Substance Use Disorders in the U.S. Armed Forces (2013) / Chapter Skim
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7 Access to Care for Substance Use Disorders
7 Access to Care for Substance Use Disorders
Pages 185-226
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From page 185... ...
. It reviews access to SUD care for active duty personnel; military dependents; and, to the extent data were available, members of the National Guard and Reserves.
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From page 186... ...
Access includes both the availability of services and the use of appropriate modalities and types of services at the appropriate times. As described in Chapter 5, contemporary substance use treatment systems include frequent screening, brief counseling, brief interventions in primary care settings, a focus on client-centered motivational interviewing, multiple entry points to treatment, pharmacotherapies that reduce cravings and maintain functioning, outpatient counseling, intensive outpatient programs, residential treatment when needed, and continuous contact with counseling professionals after an intense period of treatment.
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From page 187... ...
Social factors include marital status, family, and social networks; these are the social contextual characteristics that influence treatment seeking. In the substance abuse field, social networks are distinguished by whether they include individuals who are influences for not using versus using substances, as well as treatment seeking versus nonseeking.
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From page 188... ...
Receiving treatment, even when treatment causes the desired change in behavior, is perceived as resulting in a negative career trajectory. Consequently, active duty service members (ADSMs)
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From page 189... ...
Yet in current practice, the lack of confidential treatment even for problems that do not meet symptom criteria for substance abuse or dependence has the perverse effect of leaving many treatable problems undetected and unaddressed. As a consequence, several Army reviews have identified a high proportion of suicides, other deaths, and other negative consequences associated with untreated SUDs (U.S.
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From page 190... ...
In civilian model programs, early intervention for problem alcohol and other drug use is available in medical care settings such as primary care and emergency rooms. A new DoD policy, DODI 64990.08, may permit further development of brief interventions in military health care settings for service members at risk of alcohol use problems.
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From page 191... ...
health care system, in contrast, routinely screens for alcohol use problems and offers brief intervention and referral to further treatment if needed. As discussed in Chapter 6, the screening and brief intervention elements of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009)
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From page 192... ...
Air Force The Air Force provides SUD services through 75 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) programs, one at each military treatment facility, with nearly 400 counselors.
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From page 193... ...
were referred by Command.2 Beyond self-referrals and Command referrals, individuals can be referred to ADAPT by medical providers, but these represent the smallest proportion of referrals. Table 7-1 displays the number of active duty patients enrolled in treatment at ADAPT clinics from FY 2006 to FY 2010.
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From page 194... ...
To increase access to screening and treatment in theater, the Army is in the first phase of rolling out an Expeditionary Substance Abuse Program to provide SUD services during deployment, primarily through telephone contact with in-theater providers.5 Table 7-2 shows data on initial referrals of Army ADSMs to ASAP for FY 2006-2010. The Army Center for Substance Abuse Programs (ACSAP)
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From page 195... ...
. SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Programs, March 30, 2011.
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From page 196... ...
7 Personalcommunication, Les McFarling, Ph.D., Army Center for Substance Abuse Programs, January 13, 2012.
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From page 197... ...
The Navy Alcohol and Drug Abuse Program Office reported to the committee that 4,566 Navy patients and 5,535 Marines were treated at Navy SARPs in 2010, and 625 of the Navy patients were self-referrals.8 Table 7-3 displays the number of active duty Navy and Marine personnel who were enrolled in treatment at SARPs for FY 2006 through FY 2010 (Marines also are treated in the Service Academy Career Conference [SACC] program, described in the next section)
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From page 198... ...
. Of those Marines admitted into substance abuse treatment in FY 2011, 354 self-referred to a SACC, and 2,463 were referred by Command.9 Table 7-4 displays the total number of active duty Marines who were screened at a SACC, the number that completed the early intervention program (Impact, which is described in Appendix D)
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From page 199... ...
The committee also received information on direct care services for all ADSMs and active duty family members (ADFMs) with an SUD diagno 10 SeeTable 7-8 for the total average number of beneficiaries by region, which was used to calculate rates.
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From page 200... ...
, community mental health center, nonresidential substance abuse treatment facility, other unlisted facility, urgent care facility, home, public health clinic, rural health clinic, ambulatory surgical center, nursing facility, comprehensive outpatient rehabilitation facility, federally qualified health center, group home, ambulance-air or water, Indian Health Service freestanding facility, prison/correctional facility, assisted living facility, military treatment facility, independent clinic. SOURCE: Personal communication, Greg Woskow, TRICARE Management Activity, June 8, 2012.
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From page 201... ...
. Summary of Access in the Direct Care System The Air Force and Navy reported serving fewer individuals in their SUD programs in FY 2010 than in most prior years.
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From page 202... ...
Guard members, Reservists, and family members receive information on, among other things, accessing services for medical, mental health, and substance abuse problems. Military family life consultants may be invited as a resource.
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From page 203... ...
either weekly or daily to monitor the progress from positive drug tests to Command referrals to substance use assessment. CARE AVAILABILITY, ACCESS, AND UTILIZATION IN THE VETERANS HEALTH ADMINISTRATION The VHA also provides SUD services for ADSMs, and the committee reviewed the access standards for SUD care specified in Uniform Mental Health Services in VA Medical Centers and Clinics (VHA Handbook 1160.01)
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From page 204... ...
.12 As members of the National Guard and Reserves are not eligible for direct care unless activated (i.e., placed on federal orders for deployment 11 Personal communication, Daniel Kivlahan, Department of Veterans Affairs, November 16, 2011. 12 Personal communication, Frank Lee, TRICARE Management Activity, March 2, 2012.
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From page 205... ...
Specifically, this recent policy change states that any veteran who has served in a combat theater after November 11, 1998, including OEF/OIF veterans, and who was discharged or released from ac tive service on or after January 28, 2003, has up to 5 years from the date of the veteran's most recent discharge or release from active duty service to enroll in VA's health care system and receive VA health care services.13 13 NationalDefense Authorization Act of 2008, Public Law 110-181, 110th Congress (January 28, 2008)
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From page 206... ...
VA SUD services are offered in both specialty and primary care settings. The patient numbers shown in Table 7-7 are for veterans, including members of the National Guard and Reserves who have been demobilized from active duty but not released from service; in other words, they may be called to another deployment and return to active duty status.
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From page 207... ...
2006 2007 2008 2009 2010 Active duty 4,696 8,272 13,249 19,950 26,440 Guard/Reserves 4,423 6,594 9,576 12,860 16,058 Total 9,119 14,866 22,825 32,810 42,498 * Analysis includes OEF/OIF/OND veterans who accessed the VHA for an inpatient stay or outpatient encounter and had a primary and/or secondary SUD diagnosis.
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From page 208... ...
TRICARE benefit limits for SUD care are summarized in Box 7-4. These benefit limits are inconsistent both with current standards of care for SUDs based on recent legislation requiring parity of mental health and substance abuse care and other medical services and with requirements in the Patient Protection and Affordable Care Act of 2010 (as discussed in Chapter������������������������������������������ ����������������������������������������� 4)
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From page 209... ...
• lcohol/chemical dependency counselors are the only category A of providers specifically licensed for substance abuse treatment. Alcohol/chemical dependency counselors are not among the "qual ified mental health providers" reimbursed by TRICARE.
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From page 210... ...
West North South Active duty service members 548,086 532,163 440,337 Active duty family members (ADFMs) , aged 18 and over 320,446 318,528 278,445 ADFMs, aged 14 to 17 59,634 68,854 64,573 *
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From page 211... ...
The TRICARE regional offices assist military commanders in finding the care that is needed. It is unknown whether the ADSMs who received SUD services in these purchased care settings received any coordination of their treatment plan or aftercare by a branch military program as well.
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From page 212... ...
, All Systems of Care (FY 2010) Active Duty Service Members Active Duty Family Members Sum of Days' Sum of Days' Medication Supply No.
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From page 213... ...
To examine further what types of care are being provided in different settings, the committee reviewed additional data from TMA on the numbers of beneficiaries whose claims were selected based on diagnosis and classified by setting as detoxification, emergency, inpatient, and outpatient service for SUDs. Table 7-15 displays the services associated with an SUD diagnosis provided in purchased care settings, along with the rates of use
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From page 214... ...
TABLE 7-14 Number of Beneficiaries Receiving SUD Care by Type of Purchased Care Facility, South Region (FY 2010) Active Duty Active Duty Active Duty Service Family Members Family Members Setting Members (Aged 18 and Over)
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From page 215... ...
, community mental health center, nonresidential substance abuse treatment facility, other unlisted facility, urgent care facility, home, public health clinic, rural health clinic, ambulatory surgical center, nursing facility, comprehensive outpatient rehabilitation facility, federally qualified health center, group home, ambulance-air or water, Indian Health Service freestanding facility, prison/correctional facility, assisted living facility, military treatment facility, independent clinic. SOURCE: Personal communication, Greg Woskow, TRICARE Management Activity, June 8, 2012.
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From page 216... ...
This finding is not surprising for ADSMs given that in most circumstances, they have access to outpatient services at their military treatment facility and potentially to other levels of care if transferred to inpatient programs offered by the larger installations. As noted in Table 7-6, however, typically fewer than 1 per 1,000 ADFMs received SUD care at military treatment facilities.
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From page 217... ...
Thus, access to prevention and treatment services that incorporate the latest scientific evidence and predominate in the commercial sector (pharmaceutical therapy, individual therapy, intensive outpatient programs) , as well as care in individual practitioners' offices and outpatient clinics, is limited in the military largely by an outdated benefit structure, outdated benefit limits, and other unique policy restrictions that appear to be inconsistent with the military's goal of providing the best possible SUD care to those who need it.
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From page 218... ...
The committee concurs with the assessment in 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) that additional inpatient and residential capacity for SUD care is not needed.
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From page 219... ...
The implication of the current SUDRF regulations is that many SUD services delivered through community-based addiction treatment centers or through licensed independent practitioners are not available to TRICARE beneficiaries. This particularly affects access to SUD care for dependents of service members, who generally are unable to receive care at military treatment facilities since programs give priority to providing care to service members.
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From page 220... ...
In addition to this inhibition of care seeking, there are key structural barriers to SUD care in the armed forces. Specifically, military treatment facilities lack the full continuum of SUD services.
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From page 221... ...
To reduce the stigma associated with seeking help for mental health and substance abuse problems, a recent DoD policy (DODI 6490.08) gives health care providers more latitude in responding to requirements for notifying Command of mental health and substance abuse disorders.
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From page 222... ...
Additionally, the availability of SUD treatment at the time it is sought is an important principle in the commercial sector. On-base substance abuse programs typically offer care during duty hours, so participation in treatment programs often necessitates notifying Command to arrange adjustments to one's work schedule.
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From page 223... ...
Additionally, members of the National Guard and Reserves and their families may not qualify for the same services as active duty personnel, who receive comprehensive care through the military's direct care system. Discharge status also can present barriers to accessing care.
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From page 224... ...
Journal of Substance Abuse Treatment 14(6)
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From page 225... ...
2009. Army regulation 600-85: The Army substance abuse program.
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