M t l H lth d S b t Mental Health and Substance Use Disorders

Unique Aspects in Military PersonnelPersonnel

Russell D Hicks M DRussell D. Hicks, M.D.Madigan Army Medical Center

Department of PsychiatryDepartment of Psychiatry

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Co-Occurring Disorders & Treatment Conference October 4, 2010 Yakima, WA

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DISCLAIMER

The views expressed in this presentationThe views expressed in this presentation do not necessarily represent the views, policies, and positions of the Department p , p pof Army or Department of Defense.

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ONGOING COMBAT OPSONGOING COMBAT OPSTAKING TOLL ON TROOPS

"We've been at war for nearly 8 years. That has undeniably put a strain on our people & our equipment. Unfortunately, in a growing segment of the Army's population, we have seen increased stress & anxietypopulation, we have seen increased stress & anxiety manifest itself through high risk behavior, including acts of violence, excess use of alcohol, drug abuse, & reckless driving “reckless driving.“

GEN George W. Casey, Jr.Chief of Staff of the Army

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Alcohol is a Risk Factor Alcohol use complicates recovery from PTSD & clinical Depression

• 60% of Soldiers with PTSD have a co-occurring alcohol/drug se disorder* ( data from Madigan Intensi e O tpatientuse disorder* ( data from Madigan Intensive Outpatient

Program) Heavy alcohol use is present in almost half of all

completed Soldier suicides.p • Misuse of alcohol is common after returning from war;

27% of Soldiers screen positive for alcohol misuse onanonymous post-deployment surveys.anonymous post deployment surveys.

17-18% of senior enlisted & officers screen positive for alcohol misuse on anonymous surveys

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Soldiers who drink too much areSoldiers who drink too much area HIGH RISK GROUP Screen NEG Screen POS Suicidality* 0.4% 2.4% Depressive sx* 7.7% 30%p Aggressive Ideation* 1.5% 7.2% Drove after drinks** 9.1% 33.0% Rode with driver who Rode with driver who drank too much** 6.8% 30.0% Late or missed work** 1.3% 11.2%

(drinking related)

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**Anonymous data from Land Combat Study

Fig re 36 Acti e D t S icide Rate b Calendar Figure 36 – Active Duty Suicide Rate by Calendar Year, 2003-2009

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Active Duty Suicide Deaths (CY 2003-2009)

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In a recent briefing, the Army In a recent briefing, the Army Surgeon General:

almost 14% (76,463) of the force were prescribed some form of an opiate drug. • 95% (72,764) were on oxycodone. • 34% (25,761) had two or more active

prescriptions.

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Army Installations NortheastFort

Yakima TrainingCenter

Northwest

Tobyhanna Army Depot

Carlisle B k

Charles E. Kelly Spt Fac

Fort Drum

West Point Fort Monmouth

Picatinny Arsenal

Watervliet Ars Ft. Hamilton

Natick R & D Ctr

USA Cold Reg Lab

Fort Devens RFTA (USAR)

Northeast

Detroit Ars

USAG Selfridge

Fort McCoy (USAR)

LewisCenter

Umatilla Chem Depot

Vancouver Barracks (USAR)

R k I l d

F t

Aberdeen Proving Ground

Fort Story

Fort Lee

Fort EustisFort Monroe

Ft. AP Hill

Radford AAP

Letterkenny AD

Barracks

Fort McNair

Ft. Meade

Fort

Walter Reed

Ft Detrick

Adelphi Lab Ctr

Kelly Spt Fac (USAR)

MonmouthFort Dix (USAR)

Fort

Blue Grass AD

Presidio of Monterey

Riverbank AAP

Sierra Army Depot

Hawthorne AD

Camp Parks (USAR)

Fort Hunter Liggett

Lima Army Tank Plt

Fort Leonard Wood

Fort RileyFort Leavenworth

Iowa AAP

Kansas AAP

Lake City AAP

Dugway Proving Ground

Pueblo Depot

Fort Carson

Tooele AD

Deseret Chem Depot

Rock Island Arsenal

Fort Belvoir

Myer

Fort McPherson

Fort Gordon

Fort Hunter Army Airfield

Fort Jackson

Fort Campbell

Knox

Redstone Arsenal

Fort Benning

Fort Rucker

Anniston AD

Ft. Gillem

Milan AAP

Holston AAP Fort BraggMOT Sunny Point

Fort Irwin

Yuma Proving Ground

Fort Hauchuca

gg(USAR)

White Sands Missile Testing Center

Fort Sill

Fort Bliss Fort Hood Fort

Polk

Pine Bluff Ars

McAlester AAPRed River

ADLone Star AAP

Louisiana AAP Director Locations

NE: Ft MonroeSE: Ft McPhersonNW R k I l d AFort

StewartAirfield

Ft Buchanan, PR

Rucker

Mississippi AAP

Camp Stanley Storage Actv

Fort Sam Houston

Corpus Christi AD

SoutheastSouthwest

Fort Wainwright

Fort Richardson

Ft. Greely

Pacific

Tokyo/YokohamaAkizuki/KureZama/Sagamihara

NW: Rock Island Ars SW: Ft Sam HoustonEurope: HeidelbergPacific: Ft ShafterKorea: Yongsan

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Overseas: EuropeKorea

Fort ShafterSchofield

Barracks

OkinawaKwajalein

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Army Values Every soldier needs to demonstrate

the Army core Values in his/herthe Army core Values in his/her personal behavior.

• On and off duty.

• On and off post.

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• 24 hours a day, 7 days a week.

Rank / Grade

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Program EvolutionProgram EvolutionProgram EvolutionProgram Evolution

Army RegulationPublic Law DoD Directive 1010.1 Army Regulation 600-85 2 Feb 2009Army Substance

Public Law 92-12928 Sep 1971Established drug

DoD Directive 1010.1 9 Dec 1994 - Drug Abuse Testing Program.

Army Substance Abuse Program (ASAP)*

Established drug prevention and control programs in the Armed

DoD Instruction 1010.16 9 Dec 1994 - Technical Procedures for the

* Formally known as Alcohol and Drug Abuse Prevention C l P

in the Armed Forces. Military Personnel Drug

Abuse Testing Program.

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Control Program (ADAPCP)

Army Regulation 600–85Army Regulation 600 85

The Army Substance Abuse ProgramDepartment of the Armyp y

Washington, DC2 February 20092 February 2009

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Army Substance Abuse ProgramArmy Substance Abuse Program

VISIONA program that …

• … Commanders identify as their own, to empower them with the knowledge and skill toempower them with the knowledge and skill to recognize and reduce risk in their units, and to provide their Soldiers access to appropriate and effective prevention and treatment;

• … enables Soldiers to recognize the risks of substance abuse in order to self-monitorsubstance abuse in order to self monitor, provide support to their fellow Warriors, and encourages them to seek help without ti ti ti

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stigmatization.

Army Substance Abuse ProgramArmy Substance Abuse ProgramO i ti i t 1 O t 2010O i ti i t 1 O t 2010Organization prior to 1 Oct 2010Organization prior to 1 Oct 2010

Garrison Commander M di l T t t F ilitGarrison Commander Medical Treatment Facility Commander

Director Human Resources

Alcohol & Drug Control Officer(ADCO)

ClinicalDirector

(CD)

Medical Review Officer (MRO)

Employee InstallationDrug and Alcohol

Counselors

p yAssistanceProgram

Coordinator(EAPC)

BiochemicalTest

Coordinator (IBTC)

PreventionCoordinator

(PC)

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(EAPC) (IBTC)

Army Substance Abuse ProgramArmy Substance Abuse ProgramO i ti AFTER 1 O t 2010O i ti AFTER 1 O t 2010Organization AFTER 1 Oct 2010Organization AFTER 1 Oct 2010

Garrison Commander M di l T t t F ilitGarrison Commander Medical Treatment Facility Commander

Director Human Resources

Alcohol & Drug Control Officer(ADCO)

ClinicalDirector

(CD)

Clinical Consultant (CC)

Employee Installation

Medical Review Officer (MRO)

Drug and Alcohol

Counselors

p yAssistanceProgram

Coordinator(EAPC)

BiochemicalTest

Coordinator (IBTC)

PreventionCoordinator

(PC)

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(EAPC) (IBTC)

Guiding Principles

The Army Substance Abuse Program is a command program that emphasizes readiness and personal responsibilityreadiness and personal responsibility.

The command role in prevention, biochemical testing early identificationbiochemical testing, early identification, rehabilitation and administrative or judicial actions is essential.

Commanders will ensure that all officials and supervisors support the ASAP.

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ASAP MissionASAP MissionAR 600-85, 1-6

To Conserve the Fighting Strength To prevent, identify, & provide definitivep , y, p

clinical care for drug & alcohol problemsthat can potentially compromise readinessthat can potentially compromise readiness& adversely affect the well-being ofS ldi & th i F iliSoldiers & their Families

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Alcohol Incident Policy

Alcohol related incidents:– Referred for screening – Considered for disciplinary action under UCMJ

An administrative separation action will be processed for– An administrative separation action will be processed for Soldiers involved in two serious incidents of alcohol related misconduct in a year

– Alcohol Related Incidents (Misconduct) include but are not li it d tlimited too: Impaired on duty DWI/DUIs Underage drinkingg g Providing alcohol to someone under 21 Negative incident involving alcohol – fighting, child or spouse

abuse etc.

Drug PoliciesSoldiers identified as drug abusers – using

illegal drugs, using someone else’s prescribed drugs or abusing your own prescriptiondrugs or abusing your own prescription.

– Referred for screening at ASAPC id d f di i li ti d UCMJ– Considered for disciplinary action under UCMJ–Courts-Martial–Article 15

– Processed for administrative separation

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Army Substance Abuse Program FunctionsArmy Substance Abuse Program Functions

Prevention: Education TrainingPrevention: Education, Training, Campaigns and Intervention, Risk Reduction, Employee Assistance Program and Deterrence through Random

Treatment: Screening, Biopsychosocial Assessment, Counseling

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Deterrence through Random Drug Testing Services.

Army Substance Abuse Program

Challenge Initiative

Responsible Drinking Campaign

Culture of Acceptance

Army Values Social Marketing Campaign

18 – 25 Year Olds

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Marketing Campaign

Army Substance Abuse Program

Challenge InitiativeConfidential Alcohol Treatment &

Fear

Education Pilot (CATEP)

Fear

Stigma Study

Meeting Demand

Increase ASAPN ti l C i

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- National Campaign- Increase Incentives

ASAP Principles Abuse of alcohol or use of illicit drugs by

both military and civilian personnel is inconsistent with Army values, standardsinconsistent with Army values, standards of performance, discipline, and the readiness necessary to accomplish the Arm ’s missionArmy’s mission.

AND The Army recognizes that substance abuse The Army recognizes that substance abuse

and dependency are preventable and treatable.

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AR 600-85 3–2. PolicyAl h l b d l i i d illa. Alcohol abuse and resulting misconduct will not be condoned. On-duty impairment due to alcohol consumption will not be tolerated. Impairment of Soldiers is defined as having a blood alcohol content equal to or greater than .05 grams of alcohol per 100 milliliters of gblood.

j. To remain in the Army, all Soldiers who are identified as alcohol abusers mustidentified as alcohol abusers must successfully complete an ASAP education and/or rehabilitation program. Soldiers who fail to be rehabilitated will be processed for

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to be rehabilitated will be processed for separation…

Army Regulation 600-85 Army Regulation 600 85 2–37. All Soldiers Will---

a Be responsible for their personal decisions relating a. Be responsible for their personal decisions relating to alcohol and drug use and be fully accountable for substandard performance or illegal acts resulting from such usefrom such use.

b. Encourage Soldiers suspected of having an existing or possible alcohol or drug abuse problem to seek assistanceseek assistance.

c. Be prepared to provide a copy of any prescription or medical treatment involving controlled substances received from any medical personnel outside thereceived from any medical personnel outside the military medical system for at least 6 months after receiving such prescription or medical treatment.

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7–2. Methods of identification7 2. Methods of identification

(1) Voluntary (self) (2) Command ( ) (3) Drug testing (4) Alcohol testing (4) Alcohol testing (5) Medical

(6) I ti ti / h i (6) Investigation/apprehension.

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Limited Use Policy

Objectives:

Encourage Soldiers to self refer for Encourage Soldiers to self refer for substance abuse problems.

To facilitate the treatment and To facilitate the treatment and rehabilitation of those identified abusers who demonstrate theabusers who demonstrate the potential for rehabilitation and retention.

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10–11. Limited Use Policy

Protected evidence under this policy is limited to:• I f ti i d l h l b i• Information concerning drug or alcohol abuse prior

to the date of initial referral to the ASAP

• Limited Use Policy does not prevent a counselor from revealing, to the appropriate authority, knowledge of illegal acts, which may have anknowledge of illegal acts, which may have an adverse impact on mission, national security, or the health and welfare of others.

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8–7. Rehabilitation levels

a. Level I. Non-Residential/Outpatient Rehabilitation.• Each Army Post– 1 counselor: 2000 Soldiers

b. Level II. Partial Inpatient/Residential pTreatment• Eisenhower Army Medical Center, Augusta, GA• Tripler Army Medical Center, Honolulu, HI • Landstuhl Army Medical Center, Germany

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Typical Enrollment: Referral by Command for an Alcohol-Related

Incident or Self-Referral Evaluation by ASAP Counselor Evaluation by ASAP Counselor Rehabilitation-Team Meeting with Command Recommendations: Recommendations:

• No diagnosis or mild Abuse– Education• Abuse- 6 week course – CBT • D d CBT• Dependence- CBT

• 12 week course • Intensive Outpatient

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• Residential or Partial Hospitalization

Confidentiality

Commanders seeking information from an individual’s ASAP record must specify their need to know specific information Theirneed to know specific information. Their request must be made to the responsible Clinical Director for proper release ofClinical Director for proper release of information.

Commanders do not have unlimited access to review a client’s ASAP counseling notes or records.

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ASAP Policy Sumary ASAP Policy Sumary AR 600-85, 1-7

ASAP i C d C d– ASAP is a Command program. Commandinvolvement is NOT optional.

– Active participation is mandatory for all– Active participation is mandatory for all Soldiers enrolled in ASAP treatment.

– Soldiers who fail to comply with or respondsuccessfully to ASAP treatment will be processed for administrative separation from military service. y

Honorable Discharge- Chapter 9

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Under current ASAP policy…E ll i ASAP f ll f h h i Enrollment in ASAP treatment falls far short those in need of ASAP treatment.

f S f– Majority of ASAP referrals are NOT self-referrals

Senior NCOs & Officers are dramatically Senior NCOs & Officers are dramatically underrepresented because of fear that there will be a negative impact on their career

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Research Triangle InstituteResearch Triangle InstituteStigma Study– ASAP treatment is associated withASAP treatment is associated with

response to alcohol-related incidents– 40% of Soldiers believe that their careers

ill b h d if th i t t t fwill be harmed if they are in treatment for alcohol abuse

– Lower-enlisted feel they are easily y yreplaced if their fitness is questioned

– NCOs and officers believe treatment is a “career killer”career killer

• Confidentiality is an issue for all Soldiers

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Madigan Army Medical Madigan Army Medical Center

Intensive Outpatient Intensive Outpatient Program

(IOP)(IOP)(“Day Hospital Program”)

A Proactive Mental HealthA Proactive Mental Health Treatment Program

Russell D. Hicks, M.D.

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Program Origins

Average daily inpatient census tripled six months after the initiation of combat.

Increase in poorly stabilized patients with:• severe depression • Post Traumatic Stress Disorder

Th th d f lt ti tThus the need for an alternative to

INPATIENT TREATMENT

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IOP Overview The program is intended The program is intended

for service members who are having difficulty with any stress-relateddifficulty with any stress related issues that prevent them from functioning effectively g y

AND/ORare not responding to weekly a e ot espo d g to ee y

psychotherapy or recently required an acute psychiatric hospitalization for

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stabilization..

Mission Statement

A program to shorten or prevent psychiatric hospitalizations

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Mission StatementMission Statement(official)

A program to shorten or prevent psychiatric hospitalizations

Mission Statement(Operational)(Operational)

A program that serves as safe place f iti ti l thfor positive emotional growth

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Emphasis on total emotional health

Primary Diagnosis

16%13%

PTSD14%

PTSDPersonality DisorderDepression

4%

1%

Adjustment DisorderBipolar DisorderP h i Di d

46%1%

4%

Psychotic DisorderAnxiety Disorder

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46% 4%

SUBSTANCE USE DISORDERSUBSTANCE USE DISORDER

33%

67%67%

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Confidential Alcohol Treatment E l ti P (CATEP)Evaluation Program (CATEP)

R d i f b b• Reduce stigma of substance abuse treatment

• Improve access to ASAP treatment for ALL Soldiers– not just the junior enlisted who have already gotten in trouble

E i d d S ldi t bt i• Encourage career-minded Soldiers to obtain care

• Provide earlier interventions for Soldiers in need BEFORE problem adversely impacts…– finances, health, relationships, social functioning or

a military career

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CATEPCATEP

Soldiers who self refer to the ASAP with alcohol (orSoldiers who self-refer to the ASAP with alcohol (or drug) problems before they have an incident –NO REQUIREMENT FOR COMMAND NOTIFICATION PRIOR TO TREATMENT

• Implementation: Schofield Barracks Hawaii 06 July 09– Schofield Barracks, Hawaii 06 July 09

– Fort Richardson, Alaska 17 Aug 09– Fort Lewis Washington 24 Aug 09Fort Lewis, Washington 24 Aug 09• Feb 2010- extent to addition sites-firm

decision in 12 months

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dec s o o t s

Thresholds forThresholds forCommand Notification

– The Soldier has an alcohol-related incident that mandates a Command referral to ASAP (e.g. arrest for DUI, EtOH-related family violence, etc.)

The Soldier abuses illegal substances or prescription medications– The Soldier abuses illegal substances or prescription medications (+ UDS)

– The Soldier’s behavior or condition• Constitutes a safety risk (potential threat to self or others)• Constitutes a safety risk (potential threat to self or others)• Constitutes a security risk• Causes impairment to his fitness for performance of duty• Constitutes or contributes to a serious medical or psychiatric• Constitutes or contributes to a serious medical or psychiatric illness; or• Requires very intensive outpatient treatment, inpatient treatment, or hospitalization for medical management of complicated

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or hospitalization for medical management of complicated alcohol withdrawal symptoms.

CATEP -RESULTS

• 45% diagnosed as Alcohol Dependence

– These are Soldiers that would not have seen before an Alcohol-relatedseen before an Alcohol-related incident had occurred

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CATEP-RESULTS

– Only 3.5% of those with Alcohol Dependence did NOT complete the treatment program

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CATEP SCATEP Surveys

Commanders (n = 10)– Commanders (n = 10)• CATEP career protections are an

important component of the program ifimportant component of the program if NCOs &officers are to get help for alcohol problemsproblems

• CATEP privacy protections are an important component of the programsp p p g

• It is better for Soldiers to get help, even if their commander is unaware, than for

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them to get no help at all

ASAP Counselor Observations• Policy changes are “doable”• Policy changes are “the right thing to do for Soldiers”• No complaints from Soldiers’ commandersp• CATEP Soldiers are more motivated & active intreatment than standard ASAP Soldiers

More self disclosure over shorter period– More self-disclosure over shorter period– More intense & active participation in their own

recovery– More likely to involve family members in their

recovery efforts

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CATEP - Summary

• CATEP reached soldiers who would not have presented as early

Soldiers were cooperative with treatment recommendations

Commanders were supportive Overcoming STIGMA is still difficult Overcoming STIGMA is still difficult

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OTHER ARMY PROGRAMS:

Specialized Care Program Track II at the Deployment Health Clinical Center (DHCC) of Walter Reed

• Intensive 3-week multidisciplinary treatment program forIntensive, 3-week, multidisciplinary treatment program for returning service members with deployment-related behavioral health concerns

• Goal of reducing co-occurring health concerns such asGoal of reducing co-occurring health concerns, such as depression, substance abuse, and domestic violence

• Access to other referral sources within the Walter Reed systemsystem

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DOD DRUG TESTING PROGRAM

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Military Personnel Drug Testing Military Personnel Drug Testing Program ---- OBJECTIVES: (1) Deter Soldiers from abusing drugs (including illegal (1) Deter Soldiers from abusing drugs (including illegal

drugs, other illicit substances, and prescribed medication).

(2) Facilitate early detection of drug abuse (2) Facilitate early detection of drug abuse. (3) Enable commanders to assess the security, military

fitness, good order and discipline of their units, and to use information obtained to take appropriate disciplinaryuse information obtained to take appropriate disciplinary or other administrative actions, including referral to the ASAP counseling center for evaluation and possible rehabilitation.

(4) Monitor rehabilitation of those enrolled in alcohol and/or other drug abuse rehabilitation.

(5) Collect data on the prevalence of drug abuse within

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(5) Collect data on the prevalence of drug abuse within the Army.

Military Personnel Drug Testing Military Personnel Drug Testing Program ----

Commander will randomly select and test Soldiers at least monthly

Soldiers will be observed – must see the rine lea ing the bodurine leaving the body

O l th S ldi d th U it P ti Only the Soldier and the Unit Prevention Leader (UPL) will touch the specimen bottle

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Drug TestingAll specimens are tested for: All specimens are tested for:

• THC, Cocaine, and amphetamines and heroin.

• At least 2 other drugs on a rotational basis including LSD, PCP, opiates and synthetic opiates-(oxycodone/hydrocodone)(oxycodone/hydrocodone)

• Soldiers testing positive for amphetamines, opiates or synthetic opiates will be referred to a Medical Reviewsynthetic opiates will be referred to a Medical Review Officer (MRO to determine if the positive is due to legal (prescription) use or illegal use/prescription abuse

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61Madigan Army Medical Center

Questions?

Russell D. Hicks, M.D.Colonel (Ret) USA

Russell.D.Hicks@us.army.mil62

Risk Reduction Program

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Types of alcohol energy drinksTypes of alcohol energy drinks

Joose Sparks Sparks Four Loko Rock Star 21

Tilt Tilt Liquid Charge Liquid Core Bud Extra Tourque Catalyst Catalyst 24/7

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Flavor is similar to standard energy drinks such as Red Bull, Monster Energy, and Rockstar, with a tart, sugary taste