IOM Calls for Better SUD Treatment in the Military

A report from the Institute of Medicine (IOM) details
failings by the military in providing treatment for substance
use disorders (SUDs) for troops and veterans.

The 351-page, heavily footnoted report, “Substance
Use Disorders in the U.S. Armed Forces,” says that there
are access problems, particularly for members of the
Reserves and the National Guard who have constituted
so many of the troops in Iraq and Afghanistan.

It also says that the system discourages troops from
seeking treatment because they are afraid of discipline,
and that certified counselors don’t have the
training required to help this population due to the
high prevalence of co-occurring SUDs and mental
illness. Finally, the report charges that the military approach
to alcohol problems is very different — “disconcertingly”
so — from its approach to problems with
other drugs, with little effort to prevent alcohol use
disorders or to utilize screening and brief intervention
for drinking. Rather, the culture is one that promotes

The report, released September 17, came from the
Committee on Prevention, Diagnosis, Treatment and
Management of Substance Use Disorders in the U.S.
Armed Forces. The Department of Defense (DoD)
asked the IOM to look at the treatment system in each
of the branches: Air Force, Army, Navy and Marine

The problem of alcohol and drug abuse is not only a
health problem for troops; it’s also a readiness problem
for the military. The report looked not only at
active duty service members (who are covered by Tricare),
but also at members of the National Guard and
Reserves, and at military dependents.

The report found that SUD treatment is usually provided
in inpatient settings, which is not the “standard of
practice in modern SUD treatment.” Instead, the report
said, treatment continuity and the amount of time
someone is in outpatient treatment is “more important
than the provision of care in residential settings.” The
IOM cites its own 2006 report to back up these claims.
There was sharp criticism of the military for not providing
access to medication-assisted treatment, including
with agonists like methadone and buprenorphine.
And there is little integration of SUD treatment into
primary care.

The VA/DoD Clinical Practice Guideline for Management
of Substance Use Disorders issued in 2009 is an
“excellent guide,” but it is not being used systematically,
the report said.

Each branch operates its SUD services without being
accountable to DoD, the report found recommending
that DoD “acknowledge that the current levels of substance
use and misuse among military personnel and
their dependents constitute a public health crisis.”
The report also said that the military had to use only
licensed providers (such as psychologists and psychiatrists)
and that while “individuals certified as alcohol
and drug counselors remain a key component of the
civilian workforce treating SUDs, their role is increasingly
limited and in the near future may disappear.”

Organizations representing certified counselors reacted
to that statement. “We have been getting more
and more master-level civilians within and outside of
the U.S. who state they are being encouraged or required
to obtain the MAC,” said Shirley Beckett Mikell,
who is in charge of the certification program run by
NAADAC, the Association for Addiction Professionals.

On average, there have been 10 new applicants for the
MAC (Master Addiction Counselor) credential, which
has been administered by NAADAC since February of
this year. More than one-half have been from foreign
bases, she said.

And from the federal advocate for the IC&RC: “IC&RC
commends the IOM for this undertaking,” said Andrew
Kessler, principal with Slingshot Solutions. “But we are
confused by some of the conclusions about the workforce.
Any counselor trained by the Navy at their facility
in San Diego has to pass an IC&RC exam.” The exams
are updated every three to four years, he said.
Go to for the report.


By Alison Knopf

IOM calls for better SUD treatment in military was first
published in Alcoholism & Drug Abuse Weekly Volume
24, No. 36, September 21, 2012.