Treatment of SUDs in the US Military

Several key events and names in US military drug programs stand out in history. In the 1960s, the Vietnam War was raging, a draft was enacted, and illegal substances were widely available. As a result, marijuana and heroin were commonly used in the military community. President Richard Nixon directed that a military drug urinalysis program be implemented as drug use increased (OUSPR, 2017). This program specifically targeted those returning from the Vietnam War and Nixon’s stated intent was to identify those in need of rehabilitation. According to a report released in 1973, “approximately 42 percent of US military personnel in Vietnam in 1971 had used opioids at least once, and half of these individuals were reported to be physically dependent at some time” (OUSPR, 2017). In 1981, memorandum number 62884 was issued by the Deputy Secretary of Defense Carlucci, which authorized “punitive actions including courts martial or administrative separation for drug use” (OUSPR, 2017). Over time, more requirements have been added to the military drug program:

• 100 percent random testing for all service members and designated civilian personnel
• Mandatory testing for individuals entering the military within seventy-two hours of arriving to training
• Mandatory separation of members who knowingly use prohibited drugs (OUSPR, 2017)

Presently, these drug testing policies remain in place, and the military continues to maintain a zero-tolerance policy for the use of illegal substances. While treatment options are available to service members for alcohol-related issues, these treatment options require the oversight of the service member’s chain of command.

Command and Supervisory Involvement

In the US military, order is paramount. The conduct of service members is governed by many policies, regulations, instructions, and similar prescriptions. Unit commanders are given much discretion as to how their units are organized and governed within the limitations of military regulations. This discretion allows those who preside over service members in the chain of command, such as supervisors or commanders, to have involvement in nearly all aspects of military life. For example, branch-specific fitness standards must be maintained by each service member. While the number of formal fitness evaluations on individual service members is limited by military regulations, commanders have the discretion to require daily physical training and monitor fitness levels off the record. In this way, commanders operate within the general confines of regulation, but they are able to exercise a great deal of latitude in the administration of their respective units. The oversight of substance use treatment in the military is, in many ways, similar to this level of oversight and monitoring.

Each service—Army, Navy, Air Force, Marines, and Coast Guard—are generally governed by the US Department of Defense (DOD), and base their respective regulations on DOD policies. DOD Instruction 1010.01 (DODI 1010.01), the Military Personnel Drug Abuse Testing Program, permits “. . . commanders to use drug testing to detect drug abuse and to assess the security, military fitness, readiness, and good order and discipline of their commands” (DOD, 2012, p. 2). Furthermore, commanders are charged to, “Process all service members who knowingly misuse drugs for separation in accordance with applicable service regulations. The established drug-testing program shall enable commanders to take action, adverse or otherwise (including referral for treatment), as appropriate” (DOD, 2012, p. 2).

This general DOD policy informs how the services operates and mandates commanders to separate service members who “knowingly misuse drugs.” This career-ending mandate does not apply to alcohol—alcohol use is treated quite differently and is afforded treatment and rehabilitation options, which are described in further detail in the treatment section of this article.

Commanders and Supervisors: Advocates or Adversaries?

As referenced earlier, commanders are charged with maintaining good order and discipline, ensuring military fitness, and guaranteeing deployment readiness among those whom they preside over within the chain of command. Within the broad scope of chain of command, supervisors are appointed to serve as mentors and have more close involvement in the daily life of their subordinates than commanders do. Though commanders and supervisors are not therapists, they have much control over the careers of service members, which includes participating in decisions pertaining to SUD treatment. Due to this close involvement with the treatment process, it is vital for military service members to have strong, positive relationships with those in their chain of command. In the AA Big Book, the author describes the importance and utility of achieving an understanding relationship between individuals in care and those who are helpers in the treatment process, stating:
Highly competent psychiatrists who have dealt with us have found it sometimes impossible to persuade an alcoholic to discuss his situation without reserve. Strangely enough, wives, parents, and intimate friends usually find us even more unapproachable than do the psychiatrist and the doctor. But the ex-problem drinker who has found this solution, who is properly armed with facts about himself, can generally win the entire confidence of another alcoholic in a few hours. Until such an understanding is reached, little or nothing can be accomplished (Alcoholics Anonymous, 2001, p. 18).
This is not to say that commanders and supervisors involved in the treatment process must be “ex-problem drinkers,” but to underscore the sentiment of a shared experience. In many ways, the comradery of the military can conceivably serve this purpose, but only if the shared military experience is mutually positive.

DODI 1010.01, on which specific service regulations are based, is aimed directly at keeping good order and discipline, placing commanders in a position to be viewed as adversaries to those who misuse drugs. In fact, if commanders know people are misusing drugs, then they are obligated to separate those service members, per DODI 1010.01. On the other hand, commanders have the best interests of their teams in mind. In some cases, members’ immediate supervisors may become adversaries if those members are unable to develop positive relationships with their supervisors.
The perception of how commanders and supervisors are viewed by service members who misuse drugs and/or alcohol are based on interactions with the chain of command. If members have a largely positive experience with the chain of command and then a negative one when caught misusing drugs or alcohol, those members may have a positive perception of the leadership. However, if members are typically in trouble related to substance use, then they may view command and supervisory relationships to be purely adversarial.

Coverage and Treatment
Coverage

For those seeking treatment in the military, the direct system of care includes providers and facilities that are directly managed by the military services. They are organized by an individual service and are managed by each service’s surgeon general. However, there is currently a push for reorganization, and the DOD is tasked to conduct an evaluation of the proposed shift toward a unified medical command that would oversee the medical services of all branches. Due to capacity and staffing limitations, military treatment facilities are unable to provide care to all eligible beneficiaries and they must purchase health care services from civilian providers. TRICARE sets a lifetime limit of three SUD benefit periods where each period is 365 days from the first visit (Lakind, Sericano, & Still, 2012).

Chemical detoxification is covered for up to seven days, although more days may be covered if medically or psychologically necessary. SUD rehabilitation can occur in an inpatient or partial hospitalization setting. Inpatient treatment is covered for up to twenty-one days in a TRICARE-authorized facility. Outpatient group therapy for SUDs must be provided by an approved SUD rehabilitation facility (SUDRF). This includes sixty group therapy sessions per benefit period. Family therapy is covered after the completion of rehabilitative care. Unless provided by an approved SUDRF, individual outpatient therapy is not covered for SUDs (Lakind et al., 2012).

Treatment

Comorbidity of PTSD and SUDs is a major concern in the military. Individuals with PTSD self-medicate with drugs and/or alcohol in an attempt to reduce hyperarousal. Pharmacotherapy—used to address both PTSD and alcohol use disorders—includes antidepressants, anticonvulsants, and antipsychotic medications (Back et al., 2012). A case study showed that exposure therapy combined with naltrexone was more effective in alcoholism comorbid with PTSD than either therapy alone (Back et al., 2012). Psychotherapy is the most effective treatment for those with comorbid PTSD and SUDs, especially as medications have limited effectiveness (Foa, Keane, Friedman, & Cohen, 2008).

There are various psychotherapies for PTSD and SUDs, but cognitive behavioral therapy, contingency management, couples and family therapy, and a variety of other types of behavioral treatments have been shown to have the best outcomes.

Integrative models of therapy, where both disorders are simultaneously addressed, show significant improvement in substance use severity, PTSD symptomatology, and overall function. Studies show that patients who improve PTSD symptomatology are significantly more likely to show subsequent improvement in substance use, whereas there is only minimal evidence that improvement in substance use yields improvement in PTSD (Back et al., 2012). These findings express the critical need to address PTSD in order to provide the most effective treatment for co-occurring PTSD and SUD patients.

Research supports cognitive behavioral therapy that addresses PTSD and SUDs concurrently. COPE—concurrent treatment of PTSD and SUDs using prolonged exposure—consists of twelve, individual, ninety-minute sessions that integrate relapse prevention for substance use with prolonged exposure for PTSD (Back et al., 2012). The SUD portion of treatment is designed to help patients identify environmental and emotional triggers as well as high-risk situations for substance use, and also effectively managing cravings through a variety of cognitive behavioral techniques. A unique addition to COPE is that it teaches patients to manage anger, a symptom of PTSD and a common trigger for SUD relapse.

The PTSD portion of treatment is designed to normalize common reactions to trauma and reduce PTSD symptoms via in-vivo (i.e., occurring in the real world) and imaginal (i.e., occurring in the imagination) exposure (Back et al., 2012). The prolonged exposure program includes education about reactions related to trauma; breathing retraining; in-vivo exposure to situations that people avoid because they are reminded of their traumatic event and become anxious; and repeated imaginal exposure to the memories associated with the traumatic event. The treatment aims for patients to stop avoidance and confront trauma to help organize their memories, gain new perspectives, decrease emotional reactivity to memories, and enhance self-competence. In patients with PTSD and SUDs, the combined use of COPE and usual treatment, compared with usual treatment alone, resulted in improvements in PTSD symptom severity without an increase in severity of substance dependence (Back et al., 2012).

Department of Veterans Affairs and DOD Joint Guideline

The US Department of Veterans Affairs (VA) and the DOD jointly published revised guidelines for treatment options using evidence-based practices, most recently in 2015 called the “VA/DOD Clinical Practice Guideline for Management of Substance Use Disorders (SUDs)” (2015). The Management of Substance Use Disorders Work Group (MSUDWG), which is a joint work group between the VA and DOD, make clear that the guidelines are only guidelines and not a rigid prescription for treatment modalities. This is important to remember for clinicians, as clients may respond differently to different treatment modalities. However, the guidelines contain evidence-based practices shown to be effective in significant numbers. The treatment guidelines cover a range of interventions for alcohol, opioid, cannabis, and stimulant use disorders and contain both pharmacotherapy and psychosocial interventions.

As referenced previously, DODI 1010.01 mandates separation for service members who misuse drugs other than alcohol. However, in addition to the separation process, the same instruction affords commanders the ability to refer members to treatment. As such, active duty practitioners may use the VA/DOD Guideline for treatment of substances other than alcohol, but should inform members about the possibilities of continued treatment at the VA when actual separation is imminent.

Treatment Modalities Recommended by the DOD and VA

With a wide array of treatment options available and emerging interventions being discovered, it is important for practitioners to be aware of treatment options which will help clients to the greatest extent. However, as with all social work, it is important to consult evidence-based practices when selecting treatment modalities. That is where the VA/DOD Guideline offers guidance for practitioners.

The recommendations mentioned in the Guideline relate to the severity of the addiction, medication-assisted treatment (MAT) or other pharmacotherapy options, and psychosocial treatment. An overall recommendation for patients with SUDs are peer linkage, network support, and Twelve Step facilitation.

Alcohol Use Disorder

The VA/DOD suggests acamprosate, disulfiram, naltrexone, and topiramate for MAT and states that “These medications should be offered in conjunction with a psychosocial intervention and considering the preferences of appropriately informed patients” (MSUDWG, 2015, p. 33). The psychosocial interventions suggested for alcohol use disorder among active duty service members are behavioral couples therapy, cognitive behavioral therapy, community reinforcement approach, motivational enhancement therapy, and Twelve Step facilitation.

Opioid Use Disorder

The MAT recommended for opioid use disorder among active duty service members is buprenorphine/naloxone and methadone. The Guideline notes that, “For patients in office-based buprenorphine treatment, there is insufficient evidence to recommend for or against any specific psychosocial interventions in addition to addiction-focused medical management. Choice of psychosocial interventions should be made considering patient preferences and provider training/competence” (MSUDWG, 2015, p. 45). The Guideline goes on to discuss the benefits of urine testing to ensure medication regimen compliance, brief counseling with a physician, and participation in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) as well as a possibility for contingency management.

Cannabis Use Disorder and Stimulant Use Disorder

There currently is no MAT recommendation for either cannabis or stimulant use disorder. No MAT is recommended for cannabis use disorder as no medication has been shown to be effective in its treatment. However, the psychosocial interventions recommended are cognitive behavioral therapy, motivational enhancement therapy, or a combination of the two. Similarly, there are no recommendations for stimulant use disorder due to a lack of evidence to suggest any MAT is effective in treating it. The recommended psychosocial interventions for stimulant use disorder include cognitive behavioral therapy, recovery-focused behavioral therapy, or a combination of these two interventions with contingency management.

Issues and Recommendations

Commander notification and lack of confidentiality in the treatment of substance abuse discourage many service members from seeking treatment for fear of disciplinary actions. The result is that many service members suffering from SUDs are likely not receiving treatment (DOD, 2011). In 2010, the “Comprehensive Plan” was developed, which includes recommendations for SUD prevention, training for health care professionals treating SUDs, SUD services for military dependents, and the dissemination of SUD prevention materials (DOD, 2011). The Plan was enacted by US Senator Claire McCaskill (D-MO), who introduced legislation to overhaul the alcohol and drug abuse treatment programs throughout the armed forces. This plan provides detailed information on treating active duty military and includes the key aims of addressing the issue of confidentiality and disciplinary versus treatment issues in substance abuse programs (DOD, 2011).

Recommendations

One recommendation is to consider the benefits of abolishing immediate separation for drugs other than alcohol. The fundamental question posed in this recommendation is, “Can service members on active duty recover from drug abuse?” For alcohol use disorder, there are options for treatment and return to duty, but for other drugs, the finality of separation is the first option. Current policy grants those with alcohol use disorder the opportunity to recover. While other drugs have the potential to be highly addictive and problematic, the viability of granting further recovery periods to those struggling with other drug use disorders to recovery while on active duty should be researched. A test run could be conducted with assigning active duty personnel to an active guard reserve (AGR) position while in recovery after inpatient or during intensive outpatient recovery. Regardless, further research is warranted to find out of such a recommendation is viable for active duty military members.

Another recommendation is to provide appropriate levels of confidentiality to those seeking treatment. There is currently no confidentiality for service members who seek care, which is a major barrier to seeking treatment. Substance abuse is a medical problem, and must be treated in a manner that protects those seeking treatment. Service members should not be discouraged to seek treatment for fear of punishment or negative consequences. Incorporating a nondisclosure statement may protect service members’ confidentiality while seeking treatment. Further evaluation of confidentiality concerns would benefit current standards of substance use treatment, particularly in researching the efficacy of having the chain of command involved in treatment. The benefit to this research is twofold:

1. Findings may uphold the involvement of commanders and supervisors, which could inform treatment protocols outside of the military to include civilian equivalents through bodies like employment assistance programs
2. Findings may show that involvement of the chain of command is a dangerous barrier to treatment, discouraging the disclosure of substance use issues and further endangering the military mission

Whether the zero-tolerance measures can be changed or confidentiality issues addressed through research, military members will inevitably continue being discharged from the military due to substance use issues. In doing so, it is vital to give our nation’s veterans every opportunity to succeed in this transition. Unfortunately, little to no research exists on the current discharge process for members exiting the military due to substance use issues. Therefore, the final recommendation is to evaluate these exit procedures and ensure the discharges provide not only the best footing for members to move forward in their own lives, but for the military to ensure these discharges are truly ensuring the readiness of our military. Discharging members from the military is expensive, and others must be recruited and trained in their place. Additionally, those new recruits may just as well follow the same path out.

If these recommendations can be thoroughly analyzed and researched, more recovery will be seen within the ranks of our military. When military members have the opportunity to recover, not only are they able to preserve their own careers, but they will have the understanding to help others in the military who find themselves struggling with addiction.

References

Alcoholics Anonymous (AA). (2001). Alcoholics Anonymous (4th ed.). New York, NY: Alcoholics Anonymous World Services.

Back, S. E., Killeen, T., Foa, E. B., Santa Ana, E. J., Gros, D. F., & Brady, K. T. (2012). Use of an integrated therapy with prolonged exposure to treat PTSD and comorbid alcohol dependence in an Iraq veteran. The American Journal of Psychiatry, 169(7), 688–91.

Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2008). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: Guilford Press.

Jerry “Woody.” May 4, 2010. Unknown medallion. [Photograph] Retrieved from https://www.flickr.com/photos/9816248@N03/4576712381

LaKind, J., Sericano, J., & Still, K. R. (2012). Substance use disorders in the US armed forces. Retrieved from http://nationalacademies.org/hmd/~/media/Files/Report Files/2012/Military-SUD/SUD_briefingslides.pdf

Office of the Under Secretary for Personnel and Readiness (OUSPR). (2017). Military drug program historical timeline. Retrieved from https://prhome.defense.gov/ForceResiliency/DDRP/Timeline/

The Management of Substance Use Disorders Working Group (MSUDWG). (2015). VA/DOD clinical practice guideline for the management of substance use disorders. Retrieved from https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf

US Department of Defense (DOD). (2011). Comprehensive plan on prevention, diagnosis, and treatment of substance use disorders and disposition of substance use offenders in the armed forces. Washington, DC: Office of the Under Secretary of Defense.

US Department of Defense (DOD). (2012). Department of Defense instruction 1010.01. Retrieved from http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/101001p.pdf