According to the VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders, patients who screen positive for unhealthy alcohol use, but do not have a diagnosed alcohol use disorder (AUD), should be provided a single initial brief intervention regarding alcohol-related risks and the advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly alcohol consumption.

Overall Treatment Considerations

Department of Defense (DOD) Instruction 1010.04 Problematic Substance Use by DOD Personnel outlines procedures for problematic alcohol and drug use prevention, identification, diagnosis, and treatment for DOD military and civilian personnel. Providers within the Military Health System (MHS) should consult DOD Instruction 1010.04, other relevant-DOD policies and individual service level policies for overall guidance and procedural requirements. Further, providers should consult the evidence-based treatment recommendations in the VA/DOD substance use disorder clinical practice guideline along with individual patient needs and characteristics, to include patient preferences and provider competencies, when making treatment decisions.

Per the clinical practice guideline, providers should offer referral for specialty AUD care for patients if they are diagnosed with an AUD that may benefit from additional evaluation of their alcohol use and related problems, or are willing to engage in specialty care. There are many factors that help to determine the appropriate level of care for AUD treatment, such as patient preference, patient motivation, patient willingness and available resources. There is no clear evidence to support using a standardized assessment to determine initial intensity and setting of AUD care rather than the clinical judgment of trained providers.

For patients with AUD in early recovery or following relapse, providers should promote active involvement in group mutual help programs using a systematic approach such as peer linkage, network support or 12-step facilitation. Patients in intensive outpatient or residential treatment should be offered ongoing systematic relapse prevention efforts or recovery support individualized on the basis of treatment response. Patients who do not respond to treatment or relapse should not be automatically discharged from treatment.

Recommended Treatment Options

Psychosocial interventions and pharmacotherapy treatment options are recommended for patients with alcohol use disorders. Providers should consider patient preference as well as their own competencies when selecting which intervention to offer.

Psychosocial Interventions

The following psychosocial interventions are recommended per the VA/DOD substance use disorders clinical practice guideline.

• Cognitive behavioral therapy focuses on teaching patients to modify both thinking and behavior related to alcohol use, as well as to change other areas of life functionally related to alcohol use through techniques such as structured practice outside of session, including scheduled activities, self-monitoring, thought recording and challenging, and interpersonal skills practice.
• Community reinforcement approach is a comprehensive cognitive-behavioral intervention that focuses on environmental contingencies that impact and influence a patient’s behavior through increasing positive reinforcement, learning new coping behaviors and involving significant others in the recovery process.
• Motivational enhancement therapy uses principles of motivational interviewing to heighten awareness of ambivalence about change, promote commitment to change and enhance self-efficacy through a structured intervention based on systematic assessment with personalized feedback.
• 12-step Facilitation aims to increase the patient’s active involvement in Alcoholics Anonymous (AA) or other 12-step-based group mutual help resource delivered as 12 sessions of individual therapy in which a provider encourages engagement with AA and walks a patient through the first steps of AA.
• Behavioral couples therapy focuses both on reducing alcohol use in the identified patient and on improving overall marital satisfaction for both partners using a series of behavioral assignments to increase positive feelings, shared activities and constructive communication.

Pharmacotherapy

For patients with moderate to severe alcohol use disorder, there are several pharmacotherapy treatments recommended, to include the following medications:

• Acamprosate
• Disulfiram
• Naltrexone — oral or extended release
• Topiramate

For patients for whom first-line pharmacotherapy is inappropriate or ineffective, there is some evidence to support offering gabapentin as an alternative pharmacotherapy. For more information regarding pharmacotherapy, refer to the VA/DoD substance use disorders clinical practice guideline or consult with a medical provider.

Medications for the Treatment of Alcohol Use Disorder is a brochure that can be provided to patients to explain alcohol use disorder and recommended treatments.