Alcohol use and treatment utilization in a national sample of veterans and nonveterans
Introduction
Alcohol use disorder (AUD) is highly prevalent in both veterans and nonveterans (Fuehrlein et al., 2016; Hasin et al., 2007) and is associated with functional impairment (Mannes et al., 2021), psychosocial and health problems (Gutkind et al., 2021), psychiatric comorbidities (Castillo-Carniglia et al., 2019), and disease burden (in terms of disability and years of life lost; Global Burden of Disease 2016 Alcohol and Drug Use Collaborators, 2018). Although some may assume that veterans demonstrate higher alcohol use problems than nonveterans, little evidence exists to support this assumption. The few studies making direct comparisons between veterans and nonveterans on alcohol problems have found that veterans and nonveterans do not differ in prevalence of heavy episodic drinking (Grossbard et al., 2013) or past-year AUD (in two all ages adult samples [Boden & Hoggatt, 2018; Wagner et al., 2007] and in a sample of adults aged 21–34 [Golub et al., 2013]). In contrast, one study found higher lifetime AUD among veterans than nonveterans (36 % in Veterans vs. 28 % in nonveterans; Boden & Hoggatt, 2018).
Risk factors for alcohol use problems may also differ for veterans and nonveterans. Findings are mixed regarding how gender and age may be associated with alcohol problems differentially for veterans vs. nonveterans. For instance, one study found that veterans reported higher past-year AUD and heavy episodic drinking than nonveterans only in men aged 18–25 (Hoggatt et al., 2017). In contrast, another study found that nonveterans demonstrate higher heavy episodic drinking than veterans only in men (Bachrach et al., 2018). Yet another study found that veterans reported higher lifetime AUD than nonveterans only in women (Evans et al., 2018). In studies investigating only veteran samples or only nonveteran samples, lower education (Bonevski et al., 2014; Gilman et al., 2008; Grant et al., 2012; O'Toole et al., 2020), lower social support (Bravo et al., 2016; Brick et al., 2018; Groh et al., 2007; McCabe et al., 2019), unpartnered marital status (Dash et al., 2020; Fuehrlein et al., 2016; Kendler et al., 2016; Kretsch & Harden, 2014), sexual minority status (Cochran et al., 2013; Crane et al., 2020; Lehavot et al., 2014), adverse childhood experiences (ACEs; Aronson et al., 2020; Hughes et al., 2017; Lee & Chen, 2017), and adult sexual assault (Caamano-Isorna et al., 2021; Forkus et al., 2020; Lindgren et al., 2012; Newins et al., 2021) were found to be associated with alcohol use problems. Among veterans, research has also found combat exposure to be associated with alcohol use problems (Miller et al., 2017; Na et al., 2021). Despite many studies investigating predictors of alcohol use problems among only veteran or only nonveteran samples, no studies to our knowledge have directly compared the strength of associations between these predictors and alcohol use problems in veteran vs. nonveterans.
Little research exists comparing veterans' and nonveterans' alcohol treatment utilization. One study found that veterans (vs. nonveterans) were more likely to be screened for alcohol use problems, and were more likely to receive advice about alcohol's harmful effects (Bachrach et al., 2018), which may lead to greater treatment utilization. Veterans (vs. nonveterans) were found to be more likely to receive substance use disorder (SUD) treatment in one study (Boden & Hoggatt, 2018), whereas another study found no such differences between veterans and nonveterans (Golub et al., 2013). This discrepancy may be due to sample/timing differences, as Golub et al. (2013) used data collected from 2004 to 2010 from a sample of adults aged 21–34, whereas Boden and Hoggatt (2018) used data collected from 2012 to 2013 from a sample of adults of all ages. In a sample of men of all ages receiving mental health treatment, the study found no differences in AUD treatment utilization between veterans and nonveterans (Manhapra et al., 2021). Given these sparse and conflicting findings, more research is needed to better understand alcohol treatment differences between veterans and nonveterans in national samples, especially among post-9/11 veterans (i.e., those who served in Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn).
Several studies using veteran or nonveteran samples have investigated predictors of alcohol treatment utilization (with many more studies focused on nonveterans than veterans). Older age and lower income have been found to be associated with alcohol treatment utilization among veterans (Halvorson et al., 2014) and nonveterans (Cohen et al., 2007; Mowbray, 2014). Among veterans, combat exposure is also associated with alcohol treatment utilization (Miller et al., 2017). Among nonveterans, male gender (Cohen et al., 2007; Mellinger et al., 2019), White race (Niv et al., 2009), higher social support (Mowbray, 2014), divorced marital status, health coverage (Kim et al., 2010), childhood maltreatment (Goldstein et al., 2013), recent sexual assault (Rothman et al., 2008), and intimate partner violence (Schonbrun et al., 2013) were all associated with alcohol treatment utilization; however, among veterans, research has not investigated these predictors. Whether education and sexual orientation may be associated with alcohol treatment utilization differentially for veterans vs. nonveterans is unclear. In veterans, one study found that education was not associated with alcohol treatment utilization (Golub et al., 2013), whereas in nonveterans, there are mixed findings (Cohen et al., 2007; Golub et al., 2013; Grant, 1996). Sexual orientation has not been investigated as a predictor of alcohol use treatment utilization in Veterans. Among nonveterans, sexual minorities generally report greater unmet need for substance use treatment (Allen & Mowbray, 2016; Haney, 2020); however, findings from one study of nonveterans indicate that unmet need for alcohol use treatment may only be greater among gay men (and not among bisexual men, lesbian women, or bisexual women; Lehavot et al., 2017). Alcohol treatment utilization outcomes are measured differently across these studies, which may account for some conflicting findings in the literature; for instance, in Halvorson et al. (2014), treatment utilization is a three category outcome (“no treatment,” “non-specialty SUD-care” and “specialty SUD-care”) based on medical chart notes, whereas in Cohen et al. (2007), treatment utilization was assessed with a single-item self-report question defining treatment more broadly: “Have you ever gone anywhere or seen anyone for a reason that was related in any way to your drinking: a physician, counselor, Alcoholics Anonymous, or any other community agency or professional?” In addition to these inconsistencies, one prominent gap in this prior literature is that no studies have directly compared these predictors of alcohol treatment use for veterans and nonveterans. Thus, whether these predictors of alcohol treatment may differ for veterans and nonveterans remains unclear.
The current study aimed to fill these research gaps in direct comparisons of veterans and nonveterans on alcohol problems and treatment utilization. The study analyzed survey data from a nationally representative samples of post-9/11 veterans and nonveterans to (1) examine differences in alcohol use and alcohol treatment utilization between Veterans and nonveterans and (2) investigate whether associations between sociodemographic (and other relevant) factors and alcohol outcomes (alcohol problems and treatment utilization, specifically) differ between veterans and nonveterans.
Section snippets
Participants and survey design
The Veterans Affairs (VA) Comparative Health Assessment Interview (CHAI) Research Study is a national, population-based survey study that examined the health and well-being of post-9/11 veterans (in Active Duty, or activated Guard/Reserve, at any point from 9/11/2001 through May 2015) and nonveterans. The response rate for the survey was 40.0 % among veterans and 56.5 % among nonveterans. This response rate is similar to response rates of other surveys (e.g., Bastian et al., 2014; Eber et al.,
Participant characteristics
The majority of veterans and nonveterans in our sample were married, White, heterosexual, and had some form of health care coverage. Among veterans needing intensive treatment, 16 % (vs. 9 % in nonveterans) received past year alcohol treatment and 36 % (vs. 14 % in nonveterans) received lifetime alcohol treatment. Among veterans needing brief treatment, 3 % (also 3 % in nonveterans) received past year alcohol treatment and 13 % (vs. 7 % in nonveterans) received lifetime alcohol treatment. See
Discussion
The current study is the first to use nationally representative samples of veterans and nonveterans to not only compare prevalence of alcohol use and alcohol treatment, but also to compare predictors of alcohol use and alcohol treatment. We found that veterans reported higher alcohol consumption and higher lifetime alcohol treatment utilization than nonveterans. However, differences in alcohol consumption between veterans and nonveterans were modest (with a mean of 3.26 among veterans vs. a
Conclusion
This study represents the first investigation to compare prevalence and predictors of alcohol use and treatment utilization among veterans and nonveterans in a national sample. Strengths of our study include accounting for the shared variance of a variety of relevant predictors and using population weights to increase generalizability of our findings. We found that veterans reported higher alcohol use consumption and higher lifetime alcohol treatment utilization than nonveterans. We also found
CRediT authorship contribution statement
Funding acquisition: Aaron I. Schneiderman.
Conceptualization: Rachel M. Ranney, Dawne Vogt, John R. Blosnich, Claire A. Hoffmire, Yasmin Cypel, Aaron I. Schneiderman, and Shira Maguen.
Methodology: Paul A. Bernhard and Shira Maguen.
Data curation: Paul A. Bernhard.
Formal analysis: Rachel M. Ranney and Paul A. Bernhard.
Roles/Writing – original draft: Rachel M. Ranney.
Writing – review and editing: Rachel M. Ranney, Paul A. Bernhard, Dawne Vogt, John R. Blosnich, Claire A. Hoffmire, Yasmin Cypel,
Declaration of competing interest
None.
Acknowledgements
This work was supported by the Department of Veterans Affairs, Office of Patient Care Services, Health Outcomes of Military Exposures, Epidemiology Program. This research is also supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Medical Research Service of the Veterans Affairs San Francisco Health Care System, and the Department of Veterans Affairs Sierra Pacific (VISN 21) Mental Illness
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Cited by (0)
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VA Advanced Postdoctoral Fellow in Mental Illness Research and Treatment, Sierra Pacific (VISN 21) Mental Illness Research Education and Clinical Center, VA San Francisco Health Care System, and the Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine.