Substance Use Disorders in the U.S. Armed Forces
A whistleblower incident at a U.S. Army base in the Midwest, coupled with rising rates of alcohol and prescription drug abuse, raised Congressional concern about substance abuse within the armed forces. Like many sectors of society, the U.S. military has a long history of alcohol and other drug misuse and abuse. Substance use disorders extend to all branches of the military and can be exacerbated by deployment. In recent years, the face of the issue has been transformed by skyrocketing prescription painkiller use. Military physicians wrote nearly 3.8 million prescriptions for pain medication in 2009, more than quadruple the number of such prescriptions written in 2001. Some have attributed these trends to combat-related injuries and strains from carrying heavy packs, body armor, and weapons over mountainous terrain during multiple deployments.
In order to better understand current substance use problems within the U.S. military, the Department of Defense (DoD) asked the Institute of Medicine (IOM) to analyze policies and programs that pertain to prevention, screening, diagnosis, and treatment of substance use disorders (SUDs) for active duty service members in all branches, members of the National Guard and Reserve, and military families. The IOM committee presents its findings and recommendations in Substance Use Disorders in the U.S. Armed Forces.
A Public Health Crisis
The DoD and individual military branches—the Air Force, Army, Marine Corps, and Navy—have developed and implemented policies to manage substance use, some dating back to the Vietnam era. Because substance abuse impairs military readiness, DoD policy sets high standards for performance and discipline and consequently strongly discourages heavy drinking, illicit drug use, and tobacco use by members of the military.
Yet 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. The IOM asserts that the highest levels of military leadership must 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.
Additional structural changes involve prescribers, who should routinely check local prescription drug monitoring programs before dispensing medications with high abuse potential. Health care professionals also should be trained to recognize worrisome patterns of prescription drug use and medication-seeking behaviors and should be given clear guidelines for referral to specialty providers. Routine screening for unhealthy alcohol use and mechanisms to support brief interventions would permit health care professionals to point out the risk of excessive alcohol consumption. Placing such interventions within the familiar context of primary care would reduce the stigma attached to seeking care for substance use disorders.
Since the start of the wars in Iraq and Afghanistan, alcohol abuse among returning military personnel has spiked. In 2008, nearly half of active duty service members reported binge drinking. (See chart.) Among the environmental changes endorsed by the committee are curbing easy access to relatively inexpensive alcohol on military bases through consistent enforcement of regulations on underage drinking—especially important because a considerable portion of military personnel are younger than the legal drinking age. The committee also recommends paring down the number of outlets that sell alcohol, restricting their hours of operation, and reducing the type and amount of alcohol purchased.
In addition to seeking to reduce binge drinking and DUIs, the committee recommends that military leaders encourage members to seek help. The IOM committee identifies a number of barriers that limit access to substance use disorder care—including availability, gaps in insurance coverage, stigma, fear of negative consequences, and lack of confidential services—and recommends remedies for each.
For example, the committee applauds the Army’s implementation of the Confidential Alcohol Treatment and Education Pilot, which demonstrated that active duty service members use confidential treatment when given the opportunity to do so. The committee recommends that such programs be expanded within the Army and to the other military branches as well. Delivering such services without taking disciplinary actions promotes better care, builds troop resilience, and encourages individuals to seek help rather than hide problems.