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

Chapter: 5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders

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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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5

Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders

This chapter reviews best practices for prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). The review that follows in Chapter 6 compares current military policies and programs pertaining to SUDs with best practices as described in the scientific literature outlined here.

PREVENTION

Prevention is a key strategy for addressing substance use problems. As a first step in delaying the onset and progression of substance abuse, effective prevention has the potential to minimize the need for diagnosis, treatment, and management of SUDs and reduce the enormous social and economic costs of alcohol and other drug dependence. The 2011 National Drug Control Strategy identifies the military as an important population for the receipt of substance abuse prevention services (ONDCP, 2011b). The strategy gives priority to three objectives pertaining directly to SUD prevention within the military: community-based efforts (both on and off base); efforts with youth (i.e., military dependents); and prevention of prescription drug abuse, a growing problem in the military as well as in the general U.S. population (ONDCP, 2011b).

The major goals of prevention are to prevent or delay the onset of substance use and to delay the progression of use from experimental to regular use and dependence. The Institute of Medicine (IOM) has identified three major types of prevention activities: universal, selective, and indicated (IOM, 1994a; NRC and IOM, 2009). In the present context, universal prevention

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

focuses on the general population or population subgroups that are not currently at high risk for SUDs. Selective prevention targets individuals and groups at greater risk of developing SUD-related problems. Finally, indicated prevention focuses on those who are already in the early stages of problematic substance use. Each type of prevention is integral to a robust and comprehensive prevention strategy.

Risk and Protective Factors for SUDs

Effective prevention programs are intended to diminish risk factors and promote protective factors for substance use. Risk factors can be divided into three categories: individual, social, and environmental. Examples include a genetic predisposition to SUD, low self-confidence, low self-efficacy, poor decision-making skills, negative peer influences, and permissive attitudes toward substance use by parents and the community, among others (Lowinson, 2005; NRC and IOM, 2000). Protective factors include, for example, having emotionally supportive parents with open communication styles who are aware of their children’s potential for substance use, a strong family orientation, religion/spirituality, involvement in organized school activities, and a strong sense of connection to teachers and school. The National Institute on Drug Abuse’s (NIDA’s) (2009b) Prevention Research Review Work Group advocates the use of a biopsychosocial approach to identifying risk and protective factors, which involves assessing context (e.g., school, workplace, military) and stage of development (e.g., early childhood, adolescence, young adulthood) (see also NRC and IOM, 2009, and Robertson et al., 2003). This section reviews evidence on risk and protective factors for SUDs by domain (i.e., individual, social, environmental) and developmental stage (i.e., childhood, adolescence, adulthood).

Risk Factors

Most individual risk factors are identified in children and adolescents (e.g., childhood maltreatment/abuse) (Horwitz et al., 2001; Hussey et al., 2006; Mayes and Suchman, 2006; NRC and IOM, 2009; Sternberg et al., 2006; Trickett et al., 2011). Some individual risk factors, however (e.g., intimate partner violence, including physical, sexual, or emotional abuse and/or coercion and degradation) (Campbell, 2002), apply more specifically to adults. While genetic susceptibility to SUD is not modifiable, recent research on executive cognitive function and arousal mechanisms in the prefrontal cortex portions of the brain suggests that sensation seeking can be controlled and redirected by pharmacotherapeutic agents (Kalivas and Volkow, 2005). There is also evidence that prevention activities can ameliorate genetic risk (Brody et al., 2009). Social (or group) risk factors include family risk factors (e.g., modeled family drug use behavior, family

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

management practices, family conflict, weak family bonding) (Kumpfer et al., 2003), as well as peer risk factors (e.g., peers who use substances increase risk by modeling and normalizing substance use) (Hawkins et al., 1992). Peer pressure may be especially strong among military members and their families because of the formal military structure that requires mutual support for effective functioning. Environmental risk factors include the availability of low-cost and easily accessible substances (e.g., discounted alcohol on military bases).

There are several risk factors associated specifically with military service. Examples include service-related injuries (Baker et al., 2009; Larson et al., 2012), trauma, and demands related to active duty (e.g., carrying heavy equipment; witnessing and experiencing traumatic events during deployment; being separated from family members; experiencing occupational stress and boredom when serving in isolated sites; and being the object of discriminatory treatment and, in some cases, acts of violence based on gender, race/ethnicity, or sexual orientation). Military service in general often involves exposure to stressful and traumatic events (Seal et al., 2009), and numerous studies have documented high rates of service-related mental health symptoms among military personnel, which are known to intensify the risk for substance use problems (Edlund et al., 2007; Foran et al., 2011a,b; Jakupcak et al., 2010).

The United States’ current conflicts are distinguishable from those of the past by the increased length and number of deployments and the types of injuries (Tanielian et al., 2008). A recent review of substance use problems and risk factors among veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn concluded that “military personnel and combat veterans have higher rates of unhealthy substance use than their age peers in the general population” (Larson et al., 2012, p. 21). The review found evidence of a positive relationship between deployment and smoking initiation and recidivism, heavy drinking, and possibly prescription drug misuse. Stress-related consequences of military service-specific conditions, such as acute stress symptoms, psychological and marital problems, and use of medication for combat stress may manifest immediately, or symptoms may be delayed, as suggested by higher rates of such problems among those with more deployments than among those with fewer (MHAT, 2006). Multiple studies have shown that deployment and combat exposure are associated with unhealthy alcohol use (Jacobson et al., 2008; Shen et al., 2012; Spera and Franklin, 2010; Wilk at al., 2010). Another IOM study currently under way is examining the physical and mental health readjustment needs of veterans of these conflicts, and should offer additional evidence on the associated types and levels of risk.1

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1 For more information, see the study website at http://www.iom.edu/Activities/Veterans/MilPersReadjustNeeds.aspx.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Certain features of military culture (e.g., drinking norms) can contribute to the initiation of problem drinking and related consequences among military personnel. For example, there may be pressure to drink excessively to prove one’s toughness, perform a rite of passage, fit into a new group culture, or cope with trauma. Boredom on military bases and in deployment settings, with few recreational activities available, was highlighted as a contributor to problem drinking in presentations to the committee and during visits to military bases. Concern about family finances also is associated with problem drinking among military personnel (Foran et al., 2011a,b). Military-relevant environmental risk factors include the ready availability of alcohol on or near bases, often at reduced prices. This latter contributing factor can be effectively addressed through environmental prevention strategies, which are discussed in detail below. Finally, the strong warrior ethos in the military may be considered a risk factor for not seeking help when treatment for SUDs or other mental health problems is needed. While both male and female members of the military are at risk for substance use as a result of military-specific stressors, men (particularly those aged 25 and younger) are at greater risk of developing drug use disorders, while women are at greater risk of developing depression (Seal et al., 2009).

Compared with military service-specific risk factors among military personnel, there is a paucity of research identifying risk factors for SUDs among their spouses and children (Mansfield and Engel, 2011). Deployments, however, have a number of effects on the spouses and children of service members that may put them at risk for SUDs. Studies have shown that deployments can impact children’s behavior and academic performance, spouses’ stress levels, and child maltreatment rates (Chandra, 2011; Chartrand et al., 2008; Gibbs et al., 2007; Lester et al., 2010). Whether such stressors associated with military service by parents or spouses are risk factors for SUDs and other mental health problems in their dependents is not yet well documented.

Protective Factors

Compared with risk factors, less research has been conducted to identify factors that protect against the development of SUDs. Protective factors that may mediate or moderate the effects of risk exposure include resiliency, attachment, positive temperament, support (either through the family or from an external support system), and religiosity (Hawkins et al., 1992; NRC and IOM, 2000). In children, resiliency refers to the ability to thrive and exhibit positive health behaviors despite exposure to adverse living conditions (e.g., extreme poverty, crime, drugs, and abuse) (NRC and IOM, 2000; Rutter, 2006). The extent to which adult military members can be resilient to the effects of risk factors for SUDs and adverse conditions (e.g.,

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

war-related life-threatening situations) is not well understood. There is some evidence that resiliency operates through other mechanisms, including religiosity, family support, peer bonding, and parenthood (NRC and IOM, 2009). Positive temperament may enable an individual to reframe or reinterpret otherwise highly threatening situations in order to cope (e.g., functioning under fire). Finally, while lack of executive cognitive function (ECF) has been found to be a predictor of substance use and SUDs (Blume and Marlatt, 2009), it is not yet known whether the reverse is true (i.e., whether high levels of ECF can protect against the development of SUDs). Since ECF consists of a host of skills required for military members to function in the armed services—including working memory, deliberate planning, decision making, emotional regulation, and behavioral impulse control skills—it may operate indirectly as a protective factor against the development of SUDs by enhancing the ability to thrive, cope, and minimize stress.

Evidence-Based Programs and Practices

Prevention activities that reduce the incidence of one problem behavior tend to reduce other problem behaviors (Karoly et al., 1998). The initial investments in these types of interventions generally are repaid in both savings to government and benefits to society, including gains in adult employment and resulting tax revenues, as well as reductions in criminal activity and associated cost savings for arrests, judicial proceedings, probation, and incarceration (Karoly et al., 2001). Evidence-based SUD prevention programming (1) addresses the appropriate risk and protective factors for the population in question, (2) employs approaches with demonstrated effectiveness, (3) takes place at the appropriate time chronologically and developmentally, (4) makes use of proper settings and domains for delivery, and (5) manages programs effectively (ONDCP, 2001). These core elements served as the basis for the committee’s assessment of the adequacy, appropriateness, and likely effectiveness of prevention programs in the various branches of the U.S. military; broader nonprogrammatic environmental prevention strategies are discussed later in this section.

Address Risk and Protective Factors

As outlined above, effective prevention programs address the risk and protective factors relevant both to the problem or issue at hand and the population(s) to be reached. Military dependents require a different set of prevention strategies from those appropriate for active duty service members, for instance. Demographic (e.g., age, race) and sociocultural (e.g., ethnicity) considerations are critical in designing effective prevention activities. Several sources (NIDA, 2009a; NRC and IOM, 2009; Robertson et al.,

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

2003) provide solid frameworks for identifying risk and protective factors as a component of the design and adoption of evidence-based programs.

Employ Effective Approaches

The National Registry of Evidence-based Programs and Practices (NREPP) lists SUD prevention programs determined to be evidence-based according to their readiness for dissemination and the quality of their evaluation research—specifically measurement reliability and validity; fidelity of implementation; appropriateness of analysis; and the handling of attrition, missing data, and confounding variables (SAMHSA, 2012). Programs that focus only on increasing knowledge or changing attitudes have had few effects on substance use behaviors compared with programs that focus on resistance and social/life skill building (Botvin et al., 1995). Evidence-based prevention programs often include skills particularly relevant to military members and their families, such as resisting peer pressure, avoiding high-risk situations, identifying and bonding with individuals who provide social support and a nonuse norm, and practicing emotional regulation and impulse control.

Not all prevention programs have been evaluated with all populations or in all settings. Often, prevention providers opt to adopt promising programs or approaches. Sometimes this process involves implementing programs effective in one population but not evaluated in another (e.g., adapting a program evaluated with college students for use in a military population). At other times, the process involves working with a program that is theory based, although not yet formally evaluated. Among the more prominent theories represented in evidence-based prevention efforts are social learning/cognitive theory (Bandura, 1977), attitudinal theory (Ajzen and Fishbein, 1980), and social network theory (Valente, 2010). According to the principles of participant modeling and social learning theory, program implementers must be perceived as credible role models to whom military members can relate. Use of slightly older peer leaders to assist program implementers enhances program participation and effects (Perry et al., 1986). The most effective program delivery is sequenced as the provision of general principles of the program, modeling of prevention skills, role playing or rehearsal of skills, and extended practice in real-life settings.

Take Place at the Appropriate Time

Skill development programs need to be age appropriate. Prevention programs for early childhood, for instance, should focus on parental management of children, parent-child communication, and basic health behavior (e.g., nutrition, sleep, and health care) (NRC and IOM, 2000; Shonkoff et al., 2012). Elementary school programs typically focus on building

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

socioemotional competence and preventing conduct problems. Adolescent programs should focus on reducing risk factors and increasing protective factors, including training in resisting peer pressure, positive adult support seeking, nonuse social norms, and nonuse leisure time activities (Hansen and Graham, 1991; Wills and Vaughan, 1989). Training for adults (i.e., spouses and military members in the emerging adulthood period) should focus on brief motivational interviewing; coping skills; social support; and skills in positive parent-child communication, rule setting, and monitoring. In addition to developmental considerations, chronology is important as well; the most successful prevention efforts are reinforced over time in a variety of settings.

Make Use of Appropriate Settings

“Appropriate” settings are based on the nature of the problem/issue being addressed and the characteristics of the population being served. The setting for program delivery can be, for example, the school, the home, a religious institution, or the workplace.

Manage Programs Effectively

The most effective prevention programs provide standardized training and manualized protocols, along with specific and measurable prevention skills and goals (Mihalik et al., 2004). Standardization helps minimize program “drift” and dilution, whereas use of a general outline, procedures, or processes is not effective in changing substance use behavior (Mihalik et al., 2004)—a point that is particularly relevant given the strong empirical link between program effectiveness and implementation fidelity. Well-trained providers and consistent monitoring and program evaluation are also integral components of an evidence-based prevention strategy.

Included within this principle as well is alignment of program values and institutional values. Program buy-in, implementation, participation, and maintenance relate to whether SUD prevention is perceived to enhance military functioning and promote individual warrior fitness. Important factors include (1) an environment supportive of the delivery of prevention programs (in terms of allocation of time and availability of qualified implementers), (2) social environmental norms consistent with nonuse, (3) supportive (versus punitive) policies that link directly and clearly to prevention programs, and (4) reinforcement of nonuse behaviors and practices.

Environmental Strategies

Beyond prevention programs and efforts aimed at impacting individual behavior, the military is uniquely positioned to implement more overarching

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

systems-level, or environmental, prevention strategies that affect the community at large. Environmental prevention strategies are directed at community norms and policy regulations. This section describes best practices in environmental prevention efforts for SUDs applicable in military settings.

Alcohol

A number of strategies based on sound theory and with proven effectiveness exist to control alcohol use and related problems at the population level. These strategies are “environmental” because they work by decreasing the availability or appeal of alcohol or illicit drugs (including prescription drugs) in the community rather than attempting to change individual behavior. These strategies lead to decreases in consumption and minimization or prevention of alcohol-related problems. Several reviews of these policies are available in the scientific literature (e.g., Babor et al., 2010a,b; Saltz et al., 2010; Wagenaar et al., 2009; WHO, 2009), some of which are addressed specifically to policy makers, including those in charge of developing and implementing health policies in the U.S. armed forces.

In the alcohol field, Babor and colleagues (2010a) discuss seven policy approaches, four of which are environmental and can be used by the U.S. armed forces to address alcohol consumption and related problems among military personnel. (An additional approach discussed by these authors—advertising regulation—affects military personnel but cannot be changed by the military.)

The first of these four pertinent approaches is controlling affordability through pricing and taxation. The evidence in this area clearly indicates that higher prices lead to a decrease in alcohol consumption (Chisholm et al., 2004; Wagenaar et al., 2009).

The second approach is restricting the availability of alcohol available for purchase (Chaloupka et al., 2002; Stockwell and Gruenewald, 2004). Consistent enforcement of the legal drinking age is a key strategy that falls under this approach and is highly effective in reducing alcohol consumption in this age group (Wagenaar and Toomey, 2002).

The third environmental prevention approach involves altering the context in which alcohol is consumed. Best practices in this area entail “server intervention” strategies, or training bar staff and liquor and convenience store employees in responsible beverage service (e.g., requiring age identification, recognizing potential problems, and exercising increased responsibility in selling alcohol and serving alcoholic beverages) and in the management and prevention of aggressive and/or problematic patrons, who may or may not be intoxicated (Babor et al., 2010a; Graham, 2000; Graham and Homel, 2008; Graham et al., 2005). Dram shop liability laws—the U.S. laws that hold bar owners responsible for injuries caused to a third party by someone

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

who was sold or served alcohol when intoxicated—are also effective in modifying drinking contexts (Rammohan et al., 2011).

The fourth approach is directed at preventing impaired driving. While policies reflecting this approach were developed to respond to drinking and driving, many of them can also be used to prevent driving under the influence of other drugs, including prescription drugs. Drinking and driving countermeasures are among the most effective population-level control policies in the alcohol field. Enforcement of these policies contributed to a decrease in alcohol-related traffic fatalities from a high of 59.5 percent of all traffic fatalities in 1982 to 32 percent in 2009 (National Highway Traffic Safety Administration, 2009). Sobriety checkpoints and random breath testing are two of the most effective policies in this area. Their effectiveness, however, is associated with the frequency of their implementation and consistency in advertising (i.e., alerting drivers in the community to the existence—although not the location—of checkpoints and random breath testing). Also relevant for the military is enforcement of blood alcohol content (BAC) limits and administrative license suspension. There is some evidence that the lower the BAC limit, the more effective it can be, although BAC limits lower than .02 are difficult to enforce (Babor et al., 2010a). Two rigorous evaluations of these types of environmental initiatives found significant reductions in alcohol-related traffic accidents, assaults involving alcohol, amount or quantity of drinking, and driving while intoxicated in intervention compared with control communities (Holder et al., 2000; Treno et al., 2007). Appendix I summarizes policy-relevant strategies discussed by Babor and colleagues (2010a) for the prevention of alcohol-related problems by category and strength of evidentiary support.

Other Drugs

Use of illicit drugs and abuse of prescription drugs continue to be a major public health problem in the United States. Prescription drug abuse, one of the major concerns that prompted this study, is a vexing problem among military personnel. As in the alcohol field, there are environmental, population-level approaches that can be useful in the prevention of drug use and abuse. Babor and colleagues (2010b) discuss various approaches, one of which is pertinent to the U.S. military to address concerns related to prescription drug abuse. This approach is what Babor and colleagues (2010b) call “prescription regimes,” which involve controlling the safety, storage, and distribution of prescription drugs to prevent or minimize their diversion to the black market for illicit use and abuse. Some of these measures entail tight regulation of prescription dispensation and control and over-the-counter sales, physician education, and enforcement of prescription regulations.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

In the context of the increasing incidence of prescription drug problems in both the military and civilian sectors, the Office of National Drug Control Policy’s (ONDCP’s) four major strategies also provide best practices in environmental prevention that correspond with the prescription regimes of Babor et al. (2010b) (ONDCP, 2012). The first strategy is education. While ONDCP’s 2011 Prescription Drug Abuse Prevention Plan focuses on parent, child, and patient education (ONDCP, 2011a), also critical is provider education regarding responsible prescribing practices and alternative pain medications with lower dependence potential. The second strategy is monitoring, which involves the implementation of prescription drug monitoring programs. In the military setting specifically, it is critically important that monitoring systems be capable of sharing data across branches and with state monitoring programs to prevent the practice of “doctor shopping.” The third strategy in ONDCP’s prevention plan is disposal, which entails “convenient and environmentally responsible prescription drug disposal programs to help decrease the supply of unused prescription drugs in the home” (ONDCP, 2012, p. 1). Finally, proper enforcement of policies and laws is necessary to ensure consistent implementation and maximum effectiveness.

Summary

In conclusion, SUD prevention in the military is a complex issue. Changing attitudes about acceptable alcohol and other drug use is central to changing drinking and drug using behavior. Intensive antismoking campaigns of the past several decades—entailing a combination of higher prices (through taxation) (Chaloupka et al., 2012); restrictions on where use is permitted; and above all, changed social norms about smoking—have resulted in major reductions in smoking initiation and tobacco use. Structural measures can impact alcohol use problems, illicit drug use, and prescription drug problems. Environmental strategies for these problems, as discussed above, are available and effective. Partnerships within the larger communities in which military bases are located are also integral to a solid environmental prevention strategy (e.g., Spoth et al., 2011). The military has a unique opportunity to communicate consistent messages about drinking (clearly the most prevalent substance use problem in the military, about which great ambivalence persists at the highest levels), illicit drug use, and nonmedical use of prescription drugs, as well as to control the environmental factors that drive both heavy drinking and prescription drug misuse through such measures as restricting availability, increasing cost, and limiting permitted times and locations for the use of legal drugs.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

SCREENING, DIAGNOSIS, AND TREATMENT

While the prevention of SUDs is the foundation of any good strategy for addressing the problem, a comprehensive strategy must also include evidence-based screening mechanisms to identify at-risk and existing users, validated diagnostic instruments with which to obtain accurate diagnoses, and empirically supported treatment approaches for effective rehabilitation.

Screening

As discussed previously, selective and indicated prevention each involve the identification of particular target groups (e.g., high-risk individuals), which is frequently accomplished through screening. Screening can detect both health problems and risk factors, the latter of which is particularly useful for these groups. As a strategy for universal prevention, screening must be linked to effective subsequent interventions. False-positive and false-negative cases each carry undesirable consequences (e.g., unnecessary anxiety and medical expenditure for the former, missed opportunities for intervention for the latter), and effort should therefore be made to minimize error.

Awareness of the limitations of screening has led the public health sector to develop a series of parameters to guide screening activities (Gray, 2001; Wilson and Jungner, 1968), including guidelines to identify the populations that should be screened and the diseases that should be screened for, performance standards for screening tests, and guidance on how performance should be assessed. Because screening for disease can be costly, inconvenient, and not always reliable, guidelines for effective screening identify situations in which screening is advantageous and will promote and protect health in the population. Classic criteria for evaluating screening programs emphasize the need for screening to focus on important health problems, link to diagnosis and treatment, have acceptable screening procedures, attend to costs, and be a continuous activity (Wilson and Jungner, 1968). The United Kingdom’s National Screening Committee added three additional criteria to be considered (Muir Gray, 2004): potential harm caused by screening, the strength of the evidence with which to evaluate success, and the opportunity costs associated with screening.

Disease Characteristics

Screening should focus on serious health problems that are highly prevalent in the target population. Preclinical symptoms or behaviors also should be highly prevalent in the population, and this preclinical phase should be long and clearly detectable. Treatment should exist, and should

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

be more effective if initiated at an early stage (Hennekens et al., 1987). Altogether, SUDs affect about 10 percent of the U.S. adult population, and the prevalence of these disorders is higher among young people (SAMHSA, 2010), who make up a large percentage of the armed forces. The preclinical phase of SUDs is also highly prevalent and of long duration, and therefore highly detectable by the use and abuse of alcohol and/or other drugs or by the presence of recognizable behavioral, interpersonal, work-related, and health-related problems (e.g., drinking and driving, family problems, work absenteeism). There is evidence that early intervention (e.g., brief intervention based on motivational interviews) can be effective in changing the course of some of these problems, especially those that are alcohol related (Ahmadi and Green, 2011).

Cultural Acceptance

Acceptance among the population being screened is fundamental to successful screening. Cultural and social acceptance hinges on the extent to which the population sees the focus of the screening as a real problem and on the characteristics of the screening procedures (e.g., how long they last; how physiologically, psychologically, and/or socially invasive they are). Screening for alcohol and other drug problems can pose major challenges. The problems are stigmatized and may be perceived as moral weaknesses rather than health problems. Questions about alcohol and illicit drug use can be experienced as invasive and may result in underreporting. In the United States, although these challenges can be present in some population groups, they do not pose considerable barriers to the implementation of screening for risky drinking, prescription drug abuse, and illicit drug use. Screening for alcohol and other drug problems can be conducted effectively with a few brief questions. Screening for drug use can be accomplished relatively easily through urinalysis.

Cost-Effectiveness

The cost-effectiveness of screening encompasses the type of screening procedure being employed, the length of screening, the background of the personnel administering the screening, and the type of health problem under focus. Screening for alcohol and other drug use does not involve complex procedures, can be done rapidly with just a few questions, and can be conducted by lay personnel. Alcohol- and other drug-dependent individuals overutilize health services because they are usually in poor health, have a higher risk of injuries that may require medical care, and may develop a number of health problems (e.g., ulcer, cancer, liver cirrhosis) that are costly to treat (Mertens et al., 2005; Weisner and Matzger, 2002). Screening

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

for SUDs is therefore cost-effective because it can circumvent costly overutilization of services.

Characteristics of Screening Tests

The ideal screening test should be brief, safe, noninvasive, inexpensive, and easy to administer and should carry no negative or legal consequences. Screening tests should have high validity, meaning they should measure what they purport to measure. In the case of alcohol and other drug use, screening should identify as “positive” those individuals who are engaging in risky (e.g., binge) drinking or other drug use (e.g., abuse of opioid prescription drugs), and as “negative” those individuals who are abstainers or normal drinkers or do not use illicit drugs or abuse prescription drugs. The sensitivity of a test (its ability to identify as true positives all of those individuals who are positive) and its specificity (its ability to identify as negative all of those individuals who are negative) reflect its validity. Ideally, these two aspects of the test should be as high as possible (e.g., above 90 percent). For alcohol and other drug screening, sensitivity is most important because the consequences of a false negative are great. Screening programs also are highly dependent on positive yield, or the proportion of individuals identified as positive by the test who are actually positive. Positive yield provides an assessment of the extent to which the test will be able to identify those who must be identified if the screening program is to be successful. These are the individuals who have preclinical disease or, in the case of alcohol and other drugs, show risky alcohol or other drug intake that puts them at risk for developing a substance use–related health problem or dependence in the future. A low predictive positive yield indicates that the screening procedure will have too many false positives, which will lead to too many second-level diagnostic procedures for false-positive individuals (Aschengrau and Seage, 2008).

Screening Tests for Alcohol and Other Drugs

Many valid and reliable screening tests are available for alcohol and other drug use (Babor and Kadden, 2005). Most are self-administered and require 1-5 minutes to complete. They can be used in a variety of health care settings, such as primary care offices and emergency rooms. Because they are brief, most can be added to more extensive and intensive health assessments. The U.S. military, for instance, uses the Alcohol Use Disorders Identification Test (AUDIT)-C as part of its Pre-Deployment Health Assessment (completed 60 days prior to deployment). The AUDIT-C is also part of the Clinical Practice Guideline for Management of Substance Use Disorders of the Department of Veterans Affairs and Department of Defense (VA and DoD, 2009).

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Besides self-report, screening tests for drug use include urinalysis and other biological methods, such as cheek swabbing or hair analysis. Urinalysis is an attractive screening option because it is independent of self-report. The circumstances in which most screening for drug use takes place (e.g., pre-employment testing) are not conducive to self-disclosure of drug use. Subjects therefore may underreport or deny use, thereby invalidating screening efforts. However, urinalysis also has a number of limitations. It is highly dependent on laboratory standards related to chain of custody, quality control, validity (sensitivity and specificity) and reliability of testing procedures, and confidentiality of results. Further, a positive test does not provide information about chronicity, frequency, and/or quantity of use; the presence of drug dependence; and in the case of prescription drugs, whether the drug was taken under medical order. Similarly, a negative test does not mean that drug use is absent. A negative test can occur because the drug was taken in a small enough dosage to be undetected, because the drug taken had already been eliminated from the body when the specimen was collected, or because the testing method was not sensitive enough to detect the presence of the drug. Urine drug screening would optimally take place in conjunction with education and treatment.

Screening and Brief Intervention

In the United States, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has sponsored the development of evidence-based screening, brief intervention, and referral to treatment (SBIRT) protocols. SBIRT includes screening with an evidence-based screener for at-risk drinking; providing a brief intervention; and, for those whose problems are more severe, referring to specialty substance use treatment. The evidence-based guidelines developed by NIAAA define “risky” drinking as having more than 4 drinks for men and more than 3 drinks for women on any given day. Also, men should not have more than 14 drinks and women not more than 7 drinks per week (NIAAA, 2005). SBIRT has been shown to be an efficacious, cost-effective intervention across heterogeneous populations (Bertholet et al., 2005; Kaner et al., 2009). It has been implemented in many different types of health care settings, including primary care and emergency room settings.

Different organizations (e.g., the Centers for Disease Control and Prevention [CDC], NIAAA, the World Health Organization [WHO]) suggest different lengths of time for the SBIRT process or do not specify a length of time. The times specified, however, are all brief—between 5 and 20 minutes. SBIRT has been shown to be effective when conducted by both physicians and nonphysician providers (Babor et al., 2006; Ockene et al., 1999; Reiff-Hekking et al., 2005). It can serve as an intervention to decrease the

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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problem in those who are experiencing at-risk substance use and as an early case-finding intervention in those whose problem is beginning to become more severe.

Diagnosis

Diagnosis is another essential part of a comprehensive response to alcohol and other drug problems. Diagnostic procedures for SUDs in the United States are guided by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) of the American Psychiatric Association (APA) (2000), which contains standardized diagnostic criteria for a number of alcohol- and other drug-related conditions. Of interest in the present context are the DSM-IV-TR diagnoses of “abuse” and “dependence” (see also Chapter 2). Abuse is defined in a previous IOM report as “a level of drug use that typically leads to adverse consequences (physical or psychological). Drug use at this level is not necessarily associated with any particular frequency but is associated with use in quantities sufficient to result in some toxicity to the user, and the patterns of use usually have some characteristics of psychopathological behavior” (IOM, 1994b, p. 2). The same report defines dependence as “a level of drug use that has significant adverse physical and psychological consequences. This level of use is characterized by the consumption of toxic doses of the substance that impair the user’s ability to function and is also characterized by a compulsive desire to use a drug repeatedly” (IOM, 1994b, p. 2).

The DSM-IV-TR diagnoses of abuse and dependence are based on the presence of specific indicators within a 12-month period. Substance dependence is “a maladaptive pattern of substance use, leading to clinically significant impairment or distress” (APA, 2000, p. 128). In order to be diagnosed as having substance dependence, the individual should have 3 or more of the following indicators: (1) tolerance; (2) withdrawal; (3) more substance use than intended; (4) desire or unsuccessful efforts to decrease use; (5) significant amount of time spent related to the substance use; (6) social, occupational, or recreational activities are given up or reduced due to substance use; and (7) use is continued despite knowledge of having a persistent or recurrent physical or psychological problem (APA, 2000). The diagnosis of substance abuse should be made only in the absence of a diagnosis of substance dependence. To be diagnosed with substance abuse, the individual should have one or more of the following indicators: (1) recurrent substance use resulting in a failure to fulfill major role obligations; (2) recurrent substance use in situations in which it is physically hazardous; (3) recurrent substance-related legal problems; and (4) continued substance use despite having persistent or recurrent social or

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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interpersonal problems (APA, 2000). As discussed in Chapter 2, the APA began to reexamine the diagnostic criteria for abuse and dependence in preparation for DSM-5. A website describes in detail the activities that have taken place as part of this effort and the proposed changes that will likely be included in DSM-5 (APA, 2012).

Standardized diagnostic procedures that are valid and reliable and reflect the latest research findings can be implemented in a busy clinical setting by professionals with various levels of training and with different backgrounds. Such standardization should not be seen as a luxury that can be implemented only by academic settings or specialized treatment facilities. Rather, this standardization is necessary for the development of accurate diagnoses, the collection of valid and reliable data on clients, and the administration of effective treatments. Standardization also is a necessary first step for the evaluation of treatment protocols. Without such evaluation, changes in service provision cannot be implemented in a rational manner so as to provide the maximum benefit to patients.

Treatment

Standards and expectations for the treatment of alcohol and other drug use disorders are changing. In the second decade of the 21st century, three environmental forces may reshape treatment services. First, as summarized in Chapter 4, health care reform and federal parity legislation enhance access to health insurance and mandate that commercial health plans provide similar coverage for general health, mental health, and SUDs. Second, standards of care continually evolve as research-based behavioral and pharmacological therapies emerge. Finally, advocates and policy makers have called for increased integration of addiction treatment and primary care (Treatment Research Institute, 2010). These influences enhance the capacity of primary care to screen, diagnose, and intervene for patients with SUDs of all levels of severity.

To integrate substance abuse treatment into primary care, however, systems of care must address four limitations:

1.    Current capacity—Most primary care settings are unprepared to screen for, assess, and treat SUDs, especially among women and men whose disorders are severe.

2.    Inadequate reimbursement—Productivity expectations, procedure codes, and reimbursement rates do not reflect the time required to address SUDs.

3.    Workforce skills and abilities—Few primary care practitioners have specialty training in addressing SUDs.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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4.    Integration strategies—Strategies to link primary care and specialty care for SUDs need to be developed and tested.

In addition, patients with comorbid serious mental illnesses often require specialty treatment services and cannot be given sufficient attention in the primary care setting.

The IOM’s Quality Chasm reports challenge the U.S. health care system to adopt evidence-based practices and to make process improvements to reduce the morbidity and mortality related to the delivery of health care (IOM, 2000, 2001). A subsequent IOM report extends the Quality Chasm recommendations to address treatment for alcohol, other drug, and mental health disorders and the integration of these services into the medical mainstream (IOM, 2006). If this is to be accomplished, change at the system level will be necessary.

The implementation of evidence-based pharmacological and behavioral therapies for alcohol and other drug use disorders is a major challenge for both policy makers and treatment providers (McCarty et al., 2010). While evidence from research demonstrates the effectiveness of evidence-based therapies for the treatment of SUDs, many practitioners do not use evidence-based treatments routinely or have adopted eclectic treatment approaches (Miller et al., 2006). Some variation in treatment approaches is to be expected and reflects patient-centered or personalized medicine; variability among patients inhibits the adoption of condition-specific practice guidelines. Patients present with a mix of comorbidities and other psychosocial and environmental factors that influence the treatment approach and their response to treatment. Research-based practice guidelines, moreover, generally are based on carefully selected research samples that exclude many complex patients, and therapists may be uncomfortable with generalizing them to apply to specific patients.

A clinical challenge for patient-centered care, then, is maintaining the effective elements of evidence-based treatment while adapting therapies for particular patients. Results of many studies suggest that general therapist skills have more influence on outcomes than specific treatments (Blatt et al., 1996; Crits-Christoph and Mintz, 1991; Luborsky et al., 1997). Experience enhances therapists’ effectiveness (Kivlighan and Kivlighan, 2009; Mallinckrodt and Nelson, 1991; Mayfield et al., 1999). Therapeutic effectiveness may also be linked to the measurement of treatment effects during treatment (outcome-informed treatment) (Duncan et al., 2003; Miller et al., 2003, 2005). Outcome-informed techniques can quickly clarify the effects of a modified treatment for a particular patient and guide the therapist’s search for an effective intervention. Outcome-informed techniques can therefore improve treatment outcomes (Brown, 2004; Lambert, 2005). Likewise, tools that measure the therapeutic alliance help clarify for the

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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therapist when the patient’s perceptions of care delivery point to a negative or ineffective status (Duncan et al., 2003; Miller et al., 2003, 2005). In quality improvement circles, the importance of measurement is well understood; the operational mantra is, “You can’t improve what you don’t measure.”

Higher-quality behavioral health provider systems (e.g., university-based care systems, credibly funded research treatment centers) promote fidelity and reduce competency drift (i.e., the reduction of clinical sharpness and skill level posttraining). They do so through specific improvement strategies in three best-practice domains as recommended by the National Institutes of Health’s Behavior Change Consortium (Bellg et al., 2004) and outlined in Table 5-1.

In summary, the best-practice principles and factors for high-quality delivery of SUD treatment at the provider-patient level include the use of evidence-based treatments specific to SUDs. Practitioners need to have skills and demonstrated competency in all of the evidence-based approaches to be effective with their treatment population. Implementation of treatment approaches also should be adapted to the patient’s specific need and stage of treatment.

Improving the Delivery and Organization of Care

SUD is often a chronic illness and needs to be treated with a system of care structured similarly to the systems of care for other chronic medical illnesses (e.g., diabetes, asthma, high blood pressure) (McLellan et al., 2000). SUD patients are treated with different levels of care based on variations in the level of protection from the outside environment and in the level of service intensity (Mee-Lee, 2001). Environmental protection and service intensity are assessed independently and drive decisions on treatment placement and needed services. Treatment plans may require creative flexibility. When health care benefits do not pay for residential care, for example, an intensive outpatient program can provide needed services while alcohol-and drug-free housing provides environmental protection.

The quality of the care delivery system or a treatment program is important to patient-level outcomes; a fragmented or broken delivery system reduces the effectiveness of treatment at the patient-provider level. To frame best practices for a SUD care delivery system, the committee referenced the principles laid out in Treatment Improvement Protocol No. 47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, authored by the Center for Substance Abuse Treatment (CSAT) (2006). These principles are based on an integration of the findings from evidence-based research and on expert opinion where there was a gap in the research.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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TABLE 5-1 Best-Practice Domains and Recommendations of the National Institutes of Health’s Behavior Change Consortium

Goals Strategies
Domain: Provider training
  • Standardize training for all provider types
  • Ensure the acquisition of provider skills
  • Identify and have processes to minimize “competency drift” in provider skills
  • Accommodate differences in providers’ backgrounds with respect to skill expectations and roles
  • Use standardized training manuals, materials, resources, field guides, structured practice and role playing; standardized patients; same instructors/supervisors; video training
  • Observe implementation of interventions with standardized patients or role playing; score providers according to a checklist; conduct debriefings; administer written pre- and posttraining examinations; certify skills during and after training
  • Conduct booster sessions; conduct in vivo observations scored against a standard checklist; supervise; obtain provider self-reports; conduct patient exit interviews or obtain feedback
  • Have certified or established professional supervisors for provider training; monitor patient dropouts and treatment effectiveness
Domain: Delivery of treatment
  • Control for provider variability
  • Reduce ineffective variation within treatments
  • Ensure adherence to evidence-based treatment protocols
  • Assess patient perceptions of providers through questionnaires, and give feedback to providers; audiotape sessions, and have different supervisors review; monitor patient complaints; have providers work with all treatment populations served
  • Use scripted protocols, treatment manual; have supervisors rate audiotapes, videotapes
  • Audiotape or videotape encounters, and review with providers; randomly monitor audio or videotapes for adherence to protocols; have providers complete a checklist of intervention components
Domain: Receipt of treatment and enactment of treatment skills
  • Ensure patients’ comprehension and acquisition of skills
  • Ensure patients’ ability to perform new skills
  • Have providers review participants’ homework, self-monitoring logs; assess, measure participants’ performance; have structured interviews with patients; use questionnaires; use hypothetical scenarios to test patients
  • Collect patient self-monitoring, self-report data; use behavioral outcome measures

SOURCE: Adapted from Bellg et al., 2004.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

The delivery system approach presented in Table 5-2 is based on the committee’s operationalization of the CSAT principles.

Transitions to different levels of care are most successful when they occur between settings of care that employ similar philosophies and can transfer client records efficiently. A step down or step up in treatment intensity within the same program or through referral to a nonaffiliated provider can be disruptive for the patient and lead to dropping out of treatment (CSAT, 2006). Mee-Lee and Shulman (2003) suggest that an effective continuum of care successfully transitions the patient to the next level of care; successful transition is defined as the patient remaining engaged in treatment posttransition and not dropping out during the critical transition period. Transitioning to a different level of care also requires a clear delineation of the appropriate clinical characteristics of the patient to ensure that they match the new level of care.

Given that SUD is often a chronic illness, long-term monitoring supports maintenance of recovery (Dennis et al., 2003; McKay et al., 2005; Scott et al., 2005); however, research has not determined an optimal duration for long-term monitoring. An analysis of 1,271 admissions to a publicly funded treatment center found that 47 percent of the sample achieved 12 months of continuous sobriety within 3 years of entering the study (Dennis et al., 2005). The mean time from first treatment to last use was 9 years, and increased for men, individuals who began using at a younger age, and participants with comorbid mental illnesses (Dennis et al., 2005). On the other hand, physician assistance programs and other assistance programs for professionals often require 5 years of continuous monitoring ( McLellan et al., 2008). What is important is that treatment systems be structured to monitor a patient as long as possible and in the same objective manner as is applied to other chronic conditions. An ideal care delivery system is comprehensive and includes long-term services in addition to preventive services, community or workplace initiatives, primary care screening and brief interventions, and specialized treatment services (McLellan, 2002). In some systems, primary care physicians assume the role of screening, brief intervention, referral, and long-term monitoring of abstinence from substance use. In general medical practices, however, the engagement of primary care physicians in best-practice treatment for alcohol use disorders was found to be very low (rates of adherence to treatment guidelines were 10.5 percent for these disorders versus 57.7 percent for depression and 64.7 percent for hypertension) (McGlynn et al., 2003). Specialty programs therefore may need to assume the role and accountability for long-term recovery monitoring.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

TABLE 5-2 A Delivery System Approach Based on the Center for Substance Abuse Treatment’s (CSAT’s) Treatment Improvement Protocol No. 47

CSAT Principle Delivery System Approach

1. Having the ability to make effective connections and treatment readily available

  • Crisis assessments available 24/7
  • Screening, brief intervention, and referral to treatment (SBIRT) approaches adopted in various medical settings; use of peers

2. Enabling easy treatment entry

  • Crisis assessments 24/7
  • Wide geographic coverage
  • Access standards and time frames from assessment to start of treatment

3. Building on existing motivation (i.e., treatment system is able to handle and manage unwilling patients’ entry into treatment)

  • Manualized readiness for treatment interviews and rating scales
  • Legal system, job jeopardy or support systems mandates
  • Staff competencies in behavioral techniques for working through treatment resistance (e.g., motivational interviewing)
  • Policies and program philosophy that promote a safe harbor that reduces stigma and maintains necessary confidentiality

4. Building an enhanced therapeutic alliance

  • Staff trained in engagement techniques
  • Measurement of the therapeutic alliance by accountable provider/program
  • Use of recovered peers

5. Offering appropriate treatment that is patient specific and not a singular provider approach

  • Move away from set program protocols and time frames
  • Individualized treatment plans and treatments
  • Adjunctive services to match the specific needs of special populations (e.g., pregnant or newly delivered mothers—skill building in parenting)

6.Providing ongoing care through a continuum and extending into the long-term sobriety period

  • Multiple levels of the care system (inpatient, residential, partial hospitalization, intensive outpatient, outpatient sessions, community support systems such as Alcoholics Anonymous
    [AA], long-term case management, primary care physician monitoring, alumni groups)
  • System that facilitates interconnectivity and collaboration necessary to create seamless care

7.Having the ability to address the multiple needs of the patient, not just the substance use disorder

  • Psychiatric services (high psychiatric comorbidity)
  • Linkage to employee assistance programs (EAPs) and employment, financial, child care services
Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

8. Retaining the patient in treatment for an adequate time period and facilitating continuous long-term connections to support recovery

  • Use of level-of-care guidelines (e.g., American Society of Addiction Medicine [ASAM] Patient Placement Criteria)
  • Treatment program protocols that incorporate linkages to community supports during the treatment process, long-term case management, alumni groups, linkages to primary care provider (PCP) as a monitoring system
  • Measurement of long-term engagement with the treatment and case management support system

9. During the treatment process, continuously assessing and modifying the treatment plan as necessary to ensure that the treatment is effective and meets the patient’s changing needs

  • Program treatment protocols
  • Use of objective tools and benchmarks to measure progress
  • Systematic reassessments during the treatment process within a level of care and upon transition to the next level of care

10. Using a treatment system that monitors for abstinence and expects successful management of treatment relapses

  • Repeated drug and breathalyzer testing
  • Use of use-limiting medications (e.g., antabuse, naltrexone)
  • Treatment program rules that do not discharge because of use during treatment but use it as a treatment opportunity

11. Using mutual-help and other community-based supports

  • Treatment protocols that incorporate use of community support groups during the treatment process (AA, Narcotics Anonymous [NA], other 12-step programs, Web-based social networking programs)

12. Successfully and appropriately engaging families, employers, and significant others

  • Family therapy as a standard part of treatment protocols and expectations
  • Appropriate incorporation of employer and/or EAP for work reentry

13. Using mutual-help and other community-based supports

  • Linkage of patients to community-based supports prior to discharge
  • Use of Web-based social networks and gaming approaches to facilitate engagement

14. Educating and promoting knowledgeable empowerment with respect to substance use, recovery, and relapse for patients and families

  • Education sessions as part of the treatment approach, with homework and testing of skills
  • Patient self-report surveys focused on the perception of confidence in new skills

SOURCE: CSAT, 2006.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

Behavioral Therapies

A substantial body of research supports the use of behavioral therapies for treating SUDs. Various approaches have emerged from empirical research as effective for treatment of SUDs, including contingency management and community reinforcement, cognitive-behavioral therapy, family and couples therapy, motivational therapy, and 12-step facilitation (Carroll, 2005; Carroll and Onken, 2005; Moos, 2007). A meta-analysis of treatment interventions for alcohol use disorders suggested that the psychosocial interventions with the most consistent evidence of effectiveness include brief interventions based on motivational enhancement therapy, social skills training, community reinforcement approaches, behavior contracting, and behavioral marital therapy (Miller and Wilbourne, 2002). A recent meta-analysis comparing effectiveness between psychosocial treatments for alcohol use disorders found that therapies on average had no difference in effect sizes when compared with one another, suggesting that while each of these treatments has demonstrated effectiveness when compared to control or non-treatment conditions, the relative effectiveness of these types of treatments is more or less equivalent (Imel et al., 2008). For other substance abuse beyond just alcohol, a meta-analysis of 34 treatments for SUDs found that psychosocial treatments had a moderate effect size (comparable to those of other efficacious psychiatric interventions); contingency management had the greatest effect sizes; and interventions for cannabis use were the most efficacious (Dutra et al., 2008). The therapeutic approaches that have consistently garnered the most empirical support are briefly reviewed in this section. As discussed earlier in this chapter, it should also be noted that the skill and experience of the therapist are presumably at least as important as the particular therapy that is delivered, a finding that is further supported by the Imel et al. (2008) meta-analysis.

Contingency management is a treatment approach based on operant conditioning theory and the principle that future behavior is based on the positive or negative consequences of past behavior. Positive (drug effects) and negative (withdrawal symptoms) reinforcers support continued substance use. To reinforce abstinence, other rewards are introduced. The challenge is to identify for a desired behavior a reward that is practical and sufficiently powerful. Recent effectiveness trials within the Clinical Trials Network confirm the value of providing inexpensive incentives for abstinence (contingency management) among stimulant users in outpatient (Petry et al., 2005) and methadone (Peirce et al., 2006) treatment settings. A Cochrane review of randomized controlled trials found that incorporating some form of contingency management or community reinforcement approach was associated with slightly better outcomes and improved retention in care among patients with stimulant use disorders (Knapp et al.,

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

2007). A meta-analysis of psychosocial treatments for SUDs also demonstrated that studies with contingency management interventions had greater effect sizes compared with studies that incorporated cognitive-behavioral therapy and relapse prevention approaches (Dutra et al., 2008). While the greatest effect sizes were seen in studies that incorporated both cognitive-behavioral therapy and contingency management approaches, this finding is limited because only two studies in the review incorporated both of these approaches.

Cognitive-behavioral therapy, based on social learning models, generally focuses on helping patients understand what factors contribute to and reinforce their substance use (Carroll, 2005). Skills training with the goal of increasing the patient’s coping skills is an integral component of this therapy. A recent review of the literature showed that cognitive-behavioral therapy is more effective than very minimal treatments or controls, but is essentially equivalent in effectiveness to other active treatments (Morgenstern and McKay, 2007). The combination of cognitive-behavioral therapy and the use of medication (naltrexone) for alcohol dependence was tested in a national randomized controlled trial and found to be more effective than cognitive-behavioral therapy combined with a placebo (Anton et al., 2006).

Family and couples therapy generally entails including family members in every stage of treatment—the intake interview, counseling sessions, observed medication, and recovery management. Research documents the value of family involvement in treatment and attests to the need for family-based treatments for adolescent drug abuse (Rowe, 2012; Rowe and Liddle, 2003). For couples, a 2008 meta-analysis found that behavioral couples therapy showed better outcomes than individual-based treatments for those with alcohol and other drug dependence (Powers et al., 2008).

Research has shown mixed results for motivational approaches such as motivational interviewing and motivational enhancement therapy (Morgenstern and McKay, 2007). A recent Cochrane review found that motivational interviewing was associated with reductions in substance use compared with no-treatment controls, but there was no significant difference between motivational interviewing and treatment as usual (Smedslund et al., 2011). Similarly, a multisite randomized controlled trial found that motivational interviewing improved retention in care for both alcohol and other drug use disorders but had no significant effect on substance use outcomes (Carroll et al., 2006). Motivational enhancement therapy appears to be more effective in alcohol abusers than in those with more severe alcohol dependence and in those who are more hostile or angry when they enter treatment (Allen et al., 1998). Research results may not translate to all populations, however. While motivational enhancement therapy has been found to enhance outcomes in Spanish-speaking individuals (Carroll et al.,

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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2009), a recent Clinical Trials Network study found that it was not efficacious for African Americans seeking outpatient substance abuse treatment (Montgomery et al., 2011). More research is needed to determine how motivational interventions and other types of therapeutic interventions compare in effectiveness and to define this effectiveness more clearly with different patient populations.

Finally, 12-step facilitation therapy is based on the behavioral, spiritual, and cognitive principles of 12-step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Abstinence is a key component of the approach, as is active participation in peer support groups. Most of the literature on the effectiveness of the 12-step approach compares the therapy with other treatment interventions. Results have been mixed but generally have shown that 12-step facilitation therapy yields effects similar to those of other treatment modalities (Morgenstern and McKay, 2007).

Pharmacotherapies

Six medications have been approved by the Food and Drug Administration (FDA) for maintenance treatment or relapse prevention after withdrawal from dependence on either opioids (buprenorphine, methadone, naltrexone, extended-release naltrexone) or alcohol (acamprosate, disulfiram, naltrexone, extended-release naltrexone). Randomized controlled trials have shown enhanced outcomes when medication is combined with psychosocial therapy for the treatment of alcohol and opioid use disorders (Anton et al., 2006). In trials completed within the Clinical Trials Network, (1) community-based addiction treatment services used buprenorphine safely (Amass et al., 2004); (2) a buprenorphine detoxification protocol was superior to a clonidine detoxification protocol for opioid dependence (Ling et al., 2005); (3) opioid-dependent adolescents and young adults responded well to buprenorphine and were less likely to use opioids while on medication (Woody et al., 2008); and (4) individuals dependent on prescription opioids were less likely to use opioids while taking buprenorphine (Weiss et al., 2011). Cochrane reviews found that methadone maintenance (Mattick et al., 2009) and buprenorphine (Mattick et al., 2008) enhance treatment outcomes for opioid dependence.

As an often chronic relapsing disorder, SUDs may require ongoing pharmacotherapy. Pharmacotherapy for opioid dependence can use an agonist (e.g., methadone) or an antagonist (e.g., naltrexone) medication. An assessment of methadone treatment found that at least 2 years was required to achieve sustained prevention of relapse to use of illicit opiates (Ball and Ross, 1991; IOM, 1995). Shorter-term treatments have shown high relapse rates (Simpson et al., 1997). Long-term treatment is probably also required for buprenorphine and extended-release naltrexone, although long-term

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." Institute of Medicine. 2013. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press. doi: 10.17226/13441.
×

outcomes have not yet been assessed for these medications. However, opioid-positive urine tests declined with longer duration of buprenorphine treatment among patients dependent on prescription opioids (Weiss et al., 2011). A critical issue for pharmacotherapy involving naltrexone is that acute withdrawal treatment is the first part of therapy, not the last (Kosten and O’Connor, 2003). The utility of naltrexone in its oral or sustained-release injectable form is limited by relatively poor compliance in the general population (Stine et al., 2004). The more structured environment of the armed forces may reinforce compliance with these blocking agents and could be used to enhance treatment outcomes, but this has not yet been studied. In another structured context, the use of extended-release naltrexone in criminal justice populations reduced relapse to use of illicit opioids (Coviello et al., 2010, 2012). The major problem with naltrexone is that opioid analgesics will be ineffective for patients taking this medication, who will then require alternative pain management strategies (Center for Substance Abuse Treatment, 2009, Chapters 4 and 5). Medication-assisted treatment, moreover, appears to be more effective when combined with psychosocial interventions for opioid maintenance treatment (Amato et al., 2008).

Withdrawal from alcohol can be treated successfully with a variety of medications; preventing delirium tremens is essential since this is a medical emergency with potential mortality (Kosten and O’Connor, 2003). Treating alcoholism then requires follow-up care. Three medications are FDA approved for this purpose—naltrexone, acamprosate, and disulfiram. They work best in patients who have already completed withdrawal treatment and have been alcohol free for about 5 days.

Cochrane reviews document the effectiveness of naltrexone (Rösner et al., 2010b; Srisurapanont and Jarusuraisin, 2005) and acamprosate (Rösner, 2011; Rösner et al., 2010a) for the treatment of alcohol dependence. The reviews observe that the moderate to small effect sizes associated with the use of medication-assisted treatment are noteworthy because medications reduce the risk of relapse despite the chronic nature of alcohol and other drug use disorders (Rösner, 2011; Rösner et al., 2010b). Duration of therapy remains an important issue for these maintenance treatments, but one study found that a year of naltrexone maintenance provided better outcomes than only 3 months, while discontinuing naltrexone even after 9 months of treatment led to relapse within 3 months of discontinuation (Krystal et al., 2001). Sustained medication treatment is as essential for alcoholism as it is for hypertension, diabetes, or other medical disorders.

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Evidence-Based Practices: Integrated Substance Abuse and Mental Health Care

Comorbidity of PTSD and SUDs is a major concern in both military and community samples (Brady et al., 2009; Kessler et al., 1995). This common comorbidity is associated with substantial psychiatric and functional impairment (Ouimette and Brown, 2002). Veterans from Iraq and Afghanistan have high rates of both of these disorders (Erbes et al., 2007; Seal et al., 2007, 2009, 2011; VHA Office of Public Health and Environmental Hazards, 2008). An estimated 20 percent of veterans who receive treatment services for PTSD through a VA medical center have a comorbid SUD (Jacobsen et al., 2001). A recent RAND Corporation study of Iraq and Afghanistan veterans diagnosed with PTSD found binge alcohol abuse rates that were twice the community rate for young adult men (Tanielian et al., 2008). The study also found that tobacco smoking occurred in 50 percent of these veterans, a rate 2.5 times greater than the community rate. Opiate abuse was detected in 9 percent—three times the community rate. Efforts of both the military and the VA provide help with these problems.

Many individuals with PTSD use alcohol, sedatives, and opiates in an attempt to reduce the chronic state of hyperarousal. Continued use of these substances may lead to SUDs. Individuals with SUDs also are at greater risk for developing PTSD because of presumed increased exposure to stressful events as a consequence of their SUD lifestyle. Gender differences have been found across several nonveteran samples, with drug abuse appearing to put women at greater risk than men for developing PTSD (Hien et al., 2010).

Addiction represents a possible physiological complication of chronic nonmalignant pain treatment with opioids. A structured evidence-based review of 67 studies found that among patients with chronic nonmalignant pain exposed to chronic opioid therapy, 3.2 percent developed abuse and addiction, while 11.5 percent developed aberrant drug-related behaviors (Fishbain et al., 2008). Published rates of abuse and/or addiction in chronic pain populations are estimated to be approximately 10 percent, ranging from 3 percent to 18 percent (Adams et al., 2001; Brown et al., 1996; Manchikanti et al., 2004; Martell et al., 2007). Treatment for comorbid opioid use disorder within the context of comprehensive PTSD therapy involves medical withdrawal (detoxification) and/or maintenance therapy using either a full opioid agonist (methadone) or a partial agonist (buprenorphine). These treatments are needed to reduce tolerance and hyperalgesia, as these complications of chronic opiate treatment often worsen the symptoms of PTSD and undermine its most effective treatments. Innovative approaches for detoxification include buprenorphine.

Pharmacotherapy is used to address both PTSD and alcohol use disorders. These medications include antidepressants, anticonvulsants, and

Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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antipsychotic medications (Back et al., 2006; Brady et al., 2000; Davidson, 2000; Marshall et al., 2001; Petrakis et al., 2006; Tucker et al., 2001). A recent case study (Back et al., 2012) found exposure therapy (progressive exposure to anxiety stimulus) combined with naltrexone to be more effective in alcoholism comorbid with PTSD than either therapy alone.

Psychotherapy remains one of the primary modes of treatment for those with comorbid PTSD and SUDs, especially as medications have limited effectiveness (IOM, 2007; Najavits et al., 2008). There are various psychotherapies for PTSD and SUDs, singularly and collectively, and a substantial number of outcome studies on such models have been conducted (Amaro et al., 2007; Carroll and Onken, 2005; Foa et al., 2008; Morrissey et al., 2005; Najavits et al., 2008).

SUMMARY

The best practices laid out in this chapter for SUD prevention, screening, diagnosis, and treatment reflect the current literature in each of these areas. While the evidence base is constantly evolving, foundational concepts remain consistent. Evidence-based SUD prevention programs and practices address risk and protective factors, use approaches with demonstrated effectiveness, are age and developmentally appropriate, take place in suitable settings, and manage programs effectively. Best practice in SUD prevention also involves the inclusion of environmental strategies that affect whole communities on a systems-wide versus individual level. Effective SUD screening programs and practices focus on prevalent disease characteristics and are culturally acceptable and cost-effective. The best screening tests are brief, safe, noninvasive, inexpensive, easy to administer, and carry no negative or legal consequences. Diagnosis follows from positive screens and involves the implementation of standardized procedures that are both valid and reliable, can be used in busy clinical settings by professionals with various levels of training and different backgrounds, and reflect the latest research findings. Best practices in SUD treatment involve both the systems of care in which treatment is provided as well as the types of therapies employed; the delivery and organization of care for SUDs must be in line with current health care reform and federal parity legislation and make use of the most up to date behavioral and pharmacological therapies.

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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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Suggested Citation:"5 Best Practices in Prevention, Screening, Diagnosis, and Treatment of Substance Use Disorders." 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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