The committee’s comprehensive review of the policies and programs on substance use disorders (SUDs) of the Department of Defense (DoD) and the branches built on DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces (Comprehensive Plan) (DoD, 2011b). The committee’s review responded to two requirements in its statement of task:
- an assessment of the adequacy and appropriateness of protocols used by the Military Health System relevant to the prevention, diagnosis, treatment, and management of SUDs in members of the armed forces; and
- an assessment of the adequacy of the prevention, diagnosis, treatment, and management of SUDs for dependents of members of the armed forces, whether such dependents suffer from their own SUD or because of the SUD of a member of the armed forces.
This chapter summarizes and assesses the policies relating to SUDs of DoD and each of the branches and comments on their adequacy and appropriateness. Box 6-1 lists the SUD policies reviewed. Note that while DoD-level policies apply to each of the individual branches, branch-level policies apply only within that branch. The chapter also highlights strengths and identifies areas for improvement within selected SUD prevention, screening, diagnosis, and treatment programs of DoD and the branches (see Appendix D for detail on these programs). The chapter concludes with a discussion
|Department of Defense (DoD)|
Military Personnel Drug Abuse Testing Program
Drug and Alcohol Abuse by DoD Personnel
Rehabilitation and Referral Services for Alcohol and Drug Abusers
DoD Civilian Employee Drug Abuse Testing Program
Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members
|Department of Veterans Affairs (VA)/DoD||
VA/DoD Clinical Practice Guideline: Management of Substance Use Disorders (2009)
Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program
Medical Operations: Mental Health
The Army Substance Abuse Program
Changes to Length of Authorized Duration of Controlled Substances Prescriptions in MEDCOM Regulation 40-51
Navy Alcohol and Drug Abuse Prevention and Control
Military Substance Abuse Prevention and Control
Navy Medicine Alcohol and Drug Prevention Program
Use of Disulfiram (Antabuse)
Standards for Provision of Substance Related Disorder Treatment Services
Marine Corps Drug and Alcohol Abuse, Prevention, and Treatment Programs
Marine Corps Substance Abuse Program
of the committee’s key findings regarding the programs and policies that address prevention, screening, diagnosis, treatment, and management of SUDs within the armed forces. Other findings on access to and utilization of programs and the TRICARE benefit used to provide SUD coverage for military dependents and on the adequacy of the workforce are presented in Chapters 7 and 8, respectively. The review of programs and policies in this chapter and Appendix D, along with the findings presented in Chapters 7 and 8, serves as a foundation for the conclusions and recommendations presented in Chapter 9.
This section reviews the policies outlined in DoD’s Comprehensive Plan, and others the committee identified, pertaining to SUD prevention, screening, diagnosis, and treatment at the DoD-wide level.
The committee made use of the best-practice elements for SUD prevention discussed in Chapter 5 to assess the adequacy and appropriateness of DoD and branch SUD policies and programs. In summary, evidence-based SUD prevention (1) addresses the appropriate risk and protective factors for the population in question, (2) employs approaches with demonstrated effectiveness, (3) takes place at the appropriate time chronologically and developmentally, (4) makes use of proper settings and domains for delivery, and (5) manages programs effectively (Office of National Drug Control Policy, 2001).
Two DoD policies—DODD 1010.1 and DODD 1010.4 (DoD, 1994, 1997)—articulate DoD’s interest in preventing and eliminating alcohol and other drug abuse and dependence in service members and employees because the disorders are incompatible with readiness. As a result, DoD seeks to “deter and identify drug and alcohol abuse and dependence,” and will not take into service military personnel or hire civilians who present with these disorders (DoD, 1997). The policies call for the provision of education to ensure that personnel understand the implications of not adhering to DoD alcohol and other drug use policies.
DODD 1010.1 guides the Military and Civilian Drug Testing Program and requires urinalysis screening to detect illicit drug use among active duty service members. Urinalysis screening deters drug use because of the consequences of positive results. However, use of random urinalysis to deter drug use has limitations, as use of substances not included in the testing panel or not included on a routine basis may not be detected. In addition, if the screening is not performed randomly or is anticipated, individuals
can avoid use of substances prior to being screened. DODD 1010.1 and DODD 1010.4 provide little or no guidance for other prevention strategies (e.g., large-scale efforts to educate individuals on the risks and health consequences of alcohol and other drug use, indicated prevention programs for those identified as at risk, prevention efforts aimed at military families, environmental prevention strategies). The policies do not appear to provide a clear strategy for preventing risky alcohol use and the potential development of alcohol use disorders. While some branches have policies that address these additional prevention strategies, they are not covered by overarching DoD policies.
The detailed review and assessment of DoD-wide prevention programs in Appendix D reveals that aside from drug testing, DoD relies heavily on campaign-style prevention programs (e.g., That Guy, the national Red Ribbon campaign). The National Institute on Drug Abuse (NIDA) has sponsored research on media campaigns to prevent drug use in youth and found that theory-based and evidence-based media campaigns can be effective in this population (Crano and Burgoon, 2002), but the effectiveness of campaign activities within the military is unknown. Moreover, campaign implementation varies across branches and bases, and participation requirements are unspecified. Overall, DoD delegates to the individual branches authority for implementing prevention for service members and their families, and the committee observed inconsistent implementation among the branches.
Monitoring for Prescription Drug Abuse
According to the ONDCP, the abuse of controlled prescription drugs such as pain relievers, central nervous system depressants, and stimulants is the nation’s fastest-growing drug problem. Although such prescription drugs have legitimate medical uses, they also pose the potential for abuse and addiction and may be diverted for nonmedical, illicit use. While it was outside the scope of the committee’s charge to study all the DoD and branch policies and programs related to the prescribing of controlled substances, the committee believes that the rising rates of prescription drug abuse in the military (as reviewed in Chapter 2) make it necessary to understand the DoD and branch policies and practices aimed at preventing the abuse of controlled substances prescribed to service members.
In both the civilian sector and the military, there are far-ranging programs and guidelines designed to ameliorate prescription drug abuse. These include diversion control activities of the Drug Enforcement Administration of the U.S. Department of Justice (GAO, 2011); education programs for primary care physicians and other specialists who prescribe these powerful medications; and additional guidelines for physicians to follow (Chou et al., 2009) when prescribing these medications that recommend a thorough
patient history to assess the risk of prescribing controlled substances to the patient (i.e., to identify any current or prior alcohol or other drug misuse), as well as frequent patient contact, monitoring, and urine screening when prescribing to high-risk patients. While the committee was concerned with the abuse of prescription pain medications among members of the armed forces, the problem is also increasing in civilian populations (Compton and Volkow, 2006).
Although its review was limited, the committee learned through testimony, an examination of the literature, and site visits about several resources intended to encourage responsible prescribing within DoD. The committee heard testimony from pain management specialists who identified far-reaching changes being planned to revolutionize pain management in the military.1 These changes include state-of-the-art interventions in theater and on the battlefield so that the wounded warrior is not started on high continuous doses of morphine, as well as expansion of multidisciplinary pain clinics that rely on physical therapy, strengthening, exercise, yoga, and cognitive-behavioral techniques to help the wounded cope with chronic pain and recondition the body rather than dull the pain with medications. The committee learned about the following resources aimed specifically at creating a military medical practice environment that reduces the risk of prescription drug abuse and diversion:
- a Department of Veterans Affairs (VA) and DoD clinical practice guideline for opioid therapy;
- recent development of pain management specialty services;
- the Army pain management task force;
- new policy guidance and policy changes on prescriptions for certain substances;
- expansion of the random urinalysis drug testing program to include additional prescribed medications; and
- special initiatives and reporting programs of DoD’s Pharmacoeconomic Center (PEC).
With regard to clinical practice guidelines, the committee learned that, to address pain management practices, the VA and DoD have jointly published the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (VA and DoD, 2010). The committee found this guideline to be in line with other accepted guidelines (Chou et al., 2009) and comprehensive in its approach to managing pain and addressing aberrant behaviors of abuse and diversion. The extent of implementation of this
1 Personal communication, Lt. Col. Kevin Galloway, Army Pain Management Task Force and Col. Chester Buckenmaier, M.D., Walter Reed Army Medical Center, July 19, 2011.
relatively new guideline at the provider level is unknown, and likely varies across installations and clinic settings.
During its site visits, the committee observed the recent development of pain management specialty services at some military treatment facilities but also learned that only a handful of pain specialists (frequently anesthesiologists) are currently serving in the armed forces.2 The integration of these services with substance abuse programs, as was observed at Fort Belvoir’s newly opened residential treatment center for substance abuse, demonstrates that the Army is beginning to address the issue of prescribing practices that contribute to the development of physical dependence and tolerance to pain medication, raising the risk of abuse. Because of the limited number of pain specialists, however, specialty pain clinics and pain management services are not available at all locations.
To help improve the quality of treatment for wounded warriors with chronic pain and simultaneously address concerns about prescription drug abuse and other problems arising from overreliance or sole reliance on prescription pain medications, the Army pain management task force was created to review current practices and policies and develop recommendations. The task force’s final report, published in May 2010, articulates a strategy for controlling and preventing opiate abuse that is science-based (U.S. Army, 2010). The committee found that one focus and four objectives laid out in the task force report are relevant to the prevention of opiate abuse. The one focus is for the armed forces to implement a drug abuse assessment strategy to ensure the efficacy of its pain treatment program, which in turn will reduce aberrant behavior, abuse, and addiction to overprescribed opioids. The four objectives include developing a patient-centric approach to injury recovery and rehabilitation, satisfaction, and pain control, with greater attention to controlling opioids and minimizing abuse. The Army is also developing an electronic pain order set for managing patients and mitigating the risk of prescription drug abuse and dependence in pain patients, focusing on controlled substances for chronic pain. Finally, the Army will identify substance abuse patients in Warrior Transition Units by embedding the necessary resources to develop and implement a coordinated care and monitoring plan. In the committee’s view, these recommendations will encourage practice and research advances in pain management and have the potential to prevent the misuse and abuse of prescription pain medications.
Additional actions by the Army and DoD are aimed at tackling prescription drug abuse in the military. These actions include a recent change in policy to set limits on the length of prescriptions and the quantity dispensed for controlled substances (U.S. Army, 2011a), which has the potential to
2 Personal communication, Ben Krepps, M.D., Director of the Pain Clinic at Fort Belvoir Community Hospital, November 15, 2011.
decrease ready access to some of the most commonly abused medications. The Army recently published policy guidance to caution providers about prescribing certain medications for the treatment of posttraumatic stress disorder (PTSD), specifically citing the lack of evidence for effectiveness of benzodiazepines and the risk for abuse of these substances (U.S. Army, 2012). In May 2012, DoD also implemented new practices for its urinalysis drug testing programs to screen for some of the most commonly abused prescription medications (e.g., hydrocodone, benzodiazepines). The new limits on the length of prescriptions for controlled medications, coupled with urinalysis for some of these substances, demonstrate that DoD, and particularly the Army, are undertaking new tactics to deter prescription drug misuse and abuse. However, it remains to be seen whether these new measures will affect the prevalence of prescription drug abuse in the military.
To monitor the use of prescription drugs, PEC has developed tools for use by installations and clinicians in identifying aberrant use and prescription patterns that increase the risk or are indicative of an SUD or diversion activity. The tools permit close monitoring when controlled substances are being prescribed for individuals with known SUDs and can also help identify high-risk behaviors of individuals with no known SUD who may need to be assessed for patterns that may lead to an SUD. PEC aims to “improve the clinical, economic and humanistic outcomes of drug therapy in support of the readiness and managed healthcare mission of the Military Health System” (DoD, 2012, p. 1). It conducts research and operates programs to monitor the prescription drug use behavior of persons identified by medical providers as exhibiting drug-seeking behavior or having a high risk of harming themselves through their drug use. Among the programs PEC operates are (1) the Prescription Restriction Program, (2) the Military Treatment Facility Lock-in Edit, (3) the Deployment Prescription Medication Analysis Reporting Tool (PMART), (4) the Warrior Transition Unit (WTU)-MART, and (5) the Controlled Drug Management Analysis and Reporting Tool (CD-MART).
The committee finds that PEC’s activities are comprehensive. In addition to the aforementioned deployment and controlled medication monitoring and reporting tools, PEC provides a full program of DoD prescription management support services, including pharmacoeconomic analysis and support for and/or collaboration with the DoD Pharmacy & Therapeutics Committee, the Pharmacy Operations Center, and the VA/DoD Clinical Practice Guidelines workgroup.
The reporting tools made available to clinicians and pharmacies through Deployment PMART, WTU-MART, and CD-MART appear to be as comprehensive and detailed as those of any state prescription monitoring program, and in fact are quite complete in that they contain all mail order
and retail pharmacy claims and prescriptions dispensed through the VA to service members. A recent report by the Defense Health Board (2011), however, found limitations to the PEC data systems. Specifically, the systems do not include in-theater pharmacy data in settings where there are no electronic medical records. Nor are they equipped to assess illicit activity on the part of service members who obtain prescriptions from civilian providers and pay out of pocket to obtain the medications from retail pharmacies.
The Prescription Restriction program gives military medical providers the ability to restrict patients to a specific pharmacy(ies) and/or provider(s) and restrict the dispensing of controlled medications from mail order and retail pharmacies. Currently the system is unable to restrict controlled medications to a specific provider and pharmacy simultaneously. Addressing this limitation might encourage more medical providers to adopt restrictions on controlled substances for more service members. As is the case with all prescription reporting tools, the key to effectiveness is adoption and use by medical providers.
Screening, Diagnosis, and Treatment
Urinalysis screening is the primary DoD strategy for identification of drug use; alcohol-related incidents are a primary source of referral for alcohol misuse screening at substance abuse clinics; and deployment health assessments (reviewed in Appendix D) are used to identify alcohol misuse in deployed service members who self-report such misuse. Beyond random urinalysis screening programs, Command may order a urinalysis screen or a breath test when performance suggests drug or alcohol use. Individual branch policies detail responsibilities for conducting and supervising random and Command screening, as well as the consequences of positive screens. DoD policies do not appear to recognize or address the limitations of urinalysis screening in identifying the extent of drug use, and fail to acknowledge that the screening identifies only the drugs tested for and miss drug use when a screen is not used or is unavailable. Several other screening programs and efforts, including the deployment health assessments, Military Pathways, and Military OneSource, are reviewed in Appendix D.
The Comprehensive Plan (DoD, 2011b) identifies four policies with elements pertinent to SUD diagnosis: DODD 1010.1, DODD 1010.4, DODI 1010.6, and DODI 6490.03 (DoD, 1985, 1994, 1997, 2011b). DODD 1010.4 uses the American Psychiatric Association’s (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) to define alcohol dependence, alcoholism, and drug dependence. This policy appropriately classifies drug and alcohol dependence as chronic psychiatric conditions that affect both individuals and families and recognizes the
need for periodic assessments of alcohol and other drug use. The practice of making SUD diagnoses, however, varies from branch to branch.
DODI 6490.08 (DoD, 2011a) clarifies DoD policy regarding the responsibility of health care providers to notify Command of potential SUDs. It is intended “to foster a culture of support in the provision of mental health care and voluntarily sought substance abuse education to military personnel in order to dispel the stigma of seeking mental health care and/or substance misuse education services” (DoD, 2011a, p. 2). The instruction directs health care providers to “follow a presumption that they are not to notify a Service member’s commander when the Service member obtains mental health care or substance abuse education services” (p. 2). This policy update could support implementation of routine screening and brief interventions in health care settings and substantially enhance the capacity of DoD and the armed forces for early intervention prior to the development of severe and disabling SUDs.
To provide an additional screening resource, the Military Pathways program, sponsored by DoD, was designed to encourage help seeking and reduce stigma for mental health disorders (including depression, PTSD, and alcohol abuse) for military populations. The Web-based program, developed by the nonprofit organization Screening for Mental Health, utilizes a “video doctor” that is meant to simulate a doctor-patient conversation and provide screening, brief advice, and referral to appropriate resources if indicated (Screening for Mental Health, 2012). Participation in the screening is anonymous and accessible to anyone (including reserve component members and dependents) through the Military Pathways website. While an evaluation of this program’s effectiveness has not been published, the concept for the program is based on research that has documented the benefit of video doctor screening and brief counseling services (Humphreys et al., 2011; Jackson et al., 2011; Tsoh et al., 2010). This screening program is an example of DoD’s utilizing new technology to help address the mental health needs of service members and their families. See Appendix D for further review of Military Pathways.
DoD policies DODI 1010.6 and DODD 1010.4 and the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) address treatment for SUDs. These policies encompass the components of health care delivery systems: patient-provider relationships, delivery of care, organizational functioning, and health care policy and regulation (Berwick, 2002) (see Chapter 5 for detail). Most policies are applicable to all active duty military personnel. Branch policies cover the governance structure for the delivery of SUD treatment; the philosophy and principles of treatment (e.g., SUD is often a chronic and relapsing disorder); and the training, certification, credentialing, and accreditation requirements for providers of care and facilities.
DODI 1010.6 addresses organizational and regulatory requirements. It outlines a governance structure with representation from the Air Force, Army, Navy, and Marine Corps and, by invitation, the VA. Constituting this governance structure is the DoD Joint-Service and VA Oversight Committee, which is responsible for coordinating policies and resources among the DoD branches and making recommendations on treatment and policy issues of joint interest. The Office of the Assistant Secretary of Defense for Health Affairs chairs this committee. DODI 1010.6 states that SUD staff members should be under the direct supervision of personnel qualified to evaluate their performance. However, the policy is vague with respect to how provider performance is to be rated or measured. The policy language implies that supervisors assess performance qualitatively; it does not describe quantitative measures of clinical effectiveness (e.g., Brief Addiction Monitor [BAM] score change or effect size, treatment adherence rates).
DoD appears to be moving toward an “umbrella structure” to connect the branches and the VA (i.e., a high-level set of policies establishing the basic governance structure, SUD treatment philosophy, and best treatment practices). This coordinated approach produced policies for DoD and VA sharing of resources under Public Law 96-22 (which created centers for PTSD counseling for Vietnam Veterans) and facilitates the standardization of basic quality structural requirements (e.g., each program must have a standard operating procedure). Current governance policies, however, allow variation among the branches in key areas (e.g., SUD program evaluations and policies related to the commander’s role in treatment decisions). This “umbrella structure” could be instrumental in driving coordination and enhanced consistency across all DoD components, including consistent implementation of measures of system/program effectiveness, performance, and efficiency. Coordination creates the opportunity to build comparability in processes and measurement across DoD and VA SUD services. Better management and analysis may support more rapid system improvements and increased efficiencies.
The VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) (see Chapter 4) provides guiding principles; it does not prevent providers from using clinical judgment. Updating of the guideline is stated as a goal; however, no timeline is given for any updating activity. Work on developing and implementing the guideline is intended to inform areas for future research and the optimal allocation of VA/DoD resources. Systematic measurement of treatment outcomes, provider capabilities, program implementation, and system performance supports continuous improvement, care responsive to patient needs, and enhanced effectiveness. DoD and VA policies and the Clinical Practice Guideline include recommendations for clinical measurement using validated tools for assessment and measurement of treatment progress: the
Alcohol Use Disorders Identification Test (AUDIT)-C for assessment and the VA’s BAM for tracking treatment progress.
The VA/DoD Clinical Practice Guideline, DoD policies (DODD 1010.9, DODI 1010.6), and branch policies generally are aligned with the best-practice principles discussed in Chapter 5 regarding detailed decision support algorithms incorporating evidence-based practices for assessments, psychotherapies, pharmacotherapies, withdrawal management, medical setting management, and management by specialty. The level of detail guides treatment choices and practices in key areas (e.g., use of validated tools for assessment and tracking of treatment response [see Chapter 5]). Individual branch policies, however, typically are silent on the use of the VA/DoD Clinical Practice Guideline. Staff training requirements are addressed in the umbrella DoD policy (DODI 1010.6) (DoD, 1985), with additional detail being provided in Army, Navy, Marine Corps, and Air Force policies. Best training practices that promote fidelity (see Chapter 5) consist of manualized training and demonstration of knowledge and/or competency with the use of a standard written examination, as well as supervision by trained instructors in clinical settings. See Chapter 8 for more detail on SUD staff training and credentialing within DoD programs.
Despite general alignment with best practices, the committee noted omissions and deviations. DODD 1010.9, for example, allows branches and programs to use idiosyncratic evaluations and metrics. Quality improvement initiatives usually rely on standardized measures of process and outcomes. The Comprehensive Plan came to similar findings that policies do not address standardization of data and outcome measures (DoD, 2011b). The lack of standardized outcome measures and benchmarks or a system that promotes the development of measures will undoubtedly lead to difficulties in evaluating program effectiveness and impact. Having a set of basic metrics that reflect the overarching goals of SUD treatment (e.g., sobriety, stabilization, and functionality) would be a good starting point. Some branches of the military (e.g., the Marine Corps) have begun outlining performance measures for SUD programs in their policies. Another area of omission within the policies is the absence of systems for measuring the clinical effectiveness of providers at both the provider population and individual case levels. As described in Chapter 5, the use of outcome measurement to demonstrate clinical effectiveness improves clinical competency and population outcomes. The policies contain references to the use of tracking tools to monitor the response to treatment, but there is no reference to aggregating these outcomes to measure the effectiveness of individual providers or programs. Finally, although the VA/DoD Clinical Practice Guideline is applicable to all branches of the military, the lack of reference to the guideline in branch-specific policies raises questions about the degree of its adoption. The Comprehensive Plan came to similar findings that
policies do not address the level to which the Clinical Practice Guideline is implemented (DoD, 2011b). During site visits to branch SUD programs and interviews with staff at treatment sites, the committee observed wide variation in the adoption of the Clinical Practice Guideline and variations in the implementation of umbrella DoD policies.
In summary, the VA/DoD Clinical Practice Guideline and DoD/branch policies include many best practices and processes for SUD screening, diagnosis, and treatment: central governance through the DoD Joint-Service and VA Oversight Committee; a structure for accountability within the different branches of the military; well-written practice guidelines; and policies at the DoD level and within the branches that, in the aggregate, align with best practices. At the same time, increased standardization of training requirements and evaluation measures would enhance DoD’s ability to monitor and manage SUD services.
Air Force Instruction (AFI) 44-121 covers various aspects of SUD care in this branch (U.S. Air Force, 2011). Section 3C covers eligibility, identification, and referral; 3D covers targeted and secondary prevention and education; and 3F (Clinical Care in Tiers II and III) covers documentation, assessment, and program completion. Regarding eligibility, the policy identifies Air Force members, dependents, and retirees as eligible for treatment under TRICARE; other employees can be seen by Alcohol and Drug Abuse Prevention and Treatment (ADAPT) personnel.
Air Force prevention policy (AFI 44-121) uses programs, activities, and outreach to build individual and unit resiliency in the general military population and targeted high-risk groups (U.S. Air Force, 2011). The Drug Demand Reduction Program (urinalysis screens to prevent illicit drug use), the Resiliency Element (community programming to enhance resiliency and reduce the incidence of family abuse and neglect), and the ADAPT program collaborate to develop and implement prevention programs at the installation level. The policy includes educational outreach to train health care providers and individuals in leadership roles to recognize risk factors, serve as role models, and provide support for prevention.
Air Force prevention programs promote military readiness, health, and wellness and minimize the negative consequences of substance misuse and abuse. The primary source of prevention services is the ADAPT program. ADAPT prevention programs are stipulated at two levels, or tiers. Tier I includes prevention and education for general military populations, delivered
through a variety of channels that are tailored to the specific needs of each installation and specific groups (e.g., military members, leaders, family members, youth). Channels include population-based and community outreach through the Culture of Responsible Choices (CoRC), Enforcing Underage Drinking Laws (EUDL), Drug Education for Youth (DEFY), and Adolescent Substance Abuse Counseling (ASAC) programs for youth, as well as programs that reach military members and their families, including the recently developed New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness (NORTH STAR) program (see Appendix D for program descriptions).
AFI 44-121 requires that at least four groups of military members receive prevention education. First, for service members on their first duty assignments, prevention focuses on responsible behavior, healthy alternatives to substance use, consequences of use, and techniques for dealing with peer acceptance. Second, for service members in grades E1-E4 on a second assignment or permanent change of station, the same set of prevention concerns is addressed within 60 days after change of station. Third, health care professionals who provide direct patient care receive training in prevention, as well as substance use identification and diagnosis and treatment of substance abuse. Fourth, for Airman Leadership School or Non-Commissioned Officer Academy students who are being trained for leadership roles, education and training emphasize leadership in delivering prevention, identification and referral of substance abusers, and education and counseling processes. Tier II includes screening, assessment, education, brief preventive counseling, and feedback to individuals or groups identified as at higher risk for substance abuse than the general military population.
Two Air Force prevention initiatives could be considered potential models for improving program standardization across the branches—the CoRC and NORTH STAR programs. The logic model or flow pattern used in the CoRC program starts with annual training of leadership (i.e., commanders and health care providers) in prevention programs. Program implementation sequentially targets service members and their families, military bases, and finally surrounding communities. Although there are no published studies on the efficacy of CoRC, it specifies a clear chain of command regarding leadership, training, responsibility for implementation, and dissemination from the base to the surrounding community. CoRC provides a good model for standardizing prevention training and delivery across the military branches, and should be evaluated to determine its efficacy.
NORTH STAR, a randomized controlled trial of 24 Air Force bases and more than 50,000 active duty military members, funded by DoD and the Department of Agriculture, provides “a community-based framework for the prevention of family maltreatment, suicidality and substance problems” (Heyman et al., 2011, p. 85). It is an integrated delivery system
involving commanders and providers partnered with Air Force community action and information boards at each of the 10 major Commands (Heyman et al., 2011). Using a guide on evidence-based programs that are rated according to evaluation outcomes and targeted risk and protective factors, the partners at each Command selected the programs that matched their specific risk and protective factor profiles. The guide also reviews training, implementation, and survey evaluation protocols. The use of a framework, delivery system, and guide to select prevention programs that fit a particular base’s risk and protective factor profile is based on extensive community-based prevention research strategies that have been evaluated in civilian populations (Heyman and Smith Slep, 2001; Pentz, 2003; Riggs et al., 2009). Initial results of the NORTH STAR program suggest significant reductions in alcohol abuse among military members and reduced prescription drug use after controlling for level of integrated delivery system functioning and Command support (Heyman et al., 2011). Training and programs are manualized, and individual bases can select from a menu of evidence-based programs tailored to their needs.
The EUDL program should be noted as a promising example of the implementation of environmental prevention strategies to reduce underage drinking in service members. In this discretionary grant program, “funds were used in each community to form a broad-based coalition, with the responsibility of implementing a set of environmental strategies to reduce drinking and associated alcohol-related misconducts among Air Force members, with a focus on the underage active duty population” (Spera et al., 2012, p. 513). The results of a recent evaluation demonstrated the effectiveness of the environmental strategies employed (Spera and Franklin, 2010; Spera et al., 2012). This program is further reviewed in Appendix D.
Screening, Diagnosis, and Treatment
Unit commanders, first sergeants, substance abuse counselors, and military medical professionals encourage self-identification of alcohol and other drug problems. Commanders may grant limited protection to individuals who self-identify and may not use self-disclosure against those individuals in personnel actions. Air Force policy provides incentives to encourage members to seek help for problems with substances. Self-identification is reserved for members who are not currently under investigation or pending action as a result of an alcohol- or other drug-related incident (U.S. Air Force, 2011).
Commanders are required to refer service members for an assessment if there is suspicion that substance use led to problematic behavior (e.g., driving under the influence/driving while intoxicated, public intoxication, drunk and disorderly conduct, spouse/child abuse and maltreatment, underage
drinking). Blood alcohol tests should be conducted as soon as possible after an instance of problematic behavior to determine alcohol involvement. Commanders are required to contact ADAPT for assessment of SUDs within 7 days of a potential alcohol- or other drug-related incident. In the case of driving-under-the-influence/driving-while-intoxicated offenses, commanders are required to contact ADAPT within 24 hours, but no later than the next duty day. Members who return from deployment because of problematic behavior must be assessed at the nearest ADAPT program. Air Force policy requires commanders or first sergeants to “actively participate” on the treatment team “by providing input to treatment decisions” (U.S. Air Force, 2011). Health care providers can also identify substance abuse. They are required to notify unit commanders and the ADAPT program manager when a service member is observed, identified, or suspected to be under the influence of alcohol or other drugs; receives treatment for an injury or illness that may be the result of substance use; is suspected of abusing substances; or is admitted as a patient for alcohol or other drug detoxification.
In the committee’s review of Air Force programming, the Behavioral Health Optimization Program (BHOP) stood out as a useful model for integrating behavioral health with primary care services. The Air Force recognizes that the primary care work setting differs substantially from specialty behavioral health care and requires a different practice pattern and pace. The BHOP training is designed to prepare behavioral health consultants to work effectively in the primary care setting. A study on the initial implementation of BHOP showed high levels of satisfaction among patients and primary care providers at pilot sites with integrated behavioral health care (Runyan et al., 2003). BHOP is an important step toward fully integrated care, particularly as it evolves from identification and referral to specialty care to include the provision of early and brief intervention for SUDs by primary care providers. BHOP may be a model for expanding integrated care in all military treatment facilities.
Individuals referred to ADAPT complete a detailed computerized assessment with the Substance Use Assessment Tool (SUAT). The use of this tool is standardized across all Air Force ADAPT sites, and contains validated screening tools to assess for SUD. The committee heard during its site visit to Keesler Air Force Base that use of the SUAT allows service members to complete a detailed assessment without having to spend hours being interviewed by a licensed clinician. Once the SUAT has been completed, a licensed clinician reviews the results and meets with the service member to ask follow-up questions and determine an appropriate diagnosis (the SUAT even provides a diagnostic impression as part of its results). After reviewing the content of the SUAT, the committee found it to be comprehensive and based on the use of validated screening instruments (see Appendix D for further review of the SUAT).
Individuals identified with high-risk alcohol and other drug use who do not meet the requirements for an SUD diagnosis are targeted for secondary prevention and educational activities—Alcohol Brief Counseling (ABC) (see Appendix D) and education on Air Force and DoD policies related to alcohol use, plus educational modules covering anger management, assertive communication, changing self-talk, sleep enhancement, and other areas. The ABC counseling sessions last 45 minutes and are usually offered one to four times per week, depending on the individual’s needs and risk level. ADAPT counselors use motivational interviewing techniques to provide individual feedback based on what was found during the SUAT initial assessment.
Overall, AFI 44-121 is comprehensive. Encouragement of self-identification is a plus, particularly the recognition that commanders should support self-disclosure; that self-disclosure should not be used against service members in personnel actions; and that when self-disclosure occurs, Command should contact ADAPT for an assessment. On the other hand, encouraging medical personnel to communicate with commanders and ADAPT personnel if alcohol and other drug problems are suspected may be necessary for commanders to assess fitness and readiness for military duty, but it also removes confidentiality from the identification and treatment process and may ultimately inhibit self-disclosure. Moreover, targeted prevention education and brief counseling for those suspected of high-risk alcohol and other drug use is appropriate, but “high-risk” is not defined. Further, the policy requires that treatment or prevention counseling for all clients be based on a thorough assessment (e.g., the SUAT, a clinical interview, and the collection of collateral data as appropriate) and determination of risk and be tailored to the individual; however, it fails to identify specific procedures for conducting a standardized initial assessment and making a subsequent diagnosis.
Clinical services are required for service members medically diagnosed with substance abuse or dependence. The level and intensity of care are determined by the ADAPT program manager using the American Society of Addiction Medicine (ASAM) Patient Placement Criteria. The Air Force’s philosophy is to place personnel with substance abuse problems in the least intensive or restrictive treatment environment that is appropriate to their therapeutic needs. Depending on the service member’s needs, variable lengths of stay or durations of treatment are provided within an array of treatment settings. For example, individuals may be placed in short-term outpatient or intensive outpatient programs at their local base, referred to a partial hospitalization program, or entered into an inpatient residential treatment program with a variable length of stay. Regardless of the level or intensity of care, programs are tailored to meet the specific needs of the individual.
Army Regulation (AR) 600-85 (U.S. Army, 2009) guides the implementation of the Army Substance Abuse Program (ASAP). AR 600-85 “provides comprehensive alcohol and drug abuse prevention and control policies, procedures, and responsibilities for Soldiers of all components, Army civilian corps members, and other personnel eligible for Army Substance Abuse Program (ASAP) services” (U.S. Army, 2009, p. 1). The regulation’s 18 chapters and 8 appendixes specify the purpose and authority of the regulation; articulate staffing roles and responsibilities; review the policies for alcohol and other drug testing for officers, soldiers, and civilian employees; and list services available for civilian corps members, family members, and retirees. The regulation also addresses procedures for identification, referral, and evaluation of individuals with suspected SUDs; describes the rehabilitation procedures and programs for prevention, education, and training; and specifies legal and administrative procedures. Drug testing standards are listed, and the risk reduction program is described. Chapters also detail procedures for program evaluation, data collection, and record keeping. The regulation concludes with descriptions of services for the Army National Guard and Army Reserve, a review of Army awards and campaigns, and guidance for resource management.
The Army Center for Substance Abuse Programs manages the ASAP services as part of its mission “to strengthen the overall fitness and effectiveness of the Army and to enhance the combat readiness of its personnel and units by eliminating alcohol and/or other drug abuse” (U.S. Army, 2009, p. 104). Located within the Army’s Human Resources Policy Directorate, ASAP is a Command program that emphasizes readiness and personal responsibility. ASAP provides prevention (education, deterrence, identification/detection, referral, and risk reduction programs) and treatment (screening and rehabilitation) services. Box 6-2 summarizes ASAP’s prevention and treatment capabilities.
ASAP prevention and treatment services are currently in transition. In October 2010, personnel, resources, and equipment used for screening and rehabilitation services in ASAP were transferred from Medical Command (MEDCOM) to Installation Management Command (IMCOM) to consolidate the program’s prevention and rehabilitation services within one Command. Services are being reengineered “to promote a full spectrum of care based on a public health model.”3 The committee’s discussions with ASAP staff during site visits to the Fort Belvoir and Fort Hood Army bases revealed strong support for the consolidation of prevention and treatment
3 Personal communication, Col. John Stasinos, Addiction Medicine Consultant for the Army Office of the Surgeon General, November 15, 2011.
- Education and training—Instruction for soldiers to increase knowledge, skills, and/or experience.
- Deterrence—Actions to dissuade soldiers from abusing or misusing substances. Random drug testing is the primary deterrence activity.
- Identification/detection—Identification of soldiers as potential substance abusers through self-identification, Command identification, drug testing identification, medical identification, or investigation or apprehension identification.
- Referral—Self-referral and Command referral to ASAR
- Risk reduction—Analysis of behavioral risk data to identify units with high-risk profiles and provide prevention interventions to mitigate high-risk behaviors.
- Screening—Individual biopsychosocial evaluation interviews to determine whether soldiers need to be referred to treatment.
- Rehabilitation—Clinical intervention to either return soldiers to full duty or identify soldiers who cannot be rehabilitated successfully.
SOURCE: Adapted from U.S. Army, 2009.
services. The ASAP staff acknowledged, however, that under the new structure, it is more difficult to coordinate treatment for SUDs with other medical care. ASAP no longer has access to a scheduling and tracking database previously used to track compliance with treatment requirements. In addition, the medical record permits limited documentation of ASAP care because of concern about the confidentiality of alcohol and other drug abuse records (42 Code of Federal Regulations [CFR] Part 2). During the transition period from MEDCOM to IMCOM, moreover, attrition of clinical staff has exacerbated the need to hire additional clinicians.
ASAP prevention, education, and training services are intended to prevent, deter, and reduce alcohol and other drug abuse and to provide soldiers
with prevention and awareness training (U.S. Army, 2009). Prevention and awareness training includes information on “a) ASAP policies and services, b) consequences of alcohol and other drug abuse, and c) incompatibility of alcohol and other drug abuse with physical and mental fitness, combat readiness, Army Values, and the Warrior Ethos” (U.S. Army, 2009, p. 55). Training to sustain and improve prevention counseling and training also is emphasized as a mission-wide effort. Specifically, the policy requires cooperation and partnerships with the installation and local communities and the availability of information about counseling and other substance abuse services at the installation. Deglamorization of alcohol is viewed as essential, and marketing and promotion of practices that glamorize alcohol use are prohibited. Commanders and supervisors are trained to identify early substance abuse problems among their personnel. The Army Training System incorporates alcohol and other drug abuse education and is compatible with the indoctrination of recruits in standards of discipline, performance, and behavior.
Drug testing is part of the prevention program, with detailed requirements for urine sample collection, screening of tests, breath testing, and personnel training. The policy extends substance abuse awareness training to all civilian employees and drug testing to those in designated positions (e.g., Department of Transportation [DOT] personnel). Prevention programs are encouraged for families, retirees, and off-duty contract personnel and their families, as well as for K-12 schools associated with military installations. ASAP is specifically authorized to purchase promotional items to encourage prevention (e.g., T-shirts, mugs, pens), particularly in connection with prevention campaigns (e.g., Red Ribbon Week, Warrior Pride, National Alcohol Awareness month). However, the committee did not identify any published peer-reviewed articles evaluating the effectiveness of these prevention campaigns and activities in military populations. Training in healthy life choices, responsible decision making, Army values, and alternatives to alcohol all reinforce the mission of preventing alcohol and other drug abuse. ASAP establishes goals and milestones in annual prevention plans and evaluates methods and outcomes of prevention activities. (The committee did not receive copies of evaluation reports or data on outcomes of prevention services.) Army policy states that prevention programs must be science based and focuses on deterrence through drug testing and law enforcement (i.e., eliminating supplies of illegal drugs, enforcing laws on driving under the influence and underage drinking).
Screening, Diagnosis, and Treatment
Chapter 7 of AR 600-85 addresses identification, referral, and evaluation of substance use, abuse, and dependence (U.S. Army, 2009). The
policy notes (Chapter 7, section I) that substance abuse and dependence are preventable and treatable and states that military personnel who abuse alcohol should receive education, counseling, and rehabilitation services. Self-identification is the preferred mode of identification, but Command referral is more common. Positive identification of alcohol abuse and dependence requires referral to ASAP in order to return the service member to “full duty status.” Although DoD policies identify alcohol and other drug abuse and dependence as chronic conditions, AR 600-85 permits only “one period of rehabilitation” per alcohol incident. In exceptional cases, commanders may recommend a second period of rehabilitation. Any alcohol-related incidents occurring after two rehabilitation periods require separation. According to the policy, soldiers identified as drug abusers are referred to ASAP, and a diagnosis of drug dependence leads to detoxification and treatment while separation procedures are initiated. AR 600-85 (U.S. Army, 2009, p. 47) asserts that soldiers diagnosed as drug dependent “generally, do not have potential for continued military service and should not be retained.”
AR 600-85 describes six different methods of identification of alcohol and other drug abuse and dependence: (1) voluntary (self-referral), (2) Command referral, (3) drug testing, (4) alcohol testing, (5) medical referral, and (6) investigation and apprehension. As noted, voluntary disclosure is the preferred method of identification, and commanders must be involved in the process of evaluation. Commanders should encourage self-identification and avoid actions that would discourage personnel from seeking help. Civilian employees and family members seeking help should be offered employee assistance program evaluation. Commander identification, drug and alcohol testing identification, and identification through investigation and/or apprehension lead to referral to ASAP. Referrals to ASAP are required within 5 duty days of receipt of test results. If identification occurs during a routine medical screening, the provider should refer the soldier to ASAP and notify the commander. In the case of identification of a problem in a civilian employee or family member, the referral should be to the employee assistance program.
Overall, the methods of identification described in the policy are comprehensive, and the emphasis on encouraging self-referral is constructive. The specification of the number of days within which referral to the ASAP program should be made strengthens the policy. Still, the policy is vague regarding identification methods, especially during routine medical exams. As suggested above, commander involvement and disclosure of self-referral to commanders by health care providers may discourage rather than encourage self-disclosure because it gives commanders access to in-depth confidential information about soldiers’ alcohol and other drug abuse and dependence.
Chapter 8 outlines the rehabilitation services provided through ASAP. AR 600-85 requires the unit commander to participate in the treatment team and support the rehabilitation process. The goal of rehabilitation is to (1) return the soldier to full duty as soon as possible, and (2) identify soldiers for separation who cannot be rehabilitated with ASAP services. ASAP rehabilitation services include four elements: (1) identification and referral, (2) biopsychosocial assessments and Command consultation, (3) rehabilitation and follow-up, and (4) mandatory monthly alcohol and drug testing for soldiers enrolled in the rehabilitation program. Specific rehabilitation services include Level I (nonresidential outpatient rehabilitation) and Level II (partial inpatient and residential treatment). Level I services require a minimum of 30 days and a maximum of 360 days of participation. Education services may be provided as appropriate. Level II services provide intensive partial residential treatment programs of varying lengths and a 1-year period of mandatory nonresidential follow-up for individuals who do not respond favorably to outpatient treatment. Participating soldiers are encouraged to attend self-help groups, and the rehabilitation plan must “specify an appropriate number of meetings per week the client will be encouraged to attend” (U.S. Army, 2009, p. 53). AR 600-85 does not describe the content of Level I and Level II services and is silent on the use of evidence-based behavioral and pharmacological therapies. While the policy identifies the need for an in-depth biopsychosocial interview, it does not specify how this interview should be conducted. The regulations require that ASAP clinical providers have a master’s degree in social work or psychology from an accredited university.
AR 600-85 underscores the importance of Command. Commanders can make decisions about who should be evaluated, how evaluation and rehabilitation will take place, and whether soldiers can remain in the service.
The Confidential Alcohol Treatment and Education Pilot (CATEP) permits soldiers to self-refer to ASAP (if not involved in an alcohol incident) and receive confidential treatment without Command notification. The pilot initiative seeks to engage soldiers in alcohol treatment at earlier stages of the disorder. CATEP began in July 2009 and is now at six Army sites across the United States. Soldiers in CATEP are not subject to negative personnel actions (i.e., barred, flagged), and those who fail treatment will not be administratively separated. Enrollment in CATEP treatment does not count toward the number of trials of rehabilitation allowed per military career.4 This small but promising program emphasizes confidential alcohol treatment. Soldiers seeking services for drug use many not enroll in CATEP. CATEP appears to be worthy of expansion within the Army and could be
4 Personal communication, Col. Charles S. Milliken, M.D., Walter Reed Army Institute of Research, May 3, 2011.
considered as a strategy for addressing misuse of prescription opioids in addition to alcohol.
The committee also interviewed several staff at the Fort Hood pilot Intensive Outpatient Program (IOP) (see Appendix A for the committee’s site visit agenda). The IOP, which opened in February 2010, provides more intensive care than is typically available from ASAP clinics. The program also treats soldiers with comorbid mental health disorders and SUDs. The Fort Hood pilot IOP provides ASAM Level II.5 care as a 4-week day treatment program. It provides both group and individual therapy sessions using cognitive-behavioral therapies and eye movement desensitization and reprogramming therapy (DCoE, 2011). While the IOP program was initially created to provide intensive outpatient-level care, the actual level of care provided is partial hospitalization; the program’s name is therefore being changed. To enroll in the program, patients must have a primary diagnosis of SUD, and their commander must support their participation. The primary substance of abuse is alcohol, but the program addresses both alcohol and other drug use disorders. Currently, staff conduct follow-up interviews to assess patient outcomes at 30, 60, and 90 days after treatment completion. Typically, 70 percent of patients reached remain on active duty after completing treatment. Continuing care includes regular appointments for acudetox and eye movement treatments. Anecdotal evidence suggests that soldiers—at least those that continue in the Army rather than being administratively separated—continue to do well after completing the program. The Fort Hood IOP pilot may be an excellent model for expansion and adoption at other bases.
The committee also visited the Army SUD treatment programs at Fort Belvoir. The Co-Occurring Program is housed at the DeWitt Army Hospital within the Warrior Transition Brigade (WTB). Once enrolled in the WTB, soldiers are engaged in care for 18 to 24 months, but they must have complex case management needs in order to be enrolled. Program personnel reported that two-thirds of the Fort Belvoir WTB population has been diagnosed with a mental health condition rather than a physical health condition or injury, which necessitates access to mental health care within the WTB. The Co-Occurring Program provides several treatment tracks: strictly substance abuse treatment, no substance abuse treatment, and treatment of substance abuse with a comorbid anxiety or other mood disorder. The length of stay is typically 4 to 6 weeks, and most referrals come from the national capital area. Upon completion of the program, soldiers return to ASAP at their individual unit for follow-up care. The program will be using the Parent Management Training Oregon model and Seeking Safety as part of its treatment programming. All patients receiving any level of treatment in the Co-Occurring Program must also be enrolled in ASAP. The committee heard testimony that psychiatrists involved in patient care often walk a
fine line with respect to how much information to share with the patient’s commander, depending particularly on how receptive commanders are to helping their soldiers get the care they need.
Navy Instructions 5350.4D (U.S. Navy, 2009) and 5300.28E (U.S. Navy, 2011) govern the Navy’s Alcohol and Drug Abuse Prevention and Control programs and establish policies and procedures for the prevention and control of alcohol and other drug abuse within the Department of the Navy (U.S. Navy, 2011). Navy Bureau of Medicine (BUMED) Instruction 5353.4A operationalizes the standards for provision of SUD treatment services (U.S. Navy, 1999). Two additional BUMED instructions detail the operation of BUMED’s Alcohol and Drug Prevention Program (U.S. Navy, 2009) and provide guidance on the use of disulfiram (Antabuse) for the treatment of alcohol dependence (U.S. Navy, 1990).
Navy Instruction 5340.4D states that alcohol and other drug abuse undermines combat readiness and interferes with maintaining high standards of performance and military discipline. Specific attention is given to responsible drinking by those of legal age (21 and over) who choose to drink (U.S. Navy, 2009). Navy policy supports those who choose not to drink and does not condone drinking during working hours (except in the case of special authorized occasions). Prevention is focused on enhanced detection, deterrence, prevention, and education within a Command climate of “zero tolerance” for drug use. The Navy’s urinalysis program detects and deters the use of illegal drugs. Enlisted recruits, officer candidates, midshipmen, and officers in pre-Fleet assignment or entry programs also complete alcohol and other drug abuse prevention education programs. Alcohol and other drug abuse prevention curricula must be included in General Military Training.
Responsibilities of different Command levels include ensuring that education and training in alcohol and other drug use prevention are carried out effectively and maintaining data on all related activities. Senior personnel act as alcohol and drug control officers (ADCOs) and provide guidance to drug and alcohol program advisors (DAPAs). DAPAs manage the substance abuse prevention program and conduct prevention education courses: Alcohol-AWARE, Personal Responsibility and Values Education and Training, Alcohol and Drug Abuse Management Seminar for Leaders/Supervisors, and Skills for Life. Courses are provided for multiple levels of Command to ensure clear and consistent delivery of the prevention messages.
In May 2011, a policy update (SECNAVINST 5300.28E) expanded the role of drug testing to include commonly abused prescription drugs (U.S. Navy, 2011). Guidance issued in March 2012 specifies testing practices for synthetic compounds (e.g., Spice and bath salts) using the Navy’s steroid testing model (U.S. Navy, 2012a). To address alcohol abuse, current policy under SECNAVINST 5300.28E stipulates that breath testing may be used as a prevention strategy, and the Navy planned to roll out an alcohol breath testing program in late 2012 (U.S. Navy, 2012b). Random breath testing will be conducted aboard Navy ships, and positive tests will lead to referral to the Navy Substance Abuse Rehabilitation Program (SARP). The updated policies and programs reflect the Navy’s leadership in implementing strategies to deter alcohol, prescription drug, and designer drug abuse. It remains to be seen whether these new measures will be effective.
SECNAVINST 5300.28E further stipulates that prevention programs should be directed toward known SUD threats in a geographic area or Command. The programs may include threat assessment, policy development and implementation, public information activities, education and training, deglamorization messages, and evaluations tailored to individual Commands (U.S. Navy, 2011).
Navy prevention policies appear to focus primarily on drug testing procedures and contain little guidance or information on other prevention activities. The committee’s review of Navy material and information, however, indicated that the Navy has the largest number of formal and established prevention programs among the armed forces (see Appendix D for detail on these programs). Although they are not described in policy, the Navy provides a wide range of prevention services beyond the urinalysis drug screening program.
Screening, Diagnosis, and Treatment
OPNAVINST 5350.4D recognizes that alcohol abuse and dependence are preventable and treatable (U.S. Navy, 2009). SECNAVINST 5300.28E (U.S. Navy, 2011) states that alcohol and other drug abuse is incompatible with high performance standards, readiness, discipline, and military missions, and that drug-dependent individuals should not be inducted into the Navy or Marine Corps. The policy states that military members who are diagnosed as drug dependent should be disciplined and separated, as should those who are involved in an “alcohol-related incident” after entering treatment. Any alcohol-related incident after two treatment periods triggers separation. Military personnel receive detoxification and limited treatment prior to separation. Exceptions are made for those with a “high probability of successful treatment.” SECNAVINST 5300.28E, however, does not identify specific evidence-based prevention and treatment services,
when and how interventions should be implemented, or what type(s) of personnel should provide such services.
The Navy encourages both Command and self-referrals for alcohol misuse, abuse, and dependence. Self-referral cannot be associated with an alcohol-related incident. Command referral can be based on personal observation of behavior or a change in job performance. If the service member is involved in an alcohol-related incident (e.g., driving under the influence, alcohol-related arrest, alcohol-related domestic violence, drunkenness), screening is required. After assessment within SARP, Command receives results and treatment recommendations.
Urinalysis is the main drug testing program in the Navy. The policy provides guidance on response to a positive drug screen, an alcohol incident such as impaired driving, or a positive alcohol blood level while on duty. But the policy tends to perceive substance use as a personnel-related rather than a health-related issue. It does not specify how screening should be conducted or who should conduct it, and there is no mention of targeted prevention for high-risk users or the types of treatment offered. The policy defines alcohol abuse and dependence and drug abuse and dependence based on standard criteria in DSM-IV-TR (APA, 2000). It also defines alcohol incidence, anabolic steroids, controlled substances, driving under the influence/driving while intoxicated, drug abuse paraphernalia, drug trafficking, inhalant abuse, and other relevant terms.
Navy policy has positive characteristics, including recognition that alcohol abuse and dependence are preventable and treatable; encouragement of self-referral; and recommendation for assessment, diagnosis, and treatment. As with Air Force and Army policies, however, Command involvement in screening and treatment may severely inhibit self-disclosure of alcohol problems. The Navy SARP program that the committee visited on the San Diego Naval Base used evidence-based treatments. It utilized identifiable definitions of treatment failure and conducted periodic evaluations to understand its successes and areas in which improvements were needed. The San Diego SARP has an expressed focus on assessing depression, PTSD, and other psychiatric comorbidities among the patients it treats. Information was presented to the committee on the capacity of the program to provide dual-disorder treatment based on Dual Diagnosis Capability in Addiction Treatment (DDCAT) scoring. The DDCAT scoring, however, is based on self-report rather than an external assessment. All SARPs encourage aftercare. Unlike other branches, the Navy has a specialized aftercare program, My Ongoing Recovery Experience (MORE), that uses telephone and Web-based follow-up to support service members in maintaining their recovery (see Appendix D for further review of the Navy MORE program). By utilizing MORE to provide ongoing follow-up and recovery support,
Navy SARP counselors can focus more of their time on providing screening and treatment services.
Overall, the committee finds Navy SARPs to be comprehensive treatment programs that offer several therapeutic interventions with varying levels of intensity depending on the ASAM Patient Placement Criteria (Levels 0.5 to IV). Besides treatment, SARP activities appropriately encompass prevention, early indicated intervention, screening and diagnosis, and aftercare. Evidence-based practices are applied throughout. The effectiveness of treatment is monitored, although no assessment of effectiveness with state-of-the-art randomized techniques has been conducted. The committee was particularly impressed with the focus, breadth, supervision, and operation of the SARP prevention, screening, diagnostic, and treatment services.
Two policies guide SUD prevention, screening, diagnosis, and treatment for the Marine Corps: NAVMC 2931 and MCO 5300.17. Unlike the other military branches, the Marine Corps does not have its own Medical Command and therefore receives medical services through the Navy.
Marine Corps prevention awareness and education training policy has two stated goals: (1) to enhance mission readiness and (2) to provide knowledge of the effects of substance abuse to assist individuals in making responsible decisions (U.S. Marine Corps, 2011). Training military and civilian supervisors in the importance of eliminating alcohol abuse and illegal drug use is a secondary purpose of prevention policy. While the primary emphasis of Marine Corps prevention policy is information and knowledge transmission, the policy also recognizes the importance of using this information to clarify personal values, improve decision making, and understand alternative lifestyle choices that do not depend on alcohol and other drug use.
Marine policy mandates prevention awareness education and training for Marines at all levels at least annually. The committee, however, did not receive data on the proportion of Marines who receive this education and training or on how it is delivered (e.g., whether prevention is embedded in other aspects of Marine education and training or is addressed separately). Initial training for officer candidates and recruits includes alcohol and other drug abuse prevention as part of the core training curriculum. Training consists of information and guided discussion on the progressive nature and risks of alcohol and other drug abuse (i.e., domestic abuse, sexual assault, and financial difficulties). Specific information on alcohol
describes alcohol metabolism and physiological effects, defines and outlines effects of blood alcohol levels, and identifies factors that influence these levels. Supervisors have key roles in setting positive examples in prevention and referral of abusers to treatment, as well as in supporting alternative, nondrinking recreational activities, including tutoring in the community, coaching sports, and volunteering for fire and rescue services. The essential elements of Marine Corps prevention policy are aggressive random urinalysis testing, random vehicle inspections, and use of drug detection dogs. The policies also actively endorse nondrinking and non-drug-using norms (e.g., no drinking contests, no alcoholic beverages as gifts or prizes, food and nonalcoholic beverages made readily available). Deterrence is a key prevention policy goal, although it is unclear to what extent these measures are employed consistently on the ground or have been evaluated for effectiveness.
Screening, Diagnosis, and Treatment
Two Marine Corps policies address prevention and treatment for alcohol and drug use, abuse, and dependence (MCO 5300.17 and NAVMC 2931). MCO 5300.17 identifies prevention, timely identification, and education and/or treatment, as well as “appropriate discipline or other administrative actions” (which may include restoration to full duty or separation), as key elements of Marine substance abuse programs (U.S. Marine Corps, 2011). The policy specifies that the wrongful use of drugs may result in prosecution and administrative action. The Personal and Family Readiness Division prepares a prevention plan covering training curricula and materials and assesses effectiveness, hosts conferences and working groups on substance abuse programs, conducts research and provides evidence-based models for prevention and treatment services, and evaluates programs. Commanders are intimately involved in responding to alcohol and drug use incidents and problems. They are directed to refer service members to prevention and intervention services and designate a substance abuse control officer (SACO). SACOs refer personnel for screening, maintain records of personnel with alcohol and other drug problems, ensure annual drug screening and proper implementation of screening, and conduct substance abuse prevention education. Medical officers (e.g., physicians, clinical psychologists) are responsible for diagnosis and for all aspects of treatment.
Chapter 2 of MCO 5300.17 addresses substance abuse prevention. Item 4 (Chapter 2) covers the drug testing program, designed to inspect personnel and assess Command readiness. Urinalysis testing is random and applied to all personnel. Commanders may order a drug test if there is suspicion of drug use. If a urine test is positive for one or more illicit drugs and other evidence corroborates drug use, commanders commence separation
proceedings. NAVMC form 11700 guides assessments for SUDs—the signs and symptoms of abuse and dependence that constitute DSM-IV-TR criteria for abuse and dependence. Items listed on NAVMC form 11700, however, do not appear to come from a recognized standardized psychiatric interview with known psychometric properties. If screening rules out the need for a more complete assessment, the Marine receives early intervention and returns to duty. If a more complete assessment is necessary, it is conducted by a counselor (who becomes the Marine’s case manager) using NAVMC form 11692. The counselor conducts a detailed assessment of cultural and family background, education and work, military experience, socialization, self-concept and communication, financial status, spirituality, and emotional and behavioral areas. Form 11692, however, does not incorporate a standardized diagnostic instrument with which to identify alcohol and other drug abuse or dependence. Diagnosis appears to occur in a nonstandardized manner or with NAVMC form 11700. NAVMC 2931, which describes procedures for drug and alcohol prevention and treatment programs, contains several forms used in comprehensive assessments of alcohol and other drug use and related problems. Although the forms cover signs and symptoms of abuse and dependence (e.g., withdrawal, job and financial problems), the questions in these areas do not appear to come from standardized screening interviews or psychiatric interviews designed to provide DSM diagnoses. Despite the wide array of assessments described in the policies, screening and diagnostic procedures fail to take advantage of standardized screening instruments or psychiatric interviews to reach DSM diagnoses.
Chapter 3 of MCO 5300.17 addresses substance abuse treatment provided by a physician or clinical psychologist. The Substance Abuse Counseling Center (SACC) provides alcohol and drug abuse treatment that includes screening, early intervention, biopsychosocial assessment, and treatment. The vast majority of Marines (approximately 90 percent) who receive treatment from the Marine Corps program have been identified either by Command or through the screening process. Very few Marines self-refer to treatment because of the belief that there will be consequences for their job position if they admit to needing help (as discussed further in Chapter 7). Moreover, according to information the committee received during its site visit to Camp Pendleton, the identification of problems is highly variable, depending on the SACOs and particular commanders. Once a Marine has been identified for treatment, the treatment program follows ASAM’s Patient Placement Criteria, including early intervention and outpatient and intensive outpatient treatment.
The committee had concerns regarding several elements of the Marine Corps’ substance abuse program. First, there is no uniformity in treatment programs or modalities across sites. For instance, the Marines Alcohol
Awareness Course is used only at Camp Pendleton. The majority of SACCs utilize the Impact as an indicated prevention program, but treatment modalities vary from site to site; some use 12-step programs, others use motivational interviewing, and so on. Second, Marines ordered to treatment are given mandatory orders to attend or face separation, but there are no data on whether mandatory treatment ensures treatment “success.” In the case of alcohol abuse/dependence, separation decisions are made following treatment. Marines who self-refer for treatment for drug abuse/dependence and receive a diagnosis of abuse are processed for separation without treatment and are subject to disciplinary action; those who receive a diagnosis of dependence are processed for administrative separation, but are offered treatment and are exempt from disciplinary action. Third, it is unclear whether the Marine Corps’ 58 substance use counselors make use of evidence-based treatments. Fourth, aftercare is insufficient; it serves more as administrative monitoring than recovery support. Finally, while treatment programs are accredited by the Commission on Accreditation of Rehabilitation Facilities, they have not been internally evaluated.
Because the Marines work with the Navy for many of their services, they share many of the same strengths and weaknesses. Marine policies, however, have additional weaknesses. They do not require measurement of clinical outcomes or provision of relapse treatment. Further, SUD treatment in the Marine Corps does not use a multidisciplinary team approach, nor does it employ master’s-level counselors with SUD training, relying instead on certified substance abuse counselors to provide counseling and group therapy. Only two of the Marine Corps programs offer integrated traumatic brain injury (TBI)/PTSD treatment, and they are provided by the Navy (Camp Pendleton and Naval Medical Center Portsmouth).
Dependents of military members include adult spouses and children who may have their own needs for SUD care. Dependents who enroll in the TRICARE Prime program have the option at the commander’s discretion to use medical and behavioral care in the direct care system (see Chapter 3 for a description of TRICARE benefit programs); however, dependents who require behavioral health services, including SUD treatment, make use of civilian providers paid through a TRICARE benefit. The committee’s findings on the adequacy of the SUD benefit coverage and the utilization of SUD care by service members and their dependents are presented in Chapter 7. This section describes whether and how the policies and programs reviewed in this chapter and Appendix D specifically target military dependents.
DODI 1010.6, which addresses rehabilitation and referral of alcohol and drug abusers, contains a specific clause referencing dependents: “Rehabilitative and educational services shall be provided, when feasible, to the family members of DoD personnel and other eligible beneficiaries.” While this policy grants permission to extend SUD services to family members, the committee found that in practice, this is beyond the capacity of most programs given the decade of involvement in overseas conflicts and the need to devote resources to the highest-priority issues affecting force readiness. As discussed in Chapter 7, only a fraction of family members have made use of SUD treatment services in the direct care system. Table 6-1 lists the DoD and branch programs that make specific mention of targeting military family members, according to the Comprehensive Plan (DoD, 2011).
|Program||Clinical Focus||Target Population|
DoD National Red Ribbon Campaign
Active duty, dependents
DoD Military Pathways Program
Active duty, Reserves, National Guard, dependents
DoD Real Warriors Campaign
Active duty, dependents
Adolescent Substance Abuse Counseling (ASAC) Program
Prevention, screening, diagnosis, treatment
Active duty, Reserves, National Guard, dependents
Air Force Culture of Responsible Choices (CoRC)
Prevention, screening, diagnosis, treatment
Active duty, dependents
Air Force, Navy, and Marines Drug Education for Youth (DEFY)
Air Force Enforcing Underage Drinking Laws (EUDL)
Active duty, dependents
Army Employee Assistance Program (EAP)
Dependents, civilian employees
Navy Drug and Alcohol Advisory Council (NDAAC)
Active duty, Reserves, dependents
Appendix D contains a description of these programs, which are assessed only briefly below.
While some prevention resources target military spouses and children, no single uniform DoD program provides comprehensive prevention programming for dependents, and the committee found no reports on the effectiveness of prevention resources for this population. A number of programs targeting primarily service members, however, do include services for military family members.
The Red Ribbon campaign is a universal prevention campaign aimed at addressing peer pressure and prosocial bonding in youth, as well as parental monitoring. Thus, it is most developmentally appropriate for young military members with families. Red Ribbon Week is an annual campaign that is conducted nationwide in the United States every October both at the community level and on military bases. There is no evidence on this program’s effectiveness, and both military bases and communities vary widely in the activities they sponsor under the auspices of the campaign. There is presently no published information on Red Ribbon’s theoretical basis or on its outcomes.
Military Pathways is described as inclusive of universal and selective prevention approaches. The private contractor has developed family resiliency materials designed to help educate and support military families in coping with deployment stress, recognizing signs and symptoms of mental health problems, and building resiliency, and to help service members reconnect with their children.
The Real Warriors Campaign is an initiative launched by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Its goal is to “promote the processes of building resilience, facilitating recovery and supporting reintegration of returning service members, veterans and their families” (DCoE, 2012, p. 1); it is not aimed specifically at the prevention of SUDs. Further, as suggested by its title, the program’s primary emphasis is not on family members but on assisting service members returning from deployment.
The Air Force’s CoRC program appears to be aimed primarily at service members. However, it includes Toolkit 4, a training and resource guide for Command, ADAPT staff, and Drug Demand Reduction staff focused on building community collaborations for prevention. This toolkit includes training in prevention concepts, screening, social norms, consulting to the community, and prevention program management. It follows evidence-based practices for community implementation processes and prevention operating systems (Hawkins and Catalano, 1992). The committee did not
hear testimony on CoRC implementation or its use to reach Air Force dependents.
DEFY is a comprehensive prevention program offered by the Air Force, Navy, and Marine Corps. It is operated worldwide and consists of a summer leadership camp (Phase 1) and a school-year mentoring program (Phase 2). The program’s curriculum encompasses a variety of topics, including substance abuse prevention and other vital life skills, such as conflict resolution, self-management skills, study skills, leadership, and community service.
The EUDL program was a pilot that showed significant reductions in underage drinking (Spera and Franklin, 2010). Its primary target appears to be drinking among underage airmen, although some components include environmental changes in the community that may also benefit spouses and child dependents. The committee learned that EUDL was a demonstration project and that there are currently no plans to expand it to all Air Force bases; however, some of its components will be implemented within other Air Force–wide initiatives.5 The committee finds the EUDL program to be a promising example of an effective approach to SUD prevention in military settings.
The Army’s Employee Assistance Program provides a wide variety of services addressing various adult living problems. Examples include screening, short-term counseling, and referral. The extent to which military spouses use this program is unclear.
Finally, the Navy’s Drug and Alcohol Advisory Council (NDAAC) is a local and regional mechanism by which commanders can monitor and communicate achievements or lack of success in attaining prevention goals related to alcohol-related incidents. As it targets incidents resulting from alcohol misuse, it is not a primary prevention program. Furthermore, while the NDAAC is described as available to dependents, the scope of commander monitoring is most likely limited to incidents involving service members rather than family members in the community. The committee was informed that the NDAAC could provide a mechanism for establishing specific short- and long-term branch-level goals for reducing harmful alcohol use, but the means by which this might be accomplished were not described.
Screening, Diagnosis, and Treatment
The Military Pathways program includes a self-assessment/self-screening component that can serve as a secondary prevention mechanism
5 Personal communication, Lt. Col. Mark S. Oordt, Ph.D., USAF ADAPT Program, October 25, 2011.
for military members or spouses who self-identify as being at personal risk for SUD and subsequently seek help. The committee found that these materials appear to follow evidence-based principles. A RAND report estimates that this intervention reaches more than 305,000 active duty service members and their families each year (Weinick et al., 2011).
The Comprehensive Plan identifies the Adolescent Substance Abuse Counseling (ASAC) program as an Army contract, but in January 2010, DoD extended a blanket purchase agreement with a value of up to $80 million so the program could serve dependents of members of the Air Force, Navy, and Marine Corps (SAIC, 2010). The focus is described as children of military families in grades 6-12 who are considered at risk for substance use and who are authorized to use military treatment facilities. Services specified in the contract include treatment, identification and referral, and prevention education in community settings (U.S. Army, 2011b). The committee did not hear testimony on this program from any branch representatives, which appears to suggest that use of an independent private contract has not led to maximum coordination of these services with Command-directed programs.
Finally, Military OneSource provides a confidential means for service members and their families to be screened for SUDs and referred to resources. The counseling provided by Military OneSource’s contracted providers is nonmedical in nature (e.g., connecting people to resources; counseling on relationship issues, readjustment, and stress). The committee did not learn of the volume of referrals made through this service.
Other than the above three programs, the committee is not aware of organized, stand-alone SUD screening, diagnosis, or treatment initiatives for military spouses or children in the direct care system. Note that while this discussion has focused on policies and programs relevant to military dependents, the TRICARE benefit pays for certain SUD services, including assessment and diagnosis by SUD professionals, in specialty programs. The adequacy of the benefit and utilization of these services are discussed in Chapter 7.
The committee’s review of SUD policies and programs within DoD, the Air Force, the Army, the Navy, and the Marine Corps revealed both strengths and limitations. Policies outline roles, responsibilities, and options for SUD prevention, screening, diagnosis, and treatment services and provide the foundation for program implementation. Variation in program implementation, however, reflects a lack of standardization and reveals inconsistency in the interpretation of policy. Increased standardization of SUD prevention, screening, diagnosis, and treatment services across the
branches of the U.S. military could enhance the effectiveness and efficiency of these services and permit branches to share resources and provide more consistent and higher-quality services.
Finding 6-1: DoD and branch policies recognize the deleterious effects of alcohol and other drug use and support the need for SUD prevention, but programs fall short of meeting this need.
DoD, Army, Navy, Air Force, and Marine Corps policies on alcohol and other drug use among service members, their dependents, and civilian employees consistently address the impact and the need for services. First, all of the policies are based on recognition that alcohol and other drug use can be harmful to individuals and hamper their ability to perform their military jobs. Second, there is a need within each of the branches to address SUDs through prevention, screening, referral to proper services, diagnosis, and treatment. Current policies assign primary responsibility for identification and referral to unit commanders and health personnel. Air Force and Navy policies provide guidance on the behaviors that may indicate alcohol and other drug use problems, such as driving while intoxicated, public intoxication, and domestic violence. These policies also recognize that personnel may self-refer for help with alcohol and other drug use, and describe Command procedures for addressing self-referral.
DoD policy recognizes the need to prevent substance abuse and maintain fitness for duty among its forces. As a prevention strategy, drug testing has a presumed deterrent effect through increased awareness of the consequences of testing positive for illicit drug use (i.e., separation from the military). There is no research, however, showing that drug testing is an effective prevention strategy for service members and their dependents. Reports that cite decreasing rates of illicit drug use as evidence of the effectiveness of drug testing do not take into account causality, secular trends, or other factors that affect rates of illicit drug use. By focusing on drug testing as prevention, the branches may fail to implement more evidence-based prevention strategies with proven effectiveness. Finally, drug testing does not address risky alcohol use or prescription drug abuse, which is epidemiologically a far more prevalent problem in the military than illicit drug use. However, the committee finds that the changes recently made to the panel of tested drugs to include often abused prescription medications such as hydrocodone and benzodiazepines (U.S. Army, 2012) demonstrate DoD’s attention to these problems and efforts to deter the abuse of prescription medications.
As discussed in Chapter 5, ample opportunities exist for the military to implement systems-level environmental strategies to curb alcohol and prescription drug problems. However, the committee’s site visits and other
information gathering activities revealed inconsistencies in actual adoption and implementation of these strategies. The first major environmental alcohol abuse prevention strategy outlined in Chapter 5 is controlling affordability through pricing and taxation. The committee finds that while the U.S. military cannot control the prices or taxation of alcohol sold in communities around bases, it does have control over the prices of alcohol sold at stores located on bases, which are often discounted.
The second environmental strategy is restricting the availability of alcohol for purchase. The very existence of liquor stores on bases is in direct conflict with this approach. The committee heard during its site visits that in addition to military bases allowing alcohol use on base, revenues from the sale of alcohol support recreational and morale programs. Ironically, curbing the sale of alcohol would affect the amount of non-alcohol-related recreational activities available on base. In addition, below-market prices on alcohol (i.e., no state taxes) likely encourage elevated rates of unhealthy alcohol use. During visits to bases and from presentations during its information gathering meetings, the committee learned that while there is some military cooperation with the local communities surrounding bases, the extent of this cooperation varies site to site. Commanders may or may not elect to pursue it as part of an overall policy to prevent alcohol and illicit drug use by military personnel.
The third strategy is altering the context in which alcohol is consumed. In particular, bases that sell alcohol only for off-base consumption and those without liquor stores can work with the community, especially local bar owners, in the implementation of the server interventions described in Chapter 5. However, the committee’s review of policies and programs revealed that such partnerships with local authorities and hospitality-related businesses (e.g., bars, hotels, casinos) are not mandated by policy and therefore are inconsistent.
The fourth strategy is prevention of impaired driving. Sobriety checkpoints and random breath testing can be applied to driving on military bases. However, the effectiveness of these measures is contingent on consistency of enforcement. Among the various military bases the committee visited, Keesler Air Force Base was the only one that administered random breath testing for those returning from leave and driving back onto the base.
The committee did find some examples of promising environmental prevention and deterrence strategies to address alcohol abuse. One was the Air Force’s EUDL program (discussed briefly above and in detail in Appendix D). The committee determined that this program incorporates many of the best-practice environmental strategies reviewed in Chapter 5. A recent evaluation demonstrated declines in arrest rates for minors in possession of alcohol and for driving under the influence at sites that implemented
the program (Spera et al., 2012). The committee found another example of a promising strategy for addressing alcohol abuse in the Navy’s plan to institute a random breath testing program on board its ships during 2012. Those who test positive will be referred to the SARP for further screening and possible treatment. While the committee finds these efforts by the Air Force and Navy to be promising, similar efforts in the Army and Marine Corps (where prevalence rates for alcohol abuse are higher) may be needed.
To deter prescription drug abuse, DoD instituted stricter limits on the length of prescriptions for controlled drugs in May 2012. Previously, if a service member tested positive for a prescription drug but had a valid prescription on file within the past 6 months, the medical review of the positive test would likely determine that the use was legal. If a service member does not have a valid prescription, a positive test is determined to indicate illicit use, just as with any other illicit drug, with possible personnel consequences. Under the new policy, service members who need ongoing treatment with controlled substances will have greater contact with their prescribing physician, and those who need these medications only on a short-term basis will not be allowed to continue using them beyond their 30-day prescription without risking the personnel consequences of a positive drug test. By limiting prescriptions for controlled substances to 30 days, DoD is tightening the controls of these medications—a clear example of an environmental prevention strategy. The committee finds this policy change to be a promising effort to deter prescription drug abuse; however, it remains to be seen whether the change will be effective in accomplishing this goal.
Finding 6-2: DoD and branch screening policies and programs fall short of identifying all service members who have or are at risk for developing SUDs.
Current policy and screening practices tend to rely on random urine tests to detect the use of illicit drugs and on alcohol-related incidents to detect problematic alcohol use. These practices are relatively inefficient and identify only a portion of drug users at risk for developing severe SUDs and individuals with unhealthy alcohol use. Systematic screening in health care settings could be a more efficient strategy for identifying those with unhealthy alcohol use. The VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) specifies that patients seen in general medical and general mental health settings should be screened for unhealthy alcohol use. Routine annual screening using validated tools has the potential to identify at-risk substance users before use becomes problematic and more severe. DoD and branch policies and programs, however, do not explicitly reference the VA/DoD guidance (VA
and DoD, 2009), and the Comprehensive Plan notes that evidence-based screening tools are not consistently utilized in settings outside of deployment health assessments (DoD, 2011b). Rigorous screening of those newly entering the military for any current SUDs or a history of such disorders is also important to identify those who have SUDs or may be at risk for relapse.
Requirements for Command notification when an SUD is diagnosed may be inhibiting routine medical screening for at-risk alcohol use. Therefore, DoD’s clarification that health care providers may not notify Command when they offer substance abuse education services (DoD, 2011a) provides an opportunity for enhanced screening and brief intervention. The public health goal of screening is early identification to prevent the development of more severe problems. DoD support for substance abuse screening and brief intervention in health care settings should encourage the Military Health System to implement the VA/DoD guidance on routine annual screening for unhealthy alcohol use.
With regard to identifying those individuals who are misusing and/or abusing prescription medications, DoD’s PEC has developed tools that can be used by health care providers and commanders to review pharmacy data. Overall, the committee finds the activities of PEC to be comprehensive, yet it did not learn whether providers are fully using the available tools to monitor prescriptions received by patients from other physicians. Efforts should be made to encourage the use of these tools and to improve them to make them as comprehensive and as physician-friendly as possible. The committee also finds that the inability of pharmacy systems to track all prescription medications dispensed in theater is a major barrier to identifying misuse and abuse of these drugs.
Finding 6-3: Military policies reflect different attitudes toward alcohol and other drug use.
Military policies treat alcohol and other drug use differently because alcohol use is legal for those aged 21 and older, whereas other drug use is not legal. The differences appear in at least three areas. First, as stated in the discussion of Finding 6-1, drug testing is regarded as the main emphasis in prevention of substance abuse across all branches of the military, but currently focuses primarily on illicit drugs, not alcohol. Second, military bases allow alcohol use and use alcohol revenues to support recreational and morale programs. Below-market prices on alcohol probably encourage elevated rates of unhealthy alcohol use. While difficult to evaluate systematically, information derived from the committee’s site visits suggests that drinking is acceptable as long as one is not caught with an infraction (e.g., driving under the influence) or does not show up for an active duty
assignment incapacitated by alcohol. Third, alcohol misuse or abuse does not appear to carry the same consequences as illicit drug use with respect to military separation. If an individual receives a diagnosis of alcohol abuse or dependence, he/she receives treatment, whereas other drug abuse/dependence diagnoses result in initiation of separation proceedings and possible enrollment in treatment, although the policies on this issue vary (e.g., the Air Force policy is the strictest, whereas Army policy requires referral to treatment for drug “dependent” individuals but not drug “abusers”). The difference in perceived potential for rehabilitation and treatment between soldiers with alcohol and other drug dependence is not supported by scientific evidence. While the committee understands the desire to separate service members who violate laws against illicit drug use, a more systematic and evaluative approach might result in retaining highly skilled service members. Also, it should be noted that when the fifth edition of the DSM is released in May 2013, the distinction between “abuse” and “dependence” will be eliminated, and diagnosis will instead be classified as “mild,” “moderate,” or “severe.” Therefore, DoD and branch policies that call for different personnel and treatment decisions based on diagnoses of “abuse” and “dependence” will need to be revised.
Finding 6-4: There is substantial variability among SUD-related policies, programs, procedures, and instruments across the military branches.
DoD policy lays out strategies and guidelines for SUD prevention, screening, diagnosis, and treatment, but the actual implementation of these strategies and guidelines varies according to specific branch-level policies. While DoD offers several SUD programs that could be utilized across the branches, it does not require or monitor their adoption by the branches. The RAND (Weinick et al., 2011) analysis of psychological health and TBI programs for U.S. military service members and their families yielded similar observations about the lack of standardization and the variability of implementation across the armed forces. With the exception of the Air Force’s Substance Abuse Prevention Specialist Training and CoRC and the Navy’s Alcohol and Drug Abuse for Managers and Supervisors (ADAMS) and Prevention Specialist programs, the branches do not make use of standardized training processes or protocols for implementers of prevention programs or for the leaders who oversee them. Programs for youth (e.g., DEFY) are delivered by contractors, and spouses and other family members receive prevention services through health care service agencies or programs such as Families OverComing Under Stress (FOCUS) (reviewed in Appendix D).
Lack of standardization is an issue of concern for screening and diagnosis as well. As noted in the discussion of Finding 6-2, DoD and branch
policies acknowledge and emphasize screening as a key strategy in combating SUDs, but do not specify standardized screening procedures or instruments. Air Force policy and the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders identify specific instruments to be used in screening (e.g., AUDIT-C). These policies, as well as DODD 1010.4, also recognize that there are standardized criteria for SUD diagnoses in DSM-IV-TR. Aside from these examples, however, policies do not identify specific screening instruments or the health care professions authorized to screen and diagnose (e.g., nurses, physician assistants, licensed counselors, physicians). Standardized psychiatric interviews are not identified for diagnostic assessments.
Current governance policies are high-level and have gaps that allow for variation among the branches in such key areas as SUD program evaluations and the influence of Command on treatment plans. Expansion of the “umbrella structure” of governance discussed earlier in this chapter could promote increased coordination of resources and services and enhance consistency across the armed forces for measurement of system/program effectiveness and performance and efficiency. The Comprehensive Plan (DoD, 2011b) notes that utilization of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders is inconsistent across DoD facilities. DoD does not systematically monitor compliance with its policies or with the VA/DoD Clinical Practice Guideline, and the branches do not routinely monitor compliance with policy across installations. Consequently, the sophisticated planning and design that go into the development of SUD prevention and treatment policies can be lost in translation as principles filter through the branches to local installations. Further, the committee would be remiss not to acknowledge that each military branch’s distinctive history and culture undoubtedly play a role in the variation that exists from branch to branch in policy and program design, adoption, and delivery. The additional cultural and contextual differences that exist between the active duty population and members of the National Guard and Reserves further complicate the situation and cannot be ignored in addressing the needs of all service members across all branches of the military.
Finding 6-5: DoD and the branches do not evaluate programs and initiatives consistently and systematically.
The committee found little evidence of systematic evaluation of cognitive, affective, or behavioral change resulting from prevention programs or treatment interventions using single- or multiple-group design evaluations. The Comprehensive Plan (DoD, 2011b) and the RAND report (Weinick et al., 2011) also identify program evaluation as an area for improvement.
Current research projects (see Box 6-3) may yield benchmarks, such as voluntary participation rates and change in risky behaviors related to SUD development and relapse, which could be used for systematic evaluation processes and metrics. These studies are testing the extension of programs
National Institute on Drug Abuse
- Use and Abuse of Prescription Opioids among Operation Enduring Freedom/Operation Iraqi Freedom Veterans
University of Arkansas for Medical Sciences at Little Rock
- Integrated Treatment of Operation Enduring Freedom/Operation Iraqi Freedom Veterans with Post Traumatic Stress Disorder and Substance Use Disorders
Medical University of South Carolina
- First Longitudinal Study of Missed Treatment Opportunities Using DoD and VA Data
- Integrated Cognitive Behavioral Therapy for Co-Occurring Post Traumatic Stress Disorder and Substance Use Disorders
- Effectiveness of a Web-Enhanced Parenting Program for Military Families
University of Minnesota, Twin Cities
National Institute on Alcohol Abuse and Alcoholism
- Stress-Induced Drinking in Operation Enduring Freedom/Operation Iraqi Freedom Veterans: The Role of Combat History and PTSD
Medical University of South Carolina
- Veteran Reintegration, Mental Health and Substance Use in the Inner-City
National Development and Research Institutes, Inc., in New York City
- Web-Based Cognitive Behavioral Therapy for Substance Misusing and Post Traumatic Stress Disorder Symptomatic Operation Enduring Freedom/Operation Iraqi Freedom Veterans
National Development and Research Institutes, Inc., in New York City and Syracuse University
- Personalized Drinking Feedback Interventions for Operation Enduring Freedom
Operation Iraqi Freedom Veterans/University of Missouri-Columbia
effective with civilian populations to service members and their families. NORTH STAR, for example, uses community-based prevention research from Communities That Care (Hawkins et al., 1992), the Midwestern Prevention Project (Riggs et al., 2009), and Steps Toward Effective Prevention (STEP) (Valente et al., 2007). The Comprehensive Soldier Fitness program is based on the Penn resiliency program (Seligman, 1998) for preventing and reducing depression. ADAPT (After Deployment: Adaptive Parenting Tools, differentiated from the overall ADAPT program used by the Air Force) is based on the Parent Management Training Model-Oregon (Forgatch and Patterson, 2010; Gewirtz et al., 2011), used with parents whose children are exhibiting behavioral problems. And FOCUS is based on resiliency and coping training for families experiencing stress (Forgatch and Patterson, 2010; Gewirtz et al., 2011).
Finding 6-6: DoD and branch policies support the use of evidence-based prevention and treatment but do not identify specific practices.
This finding is overarching and applies to both policies and programs for prevention, screening, diagnosis, and treatment. It is also highlighted in both the Comprehensive Plan (DoD, 2011b) and the RAND (Weinick et al., 2011) analysis. Current policies have been ineffective in preventing alcohol abuse and prescription drug misuse. These policies could make better use of scientific evidence on the nature of alcohol and other drug use behaviors and the best prevention and treatment efforts for the full range of SUDs. As stated in Finding 6-3, DoD and branch policies treat alcohol and other drugs very differently. They place differential emphasis on the implementation of screening for alcohol and other drugs (e.g., testing for drugs but not alcohol) and have very different repercussions for alcohol versus other drug use (e.g., zero tolerance policies for other drugs but not alcohol; CATEP is for alcohol only).
While several of the prevention programs noted in the Comprehensive Plan (DoD, 2011b) assert a foundation in evidence-based principles, few specify what those principles actually are. Based on the results of this committee’s review, many of the programs appear to meet prevention needs in that they are appropriate to the populations served, are theory based, address multiple risk factors, and have evaluated behavioral outcomes. Examples include Military Pathways (DoD), DEFY (Navy, Air Force), EUDL (Air Force), CoRC (Air Force), FOCUS (selected Navy, Marine, Air Force, and Army installations), and NORTH STAR (multiple Air Force Commands and bases). However, these programs (with the exception of NORTH STAR, EUDL, and FOCUS) adapted materials and concepts from civilian prevention programs and have not been tested with military populations. Further, many of the prevention efforts appear to be focused on
campaigns, Internet games, and camps or events (e.g., That Guy, DEFY camp, Real Warrior, Red Ribbon), with no research evidence that they affect substance use. DoD and the various branches are not making strong enough use of evidence-based environmental policies and programs (e.g., reducing availability and/or raising the price of alcohol on bases).
The committee’s analysis revealed an underutilization of evidence-based pharmacological therapies, as well as insufficient continuing care. Effective treatment of substance abuse includes both pharmacological and behavioral therapies. In the military, the pharmacotherapies for acute medical withdrawal treatment focus on alcohol, sedatives, and opioids. The most effective treatment plans entail withdrawal treatment followed by relapse prevention therapy, which is frequently a combination of both medication and behavioral therapy (Kosten and McQueen, 2008). On the issue of follow-up care, the committee finds the Navy MORE program to be an innovative and promising model for the provision of ongoing recovery support and encourages the other branches to consider adopting similar approaches to improve posttreatment care for active duty service members.
Finding 6-7: Integration of SUD care with other behavioral health and medical care is lacking.
The Military Health System has clear evidence that the current operating tempo and environment are associated with increased risk of mental health disorders and SUDs and that these disorders often co-occur (U.S. Army, 2012). Separate and distinct services for mental health disorders and SUDs are neither desirable nor feasible. The committee agrees with the need to facilitate access to both types of services and provide integrated care. Integration of care can occur at two levels: (1) integration of care for mental health disorders and SUDs, and (2) integration of behavioral health care with primary care. Integration of behavioral health services with primary care may be particularly challenging in the military, whose population is often mobile and frequently changing location. The Air Force’s BHOP demonstrates the feasibility and advantages of integrating behavioral health into primary care services. Integration of services for SUDs should proceed as well to reduce stigma and enhance the development of medication-assisted treatment for alcohol and other drug use disorders. The committee supports routine screening and brief intervention for alcohol misuse within primary care settings. Screening and brief intervention are evidence-based practices, and when implemented systematically can reduce the risk of alcohol-related problems within communities and populations (Babor et al., 2007). The U.S. Preventive Services Task Force also recommends routine use of screening and brief intervention in primary care settings (O’Connor et al., 2009). DODI 6490.08 clarifies that health care providers can provide substance
abuse education and should assume that providing educational interventions does not require Command notification.
Integrated care is likely to be more difficult in the Army and Marine Corps because their programs for treatment of SUDs are located within the human resources organization rather than a Medical Command. Specific strategies will be required to facilitate interaction between Commands and full access to medical records. In the Navy and Air Force, SUD treatment programs are located within the Medical Command, but remain separate and distinct settings of care that often are not fully integrated within general health care settings. Treatment for SUDs in the 21st century will require the elimination of divisions between health care and specialty addiction treatment.
Finding 6-8: DoD and branch policies are largely silent on comprehensive programs and services for SUD prevention, screening and brief intervention, diagnosis, and treatment for military dependents.
While DoD policy permits the provision of SUD services to military dependents, the branches do not have the capacity to extend such services beyond reaching service members. Furthermore, based on best practices, the specialty SUD treatment services operated by the branches for military members are not appropriate for youth and adolescents, who require developmentally appropriate treatment. While some DoD prevention programming identifies spouse and child dependents as a target population, most of these initiatives, based on their descriptions, emphasize the ways in which service members are reached and the role of commanders. Some prevention initiatives are selective or indicated, taking place with at-risk individuals or after an incident occurs. The committee found no evaluation literature associated with most of these initiatives, particularly on their reach or effectiveness with military dependents (see also Finding 6-5).
Finding 6-9: DoD and the branches rarely use technology to enhance the delivery of screening, diagnosis, and treatment services.
The committee found few examples of technology being used to deliver SUD services in new and innovative ways. Given identified counselor shortages and challenges to staffing SUD clinics with experienced and licensed clinicians (see Chapter 8 for further discussion), as well as concern over the lack of standardized delivery of evidence-based care, DoD might consider the increased use of technology to address some of these issues. The committee identified as promising the following approaches to addressing SUD care with the use of technology.
The Navy’s MORE aftercare program represents an innovative use of technology to provide recovery support for sailors deployed internationally
and at sea (see Appendix D for further description of this service). MORE illustrates the use of technology to extend the counselor workforce and provide ongoing support to active duty service members when they return to their military assignment. The Navy also is currently pilot testing a new version of the MORE program that is delivered via smartphone technology. The other branches appear not to be using this type of treatment and aftercare technology. Additional research on the effectiveness of the MORE program with military populations and other innovative models for delivering treatment services by means of telephone, video conferencing, and web-based formats might provide DoD with some alternative methods for extending its counseling workforce.
Additionally, the Air Force’s use of the SUAT computerized assessment tool is an example of the utilization of technology to standardize clinical processes and improve efficiency within SUD programs. The committee finds the SUAT tool to be a promising model for DoD to evaluate and consider for dissemination to the other branches.
Finally, the committee found value in the approach taken by Military Pathways of using web-based video doctor technology to reach service members and their families who might otherwise not receive screening and referral to services for mental health conditions, including alcohol abuse. A rigorous evaluation of this program and its effectiveness would provide DoD with guidance on whether this is a beneficial use of resources and whether the approach should be considered for other uses.
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