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Evaluation of the DoD’s Management of Opioid Use Disorder for Military Health System Beneficiaries

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Objective

We determined whether the DoD’s management of opioid use disorder treatment aligned with DoD policies and national guidance. Specifically, we determined whether the DoD:

  • had policies and programs in place to manage the treatment of opioid use disorder for Military Health System beneficiaries; and
     
  • established and implemented opioid use disorder treatment outcome and process measures to inform quality improvements.

Background

Opioids are a broad group of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, and codeine. Opioids reduce the perception of pain but can also produce drowsiness, mental confusion, euphoria, nausea, and constipation. Also, depending on the amount of drug taken, opioids can depress respiration. Opioids can cause serious health effects in those who misuse them.

Opioid use disorder is a substance abuse disorder associated with the recurrent use of opioids that causes significant impairments, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. The DoD has incorporated opioid use disorder within DoD substance use disorder policies and programs.

On October 26, 2017, the White House issued a Presidential memorandum directing the heads of Executive departments and agencies to exercise all appropriate emergency authorities to reduce the number of deaths and to minimize the devastation of the opioid crisis. On the same day, the Acting Secretary of Health and Human Services determined that the nationwide opioid crisis was a public health emergency.

In the October 2017 DoD Report to Congress on “Prescription Opioid Abuse and Effects on Readiness,” the Office of the Under Secretary of Defense for Personnel and Readiness reported that prescription opioid misuse in service members remained an issue of concern for the DoD because it negatively affects performance, military readiness, and the DoD’s overall mission.

Findings

We determined that the DoD has policies and programs in place to manage the treatment of opioid use disorder for Military Health System (MHS) beneficiaries.

However, we also found that Marine Corps Substance Abuse Counseling Center (SACC) counselors made substance use disorder diagnoses in violation of DoD and Navy Bureau of Medicine and Surgery (BUMED) policies. Although the SACC counselors were licensed, the SACC counselors:

  • were not granted clinical privileges, and
     
  • did not have access to the DoD Health Record system. As a result, the Marine Corps SACC counselors could not document the substance use disorders in the DoD Health Record, which could impact quality of care provided to MHS beneficiaries and the quality of medical data in the DoD Health Record.

Additionally, we found that the DoD did not implement DoD-wide standard outcome and process measures specific to opioid use disorder, such as the percentage of opioid use disorder patients who initiated treatment within 14 days of diagnosis. This occurred because DoD Instruction (DoDI) 1010.04 does not identify the organization responsible for adopting minimum program and outcome measures to compare program performance and identify best practices. As a result, the MHS had no mechanism to compare the performance of opioid use disorder treatment programs to civilian benchmarks or across Military Treatment Facilities (MTFs) to identify best practices and any outliers that need improvement. Additionally, due to a lack of standard methodology to identify the population of patients with opioid use disorder, the full extent of the DoD’s opioid use disorder population is unclear.

Recommendations

We recommend that the Secretary of the Navy:

  • Modify Marine Corps orders, policies, and memorandums of understanding to reflect that SACC counselors may not independently make substance use disorder diagnoses without clinical privileges and that all substance use disorder diagnoses must be documented in the DoD Health Record;
     
  • Review all historical records of individuals served by the Marine Corps Substance Abuse Counseling Centers and document all appropriate medical information using the DoD Health Record; and
     
  • Certify that all substance use disorder diagnoses are made by a privileged health care provider, and that all diagnoses are documented in the DoD Health Record.

We recommend that the Assistant Secretary of Defense (Health Affairs):

  • standardize the methodology to identify the population of patients with opioid use disorder, and
     
  • establish and implement minimum standard outcome and process measures for the treatment of opioid use disorder.

Management Comments and Our Response

The Deputy Assistant Secretary of the Navy (Military Manpower & Personnel), responding on behalf of the Secretary of the Navy, did not address the specifics of our recommendations. Specifically, the Deputy Assistant Secretary stated that the Department of the Navy requests that the recommendations related to modifying Marine Corps orders, policies, and memorandums of understanding be modified to state that the Department of Navy should continue conducting its internal evaluation of the program and address any pertinent findings. While we did not adjust the recommendation as requested, we did update them to clarify the actions that we recommend the Secretary of the Navy take to address the findings of the report.

We consider the recommendations to the Secretary of the Navy to be unresolved. We request that the Secretary provide comments in response to the final report that address the recommendations on modifying Marine Corp Substance Abuse Counseling Centers’ policies, position descriptions, and records for consistency with DoD policy on substance use disorder diagnoses; and certifying diagnoses by privileged health care providers and documentation in the DoD Health Record.

The Principal Deputy Assistant Secretary of Defense (Health Affairs) (PDASD[HA]), responding on behalf of the Assistant Secretary of Defense (Health Affairs), agreed with our recommendation to standardize the methodology to identify the population of patients with opioid use disorder within the Military Health System, and will update DoD and Defense Health Agency instructions to issue a DoD-wide standard of reporting.

The PDASD(HA) also agreed with our recommendation to establish and implement minimum standard outcome and process measures, including data for both direct care and purchased care, for the treatment of opioid use disorder. The DoD will ratify in policy the sustainment of two clinical outcome measures—opioid use disorder prevalence and opioid overdose death rates.

Therefore, the recommendations are resolved but remain open. We will close these recommendations once we receive and review the documents to ensure that the issues are addressed.

This report is a result of Project No. D2018-D00SPO-0156.000.