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9 Conclusions and Recommendations One of the most important lessons learned in recent years is that we cannot simply deal with health or discipline in isolation; these issues are interrelated and will require interdisciplinary solutions. —GEN Peter W. Chiarelli, 2012 Army 2020 Report, p. 6 T he charge for this study directed the committee to assess the ade- quacy and availability of and access to services for the prevention, diagnosis, screening, treatment, and ongoing management of sub- stance use disorders (SUDs) for military members and their families (Chap- ter  1). In response, the committee examined the scope of SUD problems in the military (Chapter 2) and the Military Health System that provides services for military personnel with those problems (Chapter 3); identified modern standards of SUD care (Chapter 4) and best practices from research and practice (Chapter 5); analyzed the SUD-related Department of Defense (DoD) and branch-level SUD policies and programs and compared them with standards of care and best practices (Chapter 6); inventoried access to care for service members, members of the National Guard and Reserves, and military dependents (Chapter 7); and assessed the credentialing and adequacy of staffing for the workforce providing SUD care (Chapter 8). Based on the findings of this comprehensive review, the committee devel- oped conclusions and recommendations designed to enable DoD and the branches to deliver to military members and their families with SUDs the best possible support and care that would be efficient, realistic, up to date, evidence-based, and in conformance with DoD policies. These conclusions and recommendations are presented in this chapter. 247

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248 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The committee recognizes the challenge of managing one of the nation’s largest health systems, but notes that the different branches tend to operate their SUD services with minimal direction from and accountability to DoD. Consequently, DoD needs to acknowledge that the current levels of substance use and misuse among military personnel (e.g., reported binge drinking among 47 percent of active duty service members in 2008 [Bray et al., 2009]) and their dependents constitute a public health crisis; require consistent implementation of prevention, screening, and treatment services; and assume the leadership necessary to achieve this goal. This complex task will undoubtedly require changes to military culture, which is perceived by many as inhibiting case finding and discouraging self-referral for alcohol and other drug use problems. Based on the demographics of the U.S. armed forces (i.e., the majority of men and women under age 30), the results of self-report surveys on drug and alcohol use (Bray et al., 2009), and the ready access to relatively inexpen- sive alcohol on military bases, the committee recognizes that the need for prevention and treatment efforts and services is higher than the utilization data reported in Chapter 7 suggest. The committee believes that the foun- dation for SUD policy and program formulation and resource allocation should be an understanding that the levels of alcohol and other drug use constitute a public health crisis in the military. The highest leadership levels throughout the military should recognize that alcohol and other drug use problems • are currently at unacceptably high levels and detrimental to readi- ness and total force fitness; • should be addressed with an arsenal of public health strategies (e.g., universal, selective and indicated prevention programs and policies) applied to population groups, particularly those at high risk; • require medical and behavioral interventions for individuals with emergent problems; • can be prevented and treated when detected early and addressed with confidential interventions; and • demand the attention of unit leaders and commanders. The committee recognizes the need for disciplinary action when crimi- nal behavior occurs, supports a strong surveillance program to detect the use of substances that impair performance, and applauds current efforts to enhance the quality and effectiveness of SUD prevention and treatment services. Increased routine screening for unhealthy alcohol use and mecha- nisms to support brief interventions and confidential treatment (each of

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CONCLUSIONS AND RECOMMENDATIONS 249 which is discussed in the recommendations that follow) could inhibit the development of severe alcohol and other drug use disorders, promote force readiness, and prolong careers. The recommendations presented in this chapter focus on • increasing emphasis on efforts to prevent SUDs in service members and their dependents; • developing strategies for identifying, adopting, implementing, and disseminating evidence-based programs and best practices for SUD care (including prevention, screening, brief intervention, diagnosis, treatment, and ongoing management); • increasing access to care for military service members and their dependents; and • strengthening the workforce treating SUDs within the armed services. In addition, although this issue is not addressed by a specific recommenda- tion in this report, DoD and the branches will need to update policy and program language to reflect the forthcoming changes in SUD diagnostic labels and criteria in the Diagnostic and Statistical Manual of Mental Dis- orders, Fifth Edition (DSM-5). INCREASING EMPHASIS ON EFFORTS TO PREVENT SUBSTANCE USE DISORDERS Culture change will require the use of strong prevention programs that use the full range of evidence-based prevention interventions. Institute of Medicine (IOM) reports have differentiated three levels of prevention: (1) universal strategies that target communities to reduce the population risk for specific problems (e.g., enforcement of laws on minimum drinking age that affect everyone under age 21); (2) selective prevention strategies that target groups at elevated risk for specific disorders to reduce the probability of their developing those disorders (e.g., a program to prevent tobacco use among children whose parents smoke); and (3) indicated efforts that target individuals who have early signs of a disorder but do not meet diagnostic criteria (e.g., screening and brief intervention for service members seen in primary care) (IOM, 1994; NRC and IOM, 2009). Recommendation 1: DoD and the individual branches should imple- ment a comprehensive set of evidence-based prevention programs and policies that include universal, selective, and indicated interventions.

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250 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES In Finding 6-1,1 the committee identified the extent to which military policies and programs fall short of incorporating best practices in the field of SUD prevention. The most effective universal, population-based envi- ronmental prevention strategies increase the price of and reduce access to alcohol and other drugs. Successful environmental prevention strategies that DoD and the branches should adopt include consistent enforcement of regulations on underage drinking, a reduced number of alcohol outlets, and limited hours of operation for those outlets. Availability on bases can be reduced by controlling the types of alcohol sold, the days and hours of sale, and the amount of purchase per sale and by enforcing the minimum legal purchase age. While each of these measures is relevant, working with communities to reduce availability by enforcing the minimum legal drinking age is particularly important given that a considerable proportion of mili- tary personnel are between the ages of 18 and 20, or under the legal age for drinking. Efforts such as the Enforcing Underage Drinking Laws (EUDL) program (reviewed in Chapter 6 and Appendix D) should be expanded and investigated more broadly across military sites as part of efforts to stem underage drinking. With respect to availability off base, Commands can work actively with local authorities in surrounding communities to ensure that existing controls on availability are implemented and to develop con- trol measures where such measures are not already in place. The committee sees partnerships with local authorities and hospitality-related businesses (e.g., bars, hotels, casinos) as critically important, and their absence is a missed prevention opportunity. Commands should undertake partnerships with local communities and businesses as a rule rather than as an exception. Commands, especially those on large bases, have considerable control over access to a large population of consumers important to the local economy. Thus, they can influence the level of enforcement of alcohol control laws, as well as help with such enforcement. Commands should also work with local authorities to make sure that driving under the influence (DUI) preven- tion measures are implemented and enforced consistently in communities surrounding military bases. Similarly, as a universal prevention strategy, DoD and the individual branches should proactively prevent the misuse and abuse of prescription medications by limiting access to controlled medications. On this latter point, DoD currently participates in Drug Enforcement Administration (DEA)-approved prescription drug take-back programs, which can reduce the amount of unused medications in the community that otherwise could be diverted and abused. DoD’s participation in drug take-back events should continue to be promoted at all military sites. A recent change in 1 The findings that support the committee’s conclusions and recommendations are numbered by chapter and are discussed in detail in the respective chapters (Chapters 6-8).

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CONCLUSIONS AND RECOMMENDATIONS 251 policy to set limits on the length of prescriptions and the quantity dispensed for controlled substances (U.S. Army Surgeon General, 2011) has the poten- tial to decrease ready access to some of the most commonly abused medica- tions. Monitoring of the implementation of this policy change, coupled with an enhanced prescription drug monitoring system, could identify risky use, abuse, and questionable prescribing practices. Additionally, DoD should conduct research on the current utilization of Pharmacoeconomic Center (PEC) programs intended to support the clini- cians who care for service members receiving prescriptions for long-term (i.e., more than 180 days) use of controlled substances (at a minimum, opioids and benzodiazepines) that may impair their health and combat readiness. This research should identify the extent to which clinicians make use of the Controlled Drug Management Analysis and Reporting Tool (CD-MART) and Deployment MART to identify and monitor the use of controlled substances among all individuals with long-term use, as well as the clinical response among medical personnel preparing service members for deployment. DoD should investigate how it can enhance the clinical utilization of these PEC reporting tools by disseminating additional clinical guidelines on the prescribing of controlled substances and instruc- tions on the use of the tools for providers, or by promulgating mandates, regulations, and policy changes requiring the use of these tools in caring for service members. DoD should also investigate the extent to which indi- viduals with high-risk alcohol use behavior or aberrant drug use behavior are receiving long-term supplies of controlled substances for use during deployment. This research should focus on determining whether additional guidance or policy changes are needed to ensure that controlled medications are given only when not clinically contraindicated for individuals at risk of developing an alcohol or other drug use disorder. While it is necessary for Army medics and Navy corpsmen to be able to dispense medications in the field that have the potential for abuse, such as opioids and benzodiaz- epines, enhanced training is needed on dose limitations and signs of aber- rant behavior or abuse. Health care professionals at all levels (e.g., general medical officers, flight surgeons, medics) should be trained in recognizing patterns of substance abuse and misuse and provided clear guidelines for referral to specialty providers, including pain management specialists and mental health providers. Training and ongoing education should also be provided to all clinicians on effective pain management, with attention to the risks associated with prescribing pain medications, particularly short- acting opioids, which have a high potential for abuse and have not been found to be effective for treating chronic pain conditions (Martell et al., 2007). Beyond general training and education of providers, a system is needed to monitor the implementation of the VA/DoD Clinical Practice Guide-

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252 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES line for Management of Opioid Therapy for Chronic Pain (VA and DoD, 2010), with clear and measurable standards of practice and accountability of providers to deliver evidence-based care. DoD should move forward to implement the recommendations in the final report of the Army pain management task force, particularly those related to routinely assessing for drug abuse in patients on opioid therapy and implementing sole provider programs to prevent “doctor shopping” (U.S. Army, 2010). DoD cur- rently does not share its pharmacy data with state-run prescription drug monitoring programs (PDMPs). Because many service members and their dependents fill prescriptions in community pharmacies, it is important for DoD to partner with community efforts to identify those individuals who are abusing prescription drugs. During its site visit to Fort Belvoir, the committee heard that physicians at the military treatment facility routinely checked the locally available state-run PDMPs before dispensing controlled substances.2 However, the extent of this practice among military physicians is unknown. The committee therefore recommends that DoD providers routinely check any locally state-run PDMPs before dispensing prescription medications that have abuse potential. As the state-run PDMPs or other related community efforts are further developed, DoD should consider investigating the potential value of sharing its pharmacy data with those programs and efforts. With regard to prevention programming, DoD and the branches should focus on adapting and testing efficacious developmentally focused univer- sal, selective, and indicated prevention initiatives for children and families, including broader child development programs that do not address sub- stance abuse specifically. Branch policy makers and commanders in charge of units should develop procedures that routinely include family members in evidence-based prevention programs at the entry, predeployment, and postdeployment stages for active duty members and at entry for members of the reserve component until they become active. The military branches, through their respective surgeon general or Command structure, should coordinate the sharing and use of evidence-based programs and models of standardized annual training of program implementers and their supervi- sors. Several evidence-based programs that are already being disseminated across branches (e.g., Families OverComing Under Stress [FOCUS], New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness [NORTH STAR]) appear to have been disseminated as part of a research trial rather than DoD or branch policy. Standardized training models are included in the Alcohol and Drug Abuse Managers/ Supervisors (ADAMS) and Culture of Responsible Choices (CoRC) pro- 2 Personal communication, Ben Krepps, M.D., Director of the Pain Clinic at Fort Belvoir Community Hospital, November 15, 2011.

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CONCLUSIONS AND RECOMMENDATIONS 253 grams, which are used in the Navy and Air Force, respectively (see Appen- dix D for descriptions of these programs). Finding 6-5 states that neither DoD nor the branches evaluate their programs and initiatives consistently or systematically. This finding is in line with a recent RAND report examining the psychological health pro- grams available to service members, which also notes a lack of evaluation of program effectiveness (Weinick et al., 2011). To address this gap, the committee advises DoD and each branch to require annual evaluation of the effects of prevention programs. Benchmarks with which to determine whether programs are effective or need to be changed should be established as part of the evaluation design. As noted in Finding 6-1, DoD and the individual branches use drug testing as an integral component of their prevention strategies; however, the committee notes the limitations of these drug testing programs in preventing SUDs. The committee encourages DoD to sponsor research on the cost-effectiveness of the current urinalysis programs. Considering the complexity of drug use behavior and the continuing problem it poses for the armed forces, this research should identify ways to improve the deter- rence effect of these programs and provide insight into how the programs affect service members’ attitudes toward the use of tested and untested illicit drugs. The research should also yield quantitative data on the cost per annual drug user deterred that can be compared with the cost-effectiveness of alternative evidence-based prevention programs, particularly those that may be implemented to deter alcohol misuse, which is far more prevalent than other drug misuse in the military. There appears to be a temporal correlation between the introduction of random urinalysis testing to detect and deter illicit drug use among military personnel and a declining trend in the prevalence of some drug use in the military. However, no other data are available on the effectiveness of drug screening in the armed forces, and this temporal association by itself does not meet the burden of proof for establishing a causal relationship. Further, the panel of tested substances is minimal and historically has not included some opioids and benzodiaz- epines that are frequently abused. Recently, DoD made changes to its drug testing program to expand the panel of tested substances to include hydro- codone and benzodiazepines, two of the most widely abused prescription medications. DoD should continue to revise the panel of tested substances as feasible to include the detection of emerging drugs of abuse, such as Spice and bath salts. DoD should also undertake evaluations to determine whether decreases in prevalence rates occur for substances recently added to the testing panel. The committee cautions DoD not to take hasty action by reducing funding for its drug testing programs before reviewing the results of cost-effectiveness research regarding whether decreased illicit drug use is causally related to these programs.

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254 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES A public health approach to prevention of SUDs would integrate uni- versal, selective, and indicated prevention within the medical care system. Research has found that routine screening and brief intervention in medical settings can allow health care professionals to point out the risks of high levels of alcohol use and consistently support reductions in population levels of use (Whitlock et al., 2004). As noted in Finding 7-1, the need for this type of early screening and intervention is high within military popu- lations. Additionally, while the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) indicates the appropriateness of screening and brief intervention protocols, the commit- tee found a lack of implementation of these protocols. Integration of screen- ing and brief intervention for alcohol misuse into primary care settings could reduce stigma and expand access to care. DoD should explore ways to increase the use of screening and brief intervention for alcohol misuse in all medical care settings to make it possible to identify those at risk of developing alcohol use disorders and intervene before more intensive care may be needed. It may be noted that, while there is clear evidence in sup- port of screening and brief intervention in primary care to address alcohol use (Kaner et al., 2009; Whitlock et al., 2004), the efficacy of this approach for other substances besides alcohol is less apparent (Polen et al., 2008). Ultimately, among the most important factors to consider in selecting evidence-based policies, programs, and practices is the extent to which they fit logically into an appropriate overarching strategic plan that addresses the unique conditions found in differing environments. To inform their decision making regarding the selection and implementation of appropriate evidence-based practices, DoD and the service branches will need to adopt a reliable, consistent, yet flexible problem-solving framework. Further, no single evidence-based practice in isolation is likely to result in a significant change in substance use behavior; the optimal prevention strategy will involve the coordination of multiple, mutually reinforcing evidence-based universal, selective, and indicated efforts at both the environmental and individual levels. DEVELOPING STRATEGIES FOR IDENTIFYING, ADOPTING, IMPLEMENTING, AND DISSEMINATING EVIDENCE-BASED PROGRAMS AND BEST PRACTICES FOR SUD CARE The use of evidence-based practices in the care of SUDs (as well as the training of providers in these practices) is integral to ensuring that indi- viduals receive effective, high-quality care. In Finding 6-6, the committee notes that while DoD and individual branches advocate for the adoption and implementation of evidence-based practices throughout their policies and program literature, scant detail is provided on the specific practices to

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CONCLUSIONS AND RECOMMENDATIONS 255 be used. As a result, adoption and implementation are highly variable both across and within branches. In collaboration with the Department of Veter- ans Affairs (VA), DoD has already developed evidence-based guidelines for the treatment of SUDs (VA and DoD, 2009); however, the committee found a lack of implementation, as well as monitoring of implementation, of these guidelines (Finding 6-4). Recent DoD reports present similar findings about the lack of dissemination and implementation of clinical practice guidelines across branches and settings of care (Defense Health Board, 2011; DoD, 2007, 2011b). Recommendation 2: DoD should assume leadership in ensuring the consistency and quality of SUD services. DoD also should require improved data collection on substance use and misuse, as well as the operation of SUD services. Findings 6-4, 6-5, and 6-6 identify problems arising from the lack of standardization, monitoring, and evaluation of SUD policies and pro- grams by DoD or the individual branches, as well as the underutilization of evidence-based practices. The committee struggled to obtain from DoD and the branches basic data on the number of prevention events and par- ticipation rates, individuals treated for SUDs, and the characteristics of the workforce treating SUDs. The committee also noted a lack of benchmarks and standards for prevention, screening, diagnosis, and treatment services. DoD and the individual branches need accurate and valid performance measures to better monitor the implementation and effectiveness of SUD prevention, screening, and treatment services. Consequently, DoD should assume responsibility for ensuring the consistency and quality of these services. Each branch organizes these services idiosyncratically, with little consistency in service implementation and data collection. DoD should monitor adherence to policies and the implementation of clinical practice guidelines, develop performance measures related to SUD prevention and treatment, and hold providers and systems accountable for their perfor- mance on these measures. Specifically, full implementation of the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) in general medical care and specialty care settings would facilitate implementation of the committee’s recommendations for routine screening, effective prevention and treatment efforts, integration with general medical care and mental health services, greater use of tech- nology, confidential care, and greater use of ambulatory and continuing care. Where evidence-based prevention, screening, diagnosis, and treatment practices are nationally known and accepted, they should be incorporated into the principles and structures of DoD policies as an overarching expec- tation for all branches as a means of driving consistency and minimizing

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256 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES variability. DoD operates one of the nation’s largest health care systems and should use 21st-century management standards and process improvement tools to ensure the quality and effectiveness of its services. Recommendation 3: DoD should conduct routine screening for unhealthy alcohol use, together with brief alcohol education interventions. Finding 6-1 acknowledges that DoD and branch policies emphasize screening as a key strategy in combating SUDs in the military, but Finding 6-2 points out that screening policies and programs fall short of identify- ing all service members with SUDs or those who are at risk for develop- ing them, while Finding 7-1 makes note of the unmet need for effective screening and brief intervention strategies. Additionally, the committee notes in Finding 6-3 that DoD and branch policies reflect very different (and somewhat disconcerting) attitudes toward alcohol and other drugs. Annual screening for unhealthy alcohol use in all patients is recommended in the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) based on extensive evidence that such screening, followed by brief alcohol counseling, is efficacious in reducing drinking. Routine screening during annual medical checkups includes use of a validated screening instrument to identify individuals drinking above recommended daily and weekly limits (i.e., 4 drinks per day and 14 drinks per week for men and 3 drinks per day and 7 drinks per week for women). The screening should identify patients who are drinking despite contrain- dications to alcohol use (i.e., pregnant or trying to conceive; liver disease, including hepatitis C; pancreatitis; congestive heart failure; use of medica- tions with clinically important interactions with alcohol) even if they screen negative for unhealthy alcohol use. Outside of deployment health assess- ments, the committee found little evidence of the actual implementation of these components of the VA/DoD Clinical Practice Guideline (Finding 7-1). Likewise, DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed Forces (Comprehensive Plan) finds that evidence- based screening tools are not used consistently in the military, particularly in primary care settings (DoD, 2011b). In an update to the Comprehensive Plan, DoD notes that policy language is currently under development to call for more consistent use of screening measures in primary care settings.3 The committee recommends that DoD move forward with this action and specifically cite the use of validated screening tools and adherence to the screening procedures identified in the VA/DoD Clinical Practice Guideline. 3 Personal communication, Alfred J. Ozanian, Ph.D., Addiction Medicine Program Manager, TRICARE Management Activity, June 6, 2012.

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CONCLUSIONS AND RECOMMENDATIONS 257 Further, it is imperative that screening for unhealthy alcohol use be available without stigma or disciplinary consequences so that screening responses will be truthful, and a brief intervention can be delivered clini- cally, either by Internet programs or in direct clinical encounters, such as in a primary care setting. Screening and brief intervention should be under- stood according to DoD policy to be an educational intervention akin to an indicated prevention approach. Screening is not diagnosis, and brief advice is not treatment. The applicable DoD policy supporting this approach is Instruction DODI 6490.08, Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members (DoD, 2011a). DoD providers should be trained to follow the guidelines in DODI 6490.08, which allow for administration of a brief and confidential prevention inter- vention to those who are identified as at risk for SUDs but do not yet meet diagnostic criteria. Branch policies and programs should allow for the deliv- ery of indicated prevention programming for those at risk for SUDs without the notification of commanders (within the guidelines of DODI 6490.08). Recommendation 4: Policies of DoD and the individual branches should promote evidence-based diagnostic and treatment processes. As discussed above, while DoD and the branches advocate for the adoption and implementation of evidence-based practices, their policies and program literature provide little detail on specific practices; the result is great variation in practices both across and within branches. Also as noted above, DoD supports implementation of the VA/DoD Clinical Prac- tice Guideline for Management of Substance Use Disorders (VA and DoD, 2009), but the committee found little evidence of its implementation within the branches. The lack of routine screening, limited use of anticraving and agonist medications, minimal training in the use of psychosocial interven- tions, and the poor connections between specialty SUD care and general medical care suggest passive rather than active implementation of the guide- line. DoD needs to review the guideline’s implementation at the branch level and develop system measures with which to monitor ongoing implementa- tion and compliance. Implementation measures might include tracking the percentage of active duty service members annually completing routine screening, the percentage of patients referred for SUD assessment who complete an assessment and engage in care, and the number of prescriptions for addiction-focused pharmacotherapy. The SUD measures tracked by the National Committee for Quality Assurance using the Healthcare Effective- ness Data and Information Set should be adapted for use in the direct and purchased care systems of the Military Health System. Specifically, the committee found in the purchased care system under­ utilization of effective treatment modalities such as individual outpatient

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260 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Recommendation 6: The Military Health System should reduce its reliance on residential and inpatient care for SUDs in its direct care system and build capacity for outpatient and intensive outpatient SUD treatment using a chronic care model that permits patients to remain connected to counselors and recovery coaches for as long as needed. The Military Health System appears to have sufficient access to inpa- tient beds within existing regulations. The direct care system needs to build capacity for intensive outpatient and outpatient services. Contemporary systems of care for SUDs rely on outpatient services and ongoing disease management. For many individuals, SUDs are relapsing conditions that require ongoing monitoring and periodic stabilization. Monitoring systems similar to those used by the Department of Transportation and physician assistance programs allow highly trained individuals to continue to work without jeopardizing health and safety. The military branches are well posi- tioned to provide the most effective environment for alcohol and other drug treatment in the nation. In so doing, they can emulate the services and struc- ture of state programs for physicians with alcohol and drug use disorders (DuPont et al., 2009; McLellan et al., 2008). The elements critical to high rates of recovery appear to be ongoing care in an outpatient setting, coupled with routine monitoring and clear consequences associated with a return to use (loss of license). A similar program in military treatment facilities would facilitate retention of trained personnel, noncommissioned leadership, and commissioned leadership while enhancing unit capacity and safety. INCREASING ACCESS TO CARE As described in Chapter 7, the committee’s review of access to SUD services revealed substantial unmet need and policies and practices that inhibit access to care (Findings 7-1, 7-2, 7-3, 7-4, and 7-5). The commit- tee’s findings on access are in agreement with findings from the report of DoD’s Mental Health Task Force, which documents many barriers faced by service members and their families in accessing mental health services in both direct and purchased care settings (DoD, 2007). The following recommendations outline strategies for improving access to and enhancing utilization of SUD care. Recommendation 7: DoD should update the TRICARE SUD treatment benefit to reflect the practices of contemporary health plans and to be consistent with the range of treatments available under the Patient Protection and Affordable Care Act. This recommendation is based on Finding 7-2, which notes that access to care is restricted by the TRICARE SUD benefit’s lack of coverage for

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CONCLUSIONS AND RECOMMENDATIONS 261 intensive outpatient services, office-based outpatient services, and certain evidence-based pharmacological therapies. This recommendation is related to Recommendation 6 regarding the expansion of intensive outpatient and office-based outpatient treatment in the direct care system. As outlined in Chapter 5 and incorporated in the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009), contem- porary SUD care includes the use of maintenance medications and a focus on outpatient rather than residential treatment. The TRICARE benefit at present does not permit use of maintenance medications in the treatment of SUDs and thus deprives many patients of therapies that could help reduce craving and support long-term recovery. Further, TRICARE coverage does not permit use of office-based individual therapy (outside of SUDRFs) to treat SUDs, although such therapy is permitted for other mental health dis- orders. This restriction is inconsistent with current best practices reflecting parity in coverage for SUDs and mental health disorders, as well as medical conditions. The TRICARE benefit for SUD care should provide coverage for all evidence-based forms of care, including maintenance medications. DoD recently proposed a rule to remove the prohibition on the use of maintenance medications in 32 Code of Federal Regulation (CFR) Part 199, and the proposed rule was published in the Federal Register to elicit public comment (DoD, 2011c). DoD should move forward to publish the final ruling to change 32 CFR Part 199 to ensure that every patient enter- ing SUD treatment is evaluated for possible use of agonist and antagonist maintenance medications approved by the Food and Drug Administra- tion for the treatment of opioid and alcohol use disorders, and that the TRICARE benefit covers such maintenance medications. Congress should review any such final rule to ensure that Recommendation 7 in this report is appropriately represented in the changes to 32 CFR Part 199. Once the final rule has been accepted, DoD should move quickly to institute needed policy changes to revise the TRICARE benefit. DoD should also move forward to propose a rule change to 32 CFR Part 199 to remove the restriction of care to SUDRFs and expand the TRICARE benefit coverage to include care provided in intensive outpatient treatment settings. Continued restriction of SUD treatment to SUDRFs is outdated. The range of SUD treatment services available in community settings has evolved substantially since the development of the regulation restricting care to SUDRFs. Inpatient and residential care is no longer the expected standard, and its use is restricted to the most severe, complex cases. Randomized controlled trials and retrospective cohort analyses com- paring inpatient rehabilitation services with intensive outpatient services consistently have found little difference in outcomes. Patient placement criteria (Mee-Lee, 2007) encourage the use of appropriate levels of care and support a full continuum of services, including intensive outpatient services. The limited capacity for intensive outpatient services and office-based out-

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262 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES patient services forces TRICARE and the Military Health System to rely on the most intensive and restrictive levels of care. Employed and housed patients can usually be treated effectively in their community and need not be sent to geographically distant residential facilities. Accessing TRICARE services can be difficult for military dependents because of the requirement to use SUDRFs. In Finding 6-8, the committee explained that DoD and branch policies are largely silent on SUD programs and services for dependents; expanded capacity for community-based out- patient services is a key to improving access to care for family members. The committee agrees with and supports efforts to better coordinate services in the VA and the Military Health System and strongly supports the recent extension of VA mental health personnel to serve veterans returning from Iraq and Afghanistan more promptly. Further, the committee agrees that TRICARE benefits for mental health disorders and SUDs should conform to the Mental Health Parity and Substance Abuse Equity Act, and quantitative and nonquantitative limits on behavioral health services should be elimi- nated. Evaluations of mental health parity have found little impact on the utilization and cost of health care, with the potential to reduce stigma and enhance access to care (Goldman et al., 2006; McConnell et al., 2012). In the update to the Comprehensive Plan, DoD notes that policy language is being drafted to revise the lifetime limits on SUD treatment episodes.4 Cur- rently, there is a lifetime limit of only three SUD treatment benefit periods per beneficiary (with additional benefit periods requiring a waiver). DoD should move forward expeditiously to enact this policy change and propose any needed rule change to 32 CFR Part 199. The TRICARE SUD benefit is out of date with current standards for evidence-based care and needs to be revised without delay. If DoD fails to make the needed changes to the TRICARE SUD benefit in a timely man- ner, the committee recommends that Congress consider taking action to mandate that DoD make these changes. Recommendation 8: DoD should encourage each service branch to provide options for confidential treatment of alcohol use disorders. Finding 7-3 notes that low rates of self-referral to treatment corrobo- rate reports of the perceived stigma of receiving treatment for SUDs, while Finding 7-4 identifies various structural, social, and cultural barriers that inhibit access to SUD care, paramount among them being a lack of confi- dential services. The committee was impressed with the Army’s implementa- tion of the Confidential Alcohol Treatment and Education Pilot (CATEP) 4 Personal communication, Alfred J. Ozanian, Ph.D., Addiction Medicine Program Manager, TRICARE Management Activity, June 6, 2012.

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CONCLUSIONS AND RECOMMENDATIONS 263 (discussed in Appendix D). CATEP attracts a broad range of patients, including officers who are not often seen in ASAP programs, and provides confidential treatment for alcohol use disorders (Gibbs and Rae Olmsted, 2011). The committee is not concerned that CATEP has a low treatment completion rate because the ASAP definition of treatment completion is an arbitrary number of sessions or weeks; many individuals benefit from brief treatment and need not complete a specified treatment regimen. The results of preliminary surveys of CATEP participants and commanders who were aware of their soldiers’ participation in the program showed that there was broad support for expansion of the program and that career protections were seen as an important component. Referral rates to ASAP from postdeployment health assessments also increased at the pilot sites, presumably because of providers’ increased willingness to refer to ASAP.5 The committee recommends that programs such as CATEP be expanded to all ASAP sites within the Army, as well as to the other branches. Policies should be updated to facilitate Command support for recovery through these confidential programs. Currently, CATEP functions by offering treatment services outside duty hours so soldiers can participate without informing their commander. CATEP encourages but does not require soldiers to disclose their participa- tion in treatment to their commanders. A recent qualitative study found that participants in CATEP highly valued the provision of treatment ser- vices outside duty hours and the option to engage in confidential treatment (Gibbs and Rae Olmsted, 2011). The committee understands the need to balance health and discipline, and agrees with the approach CATEP has taken to providing confidential treatment outside of duty hours. Access to confidential brief counseling, brief treatment, and more intensive treatment promotes good care and builds resilience. Delivering these services without sanctions would promote an effective response to alcohol and other drug use problems as they emerge and foster a system in which individuals seek help instead of hiding problems. Service members should feel confident in disclosing problems to their commanders, who should then fully support service members’ participation in treatment. In the absence of such support, it is essential that service members also have access to confidential systems of care. Recommendation 9:  DoD should establish a joint planning process with the VHA, with highly visible leadership (perhaps recently retired military personnel), to address the SUD needs and issues of access to care of reserve component personnel before and after mobilization. 5 Personalcommunication, COL Charles S. Milliken, M.D., Walter Reed Army Institute of Research, May 3, 2011.

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264 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Over the last 10 years, the military has relied heavily on its reserve component forces in the ongoing military operations in Iraq and Afghani- stan. In its review, the committee found a lack of access to SUD care for National Guard and Reserve members (Finding 7-5). These individuals are at high risk for developing SUDs and in many cases lack continuity of care for ongoing mental health problems once demobilized. Therefore, DoD should mount new programs to reach demobilized and discharged reserve component personnel and fund research to determine which strategies for doing so are most effective. A planning process should be used to establish new avenues for reaching or increase active outreach to all demobilized and discharged reserve component personnel if they have not enrolled in Veterans Health Administration (VHA) care within 6 months and if their VHA or alternative medical records do not contain a recent result from an alcohol or other drug use screening. DoD also should make provisions for veterans with other than honorable discharges to receive referrals for outreach and continued SUD assessment and services by designated community-based providers. In addition, DoD should provide the option of receiving confidential screening and assess- ment in alternative venues to the VHA. Such venues include a telemedicine visit with a former DoD clinician with whom the service member had an established relationship or a community-based civilian program specifically designed to engage and serve demobilized and discharged reserve compo- nent veterans, innovative telehealth programs, smartphone and Web-based technology that can provide confidential self-assessment and motivational interviewing to address a reluctant veteran’s concerns about visiting the VHA or seeking help, and active engagement in primary care settings at VHA programs when a reserve component member appears for medical services. DoD should develop alternative procedures for demobilized and dis- charged reserve component veterans with elevated postdeployment health reassessment scores (indicating alcohol use and/or other high-risk behavior) to receive a “warm hand-off” to or facilitated appointment with a VHA or community-based provider with specialty training in serving veterans at risk of SUDs and/or suicide. DoD and the VHA should collaborate to contract with community providers or existing programs (e.g., Military OneSource) to perform some of the active outreach telephone contacts and facilitated linkage needed for particularly high-risk or difficult-to-contact reserve com- ponent members who have been demobilized or discharged. Additionally DoD should fund research and evaluation on the most effective technolo- gies and strategies for active engagement of high-risk reserve component members in order to refine its future programming. Recommendation 10: DoD and the individual service branches should evaluate the use of technology in the prevention, screening, diagnosis,

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CONCLUSIONS AND RECOMMENDATIONS 265 treatment, and management of SUDs to improve quality, efficiency, and access. Finding 6-9 indicates that DoD and the service branches are infre- quently using new technologies that could help standardize the delivery of evidence-based care and could also potentially reduce counselor workloads and increase access to care. Research is beginning to show support for various technological approaches to delivering health care screenings and interventions (Humphreys et al., 2011; Jackson et al., 2011; Tsoh et al., 2010) and SUD care in particular (Cunningham et al., 2009; Godley et al., 2010). DoD has an admirable track record in the implementation and adoption of technology, and while the effectiveness of these technological approaches is still somewhat unknown, DoD has a unique opportunity to participate in research designed to evaluate some of these approaches for use with service members and their families. The committee found several promising examples of the use of tech- nology in DoD’s SUD programs, and sees value in further evaluation of the effectiveness of these efforts. The Air Force’s use of the Substance Use Assessment Tool (SUAT) computerized assessment in all of its Alcohol and Drug Abuse Prevention and Treatment (ADAPT) programs is one example. The SUAT incorporates validated screening instruments in its assessment, and the committee found the content of the SUAT questions to be compre- hensive. This tool may be useful for the other service branches, and DoD should explore this possibility further. Additionally, the use of Internet tech- nology has the potential to provide patients with access to SUD care when deployed in settings where mental health providers are scarce. The Navy’s use of Hazelden’s My Ongoing Recovery Experience (MORE) (described in Appendix D) is a promising example of continuing aftercare being deliv- ered in this manner, and its effectiveness for military populations should be evaluated systematically. DoD should evaluate whether the MORE program helps decrease counselor workloads in providing aftercare and therefore allows other screening and treatment services to receive greater priority. STRENGTHENING THE SUD WORKFORCE Nationally, the workforce that provides treatment for SUDs appears to be in transition. Alcohol and drug treatment emerged as freestanding residential services in the 1950s, 1960s, and 1970s. Many counselors used their personal experience in recovery to help patients initiate and maintain a stable recovery. State standards for counselors supported the nascent profession and did not require graduate degrees or professional licensure (IOM, 1990). Certification of alcohol and drug counselors emerged as an alternative to licensure and as documentation of specialty training and skill.

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266 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Since the 1970s, the SUD patient population has become considerably more complex; poly-substance use has become common, the rates and severity of psychiatric and medical comorbidities have increased, and ser- vices have increasingly been integrated with behavioral health and primary care services. Individuals in recovery no longer dominate the workforce; counselors with graduate degrees are prevalent, and health care reform is likely to demand counselors who are licensed independent practitioners. Although individuals certified as alcohol and drug counselors remain a key component of the civilian workforce treating SUDs, their role is increasingly limited and in the near future may disappear. Rather than continuing to use a 20th-century workforce to treat SUDs, DoD is challenged to structure and staff treatment services for alcohol and drug use disorders for the 21st century. The emerging model of 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 independent practitioners. Treatment plans include evidence-based pharma- cological and behavioral therapies and long-term continuing care with peer support. To increase caseloads and enhance productivity, services emphasize outpatient and intensive outpatient modalities, rely on group therapy, and use computer-assisted cognitive-behavioral techniques. The VA and leading fully integrated health plans provide models for the organization of services for optimal patient outcomes. In reviewing DoD’s SUD workforce requirements and comparing them with emerging models of care, the committee found shortages of SUD coun- selors across the branches (Finding 8-5), a conspicuous lack of physicians trained in addiction medicine or psychiatry (Finding 8-3), wide variation in training and credentialing requirements for SUD counselors across the branches (Finding 8-1), outdated training manuals for Air Force and Navy SUD counselors in particular (Finding 8-2), and a noticeable shortage of a workforce trained in SUD prevention (Finding 8-6). The committee makes the following recommendations for DoD to enhance its workforce provid- ing SUD care. Recommendation 11: The individual service branches should restruc- ture their SUD counseling workforces, using physicians and other licensed independent practitioners to lead and supervise multidisci- plinary treatment teams providing a full continuum of behavioral and pharmacological therapies to treat SUDs and comorbid mental health disorders. The committee found high levels of comorbid mental health disorders among active duty service members and their dependents who seek care for

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CONCLUSIONS AND RECOMMENDATIONS 267 alcohol and other drug use disorders. As noted above, moreover, emerging systems of care rely on multidisciplinary teams led by licensed independent practitioners (e.g., licensed clinical psychologists, licensed clinical social workers, licensed professional counselors). Licensed independent practi- tioners complete multidimensional assessments that include assessments of mental health and physical health disorders, develop comprehensive treatment plans, and provide active treatment using evidence-based phar- macological and behavioral therapies. Certified counselors and individuals in recovery may provide support and continuing care services under the direction of licensed practitioners. Additionally, the evolution from residen- tial services to ambulatory treatment systems with continuing care requires a varied workforce. Licensed independent practitioners with appropriate training and cre- dentialing can provide active integrated treatment for both mental health disorders and SUDs. They can also be integrated into primary care settings as members of medical treatment teams. Care is likely to be more effective and efficient when integrated and coordinated. The workforce for SUD care also must have the capacity to provide ongoing monitoring and continuing care. Many individuals struggle to maintain a stable recovery. Chronic care models of treatment for SUDs are replacing time-limited acute care models. Physician support programs provide one model that DoD may choose to emulate. The Air Force, Navy, and Marine Corps rely heavily on certified alco- hol and drug counselors to staff their treatment programs. A transition to licensed independent practitioners could be phased so that credentialed counselors could complete graduate education and obtain professional licensure. The committee recognizes that hiring licensed practitioners may be particularly challenging for military bases located in rural areas and encourages increased use of Internet technology to promote access to appro- priately trained and licensed counselors. The committee recommends that DoD begin planning to restructure the counselor workforce and strategize ways of responding to treatment needs among active duty service members and their dependents. Recommendation 12: DoD should incorporate complete data on SUD encounters into the MDR database and recalculate the PHRAMS esti- mates for SUD counselors. The committee’s charge included proving guidance on how to calculate appropriate ratios of physicians and licensed practitioners for the popula- tion of DoD beneficiaries to provide sufficient services for alcohol and other drug use disorders. Calculating these ratios is an imprecise process. There is wide variation in the ratios in civilian health plans, reflecting the

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268 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES organization of care, productivity expectations, and the balance of group versus individual therapy. Systems that rely on residential and inpatient care require more intensive staffing ratios than those that emphasize ambulatory care. Integration of SUD care with primary care and behavioral health ser- vices requires different ratios than freestanding care. Treatment systems that build automated tools and information technology infrastructure require fewer staff. Population needs and the prevalence of SUDs affect staffing needs as well. Finally, continuing care and peer support services require different staffing patterns than acute care services. DoD built the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) to help in making decisions about needed staffing ratios for behavioral health care. PHRAMS estimates staffing needs using service utilization data by encounter type from the Military Health System Data Repository (MDR) files. The encounter-based staffing requirement divides the anticipated number of clinical encounters by the productivity expecta- tion. The encounter estimate 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 gen- erated for each risk group and 12 diagnostic groups. 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). In Finding 8-4, the committee suggests that PHRAMS provides a rea- sonable starting point for determining the quantitative relationship between the need for SUD care and staffing levels. Yet while the PHRAMS estimates are careful and logical, they are far below the number of existing counsel- ors. The individual branches, moreover, report needing more counselors. The underestimate appears to reflect incomplete data on SUD services in the MDR database, which excludes encounters in specialty SUD treatment programs. Consequently, the estimates are based on incomplete data and are inaccurate estimates of the number of needed counselors and physicians. Therefore, while the approach is strong, the wrong data are being used. Services provided by substance use counselors, moreover, may fall outside the definition of “psychological health provider” used for PHRAMS esti- mates. To apply PHRAMS to estimating the workforce required to address SUDs, DoD needs to modify the PHRAMS model and estimating proce- dures. An update to the Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed Forces notes that DoD is aware of this limitation in the PHRAMS model and is currently reviewing options for increasing the accuracy of PHRAMS estimates for SUD staffing requirements.6 6 Personalcommunication, Alfred J. Ozanian, Ph.D., Addiction Medicine Program Man- ager, TRICARE Management Activity, June 6, 2012.

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CONCLUSIONS AND RECOMMENDATIONS 269 CONCLUSION SUDs are a serious threat to force fitness and resilience. Greater inte- gration with primary care, routine screening for unhealthy alcohol use, full implementation of the VA/DoD Clinical Practice Guideline for Manage- ment of Substance Use Disorders (VA and DoD, 2009), enhanced data systems and performance measurement, and a well-trained workforce that specializes in preventing and treating SUDs and comorbid physical health and mental health problems would strengthen the Military Health System and improve the lives and careers of active duty and reserve component and retired service members and their dependents. REFERENCES 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. Cunningham, J. A., T. C. Wild, J. Cordingley, T. Van Mierlo, and K. Humphreys. 2009. A randomized controlled trial of an Internet-based intervention for alcohol abusers. Ad- diction 104(12):2023-2032. Defense Health Board. 2011. Psychotropic medication prescription practices and use and complementary and alternative medicine use. Falls Church, VA: Defense Health Board. 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. DoD. 2011a. Instruction 6490.08: Command notification requirements to dispel stigma in providing mental health care to service members. Washington, DC: DoD. DoD. 2011b. 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. DoD. 2011c. TRICARE: Removal of the prohibition to use addictive drugs in the mainte- nance treatment of substance dependence in TRICARE beneficiaries. Federal Register. https://www.federalregister.gov/articles/2011/12/29/2011-33106/tricare-removal-of-the- prohibition-to-use-addictive-drugs-in-the-maintenance-treatment-of-substance#p-3 (ac- cessed August 6, 2012). DuPont, R. L., A. T. McLellan, W. L. White, L. J. Merlo, and M. S. Gold. 2009. Setting the standard for recovery: Physicians’ health programs. Journal of Substance Abuse Treat- ment 36(2):159-171. Gibbs, D. A., and K. L. Rae Olmsted. 2011. Preliminary examination of the confidential alco- hol treatment and education program. Military Psychology 23(1):97-111. Godley, M. D., V. H. Coleman-Cowger, J. C. Titus, R. R. Funk, and M. G. Orndorff. 2010. A randomized controlled trial of telephone continuing care. Journal of Substance Abuse Treatment 38(1):74-82. Goldman, H. H., R. G. Frank, M. A. Burnam, H. A. Huskamp, M. S. Ridgely, S. L. T. Normand, A. S. Young, C. L. Barry, V. Azzone, A. B. Busch, S. T. Azrin, G. Moran, C. Lichtenstein, and M. Blasinsky. 2006. Behavioral health insurance parity for federal employees. New England Journal of Medicine 354(13):1378-1386. Humphreys, J., J. Y. Tsoh, M. A. Kohn, and B. Gerbert. 2011. Increasing discussions of intimate partner violence in prenatal care using Video Doctor plus provider cueing: A randomized, controlled trial. Women’s Health Issues 21(2):136-144.

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