Unhealthy alcohol use can be dangerous — and for military members, it can contribute to lack of operational readiness and impede recovery from common conditions like post-traumatic stress disorder and traumatic brain injury. In August 2019, Institute for Behavioral Health Scientist Rachel Sayko Adams, PhD’13 published "Post-Deployment Screening in the Military Health System: An Opportunity to Intervene for Possible Alcohol Use Disorder" in Health Affairs with colleagues from the Heller School and the Uniformed Services University of the Health Sciences, including Joshua C. Gray. In this Q&A, she offers insights into their findings and recommendations:
Why is it important to study unhealthy alcohol use in the military?
For decades, unhealthy alcohol use has been embedded in military culture, not unlike many college campuses. More recently, because of the military conflicts in Afghanistan and Iraq, drinking has often been used as a way to celebrate, manage stress, and cope with traumatic experiences from deployment after returning home. Military members are predominantly male, younger than age 30, and report higher rates of binge drinking than their same-age civilian peers. Unhealthy alcohol use and binge drinking increases the risk for and impedes recovery from many conditions also common to military members including depression, post-traumatic stress disorder, traumatic brain injury, and suicidality. Therefore, unhealthy alcohol use may not only impede the operational readiness of military members, but also contribute to the decreased health and wellbeing of a large cohort of our nation’s military members who will require care for decades to come in the Veterans Health Administration and civilian health care settings.
What were your key findings and their implications?
Military members are routinely screened for unhealthy alcohol use and possible alcohol use disorder when returning from deployments as a part of the Department of Defense’s (DoD) post-deployment health surveillance program. We focused on how the Military Health System responds to positive alcohol screens in a cohort of over 379,000 Army active duty soldiers returning from a deployment associated with the Afghanistan or Iraq conflicts (fiscal years 2008-2013). We found that 41% had a positive alcohol screen, including 11% with severe scores indicative of possible alcohol use disorder. Among soldiers with a screen score of severe alcohol use, we learned that 10% were diagnosed with an alcohol use disorder within 150 days, yet only half received a follow-up behavioral health visit; this revealed a missed opportunity for early intervention and the possibility of undetected alcohol use disorder among many soldiers. Permitting confidential access to treatment and implementing an automatic referral for additional assessment with a behavioral health provider following a positive alcohol screen may improve the early detection and treatment of alcohol use disorder among military members.
What steps has the Army taken to address the issue of unhealthy alcohol use?
In 2013, the Institute of Medicine released a report on Substance Use Disorders in the U.S. Armed Forces which deemed unhealthy alcohol use in the military a significant public health crisis. Brandeis co-author Mary Jo Larson, PhD ’92, was a member of the committee conducting the Institute of Medicine study. Since then, the Army has made numerous improvements, including mandating alcohol screening via the Periodic Health Assessment, integrating substance use care into behavioral health clinics, moving alcohol treatment back into the medical command, and embedding a behavioral health provider in Army primary care clinics. Perhaps most significantly, in March of 2019, the Secretary of the Army released a new directive to implement a voluntary and confidential program for alcohol use treatment which encourages alcohol screening and treatment in primary care, if needed. This new policy represents a monumental change intended to reduce stigma and remove barriers associated with disclosure of alcohol use behaviors without fear of actual or perceived negative career ramifications. Prior to this new policy, DoD policy required mandatory disclosure of alcohol use treatment-seeking to a military member’s commander, obviously a barrier for frank, honest discussion about alcohol use in a medical appointment.
What further steps could the Army and Department of Defense take to reduce unhealthy alcohol use?
With the implementation of this 2019 Army directive and its requirement for voluntary and confidential care, the Army now should be able to implement confidential screening, brief intervention, and referral to treatment for unhealthy alcohol use within Army primary care clinics, as recommended by the Institute of Medicine in 2013. This would place more emphasis on prevention, which may minimize the progression to more serious alcohol use problems among soldiers. We recommend that the other services (i.e., Air Force, Navy/Marines) implement similar policies to provide confidential and voluntary care for alcohol use treatment. We also recommend that the Department of Defense enforce existing underage drinking laws and implement evidence-based prevention programs such as motivational interviewing and cognitive behavioral therapy. Other innovative strategies are needed to influence cultural norms that reinforce unhealthy drinking, including environmental-based interventions to reduce alcohol consumption via price increases or restriction of retail hours for alcohol sales on military installations, which have shown to be effective and relatively straightforward to implement.
Is there anything else you’d like to add?
We concluded in our Health Affairs paper that “unhealthy alcohol use may be a canary in the coal mine, and failure to heed its warning signals decreases the success of critical public health initiatives” underway in the Department of Defense and Veterans Health Administration such as suicide and sexual assault prevention programs. We contend that if unhealthy alcohol use is not identified early and appropriate interventions offered, it will complicate symptoms of co-occurring mental health problems such as post-traumatic stress disorder and depression, and that the burden of these problems will eventually be transferred to the Veterans Health Administration or civilian providers. Our study found that the Department of Defense’s post-deployment health surveillance program is a useful tool to capture indicators of unhealthy alcohol use, and that the Department of Defense should improve its responsiveness to these warning signals.
The opinions and assertions herein are those of the authors and do not necessarily reflect official policy or position of the Uniformed Services University, Department of Defense, or the National Institutes of Health.