Further steps needed to reduce stigma and expand access to substance abuse screening and care in U.S. Armed Forces

"We commend the steps that the Department of Defense and individual service branches have recently taken to improve prevention and care for substance use disorders, but the armed forces face many ongoing challenges," said Charles P. O'Brien, Kenneth Appel Professor and vice chair, department of psychiatry, and director, Center for Studies of Addiction, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and chair of the committee that wrote the report. "Better care for service members and their families is hampered by inadequate prevention strategies, staffing shortages, lack of coverage for services that are proved to work, and stigma associated with these disorders. This report recommends solutions to address each of these concerns."

About 20 percent of active duty personnel reported having engaged in heavy drinking in 2008, the latest year for which data are available, and binge drinking increased from 35 percent in 1998 to 47 percent in 2008. While rates of both illicit and prescription drug abuse are low, the rate of medication misuse is rising. Just 2 percent of active duty personnel reported misusing prescription drugs in 2002 compared with 11 percent in 2008. The armed forces' programs and policies have not evolved to effectively address medication misuse and abuse, the committee noted.

To tackle these disorders better, DOD needs to lead from the top to ensure that all service branches take excess drinking and other substance use as seriously as they should, and that they consistently adhere to evidence-based strategies for prevention, screening, and treatment, the report says. Inconsistent use of evidence-based diagnostic and treatment strategies contributes to lower quality care. The department's own Clinical Practice Guideline for Management of Substance Use Disorders is an excellent resource on effective approaches that is not being consistently followed, the committee said.

TRICARE, which provides health insurance to service members and their dependents, does not cover several evidence-based therapies that are now standard practice, the committee found. It also does not permit long-term use of certain medications for the treatment of addiction and covers treatment delivered only in specialized rehabilitation facilities. TRICARE's benefits should be revised to cover maintenance medications and treatment in office-based outpatient settings delivered by a range of providers, which would enable ongoing care for patients struggling to avoid relapses.

Alcohol has long been part of military culture, and attitudes toward drinking vary across the service branches, the committee found. The armed forces should enforce regulations on underage drinking, reduce the number of outlets that sell alcohol on bases, and limit their hours of operation, the report says. In addition, the service branches should conduct routine screening for excessive alcohol consumption in primary care settings and provide brief counseling when screening points to risky behavior. Making screening and intervention services part of primary care would reduce the stigma associated with seeking substance abuse treatment and increase the number of places where service members and families can get basic care for these disorders.

Health care providers should not have to include service members' commanding officers when developing care plans for those who do not meet diagnostic criteria for alcohol use disorders and need only brief counseling. Each branch also should provide options for confidential treatment; the Army's Confidential Alcohol Treatment and Education Pilot offers a promising example.

Military health care professionals at all levels need training in recognizing patterns of substance abuse and misuse and clear guidelines for referring patients to specialists such as pain management experts and mental health providers. Team care by a range of providers not only is a more effective approach but also would help alleviate the provider shortage created by the military's sole reliance on specialty substance abuse clinics to provide care, the committee concluded.

Easier access to providers and better management of substance use disorders could improve detection and care for related conditions, such as post-traumatic stress disorder, depression, and suicidal thoughts, the committee noted. Substance misuse and abuse frequently occur along with these conditions. Rising suicide rates among both active duty personnel and veterans have alarmed the public and government officials.

The report was sponsored by the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The Institute of Medicine, National Academy of Sciences, National Academy of Engineering, and National Research Council together make up the independent, nonprofit National Academies. For more information, visit http://national-academies.org or http://iom.edu.