SUBSTANCE USE DISORDERS
in the U.S. Armed Forces
Committee on Prevention, Diagnosis, Treatment and Management of
Substance Use Disorders in the U.S. Armed Forces
Board on the Health of Select Populations
Charles P. O’Brien, Maryjo Oster, and Emily Morden, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by the U.S. Department of Defense through an interagency agreement with the U.S. Department of Health and Human Services under Contract No. HHSP23337030T. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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Suggested citation: IOM (Institute of Medicine). 2013. Substance use disorders in the U.S. armed forces. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON PREVENTION, DIAGNOSIS, TREATMENT AND MANAGEMENT OF SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES
CHARLES P. O’BRIEN (Chair), Kenneth E. Appel Professor of Psychiatry and Vice-Chair of Psychiatry, and Director, Center for Studies of Addiction, University of Pennsylvania School of Medicine, Philadelphia
HORTENSIA D. AMARO, Associate Vice Provost for Community Research Initiatives and Dean’s Professor of Social Work and Preventive Medicine, University of Southern California, Los Angeles
RHONDA ROBINSON BEALE, Chief Medical Officer, OptumHealth Behavioral Solutions, Glendale, CAL
ROBERT M. BRAY, Senior Research Psychologist and Senior Director of the Substance Abuse Epidemiology and Military Behavioral Health Program, RTI International, Research Triangle Park, NC
RAUL CAETANO, Regional Dean and Professor, Dallas Regional Campus of the University of Texas School of Public Health
MATHEA FALCO, President, Drug Strategies, Inc., Washington, DC
JOYCE M. JOHNSON, Vice President of Health Services, Battelle Memorial Institute, Arlington, VA
THOMAS KOSTEN, J.H. Waggoner Chair and Professor of Psychiatry, Pharmacology and Neuroscience, Baylor College of Medicine, Houston, TX
MARY JO LARSON, Senior Scientist, Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, MA
DAVID C. LEWIS, Professor Emeritus of Community Health and Medicine, and the Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, Brown University, Providence, RI
DENNIS McCARTY, Professor of Public Health and Preventive Medicine and Division Head, Health Services Research, Oregon Health and Science University, Portland
MARY ANN PENTZ, Professor of Preventive Medicine and Director, Institute for Health Promotion and Disease Prevention Research, University of Southern California, Los Angeles
TRACY STECKER, Assistant Professor of Community and Family Medicine, Dartmouth Medical School, Lebanon, NH
CONSTANCE WEISNER, Professor of Psychiatry, University of California, and Associate Director for Health Services Research, Kaiser Permanente, Oakland
IOM Staff
MARYJO M. OSTER, Study Director
EMILY C. MORDEN, Research Associate
JON Q. SANDERS, Program Associate
NANCY LESTER, Uniformed Services University of the Health Sciences Intern (Spring 2012)
ANDREA COHEN, Financial Associate
FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Thomas F. Babor, University of Connecticut Health Center
Mady Chalk, Treatment Research Institute
Arthur T. Dean, Community Anti-Drug Coalitions of America
Michael Fitzsimons, Massachusetts General Hospital
Deirdre Hiatt, Managed Health Network
Cristine S. Hunter, U.S. Office of Personnel Management
Kimberly C. Kirby, Treatment Research Institute
Daniel Kivlahan, VA Puget Sound Health Care System
James McKay, Treatment Research Institute
Thomas McLellan, Treatment Research Institute
Roland S. Moore, Pacific Institute for Research and Evaluation
Rumi Kato Price, Washington University School of Medicine
Eve E. Reider, National Institute on Drug Abuse
Stephen N. Xenakis, U.S. Army (Ret.)
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Richard J. Bonnie, University of Virginia, and Susan J. Curry, The University of Iowa. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface
Substance abuse has long been an issue of concern for the U.S. population and for its military in particular. Dating as far back as the Revolutionary War, Dr. Benjamin Rush detailed the effects of alcohol on the troops. During the Civil War, addiction to opium prescribed for pain became known as the “soldier’s disease.” Drug problems in both the military and civilian sectors have intensified throughout the 20th century as the types and formulations of substances being used have increased.
Since the 1970s, the Institute of Medicine (IOM) has been called upon numerous times to advise the government on both medical and legal solutions to the problem of substance abuse. Experts from various fields, ranging from mathematics and epidemiology to pharmacology and law, have spent many hours on about a dozen different committees struggling with this thorny problem, which affects our country on societal, economic, personal, and public health levels. While the popular substances of abuse may shift from decade to decade, the overarching problem continues. In the 21st century, prescription opioid abuse has arisen as a major area of concern while problems of alcohol, nicotine, and stimulants have persisted as well. Research has demonstrated that stress and availability are important background factors for causing the initiation and abuse of drugs. As the United States approaches the end of the longest continuous period of war in our history, the stresses faced by our military population are apparent. Our all-volunteer military has endured long periods of deployment and redeployment in highly taxing and demanding environments. Consequently, posttraumatic stress, traumatic brain injury, substance abuse, and suicide are at very high levels.
Press reports of substance abuse among the military stimulated congressional interest and a call for action. The Department of Defense requested that the IOM take a fresh look at the policies and programs of each of the branches of the military and evaluate the adequacy and appropriateness of their prevention, screening, diagnosis, and treatment of substance use disorders. The committee approached this task by holding public meetings to gather information from representatives of each of the military branches and TRICARE (the military’s purchased care health plan), as well as from academic researchers and interested members of the public. The committee also conducted visits to military bases and met with a variety of care providers, including those working in substance abuse specialty programs and those in primary care, behavioral health, and pain management.
The committee requested information from each branch of the military and from TRICARE Management Activity regarding program descriptions, access, utilization, and evaluation results. We also requested data on the providers in the substance abuse programs. We extend our appreciation for the exceptional cooperation from all of those who presented at our meetings, hosted our visits to military bases, and assisted with our information gathering efforts.
In addition, the committee wishes to express our appreciation to the study director, Dr. Maryjo Oster, and to the IOM staff, Ms. Emily Morden, Mr. Jon Sanders, and Dr. Rick Erdtmann.
Charles P. O’Brien, Chair
Committee on Prevention, Diagnosis, Treatment and Management of Substance Use Disorders in the U.S. Armed Forces
Acknowledgments
The committee thanks the Department of Defense, the individual service branches, and TRICARE Management Activity for the opportunity to review and comment upon the organization and content of their substance used disorders prevention and treatment services. We appreciate their assistance and collaboration in the review.
Many individuals assisted the committee in its work by providing useful data and presenting information at the committee’s public meetings and during its site visits. We thank the following people for their contributions: Capt. Robert DeMartino, Alfred Ozanian, Greg Woskow, Frank Lee, and Diana D. Jeffery, TRICARE Management Activity; Les McFarling, Army Center for Substance Abuse Programs; Charles Gould, U.S. Navy Bureau of Medicine and Surgery; Lt. Col. Mark S. Oordt, U.S. Air Force Medical Operations Agency; Keith Humphreys, Stanford University; Don Jansen, Congressional Research Service; Brig. Gen. Margaret Wilmoth, Office of the Assistant Secretary of Defense for Health Affairs; Col. John J. Stasinos, Department of the Army, Office of the Surgeon General; Capt. Mary Rusher, Naval Medical Center San Diego; Vladimir Nacev, Defense Centers of Excellence; Col. Charles Milliken, Walter Reed Army Institute of Research; Wilson Compton and Eve Reider, National Institute on Drug Abuse; John Veneziano, Marine Corps Consolidated Substance Abuse Counseling Center; Ted Jutson and Jerry Sinel, Navy Drug and Alcohol Counselor School; John Sparks, TRICARE Regional Office-West; Andrea Brooks Tucker, TRICARE Regional Office-South; Marie Mentor, TRICARE Regional Office-North; Frank Maguire, TriWest; Debbie Del Rosario and Gary Proctor, ValueOptions; Ian Schaffer and John Wagoner,
Healthnet Federal Services; John M. Morrow, Substance Abuse and Mental Health Services Administration; Abigail Gewirtz, University of Minnesota; Ron Astor, University of Southern California; Barbara Cohoon, National Military Family Association; Lisa Najavits, Harvard University; Anthony Hassan, University of Southern California; Eugene Moore, Cdr. Joseph B. Lawrence, Josh Devine, and Libby Hearin, TRICARE Pharmacy Operations; Isabel Jacobson, Naval Health Research Center; Lt. Gen. David Fridovich, United States Special Operations Command; Lt. Col. Kevin Galloway, Army Pain Management Task Force; Col. Chester Buckenmaier, Walter Reed Army Medical Center; Anthony H. Dekker, Ben Krepps, and Jennifer Weaver, Fort Belvoir Community Hospital; Chideha Ohuoha, Doryan Dixon, Jorge Grandella, and Susan Jessup, Dewitt Army Hospital, Ft. Belvoir; Bob Huebner, National Institute on Alcohol Abuse and Alcoholism; Col. Charles Engel, Department of Defense Deployment Health Clinical Center; Harold Holder, Prevention Research Center of the Pacific Institute for Research & Evaluation; Daniel Kivlahan, Office of Mental Health Services, Veterans Health Administration; 1Lt. Julianna Petrone, SSgt. Cecilia Cardenas, Paul Ahlberg, SrA. Stephanie Tipton, Kim Perez, Eva Shinka, Myron Horn, and Maj. David Cordry, Keesler Air Force Base; Capt. Mary K. Rusher, Joanne Rigoloso, Capt. Warren Peter Klam, Tara Leverett, Valerie Sudduth, Nelson Ferrer, Richard Arriaga, Steven Sovich, and Steven Hanling, Naval Medical Center, San Diego; LTC Sharette Gray, Nicolette Dennis, MAJ Agius, and April Arrington, Carl R. Darnall Army Medical Center, Fort Hood; Dan Harris, CNA; and Caryn Blitz, U.S. Department of Health and Human Services.
Contents
2 UNDERSTANDING SUBSTANCE USE DISORDERS IN THE MILITARY
Understanding Substance Use Disorders
Development of Military Substance Abuse Policy: A Brief Overview
Composition and Sociodemographic Characteristics of the Armed Forces
Prevalence of Substance Use in the Military
Health Care Burden of Substance Use Disorders
Conceptual Approach to Prevention, Intervention, and Treatment of Alcohol Use Problems
Direct Care: Military Treatment Facilities
Care for Substance Use Disorders for Military Service Members and Dependents
4 CHANGING STANDARDS OF CARE FOR SUBSTANCE USE DISORDERS
Health Care Reform and Parity Requirements
Office of National Drug Control Policy’s National Drug Control Strategy
National Quality Forum’s Voluntary Consensus Standards
Clinical Practice Guideline of the Department of Veterans Affairs and DoD
5 BEST PRACTICES IN PREVENTION, SCREENING, DIAGNOSIS, AND TREATMENT OF SUBSTANCE USE DISORDERS
Screening, Diagnosis, and Treatment
6 POLICIES AND PROGRAMS ON SUBSTANCE USE DISORDERS
SUD Policies and Programs for Military Dependents in the Direct Care System
Care Availability, Access, and Utilization in the Direct Care System
Care Availability, Access, and Utilization in the Veterans Health Administration
Care Availability, Access, and Utilization in the Purchased Care System
8 SUBSTANCE USE DISORDER WORKFORCE
DoD Efforts to Review Staffing Requirements
9 CONCLUSIONS AND RECOMMENDATIONS
Increasing Emphasis on Efforts to Prevent Substance Use Disorders
Strengthening the SUD Workforce
B S. 459 (111th): SUPPORT for Substance Use Disorders Act
C Section 596 of Public Law 111-84, October 28, 2009
E Features of TRICARE and Related Purchased Care Plans
F Workforce Standards for Substance Use Disorder (SUD) Care
G Access Standards for TRICARE Prime Enrollees
I Summary of Policy-Relevant Strategies for the Prevention of Alcohol-Related Problems
Tables, Figures, and Boxes
Tables
1-1 Military Policies Addressing Substance Use Disorders as of February 2009
1-2 Military Policies Addressing Substance Use Disorders as of May 2012
2-1 Size of the Military Active Duty and Reserve Components in Fiscal Year 2010
2-4 Alcohol AUDIT Scores of Active Duty and Reserve Component Personnel
3-1 Reserve Component Health Care Continuum
3-2 Continuum of Care When on Active Duty
3-3 Military Treatment Facilities That Provide Specialty Care for Substance Abuse, by TRICARE Region
7-15 Number of Beneficiaries with Claims in Purchased Care Settings, by Type of SUD Care (FY 2010)
8-1 Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Workforce
8-2 Army Substance Abuse Program (ASAP) Prevention Workforce
8-3 Army Substance Abuse Program (ASAP) Clinical Workforce as of December 2011
8-4 Substance Abuse Rehabilitation Program (SARP) Workforce
8-5 Substance Abuse Counseling Center (SACC) Workforce
I-1 Ratings of Policy-Relevant Strategies and Interventions
Figures
2-1a Active duty component members with and without children
2-1b Reserve component members with and without children
2-2a Active duty component family status
2-2b Reserve component family status
2-3 Substance use trends for active duty military personnel, past 30 days, 1980-2008
2-4 Use of selected categories of illicit drugs, past 30 days, DoD branches, 2002, 2005, and 2008
2-6 Prevalence of alcohol-related disorders among the active duty component (rates per 100,000)
2-7 Prevalence of drug-related disorders among the active duty component (rates per 100,000)
2-9 Prevalence of alcohol- and other drug-related disorders among dependents
2-11 Alcohol use problems and interventions
3-1 Defense Enrollment Eligibility Reporting System (DEERS)
3-2 TRICARE organization of services
3-4 Terminology related to the uniformed services health care system
H-1 Components of health care delivery systems
Boxes
3-1 TRICARE Patient Priority System
4-1 ACO Accreditation Standards
4-2 Dimensions of American Society of Addiction Medicine’s (ASAM’s) Patient Placement Criteria
6-1 Policies and Directives Related to Substance Use Disorders
6-2 Army Substance Abuse Program (ASAP) Prevention and Treatment Capabilities
7-1 A Soldier’s Untreated Substance Abuse
7-3 Access Standards of the Veterans Health Administration for SUD Care
7-4 TRICARE Policies Governing Access to SUD Care
8-1 12 Core Functions of Substance Abuse Counselors
8-2 Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) Diagnosis and Risk Groups
AA | Alcoholics Anonymous |
ABAM | American Board of Addiction Medicine |
ABC | Alcohol Brief Counseling |
ACO | Accountable Care Organization |
ACSAP | Army Center for Substance Abuse Programs |
ADAMS | Alcohol and Drug Abuse Management Seminar |
ADAPT | Alcohol and Drug Abuse Prevention and Treatment |
ADC | alcohol and drug counselor |
ADCO | alcohol and drug control officers |
ADFM | active duty family member |
ADMITS | Alcohol and Drug Management Information Tracking System |
ADSM | active duty service member |
ADT | active duty training |
AFI | Air Force Instruction |
AFIP | Armed Forces Institute of Pathology |
ALARACT | All Army Activities |
APA | American Psychiatric Association |
AR | Army regulation |
ARI | alcohol-related incident |
ARM | Alcohol-Related Misconduct |
ASAC | Adolescent Substance Abuse Counseling |
ASAM | American Society of Addiction Medicine |
ASAP | Army Substance Abuse Program |
AUD | alcohol use disorder |
AUDIT | Alcohol Use Disorders Identification Test |
BAM | Brief Addiction Monitor |
BASIC | Building Alcohol Skills Intervention Curriculum |
BHIVES | Buprenorphine and HIV Care Evaluation and Support |
BHOP | Behavioral Health Optimization Program |
BUMED | Bureau of Medicine and Surgery |
CARF | Commission on Accreditation of Rehabilitation Facilities |
CATEP | Confidential Alcohol Treatment and Education Pilot |
CBT | cognitive-behavioral therapy |
CDC | Centers for Disease Control and Prevention |
CD-MART | Controlled Drug Management Analysis and Reporting Tool |
CEOA | comprehensive effects of alcohol |
CFR | Code of Federal Regulations |
CHCBP | Continued Health Care Benefit Program |
CM | contingency management |
CO | commanding officer |
COBRA | Consolidated Omnibus Budget Reconciliation Act |
CoRC | Culture of Responsible Choices |
CPG | Clinical Practice Guideline |
CSAP | Center for Substance Abuse Prevention |
CSAT | Center for Substance Abuse Treatment |
CSF | Comprehensive Solider Fitness |
DAPA | Drug and Alcohol Program Advisor |
DCoE | Defense Centers of Excellence |
DDCAT | Dual Diagnosis Capability in Addiction Treatment |
DEA | Drug Enforcement Agency |
DEERS | Defense Enrollment Eligibility Reporting System |
DEFY | Drug Education for Youth |
DoD | Department of Defense |
DODD | Department of Defense Direction |
DODI | Department of Defense Instruction |
DOJ | Department of Justice |
DOT | Department of Transportation |
DRI | drug-related incident |
DSM | Diagnostic and Statistical Manual |
DUI | driving under the influence |
DWI | driving while intoxicated |
EAP | Employee Assistance Program |
EBP | evidence-based practices |
ECF | executive cognitive function |
EUDL | Enforcing Underage Drinking Laws |
FEHBP | Federal Employees Health Benefits Program |
FOCUS | Families OverComing Under Stress |
FTE | full-time equivalent |
FY | fiscal year |
GAO | Government Accountability Office |
GAT | Global Assessment Tool |
GBL | gamma butyrolactone |
GHB | gamma-hydroxybutyric acid |
HRB | Health Research Board |
HRSA | Health Resources and Services Administration |
IC&RC | International Certification and Reciprocity Consortium |
ICD | International Classification of Diseases |
IDS | integrated delivery system |
IDT | Inactive Duty Training |
IHI | Institute of HealthCare Improvement |
IMCOM | Installation Management Command |
IntNSA | The International Nurses Society on Addictions |
IOM | Institute of Medicine |
IOP | intensive outpatient |
JCAHO | Joint Commission on Accreditation of Healthcare Organizations |
LCSW | Licensed Clinical Social Worker |
LIP | Licensed Independent Practitioner |
LMFT | Licensed Marriage and Family Counselor |
LOD | line of duty |
LPC | Licensed Professional Counselor |
LSD | lysergic acid diethylamide |
MAAC | Marine Alcohol Awareness Course |
MCO | Marine Corps Order |
MDMA | 3,4-methylenedioxy-N-methylamphetamine |
MDR | M2 Data Repository |
MEDCOM | Medical Command |
MET | motivational enhancement therapy |
MHAT | Mental Health Advisory Team |
MHS | Military Health System |
MORE | My Ongoing Recovery Experience |
MOU | Memorandum of Understanding |
MTF | military treatment facility |
NCQA | National Committee for Quality Assurance |
NDAAC | Navy Drug and Alcohol Advisory Council |
NDACS | Navy Drug and Alcohol Counselor School |
NIAAA | National Institute on Alcohol Abuse and Alcoholism |
NIDA | National Institute on Drug Abuse |
NOAA | National Oceanic and Atmospheric Administration |
NORTH STAR | New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness |
NQF | National Quality Forum |
NRC | National Research Council |
NREPP | National Registry of Evidence-Based Programs and Practices |
OEF | Operation Enduring Freedom |
OIF | Operation Iraqi Freedom |
OND | Operation New Dawn |
ONDCP | Office of National Drug Control Policy |
PC | prevention coordinator |
PCM | primary care manager |
PCP | phencyclidine |
PDHA | Post-Deployment Health Assessment |
PDHRA | Post-Deployment Health Reassessment |
PDMP | Prescription Drug Monitoring Program |
PEC | Pharmacoeconomic Center |
PFL | Prime for Life |
PHA | Periodic Health Assessment |
PHRAMS | Psychological Health Risk-Adjusted Model for Staffing |
PMART | Prescription Medication Analysis Reporting Tool |
POC | Pharmacy Operations Center |
POS | point of service |
PREVENT | Personal Responsibility and Values Education and Training |
PTSD | posttraumatic stress disorder |
RE | Resiliency Element |
ROSC | recovery-oriented systems of care |
RT | resiliency training |
RTCQ | Readiness to Change Questionnaire |
SACC | Substance Abuse Counseling Center |
SACO | Substance Abuse Control Officer |
SAIC | Science Applications International Corporation |
SAMHSA | Substance Abuse and Mental Health Services Administration |
SAODAP | Special Action Office for Drug Abuse Prevention |
SAPST | Substance Abuse Prevention Specialist Training |
SARP | Substance Abuse Rehabilitation Program |
SBIRT | screening, brief intervention, and referral to treatment |
SECNAVINST | Secretary of the Navy Instruction |
SIP | Short Index of Problems |
SM | service member |
STD | sexually transmitted disease |
SUAT | Substance Use Assessment Tool |
SUD | substance use disorder |
SUDRF | Substance Use Disorder Rehabilitation Facility |
TAMP | Transitional Assistance Management Program |
TAP | Technical Assistance Publication |
TBI | traumatic brain injury |
TDP | TRICARE Dental Plan |
TMA | TRICARE Management Activity |
TPR | TRICARE Prime Remote |
TRS | TRICARE Reserve Select |
TSF | twelve-step facilitation |
UPL | Unit Prevention Leader |
URI | unit risk inventory |
USAF | U.S. Air Force |
USMC | U.S. Marine Corps |
VA | Department of Veterans Affairs |
VET | veterans |
VHA | Veterans Health Administration |
WHO | World Health Organization |
WTB | Warrior Transition Brigade |
WTU | Warrior Transition Units |