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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.
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INTRODUCTION 23
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