Considerations for Enhanced Alcohol and Substance Use Assessment as Veterans Affairs (VA) Prepares for Increased Substance Treatment Services in Primary Care Settings

Katherine Buckheit, PhD^✉; Julie Gass, PhD^✉; Jennifer Funderburk, PhD^✉; and Tanya Bowen, PhD; Military and Veterans' Health and Integrated Primary Care SIGs

Alcohol/substance use are prevalent among service members and Veterans. The Veterans Health Administration (VHA) Strategic Plan has prioritized access to substance treatment via integrated behavioral health providers (BHPs) in primary care (PC). As service provision for alcohol/substance use evolves, so should its assessment. Assessment of substance use and related problems using standardized measures is largely absent in PC other than annual administration of the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C), which only assesses alcohol consumption and may not be adequately sensitive to change to monitor treatment progress. The purpose of this article is to highlight validated measures of alcohol and substance use for screening/monitoring alcohol and substance treatment progress in PC. The particular measures selected were intended to provide a comprehensive and complementary range of assessment options that is highly feasible in primary care settings.

CAGE-AID (Brown et al., 1998) is a four-item measure that assesses alcohol/substance-related problems that correspond to DSM-5 symptoms of alcohol and substance use disorder (AUD/SUD) (i.e., have you ever felt the need to cut down on your drinking/drug use; have people annoyed you by criticizing your drinking/drug use; have you ever felt guilty about your drinking/drug use; have you ever felt you needed a drink/drug first thing in the morning (eye-opener)). The CAGE-AID complements the assessment of consumption (i.e., the AUDIT-C), while its brevity and ease of administration and scoring render it feasible for PC. However, a disadvantage of the CAGE-AID is that it may be overly broad due to its timeframe (lifetime use), particularly for monitoring treatment progress over time. The CAGE-AID is available from the US Health Services and Research Administration.

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST; Humeniuk et al., 2010) is an 8-item measure assessing lifetime and current use of substances and substance-related problems that correspond to DSM-5 symptoms of AUD/SUD. The ASSIST yields an overall risk score which maps directly onto a targeted intervention strategy in the ASSIST manual. Advantages of the ASSIST include its consolidation of assessment and intervention into one comprehensive package which is likely to facilitate implementation into PC settings. However, a disadvantage of the ASSIST is that it assesses lifetime and current use for 10 classes of substances, which may render it less feasible for patients using multiple substances within the time constraints of integrated PC settings. The ASSIST is available from the World Health Organization.

Brief Addiction Monitor (BAM; Cacciola et al., 2013) and its revision (BAM-R; Hallinan et al., 2021) include 17 items that assess alcohol/substance consumption, risk factors, and protective factors. The BAM has been adopted by many VA substance use clinics to monitor treatment progress. An advantage of the BAM is that it is the most comprehensive of the included measures in its assessment of substance use and related factors (i.e., risk and protective factors). However, this can also be a disadvantage in primary care settings. The BAM is longer than most measures used in PC, however it may be appropriate during behavioral health treatment in PC. Online/mobile platforms to support measurement-based care (MBC) (i.e., VHA’s Mental Health Checkup) allow patients to complete measures at home in advance of a session. Additionally, although use of the aggregate and subscale scores is recommended, the BAM also screens for health, mood, substance use, craving, income, social support, and treatment satisfaction based on single items. The BAM is available from the VA Center for Integrated Healthcare.

This article offers suggestions for enhanced assessment of alcohol and substance use in PC for consideration by both VHA and non-VA providers.  The CAGE-AID, ASSIST, and BAM offer three alternatives to assess alcohol/substance use and monitor treatment progress in PC with complementary strengths and weaknesses. Factors such as time (i.e., a warm handoff versus follow-up) and patient characteristics (e.g., polysubstance vs. monosubstance use; comfort with technology) should be taken into consideration as providers choose among these measures. As the VHA strives for alcohol and substance use services in PC settings, assessment of outcomes may need adaptations. MBC is crucial to integrated PC settings to inform clinical care via reliable, validated measures administered at consistent intervals. MBC facilitates shared-decision making, ongoing treatment monitoring and treatment planning, may reduce stigma, and can improve outcomes, yet has not been widely adopted in the practice of treating alcohol/substance use problems. Providers should strive to incorporate MBC via reliable, validated measures such as those presented in this article when providing treatment for substance use in primary care.

 

References

• Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (1998). The prevalence and detection of substance use disorders among inpatients ages 18 to 49: An opportunity for prevention. Preventive Medicine, 27(1), 101-110. https://doi.org/10.1006/pmed.1997.0250
• Cacciola, J. S., Alterman, A. I., DePhilippis, D., Drapkin, M. L., Valadez Jr, C., Fala, N. C., Oslin, D., & McKay, J. R. (2013). Development and initial evaluation of the Brief Addiction Monitor (BAM). Journal of Substance Abuse Treatment, 44(3), 256-263. https://doi.org/10.1016/j.jsat.2012.07.013
• Hallinan, S., Gaddy, M., Ghosh, A., & Burgen, E. (2021). Factor structure and measurement invariance of the Revised Brief Addiction Monitor. Psychological Assessment, 33(3), 273-278. https://doi.org/10.1037/pas0000973
• Humeniuk, R., Henry-Edwards, S., Ali, R., Poznyak, V., & Monteiro, M. G. (2010). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. (9522727083). Geneva, Switzerland: World Health Organization