Preventing, Identifying, and Treating Prescription Drug Misuse Among Active-Duty Service Members

by Rosalie Liccardo Pacula, Sarah B. Hunter, Allison J. Ober, Karen Chan Osilla, Raffaele Vardavas, Janice C. Blanchard, David DeVries, Emmanuel Fulgence Drabo, Kristin J. Leuschner, Warren Stewart, Jennifer Walters

This Article

RAND Health Quarterly, 2017; 7(1):8

Abstract

Prescription drug misuse (PDM) is of critical concern for the military because of its potential impact on military readiness, the health and well-being of military personnel, and associated health care costs. The purpose of this study is to summarize insights gleaned from a series of activities that the RAND Corporation undertook for the Deputy Assistant Secretary of Defense for Readiness to address this important health and military readiness issue. The authors completed a review of U.S. Department of Defense policies and a comprehensive literature review of clinical guidelines and the empirical literature on the prevention and treatment of PDM and conducted individual face-to-face interviews with 66 health and behavioral health care providers at nine medical treatment facilities across three regions within the contiguous United States to identify best practices in the prevention, identification, and treatment of PDM and the extent to which those practices are known and followed. The study also presents the framework of an analytic tool that, once informed by data available to the military but not available to the authors, can assist the military in predicting future trends in PDM based on current demographics of active-duty service members and rates of injury and prescribing of prescription drugs. The findings from this work led the authors to formulate a set of key insights that they believe might improve the rapid identification and treatment of service members dealing with PDM, thereby improving future force readiness.

For more information, see RAND RR-1345-OSD at https://www.rand.org/pubs/research_reports/RR1345.html

Full Text

Analyses of medical and pharmacy claims and drug-screening data from fiscal year 2010 show that nearly one-third of active-duty service members (ADSMs) have received at least one prescription for an opioid, central nervous–system depressant, or stimulant, and well over one-quarter (26.4 percent) receive at least one prescription opioid during this period (Jeffery, May, et al., 2014). The U.S. Department of Defense (DoD) defines prescription drug misuse (PDM) as either medication misuse caused by using it too frequently or in higher doses than prescribed or medication use without a prescription (Bray, Pemberton, Hourani, et al., 2009). PDM is an increasingly common problem in both civilian and military populations. Anonymous surveys of active-duty military personnel suggest an increase of PDM (Bray, Pemberton, Lane, et al., 2010). This parallels the recent trend of PDM seen in the civilian population, in which there is growing concern among policymakers, the Centers for Disease Control and Prevention, and other stakeholders about nonmedical initiation and use of pain relievers (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011).

The misuse of prescribed substances is of special concern for the military because of its potential impact on military readiness, the health and well-being of military personnel, and associated health care costs. However, addressing this problem poses special challenges in the detection and prevention of misuse because of the important clinical indications for which these drugs might be prescribed. Effective strategies are needed to reduce the risk of PDM and ensure safe use.

To help DoD address these issues, the RAND National Defense Research Institute conducted three related efforts that could provide useful information for assisting the military in preventing, identifying, and treating PDM: a review of guidelines and empirical literature for the prevention, identification, and treatment of PDM in clinical settings (both military and civilian) to help identify best practices; the development of an analytic tool that can be used to predict trends and changes in PDM among ADSMs today and into the future; and interviews with civilian and military providers at military installations. This study includes information gleaned from each of these three major activities and summarizes common themes from across them. Of course, as is true with any study, to some degree the limitations of the approaches taken, which we describe in detail in each of the chapters, shape the findings and insights, which should be viewed within the contexts of the strengths and limitations of the study.

Evidence-Based Practices for Preventing, Identifying, and Treating Prescription Drug Misuse

We reviewed all publicly available DoD policies and clinical guidelines and examined the empirical literature to identify practices for preventing, identifying, and treating PDM. We were specifically interested in identifying evidence-based practices for PDM (rather than substance abuse more broadly) and understanding whether they have been tested and were being used in military settings. Our project officer defined prescription drugs of interest based on DoD interest (see Table 1) and included opioids (i.e., morphine, codeine, hydrocodone, oxycodone, methadone, fentanyl, and meperidine), stimulants (i.e., methylphenidate and a combination of dextroamphetamine and amphetamine), benzodiazepines, and barbiturates.

Table 1. Prescription Drugs of Interest for Our Study

Class Generic Common Brand Names
Opioids Morphine Duramorph, DepoDur, Astramorph, Infumorph
Codeine
Hydrocodone Zohydro Extended Release, Hysingla Extended Release
Oxycodone Oxycontin, Roxicodone, Oxecta
Methadone Methadose, Diskets, Dolophine
Fentanyl Duragesic, Abstral, Subsys, Ionsys, Sublimaze
Meperidine Demerol
Stimulants Methylphenidate Ritalin, Daytrana, Concerta, Methylin, Aptensio
Dextroamphetamine with amphetamine Adderall
Benzodiazepines
Barbiturates

U.S. Department of Defense Directives Provide Little Guidance on Preventing and Managing Prescription Drug Misuse

The 20 DoD directives we reviewed provide little guidance specifically pertaining to the management of prescription drug use and misuse within the military. Instead, many focus on defining PDM and the consequences following identification, such as the process for adjudicating urine tests. Some directives included so-called limited-use policies that were inconsistently presented alongside zero tolerance guidelines. The majority of the clinical guidelines reviewed (both military-specific and others) focus on prescription opioids, with little guidance on the management of misuse of other classes of prescription drugs. Current DoD clinical recommendations for prescription opioid misuse appear to be similar to non-DoD clinical guidelines. Most guidelines note the lack of strong research evidence for many of the current care recommendations that address the prevention of misuse of prescription opioids.

All guidelines, both military and civilian, support an initial assessment to evaluate risk of PDM at the time a provider is considering prescribing the opioid. Guidelines provide consistent support for conducting a comprehensive assessment of a patient's medical history, including history of substance abuse and comorbid psychiatric and medical history, before initiating therapy (Cantrill et al., 2012; Chou, Fanciullo, et al., 2009; Manchikanti et al., 2012a, 2012b; Thorson et al., 2013). However, there is little supporting evidence concerning the effectiveness of approaches, such as screening exams, to predict patient characteristics for misuse. Many guidelines recommend written management plans and urine drug screens when there is a high risk of PDM despite limited evidence of these tools' effectiveness (Cantrill et al., 2012; Chou, Fanciullo, et al., 2009; Manchikanti et al., 2012a, 2012b; Thorson et al., 2013).

The current DoD guidelines regarding substance use discuss general approaches to treatment and are generally not focused on specific management of PDM (Management of Substance Use Disorders Work Group, 2009). The problem of opioid abuse is particularly challenging, given the need to balance the benefits of pain management and the risk of addiction (Prescription Drug Abuse Subcommittee, 2013). There is also a paucity of studies addressing the specific problem of prescription opioid abuse in the broader literature, and few empirical studies specifically address the prevention or treatment of PDM.

In 2009, then–U.S. Army Surgeon General LTG Eric B. Schoomaker led a multidisciplinary task force to address pain management issues in the military (Office of the Army Surgeon General, 2010). This task force stressed the importance of deemphasizing opioid therapy for the management of chronic pain and having providers focus more on problems of prescription opioid abuse. However, as this systematic review shows, more evidence is needed to help guide proper implementation of task-force recommendations with respect to alternatives to writing prescriptions.

Given the complexities of managing patients suffering with chronic, as well as acute, pain; the tremendous potential for these patients in particular to misuse prescription drugs, as well as other substances (McLellan and Turner, 2010; Nuckols et al., 2014); and the fact that providers typically lack general knowledge or training on how to deal with these patients, it would seem that, alongside remedial training of existing health care providers, immediate training of all new military health care providers would be useful. In particular, this training would allow the military the opportunity to promote and adopt a single standardized assessment tool for identifying a variety of substances that might be misused (e.g., prescription opioid, alcohol, benzodiazepines); train providers on how to use the tool and what to do when someone is identified as being at risk; provide clear directives on the military's position regarding pharmacotherapy's role in treating opioid misuse (or alcohol dependence); and provide clarity on policies, protocols, and clinical guidelines to follow for these particularly difficult and unique cases.

Analytic Tool to Predict Trends and Changes in Prescription Drug Misuse Among Active-Duty Service Members

To know when to intervene with those experiencing PDM problems, one must first know where these people might be identified. To assist the military in its effort to better understand the extent to which PDM stems from medically indicated use (i.e., misuse that stems from a having a prescription for a highly addictive prescription) and nonmedical use (i.e., misuse of a prescription drug that was not prescribed to that person), we developed an analytic tool that, once populated with data that the military owns, can serve as a valuable means for understanding the dynamics of the current PDM problem. In addition to identifying for policymakers the share of PDM that emerges from medically indicated use versus nonmedical use and how these will change over time, the analytic tool can be used to identify nodes in the model at which prevention and treatment resources might more effectively be concentrated so as to more efficiently and effectively tackle the problem. Prevention and treatment dollars are limited, so understanding the key factors (nodes, in our model) that drive higher rates of misuse will also tell decisionmakers where limited resources might be focused so as to more efficiently reduce the problem.

In addition to providing military officials with a better understanding of the incidence and prevalence of PDM beyond what can be determined from regular drug testing and occasional survey data, the analytic tool can be used to forecast how the incidence and prevalence of PDM will change in the future if current practices stay the course. For example, the analytic tool can be used to project how PDM might grow among those with medical indications vis-à-vis growth in the non–medical use population. Alternatively, the analytic tool could be used to project how current trajectories might change with a change in any of the tool's underlying assumptions, such as the rate of heavy use among the medically indicated, escalation rates from light to heavy use, the rate at which people enter treatment, and the relative effectiveness of different treatments. Using the tool in this manner is commonly referred to as predictive forecasting. Alternatively, the analytic tool could be restructured to accommodate different classes of prescription drugs individually (e.g., narcotics only, stimulants only) and then could be used to describe patterns of use and trends for particular prescription drug trajectories.

Like the value of any epidemiological model of health behavior, the value of the tool we propose here will depend on the reliability of estimates obtained for the various assumptions that make up the model that underlies it. Our scan of the data fields contained in TRICARE (the military health care system that includes insurance claims), the DoD Health Related Behaviors Survey and drug-testing data suggest that sufficient data exist to develop empirically driven assumptions for the model variables needed. Standard techniques for checking reliability and validity of the model would be necessary, but, assuming that the model is shown to be both externally valid and reliable, the tool proposed here could provide military health leaders with guidance on how to target limited prevention and treatment dollars toward the key factors that appear to drive higher rates of misuse.

Qualitative Interviews

Finally, we conducted semistructured interviews with military personnel to better understand perceptions of the nature and extent of PDM among ADSMs; current practices and policies to prevent, identify, and treat PDM; and barriers to effective management of PDM. To collect information from personnel with relevant experience, we developed a strategic sampling of military bases with medical treatment facilities (MTFs) in regions of the conterminous United States where selective prescription drugs, particularly opiates and benzodiazepines, were frequently administered in 2010, according to evidence in the TRICARE pharmacy claim data. TRICARE is a health care insurance program of the U.S. Military Health System (MHS) (formerly known as the Civilian Health and Medical Program for the Uniformed Services) that covers care not available through U.S. military medical service or public health service facilities. Our goal was to include bases from each of the service branches, although our ability to reach base commanders and obtain necessary approvals for the interviews within the time frame allotted for the study greatly influenced the list of final bases we included in our sample. Our final sample included 66 health providers at nine MTFs across the services.

In general, providers reported that PDM is a problem among ADSMs and that PDM most commonly occurs among those who, at one time, had medically indicated use. Although diversion of prescription drugs for nonmedical purposes occurs, most providers we interviewed do not think the prevalence of this type of misuse is high. The providers we interviewed perceive that PDM occurs because of a combination of factors, including the high prevalence of pain among ADSMs; psychological vulnerability to addiction; and provider problems, such as overprescribing and lack of training and expertise in recognizing PDM and in treating people who have chronic pain.

Although the providers we interviewed had some knowledge of clinical practice guidelines for chronic pain, as well as DoD directives around substance abuse and PDM, practices and adherence tend to vary by provider and MTF in those we accessed, with providers noting the need for more-consistent guidelines and greater adherence. For example, most of the MTFs reported using so-called sole-provider agreements, which are agreements between health care providers and patients that limit patients to a single prescribing physician for all medications (i.e., a sole-provider agreement) and might have other requirements regarding refills, frequency of medical appointments, and consequences of misuse (a high-risk medication agreement). However, even clinics within the same MTFs have different patient criteria for utilizing agreements, the terms of the agreements, and the names of the agreements. Additionally, despite policies that state otherwise, providers perceive that typically a zero tolerance policy around PDM parallels the policy for illicit-drug use. However, they also reported that decisions around PDM are made on a case-by-case basis. This discrepancy seems to lead to uncertainty about how to handle PDM. The providers with whom we spoke mentioned that they would like to see more-consistent guidelines, more-consistent monitoring of and adherence to clinical practice guidelines, and more guidance around administrative outcomes for ADSMs with PDM.

Evidence-based practices, such as standardized assessments for potential misuse and behavioral and pharmacological treatments, are not typically implemented in primary care or emergency room settings, according to our sample. Some pain specialists employ screening procedures, and there have been some efforts to bring screening to primary care and family practice settings, but with little success. Although providers acknowledge that there is very little time to conduct assessments, as well as a lack of understanding about what to do if a patient with pain is susceptible to PDM (according to an assessment), they see the value of having a more standardized tool for assessing the potential for PDM. Use of medication-assisted treatment for PDM was not mentioned. However, when prompted, some providers noted that medication-assisted treatment might present a challenge for providers: To prescribe Suboxone (a medication for opioid dependence containing buprenorphine and naloxone) to treat addiction, a provider must have a special U.S. Drug Enforcement Administration license. Providers with whom we spoke also lack understanding about their role in treating opioid dependence pharmacologically within the MTF. Naltrexone, both injectable and oral, is a viable option for treating some opioid-dependent patients (SAMHSA, 2015), but the providers with whom we spoke are not familiar with the medication, not comfortable providing medication for opioid dependence, or not aware of the regulations around doing so.

The greatest challenge in managing PDM facing the providers with whom we spoke is the lack of a clear definition of PDM, therefore leading to challenges in appropriately preventing, identifying, and treating PDM. Also, a lack of clarity around the policies, protocols, and guidelines across MTFs and bases leads to inconsistent practices. Providers offered a variety of recommendations for addressing these challenges, including expanding resources for preventing, identifying, and treating PDM by embedding case managers and clinical pharmacists into clinics; having pain specialists at each clinic; offering patient-centered practices, such as complementary approaches to medication; improving patient education around prescriptions, including the provision of self-management tools; clarifying and supporting adherence to guidelines and policies; improving electronic systems to enhance tracking of all prescriptions; and increasing provider training and interdisciplinary support and coordination of care.

Additionally, the substance abuse treatment providers with whom we spoke reported that there might be a lack of capacity to treat PDM on base as opposed to at a nonmilitary treatment center. Some providers said that MTF substance abuse treatment programs typically treat only alcohol problems, while others reported also treating PDM but not having specific tools for doing so. Some providers reported using educational treatment models and others reported including members with PDM into treatment groups with other illicit-drug users. The substance abuse providers with whom we spoke would like to see more-tailored educational and treatment protocols for ADSMs with PDM.

Key Insights from This Work and Strategies for Going Forward

Determining what should be done about PDM is a complex task. As indicated in our systematic literature review, few available evidence-based solutions focus specifically on the prevention, identification, or treatment of PDM in the military or civilian practice. Moreover, the DoD regulations are complex, emphasizing a general zero tolerance approach to drugs with little mention of addressing prescription drug use and misuse. Furthermore, the providers we interviewed made many recommendations with limited knowledge of the significant barriers to implementing the change suggested (e.g., distributing standardized guidelines on identification and treatment of PDM requires existence of effective evidence-based models). However, given the information gleaned from our literature review and interviews with selected providers, we can offer the following insights for consideration and potential paths forward.

Implement and Parameterize the Compartmental Model Developed in This Study to Enable a Clear Assessment of the Extent to Which the Current Prescription Drug Misuse Problem Within the Military Stems from Abuse Following Legitimate Medical Need or Simple Inappropriate Use

Military leadership can use the model, once parameterized and tested, to track the evolution of the PDM problem over time (based on trends in key characteristics driving the problem over time) and identify the extent to which particular policy approaches (e.g., harsh penalties targeting misusers, or broader implementation of step-down therapies and pain management techniques for patients suffering from severe injuries causing pain) might be effective at addressing the unique PDM problem that the military faces.

Dedicate Resources to Providing Remedial Training and Support to All Military Health Care Providers in the Identification and Treatment of Substance Abuse in Patients

Our findings provide justification for clinical training of all new and existing medical personnel on identifying and treating addictions (i.e., a comprehensive course providing information on identifying early signs of all addictive behaviors, not just those most problematic today). In doing so, the military can address the current PDM problem and educate its providers on how to identify future potential health problems, such as problems with benzodiazepines, alcohol, or even e-cigarettes. However, the military needs to do more than just provide training. In particular, it needs to make sure that the training that is provided is indeed scientifically supported and effective. It must make sure that the training is easy for providers to access and use, even when time is limited with patients. Remedial courses with military health care providers before they are assigned to their posts is one way to engage providers early on and educate them on preferred practices, such as the use of a single standardized, evidence-based screening tool for identification of substance misuse across the MHS and what to do if someone screens positive using that tool.

The military needs to go further than just providing training to providers, however, for the training to be truly effective. The military needs to be aware of and address for providers the system- and patient-level barriers that make providing linked care so difficult. It could remove patient barriers through the broad-scale implementation of a modified limited-use policy, such as the Army's Confidential Alcohol Treatment and Education Program (CATEP), but applied to PDM. Health system barriers might be overcome through electronic connectivity between providers, brief case-management strategies, and supportive care activities to better connect care received in the medical and specialty treatment settings (Cucciare and Timko, 2015; Molfenter et al., 2012; Rapp et al., 2008). These are just a couple of strategies currently being adopted within the civilian health care system in light of mandates associated with the Patient Protection and Affordable Care Act (Pub. L. 111–148, 2010) to better integrate behavioral and medical health care for people suffering from substance use disorders (Humphreys and Frank, 2014; Ghitza and Tai, 2014).

Facilitate Interdisciplinary Provider Coordination in Approaches to Identifying and Treating Prescription Drug Misuse, as Well as the Transition to Integrated Care

Although effective coordination of care through electronic medical records might be years away, changes in civilian and military health care systems that include care coordination through patient-centered medical homes (PCMHs) provide a natural opportunity for expanded prevention, identification, and treatment of PDM. Several models of PCMHs are currently being evaluated within the military sector (Nathan, 2013). In MTFs that have already begun to make these changes, providers reported greater collaboration between providers since the institution of PCMHs through the use of embedded case managers and behavioral health therapists to facilitate chart reviews and communication about and management of ADSMs with PDM and at risk for PDM. Given that service integration is relatively new, it is important to continue to monitor these efforts to help inform how to best design these systems for the future.

For Those Suffering with Chronic Pain, Expand the Availability of and Access to Pain Management and Patient-Centered Practices Within the Military Health System

It was clear from our discussion with providers that pain management and patient-centered, complementary services are not readily available or accessible to those suffering from chronic pain. Providers believe that these practices can support treatment for patients with chronic pain, but there are few within the MHS who provide these services and, where they are available, waiting lists can be long. Treatment outside of the MHS is also possible, but coverage for that care might be limited, and the tracking of these alternative treatments is often difficult.

Given the unique challenges of managing PDM patients suffering from either acute or chronic pain, as well as the lack of general medical training on how to treat these patients, the military could benefit from the development of some remedial training for all new military health care providers on this topic as well. This training, which could commence before the medical and paramedical personnel are first assigned to their posts, would provide the military the opportunity to educate its medical providers on how to use a single standardized assessment tool for identifying pain patients who are at risk of substance abuse (e.g., PDM or alcohol) and what to do when ADSMs are identified as at risk from these assessments. Remedial training for existing medical personnel encountering these types of patients should also be encouraged. Clear directives could be provided to all medical and paramedical personnel on the policies, protocols, and clinical guidelines that the military believes are the most effective to follow for these patients, as well as provide clear directives to providers regarding the role of pharmacotherapies for treating opioid (or even alcohol) misuse.

Encourage the Use of State Prescription Drug Monitoring Programs

Existing state prescription drug monitoring programs (PDMPs) are infrequently used and fraught with barriers for those providing medical services within the military. Enhanced policies and procedures to direct military providers to PDMPs to check for purchases made outside the TRICARE system would help reduce risk of overprescribing and overcome some, although not all, of the barriers. Potential challenges to this approach include making sure that someone at each military medical facility or clinic has access to the state's PDMP (different states have different rules regarding who is allowed to access their PDMPs). Potential policy changes might be needed to fully realize the benefit, such as allowing military health providers access to state PDMPs or requiring prescriptions purchased through TRICARE to be included in state PDMPs. However, these policy changes are likely to happen far more expeditiously than the adoption of a military-wide PDMP that also has access to state PDMPs, which is likely to be the only way for any PDMP to reduce prescription drug abuse among active service members and their dependents, but considerably more costly to build and implement.

Determine Whether Military Substance Abuse Programs Should Provide Unique, Prescription Drug Misuse–Focused Treatment for Service Members Who Develop Dependence on Prescription Medications

The military should explore the potential use of pharmacological maintenance, tapering, and anticraving medications for opiate dependence (e.g., buprenorphine/naloxone or oral, injectable, or extended-release naltrexone). These treatments have been shown to be potentially effective for opioid-dependent populations (SAMHSA, 2015). Although there are administrative and practical complexities to providing some of these pharmacological treatments for substance dependence to ADSMs, adoption of these forms of treatment could facilitate and expedite recovery and reintegration of service members into active duty. Other evidence-based behavioral therapies tailored for people misusing prescription drugs, including those suffering from opioid misuse and chronic pain, also exist (e.g., Rawson, Shoptaw, et al., 1995; Rawson, Marinelli-Casey, et al., 2004).

If the number of ADSMs who experience PDM is expected to grow in the future, which the full implementation of our proposed analytic tool could reveal, then attention to building and sustaining the internal treatment capacity for PDM will definitely be needed. Although it is expensive to seek broader-scale adoption of any of the treatment approaches described in the previous paragraph, the cost-effectiveness of doing so would dramatically decrease if the size of the hidden population is substantially larger than the relatively small number of ADSMs who seek or receive treatment within the military today. Thus, use of a forecasting tool, such as the one we describe in this study, could be very helpful for evaluating the desirability of pursuing the development of any particular approach broad scale at military treatment centers.

Consider Adoption, Implementation, and Improved Dissemination of a U.S. Department of Defense–Wide Limited-Use Policy

DoD policies toward substance abuse are quite complex but generally emphasize a zero tolerance approach to controlled substance use, including the nonmedical use of a prescription drug. However, some of the services have adopted what is commonly referred to as limited-use policies, in which people who misuse prescription drugs can, under very specific conditions, self-refer to treatment and avoid harsh disciplinary actions or administrative separation. These programs are modeled on the successful Army CATEP, which was implemented with the explicit purpose of encouraging ADSMs to self-refer to treatment for alcohol problems before a reportable event occurs. Limited-use policies exist today in the Army (Army Regulation 600-85, 2012 [Headquarters, Department of the Army, 2012], p. 25, § 4-2) and Navy (Chief of Naval Operations Instruction 5350.4D, 2009 [Director, Personal Readiness and Community Support Branch, 2009], enc. 2, § e, p. 12) for those suffering from PDM, although they vary in terms of allowable behaviors and remain quite complex to fully interpret in light of the harsh zero tolerance language that surrounds them. Very few military medical providers with whom we spoke made any mention of the ability to self-refer to treatment, even though these policies exist, and those who did retained their belief that the risk of administrative separation from the military was a strong deterrent. Thus, either (1) broad awareness of these policies has not been achieved or (2) they do not represent a true change in the previous culture or perception of PDM as an illegal behavior worthy of separation from the military. Our reading of these policies suggests that expanding PDM limited-use policies to more service branches might be possible, making PDM function more like alcohol use does in CATEP. However, legal experts more familiar with the specific nuances of these policies and legal precedent within each of the service branches would need to be consulted before such a conclusion could be definitively made.

Of course, the insights from this study need to be considered in light of the study's limitations. In particular, there was limited evidence of effective strategies at the time in which we conducted our systematic review of the literature, but substantial attention given to the problem of PDM in the civilian sector in the past year might have generated some new evidence. Additional limitations of our study include the use of a limited sample of military medical providers and MTFs and missing data to inform the mathematical model. Before considering action on any of the study's key insights, it might be wise to conduct a more comprehensive survey of military health providers to obtain a more representative perspective of providers' barriers, challenges, and recommendations of providers, one that can consider differences that are likely to exist across regions, military facilities, and provider types.

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This research was sponsored by the Deputy Assistant Secretary of Defense for Readiness and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.