(92) Military and Veteran Intensive Clinical Program with Alcohol and Substance Use Treatment

Background & Introduction: Active-Duty service members and veterans experiencing posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) may suffer from decreased resilience and optimism along with increased loneliness.1 These conditions are also associated with decreased treatment adherence, and increased risk of morbidity and mortality, depression, suicide, and alcohol use disorders.2 Alcohol use is highly comorbid with combat exposure, with significantly higher rates of use post-deployment than pre-deployment3, but due to stigma is often undertreated, particularly among active-duty service members.4 The Home Base Intensive Clinical Program (ICP) is a comprehensive evaluation and treatment model for PTSD and TBI.5 The voluntary Dual Recovery (DR) supplement to the ICP launched in 2021 to increase access to and facilitate successful completion of ICP for patients who are also in early recovery or are managing active substance misuse. The DR supplement includes enhanced screening and case management during the ICP admissions process. A clinician trained in addiction treatment conducts an educational meeting the week prior to arrival and six additional individual therapy sessions during their treatment incorporating Motivational Interviewing and cognitive-behavioral strategies. A Recovery Coach is available to all patients during ICP and sends DR participants non-demand caring contacts for at least one year following program completion.

Methods: The sample included patients who attended the ICP between November 2021 and November 2023 (n = 896). Of those, 179 were in the DR track and 714 in the non-DR track. This analysis specifically sought to determine whether there was a difference in treatment outcomes in veterans (n = 609) versus active-duty service members (n = 265), and whether participation in the DR track significantly influenced treatment outcomes with regard to substance use.
Measures included the BAM-R (Brief Addiction Monitor-revised) and AUDIT-C (Alcohol Use Disorders Identification Test), as well as abstinence scores for various substances. We compared pre- and post-treatment measures between veterans and active-duty service members, and DR track patients and non-DR track patients. We excluded participants with missing data or who did not complete the program and therefore did not complete post-treatment measures (n = 42). Pre- and post-treatment score changes were measured through a series of paired samples t-tests split by military status, and again by whether patients participated in the DR track. Effect sizes were also conducted (Cohen’s d). A chi-square test between military status and DR track participation was also conducted.

Results: Both veterans and active-duty service members, as well as patients who were in the DR track and non-DR patients, experienced a statistically significant improvement in AUDIT-C scores (p = <.001), alcohol abstinence scores (p = <.001), and marijuana abstinence scores (p = <.001). Participants who were active-duty service members also experienced a statistically significant improvement in BAM-R risk scores (p = .009) and tobacco abstinence scores (p = .002). Both DR track patients and non-DR track patients experienced a significant change in tobacco abstinence scores (p = .009; p = .008). Interestingly, non-DR track patients exhibited a significant change in BAM-R risk scores (p = .009), whereas DR track patients did not. The chi-square test revealed a significant relationship between track category and military status (p = <.001). The large treatment effect in both Non-DR and DR track participants and in active-duty service members and veterans may be secondary to the robust massed therapy and holistic/integrative aspects including Resilient Warrior and health and wellness. Active-duty service members may also be more motivated for abstinence due to work.
Of the measure changes that experienced statistically significant improvements, DR track alcohol abstinence scores had the largest effect size (Cohen’s d = -.878), with non-DR track alcohol abstinence scores yielding a more moderate effect size (Cohen’s d = -.640). The analyses also observe a similar difference in effect size for DR track marijuana abstinence scores (Cohen’s d = -.612) and non-DR track marijuana abstinence scores (Cohen’s d = -.405). This indicates that the DR track may result in more clinically significant improvement in abstaining from alcohol and marijuana use than the non-DR track, but still displays that non-DR track patients experience a significant improvement in abstinence regardless. The association between track category and military status as observed by the chi-square test is further explained by the contrast between expected and observed counts. There are fewer active-duty service members in the DR track than expected (expected = 52.9; observed = 47), and more in the non-DR track than expected (expected = 211.5; observed = 218). Similarly, there are more veterans in the DR track than expected (expected = 121.9; observed = 125), and slightly fewer in the non-DR track than expected (expected = 486.8; observed = 484). This suggests that active-duty service members might be more reticent than veterans to pursue substance use treatment.

Conclusion & Discussion: These results support the feasibility and effectiveness of treating alcohol and substance use concerns concurrently with, and as a secondary rather than primary treatment target, among veterans and service members with PTSD and TBI. In addition to individual and group treatment focusing on PTSD, TBI, and the DR supplement, the ICP participants receive integrative health approaches including Resilient Warrior (mindfulness, stress management) and health and wellness (art therapy, exercise, nutrition, and yoga), peer-to-peer veteran and family outreach. All ICP patients, regardless of DR status, also attend an educational group on the impact of alcohol and substance use in mental health. Limitations include the robust aspects of the ICP itself, regardless of DR and Non-DR track.

References: 1. Chen JI, Hooker ER, Niederhausen M, et al. Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients. Soc Psychiatry Psychiatr Epidemiol. 2020 May;55(5):589-597. doi: 10.1007/s00127-019-01785-9. Epub 2019 Nov 6.
2. Zulman DM, Pal Chee C, Wagner TH, et al. Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ Open. 2015 Apr 16;5(4):e007771. doi: 10.1136/bmjopen-2015-007771.
3. Meadows SO, Beckman R, Engel CC, Jeffery DD. The Culture of Alcohol in the U.S. Military: Correlations With Problematic Drinking Behaviors and Negative Consequences of Alcohol Use. Armed Forces & Society, 2023, 49(2), 531–555. doi: 10.1177/0095327X211069162
4. Walker, D. D., Walton, T. O., Neighbors, C., Kaysen, D., Mbilinyi, L., Darnell, J., ... & Roffman, R. A. (2017). Randomized trial of motivational interviewing plus feedback for soldiers with untreated alcohol abuse. Journal of consulting and clinical psychology, 85(2), 99.
5. Harvey M, Petersen T, Sager J. An intensive outpatient program for veterans with posttraumatic stress disorder and traumatic brain injury. Cognitive Behavioral Practice. 2019; 26: 323-334.