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Substance Use and Abuse in the Military

Chapter 29

substance use and abuse in the 

military

R. GREGORY LANDE, DO*; BARBARA A. MARIN, PhD†; JAMES J. STAUDENMEIER, MD, MPH‡; and

DARYL HAWKINS, PhD§

INTRODUCTION

EFFECTS OF ALCOHOL ABUSE ON PERFORMANCE

Cognitive Impairment

Memory Impairment

Sleep Impairment

SCREENING FOR ALCOHOL ABUSE

TOBACCO USE

OTHER DRUGS OF ABUSE

THE ROLE OF THE MILITARY MEDICAL REVIEW OFFICER

THE ARMY SUBSTANCE ABUSE PROGRAM

SUMMARY

*Chief, Psychiatry Continuity Service, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 2, Room 5343, 

Washington, DC 20307; Clinical Consultant, Walter Reed Army Medical Center Substance Abuse Program, Washington, DC

†

Integrated Chief, Department of Addictions Treatment and Clinical Director, Army Substance Abuse Program, Walter Reed Army Medical Center, 6900 

Georgia Avenue NW, Washington, DC 20307-5001

‡

Colonel, Medical Corps, US Army; Consultant, Army Substance Abuse Program, Department of Psychiatry, USAMEDDAC, 11050 Mount Belvedere 

Boulevard, BMD (Wilcox), Fort Drum, New York 13602; formerly, Fellow in Geriatric Psychiatry, Walter Reed Army Medical Center, Washington, 

DC 

§

Alcohol and Drug Control Officer, Army Substance Abuse Program, Building 6, Room 2066, Walter Reed Army Medical Center, 6900 Georgia Avenue 

NW, Washington, DC 20307-5001
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INTRODUCTION

Through the centuries of armed conflict, soldiers 

have sought to immunize themselves from the fear 

and uncertainty of combat. The principle shield that 

protects these combatants is training. Endless training 

breeds confidence in military skills and weapons. A 

strong group milieu firmly centered around camaraderie, mutual support, and confidence further strengthens emotional resilience. These are the positive factors 

reinforcing a sense of “invulnerability.”

The emotional shield protecting soldiers from the 

stress of combat is further strengthened by training 

and group cohesion, but weakened by other hidden, 

pernicious factors. Chief among the factors battering 

the emotional shield are individually experienced 

traumas. Although substance use may be perceived 

by soldiers as a way of reducing the stress of these 

traumas, the corrosive influence of substance abuse 

is substantial.

Modern militaries are dominated by complex machinery, precision weaponry, advanced information 

technologies, and a structural agility necessary for 

rapid adaptation to a wide range of threats. In a similar 

fashion, today’s soldier is more sophisticated, relying 

more than ever on “brain over brawn.” Nonetheless, 

physical stamina is important, given the grinding 

endurance required of combat operations. As a consequence, all military personnel must maintain a level 

of physical fitness. Despite the obvious importance 

of physical training, cognitive stamina may be even 

more important. A successful military career requires 

persistent honing of the basic cognitive tasks involving 

information processing and psychomotor skills. 

EFFECTS OF ALCOHOL ABUSE ON PERFORMANCE

Cognitive Impairment

The use of alcohol promotes a wide range of 

biobehavioral impairments, many of which have 

particular significance to military activities. Alcohol 

impairs cognitive function in ways both subtle and 

severe. The nature and intensity of alcohol-related 

impairments vary according to consumption patterns, 

physiologic response, social acceptance, and the presence of co-occurring medical or psychiatric problems. 

Despite these intraindividual variations, at least for the 

purposes of comparison, the average man weighing 

150 pounds can reliably achieve a blood alcohol concentration (BAC) of 0.04% following the consumption 

of two standard alcohol drinks in 1 hour.1

 Thus, even 

low levels of alcohol consumption impair cognition. 

Complex tasks are even more sensitive to the intoxicating influence of alcohol.

Mental activities that require divided attention, such 

as managing a weapon and scanning the environment, 

can suffer when blood alcohol levels hover as low as 

0.02%.2

 The brain’s information processing system 

attempts to compensate by focusing mental acuity 

in one area. This can lead to a devastating outcome 

when mental agility and survival are closely linked. 

The average man can achieve a BAC of 0.02% with 

as little as one standard drink in 1 hour, or be on the 

downward alcohol concentration slope after a bout of 

heavier drinking.2

One psychomotor task with special significance 

in military operations involves the ability to visually 

track objects. Whether sighting a weapon or driving a 

vehicle, the smooth and accurate control of eye motion 

is critical to mission success. Military personnel can 

experience impaired visual acuity, mostly in terms of 

difficulty focusing, with BAC as low as 0.03%.2

Clearly, the “blurred” vision associated with alcohol use is common. A less recognized, but potentially more hazardous, consequence of consumption 

involves a visual–spatial impairment. Visual–spatial 

exercises require the proper placement of objects in 

space. To effectively respond to an enemy sniper firing from multiple areas requires recognition of the 

sniper’s relative positions and possible extrapolation 

to the next location. This sort of analysis relies on 

accurate perception and the application of abstract 

thinking.

Alcohol interferes with visual–spatial processing 

in two broad ways: intoxication makes multitasking 

more difficult or it simply renders the vision less accurate. The long-term use of alcohol, where duration 

and quantity are not fully defined, seems to produce a 

fixed change in cognition. The change is expressed in a 

loss of mental agility, inhibiting the ability to confront 

a novel problem with a creative solution. Clues to this 

condition emerge when an otherwise adequately performing individual is thrust into a new environment 

and cannot adapt old skills to the current reality.2

The greatest degree of impairment in the ability to 

apply abstract reasoning occurs in the weeks following 

reduction or cessation of significant alcohol consumption. Military personnel accustomed to substantial 

levels of alcohol use may be forced into an unwelcome 

abstinence when deployed, which can be accompanied 

by the emergence of worrisome symptoms of cognitive decline.
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Substance Use and Abuse in the Military

Memory Impairment

Chronic alcohol use disrupts the communication 

paths between areas of the brain responsible for 

processing memories, specifically the frontal lobes 

and the hippocampus.3 In fact, long-term alcohol use 

structurally reduces brain volume.4 The resulting 

memory deficits profoundly influence the acquisition 

and retention of knowledge.

A more intriguing and potentially harmful effect of alcohol use arises from acute intoxication. It 

seems increasingly apparent that alcohol consumption interferes with memory formation. The risk of 

acute alcohol-related memory impairment correlates 

closely with quantity consumed and the speed of 

absorption. Bolus, or binge, drinking among men is 

defined as five or more drinks in 2 hours. For women, 

four or more drinks in 2 hours constitutes bolus 

drinking. A much higher probability of memory 

impairment exists if bolus drinking occurs on an 

empty stomach. 

Blackouts—the complete failure to transcribe events 

into memory—are not a rare phenomenon. Indeed, 

surveys among college students, a cohort closely agematched with the largest military contingent, would 

suggest that blackouts are common. Based on these 

surveys, an estimated 40% to 50% of college students 

report a prior blackout. Fragmented memory loss 

is more common than a total blackout.3

 Just a few 

drinks, ambiguously regarded as “social drinking,” 

can produce lapses in attention and word finding. 

Neither condition benefits military personnel engaged 

in fast-paced military operations.

Sleep Impairment

Alcohol’s negative impact on cognition and memory is amplified by another side effect of consumption. Even small amounts of alcohol can profoundly 

affect the sleep cycle.5 Although alcohol consumption 

reduces the amount of time necessary to fall asleep, 

it disturbs the late parts of the sleep cycle. The night 

is spent with frequent awakenings, many of which 

occur during rapid eye movement (REM) sleep. Disruption of REM sleep may have particular relevance 

in exacerbating fatigue, irritability, and the recall of 

disturbing dreams.

The sleep-inducing benefits of alcohol fade with 

repeated use, while at the same time the sleep cycle becomes ever more fragmented. It seems natural enough 

to use alcohol as a soporific during periods of stress 

and trauma. However, shift work and deployment 

across time zones may synergistically combine with 

an alcohol-induced sleep disorder to further impair 

the individual.

Alcohol withdrawal, perhaps induced by the forced 

abstinence of rapid mobilization, characteristically 

produces marked insomnia, disturbing dreams, and 

even hallucinations.5

 This can be an especially troublesome development when a service member deploys 

to an area of combat operations. The normal anxiety 

associated with deployment fuses with the symptoms 

of withdrawal and may produce substantial incapacitation. 

SCREENING FOR ALCOHOL ABUSE

The detection of alcohol abuse begins with an understanding of its prevalence. Epidemiologic studies categorize alcohol use as light, moderate, and heavy.6

 Light 

drinking consists of three or fewer beverages per week. 

Light drinking is common. Nearly 43% of Americans 

meet the consumption criteria for light drinking.

Gender influences the values associated with moderate and heavy drinking. Moderate drinking among 

women consists of more than three but less than eight 

drinks per week; for men, no more than 14 drinks per 

week. Heavy drinking among women consists of more 

than one daily drink per week; for men it is more than 

two daily drinks per week. Based on these criteria, 14% 

of Americans are moderate drinkers and almost 4.5% 

meet the definition of heavy drinking.6

Epidemiologic consumption patterns contributed 

to the development of a simple screening tool referred 

to as the “Quantity Frequency Questionnaire.”7 The 

first set of questions queries quantity by asking, “On 

average, how many days a week do you drink alcohol?” and “On a typical day when you do drink, how 

many do you have?” If the multiplied sum of the two 

responses exceeds 14 for men (or seven for women) 

this can be considered “at-risk” drinking.

Bolus drinking is another “at-risk” drinking behavior. This pattern of drinking is the other half of the 

Quantity Frequency Questionnaire. The individual 

is asked, “What is the maximum number of drinks 

you had on any given day in the past month?” “At 

risk” bolus drinking occurs when men exceed four 

(and women three) drinks at one time. If the person 

is deemed “at-risk” based on the Quantity Frequency 

Questionnaire, then the CAGE questions should be 

asked.8

 The CAGE questionnaire inquires about alcohol use over the past year by asking:

C: Have you ever felt that you should CUT 

down on your drinking?
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Combat and Operational Behavioral Health

 A: Have people ANNOYED you by criticizing 

your drinking? 

G: Have you ever felt bad or GUILTY about your 

drinking?

 E: Have you ever tried a drink first thing in the 

morning? (EYE opener) 

If the person answers yes to any of the CAGE 

questions, this should trigger a more comprehensive 

assessment of substance use.

Alcohol screening questionnaires can be combined 

with certain laboratory tests. (Most biochemical markers require a blood sample.) The accuracy of these tests 

in detecting alcohol use depends on the tests’ sensitivity and specificity. By itself, no single test conclusively 

identifies alcohol use. Multiple tests, combined with an 

“at risk” history, provide better evidence of problem 

drinking.9 Perhaps the best single biochemical marker 

of alcohol use is gamma glutamyl transferase, or GGT. 

Elevated GGT occurs in a range of 30% to 50% among 

problem drinkers.

Problem drinking may also elevate aspartate aminotransferase and mean corpuscular volume, but both 

are less sensitive than GGT. Carbohydrate deficient 

transferrin is elevated among heavy drinkers and has 

sensitivity levels approaching GGT. Ethyl glucuronide 

can be detected in a urine specimen up to 5 days after 

heavy alcohol use. Ethyl glucuronide might play a 

clinically useful role in detecting alcohol use after bolus 

drinking on weekends. 

TOBACCO USE

Although alcohol remains the most commonly used 

substance, tobacco use is almost as frequent. Approximately 29% of Americans use tobacco, with nearly 24% 

of that figure accounted for by cigarettes. Another 

3% of the population uses smokeless tobacco.10 Thus, 

healthcare practitioners should inquire about all forms 

of tobacco, including smokeless products.

 During periods of major upheaval, such as natural 

or manmade disasters, an increase in the use of tobacco 

occurs. Several studies explored tobacco use among 

individuals exposed to the Oklahoma City bombing in 

1995, in the aftermath of the 2001 terrorist attack on the 

twin towers of the World Trade Center in New York, 

and during other stressful events.11–13 The findings from 

these collective studies provide evidence of increased 

smoking among traumatized individuals. Individuals 

who increase their smoking during periods of stress 

subsequently develop the symptoms of posttraumatic 

stress disorder (PTSD) at rates exceeding nonsmokers. 

The problem is further compounded when traumatized individuals report an inability to quit smoking. 

In a more quantifiable way, smoking appears to double 

the risk of developing PTSD.14

Tobacco use appears to play a key role in amplifying 

anxiety, inhibiting more effective coping strategies, and 

possibly contributing to heightened irritability. Military planners and healthcare practitioners can monitor 

tobacco use as a potential risk factor for emotional 

distress. For example, the predeployment phase begins 

with official notification of a pending assignment. 

Some military personnel may respond by initiating or 

markedly increasing their use of tobacco.

The Fagerström Test for Nicotine Dependence15 is a 

screening tool used to assess cigarette use and can be 

administered at any phase of the deployment cycle, 

be it pre-, during, or postdeployment, to assess the 

degree of nicotine use. The test has a total of six questions, covering the following areas for an individual 

smoker:

1. time of day first cigarette is smoked;

2. whether the subject has difficulty refraining 

from smoking in places where it is not allowed;

3. time of day it would be most difficult to go 

without a cigarette;

4. total number of cigarettes smoked each 

day;

5. time of day, if any, when the subject smokes 

more frequently; and

6. whether or not the subject smokes even when 

ill enough to be home in bed.15

Points are assigned to the responses, ranging from 

0 to 3 points, depending on the particular question. 

The test has a maximum total of 16 points; any score 

above 7 points is considered a very high addiction.15

Military personnel scoring at the higher levels may 

be at increased risk of emotional deterioration. The 

increased use of tobacco may be an effort to selfmedicate. Healthcare practitioners should take the 

opportunity to explore this possibility.

OTHER DRUGS OF ABUSE

A sizable minority of the American public regularly 

skirts potentially severe legal penalties to use, abuse, 

or sell a wide range of illegal drugs. A person’s drug 

of choice is a complex judgment based on personality 
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Substance Use and Abuse in the Military

dynamics, cost, availability, and the drug’s effects. In 

some situations, such as deployment to foreign locations, the new environment can either restrict options 

or provide new opportunities.

The National Survey on Drug Use examined patterns among individuals 18 to 25 years old, the age 

range that correlates well with the majority of the 

military population. Among this group, the survey 

reported 16.4% used marijuana, 6% used prescription 

drugs for recreational purposes, 1.7% used cocaine, 

and 1.5% used a hallucinogen.10

Marijuana is the most commonly used illegal drug, 

with 5.8% of Americans 12 years and older reporting 

use in the month proceeding the administration of the 

National Survey on Drug Use.16 During the same time 

period, 2.1% reported the nonmedical use of prescription pain relievers, 0.8% of Americans reported the use 

of cocaine, and 0.4% used a hallucinogen. “Ecstasy” 

accounts for half of the reported hallucinogen use.10

The nonmedical use of prescription pain-relieving 

drugs is an area of special concern. The most likely 

source of these prescription drugs was a friend or 

family member.

The extent to which military use of illegal drugs 

bears some similarity to the National Survey on Drug 

Use is not precisely known. It seems reasonable to 

conclude that social trends are reflected in the military 

population. Following this line of reasoning, marijuana, cocaine, and the nonmedical use of prescription 

drugs would be the most likely problem areas.

The abuse of prescription pain relieving medications is particularly vexing. Traditional medical tests 

designed to detect opiate use will not identify the most 

likely offenders. Medications derived naturally from 

the poppy plant include morphine and codeine. These 

naturally occurring compounds are referred to as 

opiates and are included in most standard urine drug 

screens. Opioids are semisynthetic or fully synthetic 

opiates. Heroin, hydromorphone, hydrocodone, oxycodone, and fentanyl are examples of opioids. Opioids 

are not included in most standard medical urine drug 

tests and must be specifically ordered by name. If a 

clinician suspects the nonmedical use of oxycodone, 

for example, then oxycodone must be ordered by name 

from the testing laboratory. Clinicians should consult 

their laboratories for guidance. 

Military planners and healthcare professionals 

should recognize the difficulty identifying opioid 

abuse and the ease in obtaining these medications. 

Detection of the nonmedical use of prescription drugs 

begins with an increasing index of suspicion triggered 

by certain behaviors. Routine screening should be 

part of every health encounter, which should include 

several questions aimed at understanding the person’s use of addicting medications. Greater concern 

is occasioned by frequent medical visits rewarded 

with overlapping prescriptions. Some of the excess 

medications may be destined for diversion. The truly 

resourceful individual will seek prescription medications from multiple healthcare providers, both military 

and civilian, as well as the Internet.

The US government, through the Controlled 

Substances Act, classifies drugs into five schedules 

based on abuse potential. Drugs in schedule I or 

II are considered “illegal drugs” for purposes of 

prosecution. The Controlled Substances Act applies 

in all settings, be it a tertiary care medical facility in 

the United States, a regional military hospital in a 

foreign country, or mobile medical assets in support 

of combat operations.

The US military fields a robust drug-testing program. Today’s modern drug-testing programs are direct descendants of embryonic military efforts initiated 

in the 1970s. Roughly a decade later, President Ronald 

Reagan signed Executive Order 12564,17 mandating 

federal drug testing. Federal regulators understood 

the importance of clinical oversight and by the mid1980s created the position of a medical review officer 

(MRO). The MRO plays a critical role in the fair and 

effective administration of the Federal Drug Testing 

Program. The US Department of Transportation and 

the Substance Abuse and Mental Health Services 

Administration both have extensive print and online 

documentation outlining the exact responsibilities of 

the MRO. US Army policies and procedures are found 

in Medical Command Regulation 40-51.18

THE ROLE OF THE MILITARY MEDICAL REVIEW OFFICER

For the sake of brevity, and in light of the changing 

rules and variances among the services, this chapter 

will not cover all the responsibilities and regulations 

pertaining to the military MRO. The official definition 

of the MRO is “a licensed physician responsible for 

receiving laboratory results generated by an agency’s 

drug testing program who has knowledge of substance 

abuse disorders and has appropriate medical training 

to interpret and evaluate an individual’s positive test 

result together with his or her medical history and any 

other relevant biomedical information.”19(p5)

The military treatment commander appoints the 

MRO (always a physician) specifically to function in 

that capacity. The MRO must be familiar with laboratory procedures, which include screening immunoassay, gas chromatography, and mass spectrometry. The 
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Combat and Operational Behavioral Health

Figure 29-1. Standard Form 513, Medical Record Consultation Sheet.
479

Substance Use and Abuse in the Military

testing procedures are consistent among the services. 

For purposes of illustration, the Army’s procedures are 

set forth in Army Regulation (AR) 600-85,20 Chapter 8, 

which places the responsibility of test result reporting 

in the hands of the alcohol and drug control officer 

(ADCO). The ADCO is a member of the garrison or 

administrative section of Army Substance Abuse 

Program (ASAP). The installation biochemical testing 

coordinator (IBTC) works for the ADCO and coordinates the testing and review of the urinalysis. The 

IBTC and ADCO do not have a direct affiliation with 

the military treatment facility. The IBTC or ADCO 

sends the MRO a consult or request (using an SF513, shown in Figure 29-1) requesting a review of the 

positive urinalysis. The SF-513 request should include 

the military person’s identifying data, specific drugs 

in question, and the date the biochemical test was 

conducted. The MRO should also review DD Form 

2624 (Figure 29-2), otherwise known as the Specimen 

Custody Document: Drug Testing. 

The MRO will review the military person’s medical records seeking a legitimate medical prescription 

that would account for the biochemical test result. 

If such evidence is lacking, the MRO will document 

this finding on the consult and forward the response 

to the ADCO or IBTC. The MRO’s response triggers 

one of the important safeguards of the biochemical 

testing program. Up to this point, the MRO’s opinion 

rested solely on medical documentation. To ensure 

that a comprehensive medical review occurs before 

a drug test is deemed “positive,” the military person 

will have the opportunity to meet with the MRO and 

present medical evidence that might account for the 

test result. Normally, the ADCO or IBTC will arrange 

the interview with the MRO. 

If the service member agrees to proceed, the MRO 

reviews the purpose of the interview and reviews 

the test results. Most importantly, the service member is afforded the opportunity to present evidence, 

such as a valid prescription, that might account for 

Figure 29-2. DD Form 2624, Specimen Custody Document: Drug Testing, page 1. (Figure 29-2 continues)
480

Combat and Operational Behavioral Health

Figure 29-2 continued. DD Form 2624, Specimen Custody Document: Drug Testing, page 2. 

the drug test. If satisfied that the evidence confirms 

legitimate drug use, the MRO will annotate “legitimate drug use” on the SF-513 and return the form to 

the ADCO.

THE ARMY SUBSTANCE ABUSE PROGRAM

Biochemical testing is only one of several methods 

through which referrals are made to the ASAP, or its 

counterparts in the other military services. Referrals 

can also be initiated by commanders and supervisors in response to observed changes in occupational 

performance, interpersonal relations, and physical fitness or health problems suspected to be secondary to 

substance use. These referrals are made by physicians 

and other healthcare providers in the context of routine 

or emergency medical treatment, as a consequence 

of military or civilian law enforcement investigation 

or apprehension identifications, or through the individual’s voluntary self-identification to the clinic. 

In fiscal year 2008, the Army’s Drug and Alcohol 

Management Information System reported that 10,407 

soldiers were enrolled in the ASAP Army-wide. An 

additional 10,310 soldiers were evaluated, though not 

enrolled. Of those evaluated and subsequently enrolled 

for outpatient treatment, 22% were referred through 

biochemical identification, 27% through commander 

or supervisory intervention, 11% as a result of a driving under the influence/driving while intoxicated 

arrest, 5% through other investigation or apprehension identification, 10% as medical referrals, 24% as a 

result of self-identification, and the remainder through 

a variety of other channels (ie, security clearances, 

family members).21

 Regardless of the method of identification, all of the 

military substance abuse treatment programs function 

in large measure within the conceptual model of an 

employee assistance program, focusing on personnel 

conservation and military readiness. Optimizing the 
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Substance Use and Abuse in the Military

advantages of coercive treatment through effective 

leveraging of command oversight, the ASAP benefits 

from a well-articulated team approach in the service of 

behavior change. The relationship between the ASAP 

and the command is clearly defined in AR 600-85,20

with parallel guidance in Air Force Instruction 44-121,22

and Operational Navy Instruction 5350.4C.23 AR 600-

85 differentiates the responsibilities of the command 

from that of the clinical staff, placing clinical decision 

making in the hands of the ASAP’s professional staff. 

All of the clinical staff is required, per AR 40-68,24 to be 

licensed to practice independently and to be certified 

in substance abuse rehabilitation. The clinical consultant, an addictions-trained physician, assists the ASAP 

staff, providing medical consultation and adjunctive 

medication management. It is the ASAP clinical staff’s 

responsibility to advise command of all referrals and to 

secure command input into their assessments. 

Although only the clinical staff may define treatment recommendations, unit commanders retain authority for all administrative decisions, ranging from 

deployments to retention or separation from service, 

extensions on active duty to permit reenlistment, or 

bars to reenlistment.20(p9) When retention decisions are 

required, commanders must assess the service members’ rehabilitation efforts in the context of their occupational specialties, prior service records, the needs 

of the military, and their potential for future military 

service. In general, each of the military services will 

tend to separate drug- or alcohol-dependent service 

members who do not respond to treatment. 

The Secretary of Defense is required to identify 

and treat all active duty service members who are 

drug and alcohol dependent.25 Regardless of service 

designation, referral for evaluation is mandatory and 

early intervention is key. All of the military services 

have procedures and policies to identify and offer 

treatment to those active duty members who have 

drug and alcohol problems. The unique challenges to 

deployed commanders in managing substance abuse 

issues are addressed in an information paper produced 

by the Army Center for Substance Abuse Programs.26

It provides guidance to deployed unit commanders 

regarding accessing ASAP services prior to deployment, in theater, and upon return. 

Once identified and referred, a comprehensive 

biopsychosocial and substance use assessment is completed by the ASAP staff. The assessment explores the 

extent of substance use; intervention is recommended 

according to the degree of impairment. Such treatment 

recommendations are based upon careful consideration of the criteria for substance use disorders, per 

the current Diagnostic and Statistical Manual of Mental 

Disorders.

27 Diagnoses of abuse and dependence generally require enrollment in treatment for periods of 3 

months to 1 year. The intensity of response can range 

from a 12-hour instructional program called ADAPT 

(Alcohol and other Drug Abuse Prevention Training) 

to outpatient treatment activities in the ASAP. Referrals to higher levels of care for detoxification, intensive 

outpatient programs, partial hospitalization programs, 

or residential treatment are often incorporated into the 

treatment plan. 

Per Health Affairs Policy 9700029,28 a continuum 

of substance abuse care must be considered for active 

duty service members, consistent with the patient 

placement criteria of the American Society of Addiction Medicine. “These criteria reflect the philosophy 

of placing patients in the least intensive/restrictive 

treatment environment, appropriate to their therapeutic needs.”29(p2) In addition to defining a crosswalk for 

level-of-care determinations, the American Society of 

Addiction Medicine posits a multidimensional analysis to enhance treatment decision making. Acute intoxication or withdrawal potential (Dimension 1) and 

the patient’s biomedical conditions and complications 

(Dimension 2) must receive primary consideration 

in the stabilization process, after which the patient’s 

emotional, behavioral, and cognitive conditions and 

complications (Dimension 3); readiness for change 

(Dimension 4); relapse, continued use, or continued 

problem potential (Dimension 5); and recovery/living environment (Dimension 6) are considered in the 

formulation of a dynamic and individualized treatment plan.30(p4) Treatment emphasizes motivational 

enhancement over confrontational drama, supported 

by a multidisciplinary team approach to facilitate 

change. 

Although the clinical role of the ASAP providers 

and the administrative domain of the command are 

clearly differentiated, a collaborative thread is woven between the command and clinical staff through 

implementation of the “rehabilitation team.” The rehabilitation team concept is developed in AR 600-85,20(p17)

and is a core ingredient of an effective program. With 

the ASAP clinician serving as chair, the rehabilitation 

team is composed of the soldier, the unit commander 

or first sergeant, and others as needed. In its most effective implementation, the rehabilitation team meeting 

provides the soldier with a positive outlook to start 

treatment. It offers a forum to clearly define program 

expectations and to explain the benefits for successful 

completion, while also articulating the consequences 

of failure to comply with treatment guidelines. It also 

offers a setting in which to provide assurances of support to mitigate a soldier’s fears, to explain patient 

rights, and to discredit some of the myths that pervade 

early beliefs and undermine success. Careers are more 

often enhanced than lost through the rehabilitation 

process. Therefore, it is imperative that soldiers experi-
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Combat and Operational Behavioral Health

ence the ASAP staff and command group as a unified 

team whose primary mission is to conserve personnel 

and promote health and well-being. Career retention 

goals and personnel conservation thus are married to 

rehabilitation efforts through the close collaboration 

with command. 

SUMMARY

Today’s military requires sophisticated knowledge 

and advanced technical skills to successfully navigate 

lethal battlefields. Even modest amounts of alcohol can 

impair crucial decision-making abilities and negatively 

affect military operations. Military personnel are not 

immune to the larger social problem of tobacco, illicit 

drugs, and the misuse of prescription and over-thecounter medications. The military maintains an active 

biochemical testing program to constantly assess the use 

of these substances and their impact on military readiness. In addition, each service offers specific administrative rules and clinical support to address the misuse of 

substances. The best outcome for the individual and the 

organization results from a collaborative effort involving clinicians, commanders, and a motivated patient to 

resolve issues of substance abuse.

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