About Substance Abuse

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?

An estimated 21.5 million people aged 12 and older (8.1% of the population; 1 in 12 individuals) had at least one alcohol and substance use disorder (ASUD), including AUD and OUD, in 2014. An estimated 17 million people aged 12 and older (6.4% of the population; 1 in 15 individuals) had an AUD in 2014.  

ASUD in the US Military 

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 [2, 3]. The report found that overall civilian rates of prescription drug misuse was about 4%, while the rate for veterans was about 11.7% – nearly 2.5 times higher than the civilian rate [4]. Prescription drug misuse among the active duty component nearly tripled from 2005 to 2008, from 4% to 11% [4]. Another study found that 25% of soldiers screened positive for alcohol misuse 3-4 months after returning from deployment to Iraq; 12% screened positive for alcohol-related problems [5]. In 2012, the Institute of Medicine (IOM) declared SUD among military personnel and Veterans to be a ‘public health crisis’ in response to the rising rates of SUD and the higher prevalence of SUD among military populations [6]. 

ASUD and Comorbidities 

Post-traumatic stress disorder (PTSD) is known as a ‘signature wound’ of OEF and OIF [7]. 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. PTSD and ASUD are highly comorbid among OEF and OIF service members. Of those with an AUD, 63% received a comorbid diagnosis of PTSD; of those with a drug use disorder, 63% received a comorbid diagnosis of PTSD; and of those with both an AUD and a drug use disorder, 76% received a comorbid diagnosis of PTSD [9]. Those with comorbid ASUD and PTSD are likely to experience greater symptom severity, clinical/medical and functional impairments, risk of suicidality, and negative treatment outcomes than those with either disorder alone [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 AUD concurrently. 

ASUD Treatment [1]

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. 

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; however, while TBI is of interest, there are no FDA-approved specific pharmacotherapy and none of these combined disorders have FDA-approved pharmacotherapies.

Why is the PASA Consortium needed and how will it help advance ASUD prevention and treatment? 

The goal of the PASA Consortium 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 [7]. 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 PASA Consortium 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. 

 

Sources:

[1] Substance Abuse and Mental Health Services Administration (SAMHSA). Substance use disorders. Retrieved from http://www.samhsa.gov/disorders/substance-use

[2] 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/ 

[3] 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.

[4] Department of Defense (2013). 2011 Health Related Behavior Survey of Active Duty Military Personnel, Final Report, February 2013, Department of Defense. Retrieved from http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty-survey-report.pdf

[5] Wilk, J. E., Bliese, P. D., Kim, P. Y., Thomas, J. L., McGurk, D., & Hoge, C. W. (2010). Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war. Drug and Alcohol Dependence, 108(1–2), 115–121.

[6] Institute of Medicine (IOM). 2012. Substance use disorders in the U.S. armed forces. Washington, DC: The National Academies Press.

[7] 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.

[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] Seal, K. H., Cohen, G., Waldrop A., Cohen, B. E., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116(1-3), 93-101.