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SUBSTANCE USE DISORDERS in the U.S. Armed Forces Committee on Prevention, Diagnosis, Treatment and Management of Substance Use Disorders in the U.S. Armed Forces Board on the Health of Select Populations Charles P. O’Brien, Maryjo Oster, and Emily Morden, Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by the U.S. Department of Defense through an inter- agency agreement with the U.S. Department of Health and Human Services under Contract No. HHSP23337030T. Any opinions, findings, conclusions, or recom- mendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-26055-8 International Standard Book Number-10: 0-309-26055-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Substance use disorders in the U.S. armed forces. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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COMMITTEE ON PREVENTION, DIAGNOSIS, TREATMENT AND MANAGEMENT OF SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES CHARLES P. O’BRIEN (Chair), Kenneth E. Appel Professor of Psychiatry and Vice-Chair of Psychiatry, and Director, Center for Studies of Addiction, University of Pennsylvania School of Medicine, Philadelphia HORTENSIA D. AMARO, Associate Vice Provost for Community Research Initiatives and Dean’s Professor of Social Work and Preventive Medicine, University of Southern California, Los Angeles RHONDA ROBINSON BEALE, Chief Medical Officer, OptumHealth Behavioral Solutions, Glendale, CA ROBERT M. BRAY, Senior Research Psychologist and Senior Director of the Substance Abuse Epidemiology and Military Behavioral Health Program, RTI International, Research Triangle Park, NC RAUL CAETANO, Regional Dean and Professor, Dallas Regional Campus of the University of Texas School of Public Health MATHEA FALCO, President, Drug Strategies, Inc., Washington, DC JOYCE M. JOHNSON, Vice President of Health Services, Battelle Memorial Institute, Arlington, VA THOMAS KOSTEN, J.H. Waggoner Chair and Professor of Psychiatry, Pharmacology and Neuroscience, Baylor College of Medicine, Houston, TX MARY JO LARSON, Senior Scientist, Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, MA DAVID C. LEWIS, Professor Emeritus of Community Health and Medicine, and the Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, Brown University, Providence, RI DENNIS McCARTY, Professor of Public Health and Preventive Medicine and Division Head, Health Services Research, Oregon Health and Science University, Portland MARY ANN PENTZ, Professor of Preventive Medicine and Director, Institute for Health Promotion and Disease Prevention Research, University of Southern California, Los Angeles TRACY STECKER, Assistant Professor of Community and Family Medicine, Dartmouth Medical School, Lebanon, NH CONSTANCE WEISNER, Professor of Psychiatry, University of California, and Associate Director for Health Services Research, Kaiser Permanente, Oakland v
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IOM Staff MARYJO M. OSTER, Study Director EMILY C. MORDEN, Research Associate JON Q. SANDERS, Program Associate NANCY LESTER, Uniformed Services University of the Health Sciences Intern (Spring 2012) ANDREA COHEN, Financial Associate FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations vi
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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Thomas F. Babor, University of Connecticut Health Center Mady Chalk, Treatment Research Institute Arthur T. Dean, Community Anti-Drug Coalitions of America Michael Fitzsimons, Massachusetts General Hospital Deirdre Hiatt, Managed Health Network Cristine S. Hunter, U.S. Office of Personnel Management Kimberly C. Kirby, Treatment Research Institute Daniel Kivlahan, VA Puget Sound Health Care System James McKay, Treatment Research Institute Thomas McLellan, Treatment Research Institute Roland S. Moore, Pacific Institute for Research and Evaluation Rumi Kato Price, Washington University School of Medicine Eve E. Reider, National Institute on Drug Abuse Stephen N. Xenakis, U.S. Army (Ret.) vii
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viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Richard J. Bonnie, Uni- versity of Virginia, and Susan J. Curry, The University of Iowa. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Preface S ubstance abuse has long been an issue of concern for the U.S. popula- tion and for its military in particular. Dating as far back as the Revo- lutionary 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.” Drug problems in both the mili- tary and civilian sectors have intensified throughout the 20th century as the types and formulations of substances being used have increased. Since the 1970s, the Institute of Medicine (IOM) has been called upon numerous times to advise the government on both medical and legal solu- tions to the problem of substance abuse. Experts from various fields, rang- ing from mathematics and epidemiology to pharmacology and law, have spent many hours on about a dozen different committees struggling with this thorny problem, which affects our country on societal, economic, personal, and public health levels. While the popular substances of abuse may shift from decade to decade, the overarching problem continues. In the 21st century, prescription opioid abuse has arisen as a major area of con- cern while problems of alcohol, nicotine, and stimulants have persisted as well. Research has demonstrated that stress and availability are important background factors for causing the initiation and abuse of drugs. As the United States approaches the end of the longest continuous period of war in our history, the stresses faced by our military population are apparent. Our all-volunteer military has endured long periods of deployment and redeployment in highly taxing and demanding environments. Consequently, posttraumatic stress, traumatic brain injury, substance abuse, and suicide are at very high levels. ix
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x PREFACE Press reports of substance abuse among the military stimulated congres- sional interest and a call for action. The Department of Defense requested that the IOM take a fresh look at the policies and programs of each of the branches of the military and evaluate the adequacy and appropriateness of their prevention, screening, diagnosis, and treatment of substance use disorders. The committee approached this task by holding public meetings to gather information from representatives of each of the military branches and TRICARE (the military’s purchased care health plan), as well as from academic researchers and interested members of the public. The committee also conducted visits to military bases and met with a variety of care pro- viders, including those working in substance abuse specialty programs and those in primary care, behavioral health, and pain management. The committee requested information from each branch of the military and from TRICARE Management Activity regarding program descriptions, access, utilization, and evaluation results. We also requested data on the providers in the substance abuse programs. We extend our appreciation for the exceptional cooperation from all of those who presented at our meet- ings, hosted our visits to military bases, and assisted with our information gathering efforts. In addition, the committee wishes to express our appreciation to the study director, Dr. Maryjo Oster, and to the IOM staff, Ms. Emily Morden, Mr. Jon Sanders, and Dr. Rick Erdtmann. Charles P. O’Brien, Chair Committee on Prevention, Diagnosis, Treatment and Management of Substance Use Disorders in the U.S. Armed Forces
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Acknowledgments T he committee thanks the Department of Defense, the individual ser- vice branches, and TRICARE Management Activity for the oppor- tunity to review and comment upon the organization and content of their substance used disorders prevention and treatment services. We appreciate their assistance and collaboration in the review. Many individuals assisted the committee in its work by providing useful data and presenting information at the committee’s public meetings and during its site visits. We thank the following people for their contri- butions: Capt. Robert DeMartino, Alfred Ozanian, Greg Woskow, Frank Lee, and Diana D. Jeffery, TRICARE Management Activity; Les McFarling, Army Center for Substance Abuse Programs; Charles Gould, U.S. Navy Bureau of Medicine and Surgery; Lt. Col. Mark S. Oordt, U.S. Air Force Medical Operations Agency; Keith Humphreys, Stanford University; Don Jansen, Congressional Research Service; Brig. Gen. Margaret Wilmoth, Office of the Assistant Secretary of Defense for Health Affairs; Col. John J. Stasinos, Department of the Army, Office of the Surgeon General; Capt. Mary Rusher, Naval Medical Center San Diego; Vladimir Nacev, Defense Centers of Excellence; Col. Charles Milliken, Walter Reed Army Insti- tute of Research; Wilson Compton and Eve Reider, National Institute on Drug Abuse; John Veneziano, Marine Corps Consolidated Substance Abuse Counseling Center; Ted Jutson and Jerry Sinel, Navy Drug and Alcohol Counselor School; John Sparks, TRICARE Regional Office-West; Andrea Brooks Tucker, TRICARE Regional Office-South; Marie Mentor, TRICARE Regional Office-North; Frank Maguire, TriWest; Debbie Del Rosario and Gary Proctor, ValueOptions; Ian Schaffer and John Wagoner, xi
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Tables, Figures, and Boxes TABLES 1-1 Military Policies Addressing Substance Use Disorders as of February 2009, 18 1-2 Military Policies Addressing Substance Use Disorders as of May 2012, 19 2-1 Size of the Military Active Duty and Reserve Components in Fiscal Year 2010, 33 2-2 Sociodemographic Characteristics of Active Duty and Reserve Component Personnel in Fiscal Year 2010, 35 2-3 Sociodemographic Correlates of Past 30-Day Heavy Alcohol Use, Cigarette Use, and Illicit Drug Use, Including Prescription Drug Misuse, 2008, 44 2-4 Alcohol AUDIT Scores of Active Duty and Reserve Component Personnel, 49 2-5 Health Care Burden Attributable to Substance Use Disorder and Three Other Mental Disorders, and Rank Among 139 Diseases and Conditions, Active Duty Component of U.S. Military, 2011, 57 3-1 Reserve Component Health Care Continuum, 75 3-2 Continuum of Care When on Active Duty, 76 3-3 Military Treatment Facilities That Provide Specialty Care for Substance Abuse, by TRICARE Region, 78 3-4 TRICARE Regions and Contractors, 79 xvii
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xviii TABLES, FIGURES, AND BOXES 5-1 Best-Practice Domains and Recommendations of the National Institutes of Health’s Behavior Change Consortium, 115 5-2 A Delivery System Approach Based on the Center for Substance Abuse Treatment’s (CSAT’s) Treatment Improvement Protocol No. 47, 117 6-1 Military Programs Mentioning Dependents, 166 7-1 Utilization of Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Services by Active Duty Air Force Personnel, 193 7-2 Army Active Duty Initial Referrals to the Army Substance Abuse Program (ASAP), 195 7-3 Utilization of Substance Abuse and Rehabilitation Program (SARP) Treatment by Active Duty Navy and Marine Corps Members, 198 7-4 Numbers of Active Duty Marines Receiving Substance Abuse Counseling Center (SACC) Screening and Completing Treatment, 199 7-5 Numbers of Dependent Beneficiaries Receiving SUD Care in Military Treatment Facilities by TRICARE Region (FY 2010), 200 7-6 Number of Active Duty Service Members (ADSMs) and Active Duty Family Members (ADFMs) Who Accessed Care at Military Treatment Facilities for an SUD Diagnosis by Type of Service (FY 2010), 200 7-7 Substance Use Disorders of Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF)/Operation New Dawn (OND) Veterans in Department of Veterans Affairs Programs, 2002-2012, 207 7-8 Number of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF)/Operation New Dawn (OND) Veterans Treated in Department of Veterans Affairs Programs for an SUD Diagnosis, 207 7-9 Average Number of Beneficiaries by TRICARE Region for Fiscal Year 2010, 210 7-10 Number and Rate per 1,000 Beneficiaries Utilizing the Purchased Care Sector for SUD Care, by TRICARE Region (FY 2010), 210 7-11 Medications for Addiction Treatment Given to Active Duty Service Members and Active Duty Family Member Adult Dependent Beneficiaries (aged 18 and over), All Systems of Care (FY 2010), 212 7-12 Number of Beneficiaries Receiving SUD Care by Type of Purchased Care Facility, North Region (FY 2010), 213
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TABLES, FIGURES, AND BOXES xix 7-13 Number of Beneficiaries Receiving SUD Care by Type of Purchased Care Facility, West Region (FY 2010), 214 7-14 Number of Beneficiaries Receiving SUD Care by Type of Purchased Care Facility, South Region (FY 2010), 214 7-15 Number of Beneficiaries with Claims in Purchased Care Settings, by Type of SUD Care (FY 2010), 215 8-1 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Workforce, 229 8-2 Army Substance Abuse Program (ASAP) Prevention Workforce, 232 8-3 Army Substance Abuse Program (ASAP) Clinical Workforce as of December 2011, 233 8-4 Substance Abuse Rehabilitation Program (SARP) Workforce, 234 8-5 Substance Abuse Counseling Center (SACC) Workforce, 236 I-1 Ratings of Policy-Relevant Strategies and Interventions, 374 FIGURES 2-1a Active duty component members with and without children, 36 2-1b Reserve component members with and without children, 36 2-2a Active duty component family status, 37 2-2b Reserve component family status, 37 2-3 Substance use trends for active duty military personnel, past 30 days, 1980-2008, 39 2-4 Use of selected categories of illicit drugs, past 30 days, DoD branches, 2002, 2005, and 2008, 40 2-5a Standardized comparisons of active duty component personnel and civilians, heavy alcohol use and past 30-day smoking, by age group, 2008, 46 2-5b Standardized comparisons of active duty component personnel and civilians, past 30-day illicit drug use, by age group, 2008, 47 2-6 Prevalence of alcohol-related disorders among the active duty component (rates per 100,000), 51 2-7 Prevalence of drug-related disorders among the active duty component (rates per 100,000), 52 2-8 Prevalence of alcohol- and other drug-related disorders among the reserve component (rates per 100,000), 53 2-9 Prevalence of alcohol- and other drug-related disorders among dependents, 56
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xx TABLES, FIGURES, AND BOXES 2-10 Incidence rates of acute and chronic alcohol-related inpatient and outpatient cases, active duty component, U.S. military, 2001-2010, 59 2-11 Alcohol use problems and interventions, 60 3-1 Defense Enrollment Eligibility Reporting System (DEERS), 71 3-2 TRICARE organization of services, 72 3-3 The uniformed services, 72 3-4 Terminology related to the uniformed services health care system, 73 7-1 Number of Army Substance Abuse Program (ASAP) treatment enrollments by substance of abuse for fiscal year 2010, 195 H-1 Components of health care delivery systems, 371 BOXES 3-1 TRICARE Patient Priority System, 77 4-1 ACO Accreditation Standards, 87 4-2 Dimensions of American Society of Addiction Medicine’s (ASAM’s) Patient Placement Criteria, 88 4-3 National Quality Forum’s Voluntary Consensus Standards for the Treatment of Substance Use Conditions, 92 6-1 Policies and Directives Related to Substance Use Disorders, 138 6-2 Army Substance Abuse Program (ASAP) Prevention and Treatment Capabilities, 154 6-3 Military Studies of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, 176 7-1 A Soldier’s Untreated Substance Abuse, 189 7-2 DoD-Wide Programs to Increase Access to Behavioral Health Care Services and Encourage Help Seeking, 202 7-3 Access Standards of the Veterans Health Administration for SUD Care, 204 7-4 TRICARE Policies Governing Access to SUD Care, 209 8-1 12 Core Functions of Substance Abuse Counselors, 231 8-2 Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) Diagnosis and Risk Groups, 239
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Acronyms and Abbreviations AA Alcoholics Anonymous ABAM American Board of Addiction Medicine ABC Alcohol Brief Counseling ACO Accountable Care Organization ACSAP Army Center for Substance Abuse Programs ADAMS Alcohol and Drug Abuse Management Seminar ADAPT Alcohol and Drug Abuse Prevention and Treatment ADC alcohol and drug counselor ADCO alcohol and drug control officers ADFM active duty family member ADMITS Alcohol and Drug Management Information Tracking System ADSM active duty service member ADT active duty training AFI Air Force Instruction AFIP Armed Forces Institute of Pathology ALARACT All Army Activities APA American Psychiatric Association AR Army regulation ARI alcohol-related incident ARM Alcohol-Related Misconduct ASAC Adolescent Substance Abuse Counseling ASAM American Society of Addiction Medicine ASAP Army Substance Abuse Program xxi
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xxii ACRONYMS AND ABBREVIATIONS AUD alcohol use disorder AUDIT Alcohol Use Disorders Identification Test BAM Brief Addiction Monitor BASIC Building Alcohol Skills Intervention Curriculum BHIVES Buprenorphine and HIV Care Evaluation and Support BHOP Behavioral Health Optimization Program BUMED Bureau of Medicine and Surgery CARF Commission on Accreditation of Rehabilitation Facilities CATEP Confidential Alcohol Treatment and Education Pilot CBT cognitive-behavioral therapy CDC Centers for Disease Control and Prevention CD-MART Controlled Drug Management Analysis and Reporting Tool CEOA comprehensive effects of alcohol CFR Code of Federal Regulations CHCBP Continued Health Care Benefit Program CM contingency management CO commanding officer COBRA Consolidated Omnibus Budget Reconciliation Act CoRC Culture of Responsible Choices CPG Clinical Practice Guideline CSAP Center for Substance Abuse Prevention CSAT Center for Substance Abuse Treatment CSF Comprehensive Solider Fitness DAPA Drug and Alcohol Program Advisor DCoE Defense Centers of Excellence DDCAT Dual Diagnosis Capability in Addiction Treatment DEA Drug Enforcement Agency DEERS Defense Enrollment Eligibility Reporting System DEFY Drug Education for Youth DoD Department of Defense DODD Department of Defense Direction DODI Department of Defense Instruction DOJ Department of Justice DOT Department of Transportation DRI drug-related incident DSM Diagnostic and Statistical Manual DUI driving under the influence DWI driving while intoxicated
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ACRONYMS AND ABBREVIATIONS xxiii EAP Employee Assistance Program EBP evidence-based practices ECF executive cognitive function EUDL Enforcing Underage Drinking Laws FEHBP Federal Employees Health Benefits Program FOCUS Families OverComing Under Stress FTE full-time equivalent FY fiscal year GAO Government Accountability Office GAT Global Assessment Tool GBL gamma butyrolactone GHB gamma-hydroxybutyric acid HRB Health Research Board HRSA Health Resources and Services Administration IC&RC International Certification and Reciprocity Consortium ICD International Classification of Diseases IDS integrated delivery system IDT Inactive Duty Training IHI Institute of HealthCare Improvement IMCOM Installation Management Command IntNSA The International Nurses Society on Addictions IOM Institute of Medicine IOP intensive outpatient JCAHO Joint Commission on Accreditation of Healthcare Organizations LCSW Licensed Clinical Social Worker LIP Licensed Independent Practitioner LMFT Licensed Marriage and Family Counselor LOD line of duty LPC Licensed Professional Counselor LSD lysergic acid diethylamide MAAC Marine Alcohol Awareness Course MCO Marine Corps Order MDMA 3,4-methylenedioxy-N-methylamphetamine MDR M2 Data Repository
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xxiv ACRONYMS AND ABBREVIATIONS MEDCOM Medical Command MET motivational enhancement therapy MHAT Mental Health Advisory Team MHS Military Health System MORE My Ongoing Recovery Experience MOU Memorandum of Understanding MTF military treatment facility NCQA National Committee for Quality Assurance NDAAC Navy Drug and Alcohol Advisory Council NDACS Navy Drug and Alcohol Counselor School NIAAA National Institute on Alcohol Abuse and Alcoholism NIDA National Institute on Drug Abuse NOAA National Oceanic and Atmospheric Administration NORTH STAR New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness NQF National Quality Forum NRC National Research Council NREPP National Registry of Evidence-Based Programs and Practices OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OND Operation New Dawn ONDCP Office of National Drug Control Policy PC prevention coordinator PCM primary care manager PCP phencyclidine PDHA Post-Deployment Health Assessment PDHRA Post-Deployment Health Reassessment PDMP Prescription Drug Monitoring Program PEC Pharmacoeconomic Center PFL Prime for Life PHA Periodic Health Assessment PHRAMS Psychological Health Risk-Adjusted Model for Staffing PMART Prescription Medication Analysis Reporting Tool POC Pharmacy Operations Center POS point of service PREVENT Personal Responsibility and Values Education and Training PTSD posttraumatic stress disorder
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ACRONYMS AND ABBREVIATIONS xxv RE Resiliency Element ROSC recovery-oriented systems of care RT resiliency training RTCQ Readiness to Change Questionnaire SACC Substance Abuse Counseling Center SACO Substance Abuse Control Officer SAIC Science Applications International Corporation SAMHSA Substance Abuse and Mental Health Services Administration SAODAP Special Action Office for Drug Abuse Prevention SAPST Substance Abuse Prevention Specialist Training SARP Substance Abuse Rehabilitation Program SBIRT screening, brief intervention, and referral to treatment SECNAVINST Secretary of the Navy Instruction SIP Short Index of Problems SM service member STD sexually transmitted disease SUAT Substance Use Assessment Tool SUD substance use disorder SUDRF Substance Use Disorder Rehabilitation Facility TAMP Transitional Assistance Management Program TAP Technical Assistance Publication TBI traumatic brain injury TDP TRICARE Dental Plan TMA TRICARE Management Activity TPR TRICARE Prime Remote TRS TRICARE Reserve Select TSF twelve-step facilitation UPL Unit Prevention Leader URI unit risk inventory USAF U.S. Air Force USMC U.S. Marine Corps VA Department of Veterans Affairs VET veterans VHA Veterans Health Administration WHO World Health Organization WTB Warrior Transition Brigade WTU Warrior Transition Units
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