Most-abused substances. Alcohol is the most commonly abused substance among OEF/OIF veterans (10%-20%).40,41,43-45 Other abused substances include opioids (prescribed or illicitly obtained), synthetic marijuana (“Spice” and “K2”), and “bath salts” (synthetic stimulants) (W.M. Sauve, MD, personal communication, August 27, 2012).
OEF/OIF veterans seem to be at particular risk for developing problems related to opioid use. A 2012 retrospective cohort study showed that veterans with non–cancer- related pain diagnoses treated with opioid analgesics had an increased risk for adverse clinical outcomes compared with those not treated with opioid analgesics (9.5% vs 4.1%; relative risk [RR]=2.33; 95% confidence interval [CI], 2.20-2.46). These outcomes included traumatic accidents, overdoses, self-inflicted injuries, and injuries related to violence. This study also demonstrated that, compared with veterans without mental illness, veterans with mental illness (particularly PTSD) and non–cancer-related pain were significantly more likely to receive opioids to treat their pain and had a higher risk of adverse clinical outcomes, including overdose.46,47
Recreational use of synthetic marijuana and “bath salts” has increased in recent years. These substances are commonly labeled “not for human consumption,” which allows them to remain outside US Food and Drug Administration (FDA) regulation and be sold legally in the United States. Efforts to prohibit the sale or possession of these drugs, including the Federal Synthetic Bath Salt Ban in 2012, have fallen short, often due to creative product ”re-engineering.”33 Synthetic marijuana and stimulants are inexpensive, readily available, and perceived by users to be safe. Health care providers are often unaware that their patients are using these products. Adverse health outcomes associated with the use of these synthetic drugs include memory loss, depression, and psychosis.
These alcohol and drug screens can help
One efficient screening tool to identify veterans at risk for alcohol abuse is the AUDIT-C, developed by the World Health Organization. This brief 3-question test identifies past-year hazardous drinking and alcohol abuse or dependence with >79% sensitivity and >56% specificity in male veterans, and >66% sensitivity and >87% specificity in female veterans. These numbers are similar to those provided by the full 10-question AUDIT.48,49 The Drug Abuse Screen Test-10 (DAST-10) provides a similar screening instrument for other substances. Condensed from the original DAST-28 instrument, the DAST-10 identifies high-risk substance abuse with 74% to 94% sensitivity and 68% to 88% specificity.3
Screen for comorbidities. When you see veterans with a diagnosis of substance abuse, also evaluate for comorbid disease. Most veterans with substance use disorders (82%-93%) have at least one other mental health diagnosis (a 45% greater risk than that of civilians with substance abuse disorders),50 most commonly PTSD, depression, anxiety, and adjustment disorders.41,44,45 A number of hypotheses exist to explain the association between substance use disorders and other mental health diagnoses (“dual diagnoses”). The prevailing theory, in both veteran and civilian populations, is that substance abuse is an attempt to self-treat mental illness. Other evidence suggests that substance abuse promotes the development of mental illness, either by leading to a higher risk for traumatic experiences (increasing the chance of developing PTSD) or through a direct biochemical mechanism. Finally, con- current substance use disorder and mental illness may be due to an undefined genetic or biological vulnerability.38,44 This complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a comprehensive, multidisciplinary approach to treatment.
Treatment options. Office-based treatment options for narcotic and alcohol abuse and dependency are available to family physicians. Methadone has been used since the 1950s to treat opioid addiction and remains one of the mainstays of outpatient treatment.47,51 Originally, methadone was restricted to detoxification and maintenance treatment in narcotic addiction treatment programs approved by the FDA. In 1976, this restriction was lifted, and all physicians registered with the Drug Enforcement Agency (DEA) were permitted to prescribe methadone for analgesia.
In 2002, the FDA approved buprenorphine monotherapy and the combination product buprenorphine/naloxone for the treatment of opioid addiction. The prescribing of buprenorphine products requires physicians to undergo extra training, declare to the DEA their intent to prescribe buprenorphine, and obtain a special DEA identification number.52,53 Physicians interested in finding out more about buprenorphine treatment and prescribing requirements can go to the Substance Abuse and Mental Health Services Administration (SAMHSA) Web page at http://samhsa.gov.
Naltrexone is an opioid receptor agonist that is used primarily to treat alcohol dependency, and is thought to work by reducing the craving for alcohol. Multiple studies have proven the efficacy of naltrexone in an outpatient setting when used alone or in combination with psychotherapy.54,55 If you are uncomfortable or unfamiliar with the use or prescribing of these medications, referral to a substance abuse clinic specializing in dual-diagnosis treatment (TABLE 1) may offer optimal outcomes for patients with substance abuse disorders and other mental illness.