Substance Use and Misuse in the Military Terry A. Adirim, M.D., M.P.H. Deputy Assistant Secretary of Defense for Health Services Policy and Oversight Health Affairs Department of Defense
The Military Health System*: Direct Care System and Health Plan *FY 2016 TRICARE Annual Report System Composition: 149,116 personnel (84,104 military / 65,012 civilians) 55 Inpatient hospitals and medical centers 373 Ambulatory care clinics 251 Dental clinics 253 Vet clinics 554,439 Network providers 3,789 TRICARE network acute care hospitals 803 Behavioral health facilities 58,142 Contracted (network) retail pharmacies Who We Serve: 9.4 M Beneficiaries 4.9 M TRICARE Prime 3.9 M in direct care 1.0 M in contractor networks 2.4 M TRICARE Standard/Extra 2.1 M TRICARE For Life 2
Substance Use and Mental Health Conditions among Active Component U.S. Armed Forces - 2015 40 35 30 44,847 XXX = # of Cases 25 20 26,647 29,336 15 14,292 13,687 10 5 0 8,009 3,122 1,464 258 891 Rate of New Cases/1000/yr % Population w/conditions ever diagnosed at end of year
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2007 2008 2009 2010 2011 2012 2013 2014 2015 Overall Total Force - Active, Reserve, and Guard - Drug Test Positive Rate 4 3.5 3 2.5 2 1.5 1 0.5 In 1984, DoD s drug testing program changed from solely treatment/rehabilitation to a personal responsibility program. A positive urinalysis could be used in disciplinary proceedings. Service members could be discharged for testing positive. 0.84 0
DoD Drug Testing Program Current Drugs Tested Marijuana *Synthetic Cannabinoid: MAM-2201 Acid *Synthetic Cannabinoid: AB-CHMINACA Metabolite *Synthetic Cannabinoid: JWH-018 Acid *Synthetic Cannabinoid: JWH-073 Acid *Synthetic Cannabinoid: UR-144 Acid Cocaine d-amphetamine d-methamphetamine MDMA (Ecstasy) MDA (Adam) PCP Codeine Morphine Oxycodone Oxymorphone Hydrocodone Hydromorphone Heroin α-hydroxy-alprazolam Lorazepam Nordiazepam Oxazepam Temazepam
Military v. Civilian Higher incidence of painful conditions where narcotics may be necessary Active duty Service members may use substances to meet performance requirements The Military system motivated to prevent and address problems Military provides highly structured environment Social determinants are provided: e.g. food, housing, health care 6
MHS Policies, Programs and Initiatives Prevention Drug testing of active duty Service members Pharmacy drug monitoring programs to encourage lower, but effective, opioid dosing. Curb medication shopping through multiple doctors and pharmacies through technology that monitors prescription distribution in all venues military pharmacies, retail pharmacies, and mail order programs. Limit refills for Schedule III-V medications; and restrict Schedule II medication to 30-day prescription, no refills. MHS partners with the Drug Enforcement Administration (DEA) on all Drug Take-Back (DTB) events since 2010. During the last two DTB events, 113 participating medical treatment facilities collected ~ 18,000 pounds of unwanted, unused, or expired medications 7
MHS Policies, Programs and Initiatives Treatment Published policy and procedural guidelines for all military medical providers and facilities. Improved access to MAT by removing the prohibition on opioid replacement therapy. Training Published newly revised training for opioid prescribers includes the following three one-hour modules: Interactive, video based training raising awareness of potential prescription drug misuse in clinical settings; The essentials of pain management including evidence based pain management techniques Diagnosis and treatment of Substance Use Disorders for primary care providers. DoD providers complete by 4/2017 8
Mental Health and Substance Use Parity Rule Ensures TRICARE s substance use disorder (SUD) benefit matches and aligns services with the standard-of-care, including coverage for Opioid Treatment Programs (OTPs) and Office Based Opioid Treatment. Elimination of lifetime limit of three SUD treatments; day limits for inpatient and partial hospital care at substance use disorder rehabilitation facilities Eliminates any differential in cost-sharing between mental health and SUD benefits and medical/surgical benefits Eliminates prohibitions on SUD care and applying the same benefit coverage rules as other medical and surgical benefits. Expands covered SUD treatment under TRICARE, to include coverage of intensive outpatient programs (IOPs) and venues for Medication-Assisted Treatment (MAT) for opioid use disorder (i.e., buprenorphine, methadone). Streamlines the process for SUD providers to become TRICARE authorized providers. Developing new TRICARE payment options for newly recognized SUD treatments, IOPs and OTPs. 9
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DoD and VA Working Together Updated DoD/VA Clinical Practice Guideline "Management of Opioid Therapy for Chronic Pain to include co-prescribing of Naloxone, effective 2017 Ensure warm hand offs of patients when separated from DoD to VA care DoD s intransition Program supports Service members undergoing transition while receiving MH/SUD care by providing global, specialized, telephonic transition coaching to facilitate the connection to a new provider. Seven of our major MTFs host Federal Recovery Coordinators (FRCs) who are VA employees and provide a single point of contact for wounded warriors during transitions as they move between various case managers and health care systems Interagency Comprehensive Plan: Documents the individualized care, benefits and services needed by transitioning Service members and Veterans and covers all aspects of recovery, rehabilitation, and reintegration. The Separation Health Assessment provides an opportunity for a thorough and comprehensive review of all aspects of health, including behavioral health. IT solutions VA providers have access to all SM medical records through the Joint Legacy Viewer. 12