How Primary Care Can Change Care for Veterans Living with Alcohol Dependence

By Dr. Joseph Volpicelli,  M.D., Ph.D.

Early in my medical training, I worked with a Vietnam veteran whose struggle really changed how I thought about alcohol dependence. During his service, he used opiates to deal with the constant stress of war. When he got home, alcohol became what helped him manage the intrusive memories he couldn’t shake. One day on rounds, I presented his case to the team of attending physicians, residents, and other medical students. I confidently explained how his drinking was connected to the trauma he experienced. He was in withdrawal at the time and, when I gestured with my hands to make a point, he thought I was threatening him and suddenly stood up and slapped me. That moment was a wake-up call, reminding me that I didn’t fully understand what he was going through. 

That experience pushed me to start thinking more deeply about the biology of stress and alcohol. Severe stress disrupts the brain’s endogenous opioid system, and for some people, alcohol briefly relieves that deficit. Drinking helps them feel ‘normal’ for a while, making it incredibly hard to stop. It’s an issue veterans disproportionately face. 

Why veterans face heightened risk of alcohol dependence 

Veterans are more likely to struggle with alcohol because of what they’ve been through and what they face when they come home. More than 40% of U.S. veterans experience alcohol use disorder (AUD) at some point in their lives, compared to about 10% of the general adult population. Post-Traumatic Stress Disorder (PTSD), chronic pain, sleep problems, and anxiety are all more common among this population, especially for combat veterans, and these issues feed into one another. Alcohol can seem like an easy way to manage all of it in the moment.

Some clinicians feel treating excessive alcohol use is outside their scope, but in reality, most cases enter the health care system through primary care. That’s where the first indications of unhealthy alcohol use often first appear. However, these signs aren’t always obviously connected to drinking, and some providers aren’t always attuned to them. For example, some physical warning signs to look out for include higher blood pressure, elevated liver enzymes, or enlarged red blood cells. Chronic anxiety, chronic depression, poor relationships with loved ones, or feelings of being disconnected from the outside world are other clues that go unnoticed in primary care settings, or if observed, may not immediately be associated with possible substance use. These early signs tend to occur before someone meets the full criteria for alcohol dependence, so they’re especially important to pay attention to.

Stigma is still a big barrier. Veterans are encouraged to project an image of courage and a desire to protect others. Many veterans don’t want to talk about their drinking because they’re worried about being judged or appearing weak. Clinicians may also be unsure how to start the conversation. As a result, the subject gets avoided, signs get missed and the diagnosis happens later when the consequences are more severe. We don’t take that approach with other chronic health conditions. We don’t wait for a heart attack to treat high cholesterol or until someone can’t walk to treat diabetes. Alcohol use deserves the same kind of early, proactive care.

Screening helps providers catch dependence earlier

Proactive screening doesn’t require extensive assessments; it can be brief and done as part of a standard visit protocol. Tools such as the Alcohol Use Disorders Identification Test (AUDIT-C) can be easily incorporated into routine annual visits. Questions on the AUDIT-C can help identify patients who are drinking in a harmful way before medical complications or social consequences occur.

One of the most important things to assess when considering alcohol dependence is impaired control, meaning the person can’t stop drinking once they start. Part of the criteria for alcohol dependence is how much people think about drinking and how much they want to drink once they begin. If the urge to continue consuming alcohol increases after beginning to drink, that’s a sign that alcohol is affecting the brain’s control system. The Penn Alcohol Craving Scale can help measure that motivation and track it over time. 

Even without formal scales, a simple question such as, “If alcohol were available, would you have a hard time stopping once you start?” can give a healthcare provider clinically useful information. 

Having a compassionate, effective alcohol screening conversation

The key to effective screening is to approach the conversation in a nonjudgmental way. By making screening for alcohol use a standard part of every primary care visit, we have an opportunity to make the questions feel less personal and, as a result, potentially less pointed or threatening. The narrative then becomes less about that person feeling singled out, and more about conducting a thorough baseline assessment of each individual’s full picture of health. Establishing this as standard protocol can help minimize any defensiveness and keep the door open to candid conversation. 

Once a patient shares how much they are drinking, tie that information to clinical markers, such as the physical warning signs mentioned earlier, and help them connect those findings to the things they care about in their own lives. Sometimes that means starting with what matters most to them, whether that’s improving sleep, managing pain or feeling more present with family. People respond when a provider focuses on their concerns, not what providers think they should worry about. The goal should be to find whatever marker is meaningful to the patient and use that as the starting point for change. 

Not everyone will be ready. If someone says they’re not interested in making a change right now, providers should encourage patients to think about it and indicate they’ll check in next time. This will keep the patients engaged by not pushing yet not letting the issue drop completely. 

This is where the BRENDA approach comes in. It provides a practical structure for these visits:

B — Biopsychosocial evaluation to understand what drinking is doing for the patient
R — Report back the findings (labs, behavior, patterns)
E — Empathize with their challenges
N — Needs: ask what they want to change
D — Direct advice that aligns with their own goals
A — Assess how it’s working and follow up

The BRENDA approach is not radical, nor is it hard to implement. The challenge is time and working with patients who may not yet be able to internalize that pattern change. But not having any conversation is a miscalculation. Alcohol affects so many aspects of health, family and work that addressing it early helps prevent bigger problems later on. There was a point in time, not so long ago, when providers didn’t ask about alcohol because there was no solution. Now, though, we have effective medications and validated treatment paradigms.

Treating alcohol dependence with medication

If a patient meets the criteria for alcohol dependence, providers now have several treatment options they can recommend. As we learn more about the biology of alcohol addiction, it is clear that medications can reduce the urge to drink and stop the “brain chatter” that compels drinking. These include medications that make drinking physically uncomfortable, as well as medications that reduce cravings. In my early animal studies, I found that naltrexone could block stress-induced drinking. Later, in human research, we saw that naltrexone helped break the cycle of one drink increasing desire for the next. Supporting that ability to stop once someone starts is a key part of treating alcohol dependence. When the urge for the next drink is reduced or when patients can reach a place where they don’t drink at all, if that’s their goal, they are more able to stay in treatment and that persistence leads to better outcomes. 

However, compliance with daily naltrexone can sometimes be a challenge. People may forget to take a pill, especially at times when drinking is more likely. When that happens, the medication isn’t there to help. One way to address that is to use an extended-release medication, such as VIVITROL® which improved treatment adherence (see below). Administered by injection by a healthcare provider approximately once a month, it provides consistent medication support without requiring someone to remember a pill every day. So even during those high-risk moments, the coverage is still there.

PCPs are well-positioned to identify excessive alcohol use early as they often see changes in their patients first, hopefully long before a crisis develops. We now have both the tools to detect alcohol dependence early and the medications and approaches to treat them effectively.  When trusted providers take the lead and build routine questions into each visit, making the conversation nonjudgmental, patients stay engaged and outcomes improve. I still think about the veteran who was my wake-up call. If someone had connected his combat stress, his drinking, and his biology earlier, we would have avoided that crisis.  Primary care cannot end the trauma, but it can stop alcohol from becoming the second battle veterans are forced to fight. 

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Dr. Joseph Volpicelli,  M.D., Ph.D. is the Medical Director and Founder of the Volpicelli Center for Addiction Treatment. He graduated from the University of Pennsylvania’s prestigious Medical Scientist Training Program. Through this program, he received both his doctorate of medicine and psychology. He also completed his medical residency at the University of Pennsylvania and a fellowship in Neuropsychopharmacology. 

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