MILITARY MEDICINE, 179, 6:674, 2014
Military Inpatient Residential Treatment of Substance Abuse Disorders: The Eisenhower Army Medical Center Experience Scott R. Mooney, PhD*; COL Philip A. Horton, MS USA*; COL John H. Trakowski, Jr., MS USA*; Janet H. Lenard, EdD, LCSWf; Mark R. Barron, PhD*; CPTPeggy V. Nave, MS USA*; Melissa S. Gautreaux, MS*; Heather D. Lott* ABSTRACT Opened in 2009, the Dwight D. Eisenhower Army Medical Center Inpatient Residential Treatment Facility (RTF) is the largest and most well-established inpatient substance use disorder treatment facility in the Department of Defense. The RTF is a 28-day inpatient treatment program that employs evidence-based practices and is based on Alcoholics/Narcotics Anonymous principles that are incorporated with a hybrid of military daily structure regime including eady morning physical training. Family involvement is encouraged. The RTF is staffed by a multidisciplinary team specializing in addictions and admits Active/Activated Service Members (SMs) from all Service branches, typically those who have failed other military/civilian substance use disorder programs. Eighty-seven percent of SMs refeiTed to the program successfully commenced, with continuous sobriety observed in over half of SMs 6 months later, and 1 year relapse rates comparable to other alcohol treatment programs. Limitations of our program evaluation efforts, lessons leamed, and recommendations for the way ahead are shared.
BACKGROUND Historically, alcohol and other substance misuse has been a common problem faced by military personnel.'" Recent population-based studies of the U.S. Armed Forces from the 2001-2006 time frame note that the incidence of a newly diagtiosed substance use disorder (SUD) of one variant or another based on review of available medical documentation ranged from 6% to nearly 9%, overall.^^ However, looking closer at the U.S. Amiy, as many as 6% of nondeployed Service Members (SMs) were diagnosed with a SUD during the 2001-2006 time frame, increasing to 14.8% if deployed to Afghanistan or Iraq."* Even more alarming, it is likely that the base rates of heavy alcohol use, particularly among young adult SMs, are higher than the recorded formal SUD incidence. For instance, although the prevalence of imbibing alcohol within the past 30 days seems to be comparable between military SMs and matched civilian samples (i.e., 70% versus 69%, respectively"*), mixed evidence regarding the quantity of alcohol ingested during episodes is noted in the literature with some studies indicating comparable volume consumed,^ whereas other studies suggest young military SMs are more likely to report "heavy" alcohol consumption compared to similarly matched civilian counterparts.^ Civilian models of SUD-related treatment tend to view SUD as addictions that are best understood as chronic conditions for which relapse prevention is the goal,* Civilian treat*Dwight D. Eisenhower Army Medical Center, 300 E, Hospital Road, Fort Gordon. GA 30905. tUnit 29353 Box 200, Army Post Office, AE 09014. The opinion(s) expressed in this paper are the author's and do not reflect the official policy of U.S. Government. Department of Defense, Department of the Army, or Dwight D. Eisenhower Army Medieal Center Behavioral Health Care Line. doi: 10.7205/MILMED-D-13-00308
674
ment modalities can take many forms, representing a broad spectrum of possibilities, ranging from self-help, to outpatient individual and group approaches, to comprehensive inpatient programs.^ Fortunately, several behavioraUy and/or pharmacotherapeutic approaches for SUDs have been shown to be generally "effective,"^** although results from meta-analyses suggest that just 1 in 4 patients who complete a course of alcohol-related treatment such as 12-step or cognitive behavioral model-based program remain continuously abstinent within 1 year."^ Other studies show that only 1 in 4 patients admitted to treatment complete successfully.'" Analogous treatment modalities and programs have been established within the U.S. Department of Defense (DoD) and its various service branches including command sponsored programs (e.g.. Army Substance Abuse Program [ASAP]; Marine Corps Alcohol and Drug Abuse Program; Dwight D. Eisenhower Army Medical Center [DDEAMC] Residential Treatment Facility [RTF]), self-referral (e.g.. Military OneSource; Confidential Alcohol Treatment and Education Pilot"), and prevention or risk reduction programs (e.g.. Army's "Battlemind" Program; Air Force "Crossroads" Program; Navy's Alcohol-Aware Program; DoD's Program for Alcohol Training, Research, and Online Learning).'^ Interested readers are encouraged to refer to the original citations for more information regarding these programs/ initiatives. Unfortunately, despite incurring great financial cost within the DoD associated with investing resources to understand the scope of substance-related problems, developing programs to attenuate use, and paying for tnilitary health care,' there nevertheless remains a paucity of information available that can speak to the efficacy of these treatment programs or services rendered to SMs,^'~'"* In an effort to address this knowledge gap, at least as it pertains to DoD inpatient treatment of SUDs, we propose to share our
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Military Inpatient Residential Treatment of Substance Abuse Disorders
experience as the only well-established program currently in existence in the DoD: The DDEAMC Inpatient RET. The DDEAMC is located at Eort Gordon, Georgia. DDEAMC has an extensive history with providing evidencebased substance abuse evaluation and treatment to SMs along with other programs beginning in the early 1980s''*'^'' and currently operating the RTE established in 2009. The RTE is currently defined as a 22-bed inpatient SUD rehabilitation center, lasting 28 days, with the ability of addressing dependence of varied degrees and complexities with a primary focus on alcohol and drugs. The rationale for re-establishing a formal DoD inpatient RTE in 2009 included, in our opinion (s) (1) concerns that civilian-based RTEs facilities lose military structure and do not promote transition to a fully functioning SM on active duty; (2) allow seamless transition of high-risk substance abusing SMs who often have other comorbid conditions such as post-traumatic stress disorder (PTSD), anxiety, and/or depression who are residing in Warrior Transition Units into an inpatient setting to reduce selfmedicating for treatment of behavioral health problems; (3) possible initiation of a medical evaluation board or other administrative separation if treatment failure; (4) marital discord affected by addiction; and (5) potential cost savings by keeping SMs within the military health care settings rather than referring out to network/civilian-based programs. Enrollment into the RTE is open to all active duty SMs (i.e., AiTny, Navy, Air Eoree, Marines, and Coast Guard), Activated Reservists, and Activated National Guard who have a diagnosis of Alcohol/Substance Dependence who are ( 1 ) unable to maintain their sobriety through participation in the ASAP (or analogous program in other Service branches), (2) failed a previous inpatient rehabilitation admission for Alcohol/ Substance treatment, or (3) dual-diagnosed SMs who need treatment for both SUD and mental illness and remain actively using (see Table I for formal RTE admission criteria). In our experience, to date, the bulk of referrals come from the U.S. Army—a finding not surprising given that the RTE is located at an Army installation with the bulk of referrals being funneled through ASAP counselors. SMs are referred to the RTE by their DoD/military branch substance abuse counselors with approval by their Commands. Since its establishment in 2009, the RTE has been filled to a 90% to 100% capacity on a routine basis with four 4-person rooms and three 2-person rooms. At times, census is affected when accommodating odd numbers of female SMs. If by chance there are two female SMs, there would continue to be 100% occupancy. Upon arrival to the RTE after being escorted to the program by a higher ranking same sex Noncommissioned/Commissioned Officer, SMs are evaluated by an interdisciplinary team led by a psychiatrist to determine the extent of care specific to their diagnosis or comorbidities emphasizing an evidencebased customizable plan of care for the SMs optimal recovery outcomes. Psychological evaluation also is conducted early in the program and again at discharge. Program completion and relapse rates are tracked wherein possible (and will be
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TABLE I.
Dwight D. Eisenhower Army Medical Center RTE Admission Criteria
Enrolled in Army Alcohol and Substance Abuse Program (ASAP) or similar program in other branches. Complete a required admission packet prior to enrollment. Information collected includes contact infomiation on the SM, their Command and counselor; diagnosis; legal history; retention status; medical history; and physical training profiles; medication list; and detailed alcohol and substance abuse history. Active Duty SM or activated reservist. Current diagnosis of substance dependence. Failed treatment in outpatient setting. Prior history of civilian rehabilitation failure. Medically stable and not in acute withdrawal. May be dually diagnosed. Not currently violent or assaultive. Able to tolerate an open unit without going absent without leave (AWOL). Not currently on any narcotics, benzodiazepines or other potentially addictive substances. Able to tolerate the intensity of group therapy setting. Command, ASAP counselor (or analogous branch), and physician agree with RTF enrollment. Does not require intensive medical care such as nasogastric tube, oxygen support, daily wound care, etc.
discussed further below). SMs are cared for by a unified multidisciplinary team consisting of the following members but not limited to Psychiatrist, Physician Assistant, Clinical Psychologist, Registered Nurses, Psychological Health Technicians, Social Workers, Licensed Marriage and Eamily Therapist, Massage Therapist, Chiropractor, Acupuncturist, Physiatrist/ Pain Management and Activity Therapy Specialists including Occupational and Recreational Therapists. The recovery program at its core is based on Alcoholics Anonymous/Narcotics Anonymous practices along with empirically validated Cognitive Behavioral and Stages of Change principles and techniques. These therapeutic approaches are integrated into a military daily structure regime including early awakening (at 4:50 a.m.) and physical training to facilitate the SMs preparation to return to full duty status or, if unable to return to duty, transition to civilian life while maintaining abstinence and an active SUD recovery program (see Appendix for RTE Program schedule). Command involvement is required from a control and ultimate accountability standpoint. Eamily involvement also is encouraged. Urine drug screening occurs daily. METHODS
Patient Population This was a retrospective study of 108 consecutive clinical cases drawn from a program evaluation dataset developed and managed by the RTE. The clinical cases had been admitted into the 28-day inpatient RTE program from January 4, 2011 to June 6, 2011 and followed for a period of 12 months wherein possible to assess ongoing abstinence following RTE completion/commencement (see Tables II-III). Average age of SMs was 30.7 (ranging from 18 to 57), most of whom were
675
Military Inpatient Residential Treatment of Substance Abuse Disorders TABLE II.
RTF—6-Month Summary of Consecutive Cases Frequency (%) Mean SD MIn Max
N Age Sex Education Ethnicity Caucasian AA Other Branch Army Air Force Marine Navy Rank E5 WO Officer Number of Deployments Primary Psychiatric Diagnosis % Alcohol Dependence % Narcotic Dependence % Stimulant Dependence % Other % +Dual Diagnosis Alcohol Dependence Cases +Depression NOS +Mood Disorder NOS +Anxiety NOS (e.g., combat stress) +Full Criteria for PTSD Narcotic Dependence Cases +Depression NOS +Mood Disorder NOS +Anxiety NOS (e.g.. Combat Stress) +Full Criteria for PTSD +Abuse History +LOC History Successful Program Commencement Yes No. Medically Excused No, Relapse Failure No, Other Reason
108 107 107 107
30.7
8.3
18
57
12.7
1.9
8
20
88 9 2 1 108 50 45 1 4 1.4
1.3
0
6
80 8 3 9 34 86 22 8 6 2 9 11 11 11 33 21 38
87 1 2 10
A cohort of 108 consecutive cases who entered the 28-day RTF program from January 4, 2011 to June 6, 2011. AA, African-American; WO, Warrant Officer level; +Dual Diagnosis, Evidence of dual diagnosis at the time of discharge from RTF; NOS, "not otherwise specified"; +Abuse History, history of physical and/or sexual abuse; +LOC History, history of concussion with loss of consciousness.
Caucasian males. Eighty-eight percent of the cohort were Army, 9% from the Air Force, and 3% Marines/Navy. Half of the cohort were Noncommissioned Officers (i.e., rank > E5) or Commissioned Officers (i.e., rank > Ol). The majority of the cohort had deployed overseas at some point during their
676
N
+Relapse {%)
30 90 180 360
68 66 47 27
14.7 28.8 44.7 77.8
Considering only the Army Service Members (N = 95) who entered the 28-day RTF program from January 4, 2011 to June 6, 2011. At day 30, 28.4% of the cohort had been lost to follow up, 30.5% were lost to follow up by 90 days; 50.5% lost by 180 days, and 71.6% lost at 360 days. W, sample size of available Army Service Members at given time point not lost to follow up; +Relapse, proportion of known cases of any history of relapse occurring following commencement from RTF within specified number of days.
108
105 107
RTF Army Service Member Relapse Rates
Time Since Commencement (Days)
79 Male
60 24 16
90 108
TABLE III.
career (i.e., average number of deployments was 1.4; range 0 to 6). Eighty-seven percent of the cohort were able to tolerate and commence from the RTF. At the time of discharge or commencement from the program, 80% of the sample were diagnosed as being alcohol dependent, 8% narcotic dependent, 3% stimulant dependent, and 9% as other drug dependent. A little over one-third of the total cohort was dual diagnosis of one variant or another (e.g., 30% of alcohol-dependent cases were also diagnosed with a co-occuiTÍng mood disorder or Depression not otherwise specified (NOS) diagnosis; 8% of alcohol-dependent cases were comorbid with Anxiety NOS or PTSD diagnosis; see Table II), approximately 21% had a selfreported history of physical and/or sexual abuse, and 38% had an alleged history of prior concussion(s).
Procedure This study, employing a de-identified program evaluation dataset, was determined by local DoD Depaitment of Clinical Investigation to be exempt from institutional review board review. As part of ongoing program evaluation efforts, RTF staff had previously contacted program participant's Army Substance Abuse Counselors (or other service equivalent program) and queried Drug and Alcohol Management Information System (DAMIS) to document evidence of any history of relapse for Army SMs occurring at 30, 90, 180, and 360 days following commencement from the RTF. Note that the DAMIS system is a historical global repository of all ASAP-related information including demographic information, substance abuse history, type of specimen(s) drawn, and drug testing records from 1988 to present. Any documented evidence of substance use from DAMIS or ASAP counselor (or equivalent Service Branch) was categorized as representing a post-RTF relapse and program failure. SMs were not directly queried owing to concerns about veracity of self-reported substance abuse. RESULTS As shown in Table III, by day 30, 28% of the Army (original N = 95) cohort had been lost to follow up for a multitude of potential reasons (e.g., separated from Service, permanent
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Military Inpatient Residential Treatment of Substance Abuse Disorders
change of station, not following up with ASAP Counselor), Increasing attrition was noted over time, such that by day 90, 31 % of the Army cohort had been lost, 51 % by 180 days, and 72% by 360 days. Of those available for follow-up (considering only Army; see Table III), approximately 15% of the cohort had documented evidence by ASAP counselor feedback and/or DAMIS query of relapse within 30 days post commencetnent from the RTF. By 90 days, 29% of the cohort had relapsed, increasing to 45% by 180 days, and 78% by 360 days. DISCUSSION The DDEAMC RTF is currently the largest and most wellestablished inpatient SUD treatment facility in existence at present in the DoD. The 28-day program accepts Active/ Activated SMs from all branches within the DoD, typically Army SMs who have evidenced difficulties maintaining their sobriety through less intensive outpatient military-based programs, are dually diagnosed and require treatment for comorbid psychopathology, and/or are considered treatment failures after attending civilian-based inpatient programs all within the context of military structure. Thus, we accept SMs whose SUD prognosis is generally assumed to guard and at high risk for relapse. Most have Alcohol Dependency issues as their primary SUD, From an outcome standpoint, 87% of SMs who matriculate into the RTF are able to successfully commence from the program—a completion rate three times greater than civilian programs. This finding is perhaps not surprising, given the military command, control, and structure that can be leveraged in our setting. Continuous sobriety was maintained for more than half of SMs 6 months after commencement from the RTF. We view this as a strong positive outcome given that we are treating SMs who have failed other military/civilian-based outpatient/inpatient SUD programs and aie generally understood to have a poor prognosis for abstinence. Evidence of any SUDrelated relapse (at least for Army) for SMs after 360 days also were generally comparable to recidivism rates noted collectively across prior alcohol treatment program(s) meta-analysis. Several limitations in our outcome data are evident. First, in our opinion, it is difficult to ascertain the true base rates of relapses in our sample, where a particular SM may have used a substance to some extent but this incident was not reported, nagged, or otherwise elevated to the level of their command, substance abuse counselor and/or recorded in the DAMIS system. We adopted a fairly strict definition of what we considered a relapse or program failure. In our opinion, other substance abuse outcome studies are highly variable in their determination of a program failure or based on evidence of a lapse in abstinence (i.e., episode of substance re-use, followed by retum to sobriety) yet still considered program success versus absolute sobriety as a requirement. In a military setting where so much is at stake, we view continuous sobriety as a marker for success both for the SMs and for the RTF program given the potential effects of relapse on mili-
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tary fitness and mission accomplishment. We appreciate that there are a multitude of potential other outcomes that could have been tracked and reported (e.g., reduction in substance use; homeless or not; employed, and so on). We chose to track relapse. Second, we encountered significant attrition in our cohort over time owing to a multitude of factors such as failure of SMs to follow up with their substance abuse counselors (who also are responsible for updating/logging incidents into DAMIS) after commencing from the RTF, permanent change of station and failure to reengage ASAP at new duty station (with no coordination between prior ASAP counselor; losing and gaining ASAP counselors), and/ or being administratively separated from military service. Our RTF also encountered difficulty attempting to collect relapse information from other Sei-vice branches outside of the Army. It is difficult to know how and in what direction our relapse rates would move to if we had 100% knowledge of relapse incidents in our cohort. As we reflect on our experiences over the past 4-i- years re-establishing and operating the DoD's largest RTF, several lessons have been learned and future directions have been elucidated. First, in our opinion, we have presented preliminary evidence that our intensive inpatient SUD treatment provided within a military setting is seemingly as effective at promoting continuous sobriety as other alcohol focused civilian-based treatment programs. Our bias is that military run RTFs may also be a better fit for Active Duty, Activated Reservists, and Activated National Guard SMs than civilian inpatient SUD programs counterparts given that we strive to maintain military structure and bearing, can determine fitness for duty or need for administrative separation, can leverage additional Behavioral Health assets available at a medical center in dually diagnosed patients with the goal of return to full duty perfonnance when possible. Second, given the great financial cost incurred by the DoD for establishing and maintaining military treatment modalities and programs across the various Service branches (and paying for civilian counterparts out in the community) and the continued dearth of available compelling outcome data, we absolutely encourage program evaluation efforts to occur from a transparency and accountability standpoint in both DoD (and by extension, TRICARE) funded civilian purchased care SUD programs. We also encourage DoD/military leadership as stewards of tax payers' dollars to ask the difficult questions to SUD treatment programs they are sending affected SMs to (i.e.. What are your outcomes? What is the evidence for your program and why should we continue funding it?). Similarly, in our opinion, DoD/military leadership should also hold the same expectations and ask the same questions to civilianbased programs in network who are offering services to SMs. Third, in our view, improved surveillance and communication within and across substance abuse counselors from the various military branches will also absolutely be required if we are going to improve our ability to better inform relapse among SUD SMs. An easy concept to appreciate, but difficult
677
Militan' Inpatient Residential Treatment of Substance Abuse Disorders
in practice to actualize owing to a multitude of challenges within and across the Service branches including possible disparate agenda's locally versus higher up the Chain of Command, fiscal support, and mission prioritization, APPENDIX Residential Treatment Facility Program Schedule Time 5:00 a.m.-05:15 a.m.
Week
Procedure/Event
Wake Up/Preparation for Physical Trahiing/Urine Analysis 5:15 a.m.-6:30 a.m. All Physical Training Personal Hygiene/Breakfast/Break 6:30 a.m.-7:45 a.m. All 8:00 a.m.-8:15 a.m. All Comtnunity Meeting 8:15 a.m.-10:15a.m. 2 Interdisciplinary Teatn Meeting 8:15a.m.-10:15a.m. 1,3,4,5 Medical and Staff Assessment Individual Study 10:15 a.m.-10:30 a.m. All Break 10:30 a.m.-12:00 p.m. All Group Therapy 12:00 p.m.-l:OO p.m. All Lunch/Break l:00p.m.-2:00p.m. 1 Life Skills: Values Clarification l:00p.m.-2:00p.m. 2 Recreational Therapy Risk Factor Group l:00p.m.-2:30p.m. 3,4,5 1 Recreational Therapy 2:00 p.m.-3:00 p.m. Life Skills: Problem Solving 2:00 p.m.-3:00 p.m. 2 Guilt and Shame 2:30 p.m.-3:30 p.m. 3 4 Individual Study 2:30 p.m.-3;00 p.m. 5 Treatment Plan Per Counselor 2:30 p.m.-!l:OO p.trt. 3:00 p.m.-3:3O p.m. 1 Individual Study 2 Video: Addictive Relationships 3:00 p.m.^:OO p.m. 4 Video: Illusions of Immunity 3:00 p.m.^:OO p.m. 3:30 p.m.^:OO p.m. 1 Video: Denial Individual Study 3:30 p.m.^:OO p.m. 3 All Cornmunity Meeting 4:00 p.m.^: 15 p.m. Relaxation Class—Progressive All 4:15 p.m.^:45 p.m. Muscle Relaxation Optional Fitness/Dinner/Break 4:45 p.m.-5:45 p.m. All Alcoholics Anonymous Pre 5:45 p.m.-6:00 p.m. All Planning (Staff) Alcoholics Anonymous Meeting 6:00 p.m.-9:00 p.m. All 9:15 p.m.-9:45 p.m. All Medication Wrap Up 9:45 p.m.-10:00 p.m. All All Lights Out 10:00 p.m.
678
All
REFERENCES 1. Adams RS, Corrigan JD, Larson MJ: Alcohol use after combat-acquired traumatic brain injury: what we know and don't know. J Soc Work Pract Addict 2012; 12; 28-51. 2. Jones E, Fear NT: Alcohol use and misuse within the military: a review. Int Rev Psychiatry 2011; 23; 166-72. 3. Shen Y, Arkes J, Williams TV; Effects of Iraq/Afghanistan deployments on major depression and substance use disorder: analysis of active duty personnel in the US military. Am J Public Health 2012; 102: 80-7. 4. Ramchand R. Miles J, Schell T, Jaycox L. Marshall GN, Tanielian T: Prevalence and correlates of drinking behavior among previously deployed military and matched civilian populations. Mil Psychol 2011; 23; 6-21. 5. Bray RM, Pemberton MR, Hourani LL, et al: 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Available at http://www.tricare.mil/tma/2008Health Behaviors.pdf; accessed February 10. 2013. 6. Saitz R; Treatment of alcohol and other drug dependence. Liver Transpl 2007; 13; 59-64. 7. Skidmore WC, Roy M; Practical considerations for addressing substance use disorders in veterans and service members. Soc Work Health Care 2011; 50; 85-107. 8. Miller RW, Wilboume PL: Mesa grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002: 97: 265-77. 9. Miller RW. Walters ST. Bennett MF: How effective is alcoholism treatment in the United States? J Stud Alcohol 2001; 62: 211-20. 10. Burling TA, Seidner AL, Salvio M, Marshall GD: A cognitive-behavioral therapeutic community for substance dependent and homeless veterans: treatment outcome. Addict Behav 1994; 19: 621-9. 11. Gibbs DA, Olmsted KL: Preliminary examination of the confidential alcohol treatment and education program. Mil Psychol 2011; 23; 97-111. 12. Witkiewitz K, Estrada AX: Substance abuse and mental health treatment in the military: lessons learned and a way forward. Mil Psychol 2011: 23: 112-23. 13. Larson J, Wooten, NR, Adams, RS, Merrick EL: Military combat deployments and substance use: review and future directions. J Soc Work Pract Addict 2012; 12; 6-27. 14. Kruzich DJ; The Residential Treatment Facility, William Beaumont ArtTiy Medical Center. J Subst Abuse Treat 1987; 4; 55-7. 15. Silsby HD. Neptune C, Kruzich DJ, Gouin HD; Establishment of the first US Army alcoholism residential treatment facility in the continental United States. Mil Med 1983; 148: 21-3.
MILITARY MEDICINE, Vol. 179, June 2014
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Military Inpatient Residential Treatment of Substance Abuse Disorders: The Eisenhower Army Medical Center Experience Scott R. Mooney, PhD*; COL Philip A. Horton, MS USA*; COL John H. Trakowski, Jr., MS USA*; Janet H. Lenard, EdD, LCSWf; Mark R. Barron, PhD*; CPTPeggy V. Nave, MS USA*; Melissa S. Gautreaux, MS*; Heather D. Lott* ABSTRACT Opened in 2009, the Dwight D. Eisenhower Army Medical Center Inpatient Residential Treatment Facility (RTF) is the largest and most well-established inpatient substance use disorder treatment facility in the Department of Defense. The RTF is a 28-day inpatient treatment program that employs evidence-based practices and is based on Alcoholics/Narcotics Anonymous principles that are incorporated with a hybrid of military daily structure regime including eady morning physical training. Family involvement is encouraged. The RTF is staffed by a multidisciplinary team specializing in addictions and admits Active/Activated Service Members (SMs) from all Service branches, typically those who have failed other military/civilian substance use disorder programs. Eighty-seven percent of SMs refeiTed to the program successfully commenced, with continuous sobriety observed in over half of SMs 6 months later, and 1 year relapse rates comparable to other alcohol treatment programs. Limitations of our program evaluation efforts, lessons leamed, and recommendations for the way ahead are shared.
BACKGROUND Historically, alcohol and other substance misuse has been a common problem faced by military personnel.'" Recent population-based studies of the U.S. Armed Forces from the 2001-2006 time frame note that the incidence of a newly diagtiosed substance use disorder (SUD) of one variant or another based on review of available medical documentation ranged from 6% to nearly 9%, overall.^^ However, looking closer at the U.S. Amiy, as many as 6% of nondeployed Service Members (SMs) were diagnosed with a SUD during the 2001-2006 time frame, increasing to 14.8% if deployed to Afghanistan or Iraq."* Even more alarming, it is likely that the base rates of heavy alcohol use, particularly among young adult SMs, are higher than the recorded formal SUD incidence. For instance, although the prevalence of imbibing alcohol within the past 30 days seems to be comparable between military SMs and matched civilian samples (i.e., 70% versus 69%, respectively"*), mixed evidence regarding the quantity of alcohol ingested during episodes is noted in the literature with some studies indicating comparable volume consumed,^ whereas other studies suggest young military SMs are more likely to report "heavy" alcohol consumption compared to similarly matched civilian counterparts.^ Civilian models of SUD-related treatment tend to view SUD as addictions that are best understood as chronic conditions for which relapse prevention is the goal,* Civilian treat*Dwight D. Eisenhower Army Medical Center, 300 E, Hospital Road, Fort Gordon. GA 30905. tUnit 29353 Box 200, Army Post Office, AE 09014. The opinion(s) expressed in this paper are the author's and do not reflect the official policy of U.S. Government. Department of Defense, Department of the Army, or Dwight D. Eisenhower Army Medieal Center Behavioral Health Care Line. doi: 10.7205/MILMED-D-13-00308
674
ment modalities can take many forms, representing a broad spectrum of possibilities, ranging from self-help, to outpatient individual and group approaches, to comprehensive inpatient programs.^ Fortunately, several behavioraUy and/or pharmacotherapeutic approaches for SUDs have been shown to be generally "effective,"^** although results from meta-analyses suggest that just 1 in 4 patients who complete a course of alcohol-related treatment such as 12-step or cognitive behavioral model-based program remain continuously abstinent within 1 year."^ Other studies show that only 1 in 4 patients admitted to treatment complete successfully.'" Analogous treatment modalities and programs have been established within the U.S. Department of Defense (DoD) and its various service branches including command sponsored programs (e.g.. Army Substance Abuse Program [ASAP]; Marine Corps Alcohol and Drug Abuse Program; Dwight D. Eisenhower Army Medical Center [DDEAMC] Residential Treatment Facility [RTF]), self-referral (e.g.. Military OneSource; Confidential Alcohol Treatment and Education Pilot"), and prevention or risk reduction programs (e.g.. Army's "Battlemind" Program; Air Force "Crossroads" Program; Navy's Alcohol-Aware Program; DoD's Program for Alcohol Training, Research, and Online Learning).'^ Interested readers are encouraged to refer to the original citations for more information regarding these programs/ initiatives. Unfortunately, despite incurring great financial cost within the DoD associated with investing resources to understand the scope of substance-related problems, developing programs to attenuate use, and paying for tnilitary health care,' there nevertheless remains a paucity of information available that can speak to the efficacy of these treatment programs or services rendered to SMs,^'~'"* In an effort to address this knowledge gap, at least as it pertains to DoD inpatient treatment of SUDs, we propose to share our
MILITARY MEDICINE, Vol. 179, June 2014
Military Inpatient Residential Treatment of Substance Abuse Disorders
experience as the only well-established program currently in existence in the DoD: The DDEAMC Inpatient RET. The DDEAMC is located at Eort Gordon, Georgia. DDEAMC has an extensive history with providing evidencebased substance abuse evaluation and treatment to SMs along with other programs beginning in the early 1980s''*'^'' and currently operating the RTE established in 2009. The RTE is currently defined as a 22-bed inpatient SUD rehabilitation center, lasting 28 days, with the ability of addressing dependence of varied degrees and complexities with a primary focus on alcohol and drugs. The rationale for re-establishing a formal DoD inpatient RTE in 2009 included, in our opinion (s) (1) concerns that civilian-based RTEs facilities lose military structure and do not promote transition to a fully functioning SM on active duty; (2) allow seamless transition of high-risk substance abusing SMs who often have other comorbid conditions such as post-traumatic stress disorder (PTSD), anxiety, and/or depression who are residing in Warrior Transition Units into an inpatient setting to reduce selfmedicating for treatment of behavioral health problems; (3) possible initiation of a medical evaluation board or other administrative separation if treatment failure; (4) marital discord affected by addiction; and (5) potential cost savings by keeping SMs within the military health care settings rather than referring out to network/civilian-based programs. Enrollment into the RTE is open to all active duty SMs (i.e., AiTny, Navy, Air Eoree, Marines, and Coast Guard), Activated Reservists, and Activated National Guard who have a diagnosis of Alcohol/Substance Dependence who are ( 1 ) unable to maintain their sobriety through participation in the ASAP (or analogous program in other Service branches), (2) failed a previous inpatient rehabilitation admission for Alcohol/ Substance treatment, or (3) dual-diagnosed SMs who need treatment for both SUD and mental illness and remain actively using (see Table I for formal RTE admission criteria). In our experience, to date, the bulk of referrals come from the U.S. Army—a finding not surprising given that the RTE is located at an Army installation with the bulk of referrals being funneled through ASAP counselors. SMs are referred to the RTE by their DoD/military branch substance abuse counselors with approval by their Commands. Since its establishment in 2009, the RTE has been filled to a 90% to 100% capacity on a routine basis with four 4-person rooms and three 2-person rooms. At times, census is affected when accommodating odd numbers of female SMs. If by chance there are two female SMs, there would continue to be 100% occupancy. Upon arrival to the RTE after being escorted to the program by a higher ranking same sex Noncommissioned/Commissioned Officer, SMs are evaluated by an interdisciplinary team led by a psychiatrist to determine the extent of care specific to their diagnosis or comorbidities emphasizing an evidencebased customizable plan of care for the SMs optimal recovery outcomes. Psychological evaluation also is conducted early in the program and again at discharge. Program completion and relapse rates are tracked wherein possible (and will be
MILITARY MEDICINE, Vol. 179, June 2014
TABLE I.
Dwight D. Eisenhower Army Medical Center RTE Admission Criteria
Enrolled in Army Alcohol and Substance Abuse Program (ASAP) or similar program in other branches. Complete a required admission packet prior to enrollment. Information collected includes contact infomiation on the SM, their Command and counselor; diagnosis; legal history; retention status; medical history; and physical training profiles; medication list; and detailed alcohol and substance abuse history. Active Duty SM or activated reservist. Current diagnosis of substance dependence. Failed treatment in outpatient setting. Prior history of civilian rehabilitation failure. Medically stable and not in acute withdrawal. May be dually diagnosed. Not currently violent or assaultive. Able to tolerate an open unit without going absent without leave (AWOL). Not currently on any narcotics, benzodiazepines or other potentially addictive substances. Able to tolerate the intensity of group therapy setting. Command, ASAP counselor (or analogous branch), and physician agree with RTF enrollment. Does not require intensive medical care such as nasogastric tube, oxygen support, daily wound care, etc.
discussed further below). SMs are cared for by a unified multidisciplinary team consisting of the following members but not limited to Psychiatrist, Physician Assistant, Clinical Psychologist, Registered Nurses, Psychological Health Technicians, Social Workers, Licensed Marriage and Eamily Therapist, Massage Therapist, Chiropractor, Acupuncturist, Physiatrist/ Pain Management and Activity Therapy Specialists including Occupational and Recreational Therapists. The recovery program at its core is based on Alcoholics Anonymous/Narcotics Anonymous practices along with empirically validated Cognitive Behavioral and Stages of Change principles and techniques. These therapeutic approaches are integrated into a military daily structure regime including early awakening (at 4:50 a.m.) and physical training to facilitate the SMs preparation to return to full duty status or, if unable to return to duty, transition to civilian life while maintaining abstinence and an active SUD recovery program (see Appendix for RTE Program schedule). Command involvement is required from a control and ultimate accountability standpoint. Eamily involvement also is encouraged. Urine drug screening occurs daily. METHODS
Patient Population This was a retrospective study of 108 consecutive clinical cases drawn from a program evaluation dataset developed and managed by the RTE. The clinical cases had been admitted into the 28-day inpatient RTE program from January 4, 2011 to June 6, 2011 and followed for a period of 12 months wherein possible to assess ongoing abstinence following RTE completion/commencement (see Tables II-III). Average age of SMs was 30.7 (ranging from 18 to 57), most of whom were
675
Military Inpatient Residential Treatment of Substance Abuse Disorders TABLE II.
RTF—6-Month Summary of Consecutive Cases Frequency (%) Mean SD MIn Max
N Age Sex Education Ethnicity Caucasian AA Other Branch Army Air Force Marine Navy Rank E5 WO Officer Number of Deployments Primary Psychiatric Diagnosis % Alcohol Dependence % Narcotic Dependence % Stimulant Dependence % Other % +Dual Diagnosis Alcohol Dependence Cases +Depression NOS +Mood Disorder NOS +Anxiety NOS (e.g., combat stress) +Full Criteria for PTSD Narcotic Dependence Cases +Depression NOS +Mood Disorder NOS +Anxiety NOS (e.g.. Combat Stress) +Full Criteria for PTSD +Abuse History +LOC History Successful Program Commencement Yes No. Medically Excused No, Relapse Failure No, Other Reason
108 107 107 107
30.7
8.3
18
57
12.7
1.9
8
20
88 9 2 1 108 50 45 1 4 1.4
1.3
0
6
80 8 3 9 34 86 22 8 6 2 9 11 11 11 33 21 38
87 1 2 10
A cohort of 108 consecutive cases who entered the 28-day RTF program from January 4, 2011 to June 6, 2011. AA, African-American; WO, Warrant Officer level; +Dual Diagnosis, Evidence of dual diagnosis at the time of discharge from RTF; NOS, "not otherwise specified"; +Abuse History, history of physical and/or sexual abuse; +LOC History, history of concussion with loss of consciousness.
Caucasian males. Eighty-eight percent of the cohort were Army, 9% from the Air Force, and 3% Marines/Navy. Half of the cohort were Noncommissioned Officers (i.e., rank > E5) or Commissioned Officers (i.e., rank > Ol). The majority of the cohort had deployed overseas at some point during their
676
N
+Relapse {%)
30 90 180 360
68 66 47 27
14.7 28.8 44.7 77.8
Considering only the Army Service Members (N = 95) who entered the 28-day RTF program from January 4, 2011 to June 6, 2011. At day 30, 28.4% of the cohort had been lost to follow up, 30.5% were lost to follow up by 90 days; 50.5% lost by 180 days, and 71.6% lost at 360 days. W, sample size of available Army Service Members at given time point not lost to follow up; +Relapse, proportion of known cases of any history of relapse occurring following commencement from RTF within specified number of days.
108
105 107
RTF Army Service Member Relapse Rates
Time Since Commencement (Days)
79 Male
60 24 16
90 108
TABLE III.
career (i.e., average number of deployments was 1.4; range 0 to 6). Eighty-seven percent of the cohort were able to tolerate and commence from the RTF. At the time of discharge or commencement from the program, 80% of the sample were diagnosed as being alcohol dependent, 8% narcotic dependent, 3% stimulant dependent, and 9% as other drug dependent. A little over one-third of the total cohort was dual diagnosis of one variant or another (e.g., 30% of alcohol-dependent cases were also diagnosed with a co-occuiTÍng mood disorder or Depression not otherwise specified (NOS) diagnosis; 8% of alcohol-dependent cases were comorbid with Anxiety NOS or PTSD diagnosis; see Table II), approximately 21% had a selfreported history of physical and/or sexual abuse, and 38% had an alleged history of prior concussion(s).
Procedure This study, employing a de-identified program evaluation dataset, was determined by local DoD Depaitment of Clinical Investigation to be exempt from institutional review board review. As part of ongoing program evaluation efforts, RTF staff had previously contacted program participant's Army Substance Abuse Counselors (or other service equivalent program) and queried Drug and Alcohol Management Information System (DAMIS) to document evidence of any history of relapse for Army SMs occurring at 30, 90, 180, and 360 days following commencement from the RTF. Note that the DAMIS system is a historical global repository of all ASAP-related information including demographic information, substance abuse history, type of specimen(s) drawn, and drug testing records from 1988 to present. Any documented evidence of substance use from DAMIS or ASAP counselor (or equivalent Service Branch) was categorized as representing a post-RTF relapse and program failure. SMs were not directly queried owing to concerns about veracity of self-reported substance abuse. RESULTS As shown in Table III, by day 30, 28% of the Army (original N = 95) cohort had been lost to follow up for a multitude of potential reasons (e.g., separated from Service, permanent
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Military Inpatient Residential Treatment of Substance Abuse Disorders
change of station, not following up with ASAP Counselor), Increasing attrition was noted over time, such that by day 90, 31 % of the Army cohort had been lost, 51 % by 180 days, and 72% by 360 days. Of those available for follow-up (considering only Army; see Table III), approximately 15% of the cohort had documented evidence by ASAP counselor feedback and/or DAMIS query of relapse within 30 days post commencetnent from the RTF. By 90 days, 29% of the cohort had relapsed, increasing to 45% by 180 days, and 78% by 360 days. DISCUSSION The DDEAMC RTF is currently the largest and most wellestablished inpatient SUD treatment facility in existence at present in the DoD. The 28-day program accepts Active/ Activated SMs from all branches within the DoD, typically Army SMs who have evidenced difficulties maintaining their sobriety through less intensive outpatient military-based programs, are dually diagnosed and require treatment for comorbid psychopathology, and/or are considered treatment failures after attending civilian-based inpatient programs all within the context of military structure. Thus, we accept SMs whose SUD prognosis is generally assumed to guard and at high risk for relapse. Most have Alcohol Dependency issues as their primary SUD, From an outcome standpoint, 87% of SMs who matriculate into the RTF are able to successfully commence from the program—a completion rate three times greater than civilian programs. This finding is perhaps not surprising, given the military command, control, and structure that can be leveraged in our setting. Continuous sobriety was maintained for more than half of SMs 6 months after commencement from the RTF. We view this as a strong positive outcome given that we are treating SMs who have failed other military/civilian-based outpatient/inpatient SUD programs and aie generally understood to have a poor prognosis for abstinence. Evidence of any SUDrelated relapse (at least for Army) for SMs after 360 days also were generally comparable to recidivism rates noted collectively across prior alcohol treatment program(s) meta-analysis. Several limitations in our outcome data are evident. First, in our opinion, it is difficult to ascertain the true base rates of relapses in our sample, where a particular SM may have used a substance to some extent but this incident was not reported, nagged, or otherwise elevated to the level of their command, substance abuse counselor and/or recorded in the DAMIS system. We adopted a fairly strict definition of what we considered a relapse or program failure. In our opinion, other substance abuse outcome studies are highly variable in their determination of a program failure or based on evidence of a lapse in abstinence (i.e., episode of substance re-use, followed by retum to sobriety) yet still considered program success versus absolute sobriety as a requirement. In a military setting where so much is at stake, we view continuous sobriety as a marker for success both for the SMs and for the RTF program given the potential effects of relapse on mili-
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tary fitness and mission accomplishment. We appreciate that there are a multitude of potential other outcomes that could have been tracked and reported (e.g., reduction in substance use; homeless or not; employed, and so on). We chose to track relapse. Second, we encountered significant attrition in our cohort over time owing to a multitude of factors such as failure of SMs to follow up with their substance abuse counselors (who also are responsible for updating/logging incidents into DAMIS) after commencing from the RTF, permanent change of station and failure to reengage ASAP at new duty station (with no coordination between prior ASAP counselor; losing and gaining ASAP counselors), and/ or being administratively separated from military service. Our RTF also encountered difficulty attempting to collect relapse information from other Sei-vice branches outside of the Army. It is difficult to know how and in what direction our relapse rates would move to if we had 100% knowledge of relapse incidents in our cohort. As we reflect on our experiences over the past 4-i- years re-establishing and operating the DoD's largest RTF, several lessons have been learned and future directions have been elucidated. First, in our opinion, we have presented preliminary evidence that our intensive inpatient SUD treatment provided within a military setting is seemingly as effective at promoting continuous sobriety as other alcohol focused civilian-based treatment programs. Our bias is that military run RTFs may also be a better fit for Active Duty, Activated Reservists, and Activated National Guard SMs than civilian inpatient SUD programs counterparts given that we strive to maintain military structure and bearing, can determine fitness for duty or need for administrative separation, can leverage additional Behavioral Health assets available at a medical center in dually diagnosed patients with the goal of return to full duty perfonnance when possible. Second, given the great financial cost incurred by the DoD for establishing and maintaining military treatment modalities and programs across the various Service branches (and paying for civilian counterparts out in the community) and the continued dearth of available compelling outcome data, we absolutely encourage program evaluation efforts to occur from a transparency and accountability standpoint in both DoD (and by extension, TRICARE) funded civilian purchased care SUD programs. We also encourage DoD/military leadership as stewards of tax payers' dollars to ask the difficult questions to SUD treatment programs they are sending affected SMs to (i.e.. What are your outcomes? What is the evidence for your program and why should we continue funding it?). Similarly, in our opinion, DoD/military leadership should also hold the same expectations and ask the same questions to civilianbased programs in network who are offering services to SMs. Third, in our view, improved surveillance and communication within and across substance abuse counselors from the various military branches will also absolutely be required if we are going to improve our ability to better inform relapse among SUD SMs. An easy concept to appreciate, but difficult
677
Militan' Inpatient Residential Treatment of Substance Abuse Disorders
in practice to actualize owing to a multitude of challenges within and across the Service branches including possible disparate agenda's locally versus higher up the Chain of Command, fiscal support, and mission prioritization, APPENDIX Residential Treatment Facility Program Schedule Time 5:00 a.m.-05:15 a.m.
Week
Procedure/Event
Wake Up/Preparation for Physical Trahiing/Urine Analysis 5:15 a.m.-6:30 a.m. All Physical Training Personal Hygiene/Breakfast/Break 6:30 a.m.-7:45 a.m. All 8:00 a.m.-8:15 a.m. All Comtnunity Meeting 8:15 a.m.-10:15a.m. 2 Interdisciplinary Teatn Meeting 8:15a.m.-10:15a.m. 1,3,4,5 Medical and Staff Assessment Individual Study 10:15 a.m.-10:30 a.m. All Break 10:30 a.m.-12:00 p.m. All Group Therapy 12:00 p.m.-l:OO p.m. All Lunch/Break l:00p.m.-2:00p.m. 1 Life Skills: Values Clarification l:00p.m.-2:00p.m. 2 Recreational Therapy Risk Factor Group l:00p.m.-2:30p.m. 3,4,5 1 Recreational Therapy 2:00 p.m.-3:00 p.m. Life Skills: Problem Solving 2:00 p.m.-3:00 p.m. 2 Guilt and Shame 2:30 p.m.-3:30 p.m. 3 4 Individual Study 2:30 p.m.-3;00 p.m. 5 Treatment Plan Per Counselor 2:30 p.m.-!l:OO p.trt. 3:00 p.m.-3:3O p.m. 1 Individual Study 2 Video: Addictive Relationships 3:00 p.m.^:OO p.m. 4 Video: Illusions of Immunity 3:00 p.m.^:OO p.m. 3:30 p.m.^:OO p.m. 1 Video: Denial Individual Study 3:30 p.m.^:OO p.m. 3 All Cornmunity Meeting 4:00 p.m.^: 15 p.m. Relaxation Class—Progressive All 4:15 p.m.^:45 p.m. Muscle Relaxation Optional Fitness/Dinner/Break 4:45 p.m.-5:45 p.m. All Alcoholics Anonymous Pre 5:45 p.m.-6:00 p.m. All Planning (Staff) Alcoholics Anonymous Meeting 6:00 p.m.-9:00 p.m. All 9:15 p.m.-9:45 p.m. All Medication Wrap Up 9:45 p.m.-10:00 p.m. All All Lights Out 10:00 p.m.
678
All
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