What are Alcohol and Substance Use Disorders (ASUD)?
Alcohol and Substance Use Disorders: The misuse, dependence, and addiction to alcohol and/or legal or illegal drugs. Substance use disorders (SUD) encompass a range of severity levels, from problem use to dependence and addiction. Often, ASUDs result in significant impairment in daily life or noticeable distress, including health problems, disability, and failure to meet major responsibilities at work, school, or home.
Alcohol Use Disorder (AUD): Excessive alcohol use can increase a person’s risk of developing serious health problems in addition to those issues associated with intoxication behaviors and alcohol withdrawal symptoms. To be diagnosed with an AUD, individuals must meet certain diagnostic criteria. Some of these criteria include problems controlling intake of alcohol, continued use of alcohol despite problems resulting from drinking, development of a tolerance, drinking that leads to risky situations, or the development of withdrawal symptoms. The severity of an AUD—mild, moderate, or severe—is based on the number of criteria met.
Opioid Use Disorder (OUD): Opioids reduce the perception of pain but can also produce drowsiness, mental confusion, euphoria, nausea, constipation, and, depending upon the amount of drug taken, depressed respiration. Illegal opioid drugs, such as heroin, and legally available pain relievers, such as oxycodone and hydrocodone, can cause serious health effects in those who misuse them. Some people experience a euphoric response to opioid medications, and it is common that people misusing opioids try to intensify their experience by snorting or injecting them. These methods increase their risk for serious medical complications, including overdose. Symptoms of opioid use disorders include strong desire for opioids, inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use opioids, and withdrawal symptoms that occur after stopping or reducing use.
How common are ASUDs?
In 2018, approximately 22 million people aged 12 and older had at least one alcohol and substance use disorder (ASUD), including alcohol use disorder and illicit drug use disorder. Of those 22 million, an estimated 15 million which equates to 5.4% of the population or 1 in 19 people had an alcohol use disorder [1]. In a recent national-representative sample of VA patients Alcohol was the most prevalent substance used in the population followed by cannabis. The highest SUD prevalence was in young Veterans and those who were not employed [2].
ASUD in the US Military
Substance use has been emphasized as a major concern for military Veterans [2]. A 2011 Department of Defense (DoD) study estimated that nearly 17% of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans suffer from substance abuse problems, nearly twice the rate of the general population [3,4]. While only a short while later, drug misuse in veterans increased from 14% in 2010 to 21% in 2016; a 1% increase per year [5]. Higher environmental stressors associated with combat level increase the likelihood of veterans to engage in binge drinking to 54.8% compared to the civilian population [6, 7]. Approximately, 11% of veterans at their first treatment at a VA healthcare facility met criteria for a diagnosis of SUD [6]. In a national-representative sample of VA patients, we found a higher prevalence of substance use and related disorders than has been previously reported. These are conditions with severe health consequences, including early mortality, and accurate estimates of population prevalence are essential for program planning and resource allocation.
ASUD and Comorbidities
Alcohol and Substance Use Disorders (ASUDs) are often associated with negative mental health disorders such as post-traumatic stress disorder (PTSD), the known ‘signature wound’ of OEF and OIF [4,6]. Of the OEF and OIF veterans who have utilized VA health care between October 1, 2001 and December 31, 2014, over 30% met the criteria for possible diagnosis of PTSD [8]. Comorbid PTSD and ASUD exacerbate symptoms as compared to having PTSD or ASUD alone and are highly comorbid among OEF and OIF service members.
An additional study showed that veterans with probable AUD, 20.3% met criteria for probable PTSD. Among those, with probable PTSD, 16.8% met criteria for probable AUD. Compared to veterans with AUD only, veterans with AUD/PTSD were more likely to screen positive for major depression (36.8% vs. 2.3%), generalized anxiety disorder (43.5% vs. 2.9%), suicidal ideation (39.1% vs. 7.0%); to have attempted suicide (46.0% vs. 4.1%); and to be receiving mental health treatment (44.8% vs. 7.5%). Veterans with comorbid AUD/PTSD were more than three times as likely as veterans with PTSD only to have attempted suicide in their lifetimes [9]. Given the high comorbidity of PTSD and ASUD and the greater symptom severity associated with having coexisting disorders, there is a critical need to treat PTSD and ASUD concurrently.
ASUD Treatment [10]
Addiction is a treatable, chronic disease that can be managed successfully. Research shows that combining behavioral therapy with medications, where available, is the best way to ensure success for most patients. Treatment approaches must be tailored to address each patient’s drug use patterns and drug-related medical, psychiatric, and social problems. Treatment may include individual and group counseling, inpatient and residential treatment, intensive outpatient treatment, partial hospital programs, case or care management, medication, recovery support services, 12-Step fellowship, and peer support. For many people, the most effective behavioral health approach involves a combination of counseling and medication.
Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken.
There are multiple FDA-approved medications for AUD, OUD, and PTSD diagnosis; however, none of these combined disorders have FDA-approved pharmacotherapies, and while TBI is of interest, there is no FDA-approved specific pharmacotherapy.
Why is the PASA needed and how will it help advance ASUD prevention and treatment?
The goal of the Alliance is to fund research for developing new medications that can be brought to therapeutic use to improve treatment outcomes for ASUD, especially in the presence of PTSD and traumatic brain injury (TBI). These medications will ideally address the comorbidity between ASUDs and PTSD because this comorbidity is common in a military population along with mild to moderate TBI.
Along with an observed lack of integration in care for ASUDs with behavioral health and medical care, a 2013 IOM report found that use of pharmacotherapy-based treatment options tended to be limited in the military, despite the availability of a solid evidence base regarding their effectiveness [11]. Additionally, the potential for side effects and poor patient treatment may make the FDA medications currently approved for the treatment of alcohol dependence less-than-ideal options. Thus, new pharmacotherapies for treatment of ASUD are sorely needed.
The Alliance uses a state-of-the-art translational approach (from animal models to humans) to understand the complex interaction of substance abuse with the now-common military stress comorbidity of associated PTSD and TBI.
Updated Sources:
[1] Substance Abuse and Mental Health Services Administration (SAMHSA). Substance use disorders. Retrieved from https://www.samhsa.gov/data/sites/default/files/
[2] Hoggatt, K. J., Harris, A. H. S., Washington, D. L., & Williams, E. C. (2021). Prevalence of substance use and substance-related disorders among US Veterans Health Administration patients. Drug and Alcohol Dependence, 225, 108791. https://doi.org/10.1016/j.drugalcdep.2021.108791
[3] Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/
[4] Bagalman, Erin. (2011). Congressional Research Service: Suicide, PTSD, and substance use among OEF/OIF veterans using VA health care: Facts and figures (July 18, 2011). Report prepared for members and committees of Congress.
[5] Lin, Lewei Allison, et al. "Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans." American journal of preventive medicine 57.1 (2019): 106-110.
[6] Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. E. (2017). Substance use disorders in military veterans: prevalence and treatment challenges. Substance abuse and rehabilitation, 8, 69–77.
[7] Bray RM, Brown JM, Williams J. Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the U.S. military. Subst Use Misuse. 2013 Jul;48(10):799-810. doi: 10.3109/10826084.2013.796990. PMID: 23869454.
[8] Veterans Health Administration Office of Public Health (2015). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans: Cumulative from 1st Qtr FY 2002 through 2nd Qtr FY 2015 (October 1, 2001-March 31, 2015). Retrieved from: http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2015-qtr2.pdf
[9] Norman SB, Haller M, Hamblen JL, Southwick SM, Pietrzak RH. The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: Comorbidities, functioning, and suicidality. Psychol Addict Behav. 2018 Mar;32(2):224-229. doi: 10.1037/adb0000348. PMID: 29553778.
[10] Substance Abuse and Mental Health Services Administration (SAMHSA). Substance use disorders. Retrieved from http://www.samhsa.gov/disorders/substance-use
[11] Institute of Medicine. (2013). Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, D.C.: National Academies Press.