1

Introduction

Problems 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 to some extent in recent years. National trends indicate substantial increases in the abuse of prescription medications, specifically pain medications such as opioids. Similar increases have been found within the military, a population that also continues to experience long-standing issues with alcohol abuse (Bray et al., 2009). The problem of substance 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).

To better understand this problem, the Department of Defense (DoD) requested that the Institute of Medicine (IOM) analyze the current policies and programs in place across the different branches of the military pertaining to the prevention, screening and diagnosis, and treatment of substance use disorders (SUDs) for active duty service members, members of the National Guard and Reserves, and military dependents. The IOM committee charged with conducting this study was also tasked with assessing access to SUD care within each of these subpopulations, as well as the education and credentialing of SUD care providers, and with offering specific recommendations to DoD on where and how improvements in these areas could be made.



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1 Introduction 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 to some extent in recent years. National trends indicate substantial increases in the abuse of prescription medica- tions, specifically pain medications such as opioids. Similar increases have been found within the military, a population that also continues to expe- rience long-standing issues with alcohol abuse (Bray et al., 2009). The problem of substance 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 (Opera- tion Enduring Freedom) and Iraq (Operation Iraqi Freedom and Opera- tion New Dawn). To better understand this problem, the Department of Defense (DoD) requested that the Institute of Medicine (IOM) analyze the current poli- cies and programs in place across the different branches of the military pertaining to the prevention, screening and diagnosis, and treatment of substance use disorders (SUDs) for active duty service members, members of the National Guard and Reserves, and military dependents. The IOM committee charged with conducting this study was also tasked with assess- ing access to SUD care within each of these subpopulations, 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. 15

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16 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES BACKGROUND The impetus for this study began when criminal cases involving the illegal sale and distribution of prescription pain medications, coupled with rising rates of prescription drug abuse, reported staffing shortages in Army SUD treatment programs, concerns about access to care, and allegations of misconduct at Fort Leonard Wood, led Missouri Senator Claire McCaskill to question whether these issues were indicative of more systemic problems across the military. The Comprehensive Plan To answer this question, Senator McCaskill’s office sponsored the Sup- port for Substance Use Disorders Act (S. 459) in February 2009, “a bill to improve and enhance substance use disorder programs for members of the Armed Forces, and for other purposes.”1 The bill would have directed DoD to conduct a comprehensive review of its programs and activities for the prevention, diagnosis, mitigation, treatment, and management of, as well as research on, SUDs among members of the armed forces, and based on this review, to develop a plan for improving these programs and activities for service members and their dependents. This plan was to include recommen- dations for SUD prevention, training for health care professionals treating SUDs, SUD services for military dependents, and the dissemination of SUD prevention materials. The bill did not become law, but it did lead to a provi- sion within the National Defense Authorization Act for Fiscal Year 2010.2 Section 596 of the act authorized the Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces (Comprehensive Plan), which mandates an internal program review on these matters by DoD, as well as an external review conducted by an independent organization such as the IOM. (The full text of S. 459 and Section 596 of Public Law 111-84 can be found in Appendixes B and C, respectively.) To develop the Comprehensive Plan, the Assistant Secretary of Defense for Health Affairs formed an expert workgroup to review and assess (1) the availability of and access to SUD care, (2) DoD oversight of SUD programs, (3) credentialing requirements for providers of SUD care, (4) the epidemiology of SUDs, and (5) disciplinary actions and separations for substance abuse. The resulting Comprehensive Plan analyzes policies related to prevention, screening and diagnosis, and treatment of SUDs and 1  S. 459: Support for Substance Use Disorders Act, 111th Cong., 1st sess. (February 24, 2009). 2  National Defense Authorization Act for Fiscal Year 2010, Public Law 111-84 (October 28, 2009).

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INTRODUCTION 17 identifies areas for improvement. The report’s concise summary notes a lack of standardized tools for screening and diagnosis of SUDs in primary care and other health care settings. Policies related to SUDs, moreover, do not specify common outcome and quality measures, and it is difficult to distinguish more from less effective programs and services. Similarly, the report notes that the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) is implemented inconsis- tently because policies and standards do not require the use of evidence- based practices. The report indicates that TRICARE has plans to modify its policies prohibiting reimbursement of individual practitioners for treatment of SUDs; placing yearly and lifetime limits on the use of behavioral health care, including treatment for SUDs; and restricting the use of ongoing maintenance drugs for opioid dependence for family member beneficiaries. The Military Health System also is modifying policies requiring licensed mental health practitioners to practice under the supervision of physicians and prohibiting the use of opioid agonist therapy. The Comprehensive Plan observes that because of “ongoing, overseas military operations, the Ser- vices are facing increasing demand for substance abuse and mental health services” (DoD, 2011, p. 26). Recent Reports and Research Findings Senator McCaskill’s concern about the pervasiveness of the above issues was not off target. During the latter portion of the past decade, vari- ous public health agencies and the popular press documented increases in the prescription of opioid pain medications and subsequent increases in opioid dependence and abuse in both the civilian and military populations. Zoroya (2010) reports that military physicians wrote nearly 3.8 million pre- scriptions for pain medications in 2009, more than quadruple the number written in 2001. While these increases have been seen in both the civilian and military populations, the latter increases must be understood in the context of the two wars in which the United States has been engaged for the past decade. Multiple deployments, for example, have resulted in increases in combat-related injuries, as well as aches and strains incurred by “carry- ing heavy packs, body armor, and weapons over rugged and mountainous terrain” (Zoroya, 2010). While misuse of prescription drugs has been on the rise among both civilians and military personnel and has become a national concern (Bray et al., 2010; DoD, 2009; IOM, 2010; Manchikanti and Singh, 2008; U.S. Army, 2012), Brewin’s Broken Warriors series documents the unique fea- tures of the prescription drug epidemic within the military population, calling prescribing policies and practices into question for this popula- tion (Brewin, 2011). Likewise, recent research has shown that alcohol

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18 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES abuse among military personnel returning from Iraq and Afghanistan has increased substantially since the start of the wars (Bray et al., 2009). Although there have been reductions in the use of tobacco and illicit drugs, the stress of multiple deployments has been linked with increases not only in heavy drinking but also in posttraumatic stress disorder, depression, and suicidal ideation and attempts (Blume et al., 2010; Bray et al., 2010; M ­ arshall et al., 2012). In addition, new substances, such as “Spice” and “bath salts,” are posing new challenges for public health in both the civil- ian and military populations (Horgan et al., 2001; Rosenbaum et al., 2012; SAMHSA, 2011; U.S. Air Force Special Operations Command, 2011). Outdated Policies Another concern among some members of Congress was the outdated policies on SUD care that DoD and many of the branches continued to implement. Many of these policies had been drafted more than 10 years previously and had not been revised to reflect emerging knowledge on evidence-based practices for the prevention, screening and diagnosis, and treatment of SUDs. Table 1-1 displays the SUD policies in place when Sena- tor McCaskill first introduced S. 459. Since Senator McCaskill and other TABLE 1-1  Military Policies Addressing Substance Use Disorders as of February 2009 Policy Number Policy Name Date of Enactment DoD Directive 1010.1 Military Personnel Drug Abuse 9 December 1994a Testing Program DoD Directive 1010.4 Drug and Alcohol Abuse by DoD 3 September 1997a Personnel DoD Instruction 1010.6 Rehabilitation and Referral Services 13 March 1985 for Alcohol and Drug Abusers DoD Directive 1010.9 DoD Civilian Employee Drug Abuse 23 August 1988b Testing Program DoD Instruction 6490.03 Deployment Health 11 August 2006 Army Regulation 600-85 The Army Substance Abuse Program 2 February 2009 AFI44-121 Alcohol and Drug Abuse Prevention 26 September 2001 and Treatment (ADAPT) Program SECNAVINST 5300.28D Military Substance Abuse Prevention 5 December 2005 and Control OPNAVINST 5350.4C Drug and Alcohol Abuse Prevention 15 October 2003 and Control MCO P1700.24B Marine Corps Personal Services 27 December 2001 Manual a Incorporating Change 1, January 11, 1999. b Incorporating Change 1, January 20, 1992.

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INTRODUCTION 19 members of Congress first raised concern about this issue, several of the branches have updated their policies addressing SUDs. Table 1-2 displays the SUD policies in place as of this writing (May 2012). CHARGE TO THE COMMITTEE As required by Public Law 111-84, DoD sponsored this independent review by the IOM. The IOM was awarded the contract through the Department of Health and Human Services’ Contracting Office in October 2010 and commenced its search for committee members in December. The committee’s composition was finalized in April 2011, and its first informa- tion gathering meeting was held in Washington, DC, in March 2011. The committee’s review concluded in June 2012. The committee was charged with addressing the following issues: • Protocols for the prevention, diagnosis, treatment, and manage- ment of SUDs in members of the armed forces—The committee’s report was to provide an assessment of the adequacy and appro- priateness of protocols used by the Military Health System with respect to the prevention, diagnosis, treatment, and management of SUDs in members of the armed forces. • Care for SUDs in military medical treatment facilities and under the TRICARE program—The report was to provide an assessment of the adequacy of the availability of and access to care for SUDs in military medical treatment facilities and under the TRICARE program. It was to address the following areas: the sufficiency of clinical scope (i.e., the range and depth of clinical activities) to meet the needs of the population served by programs and services TABLE 1-2  Military Policies Addressing Substance Use Disorders as of May 2012 Policy Number Policy Name Date of Enactment Army Regulation 600-85 Rapid Action Revision 2 December 2009 Air Force Instruction 44-121 Alcohol and Drug Abuse 11 April 2011 Prevention and Treatment Program SECNAVINST 5300.28E Military Substance Abuse 23 May 2011 Prevention and Control OPNAV Instruction 5350.4D Navy Alcohol and Drug Abuse 4 June 2009 Prevention and Control Marine Corps Order 5300.17 Marine Corps Substance Abuse 11 April 2011 Program

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20 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES in military treatment facilities and the TRICARE program; whether active duty and reserve component personnel and their dependents needing SUD treatment are able to make use of the existing pro- grams and services; what obstacles exist to providing preventive services for individuals (e.g., active duty, Reserve, and National Guard personnel and their dependents); and what obstacles exist to providing substance use treatment for individuals (e.g., active duty, Reserve, and National Guard personnel and their dependents) who need such treatment. • Credentials and other requirements for physician and nonphysician health care professionals—The report was to provide an analysis of the adequacy and appropriateness of current credentials and other requirements for physician and nonphysician health care profes- sionals who treat members of the armed forces with SUDs. • Staffing ratio of physician and nonphysician care providers—The report was to address and offer recommendations on evidence- based methodology(ies) for determining the advisable ratio of phy- sician and nonphysician health care providers of SUD care for members of the armed forces. • Availability of and access to care for the active duty and reserve components of the armed forces—The report was to compare the adequacy of the availability of and access to care for SUDs for members of the active duty and reserve components of the armed forces. • Adequacy of SUD programs for dependents of armed forces ­members—The report was to assess the adequacy of programs for 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 are affected by the SUD of a member of the armed forces. The following areas were to be addressed: whether such programs and services are sufficient in scope and capacity to meet the needs of dependents, whether dependents with a need for SUD treatment are able to make use of these programs and services, and what obstacles exist to providing preventive services and/or SUD treatment to individuals who need such treatment. APPROACH TO THE CHARGE To respond to this broad charge, the IOM assembled a committee with diverse expertise in the areas of SUD prevention, screening and diagnosis, treatment, access, and workforce education and credentialing. Additionally, because the study required examination of three distinct populations (active

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INTRODUCTION 21 duty service members, Reserve and National Guard members, and military dependents), the committee’s membership needed to be well versed in the specific characteristics and needs of each of these groups. Once assembled, the committee undertook several strategies to gather the necessary informa- tion for this report. First, the committee carried out a thorough review of all DoD, Army, Navy, Air Force, and Marine Corps policies and programs related to the prevention, diagnosis, treatment, and management of SUDs to gain an understanding of how SUDs are addressed in the military. To examine services available outside the direct care system for military members and their dependents, the committee also examined the TRICARE benefit for SUD care and the accessibility and availability of such care. DoD’s Com- prehensive Plan was particularly helpful for these tasks. To supplement the information thus gathered, the committee held four public information-gathering meetings during the first year of the study. Invited speakers included representatives of the sponsoring agency and other relevant government agencies, as well as experts and researchers in the fields of SUD prevention, diagnosis, and treatment; military families; and pain management. Appendix A provides a list of the speakers who addressed the committee at these public meetings and the topics of their presentations. The committee also made site visits to SUD programs at Camp Pendleton, Fort Belvoir, San Diego Naval Hospital, Keesler Air Force Base, and Fort Hood to speak directly with individuals who provide SUD care to service members in the settings in which this care is provided. Appendix A provides more information on the committee’s site visits. The literature the committee consulted to determine the standards by which it would assess the military policies and programs reviewed and the evidence base upon which it would issue its recommendations con- sisted primarily of peer-reviewed journal publications. Most of this litera- ture addressed SUD issues among the general public, although some was m ­ ilitary-specific. Finally, in addition to researching the etiology, epidemiol- ogy, prevention, diagnosis, treatment, and relapse of SUDs, the committee reviewed literature on SUDs and comorbid disorders such as posttraumatic stress disorder (PTSD) and depression. The committee focused its attention on alcohol and other drug use and excluded tobacco use from the purview of its investigation. The IOM (2009) report Combating Tobacco in Mili- tary and Veteran Populations examines this issue in great detail and offers a variety of recommendations for tobacco use prevention and cessation. ORGANIZATION OF THE REPORT This report consists of nine chapters. Following this introduction, Chapter 2 provides more detailed background information on the issue

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22 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES of substance abuse, both among the general population and within the military in particular. Chapter 3 provides a summary of the structure of the Military Health System and describes the avenues for SUD care within this system. Chapter 4 examines the changing standards of care for SUDs, the impact of recent health care reform and drug control strategies, and current standards for addiction treatment. Chapter 5 reviews best practices in prevention, screening and diagnosis, and treatment of SUDs. Chapter 6 summarizes the existing SUD policies and programs in DoD, the Army, the Navy, the Air Force, and the Marine Corps. Chapter 7 tackles the issue of access to care for active duty service members and their dependents, as well as for members of the Reserves and National Guard. Chapter 8 reviews the regulations and instructions governing addiction counselors and licensed practitioners in each branch of the U.S. armed forces to assess current stan- dards. The report concludes with a chapter reviewing all of the committee’s major findings and recommendations for improvements to SUD prevention, diagnosis, and treatment for active duty service members, members of the Reserves and National Guard, and military dependents. REFERENCES Blume, A. W., K. B. Schmaling, and M. L. Russell. 2010. Stress and alcohol use among soldiers assessed at mobilization and demobilization. Military Medicine 175(6):400-404. Bray, R. M., M. R. Pemberton, L. L. Hourani, M. Witt, K. L. Olmsted, J. M. Brown, B. Weimer, M.  E.  Lance, M. E. Marsden, and S. Scheffler. 2009. Department of Defense survey of health related behaviors among active duty military personnel. Research Tri- angle Park, NC: RTI International. Bray, R. M., M. R. Pemberton, M. E. Lane, L. L. Hourani, M. J. Mattiko, and L. A. Babeu. 2010. Substance use and mental health trends among U.S. military active duty per- sonnel: Key findings from the 2008 DoD Health Behavior Survey. Military Medicine 175(6):390-399. Brewin, B. 2011. Military’s drug policy threatens troops’ health, doctors say. Nextgov, http:// www.nextgov.com/health/2011/01/militarys-drug-policy-threatens-troops-health-doctors- say/48321/ (accessed June 12, 2012). DoD (Department of Defense). 2009. Status of drug use in the Department of Defense person- nel. Falls Church, VA: DoD. DoD. 2011. Comprehensive plan on prevention, diagnosis, and treatment of substance use disorders and disposition of substance use offenders in the armed forces. Washington, DC: Office of the Under Secretary of Defense. Horgan, C. M., G. Strickler, and K. Skwara. 2001. Substance abuse: The nation’s number one health problem. Key indicators for policy—update. Waltham, MA: Heller School, Brandeis University. IOM (Institute of Medicine). 2009. Combatting tobacco in military and veteran populations. Washington, DC: The National Academies Press. IOM. 2010. Returning home from Iraq and Afghanistan: Preliminary assessment of read- justment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.

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INTRODUCTION 23 Manchikanti, L., and A. Singh. 2008. Therapeutic opioids: A ten-year perspective on the com- plexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 11(Suppl. 2):S63-S88. Marshall, B. D. L., M. R. Prescott, I. Liberzon, M. B. Tamburrino, J. R. Calabrese, and S. Galea. 2012. Coincident posttraumatic stress disorder and depression predict alcohol abuse during and after deployment among Army National Guard soldiers. Drug and Alcohol Dependence [Epub ahead of print]. Office of the Surgeon General. 2004. 2004 Surgeon General’s report—the health consequences of smoking. Atlanta, GA: Office of the Surgeon General. Rosenbaum, C. D., S. P. Carreiro, and K. M. Babu. 2012. Here today, gone tomorrow. And back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts), kratom, salvia divinorum, methoxetamine, and piperazines. Journal of Medi- cal Toxicology 8(1):15-32. SAMHSA (Substance Abuse and Mental Health Services Administration). 2011. Results from the 2010 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: SAMHSA. U.S. Air Force Special Operations Command. 2011. AFSOC to airmen: Use Spice, may lose ca- reer. Air Force Print News Today, http://www.afsoc.af.mil/news/story.asp?id=123255852 (accessed June 12, 2012). U.S. Army. 2012. Army 2020: Generating health & discipline in the force. Washington, DC: U.S. Army. VA (Department of Veterans Affairs) and DoD. 2009. VA/DoD clinical practice guideline for management of substance use disorders. Washington, DC: VA and DoD. Zoroya, G. 2010. Abuse of pain pills by troops concerns Pentagon. USA Today, March 17, http://www.usatoday.com/news/military/2010-03-16-military-drugs_N.htm (accessed June 27, 2012).

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