摘要：Objectives. We identified to what extent the Department of Defense postdeployment health surveillance program identifies at-risk drinking, alone or in conjunction with psychological comorbidities, and refers service members who screen positive for additional assessment or care. Methods. We completed a cross-sectional analysis of 333 803 US Army active duty members returning from Iraq or Afghanistan deployments in fiscal years 2008 to 2011 with a postdeployment health assessment. Alcohol measures included 2 based on self-report quantity-frequency items—at-risk drinking (positive Alcohol Use Disorders Identification Test alcohol consumption questions [AUDIT-C] screen) and severe alcohol problems (AUDIT-C score of 8 or higher)—and another based on the interviewing provider’s assessment. Results. Nearly 29% of US Army active duty members screened positive for at-risk drinking, and 5.6% had an AUDIT-C score of 8 or higher. Interviewing providers identified potential alcohol problems among only 61.8% of those screening positive for at-risk drinking and only 74.9% of those with AUDIT-C scores of 8 or higher. They referred for a follow-up visit to primary care or another setting only 29.2% of at-risk drinkers and only 35.9% of those with AUDIT-C scores of 8 or higher. Conclusions. This study identified missed opportunities for early intervention for at-risk drinking. Future research should evaluate the effect of early intervention on long-term outcomes. A 2013 Institute of Medicine committee report determined that substance use problems in the military are a public health crisis and recommended that the Department of Defense (DoD) improve the quality of prevention, early intervention, and treatment of substance use problems among service members. 1 Population-based studies reported increased binge drinking in the military over the past decade, 2 with almost 40% of currently drinking active duty members reporting binge drinking in the past 30 days in the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel. 3 Furthermore, young service members and those younger than the legal drinking age reported more binge drinking than did their civilian counterparts. 4,5 Cost and consequences of alcohol misuse in the military merit further attention. Binge drinkers in the military report higher rates of accidents, criminal justice problems, and military-related job problems compared with their peers, 4,6–8 hindering the readiness of US armed forces. 1,9–12 US Army and DoD forensic analysis of military suicides has linked alcohol and drug abuse with suicide cases. 13,14 In 2011, substance use disorders (alcohol and other drugs) ranked seventh for medical encounter burden in the Military Health System, first for total hospital bed days and among the top 4 conditions for duty days lost as a result of seeking medical care. 15 Furthermore, medical encounters associated with acute and chronic alcohol diagnoses were 50% higher in 2010 than in 2001. 15 Whether the upward trend in alcohol misuse is directly linked to the decade of conflict in Operation Enduring Freedom and Operation Iraqi Freedom is unknown, but alcohol misuse is associated with deployment duration and frequency and combat exposure. 16–20 The association of deployment with alcohol misuse may be mediated through combat-related comorbidities, including posttraumatic stress disorder and traumatic brain injury. 16,21 One intervention point to address alcohol misuse is through the DoD’s postdeployment health surveillance program, which includes a health assessment (Post-Deployment Health Assessment [PDHA], Form DD 2796) within 30 days after return from deployment and a second health assessment 3 to 6 months postdeployment (Post-Deployment Health Re-Assessment [PDHRA], Form DD 2900). 22 Improvements to the program over time have included additional scoring instructions and guidelines for the clinicians who review the self-report assessments 23 and revisions to the PDHA and PDHRA in 2008, including the addition of standardized screening items for alcohol consumption. 24 Previous studies have reported on self-reported alcohol misuse and mental health problems when older versions of these health assessments were used and have identified overall low referrals postdeployment to specialty alcohol treatment between 2003 and 2005. 25,26 Hoge et al. 26 examined the PDHA reports of US Army and Marine members returning from Operation Enduring Freedom and Operation Iraqi Freedom in 2003 to 2004 and reported that prevalence of mental health–positive screens for those who served in Operation Iraqi Freedom was higher than for those serving in Operation Enduring Freedom, 19.1% and 11.3%, respectively, with low referral rates for mental health problems: only 4.3% (Operation Iraqi Freedom) and 2.0% (Operation Enduring Freedom). Milliken et al. 25 studied the PDHRA reports of US Army service members returning from Operation Iraqi Freedom in 2005 to 2006 and reported that 11.8% appeared to have concern about their drinking based on 2 items 27 ; however, only 0.2% overall were referred for specialized treatment to the Army Substance Abuse Program. This study was intended to provide the DoD with targeted information to improve responsiveness to postdeployment problems among those who have served in Operation Enduring Freedom and Operation Iraqi Freedom. We used data from the Substance Use and Psychological Injury Combat Study (SUPIC) to update these findings, to examine both at-risk drinking and severe alcohol problems, and in more detail to examine the extent to which the DoD postdeployment health surveillance program identifies at-risk drinking, alone or in conjunction with co-occurring psychological problems, and refers returning service members for additional assessment or care in primary care or elsewhere. 25,26 We identify specific factors associated with service members receiving referrals and highlight missed opportunities for early intervention.
