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 practitioners, 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 carefully 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 outpatient 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 restructure their SUD counseling workforces, using physicians and other licensed independent practitioners to lead and supervise multidisciplinary 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 imprecise 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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