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 accessing care for SUDs. First, there are few to no public health interventions targeting the medical consequences of heavy drinking. Military personnel 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 addiction. 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. However, 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 several 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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