6

Policies and Programs on Substance Use Disorders

The committee’s comprehensive review of the policies and programs on substance use disorders (SUDs) of the Department of Defense (DoD) and the branches built on DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces (Comprehensive Plan) (DoD, 2011b). The committee’s review responded to two requirements in its statement of task:

  • an assessment of the adequacy and appropriateness of protocols used by the Military Health System relevant to the prevention, diagnosis, treatment, and management of SUDs in members of the armed forces; and
  • an assessment of the adequacy of the prevention, diagnosis, treatment, and management of SUDs for dependents of members of the armed forces, whether such dependents suffer from their own SUD or because of the SUD of a member of the armed forces.

This chapter summarizes and assesses the policies relating to SUDs of DoD and each of the branches and comments on their adequacy and appropriateness. Box 6-1 lists the SUD policies reviewed. Note that while DoD-level policies apply to each of the individual branches, branch-level policies apply only within that branch. The chapter also highlights strengths and identifies areas for improvement within selected SUD prevention, screening, diagnosis, and treatment programs of DoD and the branches (see Appendix D for detail on these programs). The chapter concludes with a discussion



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6 Policies and Programs on Substance Use Disorders T he committee’s comprehensive review of the policies and programs on substance use disorders (SUDs) of the Department of Defense (DoD) and the branches built on DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces (Compre- hensive Plan) (DoD, 2011b). The committee’s review responded to two requirements in its statement of task: • an assessment of the adequacy and appropriateness of protocols used by the Military Health System relevant to the prevention, diagnosis, treatment, and management of SUDs in members of the armed forces; and • an assessment of the adequacy of the prevention, diagnosis, treat- ment, and management of SUDs for dependents of members of the armed forces, whether such dependents suffer from their own SUD or because of the SUD of a member of the armed forces. This chapter summarizes and assesses the policies relating to SUDs of DoD and each of the branches and comments on their adequacy and appro- priateness. Box 6-1 lists the SUD policies reviewed. Note that while DoD- level policies apply to each of the individual branches, branch-level policies apply only within that branch. The chapter also highlights strengths and identifies areas for improvement within selected SUD prevention, screening, diagnosis, and treatment programs of DoD and the branches (see Appendix D for detail on these programs). The chapter concludes with a discussion 137

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138 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES BOX 6-1 Policies and Directives Related to Substance Use Disorders Department of Defense (DoD) DODD 1010.1 Military Personnel Drug Abuse Testing Program DODD 1010.4 Drug and Alcohol Abuse by DoD Personnel DODI 1010.6 Rehabilitation and Referral Services for Alcohol and Drug Abusers DODD 1010.9 DoD Civilian Employee Drug Abuse Testing Program DODI 6490.03 Deployment Health DODI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members Department of VA/DoD Clinical Practice Guideline: Man- Veterans Affairs (VA)/ agement of Substance Use Disorders DoD (2009) Air Force AFI 44-121 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program AFI 44-172 Medical Operations: Mental Health Army AR 600-85 The Army Substance Abuse Program ALARACT 062/2011 Changes to Length of Authorized Duration of Controlled Substances Prescriptions in MEDCOM Regulation 40-51 Navy OPNAV 5350.4D Navy Alcohol and Drug Abuse Prevention and Control SECNAVINST 5300.28E Military Substance Abuse Prevention and Control BUMEDINST 5350.4 Navy Medicine Alcohol and Drug Prevention Program BUMEDINST 5353.3 Use of Disulfiram (Antabuse) BUMEDINST 5353.4A Standards for Provision of Substance Related Disorder Treatment Services Marine Corps NAVMC 2931 Marine Corps Drug and Alcohol Abuse, P ­ revention, and Treatment Programs MCO 5300.17 Marine Corps Substance Abuse Program

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 139 of the committee’s key findings regarding the programs and policies that address prevention, screening, diagnosis, treatment, and management of SUDs within the armed forces. Other findings on access to and utilization of programs and the TRICARE benefit used to provide SUD coverage for military dependents and on the adequacy of the workforce are presented in Chapters 7 and 8, respectively. The review of programs and policies in this chapter and Appendix D, along with the findings presented in Chapters 7 and 8, serves as a foundation for the conclusions and recommendations presented in Chapter 9. DEPARTMENT OF DEFENSE This section reviews the policies outlined in DoD’s Comprehensive Plan, and others the committee identified, pertaining to SUD prevention, screening, diagnosis, and treatment at the DoD-wide level. Prevention The committee made use of the best-practice elements for SUD preven- tion discussed in Chapter 5 to assess the adequacy and appropriateness of DoD and branch SUD policies and programs. In summary, evidence-based SUD prevention (1) addresses the appropriate risk and protective factors for the population in question, (2) employs approaches with demonstrated effectiveness, (3) takes place at the appropriate time chronologically and developmentally, (4) makes use of proper settings and domains for delivery, and (5) manages programs effectively (Office of National Drug Control Policy, 2001). Two DoD policies—DODD 1010.1 and DODD 1010.4 (DoD, 1994, 1997)—articulate DoD’s interest in preventing and eliminating alcohol and other drug abuse and dependence in service members and employees because the disorders are incompatible with readiness. As a result, DoD seeks to “deter and identify drug and alcohol abuse and dependence,” and will not take into service military personnel or hire civilians who present with these disorders (DoD, 1997). The policies call for the provision of edu- cation to ensure that personnel understand the implications of not adhering to DoD alcohol and other drug use policies. DODD 1010.1 guides the Military and Civilian Drug Testing Program and requires urinalysis screening to detect illicit drug use among active duty service members. Urinalysis screening deters drug use because of the consequences of positive results. However, use of random urinalysis to deter drug use has limitations, as use of substances not included in the testing panel or not included on a routine basis may not be detected. In addition, if the screening is not performed randomly or is anticipated, individuals

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140 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES can avoid use of substances prior to being screened. DODD 1010.1 and DODD 1010.4 provide little or no guidance for other prevention strate- gies (e.g., large-scale efforts to educate individuals on the risks and health consequences of alcohol and other drug use, indicated prevention programs for those identified as at risk, prevention efforts aimed at military fami- lies, environmental prevention strategies). The policies do not appear to provide a clear strategy for preventing risky alcohol use and the potential development of alcohol use disorders. While some branches have policies that address these additional prevention strategies, they are not covered by overarching DoD policies. The detailed review and assessment of DoD-wide prevention programs in Appendix D reveals that aside from drug testing, DoD relies heavily on campaign-style prevention programs (e.g., That Guy, the national Red Rib- bon campaign). The National Institute on Drug Abuse (NIDA) has spon- sored research on media campaigns to prevent drug use in youth and found that theory-based and evidence-based media campaigns can be effective in this population (Crano and Burgoon, 2002), but the effectiveness of cam- paign activities within the military is unknown. Moreover, campaign imple- mentation varies across branches and bases, and participation requirements are unspecified. Overall, DoD delegates to the individual branches authority for implementing prevention for service members and their families, and the committee observed inconsistent implementation among the branches. Monitoring for Prescription Drug Abuse According to the ONDCP, the abuse of controlled prescription drugs such as pain relievers, central nervous system depressants, and stimulants is the nation’s fastest-growing drug problem. Although such prescription drugs have legitimate medical uses, they also pose the potential for abuse and addiction and may be diverted for nonmedical, illicit use. While it was outside the scope of the committee’s charge to study all the DoD and branch policies and programs related to the prescribing of controlled substances, the committee believes that the rising rates of prescription drug abuse in the military (as reviewed in Chapter 2) make it necessary to understand the DoD and branch policies and practices aimed at preventing the abuse of controlled substances prescribed to service members. In both the civilian sector and the military, there are far-ranging pro- grams and guidelines designed to ameliorate prescription drug abuse. These include diversion control activities of the Drug Enforcement Administration of the U.S. Department of Justice (GAO, 2011); education programs for primary care physicians and other specialists who prescribe these powerful medications; and additional guidelines for physicians to follow (Chou et al., 2009) when prescribing these medications that recommend a thorough

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 141 patient history to assess the risk of prescribing controlled substances to the patient (i.e., to identify any current or prior alcohol or other drug misuse), as well as frequent patient contact, monitoring, and urine screening when prescribing to high-risk patients. While the committee was concerned with the abuse of prescription pain medications among members of the armed forces, the problem is also increasing in civilian populations (Compton and Volkow, 2006). Although its review was limited, the committee learned through tes- timony, an examination of the literature, and site visits about several resources intended to encourage responsible prescribing within DoD. The committee heard testimony from pain management specialists who identi- fied far-reaching changes being planned to revolutionize pain management in the military.1 These changes include state-of-the-art interventions in theater and on the battlefield so that the wounded warrior is not started on high continuous doses of morphine, as well as expansion of multidisci- plinary pain clinics that rely on physical therapy, strengthening, exercise, yoga, and cognitive-behavioral techniques to help the wounded cope with chronic pain and recondition the body rather than dull the pain with medications. The committee learned about the following resources aimed specifically at creating a military medical practice environment that reduces the risk of prescription drug abuse and diversion: • a Department of Veterans Affairs (VA) and DoD clinical practice guideline for opioid therapy; • recent development of pain management specialty services; • the Army pain management task force; • new policy guidance and policy changes on prescriptions for certain substances; • expansion of the random urinalysis drug testing program to include additional prescribed medications; and • special initiatives and reporting programs of DoD’s Pharmaco­ economic Center (PEC). With regard to clinical practice guidelines, the committee learned that, to address pain management practices, the VA and DoD have jointly pub- lished the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (VA and DoD, 2010). The committee found this guideline to be in line with other accepted guidelines (Chou et al., 2009) and comprehensive in its approach to managing pain and addressing aber- rant behaviors of abuse and diversion. The extent of implementation of this 1 Personal communication, Lt. Col. Kevin Galloway, Army Pain Management Task Force and Col. Chester Buckenmaier, M.D., Walter Reed Army Medical Center, July 19, 2011.

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142 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES relatively new guideline at the provider level is unknown, and likely varies across installations and clinic settings. During its site visits, the committee observed the recent development of pain management specialty services at some military treatment facilities but also learned that only a handful of pain specialists (frequently anes- thesiologists) are currently serving in the armed forces.2 The integration of these services with substance abuse programs, as was observed at Fort Belvoir’s newly opened residential treatment center for substance abuse, demonstrates that the Army is beginning to address the issue of prescrib- ing practices that contribute to the development of physical dependence and tolerance to pain medication, raising the risk of abuse. Because of the limited number of pain specialists, however, specialty pain clinics and pain management services are not available at all locations. To help improve the quality of treatment for wounded warriors with chronic pain and simultaneously address concerns about prescription drug abuse and other problems arising from overreliance or sole reliance on pre- scription pain medications, the Army pain management task force was cre- ated to review current practices and policies and develop recommendations. The task force’s final report, published in May 2010, articulates a strategy for controlling and preventing opiate abuse that is science-based (U.S. Army, 2010). The committee found that one focus and four objectives laid out in the task force report are relevant to the prevention of opiate abuse. The one focus is for the armed forces to implement a drug abuse assess- ment strategy to ensure the efficacy of its pain treatment program, which in turn will reduce aberrant behavior, abuse, and addiction to overprescribed opioids. The four objectives include developing a patient-centric approach to injury recovery and rehabilitation, satisfaction, and pain control, with greater attention to controlling opioids and minimizing abuse. The Army is also developing an electronic pain order set for managing patients and miti- gating the risk of prescription drug abuse and dependence in pain patients, focusing on controlled substances for chronic pain. Finally, the Army will identify substance abuse patients in Warrior Transition Units by embed- ding the necessary resources to develop and implement a coordinated care and monitoring plan. In the committee’s view, these recommendations will encourage practice and research advances in pain management and have the potential to prevent the misuse and abuse of prescription pain medications. Additional actions by the Army and DoD are aimed at tackling pre- scription drug abuse in the military. These actions include a recent change in policy to set limits on the length of prescriptions and the quantity dispensed for controlled substances (U.S. Army, 2011a), which has the potential to 2 Personal communication, Ben Krepps, M.D., Director of the Pain Clinic at Fort Belvoir Community Hospital, November 15, 2011.

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 143 decrease ready access to some of the most commonly abused medications. The Army recently published policy guidance to caution providers about prescribing certain medications for the treatment of posttraumatic stress disorder (PTSD), specifically citing the lack of evidence for effectiveness of benzodiazepines and the risk for abuse of these substances (U.S. Army, 2012). In May 2012, DoD also implemented new practices for its urinalysis drug testing programs to screen for some of the most commonly abused prescription medications (e.g., hydrocodone, benzodiazepines). The new limits on the length of prescriptions for controlled medications, coupled with urinalysis for some of these substances, demonstrate that DoD, and particularly the Army, are undertaking new tactics to deter prescription drug misuse and abuse. However, it remains to be seen whether these new measures will affect the prevalence of prescription drug abuse in the military. To monitor the use of prescription drugs, PEC has developed tools for use by installations and clinicians in identifying aberrant use and prescrip- tion patterns that increase the risk or are indicative of an SUD or diversion activity. The tools permit close monitoring when controlled substances are being prescribed for individuals with known SUDs and can also help identify high-risk behaviors of individuals with no known SUD who may need to be assessed for patterns that may lead to an SUD. PEC aims to “improve the clinical, economic and humanistic outcomes of drug therapy in support of the readiness and managed healthcare mission of the Military Health System” (DoD, 2012, p. 1). It conducts research and operates pro- grams to monitor the prescription drug use behavior of persons identified by medical providers as exhibiting drug-seeking behavior or having a high risk of harming themselves through their drug use. Among the programs PEC operates are (1) the Prescription Restriction Program, (2) the Military Treatment Facility Lock-in Edit, (3) the Deployment Prescription Medica- tion Analysis Reporting Tool (PMART), (4) the Warrior Transition Unit (WTU)-MART, and (5) the Controlled Drug Management Analysis and Reporting Tool (CD-MART). The committee finds that PEC’s activities are comprehensive. In addi- tion to the aforementioned deployment and controlled medication monitor- ing and reporting tools, PEC provides a full program of DoD prescription management support services, including pharmacoeconomic analysis and support for and/or collaboration with the DoD Pharmacy & Therapeutics Committee, the Pharmacy Operations Center, and the VA/DoD Clinical Practice Guidelines workgroup. The reporting tools made available to clinicians and pharmacies through Deployment PMART, WTU-MART, and CD-MART appear to be as comprehensive and detailed as those of any state prescription monitoring program, and in fact are quite complete in that they contain all mail order

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144 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES and retail pharmacy claims and prescriptions dispensed through the VA to service members. A recent report by the Defense Health Board (2011), however, found limitations to the PEC data systems. Specifically, the sys- tems do not include in-theater pharmacy data in settings where there are no electronic medical records. Nor are they equipped to assess illicit activity on the part of service members who obtain prescriptions from civilian provid- ers and pay out of pocket to obtain the medications from retail pharmacies. The Prescription Restriction program gives military medical providers the ability to restrict patients to a specific pharmacy(ies) and/or provider(s) and restrict the dispensing of controlled medications from mail order and retail pharmacies. Currently the system is unable to restrict controlled medi- cations to a specific provider and pharmacy simultaneously. Addressing this limitation might encourage more medical providers to adopt restrictions on controlled substances for more service members. As is the case with all prescription reporting tools, the key to effectiveness is adoption and use by medical providers. Screening, Diagnosis, and Treatment Urinalysis screening is the primary DoD strategy for identification of drug use; alcohol-related incidents are a primary source of referral for alcohol misuse screening at substance abuse clinics; and deployment health assessments (reviewed in Appendix D) are used to identify alcohol misuse in deployed service members who self-report such misuse. Beyond random urinalysis screening programs, Command may order a urinalysis screen or a breath test when performance suggests drug or alcohol use. Individual branch policies detail responsibilities for conducting and supervising ran- dom and Command screening, as well as the consequences of positive screens. DoD policies do not appear to recognize or address the limita- tions of urinalysis screening in identifying the extent of drug use, and fail to acknowledge that the screening identifies only the drugs tested for and miss drug use when a screen is not used or is unavailable. Several other screening programs and efforts, including the deployment health assessments, Military Pathways, and Military OneSource, are reviewed in Appendix D. The Comprehensive Plan (DoD, 2011b) identifies four policies with ele- ments pertinent to SUD diagnosis: DODD 1010.1, DODD 1010.4, DODI 1010.6, and DODI 6490.03 (DoD, 1985, 1994, 1997, 2011b). DODD 1010.4 uses the American Psychiatric Association’s (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM- IV-TR) to define alcohol dependence, alcoholism, and drug dependence. This policy appropriately classifies drug and alcohol dependence as chronic psychi- atric conditions that affect both individuals and families and recognizes the

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 145 need for periodic assessments of alcohol and other drug use. The practice of making SUD diagnoses, however, varies from branch to branch. DODI 6490.08 (DoD, 2011a) clarifies DoD policy regarding the responsibility of health care providers to notify Command of potential SUDs. It is intended “to foster a culture of support in the provision of mental health care and voluntarily sought substance abuse education to military personnel in order to dispel the stigma of seeking mental health care and/or substance misuse education services” (DoD, 2011a, p. 2). The instruction directs health care providers to “follow a presumption that they are not to notify a Service member’s commander when the Service member obtains mental health care or substance abuse education services” (p. 2). This policy update could support implementation of routine screening and brief interventions in health care settings and substantially enhance the capacity of DoD and the armed forces for early intervention prior to the development of severe and disabling SUDs. To provide an additional screening resource, the Military Pathways program, sponsored by DoD, was designed to encourage help seeking and reduce stigma for mental health disorders (including depression, PTSD, and alcohol abuse) for military populations. The Web-based program, devel- oped by the nonprofit organization Screening for Mental Health, utilizes a “video doctor” that is meant to simulate a doctor-patient conversation and provide screening, brief advice, and referral to appropriate resources if indicated (Screening for Mental Health, 2012). Participation in the screen- ing is anonymous and accessible to anyone (including reserve component members and dependents) through the Military Pathways website. While an evaluation of this program’s effectiveness has not been published, the con- cept for the program is based on research that has documented the benefit of video doctor screening and brief counseling services (Humphreys et al., 2011; Jackson et al., 2011; Tsoh et al., 2010). This screening program is an example of DoD’s utilizing new technology to help address the mental health needs of service members and their families. See Appendix D for further review of Military Pathways. DoD policies DODI 1010.6 and DODD 1010.4 and the VA/DoD Clini- cal Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) address treatment for SUDs. These policies encompass the components of health care delivery systems: patient-provider relation- ships, delivery of care, organizational functioning, and health care policy and regulation (Berwick, 2002) (see Chapter 5 for detail). Most policies are applicable to all active duty military personnel. Branch policies cover the governance structure for the delivery of SUD treatment; the philosophy and principles of treatment (e.g., SUD is often a chronic and relapsing disorder); and the training, certification, credentialing, and accreditation requirements for providers of care and facilities.

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146 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES DODI 1010.6 addresses organizational and regulatory requirements. It outlines a governance structure with representation from the Air Force, Army, Navy, and Marine Corps and, by invitation, the VA. Constituting this governance structure is the DoD Joint-Service and VA Oversight Com- mittee, which is responsible for coordinating policies and resources among the DoD branches and making recommendations on treatment and policy issues of joint interest. The Office of the Assistant Secretary of Defense for Health Affairs chairs this committee. DODI 1010.6 states that SUD staff members should be under the direct supervision of personnel qualified to evaluate their performance. However, the policy is vague with respect to how provider performance is to be rated or measured. The policy lan- guage implies that supervisors assess performance qualitatively; it does not describe quantitative measures of clinical effectiveness (e.g., Brief Addiction Monitor [BAM] score change or effect size, treatment adherence rates). DoD appears to be moving toward an “umbrella structure” to connect the branches and the VA (i.e., a high-level set of policies establishing the basic governance structure, SUD treatment philosophy, and best treatment practices). This coordinated approach produced policies for DoD and VA sharing of resources under Public Law 96-22 (which created centers for PTSD counseling for Vietnam Veterans) and facilitates the standardization of basic quality structural requirements (e.g., each program must have a standard operating procedure). Current governance policies, however, allow variation among the branches in key areas (e.g., SUD program evaluations and policies related to the commander’s role in treatment decisions). This “umbrella structure” could be instrumental in driving coordination and enhanced consistency across all DoD components, including consistent implementation of measures of system/program effectiveness, performance, and efficiency. Coordination creates the opportunity to build comparabil- ity in processes and measurement across DoD and VA SUD services. Better management and analysis may support more rapid system improvements and increased efficiencies. The VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) (see Chapter 4) provides guiding prin- ciples; it does not prevent providers from using clinical judgment. Updating of the guideline is stated as a goal; however, no timeline is given for any updating activity. Work on developing and implementing the guideline is intended to inform areas for future research and the optimal allocation of VA/DoD resources. Systematic measurement of treatment outcomes, provider capabilities, program implementation, and system performance supports continuous improvement, care responsive to patient needs, and enhanced effectiveness. DoD and VA policies and the Clinical Practice Guideline include recommendations for clinical measurement using vali- dated tools for assessment and measurement of treatment progress: the

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 147 Alcohol Use Disorders Identification Test (AUDIT)-C for assessment and the VA’s BAM for tracking treatment progress. The VA/DoD Clinical Practice Guideline, DoD policies (DODD 1010.9, DODI 1010.6), and branch policies generally are aligned with the best- practice principles discussed in Chapter 5 regarding detailed decision sup- port algorithms incorporating evidence-based practices for assessments, psychotherapies, pharmacotherapies, withdrawal management, medical set- ting management, and management by specialty. The level of detail guides treatment choices and practices in key areas (e.g., use of validated tools for assessment and tracking of treatment response [see Chapter 5]). Individual branch policies, however, typically are silent on the use of the VA/DoD Clinical Practice Guideline. Staff training requirements are addressed in the umbrella DoD policy (DODI 1010.6) (DoD, 1985), with additional detail being provided in Army, Navy, Marine Corps, and Air Force policies. Best training practices that promote fidelity (see Chapter 5) consist of manual- ized training and demonstration of knowledge and/or competency with the use of a standard written examination, as well as supervision by trained instructors in clinical settings. See Chapter 8 for more detail on SUD staff training and credentialing within DoD programs. Despite general alignment with best practices, the committee noted omissions and deviations. DODD 1010.9, for example, allows branches and programs to use idiosyncratic evaluations and metrics. Quality im­­ provement initiatives usually rely on standardized measures of process and outcomes. The Comprehensive Plan came to similar findings that poli- cies do not address standardization of data and outcome measures (DoD, 2011b). The lack of standardized outcome measures and benchmarks or a system that promotes the development of measures will undoubtedly lead to difficulties in evaluating program effectiveness and impact. Having a set of basic metrics that reflect the overarching goals of SUD treatment (e.g., sobriety, stabilization, and functionality) would be a good starting point. Some branches of the military (e.g., the Marine Corps) have begun outlin- ing performance measures for SUD programs in their policies. Another area of omission within the policies is the absence of systems for measuring the clinical effectiveness of providers at both the provider population and indi- vidual case levels. As described in Chapter 5, the use of outcome measure- ment to demonstrate clinical effectiveness improves clinical competency and population outcomes. The policies contain references to the use of track- ing tools to monitor the response to treatment, but there is no reference to aggregating these outcomes to measure the effectiveness of individual providers or programs. Finally, although the VA/DoD Clinical Practice Guideline is applicable to all branches of the military, the lack of reference to the guideline in branch-specific policies raises questions about the degree of its adoption. The Comprehensive Plan came to similar findings that

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174 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES assignment incapacitated by alcohol. Third, alcohol misuse or abuse does not appear to carry the same consequences as illicit drug use with respect to military separation. If an individual receives a diagnosis of alcohol abuse or dependence, he/she receives treatment, whereas other drug abuse/depen- dence diagnoses result in initiation of separation proceedings and possible enrollment in treatment, although the policies on this issue vary (e.g., the Air Force policy is the strictest, whereas Army policy requires referral to treatment for drug “dependent” individuals but not drug “abusers”). The difference in perceived potential for rehabilitation and treatment between soldiers with alcohol and other drug dependence is not supported by sci- entific evidence. While the committee understands the desire to separate service members who violate laws against illicit drug use, a more systematic and evaluative approach might result in retaining highly skilled service members. Also, it should be noted that when the fifth edition of the DSM is released in May 2013, the distinction between “abuse” and “­ ependence” d will be eliminated, and diagnosis will instead be classified as “mild,” “mod- erate,” or “severe.” Therefore, DoD and branch policies that call for differ- ent personnel and treatment decisions based on diagnoses of “abuse” and “dependence” will need to be revised. Finding 6-4: There is substantial variability among SUD-related policies, programs, procedures, and instruments across the military branches. DoD policy lays out strategies and guidelines for SUD prevention, screening, diagnosis, and treatment, but the actual implementation of these strategies and guidelines varies according to specific branch-level policies. While DoD offers several SUD programs that could be utilized across the branches, it does not require or monitor their adoption by the branches. The RAND (Weinick et al., 2011) analysis of psychological health and TBI programs for U.S. military service members and their families yielded similar observations about the lack of standardization and the variability of implementation across the armed forces. With the exception of the Air Force’s Substance Abuse Prevention Specialist Training and CoRC and the Navy’s Alcohol and Drug Abuse for Managers and Supervisors (ADAMS) and Prevention Specialist programs, the branches do not make use of standardized training processes or protocols for implementers of preven- tion programs or for the leaders who oversee them. Programs for youth (e.g., DEFY) are delivered by contractors, and spouses and other family members receive prevention services through health care service agencies or programs such as Families OverComing Under Stress (FOCUS) (reviewed in Appendix D). Lack of standardization is an issue of concern for screening and diag- nosis as well. As noted in the discussion of Finding 6-2, DoD and branch

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 175 policies acknowledge and emphasize screening as a key strategy in combat- ing SUDs, but do not specify standardized screening procedures or instru- ments. Air Force policy and the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders identify specific instruments to be used in screening (e.g., AUDIT-C). These policies, as well as DODD 1010.4, also recognize that there are standardized criteria for SUD diagnoses in DSM-IV-TR. Aside from these examples, however, policies do not identify specific screening instruments or the health care professions authorized to screen and diagnose (e.g., nurses, physician assistants, licensed counselors, physicians). Standardized psychiatric interviews are not identified for diag- nostic assessments. Current governance policies are high-level and have gaps that allow for variation among the branches in such key areas as SUD program evalua- tions and the influence of Command on treatment plans. Expansion of the “umbrella structure” of governance discussed earlier in this chapter could promote increased coordination of resources and services and enhance con- sistency across the armed forces for measurement of system/program effec- tiveness and performance and efficiency. The Comprehensive Plan (DoD, 2011b) notes that utilization of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders is inconsistent across DoD facili- ties. DoD does not systematically monitor compliance with its policies or with the VA/DoD Clinical Practice Guideline, and the branches do not rou- tinely monitor compliance with policy across installations. Consequently, the sophisticated planning and design that go into the development of SUD prevention and treatment policies can be lost in translation as principles filter through the branches to local installations. Further, the committee would be remiss not to acknowledge that each military branch’s distinctive history and culture undoubtedly play a role in the variation that exists from branch to branch in policy and program design, adoption, and delivery. The additional cultural and contextual differences that exist between the active duty population and members of the National Guard and Reserves further complicate the situation and cannot be ignored in addressing the needs of all service members across all branches of the military. Finding 6-5: DoD and the branches do not evaluate programs and initiatives consistently and systematically. The committee found little evidence of systematic evaluation of cogni- tive, affective, or behavioral change resulting from prevention programs or treatment interventions using single- or multiple-group design evalu- ations. The Comprehensive Plan (DoD, 2011b) and the RAND report (Weinick et al., 2011) also identify program evaluation as an area for improvement.

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176 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Current research projects (see Box 6-3) may yield benchmarks, such as voluntary participation rates and change in risky behaviors related to SUD development and relapse, which could be used for systematic evaluation processes and metrics. These studies are testing the extension of programs BOX 6-3 Military Studies of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse • Use and Abuse of Prescription Opioids among Operation Enduring  Freedom/Operation Iraqi Freedom Veterans University of Arkansas for Medical Sciences at Little Rock • Integrated Treatment of Operation Enduring Freedom/Operation  Iraqi Freedom Veterans with Post Traumatic Stress Disorder and Substance Use Disorders Medical University of South Carolina • First Longitudinal Study of Missed Treatment Opportunities Using  DoD and VA Data Brandeis University • Integrated Cognitive Behavioral Therapy for Co-Occurring Post  Traumatic Stress Disorder and Substance Use Disorders Dartmouth College • Effectiveness of a Web-Enhanced Parenting Program for Military  Families University of Minnesota, Twin Cities National Institute on Alcohol Abuse and Alcoholism • Stress-Induced Drinking in Operation Enduring Freedom/Operation  Iraqi Freedom Veterans: The Role of Combat History and PTSD Medical University of South Carolina • Veteran Reintegration, Mental Health and Substance Use in the  Inner-City  National Development and Research Institutes, Inc., in New York City • Web-Based Cognitive Behavioral Therapy for Substance Misusing  and Post Traumatic Stress Disorder Symptomatic Operation Endur- ing Freedom/Operation Iraqi Freedom Veterans  National Development and Research Institutes, Inc., in New York City and Syracuse University • Personalized Drinking Feedback Interventions for Operation En­­  during Freedom Operation Iraqi Freedom Veterans/University of Missouri–Columbia

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 177 effective with civilian populations to service members and their families. NORTH STAR, for example, uses community-based prevention research from Communities That Care (Hawkins et al., 1992), the Midwestern Pre- vention Project (Riggs et al., 2009), and Steps Toward Effective Prevention (STEP) (Valente et al., 2007). The Comprehensive Soldier Fitness program is based on the Penn resiliency program (Seligman, 1998) for preventing and reducing depression. ADAPT (After Deployment: Adaptive Parent- ing Tools, differentiated from the overall ADAPT program used by the Air Force) is based on the Parent Management Training Model-Oregon (Forgatch and Patterson, 2010; Gewirtz et al., 2011), used with parents whose children are exhibiting behavioral problems. And FOCUS is based on resiliency and coping training for families experiencing stress (Forgatch and Patterson, 2010; Gewirtz et al., 2011). Finding 6-6: DoD and branch policies support the use of evidence- based prevention and treatment but do not identify specific practices. This finding is overarching and applies to both policies and programs for prevention, screening, diagnosis, and treatment. It is also highlighted in both the Comprehensive Plan (DoD, 2011b) and the RAND (Weinick et al., 2011) analysis. Current policies have been ineffective in preventing alcohol abuse and prescription drug misuse. These policies could make better use of scientific evidence on the nature of alcohol and other drug use behaviors and the best prevention and treatment efforts for the full range of SUDs. As stated in Finding 6-3, DoD and branch policies treat alcohol and other drugs very differently. They place differential emphasis on the implementa- tion of screening for alcohol and other drugs (e.g., testing for drugs but not alcohol) and have very different repercussions for alcohol versus other drug use (e.g., zero tolerance policies for other drugs but not alcohol; CATEP is for alcohol only). While several of the prevention programs noted in the Comprehensive Plan (DoD, 2011b) assert a foundation in evidence-based principles, few specify what those principles actually are. Based on the results of this com- mittee’s review, many of the programs appear to meet prevention needs in that they are appropriate to the populations served, are theory based, address multiple risk factors, and have evaluated behavioral outcomes. Examples include Military Pathways (DoD), DEFY (Navy, Air Force), EUDL (Air Force), CoRC (Air Force), FOCUS (selected Navy, Marine, Air Force, and Army installations), and NORTH STAR (multiple Air Force Commands and bases). However, these programs (with the exception of NORTH STAR, EUDL, and FOCUS) adapted materials and concepts from civilian prevention programs and have not been tested with military popu- lations. Further, many of the prevention efforts appear to be focused on

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178 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES campaigns, Internet games, and camps or events (e.g., That Guy, DEFY camp, Real Warrior, Red Ribbon), with no research evidence that they affect substance use. DoD and the various branches are not making strong enough use of evidence-based environmental policies and programs (e.g., reducing availability and/or raising the price of alcohol on bases). The committee’s analysis revealed an underutilization of evidence-based pharmacological therapies, as well as insufficient continuing care. Effective treatment of substance abuse includes both pharmacological and behav- ioral therapies. In the military, the pharmacotherapies for acute medical withdrawal treatment focus on alcohol, sedatives, and opioids. The most effective treatment plans entail withdrawal treatment followed by relapse prevention therapy, which is frequently a combination of both medica- tion and behavioral therapy (Kosten and McQueen, 2008). On the issue of follow-up care, the committee finds the Navy MORE program to be an innovative and promising model for the provision of ongoing recovery support and encourages the other branches to consider adopting similar approaches to improve posttreatment care for active duty service members. Finding 6-7: Integration of SUD care with other behavioral health and medical care is lacking. The Military Health System has clear evidence that the current operat- ing tempo and environment are associated with increased risk of mental health disorders and SUDs and that these disorders often co-occur (U.S. Army, 2012). Separate and distinct services for mental health disorders and SUDs are neither desirable nor feasible. The committee agrees with the need to facilitate access to both types of services and provide integrated care. Integration of care can occur at two levels: (1) integration of care for mental health disorders and SUDs, and (2)  integration of behavioral health care with primary care. Integration of behavioral health services with primary care may be particularly challenging in the military, whose population is often mobile and frequently changing location. The Air Force’s BHOP dem- onstrates the feasibility and advantages of integrating behavioral health into primary care services. Integration of services for SUDs should proceed as well to reduce stigma and enhance the development of medication-assisted treatment for alcohol and other drug use disorders. The committee supports routine screening and brief intervention for alcohol misuse within primary care settings. Screening and brief intervention are evidence-based practices, and when implemented systematically can reduce the risk of alcohol-related problems within communities and populations (Babor et al., 2007). The U.S. Preventive Services Task Force also recommends routine use of screen- ing and brief intervention in primary care settings (O’Connor et al., 2009). DODI 6490.08 clarifies that health care providers can provide substance

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POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS 179 abuse education and should assume that providing educational interven- tions does not require Command notification. Integrated care is likely to be more difficult in the Army and Marine Corps because their programs for treatment of SUDs are located within the human resources organization rather than a Medical Command. Specific strategies will be required to facilitate interaction between Commands and full access to medical records. In the Navy and Air Force, SUD treatment programs are located within the Medical Command, but remain separate and distinct settings of care that often are not fully integrated within general health care settings. Treatment for SUDs in the 21st century will require the elimination of divisions between health care and specialty addiction treatment. Finding 6-8: DoD and branch policies are largely silent on comprehen- sive programs and services for SUD prevention, screening and brief intervention, diagnosis, and treatment for military dependents. While DoD policy permits the provision of SUD services to military dependents, the branches do not have the capacity to extend such services beyond reaching service members. Furthermore, based on best practices, the specialty SUD treatment services operated by the branches for military members are not appropriate for youth and adolescents, who require devel- opmentally appropriate treatment. While some DoD prevention program- ming identifies spouse and child dependents as a target population, most of these initiatives, based on their descriptions, emphasize the ways in which service members are reached and the role of commanders. Some prevention initiatives are selective or indicated, taking place with at-risk individuals or after an incident occurs. The committee found no evaluation literature associated with most of these initiatives, particularly on their reach or effectiveness with military dependents (see also Finding 6-5). Finding 6-9: DoD and the branches rarely use technology to enhance the delivery of screening, diagnosis, and treatment services. The committee found few examples of technology being used to deliver SUD services in new and innovative ways. Given identified counselor short- ages and challenges to staffing SUD clinics with experienced and licensed clinicians (see Chapter 8 for further discussion), as well as concern over the lack of standardized delivery of evidence-based care, DoD might consider the increased use of technology to address some of these issues. The com- mittee identified as promising the following approaches to addressing SUD care with the use of technology. The Navy’s MORE aftercare program represents an innovative use of technology to provide recovery support for sailors deployed internationally

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180 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES and at sea (see Appendix D for further description of this service). MORE illustrates the use of technology to extend the counselor workforce and provide ongoing support to active duty service members when they return to their military assignment. The Navy also is currently pilot testing a new version of the MORE program that is delivered via smartphone technol- ogy. The other branches appear not to be using this type of treatment and aftercare technology. Additional research on the effectiveness of the MORE program with military populations and other innovative models for deliv- ering treatment services by means of telephone, video conferencing, and web-based formats might provide DoD with some alternative methods for extending its counseling workforce. Additionally, the Air Force’s use of the SUAT computerized assessment tool is an example of the utilization of technology to standardize clinical processes and improve efficiency within SUD programs. The committee finds the SUAT tool to be a promising model for DoD to evaluate and consider for dissemination to the other branches. Finally, the committee found value in the approach taken by Military Pathways of using web-based video doctor technology to reach service members and their families who might otherwise not receive screening and referral to services for mental health conditions, including alcohol abuse. A rigorous evaluation of this program and its effectiveness would provide DoD with guidance on whether this is a beneficial use of resources and whether the approach should be considered for other uses. REFERENCES APA (American Psychiatric Association). 2000. Diagnostic and statistical manual of men- tal disorders, fourth edition, text revision (DSM-IV-TR). Washington, DC: American ­Psychiatric Association. Babor, T. F., B. G. McRee, P. A. Kassebaum, P. L. Grimaldi, K. Ahmed, and J. Bray. 2007. Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse 28(3):7-30. Berwick, D. M. 2002. A user’s manual for the IOM’s “quality chasm” report. Health Affairs 21(3):80-90. Chou, R., G. J. Fanciullo, P. G. Fine, J. A. Adler, J. C. Ballantyne, P. Davies, M. I. Donovan, ­ D. A. Fishbain, K. M. Foley, J. Fudin, A. M. Gilson, A. Kelter, A. Mauskop, P. G. O’Connor, S. D. Passik, G. W. Pasternak, R. K. Portenoy, B. A. Rich, R. G. Roberts, K. H. Todd, and C. Miaskowski. 2009. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. Journal of Pain 10(2):113-130. Compton, W. M., and N. D. Volkow. 2006. Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug and Alcohol Dependence 81(2):103-107. Crano, W. D., and M. Burgoon. 2002. Mass media and drug prevention: Classic and contem- porary theories and research. Mahwah, NJ: Lawrence Erlbaum Associates. DCoE (Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury). 2011. DCoE pilot project evaluation report A401: Fort Hood Intensive Outpatient Pro- gram (IOP). Arlington, VA: DCoE.

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