SUBSTANCE USE DISORDERS

in the U.S. Armed Forces

Committee on Prevention, Diagnosis, Treatment and Management of
Substance Use Disorders in the U.S. Armed Forces

Board on the Health of Select Populations

Charles P. O’Brien, Maryjo Oster, and Emily Morden, Editors

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS      500 Fifth Street, NW      Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by the U.S. Department of Defense through an interagency agreement with the U.S. Department of Health and Human Services under Contract No. HHSP23337030T. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

International Standard Book Number-13: 978-0-309-26055-8
International Standard Book Number-10: 0-309-26055-8

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

COMMITTEE ON PREVENTION, DIAGNOSIS, TREATMENT AND MANAGEMENT OF SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES

CHARLES P. O’BRIEN (Chair), Kenneth E. Appel Professor of Psychiatry and Vice-Chair of Psychiatry, and Director, Center for Studies of Addiction, University of Pennsylvania School of Medicine, Philadelphia

HORTENSIA D. AMARO, Associate Vice Provost for Community Research Initiatives and Dean’s Professor of Social Work and Preventive Medicine, University of Southern California, Los Angeles

RHONDA ROBINSON BEALE, Chief Medical Officer, OptumHealth Behavioral Solutions, Glendale, CAL

ROBERT M. BRAY, Senior Research Psychologist and Senior Director of the Substance Abuse Epidemiology and Military Behavioral Health Program, RTI International, Research Triangle Park, NC

RAUL CAETANO, Regional Dean and Professor, Dallas Regional Campus of the University of Texas School of Public Health

MATHEA FALCO, President, Drug Strategies, Inc., Washington, DC

JOYCE M. JOHNSON, Vice President of Health Services, Battelle Memorial Institute, Arlington, VA

THOMAS KOSTEN, J.H. Waggoner Chair and Professor of Psychiatry, Pharmacology and Neuroscience, Baylor College of Medicine, Houston, TX

MARY JO LARSON, Senior Scientist, Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, MA

DAVID C. LEWIS, Professor Emeritus of Community Health and Medicine, and the Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, Brown University, Providence, RI

DENNIS McCARTY, Professor of Public Health and Preventive Medicine and Division Head, Health Services Research, Oregon Health and Science University, Portland

MARY ANN PENTZ, Professor of Preventive Medicine and Director, Institute for Health Promotion and Disease Prevention Research, University of Southern California, Los Angeles

TRACY STECKER, Assistant Professor of Community and Family Medicine, Dartmouth Medical School, Lebanon, NH

CONSTANCE WEISNER, Professor of Psychiatry, University of California, and Associate Director for Health Services Research, Kaiser Permanente, Oakland

IOM Staff

MARYJO M. OSTER, Study Director

EMILY C. MORDEN, Research Associate

JON Q. SANDERS, Program Associate

NANCY LESTER, Uniformed Services University of the Health Sciences Intern (Spring 2012)

ANDREA COHEN, Financial Associate

FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Thomas F. Babor, University of Connecticut Health Center

Mady Chalk, Treatment Research Institute

Arthur T. Dean, Community Anti-Drug Coalitions of America

Michael Fitzsimons, Massachusetts General Hospital

Deirdre Hiatt, Managed Health Network

Cristine S. Hunter, U.S. Office of Personnel Management

Kimberly C. Kirby, Treatment Research Institute

Daniel Kivlahan, VA Puget Sound Health Care System

James McKay, Treatment Research Institute

Thomas McLellan, Treatment Research Institute

Roland S. Moore, Pacific Institute for Research and Evaluation

Rumi Kato Price, Washington University School of Medicine

Eve E. Reider, National Institute on Drug Abuse

Stephen N. Xenakis, U.S. Army (Ret.)

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Richard J. Bonnie, University of Virginia, and Susan J. Curry, The University of Iowa. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Preface

Substance abuse has long been an issue of concern for the U.S. population and for its military in particular. Dating as far back as the Revolutionary War, Dr. Benjamin Rush detailed the effects of alcohol on the troops. During the Civil War, addiction to opium prescribed for pain became known as the “soldier’s disease.” Drug problems in both the military and civilian sectors have intensified throughout the 20th century as the types and formulations of substances being used have increased.

Since the 1970s, the Institute of Medicine (IOM) has been called upon numerous times to advise the government on both medical and legal solutions to the problem of substance abuse. Experts from various fields, ranging from mathematics and epidemiology to pharmacology and law, have spent many hours on about a dozen different committees struggling with this thorny problem, which affects our country on societal, economic, personal, and public health levels. While the popular substances of abuse may shift from decade to decade, the overarching problem continues. In the 21st century, prescription opioid abuse has arisen as a major area of concern while problems of alcohol, nicotine, and stimulants have persisted as well. Research has demonstrated that stress and availability are important background factors for causing the initiation and abuse of drugs. As the United States approaches the end of the longest continuous period of war in our history, the stresses faced by our military population are apparent. Our all-volunteer military has endured long periods of deployment and redeployment in highly taxing and demanding environments. Consequently, posttraumatic stress, traumatic brain injury, substance abuse, and suicide are at very high levels.

Press reports of substance abuse among the military stimulated congressional interest and a call for action. The Department of Defense requested that the IOM take a fresh look at the policies and programs of each of the branches of the military and evaluate the adequacy and appropriateness of their prevention, screening, diagnosis, and treatment of substance use disorders. The committee approached this task by holding public meetings to gather information from representatives of each of the military branches and TRICARE (the military’s purchased care health plan), as well as from academic researchers and interested members of the public. The committee also conducted visits to military bases and met with a variety of care providers, including those working in substance abuse specialty programs and those in primary care, behavioral health, and pain management.

The committee requested information from each branch of the military and from TRICARE Management Activity regarding program descriptions, access, utilization, and evaluation results. We also requested data on the providers in the substance abuse programs. We extend our appreciation for the exceptional cooperation from all of those who presented at our meetings, hosted our visits to military bases, and assisted with our information gathering efforts.

In addition, the committee wishes to express our appreciation to the study director, Dr. Maryjo Oster, and to the IOM staff, Ms. Emily Morden, Mr. Jon Sanders, and Dr. Rick Erdtmann.

Charles P. O’Brien, Chair

Committee on Prevention, Diagnosis, Treatment and Management of Substance Use Disorders in the U.S. Armed Forces

Acknowledgments

The committee thanks the Department of Defense, the individual service branches, and TRICARE Management Activity for the opportunity to review and comment upon the organization and content of their substance used disorders prevention and treatment services. We appreciate their assistance and collaboration in the review.

Many individuals assisted the committee in its work by providing useful data and presenting information at the committee’s public meetings and during its site visits. We thank the following people for their contributions: Capt. Robert DeMartino, Alfred Ozanian, Greg Woskow, Frank Lee, and Diana D. Jeffery, TRICARE Management Activity; Les McFarling, Army Center for Substance Abuse Programs; Charles Gould, U.S. Navy Bureau of Medicine and Surgery; Lt. Col. Mark S. Oordt, U.S. Air Force Medical Operations Agency; Keith Humphreys, Stanford University; Don Jansen, Congressional Research Service; Brig. Gen. Margaret Wilmoth, Office of the Assistant Secretary of Defense for Health Affairs; Col. John J. Stasinos, Department of the Army, Office of the Surgeon General; Capt. Mary Rusher, Naval Medical Center San Diego; Vladimir Nacev, Defense Centers of Excellence; Col. Charles Milliken, Walter Reed Army Institute of Research; Wilson Compton and Eve Reider, National Institute on Drug Abuse; John Veneziano, Marine Corps Consolidated Substance Abuse Counseling Center; Ted Jutson and Jerry Sinel, Navy Drug and Alcohol Counselor School; John Sparks, TRICARE Regional Office-West; Andrea Brooks Tucker, TRICARE Regional Office-South; Marie Mentor, TRICARE Regional Office-North; Frank Maguire, TriWest; Debbie Del Rosario and Gary Proctor, ValueOptions; Ian Schaffer and John Wagoner,

Healthnet Federal Services; John M. Morrow, Substance Abuse and Mental Health Services Administration; Abigail Gewirtz, University of Minnesota; Ron Astor, University of Southern California; Barbara Cohoon, National Military Family Association; Lisa Najavits, Harvard University; Anthony Hassan, University of Southern California; Eugene Moore, Cdr. Joseph B. Lawrence, Josh Devine, and Libby Hearin, TRICARE Pharmacy Operations; Isabel Jacobson, Naval Health Research Center; Lt. Gen. David Fridovich, United States Special Operations Command; Lt. Col. Kevin Galloway, Army Pain Management Task Force; Col. Chester Buckenmaier, Walter Reed Army Medical Center; Anthony H. Dekker, Ben Krepps, and Jennifer Weaver, Fort Belvoir Community Hospital; Chideha Ohuoha, Doryan Dixon, Jorge Grandella, and Susan Jessup, Dewitt Army Hospital, Ft. Belvoir; Bob Huebner, National Institute on Alcohol Abuse and Alcoholism; Col. Charles Engel, Department of Defense Deployment Health Clinical Center; Harold Holder, Prevention Research Center of the Pacific Institute for Research & Evaluation; Daniel Kivlahan, Office of Mental Health Services, Veterans Health Administration; 1Lt. Julianna Petrone, SSgt. Cecilia Cardenas, Paul Ahlberg, SrA. Stephanie Tipton, Kim Perez, Eva Shinka, Myron Horn, and Maj. David Cordry, Keesler Air Force Base; Capt. Mary K. Rusher, Joanne Rigoloso, Capt. Warren Peter Klam, Tara Leverett, Valerie Sudduth, Nelson Ferrer, Richard Arriaga, Steven Sovich, and Steven Hanling, Naval Medical Center, San Diego; LTC Sharette Gray, Nicolette Dennis, MAJ Agius, and April Arrington, Carl R. Darnall Army Medical Center, Fort Hood; Dan Harris, CNA; and Caryn Blitz, U.S. Department of Health and Human Services.

Contents

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Tables, Figures, and Boxes

Tables

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