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9 Conclusions and Recommendations
Pages 247-270

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From page 247...
... and the Military Health System that provides services for military personnel with those problems (Chapter 3) ; identified modern standards of SUD care (Chapter 4)
From page 248...
... The committee recognizes the need for disciplinary action when criminal behavior occurs, supports a strong surveillance program to detect the use of substances that impair performance, and applauds current efforts to enhance the quality and effectiveness of SUD prevention and treatment services. Increased routine screening for unhealthy alcohol use and mechanisms to support brief interventions and confidential treatment (each of
From page 249...
... The recommendations presented in this chapter focus on • increasing emphasis on efforts to prevent SUDs in service members and their dependents; • developing strategies for identifying, adopting, implementing, and disseminating evidence-based programs and best practices for SUD care (including prevention, screening, brief intervention, diagnosis, treatment, and ongoing management) ; • increasing access to care for military service members and their dependents; and • strengthening the workforce treating SUDs within the armed services.
From page 250...
... prevention measures are implemented and enforced consistently in communities surrounding military bases. Similarly, as a universal prevention strategy, DoD and the individual branches should proactively prevent the misuse and abuse of prescription medications by limiting access to controlled medications.
From page 251...
... Health care professionals at all levels (e.g., general medical officers, flight surgeons, medics) should be trained in recognizing patterns of substance abuse and misuse and provided clear guidelines for referral to specialty providers, including pain management specialists and mental health providers.
From page 252...
... During its site visit to Fort Belvoir, the committee heard that physicians at the military treatment facility routinely checked the locally available state-run PDMPs before dispensing controlled substances.2 However, the extent of this practice among military physicians is unknown. The committee therefore recommends that DoD providers routinely check any locally state-run PDMPs before dispensing prescription medications that have abuse potential.
From page 253...
... Benchmarks with which to determine whether programs are effective or need to be changed should be established as part of the evaluation design. As noted in Finding 6-1, DoD and the individual branches use drug testing as an integral component of their prevention strategies; however, the committee notes the limitations of these drug testing programs in preventing SUDs.
From page 254...
... Integration of screening and brief intervention for alcohol misuse into primary care settings could reduce stigma and expand access to care. DoD should explore ways to increase the use of screening and brief intervention for alcohol misuse in all medical care settings to make it possible to identify those at risk of developing alcohol use disorders and intervene before more intensive care may be needed.
From page 255...
... Specifically, full implementation of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) in general medical care and specialty care settings would facilitate implementation of the committee's recommendations for routine screening, effective prevention and treatment efforts, integration with general medical care and mental health services, greater use of technology, confidential care, and greater use of ambulatory and continuing care.
From page 256...
... . In an update to the Comprehensive Plan, DoD notes that policy language is currently under development to call for more consistent use of screening measures in primary care settings.3 The committee recommends that DoD move forward with this action and specifically cite the use of validated screening tools and adherence to the screening procedures identified in the VA/DoD Clinical Practice Guideline.
From page 257...
... , but the committee found little evidence of its implementation within the branches. The lack of routine screening, limited use of anticraving and agonist medications, minimal training in the use of psychosocial interventions, and the poor connections between specialty SUD care and general medical care suggest passive rather than active implementation of the guideline.
From page 258...
... SUD patients in direct and purchased care settings should also be offered individual and group outpatient counseling using evidence-based protocols when clinically indicated. To this end, DoD should expand its capacity to offer local outpatient services in both the direct and purchased care systems.
From page 259...
... Currently, licensed independent practitioners working in ASAP are credentialed only to treat SUDs. Even though they are trained mental health practitioners (psychologists and social workers)
From page 260...
... The Military Health System appears to have sufficient access to inpatient beds within existing regulations. The direct care system needs to build capacity for intensive outpatient and outpatient services.
From page 261...
... As outlined in Chapter 5 and incorporated in the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) , contemporary SUD care includes the use of maintenance medications and a focus on outpatient rather than residential treatment.
From page 262...
... Further, the committee agrees that TRICARE benefits for mental health disorders and SUDs should conform to the Mental Health Parity and Substance Abuse Equity Act, and quantitative and nonquantitative limits on behavioral health services should be eliminated. Evaluations of mental health parity have found little impact on the utilization and cost of health care, with the potential to reduce stigma and enhance access to care (Goldman et al., 2006; McConnell et al., 2012)
From page 263...
... CATEP encourages but does not require soldiers to disclose their participation in treatment to their commanders. A recent qualitative study found that participants in CATEP highly valued the provision of treatment services outside duty hours and the option to engage in confidential treatment (Gibbs and Rae Olmsted, 2011)
From page 264...
... In addition, DoD should provide the option of receiving confidential screening and assessment in alternative venues to the VHA. Such venues include a telemedicine visit with a former DoD clinician with whom the service member had an established relationship or a community-based civilian program specifically designed to engage and serve demobilized and discharged reserve component veterans, innovative telehealth programs, smartphone and Web-based technology that can provide confidential self-assessment and motivational interviewing to address a reluctant veteran's concerns about visiting the VHA or seeking help, and active engagement in primary care settings at VHA programs when a reserve component member appears for medical services.
From page 265...
... Research is beginning to show support for various technological approaches to delivering health care screenings and interventions (Humphreys et al., 2011; Jackson et al., 2011; Tsoh et al., 2010) and SUD care in particular (Cunningham et al., 2009; Godley et al., 2010)
From page 266...
... Recommendation 11: The individual service branches should restruc ture their SUD counseling workforces, using physicians and other licensed independent practitioners to lead and supervise multidisci plinary treatment teams providing a full continuum of behavioral and pharmacological therapies to treat SUDs and comorbid mental health disorders. The committee found high levels of comorbid mental health disorders among active duty service members and their dependents who seek care for
From page 267...
... Licensed independent practitioners with appropriate training and credentialing can provide active integrated treatment for both mental health disorders and SUDs. They can also be integrated into primary care settings as members of medical treatment teams.
From page 268...
... Systems that rely on residential and inpatient care require more intensive staffing ratios than those that emphasize ambulatory care. Integration of SUD care with primary care and behavioral health services requires different ratios than freestanding care.
From page 269...
... , enhanced data systems and performance measurement, and a well-trained workforce that specializes in preventing and treating SUDs and comorbid physical health and mental health problems would strengthen the Military Health System and improve the lives and careers of active duty and reserve component and retired service members and their dependents.
From page 270...
... 2010. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain.


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