IOM: Military Response to Substance Abuse Is Outdated, Inadequate

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By Sandra Basu

Poster used in the Army campaign to stop widespread abuse of drugs and alcohol.

WASHINGTON — The military has not done enough to accept the high level of substance misuse among its ranks or to modernize its approach to combating the problem, a new report charges.

“The continuum of care for substance misuse in the Military Health System [from prevention through intervention and aftercare] has not been modified to accord with current understanding of factors that motivate individuals to seek help, settings in which care or interventions can be delivered most effectively, training/skills required by key staff and medications that have proven useful in achieving or maintaining abstinence,” according to the report from the Institute of Medicine (IoM).

That analysis comes from “Substance Use Disorders in the U.S. Armed Forces,” in which IoM examines how DoD and the services are handling substance use. The conclusions suggest the response is falling short.

The authors write that “alcohol and other drug use in the armed forces remain unacceptably high, constitute a public-health crisis, and both are detrimental to force readiness and psychological fitness,” calling for the top levels of military leadership to “acknowledge these alarming facts and combat them using an arsenal of public-health strategies, including proactively attacking substance-use problems before they begin by limiting access to certain medications and alcohol.”

IoM Findings

The IoM report comes as DoD is battling a rise in the rate of medication misuse as well as an increase in heavy drinking. The report notes that about 20% of active duty personnel reported having engaged in heavy drinking in 2008, and binge drinking increased from 35% in 1998 to 47% in 2008. When it comes to medication misuse, only 2% of active duty personnel reported misusing prescription drugs in 2002, compared with 11% in 2008, according to the IoM committee.

Among the problems pointed out by the IoM committee, is it is a “rarity” that physicians providing care in military treatment facilities have received training in addiction medicine or addiction psychiatry.

“General medical officers and flight surgeons receive minimal instruction in SUDs yet often are on the front lines of diagnosis, suggesting these providers should receive additional training to diagnosis and treat alcohol and other drug-related disorders,” the report states.

To address this issue, the authors suggest that SUD training could be expanded to primary-care providers through a continuing medical education requirement in screening, brief intervention and referral to treatment (SBIRT) for SUD.

Additionally, the report stated that “healthcare professionals at all levels (e.g., general medical officers, flight surgeons, medics) needed to be trained in recognizing patterns of substance abuse and misuse and provided clear guidelines for referral to specialty providers, including pain-management specialists and mental-health providers.”

The shortage of counselors in the service’s substance-abuse programs also is a problem, according to the authors, who note that SUD counselor training manuals used in the Air Force and Navy are outdated and do not address the use of evidence-based pharmacological and behavioral therapies. Specifically, the report points out, the Air Force Alcohol and Drug Counselor Certification Handbook bases its skill requirements on 1984 standards for counselor credentialing.

“Counselor training in both the Navy and Air Force neglects the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009). The Clinical Practice Guideline, developed in collaboration between the Department of Veterans Affairs (VA) and DoD, should be a core element of counselor training,” the report recommends.

In addition, the group writes that TRICARE’s substance abuse treatment benefit does not reflect the “practices of contemporary health plans.”

While contemporary SUD care includes the use of maintenance medications, the IoM committee pointed out that the current TRICARE benefit does not cover that “and thus deprives many patients of therapies that could help reduce craving and support long-term recovery.”

Furthermore, the TRICARE substance-abuse benefit lacks coverage for intensive outpatient services and office-based outpatient services, even though the current approach to helping patients focuses on outpatient services over inpatient services.

If DoD fails to make changes to the TRICARE benefit in a timely manner, the authors say they recommend “Congress consider taking action to mandate that DoD make these changes.”

DoD Tackles SUDs

In response to the report, DoD spokesperson Cynthia O. Smith said DoD “appreciated the hard work of the Institute of Medicine” and is “analyzing their specific findings and recommendations.”
      “The increasing rate of substance abuse is being recognized in civilian communities, and, like our civilian health care counterparts, we, too, recognize the extent of the problem and have been hard at work instituting policies, programs and steps to combat substance-abuse issues,” she said in a written statement.

Smith also pointed out that DoD is taking action to improve its services to beneficiaries.

“We have increased efforts to detect problematic substance abuse as early as possible through screening in primary care and by placing trained personnel in primary-care clinics and are coordinating policies to place a behavioral-health practitioner within our Patient-Centered Medical Home clinics,” she noted.

Confidential treatment of substance-abuse disorders are being piloted through the Army Confidential Alcohol Treatment and Education Project, which seeks to reduce stigma by balancing confidential care with accountability, she said.

In addition, she explained, a “DoD policy governing substance-use disorder treatment is now in coordination, which further specifies the certification standards for drug and alcohol counselors.”

More about the report’s finding and recommendations can be found at http://iom.edu/Reports/2012/Substance-Use-Disorders-in-the-US-Armed-Forces/Press-Release.aspx.

Toolkit Helps Providers Follow Substance Abuse Guidelines

The IoM report found that, while the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) “represents an excellent guide for screening, diagnosis and treatment,” the guideline is not consistently followed throughout DoD.

To encourage all providers to deliver care based on these guidelines, a new suite of seven tools based on these guidelines was made available to healthcare teams earlier this year.

This includes making the information available in an all-inclusive pocket guide. Retired Col. Ernest Degenhardt, RN, MSN, MEDCOM’s chief of the Evidence-Based Practice, Quality Management Division, told U.S. Medicine earlier this year that the new pocket guide is highly extensive and, using it, providers and healthcare teams do not have to consult multiple sources for information, because almost everything that they need to know is in one small, spiral-bound tool.

“It starts with an overview and then goes into the screening and intervention and referral process, which is so important, because, in the primary-care arena, this isn’t something that providers see every day, multiple times a day. So this gives them a real advantage in providing the right care at the right time in what to do,” Degenhardt said. “It also goes into the management of substance-use disorder that is provided in the specialty care, so it covers not only care in the primary-care setting but also in your specialty-care clinics.

“The other thing it goes into is how [to] stabilize these patients who are having problems and what [to] do specifically about their withdrawal symptoms. So, it is very specific stuff that primary-care providers just do not do enough. So we wanted to give them the latest evidence.”

The pocket guide also addresses ICD coding to ensure that the diagnosis is recorded correctly in the electronic health record, Degenhardt explained. This is important to track the magnitude of the problem and whether there has been improvement.
Toolkits are not a new concept for VA and DoD. Any time the agencies develop or update clinical practice guidelines (CPG), they provide tools to help healthcare teams better implement them.

“We know they are critical, because producing a guideline is one thing, but having the tools to help them implement them every day is just as important,” Degenhardt said about the toolkits.

Carla Cassidy, RN, MSN, director of VA’s Evidence-Based Practice Guideline Program Office of Quality and Safety, explained that the first guideline for SUD came out in 1998 and was developed by VA, which then partnered with DoD for a second update. The most recent update was completed in 2009. While tools were created for each update, this is the first time the tools were released with an all-inclusive pocket guide.

Cassidy said the toolkits aid in reducing variation in care provided by VA and DoD providers, which is important to both agencies. She also pointed out that the pocket guide is not the only tool healthcare teams can order and that available brochures provide education to families.

“There is nothing more powerful than a patient picking up a brochure in the waiting room regarding a concern they have about a loved one,” she said.

For the SUD tools, providers can go to www.healthquality.va.gov or www.qmo.amedd.army.mil.

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