Publicly Released: March 14, 2022
The objective of this audit was to determine whether the Defense Health Agency (DHA) and Military Services screened and provided treatment of alcohol misuse in a timely manner according to DoD guidance.
According to the National Institute on Alcohol Abuse and Alcoholism, heavy alcohol use is a significant problem in the military. Alcohol misuse is strongly associated with mental health problems, such as anxiety and depression, that according to the National Institute on Drug Abuse, Service members commonly experience after deployments. Alcohol use disorder, a subset of substance use disorders, is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.
DoD guidance requires the Alcohol Use Disorder Identification Test– Consumption (AUDIT-C) questionnaire at least annually to identify personnel who may be at risk for developing problems related to their alcohol use. Service members can receive their screening during their periodic health assessment (PHA) or during primary care encounters.
If Service members are concerned with their alcohol use or suspected of alcohol misuse, they can be referred to the substance abuse center, or the Service member can self‑refer. Once referred, Service members undergo a comprehensive intake assessment to determine their alcohol use diagnosis and the appropriate level of treatment. DHA guidance requires that most behavioral and mental health care be scheduled using “future” or “specialty” appointment types, which provide appointments within 7 or 28 days, respectively. In addition to overall DHA guidance, each Military Service has its own policies governing the substance abuse program, including timeline requirements for alcohol misuse referrals, intake assessments, and treatment for alcohol use disorder.
Military Service health care providers did not perform annual AUDIT-C screenings for alcohol misuse in a timely manner for 163 of 210 Service members, in the 7 units we selected for review, according to DoD Instruction 1010.04. On average, the untimely AUDIT-C screenings in the units we reviewed were 66 to 200 days past the annual requirement. However, 15 Service members did not receive their alcohol screening for more than 300 days past the due date. Furthermore, personnel within the DoD medical treatment facilities, substance abuse centers, and units expressed concerns about the effectiveness of the alcohol screenings. Specifically, personnel interviewed stated that the AUDIT-C questionnaire relies on objective responses from Service members about their own alcohol use while Service members battle stigma around obtaining substance abuse treatment and the perceived negative effect on their careers. The Military Services did not perform timely alcohol screenings because providers conducted the AUDIT-C screening during a Service member’s PHA, which DoD guidance allows providers up to 15 months to complete, 3 additional months than is allowed for the AUDIT-C screening. Furthermore, the Military Services did not have a standard mechanism to track the frequency of the Service member AUDIT–C screenings. As a result, the Military Services may not have identified and taken timely action to assist Service members who were at risk for alcohol use disorders.
We also found that the DHA and Military Services did not provide timely intake assessments or treatment for alcohol misuse in accordance with DHA or Service guidance. Specifically, of the 270 Service members we reviewed who received treatment for alcohol use disorder:
- 104 Service members did not have an intake assessment to diagnose an alcohol use disorder within DHA or Service-established timeframes;
- 98 Service members who were diagnosed with an alcohol use disorder did not receive their recommended treatment within 7 or 28 days; and,
- 3 Service members who were diagnosed with an alcohol use disorder did not receive their recommended treatment.
Furthermore, 103 of the 270 Service members we reviewed were involved in an alcohol-related incident. Of these 103 Service members, 31 were not referred for an intake assessment within the Army, Marine Corps, or Air Force timeline requirements. While the Navy did not have timeline requirements from 2018 through 2020, the Navy developed draft proposed timelines and 9 Navy Service members who we reviewed would not have met the proposed timelines.
Service members were not assessed and treated in a timely manner because guidance was unclear and inconsistent; Service members or their leadership deferred intake assessments or treatment because of operational requirements, legal actions, or other reasons; and Service substance abuse centers, medical treatment facilities, or residential treatment facilities were understaffed or unavailable.
As a result, Service members experienced delays in receiving alcohol use diagnoses required to determine the appropriate care, potentially affecting physical, social, psychological, familial, and employment health. In addition, without timely access to the appropriate level of care, the DoD risks the health and readiness of Service members who may benefit from treatment and are at an increased risk of harming themselves, others, or military operations.
We recommend that the Under Secretary of Defense for Personnel and Readiness (USD [P&R]) revise DoD Instruction 1010.04, DoD Instruction 6200.06, and DoD Instruction 6025.19 to align the frequency with which AUDIT-C screenings and periodic health assessments are conducted. In addition, we recommend that the DHA Director require a standardized mechanism that will track when Service members are due for their annual AUDIT-C screenings and the progress of Service members’ substance use treatment. Furthermore, we recommend that the DHA Director, in coordination with the Military Services, review the civilian hiring and retention practices for substance abuse personnel and make applicable improvements to minimize vacant positions; establish a maximum number of days between a substance abuse referral and an intake assessment for a substance use disorder; and establish the maximum number of days to provide substance abuse treatment following a diagnosis of a substance use disorder.
We recommend that the Chief of Naval Operations and Director of the Army Resilience Directorate update Service policy to require commanders and other unit leadership to receive substance use training annually. Finally, we recommend that the Chief of Naval Operations, Commandant of the Marine Corps, Director of the Army Resilience Directorate, and Air Force Surgeon General update Service policy to require training components to review annually a sample of Service members to determine whether Service members received their required substance use training.
Management Comments and Our Response
The USD (P&R)’s comments and actions taken addressed the specifics of four of the six recommendations to the USD (P&R) and the DHA Director; therefore, the four recommendations are resolved but remain open. We will close the recommendations once we verify that the information provided and actions the USD (P&R) and the DHA Director take fully address the recommendations. The USD (P&R)’s comments did not fully address the specifics of two recommendations related to tracking AUDIT-C screenings and substance use treatment; therefore, we consider these recommendations unresolved. We request that the DHA Director provide additional comments in response to the final report for those two recommendations.
The Director, Special Assistant Health Affairs, Office of the Assistant Secretary of the Navy (Manpower and Reserve Affairs), responding for the Commandant of the Marine Corps, agreed with our recommendation to update Service policy to require training components to review annually a sample of Service members, and proposed an alternative corrective action. The Director stated that the Marine and Family Programs Division is currently monitoring compliance with the annual substance use training and that no updates to Marine Corps Order 5300.17A are necessary; however, the information provided did not meet the intent of our recommendation. Therefore, the recommendation is unresolved. We ask that the Commandant of the Marine Corps provide additional comments on the final report.
The Director, Special Assistant Health Affairs, Office of the Assistant Secretary of the Navy (Manpower and Reserve Affairs), responding for the Chief of Naval Operations; the Director of the Army Resilience Directorate; and the Medical Operations Director for the Office of the Air Force Surgeon General, responding for the Air Force Surgeon General, agreed with our recommendations and provided comments that resolved five recommendations, but the recommendations remain open. We will close the recommendations once we verify actions taken by management to update Service policies for substance use training.
This report is the result of Project No. D2021-D000AW-0036.000.