Substance Use Disorders in the U.S. Armed Forces (2013) / Chapter Skim
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5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders
5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders
Pages 97-136
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; efforts with youth (i.e., military dependents) ; and prevention of prescription drug abuse, a growing problem in the military as well as in the general U.S.
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Each type of prevention is integral to a robust and comprehensive prevention strategy. Risk and Protective Factors for SUDs Effective prevention programs are intended to diminish risk factors and promote protective factors for substance use.
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. A recent review of substance use problems and risk factors among veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn concluded that "military personnel and combat veterans have higher rates of unhealthy substance use than their age peers in the general population" (Larson et al., 2012, p.
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Protective Factors Compared with risk factors, less research has been conducted to identify factors that protect against the development of SUDs. Protective factors that may mediate or moderate the effects of risk exposure include resiliency, attachment, positive temperament, support (either through the family or from an external support system)
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military; broader nonprogrammatic environmental prevention strategies are discussed later in this section. Address Risk and Protective Factors As outlined above, effective prevention programs address the risk and protective factors relevant both to the problem or issue at hand and the population(s)
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ARMED FORCES 2003) provide solid frameworks for identifying risk and protective factors as a component of the design and adoption of evidence-based programs.
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Manage Programs Effectively The most effective prevention programs provide standardized training and manualized protocols, along with specific and measurable prevention skills and goals (Mihalik et al., 2004)
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discuss seven policy approaches, four of which are environmental and can be used by the U.S. armed forces to address alcohol consumption and related problems among military personnel.
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Prescription drug abuse, one of the major concerns that prompted this study, is a vexing problem among military personnel. As in the alcohol field, there are environmental, population-level approaches that can be useful in the prevention of drug use and abuse.
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While ONDCP's 2011 Prescription Drug Abuse Prevention Plan focuses on parent, child, and patient education (ONDCP, 2011a) , also critical is provider education regarding responsible prescribing practices and alternative pain medications with lower dependence potential.
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, which is frequently accomplished through screening. Screening can detect both health problems and risk factors, the latter of which is particularly useful for these groups.
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In the United States, although these challenges can be present in some population groups, they do not pose considerable barriers to the implementation of screening for risky drinking, prescription drug abuse, and illicit drug use. Screening for alcohol and other drug problems can be conducted effectively with a few brief questions.
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drinking or other drug use (e.g., abuse of opioid prescription drugs) , and as "negative" those individuals who are abstainers or normal drinkers or do not use illicit drugs or abuse prescription drugs.
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and reliability of testing procedures, and confidentiality of results. Further, a positive test does not provide information about chronicity, frequency, and/or quantity of use; the presence of drug dependence; and in the case of prescription drugs, whether the drug was taken under medical order.
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Diagnostic procedures for SUDs in the United States are guided by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) of the American Psychiatric Association (APA)
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To integrate substance abuse treatment into primary care, however, systems of care must address four limitations: 1. Current capacity -- Most primary care settings are unprepared to screen for, assess, and treat SUDs, especially among women and men whose disorders are severe.
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. Some variation in treatment approaches is to be expected and reflects patient-centered or personalized medicine; variability among patients inhibits the adoption of condition-specific practice guidelines.
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47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, authored by the Center for Substance Abuse Treatment (CSAT)
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BEST PRACTICES 115 TABLE 5-1 Best-Practice Domains and Recommendations of the National Institutes of Health's Behavior Change Consortium Goals Strategies Domain: Provider training • Standardize training for all • Use standardized training manuals, materials, provider types resources, field guides, structured practice and role playing; standardized patients; same instructors/supervisors; video training • Ensure the acquisition of provider • Observe implementation of interventions with skills standardized patients or role playing; score providers according to a checklist; conduct debriefings; administer written pre- and posttraining examinations; certify skills during and after training • Identify and have processes to • Conduct booster sessions; conduct in vivo minimize "competency drift" in observations scored against a standard checklist; provider skills supervise; obtain provider self-reports; conduct patient exit interviews or obtain feedback • Accommodate differences in • Have certified or established professional providers' backgrounds with respect supervisors for provider training; monitor to skill expectations and roles patient dropouts and treatment effectiveness Domain: Delivery of treatment • Control for provider variability • Assess patient perceptions of providers through questionnaires, and give feedback to providers; audiotape sessions, and have different supervisors review; monitor patient complaints; have providers work with all treatment populations served • Reduce ineffective variation within • Use scripted protocols, treatment manual; have treatments supervisors rate audiotapes, videotapes • Ensure adherence to evidence-based • Audiotape or videotape encounters, and review treatment protocols with providers; randomly monitor audio or videotapes for adherence to protocols; have providers complete a checklist of intervention components Domain: Receipt of treatment and enactment of treatment skills • Ensure patients' comprehension and • Have providers review participants' homework, acquisition of skills self-monitoring logs; assess, measure participants' performance; have structured interviews with patients; use questionnaires; use hypothetical scenarios to test patients • Ensure patients' ability to perform • Collect patient self-monitoring, self-report data; new skills use behavioral outcome measures SOURCE: Adapted from Bellg et al., 2004.
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An ideal care delivery system is comprehensive and includes long-term services in addition to preventive services, community or workplace initiatives, primary care screening and brief interventions, and specialized treatment services (McLellan, 2002)
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mandates • Staff competencies in behavioral techniques for working through treatment resistance (e.g., motivational interviewing) • Policies and program philosophy that promote a safe harbor that reduces stigma and maintains necessary confidentiality 4. uilding an enhanced therapeutic B • Staff trained in engagement techniques alliance • Measurement of the therapeutic alliance by accountable provider/program • Use of recovered peers 5. ffering appropriate treatment O • Move away from set program protocols and that is patient specific and not a time frames singular provider approach • Individualized treatment plans and treatments • Adjunctive services to match the specific needs of special populations (e.g., pregnant or newly delivered mothers -- skill building in parenting)
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as a monitoring system • Measurement of long-term engagement with the treatment and case management support system 9. uring the treatment process, D • Program treatment protocols continuously assessing and • Use of objective tools and benchmarks to modifying the treatment plan measure progress as necessary to ensure that the • Systematic reassessments during the treatment treatment is effective and meets process within a level of care and upon the patient's changing needs transition to the next level of care 10. sing a treatment system that U • Repeated drug and breathalyzer testing monitors for abstinence and • Use of use-limiting medications (e.g., antabuse, expects successful management of naltrexone) treatment relapses • Treatment program rules that do not discharge because of use during treatment but use it as a treatment opportunity 11. sing mutual-help and other U • Treatment protocols that incorporate use of community-based supports community support groups during the treatment process (AA, Narcotics Anonymous [NA]
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. A meta-analysis of treatment interventions for alcohol use disorders suggested that the psychosocial interventions with the most consistent evidence of effectiveness include brief interventions based on motivational enhancement therapy, social skills training, community reinforcement approaches, behavior contracting, and behavioral marital therapy (Miller and Wilbourne, 2002)
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. Motivational enhancement therapy appears to be more effective in alcohol abusers than in those with more severe alcohol dependence and in those who are more hostile or angry when they enter treatment (Allen et al., 1998)
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and buprenorphine (Mattick et al., 2008) enhance treatment outcomes for opioid dependence.
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. The more structured environment of the armed forces may reinforce compliance with these blocking agents and could be used to enhance treatment outcomes, but this has not yet been studied.
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Individuals with SUDs also are at greater risk for developing PTSD because of presumed increased exposure to stressful events as a consequence of their SUD lifestyle. Gender differences have been found across several nonveteran samples, with drug abuse appearing to put women at greater risk than men for developing PTSD (Hien et al., 2010)
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While the evidence base is constantly evolving, foundational concepts remain consistent. Evidence-based SUD prevention programs and practices address risk and protective factors, use approaches with demonstrated effectiveness, are age and developmentally appropriate, take place in suitable settings, and manage programs effectively.
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2006. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The combine study: A randomized controlled trial.
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1995. Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population.
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2009. A multisite randomized effectiveness trial of motivational enhancement therapy for Spanish-speaking substance users.
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2007. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain.
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2006. Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences.
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2005. A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: Findings from the National Institute on Drug Abuse Clinical Trials Net work.
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Cochrane Database of Systematic Reviews 3. Mayes, L
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2006. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A national drug abuse treatment clinical trials network study.
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2012. Family therapy for drug abuse: Review and updates 2003-2010.
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2009. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veter ans using Department of Veterans Affairs health care, 2002-2008.
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soldiers returning from the Iraq war. Drug and Alcohol Dependence 108(1-2)
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