Treatment of Substance Abuse in Military Hampered by “Old-fashioned” Approach

Abstract

TO COMBAT EMERGING SUBSTANCE use problems among military personnel and veterans, the Department of Defense (DOD) must abandon outdated treatment practices, strengthen its clinician workforce, and promote early treatment through screening and confidential care, according to a report from the Institute of Medicine (IOM) (http://tinyurl.com/cqngzkz). Substanceusedisordershavelongbeen a major concern for the military, as personnel grapple with the stresses of deployments and the physical and psychological traumasofwar.Butrecentanecdotalreportsanddatasuggestthatrisky alcohol consumption and prescription drug abuse have increased substantially inthemilitaryoverthepastdecade.Nearly half of the service men and women surveyed in 2008 reported binge drinking (definedasdrinking5ormoredrinkson the same occasion) in the past month, compared with 35% in 1998, according to data from the DOD Surveys of Health RelatedBehaviorsamongMilitaryPersonnel.Additionally, reportedmisuseofopioidpainmedicationshas increased from 2% in 2002 to 11% in 2008. Congress mandated an outside review of substance abuse care for members of the military as part of the NationalDefenseAuthorization Act, and the DOD commissioned the IOM to conduct the review. Senator Claire McCaskill (D, Mo) proposed the review and other measures to overhaul care for substance abuse in the military following a whistle-blower report of inadequate staffing and other problems hindering substance abuse treatment at Fort Leonard Wood in Missouri. The IOM found that the care being offered for substance abuse disorders in the military is decades behind the times. Committee member Dennis McCarty, PhD, professor of public health and preventive medicine at Oregon Health & Science University in Portland, explained that clinicians in the TRICARE program, which serves most active-duty service members, are bound by regulations enacted in the 1980s that were based on the treatment paradigms of the 1970s and 1980s. The result, he said, has been an overemphasis on inpatient care that not only limits access to care but also fails to account for the chronic and often relapsing nature of substance abuse disorders. Current evidence-based care reserves inpatient treatment for the most medically complex cases and emphasizes multidisciplinary outpatient care, according to the report. McCarty noted that TRICARE clinicians are also prohibited from treating substance abuse disorders with agonist medications such as buprenorphine, which have become a key tool for managing cravings in patients with these disorders. “Modern treatment of substance abuse disorders does involve medications,” said Charles P. O’Brien, MD, PhD, chair of the IOM committee that developed the report and director of the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia. “The approach to treatment of substance use disorders in the military tends to be old-fashioned.” The IOM called for better adherence to the 2009 Clinical Practice Guideline for the Management of Substance Abuse Disorders created by the Department of Veterans Affairs (VA) and the DOD (http://tinyurl.com /cc4eqt4), noting that this has helped improve care at VA facilities. However, adherence in TRICARE has been low because there has been no requirement to provide evidence-based care, according to the report. Inadequate staffing levels, particularly of clinicians with appropriate training, have also impaired the military’s response to increasing rates of substance abuse disorders. The report calls for the adoption of a model in which multidisciplinary teams, each led by a primary care physician, provide sub-