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Substance Use Disorders in the U.S. Armed Forces (2013)

Chapter: Appendix D: Program Reviews

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Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
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Appendix D

Program Reviews

This 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 prevention, 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 redundancy, these programs are reviewed in the sections on the branches responsible for their development and/or initial implementation and referenced in the sections on the other branches that utilize them.

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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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

DEPARTMENT OF DEFENSE

Red Ribbon Campaign

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The national Red Ribbon campaign raises public awareness and mobilizes communities to combat tobacco, alcohol and drug use among military personnel, civilians and their families.
  • Prevention
  • N/A
  • Active Duty
  • Dependents
  • N/A*

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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

That Guy Alcohol Abuse Prevention Education Campaign

Purpose and Goals Clinical Focus Program Evaluation/Outcomesa Target Populationb EBPsc
  • That Guy is a multiThat Guy is a multimedia campaign designed to reduce binge drinking among military enlisted personnel ages 18–24.
  • The campaign includes online and offline advertising and promotions, viral marketing, a website, www.thatguy.com, public service announcements, and branded collateral materials.
  • Prevention
  • Number of joining social network sites
  • Change in drinking behavior where implemented
  • Overall awareness of campaign
  • Change in drinking attitudes
  • Active Duty
  • N/A

aThe 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, Total number of public service announcements per Service, and Number of promotional items distributed.”

bThe table on this program in the Navy section identifies Reserves as an additional target population.

cThe 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 announcements, 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 scenario 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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

In reviewing this program, the committee found that it uses evidencebased 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 Healtd Assessment (PHA) Screening
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • Personnel arc screened annually for substance use related issues during the annual preventive health assessment. Services vary as to their use of screening instruments.
  • Screening
  • Percent of ADSM who complete annual PHA
  • Active Duty
  • Reserve
  • National Guard
Screening typically by AUDIT-C, but screening tools choice can vary*
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Force Health Protection and Readiness Post-Deployment Health Assessment (PDHA) and Post-Deployment Health Reassessment (PDHRA) Program
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • To review each service’s member’s current health, mental health/substance abuse or psychosocial issues commonly associated with deployments, 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 pcrson-to-pcrson 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-Q, 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.
  • Prevention
  • Screening
  • Comprehensive quality assurance program
  • Active Duty
  • Reserve
  • National Guard
  • AUDIT-C

NOTE: ADSM = active duty service member; AUDICT-C = Alcohol Use Disorders Identification 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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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 primary 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 Identification Test-Consumption (AUDIT-C) are used to detect risky drinking as part of Stage 1. Stage 2 collects additional information if Stage 1 screening 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 assessments 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. Referral 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 postdeployment 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 periodic and deployment-related health assessments is that positive screening should lead to further intervention depending on the severity of the condition being screened for. In the case of alcohol, identification of excessive

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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 misuse 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

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • Program offers service personnel and their families the opportunity to take anonymous, mental health and alcohol use self-assessments online, via the phone, and through special events held at installations. Program is designed to help individuals identify their own symptoms and access assistance before a problem becomes serious.
  • Prevention
  • Screening
  • Numbers of screenings
  • Quantities of promotional materials distributed
  • Customer satisfaction
  • Active Duty
  • Reserve
  • National Guard
  • Dependents
  • EBPs are utilized
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The self-assessmenrs address posrrraumaric 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 components 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 personal 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 program 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 intervention reaches more than 305,000 ADSMs and their families each year (Weinick et al., 2011). The program targets ADSMS and their families primarily 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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Real Warriors Campaign

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • A multimedia public education initiative designed to address the stigma associated with seeking psychological 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.
  • Prevention
  • Numbers of calls or hits
  • Customer satisfaction
  • Active Duty
  • Dependents
  • N/A

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 members, 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

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

the service members who would be seeking treatment, and conducted literature 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 indicators, 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

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The military and civilian drug tesring programs are a primary component of rhe installation Drug Demand Reduction Programs. The program works to ensure a drug-free workplace.
  • Prevention
  • Percentage of mandated population resting per year
  • Rate of [.intestable samples
  • Rate of verified positive samples
  • Active Duty
  • Reserve
  • EBPs are utilized

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 controlled 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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Adolescent Substance Abuse Counseling (ASAC) Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The ASAC program provides substance abuse counseling services including outreach, prevention, education, and referral services to adolescents in selected OCONUS middle and high schools.l
  • Prevention
  • Screening
  • Diagnosisd
  • Treatment
  • Total number of prevention classes
  • Total number of students referred
  • Total number of students enrolled
  • Total number of students screened but not enrolled
  • Dependents
  • ASAC counselors arc trained in EBPs such as outcome-informed counseling, solution-focused counseling, brief interventions, and ASAM Patient Placement Criteria

NOTES: The ASAC program is listed as an Air Force program in Appendix C of the Comprehensive 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 Corporation 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 providers who include licensed and certified counselors deliver early intervention 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 civilian 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).

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

The ASAC prevention education program includes information and skill-building activities designed to increase protective factors such as life skills, decision-making skills, and prosocial support for dealing with parental deployment, reintegration, and transition, as well as to minimize risk factors related to transition. Prevention is delivered both in the classroom for whole groups of students and in a counseling format for subgroups and individuals within a school. Students identified as at further risk based on a request for help, a reported behavioral or substance use event, or a substance use assessment are referred for additional intervention. The prevention education component of ASAC is relevant to all stages of military involvement, with the possible exception of the postmilitary stage. While the program does not specify a theoretical basis in its standard operating procedures, it draws from Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for addressing risk and protective factors in school-based skills training programs.

Beyond prevention activities, the ASAC program provides extensive assessments to determine whether individuals need more intensive services. Counselors use the American Society of Addiction Medicine (ASAM) criteria to determine the appropriate level of care for referral if further intervention is needed. The standard operating procedures also detail many quality-assurance activities that are built into the program, including completing utilization reviews of all activities and maintaining a clinical quality-assurance plan (U.S. Army, 2011).

The committee finds that this contracted program provides a comprehensive set of services that meet standards of care for SUD prevention and early interventions for youth. The committee is unaware of the availability of the ASAC program across different branches and military sites. Also unknown is the effectiveness of the program as no formal outcome evaluations have been conducted with the target population.

Additional Programs and Initiatives

Military OneSource is an online source of information on many topics, including 800 telephone numbers of “consultants,” the National Suicide Prevention Lifeline, and the Safe Helpline for Sexual Assault Support. DoD describes Military OneSource as

a free service provided by the Department of Defense to service members and their families to help with a broad range of concerns including money management, spouse employment and education, parenting and child care, relocation, deployment, reunion, and the particular concerns of families with special-needs members. They can also include more complex issues like relationships, stress, and grief. Services are available 24 hours a day—by telephone and online. Many Military OneSource staff members have military experience (veterans, spouses, Guardsmen, Reservists), and

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

all receive ongoing training on military matters and military lifestyle. The program can be especially helpful to service members and their families who live at a distance from installations. (DoD, 2012, p. 1)

Military OneSource also provides basic information on alcohol abuse and Web links for the Army’s Substance Abuse Program, Cocaine Anonymous, TRICARE Alcohol Awareness, and other related sources (DoD, 2012). In response to the committee’s request for information, the program manager of Military OneSource explained the scope of services available. The counseling provided by Military OneSource’s contracted providers is nonmedical in nature (e.g., connecting people to resources; counseling on relationship issues, readjustment, and stress). Individuals presenting with an issue that warrants a mental health diagnosis or pharmacotherapy are referred to services through the Military Health System or their health insurance. In July 2011, in response to concern that providers were counseling people beyond their scope,2 an internal policy clarification was sent to Military OneSource providers specifying the nonmedical nature of the counseling that should be provided. The committee finds that while Military OneSource provides a confidential means for service members and their families to be screened for SUDs and referred to resources, the lack of any clinical counseling indicates that the service is not designed to provide actual treatment for mental health issues.

AIR FORCE

Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The ADAPT Program provides substance related assessment, preventative education, clinical treatment and referral services for Airmen, civilian employees, and family members.
  • Prevention
  • Diagnosis
  • Treatment
  • Access time to substance assessment and clinical treatment
  • Proportion of participants completing treatment program (tracked locally only)
  • Active Duty
  • Reserve
  • National Guard
  • Dependents
  • Substance Abuse Counselors are trained in motivational interviewing and cognitive-behavioral interventions

____________________

2 Personal communication, Dave Kennedy, Program Manager of Military OneSource, August 11, 2011 (Office of the Secretary of Defense, Personnel and Readiness, Military Community and Family Policy).

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The objectives of the ADAPT program .ire to promote readiness, health, and wellness through the prevention and treatment of substance abuse; minimize the negative consequences of substance abuse to the individual, family, and organization; provide comprehensive education and treatment to individuals who experience problems attributed to substance abuse; and to return identified substance abusers to unrestricted duty status or assist them in their transition to civilian life.
 
  • Assessment of drinking behavior and duty performance at 3, 6, and 12 months post discharge from intensive outpatient, partial hospitalization, variable length of stay, or inpatient treatment programs (tracked locally only)
   

NOTE: ADAPT = Alcohol and Drug Abuse Prevention and Treatment; EBP = evidence-based practice.

ADAPT is described in Air Force Instruction (AFI) 44-121 (U.S. Air Force, 2011), which is discussed in Chapter 6. The purpose of the program is to restore function and return personnel to duty or assist them in returning to civilian life. ADAPT has four tiers of activities according to AFI 44-121: Tier I—primary prevention and education, Tier II—secondary/targeted prevention, Tier III—tertiary care/treatment, and Tier IV—training.

According to AFI 44-121, Tier I activities center around primary prevention and education, which have a different focus depending on the

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

individual being targeted (e.g., service member, health care professional, Air University student, commander). Program activities related to primary prevention appear to focus exclusively on the individual level, without including prevention at the environmental level (e.g., alcohol control policies).

Tiers II and III focus on secondary/targeted prevention and tertiary care/treatment, respectively. The targeted prevention program, Alcohol Brief Counseling (described below), is correctly directed at individuals who are at high risk because of heavy alcohol use but who do not qualify for a full diagnosis of abuse or dependence. All individuals seen in the ADAPT program also receive an Alcohol Education Module, which reinforces Air Force policies on use of substances and also focuses on clarification of values and anxiety and anger management.

For screening, all ADAPT sites make use of the Substance Use Assessment Tool (SUAT). The SUAT, developed for use in the Air Force in 2007, is a comprehensive mental health and substance use assessment and case management tool that is designed to be self-administered by the service member and is used across all ADAPT sites. It provides a preliminary diagnosis (to then be confirmed or revised by a licensed mental health provider), a level-of-care recommendation, and motivational interviewing feedback.

ADAPT treatment programs are designed to ensure that the individual acquires and applies an understanding of the disease of alcoholism, communication and coping skills, and mechanisms for establishing goals that reinforce an alcohol-free lifestyle. Abstinence from alcohol is required in the initial treatment phase of ADAPT. ADAPT staff evaluate any service members who have problems with abstaining from alcohol to determine appropriate interventions and, if necessary, change the treatment plan to help clients meet their goals and return to full duty status. Treatment is planned according to ASAM placement criteria. In ADAPT Level I treatment, which usually last 8 weeks, service members participate in both individual and group counseling sessions weekly. Counselors offer interventions based on motivational interviewing, as well as cognitive-behavioral treatment. The treatment team includes not only mental health professionals involved in the clinical care being provided but also the service member’s immediate supervisor and the commander and/or first sergeant. The ADAPT staff at each base coordinate with local TRICARE providers to arrange treatment for those service members requiring inpatient residential treatment, a level of care not provided within ADAPT. Upon completion of residential or nonresidential treatment off base, service members normally return to their duty stations and enter the aftercare phase. Failure to complete treatment successfully may lead to administrative separation.

ADAPT staff design individualized aftercare plans providing continued support with at least monthly monitoring. During this phase of treatment, service members demonstrate their ability to meet Air Force standards and

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

develop the skills and resources needed to maintain a substance-free lifestyle. Normally, individuals remain in aftercare for 6 months to a year after entering the ADAPT program. Procedures also include assessment of drinking behavior and duty performance at 3, 6, and 12 months after discharge from treatment at higher levels of care. The treatment team evaluates the individual’s progress quarterly and keeps the commander informed (U.S. Air Force, 2011). The committee did not have access to information about treatment success rates.

Finally, ADAPT works closely with the Behavioral Health Optimization Program (BHOP) (described further below), which provides brief intervention in a primary care setting to respond to behavioral health needs. Clients are referred by primary care physicians and are seen for three to four sessions. These sessions focus, for example, on planned behavior change, screening for depression, and planning for relapse prevention. The committee found that BHOP does not see a large number of clients with substance abuse problems because primary care providers often refer these patients directly to ADAPT for further assessment. Nevertheless, the existence of BHOP and its relationship with ADAPT are a strength of the Air Force’s approach to addressing behavioral health concerns, including substance abuse.

Overall, the committee finds that ADAPT offers a comprehensive array of services, providing interventions at different levels of intensity and complexity depending on the initial assessment of individuals referred to the program. Thus, brief intervention is available for high-risk individuals as is more intensive treatment, with the latter ranging from outpatient to day treatment to inpatient care. Aftercare plans, which include relapse prevention, also are offered.

Alcohol Brief Counseling (ABC)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • ABC is an individualized, targeted preventive intervention for members seen in ADAPT who are not diagnosed with a substance use disorder.
  • Prevention
  • Outcome survey To rrack self-reporced impact of intervention on substance use and program quality monitoring (tracked locally only)
  • Active Duty
  • Reserve
  • National Guard
  • ABC utilizes standardized assessment tools (AUDIT, CEOA, SIP, RTCQ) and motivational interviewing
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • ABC’s process is conducred wirhin 10 days of che inirial assessment. ABC components include a brief consultation and feedback, an alcohol education module and one or more follow-up sessioni s) to track progress on a personalized change plan.
       

NOTE: ABC = Alcohol Brief Counseling; ADAPT = Alcohol and Drug Abuse Prevention and Treatment; AUDIT = Alcohol Use Disorders Identification Test; CEOA = Comprehensive Effects of Alcohol; EBP = evidence-based practice; RTCQ = Readiness to Change Questionnaire; SIP = Short Index of Problems.

If individuals assessed by ADAPT do not meet diagnostic criteria for an SUD, they receive ABC as an indicated prevention measure. Counseling sessions last about 45 minutes, and service members participate in one to four sessions, depending on an assessment of risk level. If a diagnosis is assigned during the course of ABC, an individual can then enter a treatment program, with the level of treatment being determined according to ASAM criteria. The Air Force reported to the committee that it tracks recidivism rates for those who undergo the ABC intervention, but no formal evaluations are conducted to assess the program’s effectiveness.3 The Air Force Medical Operations Agency reported to the committee outcome measures related to recidivism for fiscal year (FY) 2008-2010. Of the 5,960 service members referred to ABC in FY 2010, 1,137 (19 percent) were defined as recidivists; recidivism rates were similar for FY 2008 and 2009. The implementation of ABC is assessed during the Air Force Inspection Agency’s Health Services Inspection.4

The committee finds that the use of ABC conforms to the evidence-based practice of providing brief intervention and education to those at risk for developing SUDs. The Air Force appropriately uses ABC as an initial intervention aimed at preventing more serious alcohol use in the future, and applies it to individuals who are drinking in a hazardous way but have not been diagnosed with an alcohol use disorder. The committee cannot comment on the program’s effectiveness based on the limited outcome data reported on recidivism.

____________________

3 Personal communication, Air Force Medical Operations Agency, October 25, 2011.

4 Personal communication, Air Force Medical Operations Agency, October 25, 2011.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Behavioral Health Optimization Program (BHOP)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • BHOP providers are integrated into primary care clinics to provide consultation to medical providers and focused assessment and interventions for patients with substance abuse concerns.
  • BHOP providers provide patient advice, education, and facilitate referrals to ADAPT for substance abuse assessment when appropriate.
  • Prevention
  • Screening
  • Diagnosis
  • None identified
  • Active Duty
  • Reserve
  • National Guard
  • Dependents
  • Training in EBPs is included in the basic and advanced BHOP training
  • AUDIT and AUDIT-C for screening
  • VA/DoD clinical practice guidelines
  • Motivational interviewing
  • 5-A’s model

NOTE: ADAPT = Alcohol and Drug Abuse Prevention and Treatment; AUDIT = Alcohol Use Disorders Identification Test; AUDIT-C = AUDIT-Consumption; BHOP = Behavioral Health Optimization Program; DoD = Department of Defense; EBP = evidence-based practice; VA = Department of Veterans Affairs.

BHOP providers are psychologists who work in integrated in primary care clinics, consulting on cases that involve either behavioral health (e.g., PTSD) exclusively or dual diagnoses of a physical health problem with a behavioral health component (e.g., hazardous drinking). BHOP providers also offer brief advice and refer service members to the ADAPT program if they need more intensive substance abuse assessment. The structure of the BHOP program allows for a degree of confidential screening for SUDs, as well as brief advice, in a way that counters the stigma associated with service members disclosing and discussing personal issues related to their alcohol and other drug use. This brief intervention within primary care practices is an important model for identifying and resolving SUD issues early. With this new model, the Air Force is building the capacity to provide confidential screening, brief intervention, and referral to treatment (SBIRT) for those at risk of developing SUDs.

Consistent with national trends toward the integration of behavioral health care into primary care services, the Air Force has moved aggressively toward integrated care. The committee finds that BHOP is an important step toward fully integrated care, particularly as it evolves from identification of

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

SUDs and referral to specialty care toward care that includes the provision of early and brief intervention for SUDs by primary care providers. BHOP is a model for expanding integrated care in all military treatment facilities.

Culture of Responsible Choices (CoRC)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • CoRC is a commander’s program consisting of a four-tiered approach with emphasis on leadership, individual, base, and community-level involvement—underscoring responsible behaviors including alcohol and drug abuse, the prevention of accidents, tobacco cessation, obesity and fitness, health and wellness, prevention of STDs, etc. CoRC initiatives include Assessment/Screening of risk in all personnel, education/awareness programs, brief interventions and treatment when needed, top down emphasis on responsibility and commitment. Components also include base and local community opportunities for change such as developing a range of alternate activities, media campaign promoting responsibility, coalition with community agencies, and monitoring of locally identified metrics.
  • Prevention
  • Screening
  • Diagnosis
  • Treatment
  • Alcohol-Related Misconduct (ARM) incidences per 1,000 SMs
  • Drug positives per 1,000 SMs
  • Active Duty
  • Dependents
  • Use EBPs (e.g., screening instruments) recommended by the National Institute of Alcohol Abuse and Alcoholism (NIAAAJ

NOTE: CoRC = Culture of Responsible Choices; EBP = evidence-based practice; SM = service members; STD = sexually transmitted disease.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

The CoRC program trains commanders to promote wellness at four levels: (1) leadership, (2) individual, (3) base, and (4) community. Several of the program components are designed as “toolkits.” At the leadership level, commanders and health care providers who deliver prevention (i.e., ADAPT providers, BHOP consultants, and Life Skills Support Center [LSSC] personnel) are trained annually on the purpose, use, and measurement of prevention program components. Toolkits are used to supplement Command training.

Toolkits 1-4 address the individual level. Toolkit 1 is a universal prevention program targeting population-wide screening for alcohol use using the AUDIT instrument, with the option of an additional social norms survey. It targets primarily ADSMs but can also include civilians and contract employees at Command’s discretion. Anonymous surveys are administered annually at major Command-involved activities such as Commander’s Calls. The prevention focus includes deterrence and surveillance, as well as educational feedback about consequences of alcohol misuse and perceived social norms for use. To the extent that screening and social norms surveys are used for educational feedback, this toolkit could be considered evidence based. Toolkit 2 is a selected prevention program component that trains Command on the purpose of preventive health assessment and routine care, as well as on procedures for referring ADSMs who have been or are at risk for being involved in alcohol-related incidents to appropriate selective prevention and intervention. Annual screening using AUDIT-C is recommended. Referral channels are specified; for example, individuals with comorbid behavioral health conditions should be referred to an LSSC for further intervention after screening. To the extent that referral channels and procedures are clear, this toolkit could be considered to accord with evidence-based practices (EBPs) for screening and referral. Whether Command or providers are responsible for initial identification of high-risk individuals for screening is not specified. Toolkits 1 and 2 are used at the base as well as the individual level. The six components of the Enforcing Underage Drinking Laws (EUDL) program (discussed further below) apply to both levels.

Toolkit 3 is a procedural guide for service providers in behavioral health clinics and LSSCs in use of the AUDIT screening tool. This toolkit is used as indicated prevention for service members with alcohol problems. Toolkit 4 is a training and resource guide aimed at Command, ADAPT staff, and Drug Demand Reduction staff, with the purpose of building community collaborations for prevention. This toolkit includes training in prevention concepts, screening, social norms, consulting to the community, and prevention program management. It follows EBPs for community implementation processes and prevention operating systems (Hawkins and Catalano, 1992).

The committee does not agree with the designation of CoRC in the above table as having a clinical focus in treatment.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Drug Education for Youth (DEFY)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • DEFY’s goals arc to produce 9-to 12-ycar-oIds with character, leadership, and confidence so that they arc equipped to engage in positive, healthy lifestyles as drug-free citizens, and have the necessary skills to be successful in their lives through coordinated community participation, commitment, and leadership thereby empowering military youth to make positive life choices.
  • DEFY is operated world-wide and consists of a summer leadership camp (Phase 1) and a school-year mentoring program (Phase 2). The program curriculum provides youth with a variety of topics including substance abuse prevention and other vital life skills including conflict resolution, self-management skills, study skills, leadership, and communitv service.
  • Prevention
  • Knowledge
  • Skills
  • Attitudes
  • Dependents
  • EBPsfrom the National Institute of Drug Abuse arc incorporated within the DEFY curriculum

NOTE: DEFY = Drug Education for Youth; EBP = evidence-based practice.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

The DEFY program was started by the Navy in 1993, and although it is also used by the Air Force, the discussion is on this program is in the section on Navy programs below.

Enforcing Underage Drinking Laws (EUDL) Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • EUDL is a piloc prevention program being conducted in conjunction with the Department of Justice (DOJ) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA).
  • EUDL is designed ro reduce rhe availability of alcoholic beverages ro and rhe consumption of alcoholic beverages by underage service members using environmental approaches and community coalitions.
  • Prevention
  • DWIs/DUIs
  • Traffic accidents
  • Compliance checks
  • Crimes
  • Active Duty
  • Dependents
  • Development of EUDL was predicared on rhe use of EBPs such as increased enforcement of underage drinking laws, increased DWI/DUI checks, increased compliance checks, covert underage buys, party patrols, etc.

NOTE: DUI = driving under the influence; DWI = driving while intoxicated; EBP = evidence-based practice; EUDL = Enforcing Underage Drinking Laws.

The EUDL program was a pilot that showed significant reductions in underage drinking (Spera and Franklin, 2010). A grant initiative funded by the Office of Juvenile Justice and Delinquency Prevention resulted in the development and testing of the EUDL program at five Air Force sites. The program used evidence-based strategies advocated by the Office of Juvenile Justice and Delinquency Prevention and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Its six components were (1) enforcement aimed at reducing the social availability of alcohol, (2) compliance checks at alcohol establishments, (3) driving under the influence (DUI) checks, (4)

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

education of state legislatures and development of local policies, (5) a media awareness campaign, and (6) provision of alternative activities to alcohol use. Results from the five sites showed significant reductions in rates of problem drinking both within sites and compared with control communities (Spera and Franklin, 2010; Spera et al., 2012). The committee learned during an information gathering session that EUDL was a demonstration project and that there are currently no plans to expand it to all Air Force bases; however, some of its components will be implemented within other Air Force–wide initiatives.5 The committee finds the EUDL program to be a promising example of an effective approach to SUD prevention in military settings.

Air Force Reserve Component Substance Abuse

Prevention Specialist Training (SAPST)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The SAPST program aims ro increase knowledge and improve skills of Drug Demand Reduction Program technicians and program managers in substance abuse prevention, facilitate full-scale adaptation and implementation of the SAPST model, and provide preliminary direction to the identification of related training and technical assistance needs.
  • Prevention
  • None identified
  • Reserve
  • EBPs are utilized

NOTE: EBP = evidence-based practice; SAPST = Substance Abuse Prevention Specialist Training.

A September 2011 evaluation of a SAPST session sponsored by SAMHSA in cooperation with the U.S. Air Force Reserve Command, held June 27 to July 1, 2011, measured trainees’ reactions to the training. The trainees gave high marks to the training’s design and materials and its usefulness, and expressed confidence that they could carry out the prevention programs covered. However, no follow-up outcome evaluations were conducted to determine whether the trainees actually carried out the prevention programs as they were trained to do, or to evaluate whether the programs

____________________

5 Personal communication, Lt. Col. Mark S. Oordt, Ph.D., USAF ADAPT Program, October 25, 2011.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

reduced the prevalence of SUDs in the populations to whom they were delivered. Therefore, the committee cannot determine whether the program is effective at preventing SUDs.

ARMY

Army Substance Abuse Program (ASAP)

The Army Center for Substance Abuse Programs (ACSAP) manages ASAP, which provides nonclinical prevention services (e.g., universal education, deterrence, identification/detection, referral) and clinical rehabilitation services (assessment and treatment). These services and related activities are reviewed below.

Prevention, Education, and Training Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The program provides soldiers with substance abuse prevention and awareness training to include at a minimum: Army Substance Abuse Program (ASAP) policies and services, consequences of alcohol and other drug abuse, incompatibility of alcohol and other drug abuse with physical and mental fitness, combat readiness, Army Values, and the Warrior Ethos.
  • Prevention
  • Screening Enrollment Report by Installation and Command
  • Education/Training Report by Unit
  • UPL Certification Database by Individual Command
  • Resource and Performance Report by Installation and Command
  • Active Duty
  • Reserve
  • Dependents
  • ADAPT curriculum utilizes EBPs

NOTE: ADAPT = Alcohol and Drug Abuse Prevention and Treatment; EBP = evidence-based practice; UPL = unit prevention leader.

The Army employs designated personnel called unit prevention leaders (UPLs) who oversee each unit’s prevention plan. They monitor substance abuse training, ensuring that all active soldiers meet the mandatory minimum

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

requirement to complete 4 hours of substance abuse awareness training per year (2 hours per year for Reserve and National Guard members) (U.S. Army, 2009). UPLs also monitor how commanders identify high-risk populations. UPLs are certified after a 2-week training program (U.S. Army, undated). The most noteworthy Army prevention programs are Prime for Life (PFL) and myPRIME.

PFL is based on the Lifestyle Risk Reduction Model, the Transtheoretical Model, and persuasion theory and has demonstrated efficacy in young adults and adults up to age 55 (SAMHSA, 2010). It is listed as a universal, selective, and indicated prevention program. The program’s classroom-based training, offered by certified PFL instructors (ACSAP, 2012b), focuses on the adverse effects and consequences of alcohol and other drug abuse. Designed as a motivational group intervention to prevent alcohol and other drug problems or provide early intervention, PFL emphasizes changing participants’ perceptions of the risks of alcohol and other drug use and related attitudes and beliefs. It also has been used with military personnel, college students, middle and high school students, and parents. Different versions of the program, ranging from 4.5 to 20 hours in duration, and optional activities are available for use with various populations. While PFL is listed as an evidence-based approach in the National Registry of Evidence-Based Programs and Practices (SAMHSA, 2010) and widely used throughout the United States, very few studies have been conducted that demonstrate the efficacy of PFL. It should also be noted that no studies have been conducted to evaluate the efficacy of PFL with the U.S. military population. Therefore, the committee cannot determine whether the use of this program with Army service members is effective at preventing SUDs.

The myPrime prevention program, designed specifically for use in the military, is based on the PFL curriculum. It is an indicated intervention intended for soldiers who present with issues with alcohol and/or other drugs while deployed. This online intervention-training tool enables deployed soldiers to self-assess their high-risk behaviors and is intended to influence changes in attitudes, beliefs, and behaviors (ACSAP, 2012b).

The ACSAP website (ACSAP, 2012a) identifies training appropriate at the squad to unit level. When a soldier who completed myPRIME while deployed returns to his/her home station, the commander must send the soldier to the garrison ASAP office for completion of care. The myPRIME adaptation for military personnel is generic in nature; it includes no military-specific information, nor has it been adapted for the contexts of substance use among military personnel. As with PFL, there is no evidence that this program is effective at preventing SUDs in the Army.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Risk Reduction Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Army Risk Reduction Program (RRP) is a commander’s tool designed to identify and reduce soldiers’ high-risk behaviors in the areas of substance abuse, spouse and child abuse, sexually transmitted diseases, suicide, crimes against people, crimes against property, absence without leave (AWOL), traffic violations, accidents and injuries, and financial problems. RRP focuses pn effective use of installation resources and a coordinated effort between commanders and installation agencies to implement intervention and prevention programs.
  • Prevention
  • Regression Analysis by Risk Factors by Unit, Installation, Region, and Command
  • Unit Risk Inventory (URI) Survey Administrated at Unit Level with Upper Level Comparisons, Installation, Region, and Command
  • Reintegration-URI Survey Administrated at Unit Level with Upper Level Comparisons, Installation, Region, and Command
  • Active Duty
  • Reserve
  • N/A

NOTE: EBP = evidence-based practice; N/A = not applicable.

The Army Risk Reduction Program is a Command prevention tool aimed at reducing high-risk behaviors such as substance abuse among soldiers. It began in 1994 at Fort Campbell and has since been implemented at Army sites around the world. The program is designed to collect data on high-risk behaviors at the installation level and then bring together an Installation Prevention Team to create interventions targeting the high-risk behaviors thus identified. The program’s data systems allow commanders to track trends in the incidence of high-risk behaviors and to compare those rates between specific units or with Army-wide rates (ACSAP, 2012c).

During its site visit to Fort Hood, the committee learned that the Risk Reduction Program had helped lead to the decision to close on-base liquor

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

stores at 9:00 PM instead of 12:00 AM in an effort to reduce risky drinking behaviors on base. The committee finds that this program could assist commanders in allocating prevention resources to the highest-risk behaviors, in making decisions about implementing environmental prevention strategies (such as the earlier closing of liquor stores at Fort Hood), and in tracking outcome trends after specified interventions have been delivered. The extent to which commanders are held accountable for the results of the program’s risk analyses and the extent to which the program’s tools are utilized across Army sites is unknown.

Employee Assistance Program (EAP)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Army’s Employee Assistance Program (EAP) provides a wide variety of services for various adult living problems. These services include but are not limited to screening, short-term counseling, and referral for all adult living problems.
  • Prevention
  • Screening
  • EAP reports by Installation and User
  • Screening and Enrollment Report by Installation and Command
  • Dependents
  • N/A

NOTE: EBP = evidence-based practice; N/A = not applicable.

Civilian employers frequently offer EAPs as a human resources benefit to provide assessment and brief intervention services for employees seeking behavioral health assistance. The EAPs offered in the Army are located within ASAP and provide a multitude of services, including short-term counseling and referral to care providers for more intensive needs. The Army supports EAP services for ADSMs, members of the National Guard and Reserves, and civilian employees. Unlike ADSMs, Guard and Reserve members can access treatment programs through the EAP without having to notify their Command. While the Army’s EAP services may provide some early intervention and referral services for SUDs (particularly for Guard and Reserve members who may need assistance with finding care options outside of the TRICARE network), the committee finds the location of these services within ASAP to be problematic because of the stigma associated with accessing care for SUDs. The committee did not receive enough information on the Army’s EAP to comment on the quality or effectiveness of these services in preventing and screening for SUDs.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Rehabilitation Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The objective of the Rehabilitation Program is to return soldiers to full duty as soon as possible; identify and refer soldiers who cannot be rehabilitated in the Army Substance Abuse Program (ASAP) to a rehabilitation facility in the vicinity where they reside after discharge from the Army; help resolve alcohol and other drug abuse problems in the family, with the ultimate goal of enabling the soldier to perform more effectively; and for civilian employees to restore them to effective duty performance.
  • Screening
  • Diagnosis
  • Treatment
  • Screening and Enrollment Report by Installation and Command
  • Rehabilitation Summary
  • Rehabilitation Caseload
  • DAMIS dynamic ad hoc query capability
  • Active Duty
  • Reserve
  • Dependents
  • N/A

NOTE: DAMIS = Drug and Alcohol Management Information System; EBP = evidence-based practice; N/A = not applicable.

The ASAP Rehabilitation Program focuses on returning soldiers to full duty quickly by providing outpatient, intensive outpatient, and residential rehabilitation services for SUDs. Enrollment in rehabilitation services requires Command notification, and the commander is included on the treatment team. Most ASAP clinics provide outpatient treatment (with a few exceptions noted in the next section); more intensive services often are referred to TRICARE network providers. During a site visit to Fort Belvoir, the committee found that while ASAP treats many individuals with comorbid disorders, ASAP treatment counselors are credentialed through the military treatment facility only to provide treatment for SUDs. The result is that soldiers cannot receive care in ASAP that addresses comorbid disorders. Since the Army requires master’s level counselors with independent licensure (see Chapter 8), the committee finds this limitation to be impractical. The committee is unaware of any formal evaluations of the ASAP rehabilitation program to determine its effectiveness.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Additional Programs and Initiatives

The committee reviewed two ongoing pilot programs within the Army—the Confidential Alcohol Treatment and Education Pilot (CATEP) and an Intensive Outpatient Program (IOP) pilot at Fort Hood. CATEP is a program for soldiers who self-refer to ASAP with alcohol problems before they are involved in an incident. Because participation in CATEP does not compromise one’s military career, soldiers have improved access to treatment for alcoholism earlier in the course of their illness. The IOP program at Fort Hood, which began in February 2010, was designed to provide more intensive care than was available at the ASAP clinic on base, as well as to treat those with comorbid disorders. Currently, the program is providing ASAM Level II.5 care as a 4-weekday treatment program; therefore, the name of the program will be changing to reflect that it provides care beyond the IOP level. For further discussion of these two pilot programs, see Chapter 6.

A third initiative the committee examined is the Comprehensive Solider Fitness (CSF) program, a resiliency training program with four elements: (1) a global assessment tool (GAT), an online self-report measure of the ability to adapt to stress and challenge that is used as a measure of self-assessment and goal setting and as a guide for the selection of program modules that are tailored to an individual’s needs; (2) comprehensive resilience modules, a set of self-development training modules that are accessed online and address specific resilience skills in four dimensions (social, emotional, spiritual, family) for a total of 24 hours; (3) a master resiliency train-the-trainer program that trains primarily noncommissioned officers (NCOs) to implement CSF with groups of soldiers at the unit or installation level, and requires a total of 10 days and 80 hours of training for certification; and (4) resiliency training, which is delivered by master trainers in groups to military members and their families. ADSMs are required to be trained in CSF, with a recommended implementation schedule of 2 hours/month; families and Army civilians can participate on a voluntary basis. Resiliency training can conceivably be delivered throughout the stages of military life, from entry through postdeployment.

The program, adapted from the Penn Resiliency Program, is based on resiliency theory (Rutter, 2006) and theories of positive psychology as an alternative to depression (Seligman, 1998). A special issue of American Psychologist described the CSF program and initial research results on military populations, which are focused on changes in GAT scores (Peterson et al., 2011). In addition, an internal military evaluation examined approximately 10,000 soldiers assigned by installation to one of two groups: intervention or control. Analyzing data from three GAT survey assessments conducted

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

over a 15-month period, the evaluators concluded that the intervention group showed sustained, beneficial changes in resiliency, depression, and fitness compared with the control group (Lester et al., 2011b). However, assignment was not random; installations that could not schedule the program were assigned to the control group. Furthermore, it is unclear whether changes in either nonmilitary or military populations have translated to changes in substance use behavior. Thus, while CSF might be considered a promising approach to preparing and maintaining military fitness under stressful conditions, it is unclear whether this program prevents or reduces substance use.

NAVY

Substance Abuse Rehabilitation Program (SARP)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • Using the American Society of Addiction Medicine patient placement criteria, SARP matches the appropriate intensity of treatment to the individual’s level of need. SARP covers a spectrum referred to as the continuum of care that ranges from early intervention, through outpatient, intensive outpatient, residential and medically managed care.
  • Prevention
  • Screening
  • Diagnosis
  • Treatment
  • Number of patients retained on Active Duty after 1 year
  • Percentage of patients completing treatment
  • Length of time to wait for a screening
  • Length of time before treatment begins
  • Active Duty
  • Reserve
  • Dependents
  • Motivational interviewing
  • Twelve-step facilitation
  • Living in Balance
  • Contingency management
  • Cognitive behavioral intervention

NOTE: EBP = evidence-based practice; SARP = Substance Abuse Rehabilitation Program.

SARP is the Navy’s substance use treatment program. It provides prevention, screening, diagnosis, and treatment services. The Navy recognizes that SUDs are preventable and treatable. Command is trained to identify Navy members in need of treatment. Orders are written, and those identified are required to follow through with treatment orders or be at risk for loss of clearance and discharge.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

The effectiveness of the Navy’s prevention and treatment programs is monitored in part by the Alcohol and Drugs Management Information and Tracking System (ADMITS). ADMITS collects, maintains, analyzes, and disseminates data on all incidents and activities related to the Navy’s drug and alcohol abuse prevention and control programs. It also provides screening numbers and documentation of treatment outcomes to SARP. ADMITS is able to track numbers of Drug and Alcohol Abuse Report submissions, screening results submitted accurately, and treatment results submitted accurately (DoD, 2011).

Aftercare also is provided to each individual seen in treatment. Typical aftercare includes ongoing participation in approved self-help groups and clinically monitored outpatient counseling groups, and enrollment in the Navy My Ongoing Recovery Experience (MORE) program (described in the following section). Recommendations are tailored to the individual, and Command is responsible for monitoring aftercare participation.

SARP has 40 sites plus 14 additional sites on ships to provide substance use treatment. More than 300 certified substance use counselors are available. The counselors follow the ASAM Patient Placement Criteria. Outpatient treatment consists of an 8-day program for those identified as alcohol abusers. Intensive outpatient treatment, consisting of a 3-week, full-day program, is available for individuals identified as dependent. Residential programs also are available for those who are dependent. Treatment includes programs for family members interested in learning how dependence impacts families. Evidence-based treatments provided include cognitive-behavioral therapy, motivational interviewing, and psychopharmacology.

The Navy also offers an indicated prevention program called Impact. This program was described to the committee during its visit to the naval base in San Diego. It is a 20-hour program designed for patients who have not been diagnosed with a significant substance-related disorder but whose use of substances has created concern for the patient or the patient’s Command. The program includes participation in an interactive educational curriculum and exposure to 12-step recovery programs.

The San Diego SARP, the largest and most intensive, provides both residential care (34 days of around-the-clock care, including assessment, group counseling, workshops, fitness activity, and self-help meetings) and outpatient care. Instruction 5353.4A requires SARPs to provide a continuum of care that includes

  • early intervention/education (20 hours of instruction) (ASAM Level 0.5)—Alcohol-AWARE and Alcohol-Impact (these programs are not classified as treatment, and initial completion of the programs does not require Command notification);
  • outpatient treatment and continuing care (9 hours or less contact per week unless mission requirements necessitate more compressed
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

and intense clinical contact during the first 2 weeks of care) (ASAM Level I);

  • intensive outpatient treatment and partial hospitalization (80 to 100 hours of clinical contact over a 4- to 6-week period) (ASAM Level II)—4 or more hours of care 3 to 5 days per week;
  • clinically monitored residential treatment (variable lengths of stay, generally up to 4 weeks in duration) (ASAM Level III)—for patients who require a safe and stable living environment in which to develop recovery skills; and
  • medically managed inpatient treatment (ASAM Level IV)—medical services for detoxification and comorbidities coordinated through military treatment facilities.

SARP is therefore a comprehensive treatment program that offers several therapeutic interventions with varying levels of intensity depending on ASAM placement criteria (Levels 0.5 to IV). Besides treatment, SARP’s activities appropriately encompass prevention, early indicated intervention, screening and diagnosis, and aftercare. EBPs are applied throughout. The effectiveness of treatment is monitored, although no assessment of effectiveness with state-of-the-art randomized techniques has been conducted. The committee was particularly impressed with the focus, breadth, supervision, and operation of SARP’s prevention, screening, diagnostic, and treatment services.

My Ongoing Recovery Experience (MORE)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • MORE is a continuing care program that supports patients as they leave their primary treatment. Through the use of Web technology, MORE provides tailored support to patients during the first 18 months after treatment as a means to improve treatment outcomes and eliminate, reduce, or shorten episodes of relapse.
  • Treatment
  • Abstinence and retention rates of those actively involved/completing the MORE program versus those who do not participate
  • Number of relapses during 18-month enrollment in MORE
  • Active Duty
  • Reserve
  • Dependents
  • Motivational interviewing
  • Twelve-step facilitation
  • Living in Balance
  • Contingency management
  • Cognitive behavioral intervention
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • MORE allows for ongoing support wherever a patient is located co support continued engagement in a therapeutic effort that will enhance long-term abstinence and recovery from substance dependence.
 
  • Length of relapses before returning to the path of recovery
  • Number of days patients are abstinent
   

NOTE: EBP = evidence-based practice; MORE = My Ongoing Recovery Experience.

MORE is an 18-month online support program for individuals who complete SARP. The program connects these individuals to additional tools and resources to aid in their recovery. MORE was developed and is administered by the widely recognized Hazelden treatment program and is oriented toward 12-step recovery. Since August 2010, MORE has supported those in the early stages of aftercare by giving them a recovery coach who is a licensed addiction counselor and is available to provide electronic and telephone support. The program encourages individuals to designate goals for the week and promotes insight through journaling, the development of healthy coping strategies, reading of fact sheets, and participation in a serenity area of the MORE website to help manage stress. Hazelden has also created a new recovery support tool called Mobile MORE Field Guide to Life. This iPhone application, which builds on the MORE program, is being pilot tested by the Navy.

MORE is a positive example of the innovative use of the Internet and the provision of a confidential source of support for recovery. The evaluation and outcomes of the MORE program cited in the above table are likely based on research by Hazelden’s Butler Center for Research (Klein et al., 2012). That study was conducted on a limited sample of residential patients discharged in 2006-2007 who met the diagnostic criteria only for dependence, so the study population does not appear to be comparable to the greater range of diagnostic severity encountered in discharged SARP patients. An evaluation of the outcomes of MORE with the Navy population is therefore needed.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Drug Detection and Deterrence Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Drug Detection and Deterrence Program develop policies and provide guidance for all Navy urinalysis drug-screening programs. Provides policy guidance and ensures compliance with existing policies and directives of DoD, Department of the Navy, and other agencies in development, implementation, quality assurance, and evaluation of substance abuse prevention programs.
  • Prevention
  • Number of urine samples submitted ro Navy Drug Screening Laboratories ar San Diego, Great Lakes, and Jacksonville
  • Number of drug positives due to illicit drug use
  • Number of drug positives cleared due to prescribed medication
  • Number of drug positives retained due to innocent ingestion
  • Number of drug positives retained due to break in the chain of custody
  • Number of drug positives cleared due to ADMIN board/Court-Martial acquittal and Board of Inquiry retention
  • Active Duty
  • Reserve
  • N/A

NOTE: DoD = Department of Defense; EBP = evidence-based practice; N/A = not applicable.

The policies promulgated in relation to this program are reviewed in Chapter 6. In general, policies emphasize detection and deterrence and do not specify the need for evidence-based public health interventions focused on prevention. The program is driven by concerns of commanders rather than medical providers and thus discourages early identification and education to prevent SUDs.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Drug Education for Youth (DEFY)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • DEFY’s goals are co produce 9- ro 12-year-olds wirh character, leadership, and confidence so that they are equipped to engage in positive, healthy lifestyles as drug-free citizens, and have the necessary skills to be successful in their lives through coordinated community participation, commitment, and leadership thereby empowering military youth to make positive life choices.
  • DEFY is operated worldwide and consisrs of a summer leadership camp (Phase 1) and a school-year mentoring program (Phase 2). The program curriculum provides youth with a variety of topics including substance abuse prevention and other vital life skills, including conflict resolution, self-management skills, study skills, leadership, and community service.
  • Prevention
  • Number of DEFY program sires
  • Number of youth participants
  • Number of adult staff participants
  • Longevity of individual program sites (longer running program is considered more successful)
  • Dependents
  • CSAP prevention strategies

NOTES: Appendix C of the Comprehensive Plan provides information on DEFY in both the Air Force and Navy sections. The content pertaining to program outcomes/evaluation and EBPs differs in the two tables. CSAP = Center for Substance Abuse Prevention; DEFY = Drug Education for Youth; EBP = evidence-based practice.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

DEFY is a comprehensive prevention program now shared by the Navy, Air Force, and Marine Corps. The Navy launched the DEFY prevention program in 1993. In 1999, the Air Force became a partner in the DEFY effort and began operating program sites at numerous installations worldwide. In addition, in 1996 the Attorney General’s Weed & Seed program adopted DEFY, expanding it to any location with a U.S. attorney’s office. Navy policy specifies that DEFY is a voluntary program, and local commanders should not mandate participation in any way (U.S. Navy, 2007). While DoD identifies in the Comprehensive Plan that DEFY incorporates EBPs in its curriculum, the committee is not aware of any formal outcome evaluations that have been conducted with military dependent participants. Therefore, it is unknown whether the program is effective at preventing SUDs for military dependents. The Air Force reported that DEFY administers surveys to youth participants and parents for purposes of evaluating the program.6

Right Spirit Campaign

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Right Spirit Campaign enhances fleet readiness by the reduction of alcohol abuse and related incidents, and provides a safe and productive working environment while deglamorizing alcohol use. The campaign uses videos, posters, etc.
  • Prevention
  • Number of command and self-referrals for alcohol screenings
  • Number of participants in local events held to deglamorize alcohol use
  • Reduction in number of alcohol incidents fleet-wide
  • Active Duty
  • Reserve
  • CSAP prevention strategies

NOTE: CSAP = Center for Substance Abuse Prevention; EBP = evidence-based practice.

The Right Spirit Campaign was designed to change the Navy’s attitude and culture regarding alcohol. The committee was informed that the Right

____________________

6 Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations Agency, October 25, 2011.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Spirit Campaign will be phased out during FY 2012 and therefore did not request additional information on this program to review.

Alcohol Abuse Prevention Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • A comprehensive alcohol abuse prevention and control program for all Navy military personnel that focuses on the responsible use of alcoholic beverages through education, training, and awareness. Assigns responsibility to all personnel and recognizes that alcohol abuse and dependency are preventable and treatable.
  • Prevention
  • Number of personnel with ARIs
  • Number of personnel with Duy DWI
  • Number of treatment failures
  • Number of self-referrals
  • Active Duty
  • Reserve
  • Community-based processes, environmental strategies, information dissemination, alternative activities, education, and problem recognition and referral

NOTE: ARI = Alcohol Related Incident; DUI = driving under the influence; DWI = driving while intoxicated; EBP = evidence-based practice.

This program is similar to the Drug Detection and Deterrence Program, discussed above. It assigns responsibility for alcohol abuse and dependency to all personnel and recognizes that they are preventable and treatable. The program has not been formally evaluated for effectiveness. However, alcohol misuse and abuse appear to remain highly prevalent among Navy personnel, as is the case with the other branches. Thus, the committee finds that there appears to be either a breakdown in implementation or some limitations in the materials used for the Navy’s alcohol prevention programs. Further, the program relies on information dissemination rather than motivational interviewing messages and skill-building exercises that are part of evidence-based prevention programs.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Navy Drug and Alcohol Advisory Council (NDAAC)

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The NDAAC provides local and regional commanders with written plans of action to combat identified local and regional drug and alcohol threats.
  • Prevention
  • Quarterly meetings in area of responsibility
  • Number of prevention programs/events monitored
  • Number of ARIs at AOR
  • Number of DUIs/DWIs at AOR
  • Number of days without ARI or DUI/DWI
  • Active Duty
  • Reserve
  • Dependents
  • N/A

NOTE: AOR = Area of Responsibility; ARI = Alcohol Related Incident; DUI = driving under the influence; DWI = driving while intoxicated; EBP = evidence-based practice; N/A = not applicable; NDAAC = Navy Drug and Alcohol Advisory Council.

The NDAAC is a local and regional mechanism by which commanders can monitor and communicate achievements or lack of success in attaining prevention goals related to alcohol-related incidents. Thus it is not a prevention program. While local monitoring is appropriate, it would be more effective to establish specific short- and long-term branch-level goals for reducing harmful alcohol use that are focused not just on incidents (i.e., getting caught) but also on changes in alcohol use behavior (e.g., reduced number of military personnel who binge drank during the last month; reduced number of underage personnel consuming any alcohol). The Navy also offers Commands a training course for drug and alcohol program advisers on all matters relating to alcohol or other drugs. This collateral duty Command position advises the commanding officer on all substance abuse matters, including administrative screenings, reports, prevention education, and monitoring of aftercare for service members who complete treatment programs.

Overall the committee finds that the program could be enhanced if specific short- and long-term behavior change targets were established at the branch level. Commanders should compare their progress with that of other installations and be held accountable for reaching prevention-related behavioral goals.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Training and Courses

Prevention Specialist Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Prevention Specialise Course provides education and training on how to design and implement evidence-based prevention programs at the local command level.
  • Prevention
  • Decreased number of Alcohol and Drug Rehired Incidents (ARIs/DRIs) at commands
  • Number of people successfully passing the certification examination and becoming certified
  • Prevention specialists
  • Number of prevention programs implemented at the command level
  • Active Duty
  • Dependents
  • Students are trained in CSAP strategies and learn to utilize the National Registry of Evidence-Based Programs and Practices (NREPP) in selecting prevention programs for their local community
Navy Drug and Alcohol Counselor School (NDACS)
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • NDACS provides education and Training ro Active Duty personnel who in turn provide treatment at SARP programs. This training ensures Active Duty personnel are providing high-quality patient care competently utilizing EBPs.
  • Prevention
  • Screening
  • Diagnosis
  • Treatment
  • Number of counselors certified following internship
  • Number of personnel passing certification examinations at various levels
  • Number of personnel screened out, deselected and dis-enrolled from the course
  • Active Durv
  • Adult learning model
  • Motivational interviewing
  • Twelve-step facilitation
  • Living in Balance
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Clinical Preceptorship Program
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The program provides counselors assigned co SARPs with rhe unique skills and Training required of counselors engaged in substance use disorder treatment and education.
  • Screening
  • Diagnosis
  • Treatment
  • Number of counselors passing certification examinations and becoming certified
  • Hours provided and utilized at each SARP
  • Treatment Director/Counselor’s satisfaction annual quality assessment survey
  • Number of ethical complaints per year submitted to U.S. Navy Certification board
  • Active Duty
  • Motivational interviewing
  • Interpersonal recall model
  • In vivo supervision
Personal Responsibility and Values Education and Training (PREVENT) Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • A prevention education and health promotion course (24-hr course) specifically developed to target the 18- to 25-year age group. PREVENT deals with life choices related to alcohol and drug use; interpersonal relationships (including sexual responsibility); and health, fitness, and financial responsibility.
  • Prevention
  • Number of personnel who attend annually
  • 15,798 (3-year annual average throughput)
  • Active Duty
  • Reserve
  • N/A
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Alcohol and Drug Abuse Management Seminar (ADAMS) for Supervisors Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • A course designed co provide Navy supervisors wirh knowledge and skills in alcohol and drug abuse prevention, recognition and documentation, intervention and aftercare. Because policy and programs are subject to change, ADAMS for Supervisors should be repeated every 5 years.
  • Prevention
  • Number of personnel who attend annually
  • 9,801 (3-year annual average throughput)
  • Active Duty
  • Reserve
  • N/A
Alcohol and Drug Abuse Management Seminar (ADAMS) for Leaders Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • A brief seminar designed for Commanding Officers, Executive Officers, Command Master Chiefs, Chiefs of rhe Boar, and other senior command personnel to provide an overview of what is taught in the ADAMS for Supervisors course.
  • Prevention
  • Number of personnel who attend annually
  • 723 (3-year annual average throughput)
  • Active Duty
  • Reserve
  • N/A
Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×
Alcohol-AWARE Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • Alcohol-AWARE is an alcohol-awareness training chat provides basic information about alcohol use and associated risks, Navy policies, responsible drinking, and alternatives.
  • Prevention
  • Number of personnel who attend annually
  • 7,382 (3-year annual average throughput)
  • Active Duty
  • Reserve
  • N/A
  • Course is a requirement for all personnel.
       
Drug and Alcohol Program Advisor (DAPA) Course
Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • This course provides Training to Drug and Alcohol Program Advisors for commands on all matters relating co alcohol or other drugs. This 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.
  • Prevention
  • Number of personnel who attend annually
  • 1,421 (3-year annual average throughput)
  • Active Duty
  • Reserve
  • N/A

NOTE: CO = commanding officer; CSAP = Center for Substance Abuse Prevention; EBP = evidence-based practice; N/A = not applicable; SARP = Substance Abuse Rehabilitation Program.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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 Preceptorship Program, the Personal Responsibility and Values Education and Training (PREVENT) Course, the Alcohol and Drug Abuse Management 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 installation personnel who are responsible for prevention programming. Participants 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 prevention specialists to Center for Substance Abuse Prevention (CSAP) strategies 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 Preceptorship Program as intern counselors. The Clinical Preceptorship Program 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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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 prevention 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 implementation 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 developmental 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

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

serving the Army, Air Force, Navy, and Marine Corps. Based on resiliency theory (Rutter, 1999) and multiple family and individual resiliency programs, 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

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Marine Corps Subsrance Abuse Program provides screening and assessment, and Treatment services for Active Duty military members and other eligible beneficiaries with substance abuse disorders.
  • Prevention
  • Screening
  • Diagnosis
  • Treatment
  • Number of completion of treatments
  • Number of treatment failures
  • Number of re-screens after completion of treatment
  • Active Duty
  • ASAM Patient Placemenr Criteria for rhe trearment of substance related disorders MX- Used for alcohol treatment

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 substance abuse and dependency disorders which interfere with mission readiness 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 treatment) 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,

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

assessments of illegal drug use, and training and action plans at installations 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 necessary 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 dimensions 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, December 26, 2011.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Substance Abuse Prevention and Intervention Program

Purpose and Goals Clinical Focus Program Evaluation/Outcomes Target Population EBPs
  • The Marine Corps Substance Abuse Prevention program provides prevention tools such as antidrug videos and games, substance abuse prevention tool kits, Command Summits, and the Battalion Alcohol Skill Intervention Curriculum that help commanders prevent problems that detract from unit performance and mission readiness.
  • To assist in the 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:
    • Illegal drug use prevention activities
    • Drug testing
    • Implementing prevention programs
    • Coordinating treatment services with the SACC
    • Conducting aftercare
  • Prevention
  • Number of positive samples
  • Number of multiple positives
  • Number of prescription drug confirmed positives
  • Active Duty
  • Reserve
  • Prevention tools created specifically for the Marine Corps based on research by the Naval Health Research Center

NOTE: EBP = evidence-based practice; SACC = Substance Abuse Counseling Center.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

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 Intervention Curriculum (BASIC), which is used across Marine Corps sites. Following a train-the-trainer model, SACC staff train battalion unit trainers, 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 researchers 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 College 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 modifications that would increase positive results.

The Impact program (described previously in the section on Navy programs) 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, December 26, 2011.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

problems that can result from consuming alcohol. The course focuses primarily on alcohol-related policies and consequences and how individuals can establish proper measures and responsible behavior (i.e., safety, environmental 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 postdeployment. 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

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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.

Suggested Citation:"Appendix D: Program Reviews." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
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Problems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issues has changed in recent years. National trends indicate substantial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of substance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade--in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD).

To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). Substance Use Disorders in the U.S. Armed Forces reviews the IOM's task of assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and offers specific recommendations to DoD on where and how improvements in these areas could be made.

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