VAMC Durham Substance Abuse Overview: Greg Hughes, MSW, LICSW Chief, Social Work Services

Population Served Approximately 50,000 unique patients served through Durham, Raleigh, Greenville and Morehead City. 4,500 of these are returning OEF-OIF OIF veterans. Durham has seen an 6% increase in population served over past year and 13% increase in number of visits. Projection is for this to continue as many units to return and deployments continue.

Population Served 2 distinct populations being served older veterans age 55 and up Vietnam through WWII and OEF-OIF OIF veterans ages 18-30+. Present somewhat different challenges and treatment approaches in terms of substance use.

Non-OEF-OIF OIF Veteran Average age: 55 Out of military 30 years Married/divorced more than once Considering retirement or unemployed High rate of Homelessness Significant medical issues r/t use Previous treatments Lack of primary support Vietnam Era Veteran Multiple MH diagnoses

OEF-OIF OIF Veteran Average age: 26 Out of military 0-5 years Never married, hoping to get a date Going to school, work, AND planning career Living with parents (or roommates) Comparatively good health First treatment Parents are big support 56% OEF/OIF PTSD or comorbid Anxiety and/or Mood Disorders

OEF-OIF OIF Veterans In the most recent Department of Defense anonymous Survey of Health Related Behaviors Among Active Duty Personnel 23% acknowledge a significant alcohol problem Alcohol related incidents (e.g. DUI, drunk and disorderly) reported in the Army Forces Command database increased from 1.73 per 1,000 soldiers in 2005 to 5.71 in 2006. Alcohol contributed to 65% of the markedly increased incidence of suicidal behavior in the military In a recent study of returning National Guard, 24% reported alcohol abuse Rates of all psychological problems including substance abuse increase with repeated deployments

OEF-OIF OIF Veterans Report Problematic use prior to military service DOCs: Alcohol, marijuana, opiates, cocaine, nicotine Heavy, frequent binge use or daily use Failed school, lost jobs, parents/friends concerned Increased isolation to hide use or avoid trouble Increased risk of self harm or harm to others when intox. Increase in use since return from war Use of marijuana to aid with sleep or to relax Use to cope with mood/anxiety/ptsd Want to quit or reduce use (e.g. quit ETOH, MJ to sleep) Usually a positive family hx of substance abuse/depend.

OEF-OIF OIF Typically general adjustment problems are more important than their substance use. Increased difficulty making appointments due to work or family conflicts. Difficulty transitioning from military healthcare model to VA or civilian. Brief intervention models have been showing good success focusing on presenting problems.

VA Substance Abuse Treatment Model (primary care) ASSESSMENT AND DIAGNOSIS Use a standardized alcohol screening procedure (e.g., the CAGE or AUDIT). Arrange detoxification or stabilization, if indicated. Identify patients with hazardous substance use who should receive a brief intervention. Identify patients with substance abuse or dependence who require a referral to specialty care. BRIEF INTERVENTION Give feedback about screening results and health risks. Inform about safer consumption limits. Assess readiness for change. Negotiate goals and strategies for change. If unsuccessful, consider referral to specialty care.

VA SA Model REFERRAL TO SPECIALTY CARE Referral to specialty care is clinically indicated for substance dependence. Help overcome barriers to successful referral. CARE MANAGEMENT Document specific substance use at each contact by patient report (e.g., number of drinking or substance-using using days in the past month and typical and maximum number of drinks per occasion.) Monitor biological indicators (e.g., transaminase levels and urine toxicology screens) and discuss results with the patient. Encourage reduction or cessation of use at each visit and support motivation to change. Recommend self-help groups. Address or refer for social, financial, and housing problems. Coordinate treatment with other care providers. Monitor progress and periodically assess for possible referral to specialty care rehabilitation. FOLLOW-UP Monitor substance use and encourage continued reduction or abstinence. Educate about substance use and associated problems.

VA Substance Abuse Treatment Specialty Care Model ASSESSMENT AND DIAGNOSIS Identify the patient's current problems, relevant history, and life context as a basis for the integrated summary and initial treatment plan. Identify the patient who does not require specialty care and coordinate with primary care. Complete the Addiction Severity Index. Integrate and prioritize biopsychosocial assessment information as a basis for formulating the diagnosis and treatment recommendations.

VA SA Specialty Care TREATMENT Actively involve the patient in the creation of a treatment plan. Determine, along with the patient, the most appropriate treatment approach. Clarify and/or encourage patient commitment to rehabilitation goals. Identify the least restrictive level of initial treatment intensity that will safely help the patient achieve early remission and prevent relapse. Facilitate access to treatment and promote a supportive recovery environment. Initiate addiction-focused psychosocial treatment including self-help group involvement. Consider addiction-focused pharmacotherapy for all patients Individualize treatment to address co-morbid conditions. Summarize, simplify, and solidify the recovery plan to maximize the patient's chances for achieving his/her rehabilitation goals. FOLLOW-UP Periodically reassess response to treatment, change in treatment goals, or other indications for change in the treatment plan. Provide appropriate continuity of care with primary medical or behavioral health care providers. Promote abstinence or reduced use.

VA s SA Treatment in NC Crisis/Assessment Services available through PEC/ER. Medical detox through inpatient psychiatry unless patient is medically unstable then through medicine. SA clinician is available for any inpatient consult for SA screening or brief interevntion. Outpatient detox is available on limited basis.

VA s SA Treatment in NC NA and AA meetings held weekly on inpatient unit. SAOP program offers low intensity individual and group treatment as well as psychiatric care. Patients typically seen 1-3x week. Buprenorphine induction and treatment available. Inpatient Residential Rehabilitation programs in Salem, Hampton, Salisbury and Asheville.

VA s SA Treatment in NC Programs range from 21-35 days in length with Hampton VA offering 2-4 month rehab program as well. Wait times vary, bed availability is limited. Community resources are also often utilized. New program to open in Raleigh tentatively 1/09 IOP that will work closely with Wake County shelters.