19.4 Substance Use, Abuse & Treatment Programs
Key Takeaways
- Tobacco use is the single most preventable cause of disease and death in the United States, estimated to cause 480,000 deaths per year including approximately 41,000 from secondhand smoke.
- Designated tobacco use areas must be at least 50 feet from building entrances and air intake ducts, and at least 100 feet from playgrounds.
- Ingestion of products containing or derived from hemp seed, hemp seed oil, delta-8-THC, and CBD is prohibited, and non-compliance violates Article 92, UCMJ.
- ADAPT program managers conduct required reviews of medical records and documentation within seven calendar days of notification.
- The responsibility to diagnose a substance use disorder lies with ADAPT personnel, not with supervisors or commanders.
The Tobacco-Free Force
"The USAF goal is to have a tobacco-free force." AFH 1 frames it in mission terms: "Optimal health and total fitness are force multipliers and critical to our military mission."
Tobacco use is defined broadly — "all products that may be configured to deliver nicotine, including but not limited to cigars, cigarettes, electronic cigarettes/vape pens, stem pipes, water pipes, hookahs, vaporizers, smokeless products, and any other nicotine delivery system defined as a tobacco product." Electronic devices and vape pens are inside the definition.
The cost figures are testable:
| Cost | Figure |
|---|---|
| Annual DoD cost of tobacco use (TRICARE estimate) | $1.7 billion, from increased healthcare utilization and decreased work productivity due to smoke breaks and illnesses |
| Cost of smoking a pack a day for a year | One month's base pay for an Airman Basic |
Tobacco Restrictions
AFI 48-104, Tobacco Free Living, sets the rules. "Commanders and leaders shall minimize the number of designated tobacco use areas to as close to zero as possible."
| Restriction | Distance |
|---|---|
| From building entrances and air intake ducts | At least 50 feet |
| From playgrounds | At least 100 feet |
50 and 100 feet are the two distances to memorize.
Two categorical prohibitions:
- All students in technical training, in-residence professional military education, accession, and graduate medical education programs are prohibited from using tobacco products while in uniform
- Tobacco use is prohibited at all times during basic military training
Note the difference in scope: for students in the listed programs the prohibition is while in uniform; in BMT it is at all times.
Health Risks
"Tobacco use is the single most preventable cause of disease and death in the United States." That superlative is a near-certain item.
| Fact | Figure |
|---|---|
| Tobacco smoke classification | A Class "A" carcinogen |
| Estimated deaths per year | 480,000, of which approximately 41,000 are from secondhand smoke exposure |
| Carcinogens in smokeless tobacco | 28 different cancer-causing agents |
| Oral cancers from tobacco products | Affect 30,000 people annually; one person dies every hour from the disease; only 50 percent of persons are alive at five years after diagnosis |
| Increased risk of coronary heart disease and stroke | Two to four times |
| Increased risk of lung cancer | Approximately 25 times |
The operational effects matter for a readiness chapter: tobacco use "decreases endurance, night vision, and fine motor coordination (the coordination needed to hold a weapon steady)," and increases the risk of injuries such as fractures, poses post-operative respiratory complications, and impairs or slows wound healing.
Night vision and fine motor coordination are the two effects most specific to military duty and the ones the exam is most likely to test.
Cessation
"Nicotine found in tobacco products is addictive." AFH 1 reports that seven out of 10 smokers in the United States want to completely quit and nearly one-half have tried to quit in the past year, and that "some studies suggest that it may take some people up to 30 tries before successfully quitting."
"Commanders are expected to support Airmen trying to quit tobacco products." Installation health promotion programs provide education, motivation, and intervention, and formal, structured cessation programs are available. State telephone-based quit lines are reachable at no cost at 1-800-QUIT-NOW by residents of each state, the District of Columbia, Guam, and Puerto Rico.
The ADAPT Program
The Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program is "designed to promote readiness, health, and wellness through the prevention and treatment of substance misuse and abuse."
Participation may:
- Minimize the negative consequences of substance misuse to the individual, family, and organization
- Provide comprehensive education and treatment to individuals experiencing problems
- Restore function and return identified substance abusers to unrestricted duty status, or assist them in their transition to civilian life
The Hemp and CBD Prohibition
This is one of the most reliably tested rules in Chapter 22:
"To ensure military readiness, the ingestion of products containing or derived from hemp seed or hemp seed oil, including but not limited to delta-8-tetrahydrocannabinol (delta-8-THC) and cannabidiol (CBD), is prohibited."
Why: such products "may contain varying levels of tetrahydrocannabinol, an active ingredient of marijuana, which is detectable through USAF drug testing."
The consequence: "Failure by military personnel to comply with the prohibition... is a violation of Article 92, Uniform Code of Military Justice."
Note that the prohibition covers ingestion of hemp-derived products regardless of legality under state law, and that delta-8-THC and CBD are named specifically.
Leadership Responsibilities
"Signs and symptoms of substance use and misuse may exist. If signs do exist, talk with the individual to determine if professional assistance is needed." Supervisors should document and discuss specific instances of unusual behavior with the supervisor, first sergeant, or unit commander to help expedite care.
The boundary is explicit and testable: "The responsibility to diagnose a substance use disorder lies with ADAPT personnel." A supervisor identifies and refers; they do not diagnose.
The treatment team consists of the commander, supervisor, member's counselor, medical consultants, other appropriate helping agencies, and the member. Supervisors remain focused on the member's duty performance, attendance in the program, and maintenance of standards. The commander or first sergeant and the supervisor must be involved at program entry, termination, and anytime there are significant treatment difficulties.
"The primary objective of the treatment team is to guide the clinical course of the treatment after examining all the facts."
A blanket referral rule: "All RegAF members involved in alcohol-related misconduct will be referred for a substance use assessment."
Assessment and Treatment
"The central purpose of the substance use assessment is to determine the patient's need for treatment and level of care required." ADAPT program managers conduct required reviews of medical records and all documentation within seven calendar days of notification to determine diagnosis, treatment planning, and delivery of services.
Seven calendar days is the number to memorize.
| Service type | Who receives it and what it involves |
|---|---|
| Nonclinical | Members who do not meet diagnostic criteria for a substance use disorder receive targeted prevention and education services tailored to the individual based on assessment and determination of risk, with follow-up appointments and review to reassess the need for continued services |
| Clinical | Those who meet the diagnostic criteria are entered into treatment with the level and intensity of care determined by the ADAPT program manager. To the greatest extent possible, patient detoxification will be managed on an outpatient basis; those requiring medically managed (inpatient) detoxification are entered into an appropriate medical facility. Family involvement is strongly encouraged |
Two rules attached to clinical services: individuals diagnosed with a substance use disorder will refrain from the use of alcohol during the initial phase of treatment and are strongly encouraged to continue to abstain during aftercare, and involvement in self-help recovery groups is encouraged as an adjunct to treatment.
A separation note that surprises candidates: for members being processed for separation, appropriate medical care including detoxification is provided prior to separation — but "separation action is not postponed because of a member's participation in ADAPT."
Completion and Failure
Successful completion: "Patients will not be considered to have successfully completed treatment until the patient has completed treatment and continuing care (aftercare)." The treatment team determines progress using VA/DoD Clinical Practice Guidelines, current Diagnostic and Statistical Manual of Mental Disorders criteria, and American Society of Addiction Medicine criteria.
Failing the program. The treatment team may determine failure based on:
- A demonstrated pattern of unacceptable behavior
- Inability or unwillingness to comply with the treatment plan
- Involvement in alcohol or drug-related incidents after receiving initial treatment
"An individual who has failed ADAPT will be considered for administrative separation by his or her commander."
Managing Personnel in ADAPT
"The commander is responsible for all personnel and administrative actions pertaining to patients involved in ADAPT, to include assignment availability, promotion eligibility, reenlistment eligibility, personnel reliability program, and security clearance."
The protective rule is heavily tested: "Application of administrative restrictions should be based on the establishment of an unfavorable information file or control roster resulting from the member's unacceptable behavior, and not solely based on their involvement in ADAPT." Participation alone is not a basis for restriction.
The Line of Duty Determination
"A line of duty determination is a finding made after an investigation into the circumstances of a member's illness, injury, disease, or death," and "protects the interests of both the member and the U.S. Government."
The finding concludes three things:
- Whether the illness, injury, or disease existed prior to service — and if so, whether it was aggravated by military service
- Whether the illness, injury, disease, or death occurred while the member was absent without authority
- Whether it was due to the member's misconduct
A line of duty determination may impact disability retirement and severance pay, forfeiture of pay, period of enlistment, and veteran benefits. The reference is DAFI 36-2910.
Medical care referrals. Medical personnel must notify the unit commander and the ADAPT program manager when a member:
- Is observed, identified, or suspected as being under the influence of drugs or alcohol while seeking medical care
- Receives treatment for an injury or illness that may be the result of substance use
- Is suspected of abusing substances
- Is admitted as a patient for alcohol or drug detoxification
What are the minimum distances required for designated tobacco use areas?
An Airman purchases a CBD supplement that is legal in the state where they are stationed. What does AFH 1 say?
Who holds the responsibility to diagnose a substance use disorder?