Military Culture and Substance Use Disorders

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1 Military Culture and Substance Use Disorders LTC John Rodolico Chief of Behavioral Health MA National Guard Mr. Timothy Sawyer Alcohol and Drug Control Officer MA National Guard

2 Objectives What are the signature illnesses of the Operation Iraqi Freedom/Operation New Dawn/Operation Enduring Freedom (OEF/OIF) conflicts? Give an understanding of the Military Culture What research advances are being developed to reduce substance use disorders and improve quality of life for soldiers

3 A New Generation of Veterans

4 Military Culture

5 Reasons for Joining the Military Patriotism: for the service member this is in line with Merriam-Webster s dictionary, love and devotion to one s country Sense of belonging: one large community or simply put a massive club Family tradition: military service goes on for generations, it s the thing to do in some families Better life: Education, increase standard of living, ect.

6 Norms, Values, and Tradition in Military Culture Group over individual needs, ALL THE TIME A necessity in military service to increase unit cohesion and morale, a big part of resiliency Important concept for clinicians to recognize group over individual when working with Service Members. Clinicians may be supporting a person s individuality and the SM may become defensive

7 Hierarchical Class System The lines of authority and command structure is important to military tradition and courtesies This system is not created to develop haves and have not s but to make delegating easier and transparent accountability It s important to learn where the SM stands in this hierarchy to better understand their presenting problem

8 ARMY VALUES Loyalty Duty Respect Selfless Service Honor Integrity Personal Courage

9 Language of Their Own Example Basic understanding is important but don t be shy about asking Don t suggest faking it but asking what things mean usually enhances the the therapeutic alliance Language is important in treatment and it needs to be clear

10 Strong Values of Service One can t understand the mind set and motivation of a soldier without understanding the value based system of military culture The clinician must appreciate and acknowledge this value-based life The clinician might have strong values about war and authoritative lines of responsibility this can interfere with engaging the soldier

11 Solution Focused During the initial part of training the soldier is taught how to problem solve Soldiers are required to be solution focused and are taught that every problem can be solved with the right amount of time and effort A directive approach will go a long way, nondirective could backfire

12 Show No Weakness Stoicism is a valued trait in the military (Stoic Warrior) Associated with strength, emotional control and calmness under pressure One of the triggers for seeing metal health treatment as a weakness Important that the clinician be cognizant to the stoic-warrior mind set which is highly adaptive in a military environment This mind set should not be seen as resistance or part of a pathological rigidity

13 Coming Home

14 Special Considerations of the Current OEF/OIF Conflict More than 6,712 deaths and 52,032 wounded in action as of May 31, 2014 The proportion of wounded surviving severe physical injuries is higher than previous conflicts, e.g. Vietnam Better personal protection (Body armor) Better battlefield medicine Quicker evacuation to trauma centers

15 More Psychological Stress No safe place in war zone Widespread use of IEDs by the enemy Bases are not secure Repeated deployments Personnel are older, suffer greater losses and isolation with deployment Interruption of careers Effects on spouses/children Greater awareness of issues and problems at home

16 Signature Illnesses of Operation Enduring Freedom / Operation Iraqi Freedom (OEF/OIF) Post-traumatic Stress Disorder Traumatic Brain Injury Substance Abuse and Dependence Traumatic Amputations

17 Substance Use Disorders Are Common In the general population 35% of men and 18% of women have a substance use disorder Amongst men with PTSD 52% develop an alcohol use disorder (abuse or dependence), 35% develop a drug use disorder Amongst women with PTSD 28% develop an alcohol use disorder (abuse or dependence), 27% develop a drug use disorder

18 More Substance Abuse Population Percent SUD Source: General Population 3-4.7% Alcohol Abuse National Comorbidity Survey Replication % Current SUD National Comorbidity Survey Replication 2005 Veterans 7.1% Current SUD National Survey on Drug Use and Health Returning Iraq Vets 12%Alcohol abuse or dependence Hoge et al., JAMA 2007

19 PTSD and Addictive Disorders High rates of comorbid PTSD and SUDs were first reported in Vietnam vets, in which 75% of combat veterans with lifetime PTSD also met criteria for alcohol abuse or dependence. (Kulka RA, et al: Report of Findings From the National Vietnam Veterans Readjustment Study. 1990). In the ECA study, the lifetime rate of PTSD was 7.8%. Among men with PTSD, 34.5% reported lifetime drug abuse or dependence versus 15.1% of men without PTSD. For women, 26.9% with a lifetime history of PTSD reported lifetime drug abuse or dependence versus 7.6% of women without PTSD (Kessler RC, et al: Arch Gen Psychiatry 1995; 52: ). For both combat veterans and civilians, the onset of PTSD typically precedes the onset of substance use disorders. (Bremner, Am J Psychiatry 1996) (Chilcoat, Arch Gen Psych 1998)

20 Longitudinal Course of Substance Abuse After Trauma Exposure

21 Barriers to Care: Systems Integration Disconnection between PTSD/mental health care delivery system/professional training programs, and traditional chemical dependence treatment system Clinicians typically undereducated in 1 of the 2 clinical domains Patients with both addictive and other mental health disorders are typically under-diagnosed and almost certainly under-treated

22 Summary PTSD, TBI, Substance Abuse and Traumatic amputations are the signature illnesses of the current OEF/OIF wars and will outlast the active conflict Active research is being translated to clinical care to reduce disability and to improve the quality of life of injured combat veterans

23 Substance Abuse Program

24 SAP Overview: Substance Abuse Program The ARNG has the highest illicit positive drug rate, surpassing both the Active Army and the Army Reserves. Currently, the Army Substance Abuse Program (ASAP) covers ARNG Soldiers, but the illicit drug positive rate indicates these ASAP processes are less effective for those in the Army National Guard. The ARNG Substance Abuse Program is designed to provide a continuum of substance abuse services to Soldiers that will achieve and maintain ARNG Soldier Readiness. These services include: Prevention Assessment

25 Substance Abuse Program What We Do: Provide training, knowledge, and resources to help Soldiers overcome alcohol and drug use, abuse and dependencies, as well as, provide Prevention Education designed to help guard members and their families maintain healthy lifestyles. Serving as a Subject Matter Expert regarding doctrine, policy, and training directly related to substance abuse issues. Serve as the key point of contact and coordinator of resources for soldiers and units.

26 Substance Abuse Program 4.50% 4.00% 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 4.26% 3.65% DATPOS FY14 and FY13 Comparison YTD 1.94% Cleared MRO 1.38% NOTE: Limited OCT Testing in FY % 0.47% 0.10% 0.12% Limited Use Open MRO 1.84% illicit DATPOS 1.68% FY 14 FY 13

27 Substance Abuse Program Limited Use Policy Purpose: Encourage those who need help with a substance abuse problem, or those abusing drugs or alcohol, to self-refer so they can get help. Protected Evidence: Limited Use Policy prohibits the use of evidence against a soldier in courts-martial proceedings, UCMJ action, and determination of characterization of service. Separation: No separation action is required by the Commander. If administratively discharged, the member will receive an Honorable Characterization of Service. Qualifications: Self-refer to commander, NCO or officer in chain of command, chaplain, or JSAP office Must not have knowledge of a pending drug or alcohol test Provide commander with facts and circumstances of the use Be evaluated by a state-certified treatment counselor Follow all recommendations of the treatment counselor Sign consent to release treatment information 27

28 Substance Abuse Program Limited Use Policy cont. WHAT THE LIMITED USE POLICY DOES NOT DO: Is not a Get out Jail Free Card for a unit urinalysis. Once a soldier is notified of a urinalysis, it is too late to self refer after that point. It does not protect a Service Member of future drug use of possession of drugs nor previous charges of illegal activities prior to Self-ID 28

29 Substance Abuse Program Prevention Training: M-Day - 2 hrs. / AGR - 4 hrs.- Annually Strong Choices: The Strong Choices training is a research-based drug and alcohol prevention program for the entire Army audience. It's not just for those who might have problems with drugs and alcohol it's also meant for people who never use drugs and alcohol. The Strong Choices program is not about what not to do It's about what you can do in order to be well, healthy, and strong; relate well with those important to you; work well with your team; and, live a well-balanced life with healthy pleasures and manageable stress. If you're a leader, the Strong Choices program is also about leading well and effectively. Strong Choices is made up of four modules for Soldiers, and a fifth only for Leaders. Each module explores ways in which substance abuse affects areas of your life. Once you've seen them all, you'll come away with a broad understanding of how your substance choices impact you.

30 SASI is a: Substance Abuse Program Substance Abuse Service Initiative Program Phased treatment model designed to help rehabilitate and retain deserving Soldiers who need substance abuse assistance during challenging times. Tool that allows commanders the ability to provide comprehensive assistance to deserving Soldiers at a critical point in their military career. The Substance Abuse Services Initiative (SASI) is a voucher program that pays for substance abuse services - assessments, short-term treatment and prevention training. SASI will provide a continuum of substance abuse services Which will promote Soldier Readiness Which will retain critical mission human capital for the war fight 30

31 Substance Abuse Program Why a SASI Program is Needed The current process for offering Substance Abuse services to ARNG Soldiers is not working. ARNG does not have services to offer ARNG Soldiers who may have substance abuse related concerns resulting from combat or state active duty. As members of the community, the ARNG must seek services within the complexity of their community. These services may not be easily visible, accessible or geared to the specific cultural needs of the ARNG. State Prevention Coordinators are often isolated from viable community based substance abuse resources for Soldiers due to competing demands and lack of community partnerships and support. There is limited capacity to provide prevention services prior to substance misuse. Currently, ARNG Soldiers must pay for substance abuse services either via private insurance or out-of-pocket. Most Guardsmen do not have either of these resources. 31

32 Substance Use Trends in the Military

33 Drug Use and the Military Culture Soldiers have used substances to reduce pain, fatigue, increase alertness, cope with boredom/panic that accompanies deployment since the Civil War It has been documented that 20% of Vietnam Veterans had used narcotics while deployed The military started random drug testing in 1981

34 Alcohol Use in the Military Culture As drug use decreased alcohol use remained the same and over the past few years increased Drinking in many respects is part of the culture, a culture that the military is trying to change The Dining In

35 Trends from 1980 to 2005 Drug use in the military significantly dropped Cigarette use also dropped and continues to do so. (This does not include all nicotine products) US military made great progress with illicit drug use, but lags with respect to alcohol use

36 Changing Trend in Drug Use

37 Drug Testing in the Military Positive Urinalysis Rates by Grade Grade FY06 FY07 FY08 E1-E4 3.73% 3.60% 3.94% E5-E6 0.90% 0.94% 1.05% Since the early 80 s drug testing has been a part of military life which has translated into a sharp decrease in drug use E7-E9 0.42% 0.49% 0.53% W1-W5 0.28% 0.24% 0.46% O1-O3 0.29% 0.31% 0.36% O4-O6 0.28% 0.26% 0.33%

38 Substance Use in the Theater of Operation General Order Number I: Alcohol is prohibited in the Theater of Operation (OEF) 8% of soldiers in OEF use alcohol & 1.4% use illegal drugs Increase abuse with prescribed medications Increase use of inhalant use

39 Military vs. Civilian Prescription Drug Misuse

40 Relationship of Drugs and Alcohol and Suicide

41 FY % / 123 Soldiers DATPOS 19 th Highest Nationally DATPOS % % % 0.38% 1.84% Cleared MRO Limited Use Open MRO 53 illicit DATPOS

42 FY14 and FY13 Comparison YTD DATPOS 56 Cleared MRO Limited Use 11 Open MRO illicit DATPOS 57 FY 14 FY 13

43 FY 14 TAG Adjudication Data DISCHARGED RETAINED OTHER

44 Increased testing rates Army- increased from 5% month/ 13% QTR to 10 % month/ 25% QTR Air- increased from 4% month/ 10% QTR to 9% per month SECDEF controls the quotas and is moving to testing every Service Member annually

45 REINTEGRATION Happiest day of a soldier s life Feelings of detachment, not belonging, the world went on without them Large variability between the RC vs. AC The soldier tries to use the same skills that they used in a combat situation to cope with adjustment

46 Reintegration Behaviors and emotions vary from soldier to soldier There is no set process for reintegration Simple tasks seem difficult Driving is not comfortable and often reckless Being irritable over small issues Not being comfortable around people Denial about the fact that they have changed as a person

47 Reintegration Family roles have shifted and have been reestablished Couples have learned to live apart and independent, a new relationship needs to be explored Losing developmental stages of a child s life Not knowing when to jump in with child discipline Mixed feeling of being overwhelmed with the responsibility of the family and bored with the mundane part of life

48 Change in the Military Culture

49 Comprehensive Soldier Fitness What we need to do, especially if you believe as I do that we are to continue to rotate Soldiers to combat for the next decade or so here, you need to bring mental fitness to the same level as we give physical fitness. - GEN George W. Casey Chief of Staff, Army

50 Holistic Approach to Mental Health Including Substance Abuse Emotional training the same way we treat physical training Every soldier receives a baseline assessment and will be targeted to work on their lower score Just as we would with a Army Physical Fitness Test

51 Resiliency Training Based on Martin Seligman s Positive Psychology model - Global Assessment Tool (GAT) - Self Development Modules - Institutional Resilience Training - Master Resilience Trainers Teaches Leaders to instill resilience in subordinates Platoon, Company, Battalion level: Soldiers Helping Soldiers Taught as civilian Institution short-term; TRADOC (Ft. Jackson) long-term MRTs will be at the BN, Brigade and Installation level

52 Successful Transitions Every Soldier will transition home in their own way. The key to a successful transition home is to adapt combat skills so that you are just as effective at home as you were in combat (resiliency). Build on the soldier s proven strengths.

53 Summary This is a new generation of veterans with different characteristics which means we need to adjust our treatment methods accordingly We will see the result of all combat stress reactions in many years to come particularly around psychological adjustment and addiction Continued collaboration between military and civilian research groups so all clinicians can understand the uniqueness of this population

54 Hear Their Story Let your heart feel for the affliction and distresses of everyone -- General George Washington, Leader of the Continental Army

55 Substance Abuse Program Massachusetts National Guard Substance Abuse Contact Information: Alcohol and Drug Control Officer (ADCO) Mr. Timothy Sawyer Cell: Substance Abuse Prevention Coordinator Mr. Herb Shipman Cell:

56 Thank You!