Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review

Introduction

Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU.

Methods

A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized.

Results

One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems.

Discussion

Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility.

Systematic Review Registration

Open Science Framework doi: 10.17605/OSF.IO/S849R.

Alcohol Treatment Access and Engagement Among Women in the USA: a Targeted Review of the Literature 2012-2022

Purpose of Review

The purpose of this review is to examine recent literature (2012-2022) on alcohol treatment access and engagement in women in the U.S. and propose future directions for research and clinical practice.

Recent Findings

A targeted literature review resulted in 27 studies encompassing screening and brief intervention (SBIRT), treatment utilization, treatment engagement, and barriers to treatment. Recent literature demonstrates overall low rates of screening and brief interventions and treatment utilization in the population with women less likely to be screened and utilize alcohol treatment. The magnitude of these gender differences varies with race/ethnicity. Extensive barriers to care include provider knowledge, structural barriers, and attitudinal barriers and these vary with service setting, gender, and race/ethnicity.

Summary

There is an increasing prevalence of alcohol use and Alcohol Use Disorder (AUD) in women with low rates of screening, brief treatment, treatment, and engagement which have resulted from extensive barriers to care. Possible areas of further inquiry include the impact of race/ethnicity on gender differences, improving provider and system level policies to promote SBIRT and treatment engagement and utilization, further developing digital interventions, and implementation research to investigate factors associated with optimizing effectiveness of gender-responsive and culturally tailored interventions that address the unique needs of women.

The role of gender and veteran status in healthcare access among a national sample of U.S. adults with unhealthy alcohol use

Background: Routine healthcare access is critical to reduce drinking and its effects, yet little is known about Veteran and gender differences in routine healthcare access among unhealthy drinkers. The current study examined differences in routine healthcare access, stratified by Veteran status and gender, among a national sample of adults endorsing unhealthy drinking. Method: Using data from the Centers for Disease Control and Prevention's 2019 Behavioral Risk Factor Surveillance System National Survey, we identified adults who endorsed unhealthy drinking over the past month (N = 58,816; 41.4% female; 2.7% female Veterans). Bivariate and multivariable analyses modeled associations between gender, Veteran status, and their interaction in predicting routine healthcare access. All multivariable models adjusted for sociodemographic characteristics. Results: Veterans with unhealthy alcohol use reported high rates of routine healthcare access (e.g., >86% sought care in the past 2 years) and were less likely to experience a cost barrier to care (aOR = 0.75, 95% CI = 0.62-0.92). Females were more likely than males to report better access to care but also to experience a cost barrier (aOR = 1.2, 95% CI = 1.10-1.37). The interaction between Veteran status and gender was non-significant. Conclusions: Overall, healthcare access was better for Veterans and females with unhealthy alcohol use compared to civilians and males with unhealthy alcohol use. However, given that females were more likely to report a cost barrier, future implementation research aiming to improve equity in care may want to explore reasons for cost barriers and develop strategies to help reduce these barriers in order to eliminate gender disparities in primary care-based alcohol-related care.

Subjective recovery accounts of Japanese female patients suffering from alcohol use disorder. A phenomenological study

PURPOSE

This study aimed to examine the subjective recovery accounts of Japanese female patients with alcohol use disorder (AUD) and the factors that affect their recovery.

DESIGN AND METHODS

This qualitative study used a phenomenological design. A focus group with 10 Japanese participants was conducted.

FINDINGS

Five theme clusters emerged: drinking to forget unpleasant feelings, fighting compulsive cravings with craving, unhealed wounds from past traumatic experiences, encounters with role models in self-help groups, and changing one's mindset to a proactive pursuit of happiness.

PRACTICE IMPLICATIONS

To support the recovery of women with AUD, psychiatric nurses should help them improve their family relationships, find recovery models, and proactively provide them with trauma-informed care.

Alcohol use, behavioral and mental health help-seeking, and treatment satisfaction among sexual minority women

BACKGROUND

Sexual minority women (SMW) report higher rates of heavy episodic drinking (HED) and adverse alcohol-related outcomes, including poor mental health, than heterosexual women. These disparities indicate a greater need for behavioral and mental health treatment for SMW. This study examined associations among alcohol outcomes, behavioral and mental health help-seeking, and treatment satisfaction among SMW by age, sexual identity, race/ethnicity, and income.

METHODS

Participants included a community sample of 695 SMW (Mage  = 40.0, SD = 14.1; 74.1% lesbian, 25.9% bisexual; 37.6% White, 35.8% Black, 23.2% Latinx; 26.3% annual income $14,999 or less). We used bivariate analyses to characterize the sample's demographic characteristics and multivariable logistic regression analyses to examine associations among variables.

RESULTS

SMW subgroups based on age, race/ethnicity, and annual income differed in alcohol outcomes (i.e., HED, DSM-IV alcohol dependence, alcohol-related problem consequences, alcohol problem recognition, and motivation to reduce drinking); help-seeking; and treatment satisfaction. SMW who engaged in help-seeking for alcohol-related concerns were more likely than those who did not to meet criteria for DSM-IV alcohol dependence (adjusted odds ratio [aOR] = 7.13; 95% CI = 2.77; 18.36), endorse alcohol-related problem consequences (aOR = 11.44; 95% CI = 3.88; 33.71), recognize problematic drinking (aOR = 14.56; 95% CI = 3.37; 62.97), and report motivation to reduce drinking (aOR = 5.26; 95% CI = 1.74; 15.88). SMW's alcohol outcomes did not differ based on their satisfaction with treatment or with providers.

CONCLUSIONS

This study's findings confirm SMW's elevated risk for HED and other alcohol-related outcomes and underscore the importance of identity-affirmative and accessible behavioral and mental health treatment for young, Black, and low-income SMW. Clinicians and intervention scientists should develop or enhance existing brief behavioral and mental health treatments for SMW engaging in HED who may not recognize that their drinking is problematic or who are not motivated to reduce drinking.

Using practice facilitation to improve alcohol-related care in primary care: a mixed-methods pilot study protocol

Background

Alcohol use is a significant risk factor for disability and death in U.S. adults, and approximately one out of every six Veterans seen in primary care (PC) report unhealthy alcohol use. Unhealthy alcohol use is associated with increased risk for poor medical outcomes, substantial societal costs, and death, including suicide. Based on substantial evidence from randomized controlled trials and the U.S. Preventive Services Task Force, VA/DoD clinical guidelines stipulate that all Veterans screening positive for unhealthy alcohol use should receive evidence-based alcohol care in PC, including brief counseling interventions (BI) and additional treatment (e.g., pharmacotherapy) for those with alcohol use disorders (AUD). The VA pioneered implementing alcohol screening and BI in PC, yet substantial implementation gaps remain. To improve alcohol-related care, this study will conduct a pilot study to assess whether a multi-faceted evidence-based implementation strategy—practice facilitation—has the potential to improve PC-based alcohol-related care at a single VA clinic.

Methods

We will first recruit and conduct qualitative interviews with Veterans with unhealthy alcohol use (n = 20–25) and PC stakeholders (N = 10–15) to understand barriers and facilitators to high-quality alcohol care and use results to refine and hone the multifaceted practice facilitation intervention. Qualitative interviews, analysis, and refinement of the intervention will be guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups with a small sample of PC providers and staff (n = 5–7) will be used to further refine the practice facilitation intervention and assess its acceptability and feasibility. The refined practice facilitation intervention will then be offered in the PC clinic to assess implementation (e.g., reach) and effectiveness (reduced drinking) outcomes based on the RE-AIM framework.

Discussion

This research directly addresses one of the largest public health crises of our time, as alcohol kills more people than opioids and is associated with increased risk of suicide. If successful, this pilot may generate an intervention with far-reaching effects on adverse outcomes experienced by Veterans with unhealthy alcohol use, including increased access to care and suicide prevention.

Trial registration Clinicaltrials.gov identifier: NCT04565899; Date of registration: 9/25/2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00300-x.

Increased risk of dementia in older female US veterans with alcohol use disorder

AIM

To determine whether alcohol use disorder (AUD) is associated with increased dementia risk among older women veterans.

DESIGN

Cohort study.

SETTING

United States.

PARTICIPANTS

Women veterans with AUD aged ≥ 55 years (n = 2207), receiving care from Veterans Health Administration medical centers from October 2004 to September 2015 with one or more follow-up visit and an age-matched sample of women veterans without AUD (n = 2207). Women at baseline with prevalent dementia or AUD in remission were excluded.

MEASUREMENTS

AUD, substance use disorder (SUD), smoking, psychiatric (depression, anxiety, post-traumatic stress disorder, anxiety) and medical comorbidities (diabetes, hypertension, stroke, chronic obstructive pulmonary disorder, traumatic brain disorder) and dementia determined by the International Classification of Diseases, 9th revision, Clinical Modification codes. Cox proportional hazards models were used to determine the association between AUD and dementia risk during follow-up. Sensitivity analyses were performed by excluding women (n = 349) with comorbid SUD and by excluding women (n = 1568) currently smoking.

FINDINGS

Veteran women had a mean [standard deviation (SD)] age of 65.0 (5.6) years at baseline. During follow-up (median 4 years, interquartile range: 2-6) 3.7% of women (n = 82) with AUD developed dementia compared with 1.1% (n = 24) without AUD (P < 0.001). After adjustment for demographics, medical and psychiatric conditions and accounting for different Veteran's Integrated Service Networks, the adjusted hazard ratio (aHR) for dementia was 3.12 (95% CI = 1.90-5.12) for women with AUD compared with women without AUD. After removing women with SUD (aHR = 3.53, 95% CI = 2.13-5.85) and women currently smoking (aHR = 3.80, 95% CI = 2.11-6.84), results were similar.

CONCLUSIONS

Alcohol use disorder among female US veterans aged more than 55 years appears to be associated with a more than threefold increase of dementia.

Sex Differences in Opioid Use Disorder Prevalence and Multimorbidity Nationally in the Veterans Health Administration

Opioid use disorder (OUD) is a significant problem among US veterans with increasing rates of OUD and overdose, and thus has substantial importance for service delivery within the Veterans Health Administration (VHA). Among individuals with OUD, several sex- specific differences have begun to emerge regarding co-occurring medical, psychiatric and pain-related diagnoses. The rates of such multimorbidities are likely to vary between men and women with OUD and may have important implications for treatment within the VHA but have not yet been studied. Methods: The present study utilized a data set that included all veterans receiving VHA health care during Fiscal Year (FY) 2012 (October 1, 2011 through September 30, 2012), who were diagnosed during the year with opioid dependence or abuse. VHA patients diagnosed with OUD nationwide in FY 2012 were compared by sex on proportions with OUD, and among those with OUD, on sociodemographic characteristics, medical, psychiatric and pain-related diagnoses, as well as on service use, and psychotropic and opioid agonist prescription fills. Results: During FY 2012, 48,408 veterans were diagnosed with OUD, 5.77% of whom were women. Among those veterans with OUD, few sociodemographic differences were observed between sexes. Female veterans had a higher rate of psychiatric diagnoses, notably mood, anxiety and personality disorders, as well as higher rates of pain-related diagnoses, such as headaches and fibromyalgia, while male veterans were more likely to have concurrent, severe medical co-morbidities, including hepatic disease, HIV, cancers, peripheral vascular disease, diabetes and related complications, and renal disease. There were few differences in health service utilization, with women reporting greater receipt of prescriptions for anxiolytic/sedative/hypnotics, stimulants and lithium. Men and women did not differ in receipt of opioid agonist medications or mental health/substance use treatments. Conclusions: There are substantial sex-specific differences in patterns of multimorbidity among veterans with OUD, spanning medical, psychiatric and pain-related diagnoses. These results illustrate the need to view OUD as a multimorbid condition and design interventions to target such multimorbidities. The present study highlights the potential benefits of sex-specific treatment and prevention efforts among female veterans with OUD and related co-occurring disorders.

Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration

OBJECTIVE

Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use.

METHODS

Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender.

RESULTS

Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results.

CONCLUSIONS

Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.

Gender Differences in Use of Alcohol Treatment Services and Reasons for Nonuse in a National Sample

BACKGROUND

The majority of adults with alcohol use disorders do not obtain help, and women are less likely to utilize alcohol services than men. We sought to quantify gender differences in alcohol services utilization, overall and by type, using national longitudinal data and to explore potential gender differences in perceived need for help and reasons for not seeking help.

METHODS

We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions from White, African American, and Hispanic adults (n = 2,592) who met DSM-IV criteria for alcohol abuse or dependence at Wave 1 (2000 to 2001). We tested gender differences in Wave 2 (2004 to 2005) services utilization, perceived need for help, and treatment barriers using Rao-Scott chi-square tests and assessed predictors of outcomes in multivariable logistic regression, adjusting for problem severity, co-occurring disorders, and demographics.

RESULTS

Women had much lower odds than men of utilizing any alcohol service (adjusted odds ratio [aOR] 0.53; 95% confidence interval [95% CI]: 0.33, 0.86), specialty services (aOR 0.41; 95% CI 0.19, 0.87), and 12-step groups (aOR 0.39; 95% CI 0.21, 0.71). Perceived need for help among those who had not used any services was very low (5%), with no gender difference. Further, men and women reported equivalent numbers of treatment barriers and the same rank order for the most frequently endorsed barriers. However, women were twice as likely as men to think a problem would get better by itself-the most frequent reason for not seeking help (47% vs. 24%, p < 0.001), and men were more likely than women to report unsuccessful past help-seeking and not thinking anyone could help (19% vs. 3%, p < 0.001 and 17% vs. 5%, p = 0.001, respectively).

CONCLUSIONS

Consistent with previous studies, women were less likely to utilize alcohol services than men. Future interventions should address low problem recognition, and tailoring to gender-specific barriers may help close the disparity in services utilization.

Individual versus group female-specific cognitive behavior therapy for alcohol use disorder

OBJECTIVES

To test group-based Female-Specific Cognitive Behavioral Therapy (G-FS-CBT) for women with Alcohol Use Disorder (AUD) against an individual Female-Specific Cognitive Behavioral Therapy (I-FS-CBT). This aims of this paper are to describe G-FS-CBT development, content, feasibility, acceptability, group process, engagement in treatment, and within- and post-treatment outcomes.

METHODS

Women with AUD (n=155) were randomly assigned to 12 manual-guided sessions of G-FS-CBT or I-FS-CBT; 138 women attended at least one treatment session.

RESULTS

Women in G-FS-CBT attended fewer sessions (M=7.6) than women in I-FS-CBT (M=9.7; p<.001). Women in both conditions reported high satisfaction with the treatments. Independent coders rated high fidelity of delivery of both G-FS-CBT and I-FS-CBT. Therapeutic alliance with the therapist was high in both conditions, with I-FS-CBT being slightly but significantly higher than G-FS-CBT. In the first six weeks of treatment, women in both treatment conditions significantly reduced their percent drinking days (PDD) and percent heavy days drinking (PHD) by equivalent amounts, maintained through the rest of treatment and the 12month follow up with no treatment condition effects. Women reported significant improvement in all but one of the secondary outcomes during treatment; gains made during treatment in depression, anxiety, autonomy, and interpersonal problems were maintained during the follow-up period, while gains made during treatment in use of coping skills, self-efficacy for abstinence, self-care, and sociotropy deteriorated over follow up but remained improved compared to baseline.

CONCLUSIONS

Findings support the feasibility, acceptability, and efficacy of a group format for female-specific CBT for AUD, a new 12-session, single gender, community friendly, group therapy with programming specifically for women. Similar, positive outcomes for individual and group treatment formats were found for drinking, mood, coping skills, self-confidence, interpersonal functioning, and self-care.

A randomized trial of female-specific cognitive behavior therapy for alcohol dependent women

This study compared Female-Specific Cognitive Behavioral Therapy (FS-CBT) to evidence-based, gender-neutral CBT (GN-CBT; Epstein & McCrady, 2009) for women with alcohol use disorder (AUD). Women (N = 99) with AUD, mean age 48, were randomly assigned to 12 outpatient manual-guided sessions of FS-CBT (n = 44) or GN-CBT (n = 55). Women were assessed at baseline and 3, 9 and 15 months after baseline for drinking and for specific issues common among women with AUD. A FS-CBT protocol was developed that was discriminable on treatment integrity ratings from GN-CBT. No treatment condition differences were found in treatment engagement, changes in drinking, alcohol-related coping, abstinence self-efficacy, motivation to change, or constructs directly targeted in FS-CBT (sociotropy, autonomy, depression, anxiety). Women in both conditions were highly engaged and satisfied with treatment, and reported significant reductions in drinking and changes in desired directions for all other variables except social support for abstinence. In the year following treatment, women in the FS-CBT but not in the CBT condition reported an increase in percentage of abstainers in their social networks (0.69% per month, SE = 0.21, p = .002). The value and appeal of female-specific programming in AUD treatment has been established in the wider literature (Epstein & Menges, 2013), and the current study provides support for the use of the Female-Specific Cognitive Behavioral Therapy (FS-CBT) manual as an option that may yield outcomes similar to standard gender-neutral CBT for women with AUD. Future research should examine whether FS-CBT enhances treatment utilization for women. (PsycINFO Database Record

Feasibility and acceptability of shared decision-making to promote alcohol behavior change among women Veterans: Results from focus groups

BACKGROUND

Although rates of unhealthy drinking are high among women Veterans with mental health comorbidities, most women Veterans with mental comorbidities who present to primary care with unhealthy drinking do not receive alcohol-related care. Barriers to alcohol-related treatment could be reduced through patient-centered approaches to care, such as shared decision-making.

AIMS

We assessed the feasibility and acceptability of a telephone-delivered shared decision-making intervention for promoting alcohol behavior change in women Veterans with unhealthy drinking and co-morbid depression and/or probable post-traumatic stress disorder.

METHODS

We used 3, 2-hour focus group discussions with 19 women Veterans to identify barriers and solicit recommendations for using the intervention with women Veterans who present to primary care with unhealthy drinking and mental health comorbidities. Transcripts from the focus groups were qualitatively analyzed using template analysis.

RESULTS

Although participants perceived that the intervention was feasible and acceptable for the targeted patient population, they identified the treatment delivery modality, length of telephone sessions, and some of the option grid content as potential barriers. Facilitators included strategies for enhancing the telephone-delivered shared decision-making sessions and diversifying the treatment options contained in the option grids. Focus group feedback resulted in preliminary adaptations to the intervention that are mindful of women Veterans' individual preferences for care and realistic in the everyday context of their busy lives.

Substance use disorders in military veterans: prevalence and treatment challenges

Substance use disorders (SUDs) are a significant problem among our nation's military veterans. In the following overview, we provide information on the prevalence of SUDs among military veterans, clinical characteristics of SUDs, options for screening and evidence-based treatment, as well as relevant treatment challenges. Among psychotherapeutic approaches, behavioral interventions for the management of SUDs typically involve short-term, cognitive-behavioral therapy interventions. These interventions focus on the identification and modification of maladaptive thoughts and behaviors associated with increased craving, use, or relapse to substances. Additionally, client-centered motivational interviewing approaches focus on increasing motivation to engage in treatment and reduce substance use. A variety of pharmacotherapies have received some support in the management of SUDs, primarily to help with the reduction of craving or withdrawal symptoms. Currently approved medications as well as treatment challenges are discussed.