterans Affairs website. National Center for PTSD section. Overview of PTSD and Co-Ocurring Substance Use Disorders. https://www.ptsd.va.gov/understand/related/substance_abuse_vet.asp