8

Substance Use Disorder Workforce

The committee’s charge included two tasks that required an analysis of the credentials and numbers of physicians and nonphysician health care professionals treating alcohol and other drug use disorders in members of the armed forces:

  • analyze the adequacy and appropriateness of current credentials and other requirements for physician and nonphysician health care professionals treating members of the armed forces with substance use disorders (SUDs); and
  • address and offer recommendations on evidence-based methodology(ies) for determining the advisable ratio of physician and nonphysician health care providers of care for SUDs to members of the armed forces.

This chapter reviews the regulations and instructions governing addiction counselors and licensed practitioners in each branch of the U.S. armed forces. In response to the committee’s queries, the Air Force, Army, Navy, and Marine Corps provided counts of the current counseling and physician workforce credentialed to treat alcohol and other drug use disorders. The committee also examined the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) to understand the current ratios of physicians and nonphysician health care professionals assigned to treat alcohol and other drug use disorders. The sections that follow describe and critique the addiction workforce in each branch of the U.S. armed forces. The chapter ends with a summary of key findings.



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8 Substance Use Disorder Workforce T he committee’s charge included two tasks that required an analysis of the credentials and numbers of physicians and nonphysician health care professionals treating alcohol and other drug use disorders in members of the armed forces: • analyze the adequacy and appropriateness of current credentials and other requirements for physician and nonphysician health care professionals treating members of the armed forces with substance use disorders (SUDs); and • address and offer recommendations on evidence-based meth- odology(ies) for determining the advisable ratio of physician and nonphysician health care providers of care for SUDs to members of the armed forces. This chapter reviews the regulations and instructions governing addiction counselors and licensed practitioners in each branch of the U.S. armed forces. In response to the committee’s queries, the Air Force, Army, Navy, and Marine Corps provided counts of the current counseling and physician workforce credentialed to treat alcohol and other drug use disorders. The committee also examined the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) to understand the current ratios of physicians and nonphysician health care professionals assigned to treat alcohol and other drug use disorders. The sections that follow describe and critique the addic- tion workforce in each branch of the U.S. armed forces. The chapter ends with a summary of key findings. 227

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228 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES AIR FORCE WORKFORCE The Air Force’s 75 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) programs provide services to prevent and treat SUDs. Located organizationally in the Mental Health Flight, three types of providers staff ADAPT clinics: (1) licensed clinical social workers with master’s or doctoral training; (2) licensed clinical psychologists with doctoral training; and (3) certified Air Force alcohol and drug counselors (Oordt, 2011). The certified alcohol and drug counselors make up the primary staffing for the ADAPT programs. They work under the supervision of an ADAPT pro- gram manager (a licensed psychologist or social worker). Licensed mental health counselors (military and civilian) assigned to the behavioral health clinic may also work with ADAPT patients, diagnosing, developing and amending treatment plans, and terminating treatment within the scope of their licenses. The number of privileged providers assigned specifically to each ADAPT clinic depends on the local need for services. The Air Force identified two physicians (one civilian internal medicine provider and one civilian anesthesiologist) certified in addiction medicine. In addition, the Air Force reported 144 active duty psychiatrists and 12 civilian psychiatrists; although none was certified in addiction medicine, it was reported that psychiatrists frequently provide treatment services in the ADAPT clinics. Table 8-1 shows the numbers of ADAPT providers by job title. Air Force Instruction 44-121, section 3.13, indicates that the primary objective of the treatment team for an individual ADAPT client is “to guide the clinical course of treatment of the client after examining all the facts” (U.S. Air Force, 2011b, p. 21). The treatment team meets within 14 days of the initial assessment. It includes (1) the client’s unit commander or first sergeant, (2) the client’s immediate supervisor, (3) the ADAPT program manager (treatment team leader), (4) alcohol and drug counselors and men- tal health technicians involved in the case, (5) medical providers if needed, (6) other individuals as needed, and (7) the client (unless deemed clinically inappropriate). Air Force Instruction 44-121 (U.S. Air Force, 2011b) also establishes guidance for the ADAPT program and implements Air Force Policy Direc- tive 44-172, Medical Operations for Behavioral Health Flight (U.S. Air Force, 2011c). The instruction applies to all active duty Air Force members and to members of the Air Force Reserve Command and Air National Guard. Air Force policy requires health care personnel to complete annual training on substance misuse and abuse. According to information pro- vided to the committee by the Air Force, the training begins with a review of the mandate that all suspected or diagnosed cases of substance abuse be referred to mental health services for assessment. The training reviews standardized screening tools (Alcohol Use Disorders Identification Test

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SUBSTANCE USE DISORDER WORKFORCE 229 TABLE 8-1  Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Workforce Position Active Duty Civilian Physicians   Nonpsychiatrist M.D.s certified in addiction   medicine   0   2   Psychiatrists certified in addiction medicine None (144 total None (12 total psychiatrists) psychiatrists) Licensed Independent Practitioners   Licensed clinical psychologists (Ph.D.) 218a 117a   Licensed clinical social workers 206a 216a Counselors   Certified alcohol and drug counselors (ADCs) II 289b  96b a The numbers in the table reflect the numbers of providers in each specialty area who are qual- ified to provide SUD treatment. Providers are authorized and assigned to the Mental Health Flight at each military treatment facility; they are not necessarily assigned to the ADAPT clinic but may provide treatment for SUDs when needed. Some of these providers may currently be assigned outside the military treatment facility setting (e.g., staff jobs, operational roles). At a minimum, each of the 75 Air Force military treatment facilities has one ADAPT program manager and one mental health technician working in the ADAPT program. b Noncertified mental health technicians work in ADAPT while in training for their ADC certification. These individuals are not reflected in the numbers shown. SOURCE: Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations Agency, October 25, 2011. [AUDIT] and Post-Deployment Health Reassessment [PDHRA]) and signs of commonly abused drugs and encompasses diagnosis, intervention, and the mandatory notification of ADAPT (U.S. Air Force, 2011a). The Air Force Substance Abuse Counselor Certification Board estab- lishes standards for counselor certification. The Air Force is a member of the International Certification and Reciprocity Consortium (IC&RC), which sets standards globally for certified substance abuse counselors (IC&RC, 2012), and adheres to its certification standards. The Air Force Substance Abuse Counselor Certification Board encourages mental health technicians, mental health providers, and nurses providing substance abuse treatment in a military treatment facility to seek certification as a substance abuse counselor (U.S. Air Force, 2010). Licensed practitioners (physicians, psychologists, social workers) are not required to obtain certification but may apply. The ADAPT program manager in each clinic reviews and approves applicants for certification. Certification applicants must sign the USAF Alcohol and Drug Counselor Code of Ethics and obtain 6 hours of train-

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230 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES ing in counselor ethics provided by the program manager (U.S. Air Force, 2010). Applicants complete formal education, supervised/practical training, and work experience prior to certification (U.S. Air Force, 2010): • Formal education ɶɶ  270 hours of training in domains for alcohol and other drug counseling ɶɶ  required reading (Chapters 1-5 of the Alcoholics Anonymous Big Book [Alcoholics Anonymous World Services, 1939]) • Supervised/practical training ɶɶ  300 hours of documented supervision and 10 hours of supervi- sion in each of eight core functions ɶɶ  attendance at a minimum of five support groups and five after- care sessions during a 3-year internship • Work experience ɶɶ  6,000 hours of supervised work experience (3 years) ɶɶ  1 year of work in the ADAPT program ɶɶ  following of one diagnosed patient from the beginning to the end of treatment The required hours of work experience can be reduced based on education: a 1,000-hour reduction for an associate’s degree, 2,000 hours for a bach- elor’s degree, and 4,000 hours for a master’s degree. Certified counselors must complete 60 hours of continuing education every 3 years to maintain certification. Mental health technicians who are not certified alcohol and drug coun- selors must have written training plans to develop competence in working with patients with alcohol and other drug use disorders. The training plan must include completion of Qualification Training Package 1, which includes the Twelve Core Functions of Substance Abuse Counselors identi- fied by IC&RC (U.S. Air Force, 2010) (see Box 8-1). Training continues until the technician has the education and field experience required to qualify for certification and pass the oral and written certification exams. ADAPT program managers are licensed psychologists or social workers who in many cases function as the sole licensed independent practitioner for the ADAPT clinic. There are no formal requirements for the ADAPT program manager to have specialty training in providing care for SUDs. The ADAPT program manager “coordinates clinic resources to provide effective education, identification, assessment and treatment programs as well as coordinates with the Resiliency Element (RE) to provide prevention programs” (U.S. Air Force, 2011b, p. 7). He/she is also responsible for bud- get management, workload reporting, coordination with off-base resources, development and implementation of education programs, assistance in the

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SUBSTANCE USE DISORDER WORKFORCE 231 BOX 8-1 12 Core Functions of Substance Abuse Counselors •  Screening •  Case management •  Intake •  Crisis intervention •  Orientation •  Patient education •  Assessment •  Referral •  Treatment planning • Reports and record keeping • Counseling (individual, group, • Consultation with other profes- and significant others) sionals with regard to patient treatment/services SOURCE: U.S. Air Force, 2010. identification and referral of individuals needing ADAPT services, super- vision of nonprivileged personnel, development and tracking of quality improvement metrics, and chairing of treatment team meetings. Additional responsibilities relate to HIV testing requirements; coordination with the Resiliency Element on community referral guidelines; coordination with Air Force Reserve and National Guard members, including ensuring that they receive appropriate services; and provision of monthly status reports on all ADAPT program clients and fitness-for-duty or status recommendations. ARMY WORKFORCE AR 600-85 specifies staffing requirements for the Army Substance Abuse Programs (ASAPs). ASAPs operate under the direction of alcohol and drug control officers (ADCOs), who are responsible for staff management and supervision, management of the drug and alcohol testing program, coordination of all risk reduction and prevention services, coordination of and assistance with Command referrals, development of an ASAP staff training plan, evaluation of prevention activities, and preparation and approval of all reports. A prevention coordinator, an employee assistance program coordinator, a drug testing coordinator, a risk reduction program coordinator, a suicide program manager, a clinical director, counselors, clinical consultants, and substance abuse professionals support the ADCO and the delivery of ASAP services. As of February 2012, 63 ADCOs super- vised 349 ASAP prevention staff. Table 8-2 shows the number of individu- als in nonclinical positions, who generally provide support for prevention and drug testing efforts.

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232 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES TABLE 8-2  Army Substance Abuse Program (ASAP) Prevention Workforce Position Civilian Alcohol and drug control officers (ADCOs)  63 Risk reduction program coordinators  55 Drug testing coordinators 132 Suicide program managers  34 Prevention coordinators  81 Employee assistance program coordinators  47 Total 412 SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Program, February 22, 2012. Clinical providers must have a master’s or doctoral degree in social work, psychology, counseling, or marriage and family therapy from an accredited university and a state-issued independent license. Counselors not licensed as independent practitioners must have a master’s degree and a national recognized certification in substance abuse rehabilitation. ASAP requires a minimum of 2 years of sobriety or postrehabilitation experience for counselors in recovery from an SUD. Department of Defense (DoD) reg- ulations require Medical Command (MEDCOM) to continue to credential ASAP clinicians despite the recent relocation of ASAP’s clinical services to the Installation Management Command (IMCOM). The credentialing pro- cess follows regulations specified in AR 40-68 (Medical Services: Clinical Quality Management). Table 8-3 shows the numbers of clinical providers currently assigned to ASAP. As the table indicates, ASAP staffing does not include physicians. Military treatment facilities provide physician support when needed for SUD patients with comorbid conditions, including suicid- ality, posttraumatic stress disorder (PTSD), and traumatic brain injury, and those requiring medication assistance. The committee heard testimony that as of May 2011, the staffing rate for the ASAP clinics was just 66 percent.1 During 2011, the Army made substantial efforts to recruit and retain ASAP practitioners, but there were too few applicants who met the Army’s coun- selor requirements, and ASAPs continue to be understaffed. NAVY WORKFORCE Navy Instruction 5350-4D (U.S. Navy, 2009) specifies the operation of the Navy’s alcohol and drug abuse prevention and control programs. Bureau of Medicine (BUMED) Instruction 5353.4A operationalizes the 1 Personalcommunication, Col. John Stasinos, M.D., Addiction Medicine Consultant for the Army Office of the Surgeon General, May 3, 2011.

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SUBSTANCE USE DISORDER WORKFORCE 233 TABLE 8-3  Army Substance Abuse Program (ASAP) Clinical Workforce as of December 2011 Position Civilian Physicians   Nonpsychiatrist M.D.s certified in addiction medicine None authorized for ASAP   Psychiatrists certified in addiction medicine None authorized for ASAP Licensed Independent Practitioners   Licensed clinical psychologists (Ph.D.)  17   Licensed clinical social workers 219   Licensed professional counselors 165   Licensed marriage and family therapists  70 Counselors (not licensed independent practitioners)   Master’s-level substance abuse certification 406 Other   Social workers (not licensed clinical social workers)  24 SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Program, February 22, 2012. standards for provision of SUD-related treatment services (U.S. Navy, 1999). Substance Abuse Rehabilitation Program (SARP) site directors are usually psychiatrists or doctoral-level psychologists licensed as indepen- dent practitioners. Licensed clinical social workers also are available to see patients. Civilian counselors are certified or licensed. Active duty alcohol and drug counselors must be certified or seeking certification. The Navy Certification Board is a member of IC&RC. Navy instructions are silent on the credentials and training required for alcohol and drug abuse counselors. The Navy School of Health Sciences hosts the Navy Drug and Alcohol Counselor School (NDACS), which pro- vides training to meet certification standards for alcohol and drug counselor I (nonreciprocal), alcohol and drug counselor II, and certified clinical super- visor. NDACS holds five 10-week classes per year. Three weeks of clinical rotation are included in the 10-week course. Course work, based on the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment’s Treatment Assistance Protocol 21 (SAMHSA, 1998), emphasizes counseling skills, group counseling skills, integration of 12-step programs with treatment, and biopsychosocial and spiritual aspects of substance abuse and dependence. The 1,172-page Stu- dent Guide for Navy Drug and Alcohol Counselor School (U.S. Navy, 2011) includes a lesson on the pharmacology of alcohol and other drug use and the effects on the brain. The discussion of pharmacological therapy, however, is limited to psychiatric medications and the need to continue

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234 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES taking those medications even when there is peer pressure to stop their use. There is no discussion of medications with Food and Drug Administration approval for treatment of alcohol and opioid use disorders. In addition, NDACS offers a prevention specialist course to provide education and training on designing and implementing evidence-based SUD prevention programs at the local Command level. The prevention specialists are trained to use the strategies of SAMHSA’s Center for Substance Abuse Prevention and to use the National Registry of Evidence-Based Programs and Practices to select prevention programs for their local community (DoD, 2011, Appendix C). Intern counselors must complete 270 hours of alcohol and other drug abuse education (including 3 hours of ethics train- ing) during 7 weeks of the NADCS curriculum and 120 hours (3 weeks) of supervised practical experience to complete the 10-week curriculum. Certi- fied alcohol and drug counselors I must complete 195 hours of supervised practical experience plus 2,000 hours (1 year) of supervised work experi- ence and must pass the alcohol and drug counselor I certification exam. Alcohol and drug counselors II must complete 6 hours of ethics training, 300 hours of supervised practical experience, and 6,000 hours of supervised work experience and must pass the IC&RC alcohol and drug counselor certification exam. Certified clinical supervisors must have alcohol and drug counselor II certification plus 30 hours of clinical supervision training, 10,000 hours of work experience, and 4,000 hours of supervision experi- ence and must pass the IC&RC certified clinical supervision certification exam. All counselors must have a minimum of 50 hours of supervision per year (1 hour per week). See Table 8-4 for numbers of SARP providers by job title. TABLE 8-4  Substance Abuse Rehabilitation Program (SARP) Workforce Active Position Duty Civilian Contractor Licensed Independent Practitioners Licensed clinical social workers 16 1 Licensed clinical psychologists 18 2 Psychiatrists  5 Counselors Substance abuse counselors (alcohol and drug   counselors I) 87 11 2 Substance abuse counselors (alcohol and drug   counselors II) 39 43 3 Certified prevention specialists  8 SOURCE: Personal communication, Charles Gould, Naval Bureau of Medicine, March 1, 2012.

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SUBSTANCE USE DISORDER WORKFORCE 235 The San Diego SARP is the Navy’s largest and most intensive SARP, providing both residential and outpatient services.2 Eleven interdisciplinary teams (substance abuse counselors, senior addiction counselors, licensed providers) can access medical support, a psychiatrist, and specialized men- tal health providers. A family counselor, recreation therapists, a creative art therapist, case managers, and chaplain support also are available. The residential staff includes 13.5 licensed providers (2 active duty), 2.5 rec- reation therapists, 36 alcohol and drug counselors (13 active duty), 14 administrative staff, and 14 medical staff. The outpatient staff includes 4  licensed providers (1 active duty), 16 alcohol and drug counselors (8 active duty), and 3 administrative staff. During a site visit, the committee learned that the San Diego SARP was evolving its services to fully address comorbid mental health disorders. The program now meets criteria for a dual-diagnosis enhanced program and has trained its providers in the treat- ment of comorbid disorders accordingly. MARINE CORPS WORKFORCE The Marine Corps operates 15 Substance Abuse Counseling Centers (SACCs), 14 of which have the capability to provide outpatient services. SACCs that do not provide outpatient group therapy are located at smaller installations and generally provide one-on-one counseling or refer to an outside agency. The Marine Corps transitioned to a civilian workforce for its SACCs to improve service delivery and allow for uniformity and stability while returning Marines to their primary military occupational specialty. The SACCs include both treatment and prevention staff. Coun- selors, directors, and medical officers implement and coordinate screening, assessment, and treatment services. Alcohol abuse prevention specialists and drug demand reduction coordinators have lead responsibility for pre- vention activities. Substance abuse control officers (SACOs), discussed fur- ther below, work closely with SACCs to facilitate Command referrals for screening and to supervise and implement annual drug screening. Alcohol abuse prevention specialists must complete certification as a prevention specialist within 180 days of assignment. They conduct annual assess- ments of alcohol abuse prevention needs, including a risk assessment, and develop annual alcohol abuse prevention plans. They also provide a monthly train-the-trainers course—Building Alcohol Skills Intervention Curriculum (BASIC)—to support alcohol abuse prevention (see Appendix D for further review of BASIC). Drug demand reduction coordinators assess needs for drug abuse prevention (which includes performing a risk assess- 2 Personal communication, CAPT Mary K. Rusher, M.D., Substance Abuse Rehabilitation Program Department Head, Naval Medical Center San Diego, March 1, 2012.

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236 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES ment) and develop an annual prevention plan with measurable objectives. They also provide education on illicit and prescription drugs. Civilian certified substance abuse counselors screen, assess, and coun- sel patients and draft treatment plans under the supervision of the SACC director and SACC medical officer. Counselors enter patient data into the Alcohol and Drug Management Information Tracking System (ADMITS). The SACC director is responsible for the overall SACC operation and the accuracy of data entered into the ADMITS database, consistent with Marine Corps Order 5300.17. Directors are certified as clinical supervisors and as alcohol and drug counselors. Directors provide individual and group counseling when counselors are unavailable. SACC directors report to the director of behavioral health programs. A medical officer (physician or clinical psychologist credentialed and privileged through the Naval hospi- tal) assigned to a local military treatment facility makes formal diagnoses, approves individualized treatment plans, authorizes changes in treatment plans, and makes discharge decisions. Each Command has an assigned SACO who provides technical assistance to that commander and education to the Marines on prevention of substance abuse and the related Marine Corps policies. SACOs also are responsible for urinalysis screening and act as the liaison between the Command and the SACC. As part of their train- ing, SACOs attend a mandatory 40-hour course that provides an overview of their duties and responsibilities. Staffing ratios for each SACC are determined by installation command- ers based on need and other factors. The ratio is typically 1 counselor per 2,500 active duty Marines. Table 8-5 shows the numbers of providers by job title that the Marine Corps reported to the committee. The Marine Corps is assessing the feasibility of amending credentialing requirements to include licensed professional counselors and licensed clinical social workers as licensed independent practitioners. Marine Corps Order 5300.17 requires that certified counselors staff SACCs but is otherwise silent on training and qualification. Because the Marine Corps hires certified or licensed practitioners, it no longer uses TABLE 8-5  Substance Abuse Counseling Center (SACC) Workforce Position Civilian Substance abuse counseling directors 10 Substance abuse counselors (alcohol and drug counselor I)  7 Substance abuse counselors (alcohol and drug counselor II) 56 Drug demand reduction coordinators 23 Certified prevention specialists  8 SOURCE: Personal communication, Charles Gould, Naval Bureau of Medicine, March 1, 2012, and Eric Hollins, Marine and Family Programs Division, October 25, 2011.

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SUBSTANCE USE DISORDER WORKFORCE 237 NDACS for counselor certification. The school continues to provide train- ing for certified clinical supervisor and prevention certifications. DoD EFFORTS TO REVIEW STAFFING REQUIREMENTS The committee determined early on in its deliberations that while its statement of task called for providing “recommendations on evidence- based methodology(ies) for determining the advisable ratio of physician and nonphysician health care providers of care for SUDs to members of the armed forces,” doing so would require information and use of DoD’s data systems that were unavailable to the committee. The committee determined that appropriate staffing ratios can be determined only with a thorough understanding and knowledge of the health needs of the population in question and access to health data records. Because DoD recently developed and implemented a model that takes into account the psychological health needs of its population and estimates psychological staffing requirements, the committee deemed it most helpful to review this existing model and examine whether the ratios related to SUDs are adequate. The impetus for the development of a staffing model began when DoD’s Mental Health Task Force reviewed the resources available to support psy- chological health among service members and their families. The task force concluded that funding and personnel were insufficient “to adequately sup- port the psychological health of service members and their families in times of peace and conflict” (DoD, 2007, p. 41). In response to the task force’s recommendations for increased staffing for a full continuum of psychologi- cal care within the Military Health System and the TRICARE purchased care system, the Office of the Assistant Secretary of Defense for Health Affairs contracted for the development of a risk-adjusted population-based model for psychological health staff. The resulting PHRAMS model defines psychological health services and needs broadly to include prevention ser- vices, diagnosis and treatment of mental health conditions, and behavioral and psychological health issues not defined as mental health conditions (Harris and Marr, 2011). PHRAMS forecasts staffing requirements to meet the estimated annual need by type of provider. Need is estimated on the basis of longitudinal trends in service utilization by condition type and adjusted for underutiliza- tion. The model includes a risk adjustment for recent deployment history; need varies by the number, length, and recency of deployments based on service utilization data. “PHRAMS includes all encounters reported in the direct care professional encounters or purchased care non-institutional MDR [Military Health System Data Repository] files regardless of what type of provider it was with, what clinical setting (inpatient or outpatient) it occurred in, or what sector (direct or purchased care) it was delivered

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238 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES in—as long as the encounter was psychological health in nature” (Harris and Marr, 2011, p. 17). More specifically, the total staffing requirement is the sum of encounter-based plus non-encounter-based staffing requirements. The encounter-based staffing requirement is based on the estimated number of encounters divided by the productivity expectation. The encounter esti- mate reflects the population covered in the Defense Health Plan, multiplied by the prevalence rate of the specific psychological health needs, multiplied by the encounter rate. Separate estimates are generated for each risk group and 12 diagnostic groups (see Box 8-2 for details). Non-encounter-based staffing requirements are the sum of enrollee-based requirements, plus structural unit requirements, plus support staff requirements and reflect work requirements in addition to clinical productivity (encounters). PHRAMS Version 3.0 software is available as a compact disc-based user application plus user’s guide. The databases can be updated annually to reflect changing service needs. Soft parameters allow users to modify the proportion of direct versus purchased care at the primary planning unit level, adjust the productivity metrics, change the estimates for underutiliza- tion, and alter the distribution of service members projected to fall into the deployment experience categories. For 2012, PHRAMS estimates that the DoD direct care system requires 146.1 full-time equivalents (FTEs) of counselor time to provide treatment for SUDs. The estimate for the purchased care system is 151.5 FTEs (Harris and Marr, 2011). The estimates increase to 192.7 (direct care) and 227.1 (purchased care) FTEs in 2017. The 2012 staffing requirement estimates for substance abuse counselors vary by branch: Air Force = 6.6 FTEs, Army = 112.9 FTEs, and Navy = 26.6 FTEs (Harris and Marr, 2011). (Require- ments for the Marine Corps are largely included in the Navy estimates because the Navy provides clinical services for the Marines.) The committee notes that these estimates for substance use counselor staffing are far below the current staffing levels. The PHRAMS data appear to be incomplete. The PHRAMS need estimates reflect primarily services that occur in military treatment facilities and are captured in the MDR. Encounters for SUDs that occur in the specialized treatment settings for these disorders (e.g., ADAPT, ASAP, SARP) apparently are not included in the MDR. Moreover, if care occurs under the supervision of licensed practi- tioners, the encounters are attributed to the type of practitioner supervising the case (e.g., psychologist, social worker). SUMMARY OF KEY FINDINGS This chapter has reviewed the workforce standards for health care professionals providing prevention and treatment services for SUDs for

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SUBSTANCE USE DISORDER WORKFORCE 239 BOX 8-2 Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) Diagnosis and Risk Groups • Diagnosis Groups  Affective psychosis (including major depressive disorder)  Nonpsychotic depression  Other neurotic disorders  Adjustment disorder or acute stress reaction (excluding posttrau- matic stress disorder [PTSD])  PTSD  Psychotic and nonpsychotic substance use  Nonpsychotic childhood disorder  All other psychotic disorders  Psychological health V-codes (excluding Post-Deployment Health Assessment/Reassessment [PDHA/PDHRA])  Psychological health V-codes for PDHA/PDHRA  Other psychological health not elsewhere classified ­ • Risk Groups (more than 30,000 unique risk groups)  Service (Army, Air Force, Navy, Marines, unknown)  Beneficiary category (service member, service family member, all other)  Gender (male, female)  Age group (under 18, 18-24, 25-44, 45-64, 65 and older)  Rank group (junior enlisted, senior enlisted, junior officer, senior officer)  Component (active duty, reserve, neither)  Enrollment (enrolled in a military treatment facility, enrolled in the purchased care network, not enrolled)  Deployment exposure history (never deployed, moderate–not recent deployment, moderate-recent deployment, high–not recent deployment, high-recent deployment, currently deployed) SOURCE: Harris and Marr, 2011. members of the armed forces. The committee’s analysis of the credentialing and other requirements used by each branch led to findings on the adequacy and appropriateness of these requirements. Finding 8-1: Credentialing and required training for SUD counselors vary among the branches.

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240 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The Air Force, Navy, and Marine Corps rely on certified alcohol and drug counselors, while the Army requires individuals to have graduate training and professional licenses as psychologists, social workers, or coun- selors. The committee finds that few licensed professionals (physicians, psychiatrists, psychologists, social workers, licensed professional counsel- ors, marriage and family counselors) are available to individuals seeking treatment for SUDs in the U.S. armed forces. Currently, each branch sets requirements for the staffing of its SUD programs; DoD has set forth no overarching guidelines. The result is considerable variability from branch to branch in the size and makeup of the SUD counseling workforce. The certified counselor specialty emerged in the 1980s because licensed professionals were not trained and had little interest in treating alcohol and other drug use disorders. In 1979, fewer than one in four counselors (22 percent) held a graduate degree (Camp and Kurtz, 1982). Counselor certification is a useful tool for setting minimum standards. Certification standards, however, have not evolved to keep pace with scientific develop- ments and the emergence of evidence-based pharmacological and behav- ioral therapies for SUDs. Women and men seeking treatment for SUDs are increasingly burdened with comorbid mental health and physical health dis- orders. In the U.S. military, comorbid posttraumatic stress disorder (PTSD) diagnoses are common. Treatment for comorbid mental health diagnoses is outside the scope of practice for most certified alcohol and drug counselors. The nation’s SUD workforce is evolving in response to the changing needs of the patient population. A 2007 workforce analysis found that 42 percent of counselors and 58 percent of counselor supervisors working within treatment centers participating in the National Drug Abuse Treat- ment Clinical Trials Network held a master’s or doctoral degree; in outpa- tient treatment settings, moreover, 53 percent of counselors held graduate degrees (McCarty et al., 2007). Nationally, health care reforms are likely to limit the use of unlicensed credentialed counselors. Payers will require independent licensure for counselors providing care for SUDs (McCarty et al., 2009). Instead of continuing to use a 20th-century workforce to treat SUDs, DoD is challenged to structure and staff treatment services for alcohol and other drug use disorders for the 21st century. As discussed in Appendix F, the emerging model of SUD care uses multidisciplinary treatment teams to create a varied workforce with carefully articulated roles and training. Individuals in recovery provide peer support instead of serving as primary counselors. Certified counselors work under the supervision of licensed practitioners. Treatment plans include evidence-based pharmacological and behavioral therapies, as well as long-term continuing care with peer sup- port. To increase caseloads and enhance productivity, services emphasize outpatient and intensive outpatient modalities, rely on relatively brief inten-

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SUBSTANCE USE DISORDER WORKFORCE 241 sive group therapy, use computer-assisted cognitive-behavioral techniques, and include long-term support and ongoing recovery monitoring. The U.S. military needs to begin to reconfigure the workforce provid- ing alcohol and other drug treatment services so that active duty military personnel have the same level of professional care that is afforded to the civilian population (as discussed in Appendix F). The U.S. military also appears to have an increased need for licensed practitioners to support its members with comorbid mental health disorders and SUDs. Finding 8-2: The SUD counselor training manuals of the Air Force and Navy are dated, do not address the use of evidence-based pharmacolog- ical and behavioral therapies, and do not reference the VA/DoD Clini- cal Practice Guideline for Management of Substance Use Disorders. Chapter 10 of the Air Force Alcohol and Drug Counselor Certification Handbook (U.S. Air Force, 2010) outlines knowledge and skill require- ments. The listed skills are based on the Model Professional Standards for Counselor Credentialing released in 1984 (Birch and Davis Associates, Inc., 1984). The standards developed under contract for the National Institute on Alcohol Abuse and Alcoholism were crafted to stimulate and support voluntary credentialing efforts (Birch and Davis Associates, Inc., 1984). The standards are obsolete and do not address medication-assisted treatment for alcohol and opioid use disorders, nor do they describe evidence-based behavioral therapies. The Center for Substance Abuse Treatment released an update (Technical Assistance Publication [TAP] 21, Addiction Counsel- ing Competencies) in 2008, but it, too, overlooks important developments in the use of pharmacological and behavioral therapies. The next revision of Chapter 10 of the Air Force Alcohol and Drug Counselor Certification Handbook should be updated to address the use of evidence-based pharma- cological and behavioral therapies. Similarly, NDACS bases its curriculum on the Center for Substance Abuse Treatment’s TAP 21, which as noted does not address pharmacological and behavioral therapies for treatment of alcohol and other drug use disorders. An updated curriculum should more fully encompass emerging developments in evidence-based treatments for SUDs. Counselor training in both the Navy and Air Force neglects the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009). The Clinical Practice Guideline, developed in collaboration between the Department of Veterans Affairs (VA) and DoD, should be a core element of counselor training. Finding 8-3: Physicians who provide care in military treatment facilities and have received training in addiction medicine or addiction psychia- try are a rarity.

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242 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES While the current SUD workforce serving the military falls short of meeting the need for SUD services generally, a particular shortfall is that few physicians have received training in addiction medicine or addiction psychiatry. General medical officers and flight surgeons receive minimal instruction in SUDs, yet often are on the front lines of diagnosis, suggesting that these providers should receive additional training to diagnosis and treat alcohol and other drug-related disorders. Beyond specialty training, one opportunity to increase background SUD training among the larger work- force of primary care physicians who provide care to military personnel is for these physicians to have a continuing medical education requirement in screening, brief intervention, and referral to treatment (SBIRT) and SUD treatment. As an example, the American Society of Addiction Medicine (ASAM) offers highly regarded state-of-the-art courses in this area and the Ruth Fox Course for Physicians (which educates doctors on addiction medicine) at its annual conferences. The committee also reviewed a webinar course on SBIRT created by the Defense Centers of Excellence that was offered in January 2012 to DoD providers. The committee finds this effort to train DoD providers in evidence-based practices such as SBIRT a prom- ising step toward building a more knowledgeable workforce; however, the extent to which this course is widely disseminated and whether providers are implementing the practices learned through the webinar are unclear. The committee also learned of an additional effort by the Defense Centers of Excellence to further educate providers in SUDs and their treatment. A toolkit was developed for this purpose and became available for provider use in early 2012. The committee’s review of this toolkit revealed that the materials are comprehensive and represent an excellent start toward training providers in best practices for treatment of SUDs. Because the toolkit was developed and released recently, however, the extent of its dis- semination and of implementation of the practices at the provider level is unknown. Finding 8-4: The PHRAMS program is a reasonable start toward determining the quantitative relationship between the need for SUD care and staffing levels. PHRAMS appears to be a useful tool for assessing staffing needs for care for mental health disorders. The Government Accountability Office noted that the Army, Air Force, and Navy are using PHRAMS to estimate mental health staffing requirements for their budget requests (GAO, 2010). The committee finds that PHRAMS provides an underestimate of the staff- ing required to address alcohol and other drug use disorders. DoD’s Com- prehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed Forces

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SUBSTANCE USE DISORDER WORKFORCE 243 similarly finds that SUD treatment is in some cases not being counted in the MDR database from which PHRAMS calculates estimates for staffing. PHRAMS therefore requires modification before it can be applied to esti- mate staffing needs for alcohol and drug counselors (DoD, 2011). The PHRAMS analysis, however, includes interesting data related to alcohol and drug use treatment needs. During fiscal year (FY) 2010, 10.4 percent of the psychological health encounters in the MDR data- base were related to “psychotic and nonpsychotic substance use,” with a mean of 3.5����������������������������������������������������������  ��������������������������������������������������������� encounters among individuals with a substance use encoun- ter (­ arris and Marr, 2011). PHRAMS assumes that each substance use H patient should receive a mean of 9 encounters. The PHRAMS database (FY 2003 through FY 2010) shows increasing use of psychological health services over the 8-year span and variations by service branch (Harris and Marr, 2011). Based on the trend of increasing encounters and adjusting for under­ tilization and changes in demographics, PHRAMS estimates an u increasing need for services related to SUDs. It should be kept in mind, however, that the PHRAMS FTE estimate reflects only services reported in the MDR database. The committee’s charge included offering recommendations on evidence-­ ased methods for estimating staffing needs to address SUDs. b The PHRAMS software appears to include the key variables required for estimating staffing needs, including the ratio of physician and nonphysi- cian health care providers. The underestimated need for counselors to treat SUDs, however, suggests that the parameters for making estimates need substantial modification and that the data used to generate the staffing estimates for SUD treatment may be incomplete. Refinement and complete data are required if PHRAMS is to be used to estimate staffing needs for substance use encounters. Finding 8-5: All of the branches appear to have shortages of SUD counselors. The branches all reported shortages of counselors in their SUD pro- grams. The Army was actively recruiting licensed practitioners to staff ASAPs while the committee met. The Navy had unfilled authorized posi- tions. The Air Force and Marine Corps reported minimal staffing levels in their programs as well. It is apparent that the branches have pressing needs for additional qualified counselors to staff their SUD programs. In both civilian and military programs, recruitment and retention of practitioners skilled in addressing SUDs is an ongoing challenge because the positions have low prestige, offer low salaries, and tend to attract entry- level practitioners. The low prestige reflects the lack of professional train- ing and licensure. Credentialed counselors who are not licensed often are

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244 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES seen as paraprofessionals who are not as skilled or trained as practitioners with graduate training and professional licensure. The stigma of addiction contributes to the low prestige and the view that counselors who treat only alcohol and other drug use disorders are not full professionals. Because much of the SUD workforce lacks graduate training and is unlicensed, the individuals who fill these positions accept low salaries. Low salaries in turn enhance the perception that the positions lack professional status. Staff turnover is a related issue, as industries with lower salary levels tend to have higher levels of turnover. Annual turnover rates in SUD counseling positions approach 25 percent (Eby and Rothrauff-Laschober, 2012). As a result, treatment programs are constantly recruiting and training new staff, who tend to be entry-level and to require more training investment. The U.S. military faces similar staffing challenges for SUD counselors. While higher salaries and a focus on graduate-trained individuals with professional licensure could help address some of these staffing challenges, the stigma of addiction lingers and makes positions focused on addiction treatment less attractive. Full integration with mental health and primary care services could enhance the professional status and prestige of treating alcohol and other drug use disorders. Finding 8-6: Each of the military branches could benefit from a better trained and staffed prevention workforce. While the statement of task for this study did not specifically require an examination of SUD prevention providers, during the course of its review the committee learned that each branch could benefit from improved work- force standards and staffing for SUD prevention as well as treatment. REFERENCES Alcoholics Anonymous World Services. 1939. Alcoholics Anonymous. New York: Works Publishing, Inc. Birch and Davis Associates, Inc. 1984. Development of model professional standards for counselor credentialing (Vol. 1). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Alcohol Abuse and Alcoholism. Camp, J. M., and N. R. Kurtz. 1982. Redirecting manpower for alcoholism treatment. In Prevention, intervention and treatment: Concerns and models. Rockville, MD: U.S. De- partment of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Alcohol Abuse and Alcoholism. Pp. 371-397. DoD (Department of Defense). 2007. An achievable vision: Report of the Department of De- fense Task Force on Mental Health. Washington, DC: DoD Task Force on Mental Health.

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SUBSTANCE USE DISORDER WORKFORCE 245 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. Eby, L. T., and T. C. Rothrauff-Laschober. 2012. The relationship between perceptions of organizational functioning and voluntary counselor turnover: A four-wave longitudinal study. Journal of Substance Abuse Treatment 42(2):151-158. GAO (Government Accountability Office). 2010. Military personnel: Enhanced collaboration and process improvements needed for determining military treatment facility medical personnel requirements. Washington, DC: U.S. Government Printing Office. Harris, D. M., and L. M. Marr. 2011. The Psychological Health Risk-Adjusted Model for Staff- ing (PHRAMS): Update for version 3.0. Alexandria, VA: CNA Analysis and Solutions. IC&RC (International Certification & Reciprocity Consortium). 2012. Setting global stan- dards for addiction professionals. http://internationalcredentialing.org (accessed May 28, 2012). McCarty, D., B. E. Fuller, C. Arfken, M. Miller, E. V. Nunes, E. Edmundson, M. Copersino, A. Floyd, R. Forman, R. Laws, K. M. Magruder, M. Oyama, K. Prather, J. Sindelar, and W. W. Wendt. 2007. Direct care workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, opinions, and beliefs. Psychiatric Services 58(2):181-190. McCarty, D., K. J. McConnell, and L. A. Schmidt. 2009. Policies for the treatment of alcohol and drug use disorders: A research agenda for 2010-2015. Princeton, NJ: Robert Wood Johnson Foundation. Oordt, M. 2011. Air Force substance abuse policies and programs. Lackland Air Force Base, TX: Air Force Medical Operations Agency. SAMHSA (Substance Abuse and Mental Health Services Administration). 1998. Addiction counseling competencies the knowledge, skills, and attitudes of professional practice. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, SAMHSA. U.S. Air Force. 2010. Air Force alcohol and drug counselor certification handbook. Washing- ton, DC: Department of the Air Force. U.S. Air Force. 2011a. AFMS annual training on substance misuse and abuse for healthcare personnel. Washington, DC: Department of the Air Force. U.S. Air Force. 2011b. Instruction 44-121: Alcohol and Drug Abuse Prevention and Treatment (ADAPT) program. Washington, DC: Department of the Air Force. U.S. Air Force. 2011c. Instruction 44-172: Mental health. Washington, DC: Department of the Air Force. U.S. Navy. 1999. BUMEDINST 5353.4A: Standards for provision of substance related disor- der treatment services. Washington, DC: Bureau of Medicine, Department of the Navy. U.S. Navy. 2009. Operation Navy Instruction 5350.4D: Navy alcohol and drug abuse preven- tion and control. Washington, DC: Department of the Navy. U.S. Navy. 2011. Student guide for Navy Drug and Alcohol Counselor School. San Diego, CA: Navy Drug and Alcohol Counselor School. VA (Department of Veterans Affairs) and DoD. 2009. VA/DoD clinical practice guideline for management of substance use disorders. Washington, DC: VA and DoD.

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