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 medical 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 attaching 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 installations 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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