Summary by Saadiq J. Bey, MSW, CASAC, ICADC
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Based on “Principles of Addiction Medicine” Chapter by David C. Lewis, MD, Rhonda Robinson Beale, MD, Mathea Falco, JD, Dennis McCarty, PhD, Charles P. O’Brien, MD, PhD, and Constance Weisner, DrPH, MSW
INTRODUCTION
The physical and emotional stress of active duty in the military can increase a person’s risk for alcohol and drug use. To address this issue, the Department of Defense (DoD) and the individual military branches (Air Force, Army, Marine Corps, and Navy) have established policy and protocol guidelines to prevent and reduce substance use disorders (SUDs). As SUDs weaken military performance and readiness, the DoD set high standards for performance and discipline as part of efforts toward discouraging alcohol, illicit drug, and tobacco use by military personnel.
The high rates of alcohol and drug misuse in the military threaten the health and well-being of both the military and civilian populations. In response to this public health crisis, the DoD asked the Institute of Medicine (IOM) to conduct an independent evaluation and make recommendations for changes in how SUDs are prevented, identified, and treated.
First, an analysis was done to evaluate the full extent of alcohol and drug problems in all branches of the military. Next, an exploration of SUD policies and programs within the DoD and the military were compared to the standards of care and best practices that are widely used in the civilian health care system. Moreover, an assessment of the quality of health services available to the National Guard, Reserves, and military dependents was undertaken. Lastly, the IOM conducted an assessment of the qualifications and competence of the workforce providing SUD care.
The final report highlighted the need to revise current policies and practices that limit access to substance abuse treatment, the lack of specialized treatment modalities, gaps in insurance coverage, stigma and fear of negative consequences, and the lack of confidential treatment programs, and there was a call for strengthening the SUD workforce.
PREVENTION OF SUBSTANCE USE DISORDERS
Prevention is a key strategy, which the DoD uses to manage and reduce incidents of substance misuse among active military personnel. Random drug testing is a prevention intervention conducted to discourage drug use used by all branches of the military. On the other hand, drug tests are limited in terms of their accuracy and the number of drugs that can be tested. Moreover, drug testing is frequently scheduled in advance creating time to abstain and prepare. Lastly, even when the drug testing system is run efficiently, it has not been shown to prevent or reduce substance abuse or misuse.
The DoD needs to implement comprehensive evidence-based prevention programs and guidelines in order to reduce substance misuse in the military. Evidence-based prevention programs use valid interventions to reduce substance misuse and the damage caused by SUDs; these also enhance mission readiness of active duty personnel. Yet the IOM reported the military fell short in their efforts to prevent and reduce SUDs. None of the branches conducted regular evaluations of their existing prevention programs. The activities they used were not empirically supported (e.g., Red Ribbon) and proved to be ineffective at preventing or reducing substance use and misuse. More importantly, evidence-based prevention programs may have a greater impact on alcohol misuse, which is more prevalent in the military than the use of all other drugs combined.
EVIDENCE-BASED PREVENTION PROGRAMS
Research funded by the federal government and private foundations helped establish a knowledge base of evidence-based prevention and the best practices in SUD treatment. The DoD should build on this work to ensure that there is consistent data collection on substance use and misuse along with evaluation of the quality of the services being provided. Importantly, the performance of evidence-based prevention programs should be evaluated annually so as to ascertain if these are having an impact on the problem they are supposed to address.
From an ecologic perspective, the strategies that have shown effectiveness in reducing the availability of drugs and alcohol in the civilian populations should be adapted for use in the military. Such strategies include enforcing laws on underage drinking and driving under the influence on military bases and in civilian communities; reducing the number of establishments licensed to sell and serve alcohol on military bases and communities and their hours of operation as well; and partnering with local community leaders to train alcohol providers (e.g., hotels, bars, and casinos) to require valid identification, refuse service to intoxicated customers, and report violent or illegal behavior to the military and civilian police.
MISUSE OF PRESCRIPTION OPIOIDS
Nonmedical use of opioids has become a significant problem in the military, as is the case in the civilian population. Reports surfaced of widespread abuse of opioids in Afghanistan and Iraq, where soldiers operated under stressful conditions and suffer chronic pain from injuries. Consequently, opioids were distributed without careful monitoring or oversight, which led to some soldiers becoming addicted. It is recommended that prescribers of pain medications should be trained to treat pain adequately and carefully.
The DoD and individual branches of the military should put procedures in place to prevent doctor shopping, a practice that entails obtaining a prescription for opioids from a military practitioner and then obtaining an additional prescription in the civilian community.
A solution to this problem would be for military practitioners to check their state prescription drug monitoring programs in order to determine what other prescription drugs patients may be taking, before they issue a prescription.
PROGRAMS FOR MILITARY DEPENDENT
Additional efforts to improve the quality of SUD services within the DoD and all military branches should include extending prevention programs to military families. Such programs include parenting and child development programs that emphasize complement family values and promote cohesion and resilience.
SCREENING AND BRIEF INTERVENTION
A comprehensive approach to alcohol and drug treatment should include screening and brief interventions to identify and intervene with at-risk individuals and provide follow-up care to those with more severe problems. The most effective screening tools for alcohol and drug use are noninvasive, inexpensive, and easy to administer and carry no negative consequences. In acknowledgment of some of the limitations of screening, the public health sector has developed screening activity guidelines, such as identifying 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 of screening among active duty personnel is essential to successful screening results for alcohol and drug misuse. This presents a challenge in terms of what is acceptable among military personnel because SUDs may be viewed as moral weakness rather than a health issue. Therefore, it’s recommended that alcohol and drug screenings be confidential and free of stigma and negative consequences, so respondents are more likely to give truthful responses. If necessary, alcohol and drug screenings should be followed up with a brief intervention that raises patients’ awareness of the danger of substance misuse. Brief interventions can be delivered via Web-based programs, during an individual counseling sessions, or during a routine visit with a primary care physician.
In accordance to military policy, screening and brief interventions are viewed as educational interventions. Screenings are not the same as diagnosis, and brief advice is not treatment; however, each function is equally important as the other. Moreover, further development of Web-based supports for screening and brief interventions is recommended, because these can be kept confidential and made available during deployment and postdischarge when in-person interventions are not possible.
SCREENING PROTOCOLS AND INSTRUMENTS
There are many valid and reliable screening instruments available for alcohol and other drug use. Most screening instruments are brief and self-administered and take up to 5 minutes to complete. Additionally, these can be used in diverse settings such as primary care physician’s offices, community health centers, and hospital emergency departments. The military uses the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) as part of their Predeployment Health Assessment.
Urinalysis, cheek swabs, and hair analyses are other forms of alcohol and drug screenings. Urinalysis is the most common screening option because it is distinct from self-report, yet urinalysis has a number of limitations because it detects only recent drug use. Furthermore, the effectiveness of tests depends on laboratory standards, safekeeping of specimens, quality control, and reliability of the testing procedures. Importantly, positive tests do not provide information about the frequency, severity, quantity of use, or the presence of drug dependence. Similarly, negative tests do not mean the absence of drugs. Lastly, not all drugs of use are tested for or detected by screenings; hence, they may be the drugs of choice because they can beat the test.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and Substance Abuse and Mental Health Services Administration (SAMSHA) have sponsored the development of evidence-based protocols for screening, brief intervention, and referral to treatment (SBIRT). SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.
SBIRT is most effective when it is conducted by either a physician or qualified health care professional. Thus, it has been implemented in a variety of health care settings: primary care physicians’ offices and emergency departments. Research shows that SBIRT is effective in reducing the severity of substance misuse in persons who are at risk for SUDs. The IOM recommended that the DoD conduct regular screenings for unhealthy alcohol and drug use because individual branches fall short of identifying service members with SUD or those who are at risk for developing them.
Annual screening for unhealthy alcohol and drug use is recommended in the VA/DoD Clinical Guideline for Management of Substance Use Disorders, based on findings that screening followed by brief alcohol and drug counseling is effective in reducing substance use. However, the IOM found little evidence of actual implementation of screening outside of Predeployment Health Assessments. In addition, it was found that evidence-based screenings are not used consistently in the military.
TREATMENT SERVICES FOR MILITARY PERSONNEL AND DEPENDENTS
In both military and civilian health care systems, implementation of evidence-based pharmacologic and behavioral therapies for SUDs are challenging for policy makers and treatment providers. The IOM assisted the DoD in meeting these challenges by focusing on three areas: (1) promoting evidence-based practices and guidelines, (2) expanding the use of outpatient services, and (3) combining the care of co-occurring SUDs and mental health disorders.
USE OF EVIDENCE-BASED PRACTICES AND GUIDELINES
The IOM recommended that the Veterans Administration and the DoD developed evidence-based guidelines for the treatment of SUDs; however, the IOM noticed a widespread lack of implementation of those guidelines in military treatment facilities—specifically, the use of medications to treat SUDs and tracking the number of prescriptions used for treatment. The lack of regular screening, limited use of anticraving and agonist medications, minimal training in the use of psychosocial interventions, and weak integration of SUD care and medical care suggest a passive rather than active implementation of VA/DoD guidelines.
USE OF OUTPATIENT SERVICES
As stated before, the military should reduce its reliance on inpatient treatment for SUDs; however, it needs to reallocate funding to outpatient treatment. Outpatient treatment uses a chronic care model that allows patients to remain connected to their counselor and peer network for as long as needed. In addition, outpatient programs are not disruptive; patient can continue to work without jeopardizing theirs or others health and safety.
CARE OF CO-OCCURRING SUBSTANCE USE AND MENTAL DISORDERS
Veterans that served in Afghanistan and Iraq have high rates of posttraumatic stress disorder (PTSD) and SUDs. It is estimated that 20% of veterans who receive treatment services for PTSD through the VA have a comorbid SUD. A recent study by the Research and Development Corporation on Iraq and Afghanistan veterans diagnosed with a PTSD also had high rates of binge drinking. Tobacco use was far greater (2.5 times) among war veterans than the community rate.
Chronic pain and SUDs are also a common occurrence. For instance, a review of 67 studies found that among patients receiving pain management, 3.2% developed misuse and opioid addictions and 11.5% developed deviant drug-related behaviors. The national average for opioid misuse and addiction among chronic pain populations is 10%, ranging 3% to 18%.
WORKFORCE ISSUES
The task of the IOM was to evaluate the workforce charged with providing SUD care. To conclude this part of the analysis, the IOM reviewed the regulations and directives governing alcohol and drug treatment services, as well as the training of clinical staff and other credentialed professionals and human service workers. In addition, the IOM conducted site visits of treatment programs on five military bases.
AIR FORCE
Alcohol and Drug Abuse Prevention and Treatment (ADAPT) program is the Air Force’s worldwide network of 75 prevention and treatment programs situated in the Mental Health Flight. Program managers are licensed psychologist or social workers, supervise licensed social workers (n = 420, 50% are civilians), licensed clinical psychologist doctoral level (n = 330, 35% are civilians), and certified drug and alcohol counselors (n = 480, 25% are civilians). Psychiatrist (n = 150) provides support; however, none are certified in addiction medicine. In 2010, over 1,400 active duty Air Force personnel were enrolled in ADAPT. Regulations require a treatment team that consist of a military chain of command (e.g., unit commander) including the patient’s immediate supervisor and the ADAPT program manager. The Air Force participates in the International Certification and Reciprocity Consortium that sets standard for credentialed counselors and encourages additional certifications
ARMY
In 2010, the Army Substance Abuse Programs (ASAP) treated approximately 23,000 active duty soldiers. ASAP operate within the Installation Management Command, yet have limited dealings with the medical facility. Residential treatment and other licensed alcohol and drug treatment facilities (they are not limited to the TRICARE network) are available to military personnel at the request of their commander. ASAP is managed and supervised by alcohol and drug control officers; treatment staff must be masters or doctoral degree in social worker (n = 220), psychology (n = 20), counseling (n = 165), and marriage and family therapy (n = 70). Clinicians without a professional license must have a master’s degree and be certified substance use counselors (n = 400). According to recent reports (2012), only two thirds of ASAP’s counseling positions were filled; thus, ASAP is understaffed.
NAVY
The Navy’s Bureau of Medicine operates 38 Substance Abuse Rehabilitation Programs (SARP). Thirty-five of them offer only outpatient services, and three offer intensive residential treatment. SARP treated more than 10,000 sailors and Marines in 2010. The staff consists of licensed clinical social workers (15 civilians), licensed clinical psychologist (20 civilians), and psychiatrist (5 civilians). The Navy oversees the training of certified alcohol and drug counselors with five 10-week classes per year. The Navy’s training standards for alcohol and drug treatment are based on a 1984 manual and federal guidelines from 1998. The largest and most intensive SARP facility is a 100-bed residential facility located at the San Diego Naval Base. The Navy uses Hazelden’s Web-based program My Ongoing Recovery Experience when they are discharged from residential treatment.
MARINES
Substance Abuse Counseling Centers (SACCs) are the Marine Corps’ alcohol and drug treatment programs. There are approximately 15 SACCs operated by the Marine Corp staffed entirely by 63 civilian alcohol and drug counselors. Regulations require use of certified counselors; however, the Marines do not yield information on training, education, and qualifications of their staff.
OVERALL FINDINGS
The workforce that provides alcohol and drug treatment was significantly different within the service branches; credentialing and training are not standardized. Consequently, patients with complex issues rely on counselors who do not have the proper training to treat those patients. Additionally, it was found that counselor training materials were not up to date, and there were few qualified clinicians providing care in the ASAP, ADAPT, SARP, and SACC programs.
ACCESS TO CARE
The IOM’s review revealed significant unmet need for SUD care, as well as outdated policies and procedures that are barriers to care. The Military Health System provides treatment both directly and through TRICARE insurance. However, TRICARE does not cover intensive outpatient, office-based outpatient care, and certain evidence-based pharmacologic therapies. The IOM recommends that the TRICARE benefit be expanded to include intensive outpatient and office-based settings that would give patients greater access to services.
It is also recommended that the DoD update the TRICARE alcohol and drug treatment benefit because it is out of date. Alcohol and drug treatment in the military should mirror the practices of contemporary health plans and to be consistent with the range of treatment s available under the Patient Protection Act and Affordable Care Act.
KEY POINTS
1. High rates of alcohol and other drug use in the military are unacceptably high and constitute a public health crisis, and both are detrimental to force readiness and psychological fitness.
2. The armed forces need to implement comprehensive evidence-based prevention programs and guidelines to prevent, reduce, and treat substance use in the military.
3. Screening is a more effective tool if it is followed up at once with an evidence-based brief intervention.
4. Current military policies and practices limit active duty personnels’ and military families’ access to evidence-based alcohol and drug prevention programs.
5. Each of the individual military branches offered SUD care; however, the services provided and workforce used were outdated. Contemporary models of SUD care are comprehensive and rely on multidisciplinary treatment with carefully prescribed roles and training.
REVIEW QUESTIONS
1. What is most prominent among the military’s prevention initiatives?
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