Problems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issues has changed in recent years. National trends indicate substantial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of substance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade-in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD). To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). Substance Use Disorders in the U.S. Armed Forces reviews the IOM's task of assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and offers specific recommendations to DoD on where and how improvements in these areas could be made.

The U.S. Department of Defense (DoD) faces short-term and long-term challenges in selecting and recruiting an enlisted force to meet personnel requirements associated with diverse and changing missions. The DoD has established standards for aptitudes/abilities, medical conditions, and physical fitness to be used in selecting recruits who are most likely to succeed in their jobs and complete the first term of service (generally 36 months). In 1999, the Committee on the Youth Population and Military Recruitment was established by the National Research Council (NRC) in response to a request from the DoD. One focus of the committee's work was to examine trends in the youth population relative to the needs of the military and the standards used to screen applicants to meet these needs. When the committee began its work in 1999, the Army, the Navy, and the Air Force had recently experienced recruiting shortfalls. By the early 2000s, all the Services were meeting their goals; however, in the first half of calendar year 2005, both the Army and the Marine Corps experienced recruiting difficulties and, in some months, shortfalls. When recruiting goals are not being met, scientific guidance is needed to inform policy decisions regarding the advisability of lowering standards and the impact of any change on training time and cost, job performance, attrition, and the health of the force. Assessing Fitness for Military Enlistment examines the current physical, medical, and mental health standards for military enlistment in light of (1) trends in the physical condition of the youth population; (2) medical advances for treating certain conditions, as well as knowledge of the typical course of chronic conditions as young people reach adulthood; (3) the role of basic training in physical conditioning; (4) the physical demands and working conditions of various jobs in today's military services; and (5) the measures that are used by the Services to characterize an individual's physical condition. The focus is on the enlistment of 18- to 24-year-olds and their first term of service.

Being deployed to a war zone can result in numerous adverse psychological health conditions. It is well documented in the literature that there are high rates of psychological disorders among military personnel serving in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq as well as among the service members' families. For service members' families, the degree of hardship and negative consequences rises with the amount of the service members' exposure to traumatic or life-altering experiences. Adult and child members of the families of service members who experience wartime deployments have been found to be at increased risk for symptoms of psychological disorders and to be more likely to use mental health services. In an effort to provide early recognition and early intervention that meet the psychological health needs of service members and their families, DOD currently screens for many of these conditions at numerous points during the military life cycle, and it is implementing structural interventions that support the improved integration of military line personnel, non-medical caregivers, and clinicians, such as RESPECT-Mil (Re-engineering Systems of Primary Care Treatment in the Military), embedded mental health providers, and the Patient-Centered Medical Home. Preventing Psychological Disorders in Service Members and Their Families evaluates risk and protective factors in military and family populations and suggests that prevention strategies are needed at multiple levels - individual, interpersonal, institutional, community, and societal - in order to address the influence that these factors have on psychological health. This report reviews and critiques reintegration programs and prevention strategies for PTSD, depression, recovery support, and prevention of substance abuse, suicide, and interpersonal violence.

Of Key Findings -- References -- 8. Substance Use Disorder Workforce -- Air Force Workforce -- Army Workforce -- Navy Workforce -- Marine Corps Workforce -- DoD Efforts to Review Staffing Requirements -- Summary of Key Findings -- References -- 9. Conclusions And Recommendations -- Increasing Emphasis on Efforts to Prevent Substance Use Disorders -- Developing Strategies for Identifying, Adopting, Implementing, and Disseminating Evidence-Based Programs and Best Practices for SUD Care -- Increasing Access to Care -- Strengthening the SUD Workforce -- Conclusion -- References -- APPENDIXES -- A. Study Activities -- B.S.459 (111th): Support for Substance Use Disorders Act -- C. Section 596 of Public Law 111-84, October 28, 2009 -- D. Program Reviews -- E. Features of Tricare and Related Purchased Care Plans -- F. Workforce Standards for Substance Use Disorder (SUD) Care -- G. Access Standards for Tricare Prime Enrollees -- H. Levels of Care.

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is a cognitive-behavioral psychotherapy program designed for patients who have posttraumatic stress disorder (PTSD) and a co-occurring alcohol or drug use disorder. COPE represents an integration of two evidence-based treatments: Prolonged Exposure (PE) therapy for PTSD and Relapse Prevention for substance use disorders. COPE is an integrated treatment, meaning that both the PTSD and substance use disorder are addressed concurrently in therapy by the same clinician, and patients can experience substantial reductions in both PTSD symptoms and substance use severity. Patients use the COPE Patient Workbook while their clinician uses the Therapist Guide to deliver treatment. The program is comprised of 12 individual, 60 to 90 minute therapy sessions. The program includes several components: information about how PTSD symptoms and substance use interact with one another; information about the most common reactions to trauma; techniques to help the patient manage cravings and thoughts about using alcohol or drugs; coping skills to help the patient prevent relapse to substances; a breathing retraining relaxation exercise; and in vivo (real life) and imaginal exposures to target the patient's PTSD symptoms.

Estimates indicate that as many as 1 in 4 Americans will experience a mental health problem or will misuse alcohol or drugs in their lifetimes. These disorders are among the most highly stigmatized health conditions in the United States, and they remain barriers to full participation in society in areas as basic as education, housing, and employment. Improving the lives of people with mental health and substance abuse disorders has been a priority in the United States for more than 50 years. The Community Mental Health Act of 1963 is considered a major turning point in America's efforts to improve behavioral healthcare. It ushered in an era of optimism and hope and laid the groundwork for the consumer movement and new models of recovery. The consumer movement gave voice to people with mental and substance use disorders and brought their perspectives and experience into national discussions about mental health. However over the same 50-year period, positive change in American public attitudes and beliefs about mental and substance use disorders has lagged behind these advances. Stigma is a complex social phenomenon based on a relationship between an attribute and a stereotype that assigns undesirable labels, qualities, and behaviors to a person with that attribute. Labeled individuals are then socially devalued, which leads to inequality and discrimination. This report contributes to national efforts to understand and change attitudes, beliefs and behaviors that can lead to stigma and discrimination. Changing stigma in a lasting way will require coordinated efforts, which are based on the best possible evidence, supported at the national level with multiyear funding, and planned and implemented by an effective coalition of representative stakeholders. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change explores stigma and discrimination faced by individuals with mental or substance use disorders and recommends effective strategies for reducing stigma and encouraging people to seek treatment and other supportive services. It offers a set of conclusions and recommendations about successful stigma change strategies and the research needed to inform and evaluate these efforts in the United States.