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2 Understanding Substance Use Disorders in the Military S ubstance use and abuse has long been a concern for the nation, both in and out of the workplace (IOM, 1994), with consequences that include lost productivity, disease, and premature death. Indeed, it has been estimated that more than one in four deaths in the United States each year can be attributed to the use of alcohol, illicit drugs, or tobacco (Horgan et al., 2001). Thus, it is no surprise that substance abuse is a significant issue for the U.S. military. This chapter provides essential background information on substance use disorders (SUDs) in the military. It begins with a summary of our current understanding of SUDs, the scope of the problem in the military, and the development of military substance abuse policy. The chapter then details the composition and sociodemographic characteristics of the armed services as context for a discussion of the prevalence of substance use in the military. Next is a review of the health care burden of SUDs in the armed services, followed by the description of a conceptual approach to preven- tion, intervention, and treatment of alcohol use problems—the substance use concern of greatest significance for the military. The final section pres- ents a summary. UNDERSTANDING SUBSTANCE USE DISORDERS The classification system of the current (fourth) edition of the Diag- nostic and Statistical Manual (DSM-IV) includes two possible diagnoses for SUDs: abuse and dependence. In 2013, however, a fifth edition (DSM-5) 25

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26 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES will replace this classification to reflect the recent scientific literature. A catch-all diagnosis of “substance use disorder” will replace the “abuse” and “dependence” diagnoses, and its severity will be rated according to the number of symptoms of compulsive drug-seeking behavior. Thus, alcohol- ism will become “alcohol use disorder,” and services based on the diagnosis of “dependence” versus “abuse” will have to be redefined. The symptoms as described in DSM-IV will remain the same except that “legal problems” has been eliminated as a symptom, and “craving” has been added as a symptom (APA, 2011). Several papers have analyzed the proposed crite- rion changes and demonstrate support for the new classification in DSM-5 (Hasin, 2012). The prevalence of SUDs will not be significantly affected by this change. The modern approach to SUDs begins with prevention that involves educating the population in the avoidance of risky behaviors and establish- ing and enforcing policies to discourage such behaviors. One such behav- ior is binge drinking, defined as five or more standard drinks on a single occasion for a male or four or more for a female (NIAAA, 2005). This is a common behavior among young adults, whether in the military or not, and it increases the likelihood of developing alcohol use disorders. Weekly volume of alcohol consumption also has been used as an early indicator of the risk of developing an alcohol use disorder. For men the danger level is 14 standard drinks per week and for women 7 drinks per week. Early detection of problem drinking should lead to further evaluation and spe- cific intervention according to the needs of the individual. Environmental strategies that have been effective in preventing alcohol problems include such approaches as raising the minimum legal drinking age to 21, enforc- ing minimum purchase age laws, increasing alcohol taxes and reducing discount drink specials, and holding retailers liable for damage inflicted on others by intoxicated and underage patrons. These strategies are reviewed in greater detail in Chapter 5. The dimensional approach of DSM-5, in contrast to previous categori- cal diagnoses, mirrors research findings that SUDs occur along a continuum. While some patients with milder, recent onset may be managed with out­ patient therapy, those with more severe disorders may require inpatient care followed by a long period of aftercare. The tradition of 30 days of inpatient or residential care with uncertain follow-up is no longer considered the optimal approach. Clinical research also supports medication-assisted treat- ment using an array of Food and Drug Administration–approved medica- tions, as discussed later in this report. The past three decades have seen enormous advances in our under- standing of the neurobiology of addiction. Until the 1940s, addiction was regarded as a moral failure that could happen only to people with “bad character.” As recently as 1988, the Supreme Court declared that the

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SUBSTANCE USE DISORDERS IN THE MILITARY 27 Department of Veterans Affairs (VA) did not have to pay benefits to alco- holics because their drinking was due to “willful misconduct.”1 As a result of the pioneering work of scientists at the Public Health Service Hospital in Lexington, Kentucky (Ludwig et al., 1978) and the discovery of the reward system by psychologists such as Olds (1958), our view of addiction has changed. We now know that addiction, defined as a compulsion to seek and take specific substances, is based on an aberration of normal brain function. The reward system is a set of circuits and structures that work as a unit in lower animals as well as primates and humans. Previously, animals were thought to be incapable of addiction; now they can serve as models for research relevant to human patients. The reward system developed early in evolution and is present in modern humans in a form that remains essentially unchanged from that of our early ancestors (Maclean, 1955). It is a part of the brain that is essential for survival because it is activated by all types of rewards, including the basic ones such as food, water, and sex. Activation of this system (pleasure) produces reinforcement of specific behaviors that are needed for survival. The reward system also is involved in the formation of memories. The pursuit of pleasure and the avoidance of pain, at a very fundamental level, are completely normal. Unfortunately, certain plant products, such as opioids and cocaine, are, by coincidence, able to fit perfectly into receptors in the reward circuits where they can directly produce a sensation of reward or euphoria. Other substances, such as alcohol, are able to activate the reward system by stimulating the release of neurotransmitters called endorphins or by other more complex mechanisms. While normal activation of the reward system by constructive behaviors is important for survival, activation of the reward system by the use of drugs can lead to behaviors that are nonproductive or harmful. Whereas a sense of pleasure normally is earned through constructive behaviors and natural drives, even a small amount of cocaine can directly activate this same pleasure system without the need for the usual work. Cocaine’s chemical structure blocks the reuptake mechanism of the neu- rotransmitter dopamine. Normally, nerve cells release dopamine and take it back up again after their signals are sent; cocaine blocks the reuptake process, causing continued high stimulation of the reward system. Dopa- mine accumulates in the space between nerve cells where signaling occurs (the synapses), and the cocaine effect takes over or “hijacks” the reward system (Ritz et al., 1987). Other addictive drugs, such as alcohol, nicotine, marijuana, and opioids, also directly activate the reward system; although 1 Traynor v. Turnage, 485 U.S. 535 (1988).

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28 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES they do so through different mechanisms, the net result is a similar hijack- ing (Koob and Bloom, 1988). When the reward system is hijacked in this way, the human or animal begins to choose the rapid drug activation over natural rewards such as food, water, and sex. Activation through drugs becomes repeatedly rein- forced, establishing strong memories that are difficult to change. Theoreti- cally, any human or animal can develop these strong, fixed memories that underlie addiction; however, hereditary factors influence the ease with which these memories develop. Genetic influences on addiction have been studied in both humans and animals. Large population studies have shown that many humans try drugs and do not particularly like the experience, while others experience pleasure and repeat the drug taking and, within a period of time that depends on genetic variables, become compulsive users (Anthony et al., 1994). Most addictions show substantial evidence of heritability (Goldman et al., 2005), suggesting that many alleles contribute to each type of addiction, but only in a few instances have the alleles been identified. Examples include alleles for ethanol metabolizing enzymes in alcoholism and alpha 5 nicotinic receptor subunit alleles in nicotine addic- tion. The net result is that only a few of those who initiate drug use go on to become addicts. The variables that influence the risk of progressing from a user to an addict are both genetic and environmental, but the influence of the genetic variables is similar to the strength of the genetic risk for other chronic diseases, such as diabetes or hypertension. Vulnerability to addic- tion thus depends largely on the luck of the genetic sorting at conception. Good people, smart people—anyone is at risk of developing an addiction given the presence of the right variable. Using animal models, researchers can predict whether a drug will be abused by humans because of the similarity between the reward system in lower animals and humans (Brady and Griffiths, 1983). In cases where ani- mals demonstrate liking a drug by working to obtain it, we can surmise that humans will be highly likely to like it as well. By developing addiction in animals, we can test different treatments to see which ones will reduce the animal’s drug taking with high predictive value. These advancements with animal models have served a great advantage in the development of new medications for addiction and substantially increased our understanding of addiction mechanisms (IOM, 1996; IOM and NRC, 2004; O’Brien, 2012). Addiction tends to be a chronic disorder with remissions and relapses. Short-term treatments usually are followed by relapses. Expensive residen- tial programs lasting 30 days or more are not successful unless followed by long-term (months or years) outpatient care and supported by 12-step programs (O’Brien and McLellan, 1996). Medications have been developed that reduce the craving for drugs and increase the probability of remaining abstinent. Other medications that are pharmacologically similar to drugs

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SUBSTANCE USE DISORDERS IN THE MILITARY 29 of abuse, such as methadone or buprenorphine for opioid addiction, can be used for maintenance to help stabilize the patient and permit normal func- tioning. Chapter 5 reviews these and other effective treatments for SUDs. SCOPE OF THE PROBLEM Historically, the use of alcohol, illicit drugs, and tobacco has been common in the military. Heavy drinking is an accepted custom (Ames and Cunradi, 2004; Ames et al., 2009; Bryant, 1979; Schuckit, 1977) that has become part of the military work culture and has been used for recreation, as well as to reward hard work, to ease interpersonal tensions, and to pro- mote unit cohesion and camaraderie (Ames and Cunradi, 2004; Ames et al., 2009; Ingraham and Manning, 1984). Alcoholic beverages have long been available to service members at reduced prices at military installations, including during “happy hours” (Bryant, 1974; Wertsch, 1991). Studies of the conflicts of the past decade in Iraq and Afghanistan have shown that military deployments and combat exposure are associated with increases in alcohol consumption, binge and heavy drinking, and alcohol-related prob- lems (Bray et al., 2009; Jacobson et al., 2008; Lande et al., 2008; Santiago et al., 2010; Spera, 2011). These increases in alcohol use may be associated with the challenges of war, the alcohol being used in part as an aid in coping with stressful or traumatic events and as self-medication for mental health problems (Jacobson et al., 2008; Thomas et al., 2010). The availability of and easy access to alcohol on military installations, due in part to reduced prices, may also play a role in its increased use. Service members have engaged in illicit drug use (i.e., the use of ille- gal drugs such as cocaine, heroin, and marijuana and the nonmedical use of prescription drugs) since discovering that they reduced pain, lessened fatigue, or helped in coping with boredom or panic that accompany battle. In the modern U.S. military, drug use surfaced as a problem during the Vietnam War in the late 1960s and early 1970s. Heroin and opium were widely used by service members in Vietnam, partly to help them tolerate the challenges of the war environment (Robins et al., 1975). It was estimated that almost 43 percent of those who served in Vietnam used these drugs at least once, and half of those who used were thought to be dependent on them at some time (Robins, 1974). In the active duty component of the military, marijuana has been the most widely used illicit drug since the early 1980s (Bray et al., 2009). More recently, increasing misuse of prescription drugs among both civilians and military personnel has become a national concern (Bray et al., 2012; Manchikanti, 2007; Manchikanti and Singh, 2008). Unfortu- ­ nately, ­ isuse of these drugs has risen more rapidly in military than civil- m ian populations, making this a substantial issue for military leaders (Bray

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30 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES et al., 2009, 2010a, 2012). Misuse of prescription drugs in the military is associated with increases in the number of prescriptions for these medi- cations that have been written to alleviate chronic pain among service members who have sustained injuries during a decade of continuous war. Indeed, Bray and colleagues (2012) found that the key driver of prescrip- tion drug misuse in the military is misuse of pain medications. Holders of prescriptions for pain medications were found to be nearly three times more likely to misuse prescription pain relievers than those who did not have a prescription. Although opioid misuse has been increasing, little is known about the demographic, psychiatric, clinical, deployment, or medication regimen characteristics that may be related to such misuse. Nonphysician medics and corpsmen represent one source of prescription opioids for military personnel in the field. While opioids are an important tool in first aid on the battlefield, the increasing prevalence of opioid abuse in the military services suggests that both nonphysician and physician providers need more train- ing in the use of opioids in the management and treatment of pain and the risks of opioid medication. During the conflicts in Iraq and Afghanistan, the military has increased its use of prescription medications for the treatment of pain and other health conditions (U.S. Army, 2012). This increase has raised awareness that greater availability of prescription medications may lead to greater potential for abuse. To begin addressing this concern, the Army has taken a positive step by curtailing the length of time for which a prescription is valid, but additional efforts will be needed to mount a comprehensive response to this complex issue. Tobacco use also has long been common in the military, particularly after it was sanctioned in connection with World War I (Brandt, 2007), a stance that continued during World War II (Conway, 1998). Cigarettes became readily accessible to service members, partly because the War Department began issuing tobacco rations. Cigarettes were included in K-rations and C-rations and sometimes became more valuable for trading or selling than the food items in the rations (Conway, 1998). The harm- ful effects of tobacco have been well established (Office of the Surgeon General, 1967, 1979, 2004). Tobacco use has a negative effect on mili- tary performance and readiness and results in enormous costs (an estimated cost of $564 million to the Military Health System in 2006) (IOM, 2009). DEVELOPMENT OF MILITARY SUBSTANCE ABUSE POLICY: A BRIEF OVERVIEW The Department of Defense’s (DoD’s) series of policy directives aimed at decreasing and possibly preventing alcohol and other drug abuse originated in the early 1970s (DoD, 1970, 1972; The Controlled Substances Act of

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SUBSTANCE USE DISORDERS IN THE MILITARY 31 19702), whereas policies directed toward smoking prevention were developed in the 1980s and 1990s (DoD, 1986a,b, 1987, 1994). DoD convened a task force in 1967 to investigate alcohol and other drug abuse in the military, and the resulting recommendations led to a policy directive in 1970 that guided military efforts targeting alcohol and other drug abuse during the 1970s (DoD, 1970). This policy emphasized the prevention of alcohol and other drug abuse through education and law enforcement procedures focused on detection and early intervention. Treatment was provided for problem users, with the goal of returning them to service. A urinalysis testing program was established to help deter illicit drug use, but the program was challenged in the courts3 and was discontinued from 1976 until the early 1980s. In 1980, DoD updated its policy on alcohol and other drug abuse in a new directive (DoD, 1980) that focused on prevention and empha- sized the goal of being free from the negative effects of such abuse. The policy emphasized the incompatibility of alcohol and other drug abuse with military performance standards and readiness. It continued to emphasize education and training, but gave less emphasis to treatment. This policy shift to prevention resulted from the view that many drug users were not addicted and thus were not in need of treatment (Allen and Mazzuchi, 1985). In 1981, however, drug use was one factor implicated in the crash of a jet on an aircraft carrier, resulting in further attention to the military’s drug problem. A new program to stop drug abuse was introduced, based largely on increased drug testing and the discharge of repeat offenders. Improvements in chemical testing procedures led to the decision that drug test results could be used as evidence if the procedures were strict enough to ensure that service members’ urine samples could not be misidentified. In 1981, the Navy introduced its “War on Drugs,” which initiated DoD’s emphasis on zero tolerance of illicit drug use. The other military branches soon followed the Navy’s lead and developed related programs, with drug testing playing a central role. Beginning in 1986, policies on alcohol and other drug abuse were placed in the broader context of a health promotion policy directive. This directive, which focused on activities designed to support and influence individuals in managing their health through lifestyle decisions and self-care (DoD, 1986a), included prevention and cessation of smoking and preven- tion of alcohol and other drug abuse. In a related effort, DoD launched an antismoking campaign in 1986 that emphasized the negative health impacts of smoking. Subsequent efforts to curtail tobacco use resulted in further restrictions on smoking behavior, such as permitting smoking on base only 2 The Controlled Substances Act of 1970, Public Law 91-513, 91st Cong. (October 27, 1970). 3 U.S. v. Ruiz, Court Martial Reports 48:797 (23 U.S. Court of Military Appeals 181) (1974).

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32 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES in designated smoking areas and offering smoking cessation programs to encourage smokers to quit (DoD, 1994; Kroutil et al., 1994). A 2009 Insti- tute of Medicine committee that reviewed tobacco use in the armed services and the VA urged the military to become smoke-free, although many chal- lenges to making this a reality remain (IOM, 2009). Current DoD policy strongly discourages alcohol abuse (i.e., binge or heavy drinking), illicit drug use, and tobacco use by members of the military forces because of their negative effects both on health and on military readi- ness and the maintenance of high standards of performance and discipline (DoD, 1997). The U.S. military defines alcohol abuse as alcohol use that has adverse effects on the user’s health or behavior, family, or community or on DoD, or that leads to unacceptable behavior. Alcohol use is consid- ered illegal for individuals under the age of 21 in the United States. Drug abuse is defined as the wrongful use, possession, distribution, or introduc- tion onto a military installation of a controlled substance (e.g., marijuana, heroin, cocaine), prescription medication, over-the-counter medication, or intoxicating substance (other than alcohol) (DoD, 1997). Tobacco use is defined as use of cigarettes, cigars, pipes, snuff, or chewing tobacco and is discouraged because of its negative effects on performance and association with disease. COMPOSITION AND SOCIODEMOGRAPHIC CHARACTERISTICS OF THE ARMED FORCES To better understand factors that influence substance use in the military, it is important to know the characteristics of the military population. The DoD services have an active duty component, comprising those who serve on active duty, and a reserve component, comprising those who serve in the Reserves and National Guard. The active duty component includes person- nel from the Army, Navy, Marine Corps, and Air Force; the reserve com- ponent includes personnel from the Army National Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air Force National Guard, and Air Force Reserve. All Reserve and Guard members are assigned to one of three groups: the Ready Reserve, the Standby Reserve, or the Retired Reserve. The Ready Reserve is further divided into the Selected Reserve, the Indi- vidual Ready Reserve, and the Inactive National Guard. Because Selected Reserve members train throughout the year and participate annually in active duty training exercises, they are the Reserve group of greatest interest and can be thought of as Traditional Reservists. Table 2-1 provides data on the size of the active duty and reserve components. As shown, the active duty component consists of slightly more than 1.4 million service members. The Army is the largest branch, representing nearly 40 percent of the active duty component, followed by

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TABLE 2-1  Size of the Military Active Duty and Reserve Components in Fiscal Year 2010 Enlisted Officers Total Percent of Number Percent Number Percent Number Component Active Duty Component Army 467,537 83.2 94,442 16.8 561,979  39.6 Navy 270,460 83.7 52,679 16.3 323,139  22.8 Marines 181,221 89.4 21,391 10.6 202,612  14.3 Air Force 263,439 79.9 66,201 20.1 329,640  23.3 Total Active 1,182,657 83.4 234,713 16.6 1,417,370  62.5 Reserve Component Army National Guard 319,846 88.3 42,169 11.7 362,015  42.6 Army Reserve 168,717 82.2 36,564 17.8 205,281  24.2 Navy Reserve 50,718 78.0 14,288 22.0 65,006   7.6 Marine Corps Reserve 35,423 90.3 3,799  9.7 39,222   4.6 Air National Guard 93,287 86.6 14,389 13.4 107,676  12.7 Air Force Reserve 55,559 79.2 14,560 20.8 70,119   8.3 Total Reserve 723,550 85.2 125,769 14.8 849,319  37.5 Total Active and Reserve 1,906,207 84.1 360,482 15.9 2,267,349 100.0 NOTE: Reserve component refers to the Selected Reserve, which comprises traditional drilling Reservists. SOURCE: DoD, 2011a. 33

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34 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES the Air Force and Navy, which are similar in size, and then the Marine Corps, which is the smallest. The reserve component (Selected Reserve) is much smaller than the active duty component, consisting of nearly 850,000 members. The Army National Guard is the largest branch of the reserve component (42.6 percent), followed by the Army Reserve, Air National Guard, Air Force Reserve, Navy Reserve, and Marine Corps Reserve. The Army National Guard and Army Reserve account for about two-thirds of the Selected Reserve. Together, the active duty and reserve components have just over 1.9 million members—62.5 percent in the active duty component and 37.5 percent in the reserve component. Table 2-2 presents sociodemographic characteristics of active duty and reserve component personnel based on 2010 personnel counts reported by the Defense Manpower Data Center (DoD, 2011a). As shown, the groups are similar with regard to the distributions of gender and race/ethnicity. For example, the majority of both components are male (85.6 percent active duty, 82.1 percent reserve) and white (70.0 percent active duty, 75.9 percent reserve). Likewise, the two components have fairly similar levels of education and similar rank distribution. For example, the majority of personnel in both components are in the lower and mid-level enlisted pay grades, E1-E6. In contrast to these similarities, there are two notable differences in the demographic composition of active duty and reserve component personnel. The first is that members of the active duty component are younger on aver- age than those in the reserve component. For example, 65.3 percent of the active duty component is aged 30 or younger, compared with 51.9 percent of the reserve component. The second notable difference is that active duty component personnel are somewhat more likely to be married (56.4 percent) than reserve component personnel (48.2 percent), a fact that is somewhat surprising given the overall older ages of reserve component personnel. Figures 2-1 to 2-2 provide additional information on the family status of active duty and reserve component service members. As noted in Figures 2-1a and 2-1b, although the majority of active duty and reserve component personnel do not have children, more than 40 percent of members of both the active duty component (44 percent) and the reserve component (43 per- cent) do have children. Figures 2-2a and 2-2b provide a further breakdown of the various family configurations. As shown, the family distributions of the active duty and reserve components are highly similar. The largest groups are those who are single with no children (38 percent active duty, 43 percent reserve) and those who are married to civilians and have children (36 percent active duty, 33 percent reserve). The next-largest groups are those who are married to civilians and do not have children (14 percent active duty, 13 percent reserve) and those who are single and have children (5 percent active duty, 9 percent reserve).

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SUBSTANCE USE DISORDERS IN THE MILITARY 35 TABLE 2-2  Sociodemographic Characteristics of Active Duty and Reserve Component Personnel in Fiscal Year 2010 Reserve Active Duty Component Component Sociodemographic Characteristic (N = 849,319) (%) (N = 1,417,370) (%) Service Branch Army 24.2 38.5 Army National Guard 42.6 Navy 7.6 22.1 Marine Corps 4.6 13.9 Air Force 8.3 22.6 Air National Guard 12.7 Gender Male 82.1 85.6 Female 17.9 14.4 Race White 75.9 70.0 African American 14.9 17.0 Asian 2.8 3.7 American Indian or Alaska Native 0.9 1.7 Native Hawaiian or Other Pacific Islandera 0.6 0.6 Multiraciala 0.7 2.1 Ethnicity Hispanic 9.5 10.8 Education No high school diploma 2.9 0.5 Less than a bachelor’s degreeb 76.7 79.5 Bachelor’s degree 14.0 11.0 Advanced degree 5.4 6.7 Age 25 or younger 33.3 44.2 26-30 18.6 21.1 31-35 12.2 13.8 36-40 12.1 11.1 41 or older 23.8 8.8 Marital Status Not married 51.8 43.6 Married 48.2 56.4 Pay Grade E1-E3 19.5 24.6 E4-E6 53.9 49.3 E7-E9 11.8 9.5 W1-W5 1.4 1.4 O1-O3 6.3 9.0 O4-O10 7.1 6.2 NOTE: Reserve component refers to the Selected Reserve of DoD, which comprises traditional drilling Reservists and excludes Department of Homeland Security’s Coast Guard Reserve. a The Army does not report “Native Hawaiian or Other Pacific Islander” or “Multiracial.” b Includes individuals with at least a high school diploma and possibly additional education less than a bachelor’s degree (e.g., associate’s degree). SOURCE: DoD, 2011a.

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58 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES ciated with other comorbid mental disorders (Brady et al., 2000; Keane and Wolfe, 1990). For example, approximately 80  percent of individuals with PTSD have a comorbid psychiatric disorder at some time in their lives (Foa, 2009). Studies of psychiatric inpatients have found that more than 75 percent of PTSD patients have other psychiatric or medical diagnoses, including depression, suicidal ideation and attempts, alcohol and other drug abuse, anxiety, conduct disorder, chronic pain, and metabolic syndrome (Campbell et al., 2007; Floen and Elklit, 2007; Jakovljevic et al., 2006). A study of service members previously deployed to Iraq and Afghanistan (Tanielian et al., 2008) found that 14 percent screened positive for prob- able PTSD; 14 percent screened positive for probable major depression; 19 percent reported symptoms of probable traumatic brain injury (TBI) during deployment; and about one-third met criteria for PTSD, major depression, or TBI, with 5 percent meeting criteria for all three. Adams et al. (2012) found an association between TBI and past month reported binge drinking by military personnel after controlling for PTSD and combat exposure. Comparing veterans of the Vietnam era with those of the Iraq and Afghanistan wars, Fontana and Rosenheck (2008) found that, because of the emphasis on PTSD, the latter veterans were less often diagnosed and treated for substance abuse disorders. Regarding this finding, the Army notes that “current treatment of Iraq and Afghanistan veterans should take into consideration the potential for manifestations of substance abuse and violent behavior as well as the potential for recurrence or late onset of PTSD” (U.S. Army, 2012, p. 23). Alcohol-Related Diagnoses The Armed Forces Health Surveillance Center (2011, 2012b) examined trends and demographic characteristics for acute, chronic, and “recurrent” alcohol-related diagnoses over a 10-year period from January 1, 2001, through December 31, 2010, for the active duty component of the military. Records of health care encounters, including hospitalizations and ambula- tory care, in the Defense Medical Surveillance System were searched to identify those encounters that were associated with ICD-9 diagnostic codes encompassing both alcohol abuse and dependence indicators and were classified as acute or chronic cases. Acute cases were defined by four codes: (1) alcohol abuse/drunk, (2) toxic effect of alcohol, (3) excessive blood alcohol content, and (4) alcohol poisoning. Chronic cases were defined by eight codes: (1) acute intoxication in the presence of alcohol dependence, (2) alcohol-induced mental disorders, (3)  other and unspecified alcohol dependence (chronic alcoholism), (4) alcoholic liver disease, (5) alcoholic cardiomyopathy, (6) alcoholic gastritis, (7) alcoholic polyneuropathy, and (8) personal history of alcoholism.

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SUBSTANCE USE DISORDERS IN THE MILITARY 59 Figure 2-10 presents findings on the acute and chronic inpatient and outpatient cases from 2001 to 2010. As shown, there was a gradual increase in rates of acute and chronic incident (new) alcohol diagnoses during the latter part of the decade. Numbers of hospital bed days for acute alcohol diagnoses increased more than threefold. Incidence rates of acute and chronic alcohol-related diagnoses were highest in men aged 21-24 in the Army; for women, rates were highest among those under 21. In addition, there were sharp increases in alcohol-related medical encounters, especially from 2007 to 2010. Initial analysis also indicated that approximately 21 percent of acute alcohol-related encounters were classified as “recurrent” diagnoses, mean- ing that during the 10-year period, personnel had a 12-month period that included three or more acute encounters. Following this initial report, some concern was expressed that individuals receiving treatment may have been misclassified as recurrent cases. A subsequent reanalysis using a revised algorithm found that 79 percent of cases originally classified as recurrent were likely treatment related, and further suggested that with this cor- rection, approximately 4 percent of the initial cases would be considered recurrent (Armed Forces Health Surveillance Center, 2012b). The results of this study indicate the increasing medical burden imposed on the Military Health System by excessive alcohol use and are especially Incidence rate per 1,000 p-yrs (dashed lines) Incidence rate per 1,000 p-yrs (lines) Calendar year FIGURE 2-10  Incidence rates of acute and chronic alcohol-related inpatient and outpatient cases, active duty component, U.S. military, 2001-2010. NOTE: p-yrs = person-years. SOURCE: Armed Forces Health Surveillance Center, 2011. Figure 2-10 R02254 bitmapped, not editable

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60 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES noteworthy with respect to personnel with chronic alcohol-related diagno- ses. The number of bed days attributable to chronic alcohol abuse diag- noses roughly quadrupled over the 10-year period. This finding highlights the need for continued emphasis on the prevention, early identification, and treatment of alcohol-related disorders. (It should be noted that recent increases in incident alcohol-related diagnoses may reflect increasing scru- tiny of alcohol use among military members and a concomitant focus on referrals for evaluation of alcohol misuse.) CONCEPTUAL APPROACH TO PREVENTION, INTERVENTION, AND TREATMENT OF ALCOHOL USE PROBLEMS As suggested throughout this report, alcohol use is viewed as the key substance use problem in need of intervention and/or treatment among mili- tary personnel. Using health care as an example, Figure 2-11 presents a use- ful approach for conceptualizing alcohol use and likely associated problems in the military as they can be found in primary care, as well as intervention responses in that setting (IOM, 1990). The distribution of alcohol use (and associated problems) includes individuals drinking at nonharmful levels, None Mild Moderate Substantial Severe Specialized Treatment Brief Intervention Primary Prevention FIGURE 2-11  Alcohol use problems and interventions. NOTE: The term “primary prevention” in this figure is used in the 1990 IOM report, but subsequent reports (including this one) use the term “universal preven- tion” instead. SOURCE: IOM, 1990, p. 212. Figure 2-11 R02254

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SUBSTANCE USE DISORDERS IN THE MILITARY 61 those with unhealthy alcohol use who may be at risk for developing severe problems, and those with severe problems. The figure includes the spectrum of services the committee recommends to address alcohol use problems. The bottom of this horizontal pyramid includes the largest portion of military personnel—those who do not use alcohol or who drink at levels causing no health, social, or public safety problems. (For drinkers in this category NIAAA specifies fewer than 5 drinks in a day and not more than 14 drinks in a week for men and fewer than 4 drinks in a day and not more than 7 drinks in a week for women.) Universal prevention targets this group. In line with evidence-based practice, the committee would suggest implementing programs consistent with the resiliency focus in the armed services—that is, including SUDs in the current teaching of resilience—as well as adding other evidence-based practices and policies that are imple- mented primarily in the community. The military is ideally structured for base commanders to institute environmental prevention strategies, includ- ing enforcement of existing underage drinking policies, removal of tax breaks for alcohol in exchanges (as is now being attempted with tobacco), and elimination of drink specials on premises. The next-largest group of alcohol users in the pyramid includes those who may have a higher likelihood of developing unhealthy drinking habits as a result of particular risk factors, such as younger age or diagnosis of another mental health condition. These individuals would benefit from a targeted or selective prevention effort. A third group of individuals includes those who are engaging in risky drinking but have not yet developed problems associated with their drink- ing. Individuals in this group can be identified through screening in primary care or other appropriate settings, such as the armed services’ substance abuse programs, or possibly by military buddies or noncommissioned officers in their units. The majority of these individuals are best served through motivational interviewing and brief advice. Educational interven- tions should be confidential—within the clinical practice. This approach is classified as indicated prevention and is consistent with DoD and VA guidelines. A subset of this group who have moderate problems often come into contact with Command through law enforcement or other disciplin- ary mechanisms as a result of being involved in an alcohol-related incident (e.g., driving under the influence); these individuals typically are sent to the substance abuse program of their particular service branch. At the top of the pyramid is the smallest proportion of individuals— those with substantial or severe problems. This may also be the group most likely to have comorbid PTSD or other mental health problems. These individuals require specialized treatment. Approaches to addressing SUDs need to consider the full spectrum of problems faced by service members.

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62 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES SUMMARY The military has a long history of use and abuse of alcohol and other drugs, and substance use often is exacerbated by deployment and combat exposure. To address these issues, DoD and the armed services developed and implemented a series of policy directives beginning in the early 1970s, largely as an outgrowth of concern about substance use during the Vietnam era. Current policy strongly discourages alcohol abuse (i.e., binge or heavy drinking), illicit drug use and prescription drug misuse, and tobacco use among members of the military forces because of the negative effects of these behaviors on health and on military readiness and the maintenance of high standards of performance and military discipline (DoD, 1997). Despite these official policies, however, substance use and abuse remain a concern for the armed services. Studies of substance use in the military show the following: • Heavy alcohol use in the active duty component declined from 21 percent in 1980 to 17  percent in 1988, remained relatively stable with some fluctuations between 1988 and 1998 (15 percent), showed a significant increase in 2002 (18 percent), and continued to increase gradually in 2005 (19 percent) and 2008 (20 percent). It is also notable that the heavy drinking rate for 2008 (20 percent) was about the same as that when the HRB Survey series began in 1980 (21 percent). • Binge drinking in the active duty component increased from 35 percent in 1998 to 47 percent in 2008. • Illicit drug use in the past 30 days among the active duty component declined sharply from 28 percent in 1980 to about 3 percent in 2008. • Prescription drug misuse among the active duty component dou- bled from 2 percent in 2002 to 4 percent in 2005 and almost tripled from 2005 to 2008, from 4 percent to 11 percent. • Two new types of drugs—Spice and bath salts—have recently been gaining in popularity among civilians, partly because they are advertised as safe and legal, but the extent of their use among service members is not well documented. • Compared with their civilian counterparts, active duty component military personnel were found to be more likely to engage in heavy drinking (a finding driven by personnel aged 18-35); less likely to use illicit drugs (excluding prescription drug misuse) among all age groups; and less likely to use illicit drugs (including prescription drugs) among younger personnel aged 18-25, but more likely to use these drugs among those aged 36 or older (a finding driven by prescription drug misuse).

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SUBSTANCE USE DISORDERS IN THE MILITARY 63 • Rates of heavy drinking and illicit drug use were significantly lower for the reserve component than for the active duty component. • Collectively, the data indicate that excessive alcohol use is a much greater substance use problem than illicit drug use or prescription drug misuse. • Examination of alcohol risk based on AUDIT indicates that sub- stantial percentages of military personnel (among both the active duty and reserve components) are drinking alcohol at rates that place them at risk for alcohol-related problems, even though they do not meet the current criteria for alcohol dependence; many problem drinkers would benefit from some type of alcohol inter- vention or treatment before reaching the most severe problem levels. • Analyses of record data by the military indicate that alcohol and other drug use disorders have been increasing in recent years for the active duty component, the reserve component, and military dependents. • Rates of acute and chronic incident alcohol diagnoses increased from 2001 through 2010, especially during the latter part of the decade for the active duty component. The results indicate the increasing medical burden imposed on the Military Health Sys- tem by excessive alcohol use and are especially noteworthy for personnel with chronic alcohol abuse diagnoses. The number of bed days attributable to chronic alcohol abuse diagnoses roughly quadrupled over the 10-year period. • DoD analyses of the morbidity burden for the active duty compo- nent in 2011 found that the SUD burden from medical encounters ranked seventh among 139 conditions and from hospital bed days ranked first, even though the number of service members with any medical encounter for SUD ranked only thirty-sixth. SUDs and mood disorders accounted for nearly one-quarter (24 percent) of all hospital bed days. • Empirical data on substance use among military spouses and chil- dren are highly limited. Most studies of families have examined the strain placed by deployments on military families, the mental health problems that often result, and the increased risk for sub- stance use problems. Well-designed studies are needed to under- stand substance use issues among military dependents. • Substance use disorder prevention, diagnosis, and treatment must take into account the comorbid conditions that often result from the effects of war on service members. SUDs commonly co-occur with depression, PTSD, and other psychiatric or medical diagnoses.

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