MAMP510A Adler School of Professional Psychology Public Health Perspective and Veterans’ Policy Construct a public health perspective and veterans’ policy

MAMP510A Adler School of Professional Psychology Public Health Perspective and Veterans’ Policy Construct a public health perspective and veterans’ policy on substance use disorders. Discuss your policy perspective in a 2-page briefing paper. This paper should make recommendations for a change in policy regarding a public health approach to addressing substance use disorders with the veteran population.2 pages and references and citations. * MILITARY *
PSYCHOLOGY
Clinical and Operational Applications
CHAPTER 8
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Substance Abuse Services
and Gambling Treatment
in the Military
C a r r ie H. K e n n e d y
D a v id E. J o n e s
Re v o n d a G ra yso n
In 1770, Admiral Edward Vernon of the Royal Navy directed that sailors
in the West Indies fleet be given a daily ration of grog, rum or whiskey
diluted with water (Mateczun, 1995). The Admiral’s intent was to mini­
mize the harmful effects of drinking straight liquor on the health of sailors
under his charge. The American Navy, patterned after its British predecessors, continued the practice and even formalized it through congressional
legislation in 1794, marking the first documented formal substance abuse
prevention effort in the U.S. military. The rationing of grog remained in
effect until 1862, when it was abolished by a general order, though alcohol
on U.S. Navy vessels was not banned entirely until 1914 (Sobocinski,
Substance use patterns in the military have typically been monitored
during periods of conflict. During the Civil War, for example, alcohol
abuse and opium use were common (Jones, 1995). In a sample of Civil War
veterans from Indiana, 22.4% admitted to alcohol abuse and 5.2% noted
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CL IN IC A L PRACTICE IN THE MILITARY
abuse of chloral hydrate, cocaine, morphine, or opium (Dean, 1997). His­
torically, however, the worst substance problems were evident in the Viet­
nam War: In 1971, 34% of soldiers admitted to marijuana use and 50% to
the use of heroin (Jones, 1995). Toward the end of the war, more service
members were medically evacuated for drug use than for war wounds
(Reinstein, 1972; Stanton, 1976; Watanabe, Harig, Rock, & Koshes,
1994). In contrast, U.S. forces’ exposure to alcohol during the first Persian
Gulf War was minimal because Muslim tradition forbids the consumption
of alcohol and Saudi Arabia prohibited its importation. Under these envi­
ronmental conditions, alcohol was more difficult to acquire, and many
alcohol-related problems were reduced substantially during this conflict
(Watanabe et al., 1994).
In 1980, the U.S. Department of Defense began the first in a series of
systematic studies on health-related behaviors of military personnel across
periods of peace and war (Bray et al., 1983, 1995, 2003). These studies
included surveillance of substance use trends and their impact on military
readiness. Overall, the most recent survey results reveal that the military
has made a noteworthy improvement in combating illegal drug use. Preva­
lence rates declined from 27.6% in 1980 to 3.4% in 2002 (Bray et al.,
2003) largely attributable to the military’s zero tolerance policy for illicit
drug use (Mehay & Pacula, 1999). Alcohol abuse levels have proven more
variable as indicated by declining abuse rates from 1980 to 1998 but a
recent increase noted in the 2002 survey. Service members reported an
increase in serious consequences, productivity loss, alcohol dependence
symptoms, average alcohol consumption, and heavy alcohol use (Bray
et al., 2003).
Alcohol problems affect the mission readiness of personnel across the
spectrum of military occupational specialties. For example, in the U.S.
Navy aviation community, alcohol abuse and dependence are the 5thmost commonly occurring disqualifying diagnoses and account for 5.7%
of disqualified personnel with flight status. Other substance use disorders
(SUDs) are the 10th-most commonly occurring disqualifiers, accounting
for 2.3% of grounded personnel (Bailey, Gilleran, & Merchant, 1995).
Alcohol contributed to 3 1-58% of all active-duty U.S. Army drowning
deaths (352) between the years of 1980 and 1997 (Bell et al., 2001) and
to 23% of all active-duty U.S. Air Force deaths in 1990 (Stout, Parkin­
son, & Wolfe, 1993). Service members who are heavy drinkers (five or
more drinks at least once per week) are more likely to be late to work, to
leave work early, to exhibit decreased job performance, and to suffer onthe-job injuries than nondrinkers and light drinkers (Fisher, Hoffman,
Austin-Lane, & Kao, 2000). Whereas quantifying the negative impact of
substance abuse on the military is relatively simple, addressing the prob­
lem is complicated.
Substance A buse Services and Gambling Treatment in the M ilita ry
165
Military members face a great deal of stress not typically encountered
by the civilian population (e.g., loss of personal freedom, deployment to
danger zones, and frequent moves and/or absences from family). The mililary lifestyle itself is considered a contributing factor in abusive levels of
alcohol use (Watanabe et al., 1994). In fact, it is estimated that 25% of
both military men and women use alcohol as a coping strategy (Bray,
Fairbank, & Marsden, 1999). Britt and Adler (1999) noted an approximate
50% increase in alcohol consumption during medical humanitarian assis­
tance missions by individuals who normally consume alcohol and dou­
bled cigarette usage by smokers. In a study of the health outcomes of
United Kingdom soldiers following deployment on a peacekeeping mission
(Bosnia), there was significantly heavier alcohol consumption than by per­
sonnel who did not deploy (Hotopf et al., 2003). Some authors suggest that
certain subgroups of military personnel are at increased risk of significant
alcohol problems, including U.S. Marines (Schuckit et al., 2001) and U.S.
Army Rangers (Sridhar et al., 2003). From a demographic perspective, the
military faces particular challenges because a majority of personnel are
young, adult males, a population considered at heightened risk for sub­
stance abuse problems. One 5-year longitudinal study found that 75% of
U.S. Navy recruits used alcohol prior to enlistment and 31% had used ille­
gal drugs (Ames, Cunradi, & Moore, 2002).
Although substance-related problems continue among uniformed per­
sonnel, significant attention has been given to reducing their impact across
the military community. This chapter addresses the widespread prevention
efforts (e.g., zero tolerance, random urinalysis, and mandatory education)
underway throughout the military, early intervention services (e.g., alcohol
screenings and intense education), the components of a comprehensive
evaluation of a possible substance or gambling disorder, and the comorbidity of substance use disorders (SUDs) and posttraumatic stress disorder
(PTSD). The final section examines treatment options available for activeduty service members who experience problems with alcohol, drugs, and/or
gambling (e.g., outpatient, intensive outpatient, and residential treatment).
PREVENTION AND EDUCATIONAL SERVICES
Many early prevention efforts in the military focused on punishment fo r
offenses. Alcohol-related incidents were the primary cause for 80% of U.S.
Navy floggings until the practice was abolished in 1850 (Mateczun, 1995).
Before 1970, chronic alcohol and drug problems were generally met with
legal punishment and discharge from the service. In 1970, Congress
stipulated that efforts be directed toward treatment and rehabilitation
lather than automatic punishment and discharge (Watanabe et al., 1994).
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C L IN IC A L PRACTICE IN THE MILITARY
Another significant event in the 1970s was the development of an office to
focus on the prevention of drug abuse, which was created in response to
significant increases in drug- and alcohol-dependent military personnel in
Vietnam. The earliest prevention efforts emphasized education and the
detection of drug use (Watanabe et al., 1994). In 1971, the U.S. Army
began urine testing for opiates upon the completion of Vietnam tours and
quickly added routine, unannounced testing for opiates, barbiturates, and
amphetamines. In the 1980s and later, programs were developed that have
become increasingly standardized. Military policy mandates prevention
training for 100% of new military members, and annual training is
required for all troops, in addition to random urine drug testing. Whereas
each service manages its own prevention programs, they all retain the same
basic objectives of promoting mission readiness and the health and wellness
of troops through the prevention of substance abuse. Each branch of the
military maintains a comprehensive prevention program. These prevention
services include direct contact with all recruits and service members, as well
as specialized training for members of the chain of command and preven­
tion specialists, who are assigned to various units.
The Navy’s program is an excellent example of using a public website
to disseminate best practice information on alcohol abuse prevention to
support local commands (navdweb.spawar.navy.mil). Suggestions include
first identifying the target population followed by the evaluation of envi­
ronmental risk and protective factors inherent in different locales and situa­
tions. “Three R ’s” (relationship, relevance, and responsibility) are identi­
fied to form a core program: a positive mentoring relationship; the
relevance of everyone’s role in the overall success of the mission; and the
responsibility of individuals to learn and integrate expectations and poli­
cies, as well as leadership’s responsibility to provide information and facili­
tate the prevention program. The website contains recommendations spe­
cific to the Navy’s environment and lifestyle, including planning ahead for
port calls, the most effective use of Drug and Alcohol Program Advisors
(DAPA), and preparing sailors for liberty in both U.S. and foreign ports.
In the military system, prevention services and substance abuse coun­
seling fall under the purview of certified prevention specialists, drug
demand reduction coordinators, and drug and alcohol abuse counselors. In
most situations, the provision of prevention services is not a primary
responsibility of military psychologists. Psychology and psychiatry provid­
ers across the military, however, are often assigned to lead substance abuse
treatment programs as licensed independent practitioners (LIP). This role
allows interaction with literally thousands of military members and helps
develop local command-sponsored prevention programs. Providers in these
roles are encouraged to work in conjunction with prevention specialists and
drug demand reduction coordinators to accomplish the following:
Substance A buse Services and Gambling Treatment in the M ilita ry
167
1. Take full advantage of opportunities to allow substance abuse
counselors to provide prevention education and on-site substance
abuse screenings to service members.
2. Utilize the local television (e.g., Armed Forces Network), radio, and
newspapers (e.g., Stars and Stripes) to disseminate prevention
information and program availability.
3. When stationed in areas where specific drugs or unusual alcoholic
beverages are available, provide prevention briefs to inbound
deployed units and ships to educate the chain of command on the
availability of local illegal and/or addictive substances. For exam­
ple, such briefings in Japan commonly provide warnings to troops
about the consequences of testing positive for opiates that are avail­
able in over-the-counter cough medicines from Japanese pharma­
cies and warnings about hallucinogenic mushroom use on Oki­
nawa. Also, service members are warned that alcoholic beverages
in Japanese bars can include five shots of liquor per drink.
As with prevention services, each branch of the military offers alcohol
education aimed at promoting responsible drinking. These early intervention programs are geared toward personnel at risk for developing more
serious problems such as alcohol abuse or dependence. Educational pro­
grams are typically recommended at the first sign that an individual is mak­
ing unwise decisions about alcohol use. The trigger for a referral to an early
intervention program is usually an alcohol-related incident (ARI; e.g.,
arrest for drunk and,disorderly conduct, underage drinking, or drunk driv­
ing). Generally, a single alcohol-related incident or concerns of the com­
mand about an individual’s pattern of alcohol use will result in referral to
an early intervention program. Courses usually involve 15-20 hours of
training and discussion related to improving awareness about the effects of
alcohol on the body and brain, identifying risky situations, and making
positive choices for responsible drinking. The primary goals are to promote
responsible drinking, prevent further alcohol-related incidents, and prevent
the development of clinical and psychosocial substance abuse problems.
REFERRAL AND ASSESSMENT SERVICES
Diagnostic evaluations to determine the presence of substance use disorders
generally occur in several stages: referral, screening, and comprehensive eval­
uation. Although service members are encouraged to self-refer if they think
they may have an alcohol problem, the most common referral route for a
screening is an ARI or concern of command leadership. Given that various
levels of the chain of command are involved in processing documentation
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CLINICAL PRACTICE IN THE MILITARY
related to an ARI, there is limited confidentiality in drug and alcohol abuse
referrals. For the most part, alcohol screening and intervention services are
considered “commander’s programs,” or resources that senior leaders can
use to ensure that their troops get needed help. Command-level advisors on
drug and alcohol issues across the services include DAPA (Navy), Substance
Abuse Control Officers (SACO, Marine Corps), Army Substance Abuse Pro
gram (ASAP; Army), and the Air Force Alcohol and Drug Abuse Prevention
and Treatment program (ADAPT). Table 8.1 provides the various regulations for substance abuse evaluations for each branch of the military.
Primary-care physicians play a key role in the screening and diagnosis
of alcohol-related problems. Gold and Aronson (2005) identified a four
step screening process: (1) Inquire about current and past alcohol use with
all patients, including any family history of substance-related problems; (2)
for individuals identified as “drinkers,” obtain enough detailed information
to differentiate between moderate and heavy drinkers; (3) use standard
screening questionnaires such as CAGE (e.g., Have you ever felt the need to
cut down on drinking? Have you ever felt annoyed by criticism of your
drinking? Have you ever had guilty feelings about your drinking? Have you
ever taken a morning eye opener?); (4) based on information from steps 13, ask more specific questions to determine if criteria are met for an alcohol
use disorder and to determine whether or not evidence exists for any medi­
cal, psychiatric, or behavioral complications associated with excessive
drinking and/or other substance use. Bien, Miller, and Tonigan (1993)
reviewed 44 studies and found that general practitioners can help patients
alter patterns of harmful drinking with brief interventions, including feed­
back related to personal risk and impairment; emphasis on personal
responsibility for change; clear advice for change, with a menu of change
options; and an empathic counseling style.
It is also common for substance problems to be detected by emergency
room physicians (e.g., when patients present after fights or accidents while
intoxicated), mental health providers (e.g., diagnoses made during outpa­
tient evaluation or while on the mental health unit), and internists (e.g.,
patients admitted for detoxification). A strong collaboration with these
areas of medical treatment facilities is important and can lead to an
increase in referrals and earlier detection of problems. Storer (2003) noted
significant benefits to inpatient interventions both in preventing second
alcohol-related hospitalizations to the Naval Medical Center Portsmouth
and in reducing the time of stay of individuals who were readmitted.
Once a referral is obtained, the active-duty member is given an outpa­
tient or inpatient substance abuse screening. Screenings are relatively brief
and focus mainly on the extent of the alcohol or drug use. Substancerelated diagnoses are based on criteria set by the fourth edition of the Diag­
nostic and Statistical Manual o f Mental Disorders (DSM-IV; American Psy-
TABLE 8 .1 . Substance-R elated Instructions by B ra n d o f Service
———————————————————————————————————————————–Instruction
___________ Air Force__________ Army________ Coast Guard________ Marine Corps________________ Navy______________________
Alcohol rehabilitation
failure
AFI 44-121
AFI 3 6 -3 2 0 7
AFI 36-3 2 0 8
AR 600-85
COMDTINST
M 1 0 0 0 .6 Chapters
12 and 20
M CO P 1900.16F
MILPERSMAN article
1 910-152
Drug abuse
AFI 4 4 -1 5 9
AFI 4 4 -1 2 0
AR 600-85
Chapter 1
COMDTINST
M 1 0 0 0 .6
Chapter 2 0
M CO P 1900.16F
SECNAVINST 5 3 0 0 .2 8 C
SECNAVINST 5 3 0 0 .2 8 C
MILPERSMAN article
1 9 1 0 -1 4 6 , 191 0 -1 5 0
Aviation personnel
AFI 44-121
AFI 4 8 -1 2 3
Attachments 4 – 7
AR 60 0 -8 5
Chapter 7
COMDTINST
M 6410.3
Chapter 9
BUMEDINST 5 3 0 0 .8
BUMEDINST 530 0 .8
Submarine and nuclear
weapon personnel
AFI 3 6 -2 1 0 4
AR 50-5
No specific
instruction.
SECNAVINST 5 5 1 0 .35A
SECNAVINST 5 5 1 0 .35A
OPNAVINST 5 3 5 5 3 B
Substance use and security
clearances
AFI 3 6 -2 1 0 4
AR 3 8 0 -6 7
COMDTINST
M 5520.12B
SECNAVINST 5 5 10.30A
SECNAVINST 5510.30A
Substance abuse prevention
and control
AFI 44-1 2 1
Section 3B
AR 60 0 -8 5
Chapter 2
COMDTINST
M l000 .6
Chapter 2 0
M CO P 1700.24B Chapter
3
SECNAVINST 530 0 .2 8 C
OPNAVINST 5 3 50.4C
SECNAVINST 5 3 0 0 .2 8 C
OPNAVINST 5 3 50.4C
Standards for provision of
substance-related disorder
treatment services
AFI 44-1 2 1
Section 3F
AR 600-85
Chapters 3
and 4
COMDTINST
M 1 0 0 0 .6
Chapter 2 0
M CO P 1700.24B Chapter
5
BUMEDINST 5353.4A
BUMEDINST 5353.4A
Use of disulfiram
(Antabuse)
AFI 44-121
Section 3 .1 5 .9
AR 60 0 -8 5
Chapter 4
No specific
instruction.
BUMEDINST 5 3 5 3 .3
BUMEDINST 535 3 .3
Note.
AFI, Air Force Instruction; AR, Army Regulation; BUMEDINST, Department of the Navy, Bureau of Medicine and Surgery Instruction; COMDTINST, United
States Coast Guard, Commandant Instruction; MCO, Marine Corps Order; MILPERSMAN, Navy Military Personnel Manual; OPNAVINST, Chief of Naval Opera­
tions Instruction; SECNAVINST, Secretary of the Navy Instruction. Full reference entries for the specific publications noted in this table are listed in the reference list
under the “U.S. Department of . . . ” entries.
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C L IN IC A L P R A C T IC E IN T H E M IL IT A R Y
chiatric Association, 1994). If criteria arc met for substance abuse or
dependence, the individual is referred for a more comprehensive evaluation. The majority of referrals are for one-time ARIs. Many of these one
time incident referrals do not meet diagnostic criteria for a substance use
disorder. Although some service members are returned to their command
with recommendations for “no action,” most are recommended for early
intervention education. For example, from January 2003 to August 2005, a
total of 2,982 active-duty patients (primarily Marines) were referred to the
Substance Abuse Rehabilitation Program at U.S. Naval Hospital Okinawa
Fifty-three percent of these patients (n = 1,527) did not meet criteria for an
SUD but did warrant early intervention, a week-long alcohol education
class (CDR David Jones, personal communication, September 1, 2005).
A word of caution is offered here about both the overdiagnosis and
the underdiagnosis of alcohol abuse among military personnel. Some cli
nicians strictly adhere to DSM-IV criteria for alcohol abuse and will
sometimes make the diagnosis based on two alcohol-related incidents that
occur within a 12-month period, regardless of their severity. A common
example might involve a 19- or 20-year-old service member who is
referred for evaluation because he or she ha…
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