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7 Access to Care for Substance Use Disorders A review of access to care for substance use disorders (SUDs) was a central component of two tasks in the committee’s charge: • a comparison of the adequacy of the availability of and access to care for SUDs for members of the active duty and reserve compo- nents of the armed forces; and • an assessment of the adequacy of the availability of and access to care for 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. To address these tasks, this chapter begins by defining access to care for SUDs and providing a framework for the ensuing analysis. Subsequent sections examine the availability of care, policies and other factors that affect access to care, and data on utilization of care. The chapter concludes with findings based on this analysis. The committee’s analysis considers the direct care system (military treatment facilities), the Veterans Health Administration (VHA), and the system for purchase of care (TRICARE). It reviews access to SUD care for active duty personnel; military dependents; and, to the extent data were available, members of the National Guard and Reserves. The assessment examines each branch of the military where sufficient detail was available. 185

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186 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES FRAMEWORK FOR ACCESS TO CARE The armed forces focus on maintaining warrior fitness and promoting resilience among service members and military families. Active duty person- nel experience frequent mobilizations, difficult transitions, combat situa- tions, and an operational tempo with long and multiple periods away from their families and supports. The physical and emotional stressors experi- enced by many military women and men may contribute to an increase in their use of alcohol and other drugs. Access to substance use services—from prevention to a wide spectrum of interventions for substance misuse and abuse—can help military personnel and their families maintain psycho- logical resilience and fitness. Access to routine screening, confidential brief education, brief counseling, brief interventions for those with emerging substance use problems, and more intensive treatment for those with SUDs promotes good health and may reduce the current high rates of alcohol and prescription drug misuse. If these services are delivered without sanctions or stigma, they promote an effective response to emerging alcohol and other drug use problems, and foster a system in which individuals seek help rather than hide problems. The committee’s framework for assessing access to SUD care is based on its view that alcohol and other drug use behaviors exist on a contin- uum, and that certain patterns of alcohol and other drug use place some individuals at high risk of developing medical and social problems and possibly abuse or dependence. The discussion here focuses on the use of legal substances (i.e., alcohol, controlled substances prescribed by a clini- cian) since the use of illicit substances (when detected) prompts separation proceedings. Addressing access to brief intervention and treatment for alcohol and other drug use is a complex undertaking. Access includes both the availabil- ity of services and the use of appropriate modalities and types of services at the appropriate times. As described in Chapter 5, contemporary substance use treatment systems include frequent screening, brief counseling, brief interventions in primary care settings, a focus on client-centered motiva- tional interviewing, multiple entry points to treatment, pharmacothera- pies that reduce cravings and maintain functioning, outpatient counseling, intensive outpatient programs, residential treatment when needed, and continuous contact with counseling professionals after an intense period of treatment. Modalities of care utilize evidence-based environmental, psycho- social, and medication interventions. The standard of practice in modern SUD treatment no longer relies on inpatient hospital services, except for the most medically complex patients. Continuity and duration of ambula- tory services are more important than the provision of care in residential settings (IOM, 2006).

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 187 Aday and Andersen (1974) developed a health services framework with which to examine access to medical treatment. Subsequent investigators modified this framework to assess access to services for alcohol and other drug use disorders (Hser et al., 1997; Weisner and Matzger, 2002; Weisner and Schmidt, 2001). The Aday and Andersen (1974) model addresses bar- riers and facilitators to access using three domains: (1) predisposing, (2) enabling, and (3) need. The predisposing domain consists of individual and social facilitators and barriers. Individual factors are intrinsic characteristics that describe the propensity of individuals to use health services. Social fac- tors include marital status, family, and social networks; these are the social contextual characteristics that influence treatment seeking. In the substance abuse field, social networks are distinguished by whether they include indi- viduals who are influences for not using versus using substances, as well as treatment seeking versus nonseeking. The enabling domain consists of structural/financial and environmental factors. Structural/financial facilita- tors are similar to those for general health care and include the supply and availability of treatment and the types of treatment and medications avail- able. The need domain includes the severity of alcohol and other drug use and comorbid mental health or medical problems. Barriers to Access in the Military Barriers to accessing care for SUDs can be environmental, structural, social, and/or cultural. Environmental factors, such as pressure or mandates to enter treatment, sanctions, perceptions about the effectiveness of treat- ment, and stigma, are unique to the behavioral health field, particularly the addiction field, and more apparent in the military than the civilian sector. Civilian individuals frequently enter SUD treatment as a result of legal, wel- fare, employment, or family pressures or even mandates (Weisner, 1990). The same is true in the military; most service members are assessed for the need for treatment only after receiving sanctions for a substance-related incident (e.g., driving under the influence [DUI], assault) or other drug- related infraction (e.g., possession of an illegal substance) or upon having their substance use discovered through random drug testing. Thus, the most important structural factors in the military are (1) policies that treat alcohol misuse and other drug use as a discipline problem, (2) heavy reli- ance on deterrence (i.e., random drug testing) as the prevention approach, and (3) the lack of a standard medical protocol for early identification and brief intervention before a disciplinary infraction occurs. While many predisposing and need-related facilitators of and barriers to treatment in the military are similar to those in the civilian sector, some structural and environmental barriers are unique to the military—­ otably, n policies and practices that result in random drug testing as a primary

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188 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES pathway to obtaining substance use services. First, random drug testing technology is not applicable to alcohol or to designer drugs not yet classi- fied as illicit (e.g., Spice, bath salts). Second, civilian best practice addresses unhealthy substance use as a preventable and treatable health problem with known risk factors and offers screening and interventions as part of primary care services early and confidentially. Military practices, however, focus on abuse and dependence and view alcohol and other drug misuse as violations of the code of conduct and/or as criminal activities (e.g., DUI, drug pos- session). The emergence of unhealthy use before a negative incident occurs generally goes unnoticed or is ignored by medical programs, and while policy describes the need for prevention programs (see Chapter 6), the vast majority of resources are used for random drug testing. The lack of distinction between unbecoming conduct and a medical problem creates an environment in which engaging in substance use treat- ment has counterproductive implications. Receiving treatment, even when treatment causes the desired change in behavior, is perceived as resulting in a negative career trajectory. Consequently, active duty service members (ADSMs) are not highly motivated to enter treatment. This can have the unanticipated effect on public safety of having service members continue to perform critical tasks without having had their problems treated. Indeed, during its information gathering meetings and site visits, the committee heard from military treatment professionals that many service members per- ceive alcohol treatment as a threat to their military career and consequently avoid it.1 The vignette in Box 7-1 describes an extreme, but not isolated, case in which early intervention with a soldier could have occurred. A ran- dom drug test in 2007 identified cocaine use, but 15 subsequent tests were negative. In 2011, the soldier self-enrolled in an Army Substance Abuse Program (ASAP), fully 8 years after a problem was first indicated. In keeping with the military’s occupational health model, policy DODI 1010.6 requires that a service member’s commander be notified of and involved in treatment for an SUD (DoD, 1985, 5.2.2.2.3) (see also Chapter 6). This policy applies whether the soldier self-refers, is referred by a medi- cal provider, or is referred by the commander, and regardless of whether an alcohol-related incident or positive drug test is involved. Branch policies impose similar requirements. For example, the Army policy for self-referral states: The ASAP counselor will contact the unit commander and coordinate the Soldier’s formal referral using DA Form 8003, which will be signed by the 1 Personal communication, Vladimir Nacev, Ph.D., Resilience and Prevention Directorate Defense Centers of Excellence, and Col. John J. Stasinos, M.D., Department of the Army, Office of the Surgeon General, May 4, 2011.

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 189 BOX 7-1 A Soldier’s Untreated Substance Abuse A soldier tested positive for cocaine use in March 2007. He was not required to enroll in an Army Substance Abuse Program (ASAP), and a Department of the Army (DA) Form 4833 was never completed. Despite 15 negative urinalyses from October 2008 to January 2011, the soldier self-enrolled in ASAP during the latter month for cocaine abuse and marijuana and alcohol dependence. He was apprehended in July 2011 for assault consummated by a battery (domestic violence). A review of law enforcement databases revealed that these offenses were not the beginning of the soldier’s high-risk behavior; he had been arrested for criminal trespass, marijuana possession, and evading arrest in 2003—3 years prior to his delayed-entry report date of August 2006. While driv- ing on an interstate highway in November 2011, the soldier collided with another vehicle, killing himself and two others instantly and injuring two others. He had been driving the wrong way on the highway for 2 miles at the time of the accident. While drug and toxicology results are unknown at this time, packets of Spice were found in the soldier’s vehicle. SOURCE: U.S. Army, 2012a, p. 30. unit commander and be annotated as a self referral. The commander will be a part of the rehabilitation program and, as a member of the Rehabilita- tion Team, will be directly involved in the decision of whether rehabilita- tion is required. (U.S. Army, 2009, p. 49) These policies are necessary to ensure that service members are medically ready for deployment. Yet in current practice, the lack of confidential treat- ment even for problems that do not meet symptom criteria for substance abuse or dependence has the perverse effect of leaving many treatable problems undetected and unaddressed. As a consequence, several Army reviews have identified a high proportion of suicides, other deaths, and other negative consequences associated with untreated SUDs (U.S. Army, 2010, 2012a). Historically, military policy has not addressed unhealthy alcohol use or reliance on prescribed medications that places service members at high risk for SUDs and later disciplinary problems. The military now has programs that provide screening and early intervention for depression and posttrau- matic stress disorder (PTSD) within primary care settings to reduce the stigma associated with seeking treatment for these conditions, but it has not

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190 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES adopted similar early-intervention, best-practice models for discussion of emerging alcohol and other drug use problems. In civilian model programs, early intervention for problem alcohol and other drug use is available in medical care settings such as primary care and emergency rooms. A new DoD policy, DODI 64990.08, may permit further development of brief interventions in military health care settings for service members at risk of alcohol use problems. Military culture also creates unique environmental barriers to access- ing care for SUDs. First, there are few to no public health interventions targeting the medical consequences of heavy drinking. Military person- nel are warned of the severe sanctions for alcohol or other substance use that results in a formal consequence (e.g., DUI); the message conveyed, however, is that heavy drinking is acceptable, while getting into trouble because of the behavior is not (Burnett-Zeigler et al., 2011; Gibbs et al., 2011; Skidmore and Roy, 2011). Second, alcohol and other drugs often ­ are misused as coping mechanisms for combat and other stress and hence recognized on a continuum of medical problems (Stokes et al., 2003), yet many service members are treated for long periods of time with opioid pain medications and with controlled drugs to treat anxiety and sleep disorders. These high prescribing rates introduce opportunities for abuse and addic- tion. The epidemiological data reviewed in Chapter 2 suggest that abuse of prescribed medications used to treat pain and/or sleep disorders is growing. While tracking of medications dispensed to individuals in theater is problematic (Defense Health Board, 2011), recent changes have been made to prescribing practices for certain controlled medications. For instance, ALARACT (All Army Activities) 062/2011 (U.S. Army Surgeon General, 2011) requires an expiration date on prescribed opioid medications. How- ever, the U.S. Central Command (CENTCOM) Formulary still permits the dispensing of 180 days of certain controlled substances for personnel who are deployed to war zones (DoD, 2012). These prescribing practices are intended to address the potential lack of access to medications currently being taken by the service member in a deployed environment. Yet these practices may contribute to physical dependence on such medications in sev- eral ways—being given for a longer duration than is clinically prudent, given without close medical supervision, and given to service members who have alcohol or other substance use problems. The Army has made recent policy changes aimed at reducing the prescribing of medications with the potential for abuse and addiction (U.S. Army, 2012b; U.S. Army Surgeon General, 2011). As discussed in Chapter 6, DoD instated stricter limits on the length of prescription for controlled drugs in May 2012 (see Finding 6-1). In both civilian and military populations, a frequently cited barrier to seeking treatment for SUDs is denial of the need for treatment among

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 191 those who need it (SAMHSA, 2011). Respondents to the National Survey on Drug Use and Health described their problem as not severe enough to require treatment and said that drug use helped them cope with diffi- cult emotional stimuli. Among military personnel returning from Iraq and Afghanistan stigma was the most frequently cited reason for not seeking treatment for combat-related mental health conditions, including substance use (Dickstein et al., 2010; Hoge et al., 2004; Stecker et al., 2007). Self- stigma was particularly poignant; it is difficult for military personnel to identify themselves as being in need. In the civilian sector, one role for brief advice from a clinician to patients is to address their perception of their need for treatment and the value of the available treatment, but this func- tion currently does not exist in the military. Role of Primary Care and Medical Treatment The military’s medical care model for first-line treatment of behavioral health problems that are commonly comorbid with SUDs (e.g., PTSD, depression, suicidal ideation and attempts) now relies heavily on detection and treatment in primary care. Screening for behavioral health conditions, including hazardous alcohol use, occurs routinely in primary care. As discussed in Chapter 5, evidence-based approaches of brief advice, early intervention, and referral to treatment when needed through models com- monly known as screening, brief intervention, and referral to treatment (SBIRT) should be a focus of the full continuum of care. Medical protocols for SBIRT, however, have not been implemented in military primary care programs. The Department of Veterans Affairs (VA) health care system, in contrast, routinely screens for alcohol use problems and offers brief intervention and referral to further treatment if needed. As discussed in Chapter 6, the screening and brief intervention elements of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) have not been implemented in the Military Health System. Primary care also is the setting in which pharmaceutical therapy for SUDs often takes place in the commercial sector. The lack of primary care protocols in the military (and policy restrictions on the use of some of these effective medication therapies) is an additional barrier to accessing SUD care and is inconsistent with the VA/DoD Clinical Practice Guide- line (VA and DoD, 2009). Consequently, primary care is the single largest missed opportunity in the military for early and confidential identification of alcohol and other drug misuse. DoD and branch policies and practices currently do not provide for early and confidential interventions for alcohol and other drug misuse. The committee perceives this to be a tremendous barrier to service members’ accessing SUD care.

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192 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES CARE AVAILABILITY, ACCESS, AND UTILIZATION IN THE DIRECT CARE SYSTEM DoD policy requires the armed services to provide alcohol and drug abuse prevention and treatment services for active duty personnel as part of medical readiness and risk reduction programs (DoD, 1997). The commit- tee’s analysis of access to and utilization of SUD care is organized by branch and includes a review of the size of the population addressed, the number of SUD programs available, and the data on utilization of services. The content of these programs is described in Chapter 6 and Appendix D, and the SUD workforce is described in Chapter 8. This section concludes with a brief review of DoD-wide programs that may enhance access to SUD care. There is no uniform DoD reporting system for monitoring the number of detected alcohol incidents or drug-positive events, the number of refer- rals for assessment or treatment, or the number enrolled in direct care treat- ment programs. In response to queries from the committee, each branch provided data using its own definitions, formats, and level of detail. In its site visits, the committee learned that program directors at installations can query their own systems, but do not have access to system-wide data for judging overall trends or monitoring the transfer of patients from one military installation to another. The committee does not know how any methodological differences in data reporting among branches or compo- nents affected the information provided for this study. One major challenge confronting all branches with respect to access to SUD care is that troops are dispersed across the United States, abroad in permanent stations on U.S. territories (e.g., Guam), and in foreign nations (e.g., Japan, Germany). Family members also reside with troops where there are permanent stations. Thus, access to SUD care for these troops and family members may require travel to obtain the appropriate level of clinical care. The capacity for integrated behavioral health services in areas outside the continental United States may be particularly important when SUD programs are not available. Air Force The Air Force provides SUD services through 75 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) programs, one at each military treatment facility, with nearly 400  counselors. None of these programs offer inpatient, medically supervised treatment or residential, medically monitored treatment. The Air Force has one ADAPT program that provides intensive outpatient care at Andrews Air Force Base. The Air Force Medical Operations Agency reported to the committee that during fiscal year (FY) 2010, 736 service members self-referred to ADAPT, and 4,644 members

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 193 TABLE 7-1 Utilization of Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Services by Active Duty Air Force Personnel* FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 1,559 1,429 1,532 1,565 1,454 *Includes 11-26 persons treated annually who were activated National Guard/Reserve members. SOURCE: Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations Agency, October 25, 2011. were referred by Command.2 Beyond self-referrals and Command refer- rals, individuals can be referred to ADAPT by medical providers, but these represent the smallest proportion of referrals. Table 7-1 displays the number of active duty patients enrolled in treatment at ADAPT clinics from FY 2006 to FY 2010. Comparing the number of self- and Command referrals in FY 2010 (5,380) with the number of patients enrolled in treatment in the same period (1,454) suggests that most referrals do not lead to enroll- ment in treatment. As described in Chapter 6, most individuals receiving services through ADAPT do not meet diagnostic criteria for enrollment in formal treatment and instead are enrolled in alcohol brief counseling as an indicated prevention measure. The number treated has not increased over time and was lower in FY 2010 than in 3 of the 4 prior years. Army ASAPs are located within the Army Installation Management Com- mand (IMCOM) as part of the human resources program (see also Chapter 6). The Army has 38 ASAPs, which typically offer American Society of Addiction Medicine (ASAM) Level I (outpatient service) care to military personnel and have insufficient capacity to serve family members with SUDs.3 Army regulations require all ASAP counselors to have a master’s or doctoral degree in psychology or social work. The ASAP counselors may be uniquely positioned to provide integrated care for service members with SUDs and comorbid mental health problems, but are credentialed only to treat SUDs and are not authorized to treat mental health problems. Mili- tary personnel who require partial hospitalization or inpatient care or have a dual diagnosis often are referred by Command to the civilian provider network. The extent to which ASAP programs are available to Army per- 2 Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations Agency, October 25, 2011. 3 Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Pro- grams, March 30, 2011.

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194 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES sonnel and family members permanently stationed abroad or in states and territories outside the continental United States is unclear. The TRICARE Management Activity (TMA) Section 596 report indi- cated that the Army operates only one inpatient (around-the-clock), medi- cally monitored treatment program, which has 20 inpatient beds (DoD, 2011b, p. 30). During a site visit to Fort Belvoir Community Hospital (see Appendix A for the committee’s site visit agenda), the committee learned of a newly opened residential treatment center (ASAM Level III rehabilitation program for SUDs under the Army’s Medical Command). This medical service will provide care for ADSMs from all branches of the military and eligible retirees. When referred by Command, personnel may be treated in any SUD facility under a budget agreement with the military treatment facility commander; that is, commanders are not restricted to the use of TRICARE network Substance Use Disorder Rehabilitation Facilities (SUDRFs) (SUDRFs are discussed later in the purchased care section).4 With regard to in-theater care, a report of the Army Inspector General concludes that there is a lack of compliance with Army alcohol and other drug use policy when units are in a combat operation environment (U.S. Army, 2008). CENTCOM General Order #1 states that alcohol consump- tion and possession and drug use are illegal in the combat environment (United States Central Command, 2006). AR 600-85 requires that deployed commanders maintain a drug deterrence program. However, the Inspec- tor General’s report finds little compliance with these directives and notes that DoD provides no guidance on how to implement the policies and no professional staff to implement them and monitor compliance, and that the rotation of personnel in and out of the combat environment inhibits enforcement. In efforts to deter drug use during deployment, the Army updated AR 600-85 in 2009 to include new language meant to increase random drug testing in theater. To increase access to screening and treat- ment in theater, the Army is in the first phase of rolling out an Expedition- ary Substance Abuse Program to provide SUD services during deployment, primarily through telephone contact with in-theater providers.5 Table 7-2 shows data on initial referrals of Army ADSMs to ASAP for FY 2006-2010. The Army Center for Substance Abuse Programs (ACSAP) reported to the committee that for FY 2010, 3,401 distinct active duty individuals enrolled in treatment as self-referrals, and 10,968 enrolled because of Command referral.6 ACSAP provided detailed information on 4 Personal communication, John Sparks, TRICARE Regional Office-West, March 18, 2012. 5  Personal communication, Col. John J. Stasinos, M.D., Department of the Army, Office of the Surgeon General, March 15, 2012.  6  Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Pro- grams, January 13, 2012.

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 195 TABLE 7-2  Army Active Duty Initial Referrals to the Army Substance Abuse Program (ASAP) FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 Initial Referrals 16,826 18,164 20,316 23,044 23,093 SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Programs, January 13, 2012. gender, rank, and substance of initial referral (not treatment enrollment) for 23,093 individuals in FY 2010. According to a recent Army analysis (U.S. Army, 2012a), 52 percent of soldiers referred to treatment for either alcohol or other drug problems enrolled in outpatient treatment. Many who are referred to ASAP for assessment fail to meet diagnostic criteria for SUDs and are enrolled in the Army’s indicated prevention course Prime for Life (described in Appendix D). When soldiers are enrolled in treatment at ASAP, they do not always complete the program for various reasons (e.g., deployments). The rates of successful completion of rehabilitation from FY 2001 to FY 2010 averaged 66 percent for alcohol and 47 percent for other drugs (U.S. Army, 2012a). The committee also received data on treatment enrollment in ASAP. Figure 7-1 shows the data received on the distribution of enrollment ranked 2% 1% 3% 5% Alcohol (9,895) 11% Cannabis (1,451) Opiates (663) Cocaine (366) Other Substances (216) Amphetamines (148) 78% FIGURE 7-1  Number of Army Substance Abuse Program (ASAP) treatment enroll- ments by substance of abuse for fiscal year 2010. Enrollments for the following substances were small in number and not included in the above chart: inhalants (52), sedatives (41), hallucinogens (41), and PCP (3). SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Sub- stance Abuse Programs, March 30, 2011. Figure 7-1 R02254 vector editable

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216 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES While the definition of these settings is unclear, the table supports the find- ing that few individuals received SUD care in the purchased care system. This finding is not surprising for ADSMs given that in most circumstances, they have access to outpatient services at their military treatment facility and potentially to other levels of care if transferred to inpatient programs offered by the larger installations. As noted in Table 7-6, however, typically fewer than 1 per 1,000 ADFMs received SUD care at military treatment facilities. Combined with the low utilization rates in Table 7-15, these data are evidence that ADFMs face strong barriers to gaining access to SUD care in the military treatment facility and purchased care systems combined. Data in Table 7-15 on the treatment of SUDs in purchased care facilities further demonstrate that network facilities do not provide all the SUD care received by ADFMs. In part, this reflects the finding that non-SUDRF hospi- tals are used for emergency detoxification and withdrawal from substances. Nevertheless, these data also show that the majority of inpatient SUD care was delivered outside of SUDRFs. The majority of outpatient services were received from settings other than professional SUDRFs. However, some of these outpatient services may represent not counseling services but claims for ancillary services associated with other types of care. The data in Table 7-15 indicate a substantial underutilization of care but do not directly identify the full range of barriers that contribute to this pattern. It is apparent that there is a lack of capacity in network SUDRFs; in some states there are no SUDRFS, and in most regions the SUDRFs serve only some geographic areas and are too distant to accommodate many mili- tary families. Further, all SUDRF care is facility rather than office based as prescribed by regulation, and a substantial or majority portion is in inpatient hospital facilities. This implies a reliance on the highest-cost setting for SUD care, an approach not supported by the evidence (see Chapter 5) and no longer practiced in the commercial insurance sector. According to practice guidelines, most individuals can be treated with outpatient SUD protocols. Taken together, these data imply an extreme shortage of outpatient settings for SUD care for ADFM adults and children. There may also be a shortage of outpatient services for ADSMs who lack access to SUD programs at their military treatment facility. Outpatient settings are the appropriate setting of care for most individuals with SUD needs, and they are also the setting in which aftercare services should be provided for those individuals who have undergone an inpatient episode of care. SUMMARY OF KEY FINDINGS The committee’s review of access to SUD care suggests that while services are available for ADSMs through military treatment facilities, the number of patients treated is below epidemiological expectations. Many

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 217 barriers to care apparently inhibit ADSMs’ use of these services. These bar- riers include the structure and location of the services, a reliance on residen- tial care, and stigma that substantially inhibits help-seeking behavior in a system in which regulation requires the “employer” (i.e., commander) to be informed about any use of services for SUDs. Further, many policies (e.g., drug testing and Command involvement) may actually inhibit rather than enhance access (as intended) to early SUD treatment and discourage screen- ing and brief intervention in medical settings for alcohol use disorders. Additionally, access to care for ADFMs is extremely limited in TRICARE’s ­ purchased care system. The barriers to care in the purchased care system appear to be associated with the limitations of benefit coverage (far dif- ferent from the standard of coverage in the commercial sector) and the requirements for SUDRF certification (again different from the standards used in the commercial sector). The restriction of services to SUDRFs leads to an expensive reliance on geographically distant hospital-based treatment services, a lack of access to existing community-based outpatient and inten- sive outpatient services, and poor transition from SUDRF care to primary care and from inpatient to outpatient services. Thus, access to prevention and treatment services that incorporate the latest scientific evidence and predominate in the commercial sector (pharmaceutical therapy, individual therapy, intensive outpatient programs), as well as care in individual prac- titioners’ offices and outpatient clinics, is limited in the military largely by an outdated benefit structure, outdated benefit limits, and other unique policy restrictions that appear to be inconsistent with the military’s goal of providing the best possible SUD care to those who need it. Finding 7-1: There is a significant unmet need for SUD care among service members in the U.S. armed forces. DoD policy mandates a postdeployment assessment and screening interview to identify emerging health problems, and each branch has its own procedures for ensuring the medical fitness or readiness of its person- nel for future deployments. These surveillance programs generate data on the impact of deployment and combat on mental health, including concerns about drinking, depression, and stress-related symptoms. Unfortunately, the identification of problems does not lead to referral for treatment. A recent study showed that of 6,669 Army soldiers self-reporting levels of drinking categorized as alcohol misuse, only 0.2 percent received a referral for alco- hol services, and only 29 of these were seen within 90 days (Milliken et al., 2007). Figure 2-3 and Table 2-3 in Chapter 2 provide anonymous survey data illustrating high rates of heavy drinking. Given the epidemiological data showing high rates of weekly binge drinking among military person- nel (Bray et al., 2009), it is apparent that only a fraction of those needing

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218 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES brief intervention and advice to change their alcohol-related behavior are being reached. This low level of access is potentially attributable to the lack of a clear public health message and vision within DoD with respect to its charac- terization of SUDs. A full range of SUD service modalities is not available to ADSMs and their dependents in the direct and purchased care sectors. Particularly lacking are any medical services for prevention and early inter- vention for emerging problems that could be identified through confidential medical discussions about behaviors that increase the risk of developing alcohol use disorders. While the civilian world has protocols for routine standardized medical screening, brief advice, brief counseling, and brief treatment, the armed forces lack these protocols and practices. Although medical protocols for brief intervention for those individuals who have unhealthy alcohol use are recommended in the VA/DoD Clinical Practice Guideline for Substance Use Disorders (VA and DoD, 2009), the committee found little evidence of their actual use. While the estimated unmet need for SUD care is significant, it is of note that DoD is not consistently tracking measures of need for care across service branches. The committee found that DoD has no uniform reporting system for monitoring the number of detected alcohol incidents or drug-positive events, the number of referrals for assessment or treatment, and the number enrolled in direct care treat- ment programs. While individual service branches have their own databases for collecting this information, it is challenging to understand the extent of the unmet need for care without more consistent data that are incorporated into the medical record. Finding 7-2: Access to care is restricted by the TRICARE SUD benefit’s lack of coverage of intensive outpatient services, office-based outpatient services, and certain evidence-based pharmacotherapies. The committee concurs with the assessment in DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces (Com- prehensive Plan) that additional inpatient and residential capacity for SUD care is not needed. However, the committee disagrees with that report’s con- clusion that the full range of SUD services is sufficient. As discussed above, current policies that limit outpatient services to SUDRFs inhibit access to care and require the use of expensive and increasingly antiquated inpatient facilities. In reviewing data provided by TMA, the committee found that much of the SUD care that is claimed under the TRICARE benefit is pro- vided in inpatient settings. A comparison of TRICARE utilization data with commercial practices suggests that TRICARE overemphasizes inpatient settings and underutilizes outpatient care. According to contemporary stan-

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 219 dards, however, systems of care for SUDs should rely on outpatient services and ongoing management of a potentially chronic disorder, particularly after episodes of inpatient and residential treatment. Both the direct care and TRICARE systems lack the necessary capacity for providing intensive outpatient and outpatient services. The implication of the current SUDRF regulations is that many SUD services delivered through community-based addiction treatment centers or through licensed independent practitioners are not available to TRICARE beneficiaries. This particularly affects access to SUD care for dependents of service members, who generally are unable to receive care at military treatment facilities since programs give priority to providing care to service members. Continued reliance on a small number of hospital-based and free- standing SUDRFs and limits on the settings and levels of care contribute to overall low utilization rates and to a lack of continuity in care. According to a draft update to the Comprehensive Plan, DoD is aware of this issue and is currently drafting policy language for internal review and coordination that would expand the authorized providers of SUD treatment services beyond SUDRFs.18 While it was outside the charge for this study to investigate total expenditures on SUD services, the committee notes that the current con- figuration of capacity and the current TRICARE benefit structure promote use of the most expensive settings of care and limit access to lower-cost modalities that are evidence based (outpatient counseling, intensive out- patient, and partial hospitalization modalities). The restriction of care to SUDRFs appears to be unwarranted in the current health care environment, in which the quality of services and the need for different levels of care can be determined using managed care technologies. In reviewing claims data from TMA, the committee also found limited use of pharmacological therapies for alcohol and other drug use disorders, presumably due in part to the TRICARE benefit’s limit on the use of maintenance pharmacotherapy for the treatment of SUDs. The committee finds that underutilization of effective treatment modalities such as outpatient therapy and maintenance medications inhibits service members and their dependents from accessing effective and quality care for the treatment of SUDs. Finding 7-3: Low rates of ADSM self-referral to treatment corroborate reports provided to the committee regarding the perceived stigma of receiving treatment. When the numbers of self-referrals to treatment are compared with the numbers of Command referrals, it is clear that, across the different 18 Personal communication, Alfred J. Ozanian, Ph.D., TRICARE Management Activity, June 6, 2012.

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220 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES branches, the numbers of self-referrals remain very low. The Army had a higher proportion of self-referrals than the other branches in FY 2010, a differential that presumably is due to the Army Confidential Alcohol Treatment and Education Pilot (CATEP) program (described in Chapter 6), which offers confidential treatment. The committee finds that policies requiring Command notification for the treatment of SUDs encourage ADSMs and their families to avoid rather than seek care and therefore contribute to low numbers of self-referrals. These policies also inhibit medi- cal professionals from conducting routine screening for alcohol misuse and identifying those at risk and in need of intervention. Finding 7-4: Access to SUD care is inhibited by various structural, social, and cultural barriers that are specific to military procedures, programs, and policies. A primary barrier to access to the full continuum of SUD care for military populations is the body of DoD and branch policies that rely first and foremost on the detection and adjudication of alcohol and other drug misuse as a disciplinary problem. These policies have the effect of attach- ing negative consequences and stigma to seeking help for alcohol and other drug use disorders (Gibbs et al., 2011). Studies have shown that negative attitudes and beliefs about treatment can inhibit help seeking among service members as well (Kim et al., 2011; Stecker et al., 2007). The mistaken belief that seeking help and receiving treatment are a sign of weakness, coupled with policies that tie negative career consequences to alcohol and other drug misuse, creates a climate that hampers military leaders who wish to help service members, inhibits accurate screening and diagnosis by medical professionals who care for service members, and leads to very low self- referral rates for SUD treatment. In addition to this inhibition of care seeking, there are key structural barriers to SUD care in the armed forces. Specifically, military treatment facilities lack the full continuum of SUD services. In the smaller instal- lations of some branches, there are no specialty treatment programs. In no branch did the committee learn of early, primary care-based indicated prevention for substance use problems that do not meet clear diagnostic criteria. Furthermore, there are severe practice restrictions on prescribing some pharmaceutical therapies known to support patients who wish to cut down on or abstain from alcohol and other drug use, and utilization data indicate a much lower than anticipated use of pharmaceutical therapies that are approved and known to be efficacious. One explanation for the low use of approved medications is the lack of SUD service delivery through primary care settings. Overall, the committee found a lack of adherence in

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 221 practice to the VA/DoD Clinical Practice Guideline for SUD care (VA and DoD, 2009) that has been acknowledged as the military’s standard of care. The committee’s findings are in line with earlier findings of the DoD Task Force on Mental Health (DoD, 2007). That task force observed that the stigma of mental health disorders inhibits military members and their families from seeking care. The task force recommended that DoD (1) develop public education campaigns to dispel this stigma; (2) embed mental health professionals in primary care to improve access and reduce stigma; (3) train officers, families, and medical professionals to value and promote psychological health and services; and (4) recognize that DoD regulations often inhibit seeking care (DoD, 2007). Recommendation 5.1.4.1 specifi- cally addresses the effects of policy on care for alcohol use disorders and suggests policy changes to promote access to care: The Department of Defense should promote earlier recognition of alcohol problems to enhance early and appropriate self-referral. If, in the clini- cian’s judgment, alcohol use does not warrant a diagnosis, mechanisms should exist to ensure that service members receive appropriate and non- prejudicial education and preventive services, without a requirement for command notification. Evaluations resulting in a diagnosis of substance abuse or dependence or entry into a formal outpatient or inpatient treat- ment program should continue to require command notification, as should reporting of alcohol-related incidents. (DoD, 2007, p. 21) Lack of confidentiality is a persistent barrier to SUD care and appears as well to influence the lack of preventive and early intervention services that may prevent the development of an SUD. To reduce the stigma associ- ated with seeking help for mental health and substance abuse problems, a recent DoD policy (DODI 6490.08) gives health care providers more latitude in responding to requirements for notifying Command of mental health and substance abuse disorders. The policy clarifies that if a service member voluntarily seeks drug and alcohol abuse education and does not meet diagnostic criteria, brief intervention services can be provided with- out Command notification (DoD, 2011a). The instruction also creates an opportunity for health care providers in primary care or other medical settings to screen for alcohol and other drug misuse and provide patient education. The committee suggests that policies such as DODI 64990.08 are a step toward creating confidential systems of intervention and may encourage help-seeking behavior. If DoD and branch policies do not pro- vide for early and confidential treatment of alcohol and other drug misuse, the committee believes that stigma will remain a significant barrier to SUD services. While these subclinical behaviors are not detected or treated, they may still have a tremendous impact on force health and readiness.

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222 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The committee finds that the structure of SUD services in the armed forces also inhibits access to care. For example, DoD’s Comprehensive Plan acknowledges that “gender-specific programs to treat SUDs in women are not available at MTFs [military treatment facilities]” (DoD, 2011b, p. 26). With increased enrollment of women in the military and their greater expo- sure to combat deployments, the need for gender-specific services is appar- ent. Additionally, the availability of SUD treatment at the time it is sought is an important principle in the commercial sector. On-base substance abuse programs typically offer care during duty hours, so participation in treat- ment programs often necessitates notifying Command to arrange adjust- ments to one’s work schedule. If SUD services were available at times that did not conflict with work duties (perhaps through increased use of tele- mental health technologies, which could provide care outside of duty hours delivered remotely by a provider in another time zone), ADSMs would have greater opportunities to enter care before the severity of an SUD required leave from their duty assignment. While this conflict with work duties is one rationale for commander involvement on the treatment team, it also is a perceived barrier to seeking care, particularly for career-minded service members who see daytime therapy appointments as often conflicting with job demands (Kim et al., 2011). Similarly, while waiting to enter treatment or in the middle of treat- ment, a service member may leave on deployment. Upon return, he or she may receive a different permanent station, which again disrupts continuity of care. The DoD Task Force on Mental Health reached similar findings and recommended that DoD support a full continuum of services for service members and their families, and develop policies that would ensure conti- nuity of care during deployment transitions and transitions between civilian and military providers (DoD, 2007). The task force encouraged DoD to develop strategies for recruiting and retaining mental health professionals, including social workers. The task force’s findings raised concern about access to mental health services within TRICARE and led to recommenda- tions for policy revisions to require access to care within 7 days, competitive reimbursement rates, the use of intensive outpatient services and other new approaches to care, and the use of qualified professionals not affiliated with hospitals to provide outpatient services (DoD, 2007). Finding 7-5: Members of the National Guard and Reserves have no or limited access to SUD care within the Military Health System. The large numbers of National Guard and Reserve personnel who have been activated and deployed to Iraq and Afghanistan raise concern about specific barriers to SUD care that they confront. Reserve component personnel often are dispersed within the civilian community and often live

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ACCESS TO CARE FOR SUBSTANCE USE DISORDERS 223 in rural areas a great distance from a VA medical center. Outreach efforts are challenged by this geographic dispersion, and must rely on innovative delivery methods such as Web-based outreach, telephone counseling, and telemedicine consultation. Additionally, members of the National Guard and Reserves and their families may not qualify for the same services as active duty personnel, who receive comprehensive care through the military’s direct care system. Discharge status also can present barriers to accessing care. Reserve component and discharged military personnel must have an honorable or general discharge to be eligible for the special combat veteran medical care at VA health centers. Combat veterans with SUDs are more likely to receive a less than honorable discharge because of disciplin- ary infractions. Consequently, those in need of care may be ineligible. Fur- thermore, while family members may be involved in a veteran’s care, VA clinics do not provide individual therapy for family members. An additional system-level barrier is the lack of a “warm hand-off” from the Military Health System to the VA health system (GAO, 2011a). Service members who have substance use or mental health problems must navigate the complex transition from one system to the other on their own. In contrast with physical injuries (which may result in medical treatment within the military, visible impairment, and a disability rating from the VA), the fact that many military personnel do not receive needed substance abuse care while in the military also means they do not receive a formal refer- ral to VA care. Further, the GAO noted that demobilized members of the National Guard and Reserves may be concerned about a perceived lack of confidentiality of their VA medical record with regard to their current mili- tary service. The GAO’s 2011 report identifies key barriers gleaned from a literature review and corroborates those findings through interviews. The barriers identified in that report included stigma, a lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about the quality or appropriateness of the care provided by the VA (GAO, 2011b). REFERENCES Aday, L. A., and R. Andersen. 1974. A framework for the study of access to medical care. Health Services Research 9(3):208-220. 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. Burnett-Zeigler, I., M. Ilgen, M. Valenstein, K. Zivin, L. Gorman, A. Blow, S. Duffy, and S. Chermack. 2011. Prevalence and correlates of alcohol misuse among returning Afghani- stan and Iraq veterans. Addictive Behaviors 36(8):801-806. Defense Health Board. 2011. Psychotropic medication prescription practices and use and complementary and alternative medicine use. Falls Church, VA: Defense Health Board.

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