Substance Use Disorders in the U.S. Armed Forces (2013) / Chapter Skim
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6 Policies and Programs on Substance Use Disorders
6 Policies and Programs on Substance Use Disorders
Pages 137-184
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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)
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DODD 1010.1 Military Personnel Drug Abuse Testing Program DODD 1010.4 Drug and Alcohol Abuse by DoD Personnel DODI 1010.6 Rehabilitation and Referral Services for Alcohol and Drug Abusers DODD 1010.9 DoD Civilian Employee Drug Abuse Testing Program DODI 6490.03 Deployment Health DODI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members Department of VA/DoD Clinical Practice Guideline: Man Veterans Affairs (VA) / agement of Substance Use Disorders DoD (2009)
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-- 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)
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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.
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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 Pharmaco economic Center (PEC)
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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.
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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.
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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
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. 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.
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The VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) (see Chapter 4)
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The VA/DoD Clinical Practice Guideline, DoD policies (DODD 1010.9, DODI 1010.6) , and branch policies generally are aligned with the bestpractice 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.
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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)
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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.
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. 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)
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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)
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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.
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. 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)
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Prevention ASAP prevention, education, and training services are intended to prevent, deter, and reduce alcohol and other drug abuse and to provide soldiers
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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.
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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.
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rehabilitation and follow-up, and (4) mandatory monthly alcohol and drug testing for soldiers enrolled in the rehabilitation program.
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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.
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. DAPAs manage the substance abuse prevention program and conduct prevention education courses: A lcohol-AWARE, Personal Responsibility and Values Education and Training, Alcohol and Drug Abuse Management Seminar for Leaders/Supervisors, and Skills for Life.
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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.
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The policy defines alcohol abuse and dependence and drug abuse and dependence based on standard criteria in DSM-IV-TR (APA, 2000)
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. Initial training for officer candidates and recruits includes alcohol and other drug abuse prevention as part of the core training curriculum.
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, as key elements of Marine substance abuse programs (U.S. Marine Corps, 2011)
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provides alcohol and drug abuse treatment that includes screening, early intervention, biopsychosocial assessment, and treatment. The vast majority of Marines (approximately 90 percent)
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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.
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. TABLE 6-1 Military Programs Mentioning Dependents Program Clinical Focus Target Population DoD National Red Ribbon Campaign Prevention Active duty, dependents DoD Military Pathways Program Prevention, Active duty, screening Reserves, National Guard, dependents DoD Real Warriors Campaign Prevention Active duty, dependents Adolescent Substance Abuse Counseling Prevention, Dependents (ASAC)
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The Real Warriors Campaign is an initiative launched by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
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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.
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The adequacy of the benefit and utilization of these services are discussed in Chapter 7. SUMMARY OF KEY FINDINGS 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.
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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.
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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)
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may be needed. To deter prescription drug abuse, DoD instituted stricter limits on the length of prescriptions for controlled drugs in May 2012.
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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.
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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")
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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.
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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 BOX 6-3 Military Studies of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism 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 Brandeis University • Integrated Cognitive Behavioral Therapy for Co-Occurring Post Traumatic Stress Disorder and Substance Use Disorders Dartmouth College • 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 Endur ing Freedom/Operation Iraqi Freedom Veterans National Development and Research Institutes, Inc., in New York City and Syracuse University • Personalized Drinking Feedback Interventions for Operation En during Freedom Operation Iraqi Freedom Veterans/University of Missouri–Columbia
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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.
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. 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.
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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.
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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.
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2011. Epidemic: Responding to America's prescription drug abuse crisis.
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2011. Instruction 44-121: Alcohol and Drug Abuse Prevention and Treatment (ADAPT)
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2010. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain.
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