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There is hope

Medically assisted treatment for opioid use can break the cycle of addiction. Medically assisted treatment for opioid use can break the cycle of addiction.

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Mental Health Care | Substance Abuse | Addiction | Mental Wellness | Opioid Safety

The United States is in the middle of an opioid overdose epidemic, according to the Centers for Disease Control and Prevention, which calculates that more than 350,000 deaths are attributed to opioid overdoses nationwide since 1999. The military is at the forefront of efforts to help curb those numbers through its expansion of medically assisted treatment, also known as MAT.

Vice Adm. Raquel C. Bono, director of the Defense Health Agency, reported to the House Armed Services Committee last month that the military’s rate of deadly opiate overdoses is a quarter of the national average, according to House transcripts. Dr. Fuad Issa, chief of the implementation section at the DHA Psychological Health Center of Excellence, said the availability of MAT has a lot to do with breaking the cycle of addiction.

In 2016, the Department of Defense expanded the availability of MAT as part of the TRICARE benefit, with the goal of increasing successful treatment and reducing the number of overdoses and deaths due to opiate abuse, said DHA clinical psychologist and senior policy analyst Dr. Krystyna Bienia.

“Drugs like methadone, naltrexone, and buprenorphine as a medically assisted treatment plan relieve withdrawal symptoms and psychological cravings that make opiate addiction so hard to overcome,” she said. “Used correctly, and in conjunction with psychotherapy, support, and counseling, they can help users overcome the addiction to opioids.”

The Substance Abuse and Mental Health Services Administration points out that the benefits of MAT include not only curbing withdrawal symptoms and preventing cravings, but also providing medical supervision. MAT works to normalize brain chemistry, block the euphoric effects of opioids (which include prescription drugs such as hydrocodone and oxycodone), and stabilize body functions without the negative effects of the abused drug. MAT has proven to be clinically effective and significantly reduces the need for inpatient detoxification. Bienia notes that MAT provides a comprehensive, individually tailored program of medication and behavioral therapy.

Yet some MAT medications have challenges of their own. Methadone, for example, doesn’t produce euphoria; rather, it tricks addicts into thinking they’re getting the opiate, according to the National Institute on Drug Abuse. Methadone works by changing how the brain and nervous system respond to pain. But according to Issa, methadone itself can be addictive.

That’s why Navy Capt. Edward Simmer, psychiatrist and chief clinical officer for TRICARE, believes it’s important to realize that the medication is only one component of the treatment plan. He suggests part of his patients’ treatment is going to 12-step programs such as Narcotics Anonymous, and including other community support.

“There’s a large social component to drug use,” Simmer said. “Relapses are often caused by being around others who use drugs, or stresses associated with drug use. Therefore, successful treatment requires eliminating these triggers to the greatest extent possible.”

Bienia explained that the duration of MAT depends on the patient. “After months or a year or more of treatment, the medication can be gradually reduced and eventually stopped … but in some cases [it] has to be taken for a lifetime,” she said.

Issa noted that in the past, opiate users had to get their medication at a special dosing site, but today, a prescription for drugs effective in alleviating opiate withdrawal symptoms, such as the combination of buprenorphine and naloxone, can be filled at a local pharmacy. The 2016 TRICARE Mental Health and Substance Use Final Rule allows TRICARE-authorized physicians to provide office-based opioid treatment.

Issa said he believes this may be making a difference, noting that in addition to TRICARE changes, DoD has been training medical providers on the risks of opioids. The number of DoD opioid prescriptions dropped by 56 percent between 2013 and 2017.

According to Bono’s testimony to the House committee, less than 1 percent of active-duty service members are abusing or addicted to opioids.

In 2017, the DHA Psychological Health Center of Excellence, along with the Medical Directorate - National Capital Region, trained 192 physicians to prescribe MAT, and more nurse practitioners are being added this year to expand the network and coverage of MAT providers, said Issa.

“Beating an addiction is a drastic change in someone’s life, but treatment works,” said Simmer. “People do overcome addiction when everyone works together. There is hope.”

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DHA PI 6025.15: Management of Problematic Substance Use by DoD Personnel

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This Defense Health Agency-Procedural Instruction (DHA-PI), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (aa), establishes the Defense Health Agency’s (DHA) procedures to assign responsibilities for problematic alcohol and drug use identification, diagnosis, and treatment for DoD military personnel.

  • Identification #: 6025.15
  • Date: 4/16/2019
  • Type: DHA Procedural Instruction
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DHA IPM 18-019: Guidance for Service Implementation of Separation Mental Health Assessments

Policy

This Defense Health Agency-Interim Procedures Memorandum (DHA-IPM), based on the authority of References (a) through (c), and in accordance with the guidance of References (d) through (g): • Assigns responsibilities and provides instructions for implementing Reference (d), which requires an MHA for Service members prior to separation in accordance with References (e) through (g). • Is effective immediately; it will be incorporated into DHA-Procedural Instruction xxxx.xx, “Separation History and Physical Examination.” This DHA-IPM will expire effective 12 months from the date of issue.

DHA PI 6490.01: BH Treatment and Outcomes Monitoring

Policy

This Defense Health Agency-Procedural Instruction (DHA-PI), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (k): a. Establishes the Defense Health Agency’s (DHA) procedures for the collection and analysis of BH outcome data. b. Addresses how DoD will standardize BH outcome data collection to: assess variations in mental health and substance use care among in-garrison medical treatment facilities (MTFs) and clinics; assess the relationship of treatment protocols and practices to BH outcomes; and identify barriers to provider implementation of evidence-based clinical guidance approved by DoD. c. Designates the Army as the DoD lead Service for maintenance and sustainment of the Behavioral Health Data Portal (BHDP) in specialty care mental health and substance use clinics, referred to collectively as BH clinics, until BHDP functionality can be integrated with GENESIS or another electronic health record (EHR) system managed by DHA. d. Designates DHA Information Operations (J-6) as lead on transitioning BHDP functional requirements related to outcomes monitoring to future EHR data collection platforms and processes.

DHA PI 6025.04: Pain Management and Opioid Safety in the MHS

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The purpose of our MHS Pain Management Campaign is to enable Clinical Communities to provide evidence-based pain management guided by clinical practice guidelines (CPGs): effectively treat acute and chronic pain; promote non-pharmacologic treatment; prevent acute pain from becoming chronic; and minimize use of opioids with appropriate prescribing only when indicated. The Pain Management Clinical Support Service achieves these ends through clinical improvements in pain care, clinician and patient education, and research. This Defense Health Agency-Procedural Instruction (DHA-PI) is a dual effort between the Pain Management Clinical Support Service and the Clinical Communities to achieve our stated purpose through implementation of the MHS Stepped Care Model.

DoD Instruction 6490.10: Continuity of Behavioral Health Care for Transferring and Transitioning Service Members

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In accordance with the authority in Reference (a), this Instruction establishes policy for the Military Departments, assigns responsibilities, and prescribes guidelines for establishment of Military Department policy and procedures to ensure continuity of behavioral health (BH) care at the losing and gaining installations when Service members transition from one health care provider (HCP) to another when transferring to a new duty station or transitioning out of the Service.

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DoD Instruction 6490.15: Integration of Behavioral Health Personnel (BHP) Services Into Patient-Centered Medical Home (PCMH) Primary Care and Other Primary Care Service Settings

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This instruction establishes policy, assigns responsibilities, and prescribes procedures for attainment of inter-Service standards for developing, initiating, and maintaining adult behavioral health services in primary care.

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DoD Instruction 1010.04: Problematic Substance Use by DoD Personnel

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  • Identification #: DoD Instruction 1010.04
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DoD Instruction 6490.12: Mental Health Assessments for Service Members Deployed in Connection with a Contingency Operation

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This instruction establishes the policy for person-to-person deployment mental health assessments for each member of the Military Services deployed in connection with a contingency operation according to Section 1074m of Title 10, United States Code (Reference (b)).

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DoD Instruction 6490.04: Mental Health Evaluations of Members of the Military Services

Policy

Reissues DoD Instruction 6490.4 (Reference (b)), establishing policy, assigning responsibilities, and prescribing procedures for the referral, evaluation, treatment, and medical and command management of Service members who may require assessment for mental health issues, psychiatric hospitalization, and risk of imminent or potential danger to self or others.

  • Identification #: DoD Instruction 6490.04
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DoD Instruction 6490.08: Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members

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This instruction provides guidance for balance between patient confidentiality rights and the commander’s right to know for operation and risk management decisions.

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Mental Health Assessments for Members of the Armed Forces Deployed in Connection with a Contingency Operation

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This memo describes a change in procedure for medical surveillance of U.S. forces deploying to Bosnia.

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