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Appendix D Program Reviews T his appendix summarizes programs identified in the Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed Forces (Comprehensive Plan) (DoD, 2011) as pertaining to the preven- tion, diagnosis, treatment, and management of substance use disorders (SUDs). Summary tables on each program1 are followed by descriptive analyses based on the committee’s review of relevant information gathered from policies, responses to information requests, the published literature, public meetings, and site visits. In addition to the programs discussed in the Department of Defense (DoD) report, the committee learned during the course of its research about additional pertinent programs worthy of inclusion here. These programs are reviewed at the end of the section on each branch. Several DoD programs are cited by the individual branches in the Comprehensive Plan as programs they implement; additionally, the branches occasionally make use of each other’s programs. To avoid redun- dancy, these programs are reviewed in the sections on the branches respon- sible for their development and/or initial implementation and referenced in the sections on the other branches that utilize them. 1 The summary tables are excerpted from the Comprehensive Plan (Appendix C). The elements in the tables and the subsequent findings on each program contained within were generated by DoD for the Comprehensive Plan. Based on the information presented in the Comprehensive Plan, the committee noted that when evidence-based practices (EBPs) are identified for a program, it is in many cases unclear to what extent they are being used or how specifically they are implemented. 305

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306 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES DEPARTMENT OF DEFENSE Red Ribbon Campaign Program Evaluation/ Target Purpose and Goals Clinical Focus Outcomes Population EBPs •  The national Red Ribbon •  Prevention •  N/A •  Active Duty •  N/A* campaign raises public awareness and mobilizes •  Dependents communities to combat tobacco, alcohol and drug use among military personnel, civilians and their families. NOTE: EBP = evidence-based practice; N/A = not applicable. *Note that the entry on the Red Ribbon campaign in the DoD section of Appendix C of the Comprehensive Plan lists “N/A” in the “EBP” column, while the entry in the Air Force section suggests that the campaign does, in fact, employ EBPs, including “community-based processes, environmental strategies, information dissemination, alternative activities, education and problem recognition and referral.” Red Ribbon Week is an annual campaign that is conducted nationwide in the United States every October both at the community level and on military bases. Consequently, it has the capacity to reach service members and their families at all stages of military involvement except deployment outside of the United States. Within DoD, the targets are active duty service members (ADSMs) and their families, as well as the community at large. The focus is on raising awareness about SUD prevention and risk factors (DEA, 2012). The program’s website indicates that “Red Ribbon Week educates individuals, families, and communities on the destructive effects of alcohol and drugs and encourages the adoption of healthy lifestyle choices.” The program is a universal prevention campaign aimed at addressing peer pressure and prosocial bonding in youth, as well as parent monitoring. Thus, it is most developmentally appropriate for young military members with families. The primary setting for delivery is the community, although as noted, the campaign can be implemented on base. The committee finds there is no evidence on this program’s effectiveness, and both military bases and communities vary widely in the activities they sponsor under the auspices of the campaign. There is presently no published information on Red Ribbon’s theoretical basis or on its outcomes.

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APPENDIX D 307 That Guy Alcohol Abuse Prevention Education Campaign Program Evaluation/ Target Purpose and Goals Clinical Focus Outcomesa Populationb EBPsc •  That Guy is a multi- •  Prevention •  Number of •  Active Duty •  N/A media campaign personnel designed to reduce joining social binge drinking among network sites military enlisted personnel ages 18-24. •  Change in drinking •  The campaign behavior includes online and where offline advertising implemented and promotions, viral marketing, a •  Overall website, www.thatguy. awareness of com, public service campaign announcements, and branded collateral •  Change in materials. drinking attitudes NOTE: EBP = evidence-based practice; N/A = not applicable. a The table on this program in the Navy section of Appendix C of the Comprehensive Plan lists the following under “Program Evaluation/Outcomes”: “Total number of visits per month to website per Service, Average number of minutes per visit spent on website per Service, To- tal number of public service announcements per Service, and Number of promotional items distributed.” b The table on this program in the Navy section identifies Reserves as an additional target population. c The table on this program in the Navy section lists “CSAP [Center for Substance Abuse Prevention] prevention strategies” under EBPs. The That Guy campaign uses on- and offline public service announce- ments, a website with animated risk scenarios and modeling of prevention techniques, and prevention marketing. Because of its accessibility by Internet, the campaign can reach National Guard and Reserve members, although its primary focus is on ADSMs. In a typical animated scenario, a service member is shown exhibiting socially inappropriate behavior after drinking. The sce- nario is designed to show negative consequences of binge drinking, including negative reactions from military peers. Alternative scenarios with positive decision making and outcomes also are depicted. This campaign is most developmentally appropriate for younger ADSMs. The overall aims are to increase awareness about the hazards of excessive drinking and shift attitudes toward this behavior. This represents a change from the precontemplation to the contemplation stage of substance use behavior according to Prochastka and Velicer’s (1997) transtheoretical stage of change model.

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308 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES In reviewing this program, the committee found that it uses evidence- based practices of modeling, rehearsal, discussion, and practice and focuses primarily on negative perceived consequences, negative social consequences, and peer pressure. Because it is an Internet-based campaign, its setting can be anywhere. Repeat use is dependent on the user. The March 2012 That Guy newsletter (That Guy Campaign, 2012) reports several statistics on reach and usage for 2011, including • There were more than 1.3 million ThatGuy.com sessions. • Users spent an average of 9 minutes on the site. • The That Guy Facebook page had more than 26,000 fans. • More than 2.7 million branded materials were being used by all of the branches. • More than 4,200 points of contact were engaged across the globe. • More than 800 installations, ships, fleets, submarines, and units had engaged in the campaign. • Forty-seven states and 22 countries had a That Guy presence. According to a recent RAND report, an annual DoD survey of forces indicated that awareness of the campaign had increased over time, and attitudes toward excessive drinking had changed (Weinick et al., 2011). DoD, TRICARE Management Activity, and Fleishmann-Hillard released a paper on That Guy in 2009 that mentions a “statistically significant increase in awareness of That Guy and a positive shift in attitudes toward excessive drinking,” but does not describe an evaluation methodology or provide outcome data (DoD et al., 2009, p. 2). There has as yet been no formal outcome evaluation of the That Guy campaign in a peer-reviewed journal, and based on its findings, the committee cannot determine whether the program is effective at preventing risky drinking and alcohol misuse. Health Assessments Periodic Health Assessment (PHA) Screening Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  Personnel are screened •  Screening •  Percent •  Active •  Screening annually for substance of ADSM Duty typically by use related issues during who AUDIT-C, the annual preventive complete •  Reserve but health assessment. annual screening Services vary as to PHA •  National tools choice their use of screening Guard can vary* instruments.

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APPENDIX D 309 Force Health Protection and Readiness Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHRA) Program Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  review each service’s To •  Prevention •  Compre- •  Active •  AUDIT-C member’s current hensive Duty health, mental health/ •  Screening quality substance abuse or assurance •  Reserve psychosocial issues program commonly associated •  National with deployments, Guard special medications taken during deployment, possible deployment- related occupational/ environmental exposures, and to discuss deployment related health concerns. Positive responses require use of supplemental assessment tools and/or referrals for medical consultation. The provider documents concerns available to help resolve any post- deployment issues. •  The new DoD policy mandates person-to- person mental health assessments prior to deployment and then three times after return from deployment. These assessments include use of the Alcohol Use Disorders Identification Test- Consumption (AUDIT-C), as well as intervention by a primary care provider, based on the number of positive responses made by the Service member on the AUDIT-C. NOTE: ADSM = active duty service member; AUDICT-C = Alcohol Use Disorders Identifica- tion Test-Consumption; DoD = Department of Defense; EBP = evidence-based practice; N/A = not applicable; PHA = periodic health assessment. *In the Air Force, all service members are assessed for hazardous drinking and alcohol abuse and dependence based on the AUDIT-C.

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310 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Health assessments of military members are conducted during active military duty service on a yearly basis, as well as pre- and postdeployment. Health assessment could be considered a prevention strategy to the extent that the provider discusses SUD risk factors or the service member raises questions about risk factors or strategies for preventing SUDs, but its pri- mary focus is on screening. DoD’s pre- and postdeployment health assessments have three stages. Stage 1 is based on self-report and has the objective of defining high-risk groups. The first three questions of the Alcohol Use Disorders Identifica- tion Test-Consumption (AUDIT-C) are used to detect risky drinking as part of Stage 1. Stage 2 collects additional information if Stage 1 screen- ing is positive for posttraumatic stress disorder (PTSD) or depression. If Stage 1 screening with AUDIT-C is positive, Stage 3 consists of a provider interview in which brief intervention for risky drinking is administered or a referral is made. The provider training for the deployment health assess- ments instructs the provider to do the following in the brief intervention: bring attention to the elevated level of drinking; recommend limiting use or abstaining; inform about the effects of alcohol on health; explore and help/ support in choosing a drinking goal; and follow up and refer for specialty treatment, if indicated (Vythilingam et al., 2010). Referral is recommended when the service member requires further evaluation of use, has tried and has been unable to change on his/her own, has had prior treatment, has had a recent problem with alcohol that resulted in counseling or referral to treatment, or has an AUDIT-C score equal to or greater than 8. Refer- ral options vary with the service member’s status, and include emergency behavioral health referral and referral to a provider in a military treatment facility, a TRICARE purchased care provider, a Department of Veterans Affairs (VA) medical center, a Veterans (VET) center, or Military OneSource (DoD, 2010; Vythilingam et al., 2010). The committee finds that the use of AUDIT-C for pre- and postdeploy- ment health assessments is an appropriate means of screening for excessive and hazardous alcohol use; AUDIT-C is well known and has been well validated for use in a variety of settings. Unfortunately, the only service branch to require the use of AUDIT-C in periodic health assessments is the Air Force. The other branches recommend screening by a clinician but do not identify specific screening tools to be used. The committee would prefer to see AUDIT-C used uniformly across all the branches and in all health assessments, independently of whether they are related to deployment. A second important consideration in evaluating screening in both peri- odic and deployment-related health assessments is that positive screening should lead to further intervention depending on the severity of the condi- tion being screened for. In the case of alcohol, identification of excessive

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APPENDIX D 311 use should lead to a more detailed assessment and brief intervention, with referral to treatment as indicated. Indeed, as described above, Stage 3 of the pre- and postdeployment assessments follows this procedure. However, studies have found that while positive screening rates for alcohol misuse can be as high as 27 percent among Army soldiers in postdeployment health assessments (Santiago et al., 2010), only a small proportion of those who screen positive ever receive treatment. For instance, Milliken and colleagues (2007) report that 12 percent of soldiers screened positive for alcohol mis- use in postdeployment assessments, but only 0.2 percent were referred to the Army Alcohol Safety Action Program (ASAP), and only 0.05  percent were actually seen at ASAP within 90 days of referral. This situation is critical because members who screen positive for alcohol misuse are likely also to be engaged in risky behaviors such as drinking and driving and illicit drug use (Santiago et al., 2010). The committee finds this low rate of referral and treatment for those who screen positive to be related to the stigma associated with substance abuse treatment in the military. Such stigma also exists in the larger society, but it is stronger in the military in part because of the requirement to inform Command when service members are admitted for SUD treatment. Many service members fear that Command knowledge of their need for treatment will negatively impact their career (Gibbs et al., 2011). The committee finds that the low rates of referral resulting from a positive screen for alcohol misuse in pre- and postdeployment health assessments represent a threat to public health and force readiness. Military Pathways Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  Program offers service •  Prevention •  Numbers of •  Active •  EBPs personnel and their screenings Duty are families the opportunity to •  Screening utilized take anonymous, mental •  Quantities •  Reserve health and alcohol use self- of assessments online, via the promotional •  National phone, and through special materials Guard events held at installations. distributed Program is designed to •  Dependents help individuals identify •  ustomer C their own symptoms and satisfaction access assistance before a problem becomes serious.

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312 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  The self-assessments address posttraumatic stress disorder (PTSD), depression, generalized anxiety disorder, alcohol use, and bipolar disorder. After completing a self- assessment, individuals receive referral information including services provided by TRICARE, Military OneSource, and Vet Centers. NOTE: EBP = evidence-based practice. Military Pathways encompasses a multifaceted set of program compo- nents aimed primarily at universal prevention. The program also includes a self-assessment/self-screening component that can serve as secondary prevention for military members who identify themselves as being at per- sonal risk for SUD and subsequently seek help. Designed by the nonprofit organization Screening for Mental Health, the program has as its primary goals to “reduce stigma, raise awareness about mental health, and connect those in need to available resources” (Military Pathways, 2012, p. 1). The multiple components of the program (described in the table above) enable repetition of prevention education. A theoretical basis is implied by pro- gram content that includes empowerment building and social and family support seeking. The empowerment content is consistent with military life and institutional goals of fitness. A RAND report estimates that this inter- vention reaches more than 305,000 ADSMs and their families each year (Weinick et al., 2011). The program targets ADSMS and their families pri- marily at entry into the military and predeployment. However, it is assumed that the online, telephone, and video components of the program can be accessed at any stage of military life. The family resiliency kit and a special program for youth (Signs of Suicide, or SOS) are special components aimed directly at military family members (although they do not apply specifically to the prevention of substance abuse); trained paraprofessionals deliver the family kit, and school professionals (not specified) deliver the SOS program to youth in schools. The RAND report (Weinick et al., 2011) cites ongoing trials to evaluate the effectiveness of the self-screening and youth program components, but no outcome data have yet been published on the alcohol, PTSD, or mental health screening components. Without such data, the committee cannot comment on the extent to which the program is evidence based or effective at preventing and screening for SUDs.

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APPENDIX D 313 Real Warriors Campaign Program Evaluation/ Target Purpose and Goals Clinical Focus Outcomes Population EBPs •  multimedia public A •  Prevention •  Numbers of •  Active Duty •  N/A education initiative calls or hits designed to address the •  Dependents stigma associated with •  Customer seeking psychological satisfaction health care and encourage service members and their families to reach out to resources. •  The Real Warriors Campaign website, public service announcements and broadcasts on Armed Services Radio encourage service members and their families to seek help for psychological health issues including SUD. •  The website includes original articles focused specifically on substance misuse and providing individuals multiple avenues to care. NOTE: EBP = evidence-based practice; N/A = not applicable; SUD = substance use disorder. The Real Warriors Campaign is an initiative launched by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). While its goal is to “promote the processes of building resilience, facilitating recovery and supporting reintegration of returning service mem- bers, veterans and their families” (DCoE, 2012, p. 1), the program is not specifically aimed at the prevention of substance abuse. The campaign was developed in response to recommendations of the 2007 DoD Task Force on Mental Health designed to remove the barriers that often prevent service members from obtaining treatment for psychological health issues and traumatic brain injury (Weinick et al., 2011). Utilizing print materials, media outreach, an interactive website, and social media, the campaign features stories of actual service members who have sought treatment and continue to maintain successful military or civilian careers. In developing the program, DCoE did a thorough job of analyzing the characteristics of

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314 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES the service members who would be seeking treatment, and conducted litera- ture searches and focus groups to determine the most effective content to include in the campaign (Acosta et al., 2012; DCoE, 2012). While RAND did conduct a recent study to assess the content, design, and dissemination of the campaign (Acosta et al., 2012), to date, no outcome evaluation has been conducted. DCoE does require the collection of various process indi- cators, such as the number of visitors to the website, but without further evaluation the committee cannot determine if this program is effective at preventing SUDs. Military and Civilian Drug Testing Program Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  The military and •  Prevention •  Percentage •  Active •  EBPs civilian drug testing of mandated Duty are programs are a population utilized primary component testing per year •  Reserve of the installation Drug Demand •  Rate of Reduction Programs. untestable The program works samples to ensure a drug-free workplace. •  Rate of verified positive samples NOTES: This table is included in the section on Air Force programs in Appendix C of the Comprehensive Plan, but is, in fact, a DoD-wide initiative. In addition, the Navy makes use of a software tool called the Navy Drug Screening Program that randomizes testing. EBP = evidence-based practice. The Military and Civilian Drug Testing Program is identified in the Comprehensive Plan as both a prevention and screening program. The program is guided by policy (DoD, 1994), and the stated prevention aim is deterrence. The implied prevention mediator is increasing the perceived negative consequences of positive drug testing rather than drug use per se. As described in Chapter 5, however, there is no clear evidence from con- trolled studies that drug testing is an effective prevention strategy. While the decline in rates of substance use in the military correlates temporally with the inception of drug testing for specific substances (see Chapter 2), there have been no studies assessing the causal relationship between the two; therefore, the committee cannot report on the effectiveness of the drug testing program in preventing SUDs.

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APPENDIX D 315 Adolescent Substance Abuse Counseling (ASAC) Program Program Purpose Clinical Evaluation/ Target and Goals Focus Outcomes Population EBPs •  The ASAC •  Prevention •  Total •  Dependents •  ASAC program number of counselors provides •  Screening prevention are trained substance abuse classes in EBPs such counseling •  Diagnosis as outcome- services •  Total informed including •  Treatment number of counseling, outreach, students solution- prevention, referred focused education, and counseling, referral services •  Total brief to adolescents number of interventions, in selected students and ASAM OCONUS enrolled Patient middle and Placement high schools. •  Total Criteria number of students screened but not enrolled NOTES: The ASAC program is listed as an Air Force program in Appendix C of the Com- prehensive Plan, but the committee learned during the course of its research that it is used by other branches as well, and therefore listed it here in the section on DoD programs. ASAC = Adolescent Substance Abuse Counseling; ASAM = American Society of Addiction Medicine; EBP = evidence-based practice; OCONUS = outside of contiguous United States. ASAC was initially listed as a Science Applications International Cor- poration contract with the Army, but now also includes Air Force (where ASAC is listed under “DoD/Service Branch” programs), Navy, and Marine Corps dependents. The focus is on children of military families in 6th through 12th grades who are considered at risk for substance use and who are authorized to use military treatment facilities. Contracted provid- ers who include licensed and certified counselors deliver early interven- tion counseling with adolescents and their parents and, if necessary, make referrals to additional services (U.S. Army, 2011). The counselors may include social workers, substance use counselors, family therapists, and psychologists. The program is delivered in DoD-dependent schools, in civil- ian schools, and within other existing substance abuse programs for the military. Services specified in the contract include treatment, identification ­ and referral, and prevention education (U.S. Army, 2011).

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346 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Alcohol-AWARE Course Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  Alcohol-AWARE •  Prevention •  Number of •  Active Duty •  N/A is an alcohol- personnel awareness training who attend •  Reserve that provides basic annually information about alcohol use and •  7,382 (3-year associated risks, annual average Navy policies, throughput) responsible drinking, and alternatives. •  Course is a requirement for all personnel. Drug and Alcohol Program Advisor (DAPA) Course Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  This course provides •  Prevention •  Number of •  Active Duty •  N/A training to Drug personnel and Alcohol who attend •  Reserve Program Advisors annually for commands on all matters relating •  1,421 (3-year to alcohol or annual average other drugs. This throughput) collateral duty command position advises the CO on all substance abuse matters to include administrative screenings, reports, prevention education, and monitor aftercare of service members. NOTE: CO = commanding officer; CSAP = Center for Substance Abuse Prevention; EBP = e ­vidence-based practice; N/A = not applicable; SARP = Substance Abuse Rehabilitation Program.

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APPENDIX D 347 The Navy has made an extensive and impressive investment in a series of training initiatives ranging from prevention to intervention for the entire Navy workforce and their families to sophisticated leadership training for commanders. Among these courses are the Prevention Specialist Course, the Navy Drug and Alcohol Counselor School (NDACS), the Clinical P ­ receptorship Program, the Personal Responsibility and Values Education and Training (PREVENT) Course, the Alcohol and Drug Abuse Manage- ment Seminar (ADAMS) for Supervisors and the ADAMS for Leaders Courses, the Alcohol-AWARE Course, and the Drug and Alcohol Program ­ Advisor (DAPA) Course. The purpose of the Prevention Specialist Course is to prepare installa- tion personnel who are responsible for prevention programming. Partici- pants take a certification examination upon completing the course. These specialists then design their own programs at local installations under the commander’s direction. Thus, training is provided to designated personnel in prevention programming at each installation. The committee finds that while the content of this course appears to be appropriate, directing pre- vention specialists to Center for Substance Abuse Prevention (CSAP) strate- gies and to a registry of evidence-based programs, the implementation of unique prevention programs at each installation is challenging and likely to erode overall quality. The committee also finds that it would be more cost- effective to have branch-wide initiatives in which the prevention specialists would receive training that could be modified to reflect local conditions. Fidelity to the evidence-based program models could be monitored. NDACS is a 10-week program that is divided into 7 weeks of didactic training and 3 weeks of clinical rotation. The school convenes a new class five times per year for military personnel who will be working in various drug- and alcohol-related jobs, including outreach, screening, assessment, and treatment for alcohol and other drug addictions. In reviewing the NDACS student guide (U.S. Navy, 2011), the committee noted that basic psychosocial theory and its application to clinical practice and basic biology (as regards SUDs) are covered extensively. However, there is little medical information regarding evidence-based treatment approaches, and as is the case with virtually all training materials the committee reviewed, there is a lack of attention to, or in this case no coverage of, the role of medication in the treatment of SUDs. Following their training at NDACS, graduates enter the Clinical Pre- ceptorship Program as intern counselors. The Clinical Preceptorship Pro- gram is a structured internship intended to develop knowledge and skills under the mentorship of a person with advanced skills in drug and alcohol counseling. After a minimum 12-month internship, interns may apply for certification as alcohol and drug counselor (ADC) I.

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348 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES The PREVENT Course focuses on sailors aged 18-25 and assists them in achieving their highest levels of personal development. It is believed that this will reduce risk-related behaviors and enhance mission readiness. Like the ADAMS and DAPA Courses, PREVENT has training goals and lesson plans; its facilitator guide was prepared by the Pacific Institute for Research and Evaluation, a group with sophisticated knowledge of preven- tion programs. ADAMS, developed for E-5s and above, is divided into two courses, one directed at supervisors and the other at leaders, such as commanding officers and executive officers. These seminars are basically a practical leadership course and are highly regarded by Commands, as the committee learned on its site visit to the naval base at Point Loma, California. The current evaluation metrics appear to be limited to the number of people trained annually. Alcohol-AWARE is a prevention-oriented course that provides anti- alcohol education intended for all sailors E-1 through E-4 and O-1 through O-3. The emphasis is on leadership, deglamorization, intervention, and accountability. The DAPA Course trains advisers who manage and administer the Command’s alcohol and drug abuse programs. During its San Diego site visit, the committee heard of the critical importance of this position in linking Command to effective SUD program and policy implementation. Both the ADAMS and DAPA Courses have training guides, lesson plans, and case scenarios. The committee reviewed these materials and found them to be sound learning tools. Particularly impressive are the ADAMS scenarios directed at supervisors and commanders. The committee is aware of the crucial role of the Command structure in the implementa- tion of SUD prevention and treatment programs. Hands-on training for that Command structure through ADAMS and DAPA is essential to the success of these programs. The committee believes the ADAMS and DAPA Courses are models worthy of adoption by all branches. Additional Programs and Initiatives In addition to the programs cited by the Navy in the Comprehensive Plan, the committee reviewed Families OverComing Under Stress (FOCUS). FOCUS is a family-centered program aimed at building resiliency among ADSMs; their spouses, children, and other family members; providers; and other community members. As a resiliency program, its primary clinical focus is on prevention. It is implemented and repeated over several devel- opmental stages, including pre-, during, and postdeployment. While this large-scale demonstration project was initiated by the Navy’s Bureau of Medicine and Surgery (BUMED), it has been expanded to 18 installations

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APPENDIX D 349 serving the Army, Air Force, Navy, and Marine Corps. Based on resiliency theory (Rutter, 1999) and multiple family and individual resiliency pro- grams, FOCUS is considered evidence based. The committee reviewed two published articles on the implementation and evaluation of FOCUS (Lester et al., 2011a, 2012). Based on this review, the committee finds FOCUS to be a promising program that should be widely disseminated at military sites. Efforts to evaluate the program and document its effectiveness should also be continued. MARINE CORPS Marine Corps Substance Abuse Program Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  The Marine •  Prevention •  Number of •  Active •  ASAM Patient Corps Substance completion of Duty Placement Abuse Program •  Screening treatments Criteria for provides the treatment screening and •  Diagnosis •  Number of of substance assessment, treatment related and treatment •  Treatment failures disorders services for are used Active Duty •  Number of re- for alcohol military screens after treatment members and completion of other eligible treatment beneficiaries with substance abuse disorders. NOTE: ASAM = American Society of Addiction Medicine; EBP = evidence-based practice. The Marine Corps Substance Abuse Program operates under the Marine Corps Community Services Command and within the Marine and Family Programs Division “to provide timely, consistent and effective care for active duty military members and other eligible beneficiaries with sub- stance abuse and dependency disorders which interfere with mission readi- ness and inter-personal functioning” (USMC, 2011a, p. 1). The program is responsible for prevention, screening, diagnosis, and treatment for SUDs. Three program elements (prevention, drug demand reduction, and treat- ment) form the core of the program. Prevention support services include prevention activities, urine testing, and indicated prevention programs. The Drug Demand Reduction program includes Command-level education and training, compulsory random drug testing with punitive consequences,

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350 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES assessments of illegal drug use, and training and action plans at installa- tions as needed. Substance Abuse Counseling Centers (SACCs) provide screening and assessment for alcohol and other drug problems. Outpatient education and counseling may include early intervention, outpatient care, and intensive outpatient services. Marine Corps Order 5300.17 details the requirements for SACCs: “The Marine Corps is required to identify, counsel, or treat Marines identified as alcohol or drug abusers or alcohol or drug dependent” (USMC, 2011b, p. 3-1). Individuals involved in a substance abuse incident are referred to a SACC for assessment. At the SACC, qualified personnel (generally certified substance abuse counselors), under the supervision of the medical officer (either a physician or a psychologist), provide neces- sary intervention and treatment services. The substance abuse counselor conducts the initial biopsychosocial assessment using a standard form contained in NAVMC 2931. The items on this form do not appear to reflect standardized screening instruments for assessing alcohol and other drug use. If the counselor determines that a Marine does not need formal assessment for treatment placement by a licensed independent practitioner, the Marine returns to duty or is assigned to the early intervention program offered through the SACC (Impact, which is also used by the Navy and was reviewed previously under Navy programs). At the start of treatment, an individualized treatment plan is developed and approved by the medical officer. This plan addresses seven dimen- sions to determine the required level of care: potential for withdrawal, biomedical complications, emotional/behavioral complications, readiness to change, relapse potential, recovery/living environment, and operational commitment. An interdisciplinary team reviews the assessment, treatment plan, and treatment progress weekly and makes recommendations to the medical officer. The SACC treatment modalities include a 12-step program, motivational interviewing, group therapy, and other models depending on the individual counselors providing treatment. The committee learned that the treatment modalities provided at each SACC site vary, and there are no standardized or required methods.7 The committee finds this lack of standardization and endorsement of evidence-based treatment modalities to be a weakness of the Marine Corps programs. Marine Corps Order 5300.17 requires 1 year of aftercare for those who have engaged in treatment. This aftercare is not provided through the SACC but is delivered in the unit. It involves monitoring and documentation of progress on the individual’s aftercare plan. 7 Personal communication, Erik Hollins, Marine and Family Programs Division, Decem- ber 26, 2011.

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APPENDIX D 351 Substance Abuse Prevention and Intervention Program Program Clinical Evaluation/ Target Purpose and Goals Focus Outcomes Population EBPs •  The Marine Corps •  Prevention •  Number •  Active •  Prevention Substance Abuse of positive Duty tools created Prevention program samples specifically for provides prevention •  Reserve the Marine tools such as antidrug •  Number Corps based videos and games, of multiple on research substance abuse positives by the Naval prevention tool Health kits, Command •  Number of Research Summits, and the prescription Center Battalion Alcohol drug Skill Intervention confirmed Curriculum that positives help commanders prevent problems that detract from unit performance and mission readiness. •  assist in the To commander’s prevention efforts, a Drug Demand Reduction Coordinator, Substance Abuse Control Officers, and Alcohol Abuse Prevention Specialists are available to provide support in the following areas:  llegal drug use I prevention activities  Drug testing  Implementing prevention programs  Coordinating treatment services with the SACC  Conducting aftercare NOTE: EBP = evidence-based practice; SACC = Substance Abuse Counseling Center.

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352 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Activities with the goal of preventing substance use and abuse among Marines generally are carried out in individual units and Commands. The specific content of the education delivered through these activities varies from site to site. One component of the Marine Corps Substance Abuse Prevention and Intervention Program is the Battalion Alcohol Skills Inter- vention Curriculum (BASIC), which is used across Marine Corps sites. Following a train-the-trainer model, SACC staff train battalion unit train- ers, who then train their senior leadership and unit commanders in how to deliver the BASIC program within their units. The training focuses on building skills and providing information on alcohol use, challenging assumptions about the effects of alcohol, and reducing risk associated with alcohol use based on a harm reduction rather than an abstention approach. The program grew out of work done by contracted research- ers from the University of Washington, San Diego State University, and the University of California, San Diego, to study the problem and make recommendations for possible interventions among Marines. The program is based on the BASICS (Brief Alcohol Screening and Intervention for Col- lege Students) program, an evidence-based prevention program originally developed by researchers from the University of Washington Addictive Behaviors Research Center for college students with problem drinking (Dimeff et al., 1999). The original BASICS program is listed as an evidence-based prevention program in the National Registry of Evidence-Based Programs and Practices (SAMHSA, 2012). The committee finds that the use of the BASIC program in the Marine Corps shows promise for the implementation of an evidence- based prevention program. However, the only evaluation of BASIC showed that it did not have a significant overall effect on drinking behavior among Marines (Hurtado, 2003). Additional research is needed to determine the effectiveness of BASIC in the Marine Corps and perhaps identify modifica- tions that would increase positive results. The Impact program (described previously in the section on Navy pro- grams) also falls under the umbrella of the Marine Corps Substance Abuse Prevention and Intervention Program. This indicated prevention program is delivered at the majority of SACC sites to those Marines identified as being at risk for developing SUDs because of their risky use of alcohol or other drugs. At the Marine Corps Base at Camp Pendleton, Impact has been modified to include the Marine Alcohol Awareness Course (MAAC),8 a 1-day (8-hour) group educational course designed to raise individuals’ awareness level when choosing to consume alcohol. Much like Impact, the course highlights many of the negative consequences and peripheral 8 Personal communication, Erik Hollins, Marine and Family Programs Division, Decem- ber 26, 2011.

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APPENDIX D 353 problems that can result from consuming alcohol. The course focuses pri- marily on alcohol-related policies and consequences and how individuals can establish proper measures and responsible behavior (i.e., safety, envi- ronmental and situational awareness, and a solid plan) before deciding to drink alcohol. The program is based on a risk reduction model of alcohol use and designed for delivery to those individuals who have been involved in alcohol-related incidents. Additional Programs The Marine Corps utilizes the FOCUS program, described previously in the section on Navy programs. As a resiliency program, FOCUS places primary clinical emphasis on prevention. It is implemented and repeated over several developmental stages, including pre-, during, and postdeploy- ment. FOCUS is considered to be a large-scale demonstration project that has been expanded to 18 installations serving the Army, Air Force, Navy, and Marine Corps (FOCUS Project, 2012). Based on resiliency theory (Rutter, 1999) and multiple family and individual resiliency programs, it is considered evidence-based. REFERENCES Acosta, J., L. T. Martin, M. P. Fisher, R. Harris, and R. M. Weinick. 2012. Assessment of the content, design, and dissemination of the Real Warriors Campaign. Santa Monica, CA: RAND Corporation. ACSAP (Army Center for Substance Abuse Programs). 2012a. ASAP public home. http://www. acsap.army.mil/sso/pages/index.jsp (accessed June 8, 2012). ACSAP. 2012b. Overview ADAPT/myPRIME. http://acsap.army.mil/sso/pages/public/­ resources/myprime.jsp (accessed June 8, 2012). ACSAP. 2012c. Risk reduction. http://acsap.army.mil/sso/pages/public/resources/risk-­reduction. jsp (accessed June 8, 2012). DCoE (Defense Centers of Excellence). 2012. The Real Warriors Campaign. http://www. realwarriors.net/aboutus (accessed May 29, 2012). DEA (Drug Enforcement Administration). 2012. Red Ribbon Week factsheet. http://www. justice.gov/dea/ongoing/redribbon_factsheet.html (accessed May 29, 2012). Dimeff, L. A., J. S. Baer, D. R. Kivlahan, and G. A. Marlatt. 1999. Brief Alcohol Screening and Intervention for College Students (BASICS): A harm reduction approach. New York: Guilford Press. DoD (Department of Defense). 1994. Directive 1010.1: Health promotion. Washington, DC: DoD. DoD. 2010. Training to administer DoD deployment mental health assessments: Office of Force Health Protection & Readiness and the Deployment Health Clinical Center. Washington, DC: DoD. DoD. 2011. Comprehensive plan on prevention, diagnosis, and treatment of substance use disorders and disposition of substance use offenders in the armed forces. Washington, DC: Office of the Undersecretary of Defense.

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