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CHAPTER OUTLINE
■ PREVENTION OF SUBSTANCE USE DISORDERS
■ SCREENING AND BRIEF INTERVENTION
■ TREATMENT SERVICES FOR MILITARY PERSONNEL AND DEPENDENTS
The armed forces maintain a focus on promoting fitness and resilience among service members and their families. Active duty personnel experience frequent mobilizations, difficult transitions, combat situations, and an operational tempo characterized by multiple long periods away from their families and other support systems. The physical and emotional stresses experienced by many members of the military elevate their risk for problems with alcohol and other drugs.
To address this situation, the Department of Defense (DoD) and individual military branches—the Air Force, Army, Marine Corps, and Navy—have developed and implemented policies to prevent and manage substance use disorders (SUDs). Because substance abuse impairs military readiness, DoD policies set high standards for performance and discipline and consequently strongly discourage heavy drinking, illicit drug use, and tobacco use by members of the military (1).
Yet rates of alcohol and other drug use in the armed forces remain unacceptably high and are detrimental to force readiness and psychological fitness. This situation constitutes a public health crisis because of the sheer size of the military, which has approximately 1.4 million persons on active duty and 850,000 in the reserve (2).
In view of this situation and as part of its long-term commitment to modernize and improve the health care of service members and their families, the DoD asked the Institute of Medicine (IOM) to conduct an independent inquiry and develop recommendations for changes in the way SUDs are prevented, identified, and treated. In response, the IOM convened a Committee on Prevention, Diagnosis, Treatment, and Management of SUDs in the U.S. Armed Forces.
The committee began by examining the scope of SUD problems in the military and its health care system. It analyzed SUD-related policies and programs within the DoD and the military branches and compared them with standards of care and best practices that are widely used in the civilian health care system. The committee also examined access to care for service members, members of the National Guard and Reserve, and military dependents and assessed the credentialing and adequacy of the workforce providing SUD care.
In its report, Substance Use Disorders in the U.S. Armed Forces (2), the committee identified a number of policies and practices that limit access to addiction care—including lack of availability of particular forms of prevention and treatment, gaps in insurance coverage, stigma, fear of negative consequences, and lack of confidential services—and recommended remedies for each.
In this chapter, the chair and members of the IOM Committee discuss their findings and recommendations, which raise important issues for addiction medicine specialists in both the military and civilian sectors.
In response to the recommendations of the IOM study, the DoD issued a report addressing the IOM recommendations. The authors urge readers to access that report to better understand how the DoD plans to address issues raised in this chapter (2a).
PREVENTION OF SUBSTANCE USE DISORDERS
Prevention is a critically important strategy for reducing alcohol and other drug use in the military. Not only does prevention diminish the enormous human and economic costs of substance misuse it also directly enhances mission readiness in all branches of the military.
The DoD and the individual services need comprehensive, evidence-based prevention programs and policies. However, the IOM Committee found that current efforts in all branches fall short. Also there was no consistent or systematic evaluation of current prevention programs. Some activities that are cited as prevention, such as Red Ribbon Day (an annual commemoration of a Drug Enforcement Administration officer slain by traffickers 20 years ago, at which everyone wears red ribbons), have not been proved effective.
Prominent among the military’s prevention initiatives is drug testing, which theoretically is conducted randomly in order to deter drug use. However, the drug screens are limited, do not include alcohol, and often are announced in advance. Even if the drug testing system operated comprehensively and efficiently, drug testing has not been shown to prevent or reduce substance misuse. In fact, evidence-based prevention programs may have greater impact, particularly on alcohol misuse, which is by far more prevalent in the military than all other drug use combined.
Evidence-Based Prevention Programs
Over the past three decades, research funded by federal agencies and foundations has established a solid base of knowledge as to what works and what does not to prevent and/or delay the progression of substance misuse. The military should build on that knowledge base, particularly in relation to the special challenges faced by military personnel. For example, resistance skills and life skills training both have been shown to be effective with adolescents if they are implemented with fidelity during multiple sessions (at least 8 to 10) and followed up in subsequent years with booster sessions (3).
This approach could be particularly relevant to young people in the military who are not already engaged in substance misuse. Resistance and life skills training could provide the behavioral tools needed to resist peer pressure to drink and use drugs, which can be particularly intense in military settings; to avoid high-risk situations, where heavy drinking and/or drug use can be expected; to practice impulse control when under internal and external pressures to drink and use drugs (as well as ways to avoid high-risk situations while still remaining socially accepted); and to bond with friends who support nonuse or very limited social drinking.
Environmental prevention strategies that have demonstrated effectiveness in reducing the availability of drugs and alcohol in civilian populations should be systematically implemented in the military (4–6). Strategies to reduce alcohol misuse include the following:
1. Consistently enforce laws on underage drinking and driving under the influence on military bases and in nearby communities.
2. Reduce the number of outlets where alcohol can be purchased on bases and in neighboring communities, and limit their hours of operation.
3. Work with community leaders to train alcohol providers so that servers at hotels, casinos, and bars require valid age identification, refuse to serve intoxicated customers, and report any violent or illegal behavior to military and/ or civilian police.
4. Ban the use of alcohol promotional activities, such as reduced alcohol prices or “happy hours,” on base.
The military command structure provides a unique opportunity to promote collective values that discourage drinking and drug use. The single largest drug problem in the military continues to be alcohol abuse, which historically has been an integral part of military culture. Clear, consistent, continuing messages that discourage drinking in the military, coming from top levels of the DoD and disseminated through the command leadership of the service branches, could have a significant effect in reducing binge drinking and alcohol dependence. Specific strategies to reinforce these messages would include increasing the price of and reducing access to alcohol.
Misuse of Prescription Opioids
Nonmedical use of opioid analgesics has become a significant problem in the military, as it has in the civilian population. The IOM Committee heard numerous accounts of the ready availability of opioids, particularly in theater in Iraq and Afghanistan, where service members operate under highly stressful conditions and where chronic pain from injuries and carrying heavy equipment is common. In those situations, opioid analgesics often are distributed without careful monitoring, and some soldiers become addicted.
To address this situation, all providers—including medics in the field—should be trained to treat pain adequately but cautiously. In addition, efforts should be made to prevent “doctor shopping,” which involves military personnel obtaining prescriptions for opioid medications from health care providers on base and then obtaining additional supplies through prescriptions from physicians in the civilian community.
Although the DoD does not share pharmacy data with state prescription drug monitoring programs (PDMPs), military practitioners can and should check their state PDMP database to determine what other prescription medications a patient may be taking before they issue a prescription for an opioid analgesic or other drug with abuse potential.
Programs for Military Dependents
In addition to its efforts to improve the SUD services available to service members, the DoD and the military branches should offer prevention programs to military families, including broader child development and parenting programs. This is based on recent research confirming that high-quality early childhood and parenting interventions can reduce subsequent rates of substance misuse and domestic violence, as well as having a lasting positive effect on children later in life in terms of reduced rates of delinquency and drug-related crime and enhanced earning capacity (7,8).
SCREENING AND BRIEF INTERVENTION
While prevention is the foundation of any sound strategy for addressing SUDs, a comprehensive approach also must include evidence-based screening and brief intervention to identify and intervene with at-risk individuals and provide effective follow-up care to those whose problems are more severe.
The best screening instruments are brief, noninvasive, inexpensive, and easy to administer and carry no negative consequences. As discussed in the chapter of this text on screening, brief intervention, and referral to treatment (SBIRT), awareness of the limitations of screening has led the public health sector to develop a series of parameters to guide screening activities (9,10), including guidelines to identify the populations that should be screened and the diseases for which they should be screened, performance standards for screening tests, and assistance in interpreting test results.
Acceptance among the population being screened is fundamental to successful screening. Screening for alcohol and other drug problems can pose major challenges in terms of such acceptance by military personnel, since those problems are stigmatized and may be perceived as a moral weakness rather than a health issue.
The committee strongly recommended that screening should be available without stigma or disciplinary consequences, so that service members’ responses to screening questions are more likely to be truthful. Such screening should be followed by brief interventions when indicated. These can be delivered via web-based programs or in direct clinical encounters, such as those in primary care settings.
Screening and brief intervention should be viewed as educational interventions, in accordance with the DoD policy, because screening is not the same as diagnosis, and brief advice is not treatment. (The applicable DoD policy supporting this approach is DoD Instruction (DODI) 6490.08, Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members (20).) In addition, the committee recommended further development and use of Web-based supports for screening and brief intervention because they can be confidential and made available during deployment and after discharge when access to in-person interventions is not feasible.
Screening Protocols and Instruments
Many valid and reliable screening instruments are available for alcohol and other drug use (11). Most are self-administered and require 1 to 5 minutes to complete. They can be used in a variety of health care settings, such as primary care offices and emergency departments.
The U.S. military employs the Alcohol Use Disorders Identification Test C (AUDIT-C) (12) as part of its Pre-Deployment Health Assessment (completed 60 days prior to deployment). The AUDIT-C also is part of the Clinical Practice Guideline for Management of Substance Use Disorders of the Department of Veterans Affairs (VA) and the Department of Defense (13).
In addition to self-report, screening for drug use often involves urinalysis and other biologic methods, such as cheek swabs or hair analysis. Urinalysis is an attractive screening option because it is independent of self-report. However, it also has a number of limitations, such as the fact that urine tests detect only recent use. The usefulness of such tests also is highly dependent on laboratory standards related to chain of custody, quality control, validity (sensitivity and specificity), and reliability of testing procedures, as well as the confidentiality of test 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 supervision. Similarly, a negative test does not necessarily mean that drug use is absent. Lastly, not all drugs of abuse are tested for or detected by standard screening tests, potentially leading to their use by service members trying to “beat the test.”
For alcohol, both the National Institute on Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration (SAMHSA) have sponsored the development of evidence-based protocols for SBIRT (14). SBIRT involves the use of an evidence-based screen for at-risk drinking, followed by a brief intervention if indicated and, for those whose problems are more severe, referral to specialty addiction treatment. While organizations such as the Centers for Disease Control and Prevention and the World Health Organization suggest different lengths of time for the SBIRT process, all the times specified are brief: between 5 and 20 minutes.
SBIRT for alcohol use disorders has been shown to be efficacious when conducted by either physicians or other health care professionals (15–17) and cost-effective across heterogeneous populations (15). As a result, it has been implemented in many different health care settings, including primary care offices and emergency departments. Research studies show that SBIRT is effective in reducing the severity of the problem in persons who are at risk for SUDs and that also is a helpful case-finding intervention in persons whose problem is intensifying in severity (15–19).
Based on this evidence, the IOM Committee recommended that the DoD establish programs to conduct routine screening for unhealthy alcohol and other drug use, together with brief interventions as indicated. While acknowledging that the current DoD and branch policies emphasize screening as a key strategy in combating SUDs, the committee found that such screening policies and programs fall short of identifying all service members with SUDs or those who are at risk for developing them, leading to a significant unmet need for effective screening and brief intervention strategies.
For example, annual screening for unhealthy alcohol use is recommended in the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (20), based on extensive evidence that screening followed by brief alcohol counseling is efficacious in reducing drinking. However, the committee found little evidence of actual implementation of such screening outside of Pre-Deployment Health Assessments. The DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed Forces (Comprehensive Plan) also found that evidence-based screening is not used consistently in the military, particularly in primary care settings (21).
In an update to the Comprehensive Plan, the DoD reported that policies calling for more consistent use of screening measures in primary care settings are under development. The DoD should move forward with this action as quickly as possible. The committee recommended that the new language specifically cite the use of validated screening tools and adherence to the screening procedures identified in the VA/DoD Clinical Practice Guideline (13). Such screening should be followed by brief interventions when indicated. These can be delivered via Web-based programs or in direct clinical encounters, such as those in primary care settings.
In addition, the committee recommended further development and use of Web-based supports for screening and brief intervention because they can be administered in a confidential manner and made available during deployment and after discharge when access to in-person interventions is not feasible.
Finally, the committee recommended that practitioners in the military health care system be trained to follow the guidelines in DODI 6490.08, which allow for administration of a brief and confidential preventive intervention to those who are identified as being at risk for SUDs but who do not meet diagnostic criteria for such disorders. Branch policies and programs should allow for the delivery of indicated preventive interventions without requiring notification of commanders (within the guidelines of the DODI 6490.08).
TREATMENT SERVICES FOR MILITARY PERSONNEL AND DEPENDENTS
In the civilian sector and in the military health care system, implementation of evidence-based pharmacologic and behavioral therapies for alcohol and other drug use disorders is a major challenge for both policy makers and treatment providers (22). To assist the DoD in meeting these challenges, the committee focused on the following areas: (a) promoting the use of evidence-based practices and guidelines, (b) expanding the use of outpatient services, and (c) integrating the care of co-occurring SUDs and mental health disorders.
Use of Evidence-Based Practices and Guidelines
The use of evidence-based practices in the care of SUDs (as well as the training of providers in such practices) is integral to delivering effective, high-quality care. The IOM Committee found that while the DoD and the individual branches advocated for the adoption and implementation of evidence-based practices in their policies and program literature, there is little information about the specific practices to be employed. As a result, adoption and implementation are highly variable across and within the branches.
For example, the Department of VA collaborated with the DoD to develop evidence-based guidelines for the treatment of SUDs (13), yet the committee found a widespread lack of implementation (as well as monitoring of implementation) of those guidelines in military treatment facilities, particularly with regard to the use of medications to treat SUDs and tracking the number of prescriptions used in such treatment. The lack of routine screening, limited use of anticraving and agonist medications, minimal training in the use of psychosocial interventions, and the weak integration of specialty SUD care with general medical care suggest passive rather than active implementation of the VA/DoD guidelines.
To move forward, the DoD needs to develop system-wide measures to monitor ongoing implementation and compliance at the branch level. Such measures might include tracking the percentage of active duty service members who complete screening each year, as well as the percentage of patients referred for SUD assessment who actually complete an assessment and engage in care. To facilitate this process, the SUD measures tracked by the National Committee for Quality Assurance through use of the Healthcare Effectiveness Data and Information Set (23) should be adapted for use in the military’s direct and purchased care systems.
Use of Outpatient Services
The military health care system appears to have sufficient access to inpatient beds. However, the direct care system needs to build capacity for intensive outpatient and outpatient services, because contemporary systems of SUD care rely on outpatient services and ongoing disease management.
For many individuals, SUDs are chronic relapsing conditions that require ongoing monitoring and periodic stabilization. Monitoring systems similar to those used by the Department of Transportation (24) and state Physician Assistance Programs (25) allow highly trained individuals to continue to work without jeopardizing their own or others’ health and safety and thus are good models for the DoD.
To this end, the DoD should expand its capacity to offer local outpatient services in both the direct and purchased care systems. In the direct care system, this may require the addition of addiction specialists to supervise clinical staff and the expansion of training and certification in addiction medicine for mental health practitioners.
Care of Co-Occurring Substance Use and Mental Disorders
Co-occurring posttraumatic stress disorder (PTSD) and SUD is a common presentation and a major concern (26,27), because it is associated with substantial psychiatric and functional impairment (28). Many individuals with PTSD use alcohol, sedatives, and opioids in an attempt to reduce their chronic state of hyperarousal, but continued use of such substances may lead to the development of an SUD.
Military veterans from Iraq and Afghanistan have high rates of both PTSD and SUD (29,30) (also see Chapter 90). For example, an estimated 20% of veterans who receive treatment services for PTSD through a VA medical center have a comorbid SUD (30). A recent Research and Development Corporation study of Iraq and Afghanistan veterans diagnosed with PTSD found rates of binge alcohol use that were twice the community rate for young adult men (31). The study also found that tobacco use occurred in half of these veterans—a rate 2.5 times greater than the community rate. Opiate misuse was detected in 9% or three times the community rate (32).
Comorbid pain and SUD also are a frequent occurrence. For example, a structured evidence-based review of 67 studies found that, among patients with chronic nonmalignant pain who received chronic therapy with opioid analgesics, 3.2% developed misuse and addiction, while 11.5% developed aberrant drug-related behaviors (33). Published estimates of opioid misuse and/or addiction in chronic pain populations average approximately 10%, with a range of 3% to 18% (34–37).
WORKFORCE ISSUES
The charge to the IOM Committee included an analysis of the workforce responsible for SUD care. To complete this portion of the analysis, the committee reviewed the regulations and instructions governing SUD treatment services, as well as the training of addiction counselors and other licensed practitioners in both the military and the TRICARE purchased care system, and completed visits to programs on five military bases.
Air Force
The Air Force provides prevention and treatment services through a worldwide network of 75 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) programs located within the Air Force Mental Health Flight. ADAPT program managers, who are licensed psychologists or social workers, supervise licensed clinical social workers (about 420 total; 50% of whom are civilians), licensed clinical psychologists doctoral level (about 330; 35% of whom are civilians), and certified alcohol and drug counselors (about 480; 25% of whom are civilians). Psychiatrists (about 150) are available to provide support; none are certified in addiction medicine. During fiscal year 2010, 1,454 active duty Air Force personnel were enrolled in ADAPT. Air Force regulations require a treatment team that includes the patient’s unit commander or first sergeant, the patient’s immediate supervisor, the ADAPT program manager, alcohol and drug counselors involved in the case, medical providers if needed, other practitioners as needed, and the patient. The Air Force participates in the International Certification and Reciprocity Consortium, which sets standards for certified counselors and encourages mental health technicians to seek certification (2).
Army
The Army Substance Abuse Programs (ASAPs) operate within the Installation Management Command and have limited interaction with the medical command at their base. ASAPs served 23,000 active duty soldiers during fiscal year 2010. Commanders seeking residential treatment for their personnel may use any licensed SUD facility and are not limited to the TRICARE network.
About 60 alcohol and drug control officers manage and supervise ASAP prevention and treatment staff. Practitioners must have a master’s or doctoral degree in social work (about 220), psychology (about 20), counseling (about 165), or marriage and family therapy (about 70). Counselors who lack professional licensure must have a master’s degree and be certified as a substance abuse counselor (about 400). Only two-thirds of the authorized counselor positions were filled during 2012; as a result, the ASAPs are understaffed.
Navy
The Navy’s Bureau of Medicine operates 38 Substance Abuse Rehabilitation Programs (SARPs). Of these, 35 offshore SARPs provide only outpatient care, and three US-based facilities provide intensive residential care. SARPs treated more than 10,000 Navy and Marine personnel during fiscal year 2010. The staff include licensed clinical social workers (about 15 civilians), licensed clinical psychologists (about 20 civilians), and psychiatrists (five civilians).
The Navy trains its own certified alcohol and drug counselors through five 10-week classes per year. At the time of the IOM Committee’s review, there were about 100 certified alcohol and drug counselors. The Navy’s training manual is based on the 1984 standards for counselor certification and the 1998 update from the SAMHSA. The training does not include the medications approved by the Food and Drug Administration for the treatment of alcohol and drug use disorders.
The committee visited the largest and most intensive SARP, located at the San Diego Naval Base. Staffing in the 100-bed residential unit included 13.5 licensed providers, 2 recreation therapists, 36 alcohol and drug counselors, 14 medical staff, and 14 administrative staff. The outpatient unit had an additional 4 licensed providers, 16 alcohol and drug counselors, and 3 administrative staff. The Navy enrolls patients in Hazelden’s Web-based program (My Ongoing Recovery Experience, or MORE) when they are discharged from residential care.
Marines
The Marine Corps operates 15 Substance Abuse Counseling Centers (SACCs) within Personnel Command and has transitioned to an all-civilian workforce. Marines also use the Navy SARPs. The SACC workforce included 63 alcohol and drug counselors. Marine regulations require use of certified counselors but otherwise are silent on training and education requirements. The Marine Corps reported that 2,200 service members completed care within the SACCs during fiscal year 2010.
Overall Findings
The workforce engaged in care of SUDs varies substantially within the service branches, and credentialing and training are not standardized. Reliance on counselors without graduate degrees means that patients with complicated comorbid conditions may not be receiving integrated care, which may compromise the effectiveness of treatment. Counselor training materials used in the Air Force and Navy are not up to date and do not include training in evidence-based pharmacologic and behavioral therapies. Few physicians have specialty training in addiction medicine. Overall, there are too few qualified clinicians providing care in the ASAP, ADAPT, SARP, and SACC programs.
ACCESS TO CARE
The IOM Committee reviewed access to SUD screening, prevention, and treatment services and concluded that, while some care is available to service members through the military health care system, the number of persons treated is below the number that would be expected on the basis of standard epidemiology. For example, one study found that of 6,669 Army soldiers who self-reported levels of drinking categorized as alcohol misuse, only 0.2% received a referral for alcohol services, and only 29 of those were seen within 90 days (38). Given data showing high rates of weekly binge drinking among military personnel (39), it is apparent that only a fraction of service members who need brief intervention and advice to change their alcohol-related behaviors are being reached. In fact, a full range of SUD service modalities is not available to service members and their dependents in either the direct or purchased care (TRICARE) components of the system.
Barriers to accessing care for SUDs in the military’s direct system of care may be environmental, structural, social, and/or cultural. Environmental factors, such as pressure or mandates to enter treatment, sanctions, perceptions about the effectiveness of treatment, and stigma, are unique to the behavioral health field, particularly the addiction field, and more apparent in the military than the civilian sector. Other barriers include the structure and location of the services, an overreliance on residential care, and stigma that substantially inhibits help-seeking behavior in a system in which regulation requires the commander to be informed about any use of services for SUDs.
Access to care for service members and their dependents also is extremely limited in the TRICARE purchased care system. Obstacles involve limits on covered benefits and requirements for establishing patient eligibility, both of which are far different from those in use in the civilian sector. Other problems include lack of access to existing community-based outpatient and intensive outpatient services and poorly executed transitions from SUD care to primary care and from inpatient to outpatient services.
Although federal regulations require TRICARE to provide emergency and inpatient hospital care for SUDs, TRICARE allows addiction treatment to be provided only in accredited hospitals that meet requirements for SUD rehabilitation facilities. Intensive outpatient services are not available through TRICARE, although commanders may directly purchase such services. The current TRICARE benefit structure does not allow the use of individual therapy sessions for those who have an SUD diagnosis alone. (In order to be eligible for this service, individuals must have a mental illness diagnosis.) Therefore, outpatient follow-up and monitoring by a professional are not an option for individuals diagnosed with an SUD. Moreover, although decades’ worth of research has demonstrated that SUDs are chronic medical disorders that respond to a combination of medication and behavioral interventions. The IOM Committee strongly recommended that TRICARE benefits be brought into alignment with the VA/ DoD guidelines.
Another obstacle to care is that TRICARE is not subject to the federal mental health and addiction parity laws that govern care in the civilian sector. Therefore, access to prevention and treatment services that incorporate the latest scientific evidence and predominate in the commercial sector—such as medication-assisted therapy, individual therapy, and intensive outpatient programs, as well as care in individual practitioners’ offices and outpatient clinics—is limited in the military’s direct and purchased care systems by an outdated benefit structure, inadequate 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.
One concern on which the Committee focused a forceful recommendation was the TRICARE exclusion of opioid drug maintenance therapy for treatment of dependence. However, on October 22, 2013 the DoD issued the final version of a new regulations agreed with the IOM Committee, removed the exclusion and allowed TRICARE henceforth to the cover maintenance therapy (40).
SUMMARY AND CONCLUSIONS
Despite a clearly demonstrated commitment to promoting fitness and resilience among service members and their families, the U.S. military has a long history of problems with alcohol and other drug misuse. As long ago as the Revolutionary War, Dr. Benjamin Rush detailed the effects of alcohol on the troops. During the Civil War, addiction to opium prescribed for pain became known as the “soldier’s disease.” In recent years, the issue has reached crisis proportions because of the increased use of opioids to treat pain and the physical and psychological stress of multiple deployments.
In view of this situation, it is import to recognize two overriding themes that influence military policy and health care program design:
■ The force must be fit for duty and ready for deployment at a moment’s notice. This leads to an emphasis on acute rather than chronic care.
■ Because of the need to maintain force readiness, problems with alcohol and other drugs often are classified and treated as disciplinary rather than health problems.
These two factors help explain the military’s inadequate response to SUDs, despite a clear commitment to providing high-quality health care. In an internal report, the DoD acknowledged that existing policies sometimes inhibit efforts to improve the services actually delivered—an observation that was confirmed by the IOM Committee (1). Recommendations offered by the committee to address the most pressing problems are summarized below.
Prevention and Treatment Strategies
Prevention strategies that have demonstrated effectiveness in reducing the availability of drugs and alcohol in civilian populations should be systematically implemented by the military. Among the strategies endorsed by the committee are steps to curb easy access to relatively inexpensive alcohol on military bases through consistent enforcement of regulations on underage drinking. This is especially important because a considerable portion of military personnel are younger than the legal drinking age; in fact, the largest age cohort in both active military service and the reserve is under age 25 (2). The committee also recommended paring down the number of outlets that sell alcohol, restricting their hours of operation, and reducing the types and amounts of alcohol that can be purchased.
In addition to activities to prevent SUDs, the committee recommended that military leaders encourage service members to seek help when needed. For example, the committee commended the Army’s implementation of the Confidential Alcohol Treatment and Education Pilot, which demonstrates that active duty service members will use confidential treatment services when given an opportunity to do so. Such programs should be expanded within the Army as well as to the other military branches, and Web-based technologies should be employed to extend the availability of confidential care and facilitate continuing care. Delivering such services without disciplinary consequences promotes better care, builds troop resilience, and encourages individuals to seek help rather than hide problems.
Use of Evidence-Based Programs and Practices
Full implementation of the VA/DoD Clinical Practice Guideline for Management of SUDs (13) 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, more effective use of technology, confidentiality of care, and greater use of ambulatory and continuing care. The DoD must take the lead in ensuring the consistency and quality of such services.
Access to Care
In its research, the committee found evidence of substantial unmet need for SUD treatment services, as well as outdated policies and practices that serve as barriers to such care. The military medical system provides treatment both directly and through TRICARE insurance benefits. Yet TRICARE does not cover intensive outpatient services, office-based outpatient services, and certain evidence-based pharmacologic therapies such as maintenance treatment of opioid dependence, all of which are standard components of care in the civilian sector.
The committee concluded that the TRICARE SUD benefit does not comport with current standards for evidence-based care and needs to be revised without delay. This is such an urgent matter that the committee recommended that Congress consider mandating the requisite policy changes if the DoD fails to make the needed changes in a timely manner.
The Military Workforce
The emerging model of care relies on multidisciplinary treatment teams with carefully prescribed roles and training. An emphasis on outpatient services, greater reliance on group therapy, and effective use of computer-assisted cognitive–behavioral training can help to increase caseloads and enhance productivity without sacrificing the quality of care.
Service Delivery and Outcomes
Overall, the military lacks benchmarks and standards for prevention, screening, diagnosis, and treatment services. To improve this situation, the DoD and the service branches need accurate and valid performance measures to allow them to better monitor the implementation and effectiveness of SUD prevention, screening, and treatment services. Moreover, each branch organizes these services idiosyncratically, with little consistency in service implementation and data collection. Consequently, the DoD should assume responsibility for ensuring the consistency and quality of such services by monitoring adherence to policies and implementation of clinical practice guidelines, developing performance measures related to SUD prevention and treatment, and holding providers and systems accountable for their performance on these measures. As part of this process, each military branch needs to ensure the effectiveness of its programs by evaluating tangible outcomes, such as reductions in rates of SUDs and relapse episodes. Such evaluations should be conducted at least once a year.
Grappling with the public health crisis of substance use and misuse within the ranks of the armed forces will require the DoD to proactively implement prevention, screening, diagnosis, and treatment services and take leadership for ensuring that those services expand and improve.
Risk Factors for Military Families
INTRODUCTION
Military families are often overlooked as a cultural group with its own constellation of stressors and issues. They have a “must function” ethos that often discourages them from seeking help with problems that put them at great risk for both substance use and mental health problems. For a variety of reasons, military members, veterans, and family members turn to local providers for help. Yet, community practitioners are often not attuned to the unique features of military culture that affect their willingness to seek help and engage in treatment. They may also lack the preparation necessary to provide care for service-related conditions. As large numbers of military members return home, it is essential that community providers be aware of their special issues. It is especially important that primary care providers are alert to the presence of these patients, because they are in an excellent position to identify behavioral issues in a population resistant to seeking care. Familiarity with the key issues of military members and their families will strengthen the process of assessment and treatment planning and promote more effective assistance.
Angelina V. was often asked, “When did you begin to see changes in John?” She could honestly say that following John’s return home from his second deployment, she saw subtle differences; yet they could easily all be explained as reactions to his experiences of the previous 12 months. The real changes became evident shortly after his return home from Iraq.
The man who left was a kind, gentle, compassionate, and fun loving; the man returning was a shell. When Angelina looked into his eyes, it was as though his soul was missing. A man who would say, “I can’t feel anything”; “You don’t understand—leave me alone.” He was distant, argumentative, easily angered, and irritable.
He never slept or if he did, it would be for short periods of time and often woke screaming. His need to protect led to having a loaded gun that became his constant companion, including at night while in bed, or the need to tie fishing line across the stairs and leave newspaper at the inside of doors so that he could hear if someone entered the house. There was always a sense of uncertainty— never knowing when a comment, a smell, a sound would trigger an event. There was also constant worry for his safety and/or the safety of others.
This stranger now spent the majority of his time chasing the “adrenaline train.” He was intent on doing things that would keep him moving—and more importantly anything that could test his strength or courage. When Angelina would talk to him about my concerns, he would say, “Don’t worry; if I didn’t get killed there, I won’t here.”
His belief that he was invincible culminated when he had bought a motorcycle. At that point, Angelina’s heart sank; she knew the potential outcome. Her fear was realized about 2 weeks later when she received a call from a local police department; there had been an accident and he was being transported to the hospital. Within hours, he was in surgery for resulting injuries.
During and following his recuperation, his behaviors continued to escalate. Angry outbursts and arguments increased, and his drinking and gambling intensified. This added more stress to the relationship, which was already on the brink of collapse.
While this was happening on the outside, Angelina was experiencing a different kind of turmoil internally. She had the knowing and understanding of what was happening yet, at the same time, was not able to stop it. She found herself living in a new reality. She could offer hope, guidance, and support to others; yet could not find the right words or actions to help John or save their relationship.
More difficult than this was the questions she often posed to herself, and those had no easy answers. Could she walk away from a man who she not only loved but admired for his willingness to put his life on the line for all of us? At what point was she willing to accept the potential consequences of ending the relationship?
On some days, it was a struggle to find the strength needed to support John as he transitioned home. Adding to the confusion was occasional glimpses of the man she fell in love with—a smile or act of kindness shown to a child or animal; or the selfless effort to do something kind. John continued to fight to be “normal.” He believed he could “handle it on his own.” Angelina was finally able to convince him to go for help. Although he went, he was not engaged in the process. The anger, irritation, nightmares, anxiety, etc. continued to worsen.
Then, one weekend in early fall during yet another one of their heated arguments, the realization that they could not go on anymore came to light for both of them. The strain of war had proved destructive. It was at that moment with mixed emotions and heavy hearts they decided to let go of the relationship they once knew.
Subsequently, John moved into his own apartment. The downward spiral continued ending with him questioning whether he wanted to continue to live. It was with the support of friends and family that he returned to treatment. The healing had finally begun.
This account is the lived experience of a former fiancée of an Army National Guardsmen who deployed three times in 4 years. There may be many individuals and families who have had similar experiences to what is described here and are not willing to talk about them. Over 2.3 million US forces have been deployed to Iraq and Afghanistan since 2001, the majority (76%) of which are between 18 and 30 (1). Over half (51%) are married and 45% have children. It should be noted that the military uses a narrow definition of family, “heterosexual marriages and parents with dependent children who live with them at least part of the time” (1), and thus studies do not reflect the diversity of the families affected. This is particularly true of those families serving with the National Guard or reserve component. In some cases, both parents are deployed simultaneously leaving parents, grandparents, or guardians responsible with the care of children.
Up to 75% of our all-volunteer military has been deployed more than once, and many have longer deployments and shorter times in between than in previous wars. There has been increased deployment of women, parents of young children, and Reserve and National Guard troops. Although many readjust without great difficulty, significant numbers have trouble adapting to family life, resuming education, and finding employment.
Many military personnel and their families feel that other Americans are oblivious to their situation:
Nathan, a second grader, had increasingly strong reactions to his father’s multiple deployments to Iraq and struggled hard to adjust as he grew older. One day in class, he drew battle scenes involving tanks and other military armaments. This drawing was confiscated, and he was sent to the principal for dangerous contraband.
Nathan was attempting to master his emotions and bring his father closer by depicting his situation in Iraq in his drawing. It is to be hoped that schools and other important institutions will develop greater sensitivity to the needs of these children.
MAJOR STRESSORS WHILE IN THEATER
While on active duty, the military member is living in difficult conditions, such as poor food, lack of privacy, harsh climate, and extreme physical exertion. There are periods of intense violence, followed by inactivity, but there is always a need to sustain a high degree of vigilance. There are long hours, multiple demands, and sleep deprivation. They witness death and a great deal of human suffering, while being constantly under threat of injury or death. Simple decisions take on a life-and-death significance as they face being shot at or otherwise harmed. They may suffer over ethical dilemmas about what they normally consider right and wrong and what they must do to survive and fulfill their mission.
In the midst of all this, they are separated from family and friends and often have concerns about what is going on at home. They may say little about their hardships in an effort to avoid worrying family members, and the family may be reluctant to share difficulties in order to avoid burdening their absent member. Thus, communication can become strained, superficial and emotionally unsatisfying, setting the stage for a more difficult reentry. Alcohol use is often a coping strategy for tension release and, in many segments of the military, heavy drinking is the prevailing custom.
COPING WITH WARTIME DEPLOYMENT
Family members at home may have only a blurry picture of life on active duty and have their own series of stressors. It is common for them to withdraw emotionally and become detached as the departure nears. Initially, there can be intense fear and worry, followed by an adjustment period that includes loneliness, sadness, and fear of the unknown. Ambiguity and uncertainty are dominant. Although the internet offers important new pathways for contact, communication may be limited for extended periods of time and media portrayal of the conflicts adds to the anxiety.
Family structure often changes significantly to adapt to new challenges. Spouses at home are faced with managing unfamiliar tasks. The definition of family may be expanded to include new resources from friends and the extended family. Younger families may move to be near their parents who can help. Family issues are paramount for women, and mothers who are deployed can experience great guilt and concern, particularly if they are not comfortable with the arrangements at home. Families that are flexible regarding roles and responsibilities are usually better able to adapt. Online and community support groups exist for military partners and spouses, but not everyone utilizes them.
A large-scale study of over 250,000 wives of active duty soldiers found that spouses of deployed soldiers received significantly more mental health diagnoses, associated with the length of deployment (2). The most common diagnoses were depression, sleep disorders, anxiety, acute stress reaction, and adjustment disorder, and the women were likely to have more than one condition. Children’s reactions vary with their age, developmental stage, and preexisting problems. Young children may experience separation anxiety, temper tantrums, and changes in their eating habits. School-age children may show a decline in academic performance, mood changes, and physical complaints. Adolescents may more readily express anger and act out or may show signs of apathy and withdraw (3). It is very important that families develop skills in talking with children about a parent going to war, before deployment as well as ongoing. These discussions should include the sharing of feelings as well as coping strategies for practical problems. Maintaining familiar family traditions is comforting, and monitoring children’s exposure to TV coverage of war is desirable when possible. Family conflict resolution skills are very useful. Conflict avoidance usually exacerbates problems, and it is important to be alert to the possibility that frustration and other emotions can be turned against each other in unproductive ways.
HOMECOMING AFTER DEPLOYMENT
Although the return home is eagerly anticipated as the happiest day for the military member and the family, it is filled with challenges. Responses that are adaptive while on active duty become problems during the transition phase. The “fight-or-flight” response is a survival asset in the war zone, but hyperarousal at home leads to jumpiness, poor sleep, and difficulty concentrating. These greatly elevate the risk for substance abuse problems.
Military members usually feel that a lot has changed since deployment, and they may feel out of place back home. National Guard members and reservists do not have the interaction with other soldiers that others experience and may feel particularly alone. Accustomed to a high level of arousal, civilian life can seem insignificant when compared to combat. Free time is a burden, especially if the military member is unemployed and having difficulty finding work.
Family roles have usually shifted, and new roles have become established (4). Couples have learned to live apart and independent, and upon return, a new relationship needs to be explored. Spouses and partners may enjoy learning and exercising new skills and may be reluctant to give up responsibilities. The returning parent may be keenly aware of missing important developmental stages of a child’s life and may be unsure when to “jump in” with child discipline. There can be mixed feelings of being overwhelmed with the responsibility of the family while bored with the mundane part of life.
At the same time, family members are facing their own reintegration challenges. They may feel emotionally disconnected and alone, especially when trying to assist their loved one who has sustained a serious wound or other medical condition (i.e., loss of hearing, cardiovascular, gastrointestinal, and/or musculoskeletal disorder). Family members struggle with “not knowing” what will trigger their loved one, and if they are triggered, how they will react; and when it is time for to ask for help.
Significant others often do not understand why after being away for a long period of time their veteran chooses to be with other members of their unit at the local pub instead of at home with them and the family. Some male partners may experience resentment toward their returning woman veteran, contributing to relationship difficulties. Parents of returning military members, especially those serving in the National Guard or Reserve component, face similar challenges. They are often uncertain how to deal with their child’s struggles and, as a result, may experience emotional, physical, or psychological symptoms.
SPECIAL CONSIDERATIONS FOR NATIONAL GUARD AND RESERVISTS
Many of the issues for other military personnel are common to the National Guard and Reservists, but there are some important differences as well. These are weekend warriors, civilians who are suddenly called to active duty for periods of up to 12 months. Although legally a job must be held open for them, there is no guarantee they can return to the position they left. They may be offered a lower position or be informed that their job has been eliminated. This creates considerable economic hardship and other stresses for them and their families.
When they return to the United States, they are not affiliated with a base like other active military, but scatter to their home community. If they elected to serve in a unit composed of others in a different geographic location, they will not have the potential camaraderie easily accessible once they return home. This compounds the feelings of isolation they may experience. Upon return home, research has demonstrated that reserve component military personnel required more mental health treatment in comparison to active duty personnel (5). More specifically, Reserve and National Guard personnel who deployed and reported combat exposures were significantly more likely to experience new-onset heavy weekly drinking, binge drinking, and alcohol-related problems, with the youngest service members at highest risk for alcohol-related problems (6). In addition to the effects of deployment on the military member, there is emerging evidence of the effects on the family. Sustained deployments are often described as particularly difficult for Reserve and National Guard families who have less access to military support systems and fewer connections to other military families (2,3).
Health care is also a significant issue. Although military members are eligible for VA health care, many are hesitant to access these services for fear that information will be shared with commanding officers, which may impact their military service. Instead, they may choose to seek health care in the community utilizing either private insurance or Tri-Care insurance, which also covers their families. However, because of the challenges to becoming a Tri-Care provider, there are a limited number of providers who accept it.
MEDICAL/PSYCHOLOGICAL ISSUES IMPACTING REINTEGRATION
Modern lifesaving technology has dramatically improved survival and resulted in large numbers of seriously wounded soldiers returning home. As of 2012, it is estimated that the number of wounded from Iraq and Afghanistan exceed 50,000. Many of the wounded are in their 20s and will require frequent and costly medical care throughout their lives. These servicemen also have a high prevalence of PTSD and depression, often increasing in the postdeployment period. This has a profound effect on family functioning. The majority of caregivers provide assistance with ADLs, such as bathing, dressing, getting in and out of beds and chairs, as well as administering medications and injections, and coordinating medical and rehabilitation appointments (1).
Pain is a significant cause of disability, with 47% of OEF/OIF soldiers reporting problems associated with pain. About 14% have been prescribed opiate pain medications, and 25% to 35% report being dependent on prescription pain medications or illegal drugs. Rising numbers are involved in polypharmacy, defined as the use of four or more prescription medications, of which at least one is a psychotropic drug or a controlled substance (7). The welcome emphasis on adequate pain management has resulted in significant quantities of opioid medication in the home, elevating the risk for substance abuse problems in the veteran and other family members.
Alcohol is the most common substance of abuse, followed by misuse of prescription opioids. Although illicit drug use (excluding prescription drug misuse) is much lower while on active duty, it nonetheless exists. Stimulants may be used to lessen fatigue or help cope with the boredom or panic of battle situations. Marijuana use is evident to relieve tension and for recreational purposes.
Service members returning from combat zones are particularly likely to have problems, including intimate partner violence, especially if they have PTSD (IOM 2008) or TBI. The high prevalence of military sexual trauma (MST) in women in particular has a major impact on returning veterans, particularly because they often feel betrayed by the military itself if they report the assault. These conditions place great burdens on family members and are associated with higher rates of separation and divorce
David is an OEF male veteran, late 40s and married with three children. His unit was hit by a sand storm and was running for cover when he struck his head into the top of the doorway of a concrete bunker. He had loss of consciousness, dazing, disorientation, and confusion. He was placed on a flat board and taken to a MASH unit, where he remained there overnight. He has no memory of what he was told about what happened to him. He was given pain and sleeping medications. He was also given a week of restricted duty.
Upon return, he sought treatment for persistent symptoms. His main presenting complaints included suicidal thoughts, depression, racing thoughts, history of MST, and drug abuse. In the course of assessment, other problems emerged. These include dizziness, loss of balance, poor coordination, severe headaches, nausea, light and noise sensitivity, numbness/tingling in body, appetite change, poor concentration and memory, decision-making problems, slowed thinking with organizational and task completion difficulties, fatigue, poor sleep, nightmares, anxiety, depression, irritability, and poor frustration and tolerance.
His wife is making all of the medical appointments, organizing their lives and taking care of all of the household responsibilities. David has lost his job due to memory issues and inability to function. He is currently unemployed and stays at home drinking, and his wife is considering moving him out of the home due to his angry outbursts.
These complex cases will require multiple resources for the veteran and family members over an extended period of time. His alcohol use is one of many complex problems, but it represents a “wild card” that undermines the success of other efforts. Effective care will require a high level of expertise and teamwork and resources to sustain this over time.
CONCLUSIONS
Family members are an essential support to military service members, playing an important role in readiness and effective functioning while deployed, and support and care upon return home. However, they have their own set of stressors and problems, and assisting them to meet their challenges is essential for the service member on active duty as well as those who return. In the absence of sensitive care, spouses and children are likely to become collateral damage over the long term. This includes family configurations more broadly defined than the current military focus on married couples and their children. Although resources are offered through the military, they are often inadequate in particular locations, and community providers will make a major contribution when they are prepared to meet the needs of this group.
REFERENCES
1.Committee on the Assessment of Readjustment Needs of Military Personnel, V., and Their Families, Institute of Medicine. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press, 2013.
2.Mansfield AJ, Kaufman JS, Marshall SW. Deployment and the use of mental health services among US Army wives. N Engl J Med 2010;362(2):101–109.
3.American Psychological Association (APA) Presidential Task Force on Military Deployment Services for Youth, F., and Service Members. The psychological needs of U.S. military service members and their families: A preliminary report. Washington, DC: American Psychological Association, 2007.
4.Armstrong K, Best S, Domenici P. Courage after fire: coping strategies for troops returning from Iraq and Afghanistan and their families. Berkeley, CA.: Ulysses Press, 2006.
5.Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from Iraq war. JAMA 2007;298:2141–2148.
6.Jacobson IG, et al. Alcohol use and alcohol-related problems before and after military combat deployment JAMA 2008;300(6):663–675.
7.Department of the Army. Army 2020 generating health and discipline in the force ahead of the strategic reset. Washington, DC: Department of the Army, 2012.
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