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Appendix B S. 459 (111th): SUPPORT for Substance Use Disorders Act S 459 IS 111th CONGRESS 1st Session S. 459 To improve and enhance substance use disorder programs for members of the Armed Forces, and for other purposes. IN THE SENATE OF THE UNITED STATES February 24, 2009 Mrs. MCCASKILL (for herself and Mr. CORKER) introduced the following bill; which was read twice and referred to the Committee on Armed Services A BILL To improve and enhance substance use disorder programs for members of the Armed Forces, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE. This Act may be cited as the ‘Supporting Uniformed Personnel by Providing Oversight and Relevant Treatment for Substance Use Disorders Act’ or the ‘SUPPORT for Substance Use Disorders Act’. SEC. 2. FINDINGS. Congress makes the following findings: (1) The Armed Forces is comprised of more than 1,400,000 members in the regular components and more than 1,080,000 members in the Reserves. More than 1,800,000 members of the Armed Forces have been deployed in Operation Iraqi Freedom, 283

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284 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Operation Enduring Freedom, and the Global War on Terrorism since 2001. (2) Substance use disorders are chronic diseases that can be prevented, treated, and managed effectively. Failure to prevent or treat these conditions results in severe and widespread consequences, including increased risk of suicide, exacerbation of mental and physical health disorders, increased risk of domestic violence and family discord, and increased risk of unemployment and homelessness. (3) According to the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Personnel, 24 percent of the members of the Armed Forces surveyed reported symptoms of alcohol dependence and nearly 11 percent of the members surveyed reported use of an illicit drug. Misuse of controlled prescription drugs, particularly narcotic painkillers, is a significant and growing problem among members of the Armed Forces as well. (4) Substance abuse disorders often co-occur with other health problems. According to the 2007 Report of the Department of Defense Task Force on Mental Health, 17 percent of soldiers from brigade combat teams are at risk of developing clinically significant symptoms of post-traumatic stress disorder (PTSD), major depression, or anxiety after deployment, and an even higher percentage of such soldiers, 28 percent, would experience symptoms based upon broader screening criteria. The prevalence of post- traumatic stress disorder within a year of combat deployment was estimated to range from 10 to 25 percent. (5) According to the 2007 Report of the Department of Defense Task Force on Mental Health, symptoms of disorders such as post-traumatic stress disorder often include complex disinhibitory behaviors such as self-medicating with alcohol, other medications, or illicit drugs in an attempt to return to ‘normalcy’. (6) According to the 2007 Report of the Department of Defense Task Force on Mental Health, of the 686,306 veterans separated from active duty between 2002 and December 2006 who were eligible for care from the Department of Veterans Affairs, 229,015 (or 33 percent) accessed care at a Department facility. Of those veterans who accessed such care since 2002, 83,889 (or 37 percent) were diagnosed with or were evaluated for a mental disorder, including post-traumatic stress disorder (39,243 or 17 percent), nondependent abuse of drugs (33,099 or 14 percent), and depressive disorder (27,023 or 12 percent).

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APPENDIX B 285 (7) According to the 2007 Report of the Department of Defense Task Force on Mental Health, 20 percent of married soldiers planned to separate or divorce. (8) According to the 2007 Report of the Department of Defense Task Force on Mental Health, relationship problems are the top risk factor for suicide. Mental disorders, alcohol and substance use disorders, and significant stress are other significant risk factors for suicide. The National Violent Death Reporting System of the Centers for Disease Control and Prevention determined that, of a group of former or current military personnel who died by suicide in 2005, 17.2 percent had an alcohol problem and 7.7 percent had a problem with other substances. The suicide prevention action network (SPAN) reports a 20 percent increase in suicide among members of the Armed Forces on active duty, 89 suicides in 2007 with 32 deaths under investigation, and a rise of attempted suicides by soldiers by 6 times higher than it was at the start of Operation Iraqi Freedom. (9) While some commands and facilities in the Armed Forces provide outstanding services for members of the Armed Forces for substance use disorders, the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces is inconsistent in availability, structure, and success among the various Armed Forces. SEC. 3. COMPREHENSIVE PLAN ON PREVENTION, DIAGNOSIS, MITIGATION, TREATMENT, AND MANAGEMENT OF SUBSTANCE USE DISORDERS IN MEMBERS OF THE ARMED FORCES. (a) Review and Assessment of Current Capabilities- (1) IN GENERAL- Not later than 180 days after the date of the enactment of this Act, the Secretary of Defense shall, in consultation with the Secretaries of the military departments and the Secretary of Veterans Affairs, conduct a comprehensive review of the programs and activities of the Department of Defense for the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces. (2) ELEMENTS- The review conducted under paragraph (1) shall include, but not be limited to, an assessment of each of the following: (A) The current state and effectiveness of the programs of the Department of Defense and the military departments relating to the prevention, diagnosis, mitigation, treatment, and management

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286 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES of, and research on, substance use disorders in members of the Armed Forces. (B) The adequacy of the availability of and access to care for substance use disorders in military medical treatment facilities and under the TRICARE program. (C) The adequacy of oversight by the Department of programs relating to the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces. (D) The adequacy and appropriateness of current credentials and other requirements for healthcare professionals treating members of the Armed Forces with substance use disorders, including an assessment of the advisability of adopting uniform credentials and requirements for such treatment for healthcare professionals who are members of organizations such as the Association for Addiction Professionals (NAADAC), the American Society of Addiction Medicine (ASAM), the American Psychiatric Association (APA), and the National Board for Certified Counselors (NBCC). (E) The advisable ratio of physician and non-physician care providers for substance use disorders to members of the Armed Forces with such disorders. (F) The adequacy and appropriateness of protocols for the diagnosis, treatment, and management of substance use disorders in members of the Armed Forces. (G) The adequacy of the availability of and access to care for substance use disorders for members of the reserve components of the Armed Forces when compared with the availability of and access to care for substance use disorders for members of the regular components of the Armed Forces, including an identification of any obstacles that are unique to the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the reserve components of the Armed Forces. (H) The adequacy of the prevention, diagnosis, mitigation, treatment, and management of substance use disorders and related distress in dependent family members of members of the Armed Forces, whether such family members suffer from their own substance use disorder or because of the substance use disorder of a member of the Armed Forces.

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APPENDIX B 287 (I) Any gaps in the current capabilities of the Department of Defense for the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces. (3) REPORT- Not later than 180 days after the date of the enactment of this Act, the Secretary of Defense shall submit to the congressional defense committees a report setting forth the findings and recommendations of the Secretary as a result of the review conducted under paragraph (1). The report shall-- (A) set forth the findings and recommendations of the Secretary regarding each element of the review set forth in paragraph (2); (B) set forth relevant statistics on the frequency of substance use disorders in members of the regular components of the Armed Forces, members of the reserve component of the Armed Forces, and dependents of such members (including spouses and children); and (C) include such other findings and recommendations on improvements to the current capabilities of the Department of Defense for the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces as the Secretary considers appropriate. (b) Plan for Improvement and Enhancement of Programs- (1) PLAN REQUIRED- Not later than 180 days after the date of the enactment of this Act, the Secretary of Defense shall, in consultation with the Secretaries of the military departments and the Secretary of the Department of Veterans Affairs, submit to the congressional defense committees a comprehensive plan for the improvement and enhancement of the programs and activities of the Department of Defense for the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces and their dependent family members. (2) BASIS- The comprehensive plan required by paragraph (1) shall take into account the following: (A) The results of the review and assessment conducted under subsection (a). (B) Any preliminary results of the study required by section 4. (C) Similar initiatives of the Secretary of Veterans Affairs to expand and improve care for substance use disorders among

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288 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES veterans, including the programs and activities conducted under title I of the Veterans’ Mental Health and Other Care Improvements Act of 2008 (Public Law 110-387; 112 Stat. 4112). (3) COMPREHENSIVE STATEMENT OF POLICY- The comprehensive plan required by paragraph (1) shall include a comprehensive statement of the policy of the Department of Defense regarding the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces and their dependent family members. (4) AVAILABILITY OF SERVICES AND TREATMENT- The comprehensive plan required by paragraph (1) shall include mechanisms to ensure the availability to members of the Armed Forces and their dependent family members of services and treatment for substance use disorders, including, but not limited to, services and treatment as follows: (A) Screening for substance use disorder in all settings, including primary care settings. (B) Short-term motivational counseling services. (C) Marital and family counseling. (D) Inpatient, intensive outpatient, or other residential care services. (E) Private medical, psychiatric, and professional counseling services. (F) Relapse prevention services. (G) Ongoing aftercare and outpatient counseling services. (H) Pharmacological treatments aimed at treating substance use disorders, including treating cravings for drugs and alcohol. (I) Detoxification and stabilization services. (J) Coordination with groups providing peer-to-peer counseling. (K) Such other services as the Secretary considers appropriate. (5) PREVENTION AND REDUCTION OF DISORDERS- The comprehensive plan required by paragraph (1) shall include mechanisms to facilitate the prevention and reduction of substance use disorders in members of the Armed Forces through science- based initiatives, including education programs, for members of the Armed Forces and their families. (6) SPECIFIC INSTRUCTIONS- The comprehensive plan required by paragraph (1) shall include each of the following

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APPENDIX B 289 (A) SUBSTANCES OF ABUSE- Instructions on the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces, including the abuse of alcohol, illicit drugs, and nonmedical use and abuse of prescription drugs (including addiction to prescription drugs that is an unintended consequence of otherwise required and medically appropriate pain treatment). (B) HEALTHCARE PROFESSIONALS- Instructions on-- (i) appropriate training of healthcare professionals in the prevention, screening, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces; (ii) appropriate staffing levels for healthcare professionals at military medical treatment facilities for the prevention, screening, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces; and (iii) such uniform training and credentialing requirements for physician and non-physician healthcare professionals in the prevention, screening, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces as the Secretary considers appropriate. (C) SERVICES FOR DEPENDENTS- Instructions on the availability of services for substance use disorders to military dependents (including services for dependents suffering from their own substance use disorder and dependents suffering because of the substance use disorder of a member of the Armed Forces), including instructions on making such services available to such dependents to the maximum extent practicable. (D) PREVENTION MATERIALS- Instructions on the dissemination of materials regarding substance abuse prevention, including, at a minimum, materials on the following: (i) The dangers of alcohol abuse. (ii) The risks of self-medication, and the potential co-occurrence of drug use or abuse with illnesses such as Post Traumatic Stress Disorder (PTSD). (iii) The risks associated with abuse of prescription medications and the signs of inadvertent addiction to prescription medications that may occur as a consequence of otherwise prescribed treatment plans, as well as the need to

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290 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES properly secure and dispose of such substances to safeguard such substances from third parties such as children. (iv) The risks of substance abuse faced by military dependents due to the stresses of having a spouse or parent deployed, as well as other factors relating to substance abuse that are unique to military families. (v) Strategies for prevention of drug and alcohol abuse among children of military families, and suggestions for military parents on how to intervene and find help for a child with a substance use disorder. (E) DIFFERENTIATION OF DISCIPLINARY ACTION AND TREATMENT- Instructions on the separation of disciplinary actions from prevention and treatment of substance use disorders in members of the Armed Forces. (F) CONFIDENTIALITY- Instructions on confidentiality for members of the Armed Forces in seeking or receiving services or treatment for substance use disorders. (G) PARTICIPATION OF CHAIN OF COMMAND- Instructions on appropriate consultation, reference to, and involvement of the chain of command of members of the Armed Forces in matters relating to the diagnosis, treatment, and management substance use disorders in such members. (H) CONSIDERATION OF GENDER- Instructions on gender specific requirements in the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces, including gender specific care and treatment requirements. (I) COORDINATION WITH OTHER HEALTHCARE INITIATIVES- Instructions on the integration of efforts on the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces with efforts to address co-occurring health care disorders (such as post-traumatic stress disorder (PTSD) and depression) and suicide prevention. (7) OTHER ELEMENTS- In addition to the matters specified in paragraph (3), the comprehensive plan required by paragraph (1) shall include the following: (A) LEAD AGENT- The designation by the Assistant Secretary of Defense for Health Affairs of a lead agent to coordinate implementation of the plan.

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APPENDIX B 291 (B) MILESTONES AND SCHEDULES- Milestones and schedules for the achievement of the goals of the plan, including goals relating to the following: (i) Enhanced education of members of the Armed Forces regarding substance use disorders. (ii) Enhanced and improved identification and diagnosis of substance use disorders in members of the Armed Forces. (iii) Enhanced and improved access of members of the Armed Forces to services and treatment for and management of substance use disorders. (iv) Appropriate staffing of military medical treatment facilities and other facilities for the treatment of substance use disorders in members of the Armed Forces. (C) BEST PRACTICES- The incorporation of evidence-based best practices utilized in current military and civilian approaches to the prevention, diagnosis, mitigation, treatment, and management of substance use disorders. (D) AVAILABLE RESEARCH- The incorporation of applicable results of available studies, research, and academic reviews on the prevention, diagnosis, mitigation, treatment, and management of substance use disorders. (8) UPDATE IN LIGHT OF INDEPENDENT STUDY- Upon the completion of the study required by section 4, the Secretary of Defense shall-- (A) in consultation with the Secretaries of the military departments and the Secretary of the Department of Veterans Affairs, make such modifications and improvements to the comprehensive plan required by paragraph (1) as the Secretary of Defense considers appropriate in light of the findings and recommendations of the study; and (B) submit to the congressional defense committees a report setting forth the comprehensive plan as modified and improved under subparagraph (A). SEC. 4. INDEPENDENT REPORT ON SUBSTANCE USE DISORDERS IN MEMBERS OF THE ARMED FORCES. (a) Study Required- The Secretary of Defense shall provide for a study on substance use disorders in members of the Armed Forces to be conducted by the Institute of Medicine of the National Academies of Sciences or such other independent entity as the Secretary shall select for purposes of the study.

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292 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES (b) Elements- The study required by subsection (a) shall include a review and assessment of the following: (1) The current state and effectiveness of the programs of the Department of Defense and the military departments relating to the prevention, diagnosis, mitigation, treatment, and management of, and research on, substance use disorders in members of the Armed Forces. (2) The adequacy of the availability of and access to care for substance use disorders in military medical treatment facilities and under the TRICARE program. (3) The adequacy of the oversight by the Department of Defense of programs related to the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in members of the Armed Forces. (4) The adequacy and appropriateness of current credentials and other requirements for physician and non-physician healthcare professionals treating members of the Armed Forces with substance use disorders. (5) The advisable ratio of physician and non-physician care providers for substance use disorders to members of the Armed Forces with such disorders. (6) The adequacy and appropriateness of protocols for the diagnosis, treatment, and management of substance use disorders in members of the Armed Forces. (7) The adequacy of the availability of and access to care for substance use disorders for members of the reserve components of the Armed Forces when compared with the availability of and access to care for substance use disorders for members of the regular components of the Armed Forces. (8) The adequacy of the prevention, diagnosis, mitigation, treatment, and management of substance use disorders in dependent family members of members of the Armed Forces, whether such family members suffer from their own substance use disorder or because of the substance use disorder of a member of the Armed Forces. (9) The need for and appropriate provision of confidentiality for members of the Armed Forces who seek services or treatment for a substance use disorder. (10) Such other matters as the Secretary considers appropriate for purposes of the study.

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APPENDIX B 293 (c) Report- Not later than one year after the date of the enactment of this Act, the entity conducting the study required by subsection (a) shall submit to the Secretary of Defense and the congressional defense committees a report on the results of the study. The report shall set forth the findings and recommendations of the entity as a result of the study. SEC. 5. CENTER OF EXCELLENCE IN THE PREVENTION, DIAGNOSIS, MITIGATION, TREATMENT, AND MANAGEMENT OF SUBSTANCE USE DISORDERS. (a) In General- The Secretary of Defense shall establish within the Department of Defense a Center of Excellence in the Prevention, Diagnosis, Mitigation, Treatment, and Management of Substance Use Disorders. (b) Partnerships- The Secretary of Defense shall ensure that the Center collaborates to the maximum extent practicable with the Department of Veterans Affairs, institutions of higher education, and other appropriate public and private entities (including international entities) to carry out the responsibilities specified in subsection (c). (c) Responsibilities- The Center shall have responsibilities as follows: (1) To implement the comprehensive plan of the Department of Defense for the prevention, diagnosis, mitigation, treatment, and management of substance use disorders under section 3, including the performance of research on gender and ethnic group-specific health needs related to substance use disorders. (2) To provide for the development, testing, and dissemination within the Department of evidence-based best practices for the prevention, diagnosis, mitigation, treatment, and management of substance use disorders. (3) To provide guidance for healthcare professionals and support service staff of the health system of the Department in providing quality health care for members of the Armed Forces with substance use disorders, and their dependents, when possible, who are suffering from the effects of substance use disorders. (4) To provide guidance for healthcare professionals and support service staff to make members of the Armed Forces receiving prescription pain medications aware of the potential for abuse of or addiction to such substances, and to provide such members education on ways of properly securing such substances and disposing of such substances when no longer needed.

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294 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES (5) To recommend uniform credentials and other requirements for healthcare professionals and support service staff who provide care and support for members of the Armed Forces and their dependents who suffer from substance use disorders. (6) To establish, implement, and oversee a uniform and comprehensive program to train physician and non-physician healthcare professionals and support staff in the Department in the screening, intervention, treatment, and management of substance use disorders. (7) To coordinate research, data collection, and data dissemination on the prevention, diagnosis, mitigation, treatment, and management of substance use disorders, and to maintain a database of information for that purpose. (8) To facilitate advancements in the study of the short-term and long-term physical and psychological effects of substance use disorders. (9) To disseminate evidence-based best practices within the military medical treatment facilities for training healthcare professionals and support staff with respect to substance use disorders. (10) To conduct basic science and translational research on substance use disorders in members of the Armed Forces for the purposes of understanding the etiology of substance use disorders and developing preventive interventions and new treatments. (11) To develop programs and outreach strategies for families of members of the Armed Forces with substance use disorders to address and to mitigate the impact of substance use disorders on such family members and to support the recovery of such members from substance use disorders. (12) To conduct research on the health needs of families of members of the Armed Forces with substance use disorders and develop protocols to address any needs identified through such research. (13) To disseminate information to families of members of the Armed Forces regarding ways to help prevent alcohol and drug abuse among their children, as well as educational materials to address how situations unique to military families, such as having a parent deployed, can increase stress levels and put a child at increased risk of abusing drugs or alcohol. (14) To develop and oversee a long-term plan to increase the number of healthcare professionals and support personnel within the Department in order to facilitate the meeting by the Department

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APPENDIX B 295 of the needs of members of the Armed Forces with substance use disorders while they remain on active duty and until their transition to care and treatment from the Department of Veterans Affairs. (15) To develop and deploy an education and awareness training initiative designed to reduce the negative stigma associated with substance use disorders and treatment. (16) Such other responsibilities as the Secretary shall specify. SEC. 6. CONGRESSIONAL DEFENSE COMMITTEES DEFINED. In this Act, the term ‘congressional defense committees’ means-- (1) the Committee on Armed Services and the Committee on Appropriations of the Senate; and (2) the Committee on Armed Services and the Committee on Appropriations of the House of Representatives.

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