By Rick Nauert PhDSenior News Editor
Reviewed by John M. Grohol, Psy.D. on September 18, 2012

Commissioned by Congress, a new report from the Institute of Medicine, the health division of the National Academy of Sciences, finds significant problems in how substance abuse care is managed in the military.

Researchers found that outdated approaches to prevention and treatment of substance abuse disorders, including barriers to care, compromise the U.S. Defense Department’s ability to control substance use disorders among military service members and their families.

Service members’ rising rate of prescription drug addiction and their difficulty in accessing adequate treatment for alcohol and drug-related disorders were among the concerns that prompted members of Congress to request this review.

“We commend the steps that the Department of Defense and individual service branches have recently taken to improve prevention and care for substance use disorders, but the armed forces face many ongoing challenges,” said Charles P. O’Brien, chair of the committee that wrote the report.

“Better care for service members and their families is hampered by inadequate prevention strategies, staffing shortages, lack of coverage for services that are proved to work, and stigma associated with these disorders. This report recommends solutions to address each of these concerns.”

Researchers found that about 20 percent of active duty personnel reported having engaged in heavy drinking in 2008, the latest year for which data are available. Binge drinking was also problematic as the behavior increased from 35 percent in 1998 to 47 percent in 2008.

Although investigators found low rates of illicit and prescription drug abuse, the rate of medication misuse is rising as a 9 percent increase was noted between 2002 and 2008.

The armed forces’ programs and policies have not evolved to effectively address medication misuse and abuse, the committee noted.

To tackle these disorders better, DOD needs to lead from the top to ensure that all service branches take excess drinking and other substance use as seriously as they should, and that they consistently adhere to evidence-based strategies for prevention, screening, and treatment, the report says.

The committee also discovered that inconsistent use of evidence-based diagnostic and treatment strategies has contributed to a lower quality care.

In fact, investigators discovered that even the departments own Clinical Practice Guideline for Management of Substance Use Disorders is not being consistently followed.

Surprisingly, TRICARE, which provides health insurance to service members and their dependents, does not cover several evidence-based therapies that are now standard practice, the committee found.

It also does not permit long-term use of certain medications for the treatment of addiction and covers treatment delivered only in specialized rehabilitation facilities.

The committee strongly believes that TRICARE’s benefits should be revised to cover maintenance medications and treatment in office-based outpatient settings delivered by a range of providers, which would enable ongoing care for patients struggling to avoid relapses.

Another issue pertains to alcohol abuse. Alcohol has long been part of military culture, and attitudes toward drinking vary across the service branches.

The committee believes that the armed forces should enforce regulations on underage drinking, reduce the number of outlets that sell alcohol on bases, and limit their hours of operation.

In addition, the service branches should conduct routine screening for excessive alcohol consumption in primary care settings and provide brief counseling when screening points to risky behavior.

Committee members believe primary care professionals should perform more screening and intervention services. This inclusion of substance abuse delivery as a part of part of primary care would reduce the stigma associated with seeking substance abuse treatment and increase the number of places where service members and families can get basic care for these disorders.

Furthermore, health care providers should not have to include service members’ commanding officers when developing care plans for those who do not meet diagnostic criteria for alcohol use disorders and need only brief counseling.

Each branch also should provide options for confidential treatment; the Army’s Confidential Alcohol Treatment and Education Pilot offers a promising example.

Military health care professionals at all levels need training in recognizing patterns of substance abuse and misuse and clear guidelines for referring patients to specialists such as pain management experts and mental health providers.

Team care by a range of providers not only is a more effective approach but also would help alleviate the provider shortage created by the military’s sole reliance on specialty substance abuse clinics to provide care, the committee concluded.

Easier access to providers and better management of substance use disorders could improve detection and care for related conditions, such as post-traumatic stress disorder, depression, and suicidal thoughts, the committee noted.

Substance misuse and abuse frequently occur along with these conditions. Rising suicide rates among both active duty personnel and veterans have alarmed the public and government officials.

Source: National Academy of Sciences

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A new study has found that people who begin taking anti-anxiety medications such as Xanax, Ativan or Valium after the age of 65 have a 50 percent greater chance of developing dementia within 15 years than people who have never taken this class of drugs.

Xanax, Ativan and Valium fall into a class of drugs called benzodiazepines, and are some of the most frequently used drugs in psychiatry. They are primarily prescribed to treat anxiety and sleep problems.

“Considering the extent to which benzodiazepines are prescribed and the number of potential adverse effects, indiscriminate widespread use should be cautioned against,” researchers say in the study, which was published in the British Medical Journal.

Benzodiazepines are widely prescribed for insomnia, anxiety and sedation for people over 65 in many countries, including 30 percent of this age group in France, 20 percent in Canada and Spain, 15 percent in Australia, according to the researchers. Many take this type of drug for years despite guidelines suggesting it should be limited to a few weeks, the researchers note.

Researchers carried out a study on 1,063 men and women with an average age 78 in France who were all free of dementia at the start of the study in 1987, with a planned follow-up in 20 years.

The researchers used the first five years to identify the factors leading to the first prescription for a benzodiazepine medication, then evaluated the association between the new use of this drug and the development of dementia. They also assessed the association between further benzodiazepine drug use during the follow-up period and risk of subsequent dementia.

Rates were adjusted for many factors potentially affecting dementia, such as age, gender, educational level, marital status, wine consumption, diabetes, high blood pressure, cognitive decline, and depressive symptoms.

According to the researchers, 95 of the 1,063 patients started taking a benzodiazepine medication during the study. The researchers confirmed 253 cases of dementia (23.8 percent) — 30 in benzodiazepine users and 223 in non-users.

The researchers found that the chance of dementia occurring was 4.8 per 100 person years in the group taking a benzodiazepine medication compared to 3.2 per 100 person years in the group not taking any of the drugs. A “person year” is a statistical measure representing one person at risk of developing a disease during a period of one year.

The researchers note that while many of the benzodiazepine medications remain useful for treating anxiety and insomnia, there is increasing evidence that their use may induce adverse outcomes in the elderly, such as serious falls, fall-related fractures and, now, dementia.

They say that their findings add to the accumulating evidence that the use of these drugs is associated with increased risk of dementia and, if true, that this “would constitute a substantial public health concern.”

The researchers recommend that physicians should assess expected benefits of the drugs and limit prescriptions to a few weeks. They caution against “uncontrolled use.”

They conclude that further research should “explore whether use of benzodiazepine in those under 65 is also associated with increased risk of dementia and that mechanisms need to be explored explaining the association.”

Source: British Medical Journal