The committee’s ability to make direct comparisons across branches or even within branches across years was hampered because of variations in the way data on SUD care are maintained and reported. These variations were magnified when the committee attempted to integrate direct care information with data from the TRICARE regional offices and purchased care programs. This exercise illustrated the complex nature of obtaining and reviewing data on the scope of the SUD problem DoD-wide and understanding the full extent of services offered to address alcohol and other drug problems, both emerging and chronic. The lack of consistent reporting of data DoD-wide appears to hamper monitoring of how well current programs meet the needs of the armed forces. At its various site visits, the committee learned that different systems store different types of data. Program managers must therefore consult multiple systems (typically at least one managed by Installation Command and one managed by Medical Command, and sometimes more) either weekly or daily to monitor the progress from positive drug tests to Command referrals to substance use assessment.

CARE AVAILABILITY, ACCESS, AND UTILIZATION IN THE VETERANS HEALTH ADMINISTRATION

The VHA also provides SUD services for ADSMs, and the committee reviewed the access standards for SUD care specified in Uniform Mental Health Services in VA Medical Centers and Clinics (VHA Handbook 1160.01) (VA, 2008). These standards are consistent with the National Voluntary Consensus Standards for Treatment of Substance Use Conditions endorsed by the National Quality Forum (NQF, 2007) and with the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009). Box 7-3 lists the services that must be readily available, according to the access standards, to all patients when clinically indicated.

Currently, the VA provides care for SUDs in 108 intensive outpatient clinics, 237 residential rehabilitation treatment programs (8,443 operational beds), and 63 programs with specialty SUD bed sections (1,658 beds). The Opioid Treatment Program includes 32 in-house and 22 contracted off-site formally approved and regulated opioid treatment clinics using methadone or buprenorphine as agonist medications. Office-based buprenorphine treatment is offered by “waivered” physicians in nonspecialty settings (e.g., primary care), including 132 medical centers and 109 community clinics. The VA provides an SUD-PTSD specialist funded at each facility to promote integrated care. These specialists provide treatment based on the VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) and its counterpart for PTSD



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