• Referral pathways for substance use are available via the DVA community-based AOD services panel current providers.
• Comorbid mental health problems are common with veterans who misuse illicit or prescription drugs.
• The CAGE questions adapted to include drugs (CAGE-AID) is a screening instrument designed to identify potential substance abuse and dependence. The Drug Abuse Screening Test (DAST-20) can assist in assessing the severity of the veteran’s substance use problem.

Key characteristics

Substance misuse may be a primary problem or it may be symptomatic of other mental health problems affecting the veteran. Veterans may begin to use substances to: 

• reduce anxiety
• reduce insomnia 
• improve dysphoric states (e.g. stimulants or opiates) 

Veterans often find the concept of ‘self-medication’ a useful non-judgemental way of understanding their substance misuse. Nevertheless, both short-term and long-term harm associated with substance misuse is often profound. It is common for veterans to present with comorbid problems such as:

• depression 
• anxiety 
• PTSD
• substance misuse disorders

Substance use and suicidal thoughts or behaviour are often related. 

The presence of substance misuse is often a prominent barrier to engagement in and response to the treatment of other conditions.

Prevalence

Substance use disorders are particularly common in those aged under 35 years, which is worth noting considering younger veterans returning from recent conflicts and peacekeeping operations.

• Use of illicit drugs is relatively common, with around one third of Australians using illicit drugs at some point in their lives (AIHW, 2011).
• Cannabis is the most commonly used illicit substance in the general population, followed by ecstasy, amphetamines and cocaine (AIHW, 2011).
• Around 11.3% of ex-serving ADF members report using prescription drugs for non-medical purposes in their lifetime. with 6.7% using them within the last 12 months (DVA, 2018).
• An estimate 3% of Vietnam veterans experience substance use problems in their lifetime (O'Toole et al., 1996). 
• There is a growing rate of misuse of prescription medication, particularly pain medication among veterans. This may be reflective of a general increase in prescription medication abuse in the community (AIHW, 2011).
• The rate of cannabis use in veterans, including Vietnam veterans, is often underestimated by practitioners (AIHW, 2011).

Treatment of illicit and prescribed substances

The CAGE questions adapted to include drugs (CAGE-AID) is a screening instrument designed to identify potential substance abuse and dependence. CAGE asks the following questions.

When thinking about drug use, including illegal drug use and the use of prescription drugs other than as prescribed:

• Have you ever felt you ought to cut down on your drug use?
• Have people annoyed you by criticising your drug use?
• Have you ever felt bad or guilty about your drug use?
• Have you ever used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Veterans who answer ‘yes’ to two or more of these questions should be assessed further for substance use problems.

The Drug Abuse Screening Test (DAST-20) can assist in assessing the severity of the veteran’s substance use problem. 

Where substance use problems are present, screening for risk of harm to self or others is recommended. Assessment of injecting behaviour to determine health risks is also advised.

Psychological interventions

Talking to a veteran, together with the veteran’s family, about his or her substance use is the start of treatment. A number of psychological interventions have been found to be effective in the treatment of substance use disorders. The choice of treatment will depend on:

• the substance being used
• the severity of dependence
• veteran and practitioner preferences 

Recommended treatments include Motivational Interviewing (MI) and Cognitive behavioural therapy (CBT), Behavioural couples therapy (BCT) and family therapy (FT)  

Motivational interviewing (MI)

Veterans with problematic or risky substance use, or those who are unsure or ambivalent about changing their substance use behaviour, may benefit from MI.      

Ambivalence should be acknowledged and normalised. This may involve providing the veteran with information about:

• reducing the risks associated with substance use
• normalising ambivalence
• discussing discrepancies between current substance use behaviour and personal beliefs and goals

Questions to ask include:

• “What do you like about your substance use?
• What are the things you don’t like about it?”

After summarising the pros and cons about substance. Ask the veteran about his or her intention to change in a non-directive manner. For example “Where does this leave us now?”.

This 'decisional balance' technique can assist the veteran to:

• resolve ambivalence about change
• move towards action and behaviour change

Cognitive behavioural therapy (CBT) 

Some evidence suggests that CBT can be particularly effective. CBT has some general techniques applicable across a range of disorders. Specific CBT techniques for targeting substance use are:

• behavioural self-management - teaches the veteran strategies to reduce drug use. Such as self-monitoring and identifying high risk situations.
• coping skills training - includes skills such as assertiveness and coping with cravings. This enables the veteran to cope better with situations that are linked to drug use.
• cue exposure - places veteran in the presence of cues to drug use (e.g. pre-drug rituals, drug paraphernalia and others using drugs) while not using and observing the craving fade.

Behavioural couples therapy (BCT) and Family Therapy (FT) 

Family members often play a crucial role in the origin and maintenance of addictive behaviour. BCT and FT have demonstrated effectiveness in treating substance use problems, however, there is limited research to identify which drugs these therapies are particularly effective for. Key aims of BCT and FT include:

• eliminating drug abuse
• engaging the family’s support for the client’s efforts to change their behaviour
• restructuring patterns of couple and family interactions in ways conducive to long-term, stable abstinence.

CBT treatment elements for cannabis dependence

There is emerging evidence that CBT is an effective treatment for cannabis dependence, especially when used with motivational enhancement techniques (Buckner & Carroll, 2010; McRae et al., 2003). 

Specific CBT techniques for targeting cannabis use are:

• identifying and learning about triggers:
  • external triggers include others using, cravings, relationships
  • internal triggers include negative emotional states, unpleasant thoughts
• developing problem-solving skills to manage triggers such as: 
  • drug refusal
  • coping with craving
  • avoiding 'high risk' environments
  • managing relationships
• developing cognitive strategies such as recognising automatic thoughts and thought management
• developing assertiveness and refusal skills
• managing negative mood states with relaxation exercises

Contingency management and twelve-step programs

Contingency management and twelve-step programs are other approaches used for substance use disorders. However, each has its limitations.

Contingency management (CM) 

Contingency management (CM) involves the use of incentives. Vouchers and prizes are used to encourage reduced substance use. Evidence indicates that CM is effective for promoting abstinence during and after treatment for a wide range of substance use disorders (Prendergast, et al., 2006). 

However, this approach is not widely used because it is resource and labour intensive. It may be best suited to settings such as forensic monitoring and treatment.

Twelve-step programs

Twelve-step programs include Alcoholics Anonymous and Narcotics Anonymous. They are peer-based group programs aimed to help members achieve and maintain abstinence. Alcoholics Anonymous is readily available and cost effective. There is sufficient, but not strong, evidence to suggest that long-term participation can be effective for some people (DHA, 2009).

Psychological treatment setting and duration

Psychological interventions may be delivered in either an individual or a group format. The duration of treatment should be tailored to the veteran’s needs. The choice of treatment setting will depend on the severity of the veteran’s substance use problem.

Residential programs or therapeutic communities (TC) may be considered for:

• severe dependency, 
• polysubstance use
• significant comorbid issues 

There is, however, limited evidence for the long-term benefits of these programs and their capacity to prevent relapse following treatment completion.

Pharmacological treatment

Pharmacological treatment of a substance use disorder will depend on the substance being used and whether the overall goal of pharmacotherapy is:

• replacement/substitution or
• symptom management

Appropriate pharmacotherapy for the mental health consequences of long-term substance misuse is likely to have advantages in preventing relapse behaviour. E.g. treating depression and anxiety following psycho-stimulant cessation with selective serotonin reuptake inhibitors (SSRIs). 

In general, substitution pharmacotherapy is more likely to be suitable for veterans:

• misusing opioids - this includes illicit drugs such as heroin, and prescription analgesics such as OxyContin
• misusing minor tranquilisers such as benzodiazepines 

A number of options for the pharmacological management of dependence on other drugs (e.g. cannabis, cocaine) are currently being investigated. However, at present there is insufficient evidence to support recommendations on which regimens are likely to be the most effective. Therefore, we will focus here on the treatment of opioid dependence.

Physical withdrawal from opioids can be managed by methadone or buprenorphine. Some evidence suggests that the latter is associated with briefer periods of withdrawal. Both these medications can be used as long-term maintenance (opiate substitution) pharmacotherapy. Methadone and buprenorphine (full and partial opiate agonists, respectively) can assist in the treatment of opioid dependence, particularly relapse prevention, by blocking the euphoric effects of opioids and thus removing the ‘reward’ of drug use. 

The veteran must be assessed for recency of opiate use before commencing naltrexone or buprenorphine treatment.

Where pharmacotherapy is considered necessary for the treatment of substance use, it should:

• be adjunctive to, or 
• followed by one or more of the above psychological interventions

For example, pharmacotherapy may treat the veteran’s physical dependence on the drug or concomitant mood disorders. However, it is unlikely to address broader psychosocial issues surrounding the veteran’s drug use such as:

• diminished problem solving skills 
• relationship breakdown 
• unemployment, or 
• engagement in criminal activity

In the case of naltrexone, the treatment itself has no beneficial effect on the user’s mood, and so there is no immediate incentive to engage. Therefore, concurrent psychological intervention is particularly important in maintaining treatment compliance.

Withdrawal management

Clinical judgement is essential in determining whether a withdrawal plan is necessary. Diagnosis of substance abuse or dependence will not necessarily require a withdrawal management plan. For example, users of substances with lower levels of physical dependence such as cannabis are unlikely to require a withdrawal management plan.

Withdrawal management may be conducted in:

• home-based 
• community residential, or 
• inpatient hospital settings

The choice of setting will be determined by the predicted severity of (or potential medical complications associated with) withdrawal. Where possible, participation in community-based withdrawal programs is recommended. These provide the veteran with ongoing professional support and advice while allowing him or her to begin practicing coping skills and other withdrawal management strategies in everyday life.

Inpatient withdrawal programs may be required for polysubstance users or veterans unable to participate in community-based programs due to:

• medical
• psychiatric, or
• social problems

Pharmacotherapy may have a particular role to play in managing the physical withdrawal from the substance of dependence. However this should be considered as part of an overall treatment plan for the veteran’s substance dependence. This should include both pharmacological and psychological interventions. In developing treatment plans, all stages of treatment should be considered and the continued involvement of the primary practitioner established. This allows a smooth transition from withdrawal to the maintenance phases of treatment and increases the likelihood of recovery. Research shows that clients who participate in withdrawal programs without a post-withdrawal plan are more likely to return to pre-withdrawal levels of substance use.

See also