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Summary P roblems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issue has changed in recent years. National trends indicate substan- tial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of sub- stance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade—in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD). To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the preven- tion, screening and diagnosis, and treatment of substance use disorders (SUDs). The IOM committee charged with conducting this study was also tasked with assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and with offering spe- cific recommendations to DoD on where and how improvements in these areas could be made. 1

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2 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES APPROACH TO THE CHARGE The charge presented to the committee was substantial and expan- sive. It involved several distinct topic areas (prevention, diagnosis, treat- ment, and management) and subpopulations (active duty service members, members of the National Guard and Reserves, and military dependents). Additionally, it entailed an investigation of six sets of policies and programs (DoD, Air Force, Army, Navy, Marine Corps, and TRICARE), some dis- crete and some overlapping. This broad charge necessitated a comprehensive approach. The com- mittee engaged in three types of information gathering. First, the committee held four public information gathering meetings that featured presentations by representatives from each of the military branches and TRICARE, as well as academic researchers. Second, the committee conducted five site vis- its to military bases. During these visits, the committee met with a variety of care providers, including SUD-specific providers as well as those in primary care, behavioral health, and pain management clinics. Third, the commit- tee submitted to each of the military branches and TRICARE Management Activity formal requests for information and numerical data on program reach, service access and utilization, and evaluation results, along with data on the numbers and types of SUD care providers. The committee compared all of the information thus collected with the best practices and modern standards of care in the scientific literature to assess the adequacy and appropriateness of policies and programs, access to care, and workforce standards. The committee then formulated a set of conclusions and recommendations for improvement in each of these areas, with the aim of helping DoD provide the highest-quality SUD care to mili- tary service members and their dependents. SETTING THE STAGE The military has a long history of use and abuse of alcohol and other drugs, often exacerbated by deployment and combat exposure. To address these issues, DoD and the individual branches developed a series of policy directives starting in the early 1970s, largely as an outgrowth of concern about substance use during the Vietnam era. Substance abuse has well- known negative health consequences and detrimental effects on military readiness, levels of performance, and discipline. Thus, current DoD policy strongly discourages alcohol abuse (i.e., binge or heavy drinking), illicit drug use, and tobacco use by members of the military. Despite these offi- cial policies, however, substance use and abuse remain a concern for the military. Many of the medical conditions that prevail in a heavily deployed force have led to frequent prescriptions for controlled substances, increas-

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SUMMARY 3 ing the risk for addiction or misuse. Further, the military’s reliance on drug testing limits the identification of misuse to those drugs within the laboratory panel, and does not fully address evolving patterns of drug and alcohol use. Standards of care and best practices in the prevention, diagnosis, treat- ment, and management of SUDs have changed considerably over the course of the past decade to reflect developments in the evidence base. Health care reform and federal parity legislation have enhanced access to health insur- ance and mandated that commercial health plans provide similar coverage for general health, mental health, and alcohol and other drug use disorders. Advocates and policy makers also have called for increased integration of addiction treatment and primary care. Greater integration of prevention and treatment services with primary care could reduce the stigma of alco- hol and other drug use disorders and encourage individuals to seek care. The continuum of care for substance misuse in the Military Health System (from prevention through intervention and aftercare) has not been modified to accord with current understanding of factors that motivate individuals to seek help, settings in which care or interventions can be delivered most effectively, training/skills required by key staff, and medications that have proven useful in achieving or maintaining abstinence. These developments set the stage for a comprehensive review and critique of existing SUD poli- cies and programs within DoD and of standards for access to care and SUD care providers. FINDINGS The committee’s research yielded the findings summarized below regarding the military’s policies and programs pertaining to SUDs, access to care for substance misuse and abuse, and the workforce of SUD care providers. SUD Policies and Programs in the Military In assessing the SUD policies and programs in place in DoD and each of the branches, the committee arrived at the following findings. First, while DoD and branch policies emphasize screening as a key strategy in combat- ing SUDs, these policies fall short with respect to identifying all service members who have or are at risk of developing these disorders because of a failure to screen for all substances of interest, as well as a lack of confi- dentiality protections. The committee’s review made clear that drug testing also is considered an integral component of DoD’s prevention strategy. The committee found very different attitudes toward alcohol and other drugs. These differences are reflected in the screening and drug testing policies, in

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4 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES norms and culture, and in disciplinary actions and repercussions follow- ing alcohol-related incidents versus positive urinalyses indicating drug use. The committee’s research further revealed wide variability in SUD- related policies, programs, processes, and instruments across the branches, resulting from the lack of standardization mechanisms in place at the DoD level. The existence of distinct programs in each of the military branches creates the potential for unnecessary duplication and variation from best practices. Further, branch-specific policies that divide program responsibil- ity among the military human resources, legal, installation management, and medical domains create challenges for delivering SUD services. In addition, neither DoD nor the individual branches evaluate their respective programs or initiatives consistently or systematically. While support for and promotion of evidence-based practices are per- vasive in the language of DoD and branch policies and programs, the specifics of which evidence-based practices and programs are utilized and the extent to which they are adopted and implemented are highly variable both across and within the branches. The committee found that current DoD and branch policies and efforts could have much greater efficacy if they were better informed by scientific evidence on the nature of alcohol and other drug use behaviors and made better use of efficacious prevention approaches and modern treatments for the full range of SUDs. While the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) represents an excellent guide for screening, diagnosis, and treatment, the committee found the guideline is not being implemented in a systematic way in DoD settings. Finally, the committee observed a lack of integration of SUD care with other behavioral health and medical care within the Army and Marine Corps, notably following the Army’s shifting of its substance abuse reha- bilitation program from its Medical Command to its Personnel Command. Access to Care The second major focus of the committee’s review was on access to care for SUDs for military members and their dependents. The committee’s framework for assessing access is based on its view that alcohol and other drug use behaviors exist on a continuum, and that certain patterns of alco- hol and other drug use place some individuals at high risk of developing medical and social problems and possibly abuse or dependence. Addressing access to brief intervention and treatment for alcohol and other drug use is a complex undertaking. Access includes both the availabil- ity of services and the use of appropriate modalities and types of services at the appropriate times. Contemporary substance use treatment systems include frequent screening, brief counseling, brief interventions in primary

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SUMMARY 5 care settings, a focus on client-centered motivational interviewing, multiple entry points to treatment, pharmacotherapies that reduce cravings and maintain functioning, outpatient counseling, intensive outpatient programs, residential treatment when needed, and continuous contact with counseling professionals after an intense period of treatment. Modalities of care utilize evidence-based environmental, psychosocial, and medication interventions. The standard of practice in modern SUD treatment no longer relies on inpatient hospital services except for the most medically complex patients. Continuity and duration of ambulatory services are more important than the provision of care in residential settings (IOM, 2006). Available data on the number of military personnel and family mem- bers accessing treatment suggest there is unmet need for services in com- parison with epidemiological estimates: the committee’s review in this area indicated that while services are available through military treatment facilities for active duty service members, the number of patients treated is below epidemiological expectations. Barriers to care apparently inhibit use of these services. These barriers include the structure and location of the services, a reliance on residential care, and stigma that inhibits help- seeking behavior early on. Access is even more problematic in TRICARE’s purchased care system, which is utilized by active duty service members and their dependents. The restriction of services to certified Substance Use Disorder Rehabilitation Facilities leads to an expensive reliance on geo- graphically distant hospital-based treatment services, a lack of access to community-based outpatient and intensive outpatient services, and poor transition between inpatient and outpatient services. The committee found that many policies (e.g., drug testing and Com- mand involvement in treatment planning) may actually inhibit rather than enhance (as intended) access to early SUD treatment and discourage screen- ing and brief intervention in medical settings for alcohol use disorders. For instance, military cultural norms and Command notification requirements, as well as circumstances that diminish confidentiality or attach disciplin- ary consequences, limit care-seeking behavior. Access to prevention and treatment services that incorporate the latest scientific evidence and are used predominantly in the commercial sector (pharmacotherapy, individual therapy, intensive outpatient programs, and care in individual practitioners’ offices as well as outpatient clinics) is limited in the military by an outdated benefit structure, benefit limits, and other policy restrictions. TRICARE regulations that emphasize residential treatment in Substance Use Disorder Rehabilitation Facilities rather than office-based interventions (including integration of SUD treatment into primary care) impact access, especially for family members. Finally, the committee found that members of the National Guard and Reserves, in particular, have limited access to SUD care within the Military Health System when not on active duty.

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6 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The SUD Workforce The third and final component of the committee’s charge involved the training/credentialing and staffing requirements for SUD care providers in DoD. The increased prevalence of comorbid behavioral health diagnoses necessitates access to providers with advanced levels of training rather than certified counselors or peer support by individuals in recovery. The results of the committee’s review on this topic revealed, first, that credentialing and training vary considerably across the different branches. Second, the committee found that the training manuals for counselors in the Air Force and Navy are dated, do not address the use of evidence-based pharmaco- logical and behavioral therapies, and do not reference the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009). Third, physicians who have received SUD-related training in addiction medicine or psychiatry are a rarity in any of the branches. Fourth, the committee observed that the Psychological Health Risk Adjusted Model for Staffing (PHRAMS) includes many of the variables required to calculate the optimal quantitative relationship between need and staffing levels. The databases used for the PHRAMS analysis, however, do not include most encounters for SUD treatment and therefore underestimate staffing needs for SUD care. Finally, the committee identified shortages of SUD counselors across all branches of the military. RECOMMENDATIONS The committee recognizes the challenge of managing one of the nation’s largest health systems, but notes that the different branches tend to oper- ate their SUD services with minimal direction from and accountability to DoD. Consequently, DoD needs to (1) acknowledge that the current levels of substance use and misuse among military personnel and their dependents constitute a public health crisis; (2) require consistent implementation of prevention, screening, and treatment services; and (3) assume the leader- ship necessary to achieve this goal. Accordingly, the committee offers the following recommendations for DoD, the service branches, and TRICARE, based on the findings summarized above. Emphasis on Efforts to Prevent SUDs Previous IOM reports have differentiated among three levels of prevention: universal, selective, and indicated. Successful universal, p ­ opulation-based environmental prevention strategies that DoD and the service branches should adopt include consistent enforcement of regulations on underage drinking, a reduced number of alcohol outlets, and limited

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SUMMARY 7 hours of operation of such outlets. Also within this category, DoD and the individual branches should proactively prevent the misuse and abuse of pre- scription medications by inhibiting access to controlled medications. In the arenas of selective and indicated prevention, the committee advises routine screening and brief intervention in medical settings. Integration of SUD care into primary care may reduce the stigma associated with seeking such care, as well as expand eligibility for such care. The military branches should also coordinate the sharing and implementation of evidence-based programs and models of standardized annual training for program implementers and their supervisors. Finally, the committee advises annual evaluation of prevention programs and encourages DoD to sponsor a study on the cost-effectiveness of the current urinalysis programs in particular. Collectively, these elements make up the committee’s first recommendation: Recommendation 1: DoD and the individual branches should imple- ment a comprehensive set of evidence-based prevention programs and policies that include universal, selective, and indicated interventions. Evidence-Based and Best Practices for SUD Care The use of evidence-based practices in SUD care is integral to ensur- ing that individuals receive effective, high-quality care. While DoD and the individual branches advocate for the adoption and implementation of evidence-based practices throughout their policies and program literature, there is scant detail on the specific practices to be used; consequently, adoption and implementation are highly variable both across and within branches. The lack of standardization, monitoring, and evaluation of SUD policies and programs by DoD and the individual branches contributes to a variety of strategic and quality control problems. Consequently, the com- mittee makes the following recommendation: Recommendation 2: DoD should assume leadership in ensuring the consistency and quality of SUD services. DoD also should require improved data collection on substance use and misuse, as well as the operation of SUD services. While DoD and the branches have policies that emphasize screen- ing as a key strategy for combating SUDs in the military, their screening policies and programs fall short of identifying all service members who have or are at risk of developing these disorders. Additionally, these poli- cies reflect very different (and somewhat disconcerting) attitudes toward alcohol and other drugs. Accordingly, the committee makes the following recommendation:

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8 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Recommendation 3: DoD should conduct routine screening for unhealthy alcohol use, together with brief alcohol education interventions. The VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) describes procedures for screening, assessment, and management of SUDs in specialty SUD care and in general health care settings, and provides guidance on the use of evidence-based pharmacotherapy and psychosocial interventions. The committee under- stands that DoD supports implementation of this guideline, but found little evidence of its implementation within the branches. DoD should move forward to promote evidence-based treatment modalities, such as the use of agonist and antagonist medications without restrictions on duration of care and office-based outpatient therapy for the treatment of addiction. Further, DoD and the individual branches should adopt as a consistent practice reviewing the language and content of their policies to ensure that they reflect changes such as those in the definition of SUDs in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as well as future advances in the field: Recommendation 4: Policies of DoD and the individual branches should promote evidence-based diagnostic and treatment processes. The committee’s research uncovered a lack of integration of SUD care with other behavioral health and medical care, most notably within the Army and the Marine Corps. Integration of care can occur at two levels: (1) integration of care for mental health disorders and SUDs, and (2) integra- tion of drug and alcohol education with primary care. Primary care is the single greatest missed opportunity in the military for early and confidential identification of and brief education on the misuse of alcohol, and provider credentialing restrictions within the Army also limit service provision of treatment for those with comorbid disorders. Therefore, the committee recommends improvements in integration that will ultimately increase the reach and improve the quality of SUD care: Recommendation 5: DoD and the individual branches should better integrate care for SUDs with care for other mental health conditions and ongoing medical care. Finally, the committee observed sufficient access to inpatient beds within the current system, but limited capacity for outpatient and intensive outpatient services. Contemporary systems of care for SUDs rely on out- patient services for continuing disease management. For many individuals, SUDs are relapsing conditions that require ongoing monitoring and periodic

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SUMMARY 9 stabilization. The elements critical to the high rates of recovery in inter- ventions such as physicians’ health programs (for physicians with alcohol and other drug use disorders) appear to be ongoing, continuing care in an outpatient setting, coupled with routine monitoring and clear consequences associated with a return to use. A similar program in military treatment facilities would facilitate retention of trained personnel, noncommissioned leadership, and commissioned leadership while enhancing unit capacity and safety. The individual branches are well positioned to provide these levels of care. Thus the committee makes the following recommendation: Recommendation 6: The Military Health System should reduce its reliance on residential and inpatient care for SUDs in its direct care system and build capacity for outpatient and intensive outpatient SUD treatment using a chronic care model that permits patients to remain connected to counselors and recovery coaches for as long as needed. Increased Access to Care As discussed above, the committee’s review revealed substantial unmet need for SUD care, as well as policies and practices that inhibit access to evidence-based SUD treatment in the DoD direct care system and under the TRICARE purchased care system. As noted, best practices for SUD treat- ment include the use of agonist and antagonist medications and a focus on outpatient rather than residential care. However, the current TRICARE SUD benefit does not permit use of opioid agonist medications for the treatment of addiction and therefore deprives patients access to medications that could help reduce craving and support long-term recovery. Further, the TRICARE SUD benefit does not cover the use of office-based outpatient therapy for SUDs, although such therapy is permitted for other mental dis- orders. These limitations are inconsistent with both current best practices and requirements for parity. TRICARE benefits for mental health and SUDs should conform to the Mental Health Parity and Substance Abuse Equity Act, and quantitative and nonquantitative limits on behavioral health ser- vices should be eliminated. The requirement to use Substance Use Disorder Rehabilitation Facilities should be removed from the TRICARE benefit for the treatment of SUDs, and the benefit should be expanded to include care in outpatient and intensive outpatient treatment settings. Accordingly, the committee makes the following recommendation: Recommendation 7: DoD should update the TRICARE SUD treatment benefit to reflect the practices of contemporary health plans and to be consistent with the range of treatments available under the Patient Protection and Affordable Care Act.

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10 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The committee was impressed by the Army’s implementation of the Confidential Alcohol Treatment and Education Pilot (CATEP). CATEP attracted a broader range of patients (including higher-ranking officers) than is routinely seen in the Army Substance Abuse Program (ASAP). CATEP demonstrated that when given an opportunity for confidential treatment, greater numbers of active duty service members will seek care. Such programs should be expanded to all ASAP sites within the Army, as well as to the other branches. Policies should be updated to facilitate Command support for recovery through these confidential programs. The committee understands the need to balance health and discipline. Access to confidential brief counseling, brief treatment, and more intensive treatment promotes good care, reduces stigma, and builds resilience. Delivery of these services without sanctions would promote an effective response to alcohol and other drug use problems as they emerge and foster a system in which individuals seek help rather than hide problems. To promote increased uti- lization of SUD care, the committee makes the following recommendation: Recommendation 8: DoD should encourage each service branch to provide options for confidential treatment of alcohol use disorders. Over the last 10 years, the military has relied heavily on its reserve com- ponent (National Guard and Reserve) in the ongoing military operations in Iraq and Afghanistan. These individuals are at high risk for developing SUDs and in many cases lack continuity of care for ongoing mental health services once demobilized. In its review, the committee found a lack of access to SUD care for National Guard and Reserve members in particular and several needs pertaining specifically to this subpopulation. These needs include (1) mounting new programs to reach demobilized and discharged reserve component personnel, (2) making provisions for veterans with other than honorable discharges to receive outreach and continued SUD assess- ment and services by designated community-based providers, (3) providing options for the receipt of confidential screening and assessment in alterna- tive venues to the Veterans Health Administration (VHA), (4) developing alternative procedures for reserve component demobilized and discharged veterans with elevated postdeployment health reassessment scores to receive a “warm hand-off” to a VHA or community-based provider with specialty training in serving veterans at risk of SUDs and/or suicide, (5) collabo- rating with the VHA to contract with community providers or existing programs (e.g., Military OneSource) to perform active outreach telephone contacts and facilitated linkage for particularly high-risk or difficult-to- contact reserve component members who are demobilized or discharged, and (6) funding research and evaluation on the most effective technologies and strategies for active engagement of high-risk reserve component mem-

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SUMMARY 11 bers in order to refine future programming. Based on these findings, the committee makes the following recommendation with regard to access to care for reserve component members: Recommendation 9: DoD should establish a joint planning process with the VHA, with highly visible leadership (perhaps recently retired military personnel), to address the SUD needs and issues of access to care of reserve component personnel before and after mobilization. Given that DoD and the individual service branches have the added challenge of providing SUD care to service members and their dependents in remote locations and deployment settings, innovative service delivery methods should be explored. Increasing the use of technology in care for SUDs has the potential to substantially reduce counselor workloads and permit more effective and efficient treatment. DoD has an admirable track record in the implementation and adoption of new technology, and should explore the use of technology for prevention, assessment, treatment, and continuing care for SUDs. With the use of Internet technology, for example, patients can participate remotely in prevention courses, treatment groups, counseling sessions, or continuing care, even when deployed. The commit- tee makes the following recommendation with regard to increasing the use of technology: Recommendation 10: DoD and the individual service branches should evaluate the use of technology in the prevention, screening, diagnosis, treatment, and management of SUDs to improve quality, efficiency, and access. Changing SUD Workforce Requirements Since the 1970s, the SUD patient population has become consider- ably more complex: poly-substance use has become common, the rates and severity of psychiatric and medical comorbidities have increased, and SUD services have increasingly become integrated with behavioral health and primary care services. The committee found high levels of comorbid mental health disorders among active duty service members, reserve com- ponent members, and their dependents who seek care for alcohol and other drug use disorders. Accepted standards of care for the treatment of SUDs and other mental health disorders in the civilian sector rely on multidisci- plinary teams led by licensed independent practitioners. Licensed indepen- dent practitioners complete multidimensional assessments (which include assessments of mental and physical disorders), develop comprehensive treatment plans, and provide integrated SUD and mental health treatment

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12 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES using evidence-based pharmacological and behavioral therapies. With the evolution from residential services to ambulatory treatment systems with continuing care, moreover, a varied workforce is required, and licensed independent practitioners can be integrated into primary care settings as members of medical treatment teams. Such integrated and coordinated care is likely to be more effective and efficient. Furthermore, certified alcohol and drug counselors and individuals in recovery may provide support and continuing care services under the direction of licensed independent practi- tioners, but they do not have sufficient training to provide SUD treatment independently. Individuals in recovery no longer dominate the workforce; counselors with graduate degrees are prevalent, and health care reforms are likely to demand counselors who are licensed independent practitioners. While individuals certified as alcohol and drug counselors remain a key component of the civilian workforce treating SUDs, their role is increasingly limited and in the near future may disappear. Rather than continuing to use a 20th century workforce to treat SUDs, DoD is challenged to structure and staff treatment services for alcohol and drug use disorders for the 21st century. The emerging model of care uses multidisciplinary treatment teams to create a varied workforce with care- fully articulated roles and training. Individuals in recovery provide peer support instead of serving as primary counselors. Certified counselors work under the supervision of licensed independent practitioners. Treatment plans include evidence-based pharmacological and behavioral therapies and long-term continuing care with peer support. To increase caseloads and enhance productivity, services emphasize outpatient and intensive outpa- tient modalities, rely on group therapy, and use computer-assisted cognitive- behavioral training. Findings resulting from the committee’s comparison of DoD’s credentialing and staffing requirements against these standards informed the following recommendation: Recommendation 11: The individual service branches should restruc- ture their SUD counseling workforces, using physicians and other licensed independent practitioners to lead and supervise multidisci- plinary treatment teams providing a full continuum of behavioral and pharmacological therapies to treat SUDs and comorbid mental health disorders. The statement of task for this study included providing guidance on how to calculate appropriate ratios of physicians and licensed practitioners for the population of DoD beneficiaries to provide sufficient services for alcohol and other drug use disorders. Calculating these ratios is an impre- cise process. They vary widely in civilian health plans, reflecting variations in the organization of care, productivity expectations, and the balance of

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SUMMARY 13 group and individual therapy. Systems that rely on residential and inpatient care require more intensive staffing ratios than those that emphasize ambu- latory care. Integration with primary care and behavioral health services requires different ratios than freestanding care. Treatment systems that build automated tools and information technology infrastructure require fewer staff. Population needs and the prevalence of SUDs also affect staffing needs. Finally, continuing care and peer support services require different staffing patterns from those for acute care services. To determine appropriate staffing ratios, the committee reviewed DoD’s PHRAMS, which forecasts psychological health staffing require- ments to meet the estimated annual need for care. The committee sug- gests that the PHRAMS program provides a reasonable starting point for determining the quantitative relationship between need and staffing levels. However, PHRAMS underestimates the need for SUD treatment practitioners because the Military Health System Data Repository (MDR) database used by PHRAMS excludes many SUD encounters and appears to exclude encounters in specialty SUD treatment programs. Despite being careful and logical, PHRAMS estimates are far below the number of exist- ing SUD counselors in DoD. The committee’s findings led to the following recommendation with regard to estimating staffing ratios: Recommendation 12: DoD should incorporate complete data on SUD encounters into the MDR database and recalculate the PHRAMS esti- mates for SUD counselors. REFERENCES IOM (Institute of Medicine). 2006. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Acad- emies Press. VA (Department of Veterans Affairs) and DoD (Department of Defense). 2009. VA/DoD clinical practice guideline for management of substance use disorders. Washington, DC: VA and DoD.

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