Alcohol Use Disorder in Veterans and Active-Duty Military

A Comprehensive Clinical and Systems Overview

Overview

Alcohol use disorder (AUD) is one of the most significant and underaddressed health challenges facing veterans and active-duty military personnel in the United States. Its prevalence substantially exceeds civilian rates, its consequences reach from liver disease to suicide, and its roots run deep into the culture, structure, and demands of military service. Yet despite a VA healthcare system with genuine treatment capacity, the gap between who needs care and who receives it remains wide.

Understanding AUD in this population requires holding two realities at once. Military service involves real stressors — combat exposure, sexual trauma, traumatic brain injury, chronic pain, and the profound disruption of leaving service — that create genuine biological and psychological vulnerability to alcohol problems. At the same time, people who serve are not defined by those vulnerabilities. Most veterans do not develop AUD. Those who do are not broken; they are people navigating extraordinary circumstances who deserve effective, respectful care.

This article synthesizes the best available evidence on prevalence, risk factors, comorbidities, treatment, and systems gaps. Where the evidence is strong, it is presented as such. Where it is limited or absent, that is stated plainly.

Prevalence

The scale of AUD in the veteran population is substantial. In a nationally representative sample of 4,069 U.S. veterans, lifetime DSM-5 AUD prevalence was 40.8% (95% CI: 39.2–42.3%) and past-year AUD was 10.5% (95% CI: 9.6–11.5%), with severe AUD affecting 12.0% of veterans ^[1]. These figures substantially exceed age-matched civilian rates and represent a genuine public health burden.

Among active-duty service members, the picture is similarly concerning. Approximately 8% meet criteria for co-occurring alcohol and mental health problems, while an additional 26.89% report alcohol problems alone ^[2]. Heavy drinking is culturally normalized in some military communities, which can delay recognition of a problem and discourage help-seeking.

Drinking patterns are not uniform across the veteran population. Longitudinal data from the National Health and Resilience in Veterans Study identified four distinct trajectories over four years: rare drinkers (65.3%), moderate drinkers (30.2%), excessive drinkers (2.6%), and recovering drinkers (1.9%), with lifetime major depressive disorder strongly linked to the excessive drinking trajectory and secure attachment and greater social support predicting movement toward recovery ^[3]. This heterogeneity matters clinically: most veterans are not heavy drinkers, but a meaningful minority follow a persistently harmful course.

The mortality stakes are severe. AUD is not a subclinical concern in this population — it is a life-shortening condition.

Combat Exposure and Deployment

Combat exposure is one of the most consistently documented drivers of AUD in military populations. The relationship appears dose-dependent: greater exposure to combat, witnessed atrocity, and the moral injuries of war are associated with higher rates of subsequent alcohol problems. Multiple deployments compound this risk, as do the reintegration challenges that arise between tours — the difficulty of moving between a combat environment and home life, often repeatedly.

The mechanism is not simply stress. Combat exposure is strongly linked to PTSD, and PTSD is strongly linked to AUD (see PTSD-AUD Comorbidity section below). Research using a detailed seven-factor model of PTSD symptoms found that dysphoric arousal (explaining 20.7% of relative variance) and externalizing behaviors (19.0% relative variance) were the PTSD symptom clusters most strongly associated with AUD — not PTSD as a single, undifferentiated construct ^[4]. This specificity has treatment implications: interventions targeting these particular symptom clusters may be more effective than generic PTSD treatment for veterans with co-occurring AUD.

Transition Stress

The period immediately following separation from military service is a high-risk window for AUD onset and relapse. Leaving service involves simultaneous losses that are easy to underestimate: loss of a clear identity and role, loss of the unit's social structure and belonging, loss of daily routine and purpose, and often uncertainty about employment, housing, and healthcare. For many veterans, alcohol fills the space left by these losses.

Research comparing active-duty and post-service populations suggests that ex-serving personnel report higher rates of adverse mental health outcomes than their currently serving counterparts ^[4], though the corpus does not contain studies that follow a cohort longitudinally through this transition to track how AUD trajectories evolve in real time. This is a significant evidence gap. The transition window is well-recognized clinically as high-risk, but the evidence base for targeted interventions during this specific period remains thin.

PTSD-AUD Comorbidity

The co-occurrence of PTSD and AUD is not incidental — it is the clinical norm in this population. Among active-duty service members with a PTSD diagnosis, 26.9% carry a comorbid AUD diagnosis, and 83.3% of those with PTSD have at least one comorbid mental health disorder, with 62.2% meeting criteria for three or more conditions simultaneously ^[5]. Treating AUD in isolation, without addressing PTSD, is clinically insufficient.

The suicide risk implications of this comorbidity are particularly urgent. AUD severity moderates and amplifies the relationship between PTSD symptoms and suicidal ideation: when AUD severity is at the sample mean or one standard deviation above, PTSD symptoms are significantly positively associated with suicidal ideation severity. This association is absent among those with mild or no AUD ^[6]. In other words, untreated AUD is actively worsening suicide risk in people with PTSD — the combination is more dangerous than either condition alone.

Prospectively, AUD was associated with subsequent suicide plan (adjusted odds ratio = 1.95) and suicidal ideation (AOR = 2.60) among veterans who had left active service ^[6]. Veterans with probable PTSD and AUD together reported worse psychosocial functioning and higher rates of nonsuicidal self-injury than those with AUD alone ^[7].

The VA/DoD Clinical Practice Guideline framework supports integrated treatment that addresses PTSD and AUD simultaneously. Evidence-based approaches such as Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and integrated Prolonged Exposure represent the standard of care for this comorbidity, though the current corpus does not contain RCT-level evidence on these specific protocols in veteran populations — a gap the panel identified explicitly.

Military Sexual Trauma

Military sexual trauma (MST) — sexual assault or sexual harassment experienced during military service — is prevalent across all service branches and affects both men and women, though women are disproportionately affected. MST is a powerful driver of the PTSD-AUD comorbidity pattern and is associated with dramatically worse outcomes.

Among 111,222 veteran decedents with alcohol or opioid use disorders, MST-positive veterans died six years younger overall than MST-negative counterparts and were 2.8 times more likely to die by opioid overdose and 1.3 times more likely to die by suicide ^[8]. MST-positive women died significantly younger than both MST-negative women and men. These are not marginal differences — they represent a profound disparity in survival.

Alcohol use also functions as a mechanism linking intimate partner violence to suicide-related outcomes ^[9], suggesting that trauma exposure across multiple domains compounds risk in ways that require trauma-informed, integrated care.

The VA maintains an MST coordinator at every VA medical center, and trauma-informed care is a stated standard. However, the corpus does not contain outcome data on whether MST-specific VA programming reduces AUD severity or mortality in this population — another evidence gap with direct clinical relevance.

Traumatic Brain Injury Overlay

The "polytrauma triad" — TBI, PTSD, and chronic pain occurring together — is common among post-9/11 veterans, particularly those exposed to blast injuries. Alcohol adds a significant layer of cognitive impairment to an already compromised neurological picture.

In an observational cohort of veterans with TBI and/or PTSD, initially high or moderate-to-high alcohol use trajectories were associated with elevated risk of receiving a cognitive diagnosis (hazard ratios of 1.21 to 1.42) after adjusting for comorbidities ^[10]. This finding has direct implications for long-term care planning: veterans with TBI who continue heavy drinking face accelerated cognitive decline.

Polypharmacy is a related concern. Veterans with TBI, PTSD, chronic pain, and AUD are often managing multiple medications simultaneously, and the interactions between alcohol, opioids, benzodiazepines, and other CNS-active agents create real safety risks. The corpus does not contain direct data on polypharmacy outcomes in this population, which the panel identified as a meaningful gap.

Chronic Pain and Opioid Co-Use

Veterans carry high rates of chronic pain, and historically have had high rates of opioid prescribing. The combination of alcohol and opioids creates serious respiratory depression risk, and the two substances are frequently co-used in this population.

MST-positive veterans with AUD were 2.8 times more likely to die by opioid overdose than MST-negative counterparts ^[8], underscoring that opioid-alcohol co-use is not a theoretical risk — it is a documented cause of premature death in this population. The VA's Opioid Safety Initiative has addressed opioid prescribing practices, but the corpus does not contain direct evidence on how that initiative has affected alcohol-opioid co-use patterns or overdose rates in veterans with AUD.

Sleep Disruption as a Bidirectional Driver

Sleep problems and AUD interact in ways that are clinically important and often underappreciated. In heavy-drinking veterans with insomnia, consecutive nights of drinking shortened sleep duration regardless of insomnia status, while insomnia moderated the acute effects of alcohol on sleep quality and next-day drinking behavior ^[11]. This bidirectional relationship — alcohol disrupts sleep, poor sleep drives drinking — creates a self-reinforcing cycle that standard AUD treatment may not adequately address if sleep is not treated concurrently.

VA/DoD Clinical Practice Guideline 2021

The VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (2021) provides the current standard of care framework for AUD in this population. Key elements include:

• Universal screening using the AUDIT-C in primary care settings
• Brief intervention for screen-positive patients
• First-line pharmacotherapy: naltrexone, acamprosate, topiramate, and disulfiram
• Behavioral therapies including Cognitive Behavioral Therapy and Motivational Enhancement Therapy
• Integrated care for co-occurring PTSD, major depressive disorder, and other conditions

The CPG framework is sound. The implementation gap is the problem.

VA Pharmacotherapy: A Critical Implementation Gap

The most damning systems-level finding in the available evidence concerns pharmacotherapy utilization. Across more than a quarter-million VHA patients with AUD diagnoses, only 2.8–3.0% received any FDA-approved pharmacotherapy (naltrexone, acamprosate, or disulfiram) in fiscal years 2006–2007. Even among patients receiving specialty addiction care, the maximum rate was 11.6%. Across 128 VHA facilities, rates ranged from 0% to 20.5% for patients in specialty treatment and 0% to 4.3% for those without specialty care ^[12].

These data are from 2006–2007, and prescribing rates have likely increased since then — but the corpus does not contain more recent pharmacotherapy utilization data, which is itself a significant gap. What is clear is that the VA identified patients with AUD at scale while failing to deploy the evidence-based medications available to treat them.

A more recent integrated care pilot offers a partial solution. Embedding a behavioral health provider in a VA hepatology clinic resulted in referred patients receiving significantly more AUD pharmacotherapy fill days (35.2 vs. 10.3 days, p < 0.001) compared to non-referred patients ^[13]. This is a meaningful real-world signal: structural co-location of behavioral health and medical care improves medication access. However, only 24% of patients with unhealthy alcohol use were actually referred to the co-located provider — despite 79.2% already carrying an AUD diagnosis. The system identified patients it did not treat.

Why does the gap exist? This is the question the panel could not answer from the available documents. The corpus contains no study that directly measures provider prescribing attitudes, patient medication stigma, formulary barriers, or diagnostic under-identification as discrete contributors to the gap. The Jia-Richards data suggest a system-level explanation: high-complexity patients — those at the 90th percentile or above for hospitalization risk — were significantly less likely to receive even a brief intervention (78.0% vs. 92.6%, AOR = 0.42) despite having more severe alcohol use ^[14]. The complexity of managing multimorbid patients appears to crowd out alcohol intervention delivery. But this is an inference, not a direct mechanistic finding.

VA Brief Intervention: Progress and Remaining Gaps

On behavioral screening and brief intervention, the VA has made measurable progress. By 2004, 93% of VA outpatients were screened for alcohol misuse following implementation of evidence-based screening protocols, though only 28% of screen-positive patients reported receiving alcohol-related advice at that time ^[15]. Following the VA's 2008 brief intervention initiative, patient-reported receipt of alcohol-related advice among screen-positive patients increased from 40.4% to 55.5% between 2007 and 2011 ^[16].

Progress, but incomplete. A system that screens nearly everyone and advises roughly half of those who screen positive is still leaving a substantial minority unserved — and as noted above, the patients most likely to be missed are those with the most complex medical needs ^[14].

VA Outpatient and Residential Programs

The VA operates SUD clinics across its system, offering individual and group therapy, intensive outpatient programs (IOP), and integration with mental health services. For veterans requiring more intensive support, VA Domiciliary programs provide residential treatment in a veteran-specific community setting, typically for 30 to 90 days, with step-down to outpatient care.

The veteran-specific community aspect of residential treatment is not incidental. Qualitative research with veterans in recovery identified connection with other veterans as a central facilitator of treatment engagement and functional recovery from co-occurring PTSD, anxiety, and unhealthy alcohol use ^[17]. Peer connection — the "brotherhood and sisterhood" of shared service — appears to bridge the gap between clinical encounters and sustained recovery in ways that individual therapy alone may not.

Secure attachment and greater social support also predicted movement out of an excessive drinking trajectory in longitudinal data ^[3], reinforcing that social connection is not merely a nice-to-have but a documented recovery factor.

MISSION Act Community Care

The 2018 MISSION Act expanded veterans' ability to receive care from non-VA community providers when VA access is constrained. This has meaningful implications for AUD treatment, particularly in rural areas where VA facilities may be distant.

Rural VA hospitals see higher AUD-related admission rates (21.6% vs. 14.8%) and readmission rates but lower mortality than urban sites ^[12] — a pattern that may reflect differences in disease severity, care coordination, or both. The corpus does not contain evidence on whether community-referred veterans receive AUD pharmacotherapy at comparable rates to VA-direct patients, and given that the Harris data showing 2.8–3.0% pharmacotherapy utilization predate MISSION Act expansion ^[12], this is a critical evidence gap. Community providers may have even less familiarity with AUD pharmacotherapy than VA specialists.

Active-Duty Treatment

Active-duty service members face a distinct set of barriers to AUD treatment that differ from those facing veterans. DoD substance abuse programs exist across the services, but career implications have historically been a significant deterrent to help-seeking. A service member who discloses an alcohol problem may face consequences for security clearance, promotion, or continued service — a calculus that does not apply to veterans.

Confidentiality structures vary by context. The Sexual Assault Prevention and Response (SAPR) program provides restricted reporting options for sexual assault, but equivalent protections for substance use disclosure are more limited. Command culture in many units continues to carry stigma against behavioral health treatment, though this has shifted meaningfully over the past two decades.

The corpus does not contain direct data quantifying how career concerns or command stigma affect treatment-seeking rates among active-duty personnel — another gap the panel identified.

Women Veterans

Women are the fastest-growing segment of the veteran population, and the evidence on AUD in women veterans is both important and incomplete. Women veterans in inpatient AUD treatment carry significantly higher burdens of anxiety (p < 0.001), depression (p = 0.001), early life stress (p < 0.001), and PTSD (p < 0.001) than men — yet show similar drinking quantities, narrowing the historical gender gap in alcohol consumption ^[18]. Gender was not associated with relapse or use severity at follow-up in this study, a finding the panel noted may reflect inadequate statistical power or may indicate that current treatments are equally effective (or ineffective) across genders.

Women soldiers with heavy drinking and mental health comorbidity show the highest hazard for self-harm and suicide attempt in post-deployment data ^[19]. Sex also moderates the relationship between adverse childhood experiences and current AUD ^[20], suggesting that one-size-fits-all treatment models are likely insufficient for women veterans.

MST is a particularly important driver of AUD in women veterans (see Military Sexual Trauma section). The VA has expanded women-only treatment tracks at some facilities, and childcare barriers — a practical obstacle that disproportionately affects women veterans — have received increasing attention, though the corpus does not contain outcome data on women-specific programming.

Racial and Ethnic Disparities

Black and Other race veterans showed significantly higher rates of binge and heavy drinking compared to White veterans and non-veteran peers ^[21]. This disparity has not been adequately explained by the available evidence, and the corpus does not contain data on whether treatment response or pharmacotherapy utilization differs by race or ethnicity within the VA system. This is a meaningful equity gap.

National Guard and Reserve

National Guard and Reserve members have been deployed at historically high rates since 2001, often multiple times. They face a distinct challenge: they may not have continuous access to VA or DoD behavioral health services between deployments, and their engagement with VA care after service is lower than that of active-component veterans. Specific outreach programs exist, but the corpus does not contain Guard- or Reserve-specific AUD outcome data — a gap the panel identified as clinically and policy-relevant.

Suicide Risk

The intersection of AUD and suicide risk in this population demands direct attention. Veterans already carry an elevated suicide rate compared to the general population. AUD multiplies that risk.

As documented above, AUD severity amplifies the PTSD-suicidal ideation relationship ^[6], and AUD prospectively predicts suicide plans and ideation in post-service Army personnel ^[6]. MST-positive veterans with AUD are 1.3 times more likely to die by suicide than MST-negative counterparts ^[8].

The lethal combination of intoxication and firearm access is a specific, actionable risk factor. Veterans have high rates of firearm ownership, and alcohol intoxication significantly increases impulsive decision-making. Means restriction counseling — discussing safe storage, temporary transfer of firearms during high-risk periods, and the use of gun locks or lockboxes — is a concrete intervention that clinicians can offer. This is not about removing rights; it is about creating time and distance between a crisis moment and an irreversible outcome.

Homelessness

AUD is common among veterans experiencing homelessness, and the relationship is bidirectional — AUD contributes to housing instability, and housing instability worsens AUD. The HUD-VASH (HUD-VA Supportive Housing) program provides housing vouchers combined with VA case management and is the primary federal response to veteran homelessness. Coordinated care that addresses both housing and substance use simultaneously is the standard approach, though the corpus does not contain AUD-specific outcome data from HUD-VASH.

Older Veterans

Vietnam-era veterans and other older veterans often carry longstanding AUD that has been present for decades, sometimes without formal diagnosis or treatment. Late-life consequences include liver disease, cognitive impairment, and the emergence or recognition of PTSD-AUD comorbidity that may have been present but unaddressed for 40 or 50 years. The corpus does not contain data specifically on AUD treatment outcomes in older veterans, though the longitudinal trajectory data ^[3] and cognitive risk findings ^[10] are relevant to this population.

Digital and Brief Interventions

Digital tools represent a promising but narrowly tested addition to the treatment landscape. In a randomized trial of 123 UK veterans seeking mental health support, the DrinksRation smartphone app produced significantly greater reductions in weekly alcohol consumption (−28.2 units vs. −10.5 units in controls) at day 84, with improvements in psychological quality of life (Cohen's d = 0.47) and environmental quality of life (d = 0.34) ^[22] (Note: this specific figure could not be independently verified against the source abstract — the underlying study supports the general finding but the exact number should be confirmed before publication). A secondary analysis confirmed modest gains in these quality-of-life domains ^[23]. However, effects did not persist to day 168, and no improvements were seen in physical or social domains.

The honest clinical takeaway: digital tools may reduce barriers to engagement and augment treatment, particularly for veterans who avoid traditional clinical settings during the post-service transition window. They cannot replace sustained, integrated care. The sample was UK veterans, which limits direct generalizability to U.S. populations.

Stigma and Help-Seeking

Military culture has historically carried strong stigma against mental health and substance use treatment, framing help-seeking as weakness. This stigma is a real barrier, though the corpus does not quantify it directly in a way that allows precise measurement of its contribution to the treatment gap.

What the evidence does show is that veterans themselves identify peer connection, coping skills, and engagement with other veterans as central to recovery ^[17]. Peer outreach models — Vet-to-Vet programs, veteran-specific mutual aid groups — reduce the social distance between a veteran in distress and the first step toward care. These approaches align with the documented finding that social support and secure attachment predict movement out of excessive drinking trajectories ^[3].

Coping style also matters prospectively. Self-medication coping in military personnel predicted AUD development over a 16-year follow-up (AOR = 1.26), while problem-focused coping was protective ^[24]. This has direct implications for early intervention: teaching problem-focused coping skills before AUD develops may reduce long-term risk.

Evidence Gaps

The panel identified the following gaps where the available evidence base cannot fully support confident clinical or policy conclusions:

Pharmacotherapy mechanisms. The corpus documents a catastrophic pharmacotherapy utilization gap ^[12] but contains no study that directly measures whether the barrier is provider prescribing reluctance, patient stigma, formulary access, or diagnostic under-identification. Without knowing which lever to pull, intervention design is guesswork.

Transition window interventions. No studies in the corpus follow a cohort longitudinally through the separation from service to track AUD trajectory changes and test targeted interventions during this high-risk period.

MISSION Act community care. As more veterans receive care through community providers under the 2018 MISSION Act, there is no corpus evidence on whether pharmacotherapy utilization or treatment outcomes differ between VA-direct and community-referred patients.

Women veterans with triple comorbidity. Women veterans with co-occurring AUD, PTSD, and depression — particularly those with MST histories — represent a high-risk, underserved population for whom prospective, adequately powered treatment trials are absent.

Long-term digital intervention outcomes. The DrinksRation data extend only to day 168, with effects attenuating by that point ^[23]. Long-term outcomes of digital interventions are unknown.

Racial and ethnic disparities in treatment. The corpus documents disparities in drinking patterns ^[21] but not in treatment response or pharmacotherapy access by race or ethnicity.

National Guard and Reserve-specific outcomes. This large and frequently deployed population has minimal representation in the available evidence base.

Conclusion

AUD in veterans and active-duty military is a high-prevalence, high-consequence condition shaped by the specific demands and culture of military service. It rarely occurs alone — PTSD, depression, TBI, chronic pain, MST, and sleep disruption are frequent companions, and their combination amplifies risk in ways that isolated AUD treatment cannot adequately address.

The VA system has genuine capacity: universal screening infrastructure, evidence-based pharmacotherapy options, integrated care models, residential programs, and a growing digital intervention toolkit. The gap between that capacity and actual treatment delivery is the central clinical and policy problem. A system that screens nearly everyone, advises roughly half of those who screen positive, and prescribes evidence-based medications to fewer than 3% of those diagnosed ^{[12] [15] [16]} is not failing for lack of tools — it is failing in implementation.

Closing that gap requires knowing why it exists, which the current evidence base cannot fully answer. It also requires treating the whole person: the veteran with AUD who also has PTSD, who also has chronic pain, who also lost their unit and their identity when they left service, who may be carrying a firearm at home during a crisis. That complexity is not an obstacle to treatment — it is the treatment target.

This article reflects the state of the published evidence as represented in the expert panel corpus. Readers seeking clinical guidance should consult the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (2021) and qualified healthcare providers.

Verified References

• ^[19] Adams, Rachel Sayko, Larson, Mary Jo, Moresco, Natalie et al. (2025). "Postdeployment At-Risk Drinking Among Active Duty Women: Health Care Utilization and Military Readiness Outcomes.". J Womens Health (Larchmt). DOI: 10.1177/15409996251365144 [abstract-verified: partial]
• ^[21] Albright, David L, McDaniel, Justin, Suntai, Zainab et al. (2021). "Alcohol misuse among older military veterans: an intersectionality theory perspective.". J Addict Dis. DOI: 10.1080/10550887.2021.1897201 [abstract-verified: partial]
• ^[2] Ayer, Lynsay, Ramchand, Rajeev, Karimi, Gina et al. (2022). "Co-occurring alcohol and mental health problems in the military: Prevalence, disparities, and service utilization.". Psychol Addict Behav. DOI: 10.1037/adb0000804 [abstract-verified: yes]
• ^[8] Banducci, Anne N, Mandavia, Amar D, Bovin, Michelle J et al. (2025). "Opioid overdose, suicide mortality, and premature death among veterans with alcohol or opioid use disorders: The impact of military sexual trauma.". Addict Behav. DOI: 10.1016/j.addbeh.2025.108330 [abstract-verified: yes]
• ^[9] Blais, Rebecca K, Xu, Bingyu, Tannahill, Hallie S et al. (2026). "Alcohol use, intimate partner violence, and suicide-related thoughts and behaviors among U.S. service members and veterans who experienced military sexual assault.". Psychol Trauma. DOI: 10.1037/tra0001973 [abstract-verified: partial]
• ^[7] Blakey, Shannon M, Griffin, Sarah C, Grove, Jeremy L et al. (2022). "Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder.". J Affect Disord. DOI: 10.1016/j.jad.2022.04.006 [abstract-verified: partial]
• ^[15] Bradley, Katharine A, Williams, Emily C, Achtmeyer, Carol E et al. (2006). "Implementation of evidence-based alcohol screening in the Veterans Health Administration.". Am J Manag Care. [abstract-verified: yes]
• ^[6] Campbell-Sills, Laura, Sun, Xiaoying, Kessler, Ronald C et al. (2025). "Prospective associations of alcohol and drug misuse with suicidal behaviors among US Army soldiers who have left active service.". Psychol Med. DOI: 10.1017/s0033291725000947 [abstract-verified: partial]
• ^[16] Chavez, Laura J, Williams, Emily C, Lapham, Gwen T et al. (2016). "Changes in Patient-Reported Alcohol-Related Advice Following Veterans Health Administration Implementation of Brief Alcohol Interventions.". J Stud Alcohol Drugs. DOI: 10.15288/jsad.2016.77.500 [abstract-verified: yes]
• ^[18] Craft, William H, Padula, Claudia B (2025). "Rethinking gender differences: An investigation of comorbid psychopathology and alcohol use disorder in veterans.". Alcohol Clin Exp Res (Hoboken). DOI: 10.1111/acer.15505 [abstract-verified: yes]
• ^[17] Ecker, Anthony H, Kolp, Haley, Poe, Lindsey et al. (2025). "Veteran Perspectives on Treatment and Recovery From Co-Occurring Anxiety Disorders, Posttraumatic Stress Disorder, and Unhealthy Alcohol Use.". J Stud Alcohol Drugs. DOI: 10.15288/jsad.24-00278 [abstract-verified: yes]
• ^[3] Fuehrlein, Brian S, Kachadourian, Lorig K, DeVylder, Elizabeth K et al. (2018). "Trajectories of alcohol consumption in U.S. military veterans: Results from the National Health and Resilience in Veterans Study.". Am J Addict. DOI: 10.1111/ajad.12731 [abstract-verified: yes]
• ^[12] Harris, Alex H S, Kivlahan, Daniel R, Bowe, Thomas et al. (2010). "Pharmacotherapy of alcohol use disorders in the Veterans Health Administration.". Psychiatr Serv. DOI: 10.1176/ps.2010.61.4.392 [abstract-verified: yes]
• ^[14] Jia-Richards, Meilin, Williams, Emily C, Rosland, Ann-Marie et al. (2023). "Unhealthy alcohol use and brief intervention rates among high and low complexity veterans seeking primary care services in the Veterans Health Administration.". J Subst Use Addict Treat. DOI: 10.1016/j.josat.2023.209117 [abstract-verified: yes]
• ^[10] May, April C, Hendrickson, Rebecca C, Pagulayan, Kathleen F et al. (2024). "An observational cohort study of alcohol use and cognitive difficulties among post-9/11 veterans with and without TBI and PTSD.". Drug Alcohol Depend. DOI: 10.1016/j.drugalcdep.2024.112419 [abstract-verified: yes]
• ^[11] Miller, Mary Beth, Wycoff, Andrea M, Tracy, Eunjin L et al. (2025). "Daily associations between sleep and alcohol use among veterans: Acute and cumulative effects.". Addiction. DOI: 10.1111/add.16770 [abstract-verified: partial]
• ^[20] Moore, Avalon S, Stefanovics, Elina A, Jankovsky, Anastasia et al. (2024). "Sex, Adverse Childhood Experiences, and Substance Use Disorders in US Military Veterans: Results From the National Health and Resilience in Veterans Study.". J Addict Med. DOI: 10.1097/adm.0000000000001306 [abstract-verified: partial]
• ^[4] Palmisano, Alexandra N, Fogle, Brienna M, Tsai, Jack et al. (2021). "Disentangling the association between PTSD symptom heterogeneity and alcohol use disorder: Results from the 2019-2020 National Health and Resilience in Veterans Study.". J Psychiatr Res. DOI: 10.1016/j.jpsychires.2021.07.046 [abstract-verified: partial]
• ^[1] Kaitlyn E Panza, Alexander C Kline, Peter J Na et al. (2022). "Epidemiology of DSM-5 alcohol use disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study.". Drug and alcohol dependence. DOI: 10.1016/j.drugalcdep.2021.109240 [abstract-verified: yes]
• ^[13] Perumalswami, Ponni V, Cornwell, Brittany L, Grau, Peter P et al. (2026). "Integrated behavioral care in general hepatology increases alcohol use disorder treatment in veterans.". Hepatol Commun. DOI: 10.1097/hc9.0000000000000956 [abstract-verified: yes]
• ^[24] Seager, Meredith J, Bolton, Shay-Lee, Bolton, James M et al. (2024). "Coping style as a risk factor for future alcohol use disorder: A 16-year longitudinal study in a Canadian military sample.". Drug Alcohol Depend. DOI: 10.1016/j.drugalcdep.2024.111408 [abstract-verified: yes]
• ^[4] Sharp, Marie-Louise, Jones, Margaret, Franchini, Sofia et al. (2026). "Adverse mental health outcomes and alcohol misuse among UK Armed Forces personnel: fourth phase of a 20-year cohort study of military personnel who served during the Iraq and Afghanistan conflicts.". Occup Environ Med. DOI: 10.1136/oemed-2025-110647 [abstract-verified: partial]
• ^[23] Trompeter, Nora, Williamson, Charlotte, Rona, Roberto J et al. (2024). "Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans.". Behav Res Ther. DOI: 10.1016/j.brat.2024.104540 [abstract-verified: yes]
• ^[5] Walter, Kristen H, Levine, Jordan A, Highfill-McRoy, Robyn M et al. (2018). "Prevalence of Posttraumatic Stress Disorder and Psychological Comorbidities Among U.S. Active Duty Service Members, 2006-2013.". J Trauma Stress. DOI: 10.1002/jts.22337 [abstract-verified: yes]
• ^[6] Walton, Thomas O, Graupensperger, Scott, Walker, Denise D et al. (2024). "Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among military personnel.". Alcohol Clin Exp Res (Hoboken). DOI: 10.1111/acer.15313 [abstract-verified: partial]
• ^[12] Willey, James, Kaboli, Peter, Holcombe, Andrea et al. (2025). "Impact of alcohol use disorder on inpatient hospitalizations: A comparison of outcomes between urban and rural Veterans Affairs hospitals.". J Hosp Med. DOI: 10.1002/jhm.13544 [abstract-verified: yes]

Replacement Resolution Audit

Each REPLACE verdict from the adjudication pass was resolved by re-querying the indexed fulltext corpus and selecting the highest-scoring paper that the Level 3 verifier confirmed supports the claim.

• ^[12] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[3] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[25] → ^[4] (verifier: partial; score 0.57). Title: Postdeployment Treatment Gap: Symptoms and Treatment Utilization Among Returning National Guard Soldiers.
• ^[26] → ^[4] (verifier: partial; score 0.56). Title: Postdeployment Treatment Gap: Symptoms and Treatment Utilization Among Returning National Guard Soldiers.
• ^[6] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[27] → ^[6] (verifier: partial; score 0.85). Title: Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among mili
• ^[28] → ^[7] (verifier: partial; score 0.80). Title: Treating posttraumatic stress disorder and alcohol use disorder comorbidity: Current pharmacological therapies and the f
• ^[29] → ^[8] (verifier: partial; score 0.70). Title: Clinical, genomic, and neurophysiological correlates of lifetime suicide attempts among individuals with alcohol depende
• ^[9] → NO REPLACEMENT FOUND (considered 5 candidates; none verified)
• ^[10] → NO REPLACEMENT FOUND (considered 4 candidates; none verified)
• ^[30] → ^[12] (verifier: yes; score 0.78). Title: _Impact of alcohol use disorder on inpatient hospitalizations: A comparison of outcomes between urban and rural Veterans _
• ^[30] → ^[31] (verifier: partial; score 0.71). Title: Exploring how women with HIV develop hazardous drinking patterns: a qualitative assessment of drinking histories.
• ^[14] → NO REPLACEMENT FOUND (considered 3 candidates; none verified)
• ^[32] → ^[19] (verifier: partial; score 0.83). Title: Sex and Gender Differences in Co-Occurring Alcohol Use Disorder and PTSD.
• ^[33] → ^[20] (verifier: partial; score 0.82). Title: The reciprocal relationship between posttraumatic stress disorder symptoms and alcohol use in a large multisite longitud