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This Issue: The Returning Veteran | Table of Contents: Winter 2017 | Download this issue

A Chat with Our Experts

Improving care for Veterans with substance use disorders

Dr. Keith Humphreys is the associate director for the VA HSR&D Center for Innovation to Implementation at Palo Alto, California. <em>(Photo courtesy: K. Humphreys)</em>
Dr. Keith Humphreys is the associate director for the VA HSR&D Center for Innovation to Implementation at Palo Alto, California. (Photo courtesy: K. Humphreys)

Dr. Keith Humphreys is the associate director for the VA HSR&D Center for Innovation to Implementation at Palo Alto, California. (Photo courtesy: K. Humphreys)

Dr. Keith Humphreys is the associate director for the Health Services Research & Development Center for Innovation to Implementation in Palo Alto, California, and professor, department of psychiatry, Stanford University School of Medicine. He is also the principal investigator for a VA HSR&D CREATE initiative, which is a group of interrelated research projects. Humphreys' CREATE focuses on care innovations for substance use disorders: Enhancing the Value of VA's New Uniform Package of Health Services for Substance Abuse.

Dr. Michael Cucciare is associate director for research training at the South Central Mental Illness Research, Education, and Clinical Center (MIRECC) in Little Rock, Arkansas, and assistant professor, department of psychiatry and behavioral sciences, College of Medicine, University of Arkansas for Medical Sciences. He is also the principal investigator for the VA-funded study: Web-based Intervention to Reduce Alcohol Use in Veterans with Hepatitis C.

VARQU spoke with the two researchers about their work on substance use disorders among Veterans.

Dr. Humphreys, can you tell us about the VA CREATE that you are spearheading?

Dr. Humphreys: The CREATE is an interconnected suite of projects that were co-designed by HSR&D experts in addiction and our operations partners at the Office of Mental Health Services, Office of Mental Health Operations, and Office of Public Health. One study is focused on quality measurement; one is focused on the different types of funding mechanisms; one is focused on engaging the population of Veterans who go through many, many detoxifications, trying to get them engaged in treatment; and the last one is the hepatitis C one, which is Mike's brainchild. Liver clinic staff know that they see a lot of people with alcohol problems, but they don't have a lot of time to deal with them. So the idea is to develop some technology which would extend the impact of the staff by giving the Vets direct access to the tool which would help them understand their drinking and maybe consider making a change.

What is the overall prevalence of substance use disorders in the Veteran population?

KH: We know a couple of things about Veterans as a whole— the 23 million people who have served— not just those who use the VA health system. About one in five smokes tobacco, which is more than the general population. About 22.6 percent binged on alcohol use in the last month, which means they sat down and drank five or more drinks at a sitting. About 7.5 percent are heavy alcohol users, meaning in the last month alone, they drank five or more drinks at a sitting, at least five times. And about 4.5 percent used illicit drugs in the last month. All of those things are higher than you would see in a comparable group of non-Veterans. If you match a non-Veteran population by gender and age, Vets do seem to use more substances.

When you look at the VA health system using population—about a third of the total Veteran population— that's even more the case. In our patients, substance use disorder involving tobacco, methamphetamine, alcohol, cocaine, heroin, lately OxyContin and things like that, are some of the most common and costly chronic conditions that we face in the health care system. These Veterans who seek treatment at a VA facility tend to be more ill, obviously. They tend to have lower incomes, and they have more substance use problems than do the Veteran population as a whole.

Are Veterans who experience chronic illnesses at greater risk for substance use disorder? And do Veterans with substance use disorder tend to become sicker?

KH: Both things are probably true. But it's also true that the severity of substance use disorders and the response to treatment is often connected to how much social capital people have. So people who have more education, better jobs, better marriages, and better income are more likely to have a good outcome from treatment. The VA is a safety net provider, so we serve a lot of people who have fewer of those things. And that would include people who have been treated many times, and relapsed many times. They have very challenging lives.

Does this susceptibility vary for Veterans who have served in a theater of war, like Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF)?

KH: Yes, each cohort has had its own experiences with substances. If you go back to World War II, Korean War-era Vets, alcohol use disorder overwhelmingly dominates. If you look at Veterans who served in Southeast Asia, Vietnam, I would say many experienced exposure to opiates and cannabis. Particularly opiates. There was very pure, very cheap heroin in Vietnam. That's where a lot of the drug treatment concern came about in the U.S. in the 1970s, from the Veterans who were addicted to heroin in Southeast Asia.

In the more recent conflicts — I should say I've been to Iraq — there wasn't a lot of exposure to illicit drugs (at least in the early years) because Iraq was a very conservative society and had militarized borders. But there are a lot of pharmaceuticals loose in Iraq, and that includes leakage out of the corrupt Iraqi pharmaceutical system, but also from prescribed prescriptions from Army doctors. Soldiers are getting more potent opioids than they've ever had before. And sometimes they desperately need them; I'm not saying it's wrong. But when you get a serious injury and are prescribed a lot of opioids in your transition out of the service, you are at risk of having an enduring problem. So the young men and women soldiers are far more likely to have a prescription drug problem, which makes them different than what VA has seen in the past with the Vietnam, Korea, and World War II Veterans.

Do the substance use problems for Veterans differ by gender? There are now many more women in the military than, say, during World War II.

KH: If you look at the world, men use more substances than women. That's true for every place on earth. It's true in the United States. So given that the military has more men, you are going to have a lot more substance use, especially among young men. But one of the interesting things is that while male Veterans use more substances than male non-Veterans, the difference between female Veterans and female non-Veterans is even higher.

When you look at the Vietnam data, the rate of alcohol dependence among women who served in Vietnam was something like five times higher than women who didn't. The differences for men weren't that big. So we might see more substance use disorders in women Veterans relative to women in general. Even if most Veterans are male, the women who have served and are coming in [for treatment at VA] are a lot more likely to have trouble than are women outside. And so that is something unique to their gender, relative to the men, where men are somewhat more likely [to have substance use problems], but not wildly more likely.

Dr. Michael Cucciare (center) meets with CREATE team members (from left) Kathy Marchant-Miros, BSN, Mitzi Mosier, and Traci Abraham, PhD. <em>(Photo by: Ashley McDaniel, South Central MIRECC)</em>
Dr. Michael Cucciare (center) meets with CREATE team members (from left) Kathy Marchant-Miros, BSN, Mitzi Mosier, and Traci Abraham, PhD. (Photo by: Ashley McDaniel, South Central MIRECC)

Dr. Michael Cucciare (center) meets with CREATE team members (from left) Kathy Marchant-Miros, BSN, Mitzi Mosier, and Traci Abraham, PhD. (Photo by: Ashley McDaniel, South Central MIRECC)

Dr. Cucciare, can you tell us about the research that you are doing for the CREATE study which looks at substance use interventions for Veterans with hepatitis C?

Dr. Cucciare: This study is a two-site clinical trial. The focus of it is really to determine whether a brief intervention delivered on the computer essentially one time is effective for reducing alcohol use in Veterans who have consumed any amount of alcohol in the past 30 days, and also have hepatitis C. We've actually broadened that out to include Veterans with any liver disease. The intervention we're using is borne out of the college drinking literature. There's a lot of literature over the past 10 even 15 years using very brief, one-time, computer-delivered interventions to reduce binge drinking in college students. As we all know, that can be a problem in that setting. We've slowly applied that intervention to the larger population using a public health approach, where you try to get that intervention to as many people as you can. The intervention we're using is very brief, and it tends to have very small effects. So you are not taking someone who has an alcohol use disorder and making them abstinent. But these interventions tend to reduce, for example, the frequency of binge drinking, which we know is terribly harmful to your health. So even reducing that even a little bit can be helpful in the long run.

That's what we are doing in this study, taking this very brief intervention and putting it in clinics, in San Francisco and Palo Alto VA liver clinics. As Dr. Humphreys mentioned before, the reason why we have interest in doing this is these clinics are terribly busy. They have many clinical issues to address when these patients come in, especially with these new anti-viral treatments being implemented in VA. More and more Veterans are coming in and wanting information about those interventions, and wanting that treatment.

How is the intervention structured?

MC: It takes about 20 minutes for the Veteran to go through the intervention from start to finish. And it consists of two parts: there's a brief assessment of their alcohol use and some of the consequences of their alcohol use. That information is then given back to the Veteran in the form of personalized feedback. So a piece of that feedback is letting the Veteran know, compared to other men or women your same age, here's how your drinking compares to them. And it also lets them know feedback about the health effects of drinking on their liver, on the efficacy of the anti-viral therapy, although that's staring to change now with the new treatments.

It tries to tailor the feedback specifically to help the Veteran understand how drinking can affect their disease. That's really what it is targeting. And then they can print out a feedback report that they can take with them. So even though the intervention is short, they can take that material with them, read it, and try to digest it. And if they desire, they can bring it back and discuss it with their physician during a visit.

How often do patients need to go through these interventions to benefit?

MC: That's a good question, and I think largely the literature says there is some benefit to doing them one time. I don't think that the literature has come to any conclusions about frequency. There's some debate on whether multiple, brief interventions over a period of time have any additional benefit. That first time is really where the bang is, especially with these kinds of interventions, these personalized interventions. There are other brief interventions where that is not the case. So it's one time and then they take that information and go with it. And then we follow them for six months to see if there's any change.

The study abstract says that this intervention makes liberal use of pictures and graphs. Why is that?

MC: Before we jumped into the clinical trial, we did a lot of work to try to update and revise the intervention to make it look new, to make sure that we were giving Veterans content in a way that was digestible. It wasn't text-heavy, but as you say, it had images and graphs that were easy to understand and comprehend. So we did a lot of upfront work to make sure the intervention was understandable, that Veterans liked it, and could understand the content, before we actually started this larger trial. I think it was critical before we jumped into the study looking at effectiveness.

KH: I agree with that. I think it's important to mention that's what VA and HSR&D supported, in part, was making sure that the intervention would fit the people we were taking care of.

Your study mentions that there are newer drug therapies being used to treat hepatitis C, which have fewer side effects than older drugs. How is that changing your work with Veterans?

MC: That's a very good question. The short answer is we are not entirely sure yet. It has been a moving target. The VA has been really at the forefront of implementing these wonderful treatments for hepatitis C, which in my understanding require the Veteran to take them for shorter periods of time. They also have fewer side effects and fewer contraindications, so more people can take them who have more health conditions. How that's affecting this study has been a big question over the course of it. One thought is, it is perhaps changing the landscape of the clinic a bit. The characteristics of users, the people coming into these liver clinics have changed. And we are not entirely sure what that means.

For example, in some of our recruitment efforts in some of the clinics, at different times, we have noticed that the number of Veterans who have been drinking, at least more recently, has declined. That isn't based on any big study. This is sort of our anecdotal observation of what we are seeing. I don't know if this is across the nation, or if it pertains just to the two clinics where we are doing our study.

It does seem to be apparent that the characteristics of Veterans who are coming in for treatment are changing a bit. I think we'll start to learn more as researchers start to investigate the characteristics of Veterans that are coming in now, and we'll start to see bigger papers come out of the national VA data looking at that research question.

Why is it that Veterans with hepatitis C have higher rates of alcohol use disorders?

MC: I thought long and hard about it when you sent the question to me. It is true — we do know Veterans with substance use disorders have high rates of hepatitis C infection and vice versa. And the literature shows us that having a substance use disorder is really a predisposing factor for hepatitis C infection.

But to my knowledge the exact pathways by which having a substance use disorder may put you at risk for hepatitis C infection have remained unclear. It really hasn't been spelled out in the literature. Certainly we can speculate about that: having a substance use disorder puts you at greater risk for activities, for example, that might lead to exposure to hepatitis C or HIV— like unsafe sex.

KH: You engage in behaviors that might convey risk, but you are still not going to get hepatitis C or HIV without the virus. One thing that is strongly suspected for HIV acquisition is that the heavy alcohol use suppresses the body's immune response. I am not a gastroenterologist or hepatologist, so I don't know if that is true of hepatitis C or not, but it wouldn't be surprising.

So does this mean that your study is very important for this subset of Veterans who are heavy alcohol users?

MC: Yes, I think that is true. Especially pertaining to liver health, there's evidence that suggests that even low or moderate drinking can harm the liver in people with hepatitis C. So what might be low-risk drinking for a healthy adult in his 40s, would not be low-risk drinking for an adult in his 40s with hepatitis C. Even beyond having an alcohol use disorder, for people who are consuming even low to moderate levels of alcohol, I think there is benefit in reducing that level of alcohol use as well.

KH: Our VA partners are committed to roll this intervention out if it works. That was one of the key points of the CREATE project. We aren't doing this because we are trying to prove a theory or just get another paper on our vitae. This is something affordable, scalable, and if it works, VA is committed to giving this to everybody, and giving it to other health care systems too if they want to use it. All the clinics can have it for free, as far as we are concerned.

Isn't that often the case, that VA innovations are eventually adopted in the larger medical community?

KH: Yes that is often true. In fact, that's been particularly true in addiction. If you look over the last 40 years, it is very, very hard to think of a psycho-social treatment or a pharmacotherapy for addiction that was not tested in the VA. The critical studies on disulphiram, buprenorphine, naltrexone, some of the classic studies on cognitive behavioral treatment and 12-step treatment programs, were all done in the VA. VA has been a leader in substance use disorders for half a century. So this is definitely a good springboard. If this works, I think VA has the "cred" to help this translate to people outside our health care system who are trying to work with people who have problems with substances.

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