MILITARY AND VETERANS

Substance Use and Co-Occurring Disorders Among Military and Veterans

Of the millions of men and women in the military who put their lives on the line for the United States every day, many have a substance use disorder in addition to a mental illness. During 2002, approximately 18 percent of military personnel were heavy drinkers of alcohol and 12.3 percent were dependent on alcohol. In addition, roughly 7 percent of military personnel reported using illegal drugs in the past 12 months.¹

I quit drinking 11 years ago, after a major dose of reality. That reality was that partying was no longer "cool." My family and friends lived in a constant state of fear, brought on by my violent episodes when I was under the influence of drugs or alcohol. I tried suicide; I've overdosed, and was homeless for over a year. But none of that made me realize that I had a problem, until a police officer took my children out of our home for their own protection. I would end up going through the court system and heard from these children how they lived in fear, never knowing what to expect. I finally realized that my drinking was no longer destroying my own life, but everyone who was around me was also affected. I spent a life of "taking" from the ones I supposedly loved. I took their possessions, I took their money, and then I took their souls. Today, I try to live a life of "giving." I share my story through the books I've written (Damaged Merchandise; Poems and Stories of an Alcoholic Addict and War Zone, Backing Out of Hell) and through poetry and short stories on various Web sites. With sobriety, I've come to realize it's not about perfection, just progression; it's not about the destination, just the journey; and it's not about the goal, just the effort. Looking back, I've come a long way in 11 years. And it was all because I admitted I was powerless over alcohol and I turned my life over to my Higher Power. Dave Harm Author, Poet, Editor		Yet there is hope, because like other chronic mental disorders, substance use disorders are medical conditions that can be treated effectively.2 In fact, people who are in recovery can spread a positive message to others, telling people what to expect from treatment and demonstrating that treatment is effective and recovery is possible. Substance use disorders are comprised of the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the nonmedical use of prescription drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on the substance.3 For more information on the criteria used in defining dependence and abuse, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm. Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster a greater understanding and avoid perpetuating the stigma associated with these conditions, the phrase "substance use disorders" is used as an umbrella term to encompass all of these concepts. Even after their military service ends, veterans can be extremely susceptible to substance use disorders. Trends suggest that the prevalence of substance use disorders among veterans may be rising. This is due to several factors, including that drug use disorders are more common among people born after World War II.4 The total number of patients in the U.S. Department of Veterans Affairs (VA) health care system with a substance use disorder was 485,092 in fiscal year 2002.5 Veterans with substance use disorders accounted for approximately 12 percent of VA patients and about 25 percent of total VA expenditures, or $4.2 billion.6

Studies have shown that people, particularly men, who experience a stressful event related to their occupations are at risk for developing alcohol dependence.⁷ Stress can have a large impact on members of the military who develop a substance use disorder. Such stress includes the physical or mental challenges of their service, exposure to trauma associated with combat, or a struggle to juggle military and family responsibilities.⁸ One study found that although women in the military did not associate levels of stress at work with substance use, they did experience a connection between the stress associated with being a woman in the military with illicit drug use and cigarette use.⁹

For some people, notice of impending deployment unleashes a multitude of reactions. While they are generally mild and momentary, the fear and uncertainty of looming deployment causes a more severe response in a minority of cases. In this group, a sizeable amount of people will turn to substance use to suppress the emotions caused by the news of deployment.¹⁰ This underscores the need to further understand the nature of substance use disorders among military personnel.

Prevalence of Co-Occurring Disorders Among Military and Veterans

In addition to stress, serious psychological distress (SPD) is highly correlated with substance use disorders. People with a substance use disorder and SPD at the same time are said to have a co-occurring disorder.

Meeting the criteria for SPD indicates that a person exhibits high levels of distress due to any type of mental problem, which may include general symptoms related to phobia, anxiety, or depression.¹¹ For more information on these criteria, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm. Additionally, the National Mental Health Association (NMHA) goes into greater depth about the types of mental health problems that correlate with substance use disorders on its Web site at www.nmha.org.

Adults with SPD are more likely than those without to be dependent on or abuse alcohol and illicit drugs.¹² For example, among adults with SPD in 2004, 21.3 percent (or 4.6 million) were dependent on or abused illicit drugs or alcohol, compared to only 7.9 percent among adults without SPD.¹³ This trend of co-occurring disorders is observed within most demographic groups, including military personnel and veterans.¹⁴

Co-occurring disorders are widespread among active military and veteran populations. In 2002 and 2003, 340,000 male veterans had a co-occurring serious mental illness and a substance use disorder. Furthermore, younger veterans are more likely to experience a co-occurring disorder than older veterans.¹⁵

In a survey of veterans from the first Gulf War, 32 percent met the criteria for a current or lifetime depressive disorder. Veterans who were deployed were significantly more likely to experience a substance use disorder than those who were not deployed.¹⁶ Other studies have shown that veterans who have post-traumatic stress disorder (PTSD) experienced more severe substance use disorders and other co-occurring disorders.^{17, 18} This is important to keep in mind when supporting or treating a person in the military or a veteran who may be suffering from a substance use disorder.

Substance Use Disorders and Co-Occurring Disorders are Treatable

Like other chronic disorders, such as PTSD, that affect military personnel and veterans, substance use disorders are medical conditions that can be treated.¹⁹ A major study published in the Journal of the American Medical Association in 2000 is one of several demonstrating the success of treatments for substance use disorders.²⁰ Treatment of both mental and substance use disorders can help prevent the exacerbation of other health problems, according to the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders in 2002.²¹

Thousands of veterans have sought treatment that can help them find a path of recovery:

• In 2003, more than 45,000 male veterans and nearly 4,000 female veterans were admitted to substance use treatment programs. These data do not represent veterans who were treated at VA facilities.²²
• The proportion of male veterans with a co-occurring mental illness who were admitted to treatment rose from 15 percent in 1995 to 17 percent in 2000.²³
• One survey of an alcohol treatment program at a naval hospital found that 77 percent of patients remained abstinent 1 to 2 years after treatment and 90 percent were still on active duty.²⁴

Spending for VA substance use disorder inpatient treatment declined sharply between 1997 and 1999, mostly because people were steered toward outpatient care-a trend that also occurred outside the VA health care system during that time.²⁵

To help veterans obtain treatment services, there is a need to increase general screening for substance use disorders in primary care. When people with substance use disorders that have been inadequately treated become older, they often display medical consequences, including liver disease, hypertension, and stroke.^{26, 27} Therefore, it is essential to incorporate screenings into primary care, just as diabetes, heart problems, or any other chronic disorders are monitored.

Health care providers are important in identifying people with these disorders. More than two-thirds of Americans who have substance use disorders see a primary care or urgent care physician every six months. Substance use screening at these visits is imperative for early diagnosis and intervention.²⁸ Physicians who initiate a referral provide the first step to recovery and better health. In one recorded review of all inpatient admissions over one year, an appropriate intervention provided by a substance use disorder medicine consultation service demonstrated a cost-benefit ratio of 19:1 through fewer hospital readmissions for medical problems.²⁹ Several tools are available to help providers assess people with co-occurring substance use and mental disorders, including Global Assessment of Individual Needs (GAIN), an assessment tool developed as part of a SAMHSA-sponsored project.³⁰

Stigma in the Military-Mental Illness and Substance Use Disorders

Even though the substance use disorders and mental disorders that affect military personnel and veterans can be treated as medical conditions, and treatment is highly effective, stigma can plague people with these disorders. In general, stigma detracts from the character or reputation of a person. For many people, stigma can be a mark of disgrace. Stigma can create a barrier for people with substance use disorders who wish to access treatment, and also can inhibit the ongoing recovery process.³¹ In 2004, 21.6 percent of the 1.2 million people who felt they needed treatment but did not receive it indicated it was because of reasons related to stigma.³²

Some military personnel who hold security clearances may be reluctant to seek assistance for personal problems out of concern for their clearance status. This can cause continued suffering for the person, a heightened security risk when a person's untreated problems worsen to the point of affecting his or her reliability in the workplace, and the loss of often valued workers. To combat this problem, security officers are now telling cleared personnel that their clearances will not be affected if they voluntarily seek help. In fact, civilian and military personnel have successfully utilized counseling programs and returned to work with their clearances undamaged.³³

Despite this positive news, only a small percentage of soldiers and Marines who met the criteria for a mental disorder (defined in one study as including alcohol misuse) reported that they actually received help from a mental health professional. While this finding is similar to civilian studies, unique factors may prevent military personnel from seeking help, particularly the concern about how a soldier would be perceived by peers and military leadership.³⁴

Furthermore, concern about stigma was disproportionately greater among those most in need of mental health services. Surveyed soldiers and Marines who had a mental disorder (including substance use as a symptom) were twice as likely to show concern about being stigmatized as those who did not. As the following statistics show, stigma can be a large barrier to care for many military personnel with co-occurring disorders. Out of military personnel surveyed who had a mental disorder:³⁵

• 41 percent thought receiving help would be embarrassing
• 50 percent thought receiving help would harm their career
• 65 percent thought they would be perceived as weak
• 63 percent thought that leadership would treat them differently after they received help

The numbers were much smaller among military personnel who did not have a mental disorder:

• Only 18 percent thought treatment would be embarrassing
• Only 24 percent thought receiving help would harm their career
• Only 31 percent thought they would be perceived as weak
• Only 33 percent thought that leadership would treat them differently after they received help

Addressing Substance Use and Stigma in the Military

Both the United States Department of Defense (DoD) and the VA ensure the strict confidentiality of treatment for substance use disorders. While military personnel and veterans may have a negative internal perception of their own substance use disorder that prevents them from receiving treatment, they can take comfort in the fact that the VA health care system provides some of the most comprehensive treatment for substance use disorders.

At the end of fiscal year 2003, the VA operated 215 substance use disorder treatment programs, including 15 inpatient programs, 64 residential programs, 37 intensive outpatient programs, 98 standard outpatient programs, and 1 case-finding and early intervention team.³⁶ It also provides other psychiatric services and medical care throughout the country. The VA is often the system of choice for the treatment of veterans with substance use disorders. Many veterans use this system because they are familiar with it and loyal to the health service that provides them with long-standing care. ³⁷

The DoD also has policies and programs that protect and treat personnel with substance use disorders. While alcohol programs had been around for years, the early military treatment programs were stimulated by usage by armed forces in Vietnam. As a result, the Secretary of Defense directed each service and agency of the armed forces to develop drug use prevention and control programs that would identify and treat all service members with a substance use disorder.³⁸ Other DoD actions include:

• Establishing clinical practice guidelines for the management of substance use disorders - These DoD guidelines include actions for primary care and specialty care assessment, intervention, diagnosis, referrals, and treatment.³⁹
• Adhering to laws requiring the DoD to identify and treat active duty personnel with a substance use disorder - The Secretary of Defense must use every available method to provide facilities that identify and treat members of the armed forces with substance use disorders.⁴⁰
• Developing educational programs about substance use disorders - One directive issued by the DoD recognizes that substance use disorders are preventable and treatable diseases that can affect the entire family, and education and training should be provided on DoD polices related to substance use.⁴¹ When feasible, treatment and educational services are also provided to family members of DoD personnel.⁴²
• Maintaining confidentiality and providing assistance - Another DoD directive established a program of drug testing that includes specifications for employee privacy, confidentiality, employee assistance programs, and training. DoD employee assistance programs emphasize education and counseling and also include referrals where applicable to treatment programs.⁴³

The VA also has an initiative called the Substance Use Disorder Quality Enhancement Research Initiative (QUERI) Center, which focuses on identifying, disseminating, and implementing best practices for preventing, improving detection of, and treating substance use disorders in VA patients. The goals include:

• Advancing the current system for monitoring the outcomes and care of patients with substance use disorders
• Improving the information and methods used to implement research efforts that will enhance the quality of care
• Increasing the identification and management of patients with substance use disorders and related conditions seen in primary care and other settings
• Improving specialized substance use disorder treatment practices
• Advancing treatment for patients with co-occurring disorders, such as a patient who may have a substance use disorder and PTSD at the same time
• Furthering treatment for high-risk or underserved substance use disorder patient subgroups, such as older populations⁴⁴

To overcome the stigma that many military personnel see as a barrier to treatment, efforts should be made to make members of the military feel more comfortable with mental health services and substance use disorder treatment.

Struggling through a drug addiction destroyed not only my life, but also my family. Finally, I found the answer, and for me it was going through a rehabilitation program. After graduating, I had the opportunity to help change another person's life and I couldn't let that pass by. Individuals all over the world are experiencing a drug or alcohol addiction, and being able to provide assistance to them while witnessing incredible changes is a very humbling and gratifying experience. To be able to provide peace of mind to a family is what I do. I am now happily married and have a more positive outlook on life. Mike Anzalone Deputy Executive Director for Delivery and Exchange

Making a Difference:  What Can I Do?

If you are a health care provider, currently serving in active duty, a veteran, or a family member of someone in the military or a veteran, you can help someone with a substance use disorder on a path to recovery. Learning about these disorders can help reverse the stigma that serves as a barrier to treatment:

1. Learn the signs of substance use disorders. Sudden changes in personality, an increase in aggressive behavior, irritability, nervousness, or giddiness are just a few symptoms to look for when you suspect someone has a substance use disorder.
2. Develop a more extensive screening process in your practice, if you are a health care provider. Whether you are in primary care, mental health, or even cardiac medicine, monitoring your patients for a substance use disorder, mental health disorder or both can save their health. If you don't have the capabilities to initiate treatment in your health care practice, know the treatment programs in your local area to which you can refer patients. Education, outreach, and changes to the models of health care delivery-such as more mental health services in primary care checkups and stringent confidentiality clauses-can all help change misconceptions about treatment.⁴⁵
3. For military personnel, keep in mind that substance use disorders are diseases that can be treated and educate your peers about these issues. By better understanding substance use disorders, you can help overcome the myths surrounding them and support those who are trying to overcome barriers to treatment and recovery.
4. Participate in recovery through family therapy. If you have family members with a substance use disorder, mental health disorder, or a co-occurring disorder who are currently serving, or have served, in the military, family therapy can help someone through recovery.
5. Utilize resources already in place by the DoD and the VA. Initiatives like the Veterans Health Administration's Compensated Work Therapy Program help veterans with mental illness, substance use disorders, physical disabilities, and other disabilities. The program provides veterans with skills training and development services, job development and placement services, and employment support.

Making a Difference:  How Can I Contribute to Recovery Month?

Military personnel, veterans, supporting organizations, health care providers, and family members can all contribute to the 17^th annual National Alcohol and Drug Addiction Recovery Month (Recovery Month) in September and support the observance's 2006 theme: "Join the Voices for Recovery:  Build a Stronger, Healthier Community."

1. Share your stories with other military personnel and veterans who may have a substance use or mental health disorder, or a co-occurring disorder. By discussing your own experiences with treatment with others in the military, you may help them overcome barriers to treatment.
2. Disseminate information about substance use disorders, co-occurring disorders, and treatment and recovery to members in your unit. Sharing the message that treatment is effective and improves overall health will help overturn the stigma associated with receiving treatment for substance use disorders and may encourage someone in need of services to seek treatment.
3. Plan a health fair on a military base or at a VA hospital or clinic. Set up booths for local treatment centers specifically focused on military personnel or veterans with substance use disorders.
4. Develop an educational program for new recruits about the prevalence of substance use in the military and explain the impact substance use disorders can have on general health and capabilities.
5. Engage organizations in your community to work with local military bases to develop broader initiatives for Recovery Month.

For additional National Alcohol and Drug Addiction Recovery Month (Recovery Month) materials, visit the Recovery Month Web site at www.recoverymonth.gov or call 1-800-662-HELP.

For additional information about substance use disorders, treatment, and recovery, please visit SAMHSA's Web site at www.samhsa.gov.

Military and Veteran Resources

This list is not exhaustive of all available resources. Inclusion does not constitute endorsement by the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration, or its Center for Substance Abuse Treatment.

SOURCES

¹  Bray, Robert M., Hourani, Laurel L., Rae, Kristine L., Dever, Jill A., Brown, Janice M., Vincus, Amy A., Pemberton, Michael R., Marsden, Mary Ellen, Faulkner, Dorothy L., Vandermass-Peeler, Russ. 2002 Department of Defense Survey of Health Related Behaviors Among Military Personnel. Washington, D.C.: U.S. Department of Defense, November 2003, p. 3-3.
²  Pathways of Addiction: Opportunities in Drug Abuse Research. National Academy Press.Washington, D.C.: Institute of Medicine, 1996.
³  Results From the 2004 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 05-4062. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2005, pp. 155, 160.
⁴  Grant, B.F. "Prevalence and Correlates of Drug Dependence in the United States: Results of the National Longitudinal Alcohol Epidemiologic Survey." Journal of Substance Abuse, 8(2), 1996, pp. 195-210.
⁵  Improving VA Services for Substance Use Disorder Patients: Conducting Policy-Relevant Program Evaluation. Palo Alto, CA: U.S. Department of Veterans Affairs, Veterans Affairs Health Care System, Program Evaluation and Resource Center, January 2004, p. 6.
⁶  Barnett, Paul G. "Cost and Cost-Effectiveness of VA Treatment of Substance Use Disorders." Menlo Park, CA: U.S. Department of Veterans Affairs, Health Economics Resource Center, October 15, 2002, section entitled "Findings."
⁷  Gorman, D.M. "Employment, stressful life events and the development of alcohol dependence." Drug and Alcohol Dependence, 22(1-2), October 1988, pp. 151-9.
⁸  Bray, R.M., Fairbank, J.A., Marsden, M.E. "Stress and substance use among military women and men." American Journal of Alcohol Abuse, 25(2), May 1999, pp. 239-56.
⁹  Ibid.
¹⁰  Carlson, Eve B., Bradley, John C., L.T.C., M.C., U.S.A., et. al. Iraq War Clinician Guide, 2nd Edition. White River Junction, VT: U.S. Department of Veterans Affairs, National Center for PTSD, June 2004, p. 79.
¹¹  Results From the 2004 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 05-4062, p. 83.
¹²  Ibid, pp. 86, 91.
¹³  Ibid, p. 86.
¹⁴  The NSDUH Report: Male Veterans with Co-Occurring Serious Mental Illness and a Substance Use Disorder. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, November 11, 2004, p. 1.
¹⁵  Ibid.
¹⁶  Black, D.W., Carney, C.P., Forman-Hoffman, V.L., Letuchy, E., Peloso, P., Woolson, R.F., Deobbeling, B.N. "Depression in veterans of the first Gulf War and comparable military controls." Annals of Clinical Psychiatry, 16(2), April-June 2004, pp. 53-61.
¹⁷  McFall, M.E., Mackay, P.W., Donovan, D.M. "Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans." Journal of Studies on Alcohol, 53(3), July 1992, pp. 357-63.
¹⁸  Kulka, R.A., Schlenger, W.E., and Fairbank, J.A., et al. Trauma and the Vietnam War Generation. New York: Brunner/Mazel, 1990.
¹⁹  Pathways of Addiction: Opportunities in Drug Abuse Research, p. 9.
²⁰  Kleber, H.D., O'Brien, C.P., Lewis, D.C., McLellan, A.T. "Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation." Journal of the American Medical Association, 284 (13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.
²¹  Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, p. ix.
²²  Treatment Episode Data Set (TEDS), 1992-2003 Concatenated data [Computer file]. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Original data prepared by Synectics for Management Decisions, Incorporated. ICPSR ed. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [producer and distributor], 2005.
²³  The DASIS Report: Veterans in Substance Abuse Treatment: 1995-2000. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, November 7, 2003, pp. 1-3.
²⁴  Wright, C., Grodin, D.M., et al. "Occupational outcome after military treatment for alcoholism." Journal of Occupational Medicine, 32(1), 1990, p. 24-32.
²⁵  Chen, S., Wagner, T.H., and Barnett, P.G. "The Effect of Reforms on Spending for Veterans' Substance Abuse Treatment, 1993-1999." Health Affairs, 20(4), July/August, 2001, pp. 171, 173-4.
²⁶  Booth, Brenda M., Ph.D. and Blow, Frederic C. "Utilization of Veterans Health Services for Substance Abuse: A Study of Aging Baby Boomer Veterans." Substance Use by Older Adults: Estimates of Future Impact on the Treatment System. DHHS Publication No. SMA 03-3763, Analytic Series A-21, Korper, S.P., & Council, C.L. (Eds.). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2002, section entitled "Chapter 9: Conclusions."
²⁷  Raimo, Eric B., M.D. Medical Consequences of Alcohol and Drug Use Disorders. Presentation: Alcohol Medical Scholars Program, July 2000, slides #8, 18, 19.
²⁸  "Public Policy of ASAM: Screening for Addiction in Primary Care Settings." American Society of Addiction Medicine Web site: www.asam.org, para. 3. Accessed August 19, 2004.
²⁹  Storer, R.M. "A simple cost-benefit analysis of brief interventions on substance abuse at Naval Medical Center Portsmouth." Military Medicine, 168(9), September 2003, p. 765.
³⁰  Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders, chapter 4, pp. 65, 66.
³¹  Faces & Voices of Recovery Public Survey. Washington, D.C.: Peter D. Hart Research Associates, Inc., and Coldwater Corporation, May 4, 2004, p. 2.
³²  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 78-79.
³³  Wood, Suzanne and Fischer, Lynn F. Cleared DoD Employees at Risk - Report 2; A Study of Barriers to Seeking Help. Technical Report 01-4. Monterey, CA: Defense Personnel Security Research Center, January 2002, p. ix.
³⁴  Hoge, Charles W., M.D., Castro, Carl A., Ph.D., Messer, Stephen C., Ph.D., McGurk, Dennis., Ph.D., Cotting, Dave, I., M.D., Koffman, Robert L., M.D., M.P.H. "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care." The New England Journal of Medicine, 351(1), July 1, 2004, p. 20.
³⁵  Ibid, p. 21.
³⁶  Tracey, Stephen W., Trafton, Jodie A., Humphreys, Keith. The Department of Veterans Affairs Substance Abuse Treatment System: Results of the 2003 Drug and Alcohol Program Survey. Palo Alto, CA: U.S. Department of Veterans Affairs, Veterans Affairs Health Care System, Program Evaluation and Resource Center, August 2004, p. i.
³⁷  Booth, Brenda M., Ph.D. and Blow, Frederic C. "Utilization of Veterans Health Services for Substance Abuse: A Study of Aging Baby Boomer Veterans." Substance Use by Older Adults: Estimates of Future Impact on the Treatment System, Section entitled "Chapter 9: Conclusions."
³⁸  Wood, Suzanne and Fischer, Lynn F. Cleared DoD Employees at Risk - Report 2; A Study of Barriers to Seeking Help. Technical Report 01-4. Monterey, CA: Defense Personnel Security Research Center, January 2002, p. D-3.
³⁹  Management of Substance Use Disorder in the Primary Care Setting. Office of Quality and Performance publication 10Q-CPG/SUD-01. Washington, D.C.: VA/DoD Evidence-Based Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs, and Health Affairs, Department of Defense, September 2001.
⁴⁰  10 United States Code, chapter 55, section 1090.
⁴¹  "Drug and Alcohol Abuse by DoD Personnel." Department of Defense Directive. Number 1010.4. Washington, D.C.: U.S. Department of Defense, September 1997, section 4.
⁴²  "Rehabilitation and Referral Services for Alcohol and Drug Abusers." Department of Defense Instruction. Number 1010.6. Washington, D.C.: U.S. Department of Defense, March 13, 1985, section 4.
⁴³  DoD Civilian Employee Drug Abuse Testing Program." Department of Defense Directive. Number 1010.9. Washington, D.C.: U.S. Department of Defense, August 23, 1988, sections 4 and 5.
⁴⁴  Finney, John, Ph.D. and Willenbring, Mark L., Ph.D. Substance Use Disorders QUERI Center. Washington, D.C.: U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative, March 2004, section entitled "Executive Summary."
⁴⁵  Hoge, Charles W., M.D., et. al. "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care." The New England Journal of Medicine, p. 21.