MILITARY MEDICINE, 173, 9:871, 2008

Referrals for Alcohol Use Problems in an Overseas Military Environment: Description of the Client Population and Reasons for Referral LT Adeline L. Ong, MSC USN*; CDR Antony R. Joseph, MSC USN† ABSTRACT Being stationed in an overseas installation has been associated with increased risk for alcohol use problems. Okinawa is a unique overseas environment that often challenges service members with separation from family and friends, limited resources and recreational activities, a high rate of deployment, and restrictive local laws. Single, young, male services members in the junior ranks are at increased risk for poor coping, particularly relying on alcohol use. Maladaptive alcohol use places them at increased risk for engaging in illegal behavior and other negative consequences that subsequently lead them to be referred for an evaluation for alcohol use problems. Alcohol use problems negatively affect health, safety, morale, and mission readiness. Findings from this study strongly suggest that prevention and wellness programs should target young service members in the junior ranks for training on responsible alcohol use, alcohol use problems, and basic coping for improved impact on health and mission readiness.

INTRODUCTION Alcohol use problems have been a major concern of the Department of Defense (DoD) for the past 25 years. Since 1980, the DoD has been tracking the prevalence of alcohol use among active duty U.S. military personnel, publishing findings in the DoD Survey of Health-Related Behaviors among Military Personnel.1 Alcohol use disorders are of significant concern for the DoD due to their potentially damaging and devastating impact on the health of military service members, their families, and mission readiness. Substance abuse was found to be a factor in one of every four deaths in the United States.2 Alcohol abuse and dependence can significantly impair job performance or place service members at risk for other problems.1 Overseas, alcohol use problems are greater and are capable of impacting the operational environment, especially as alcohol and illegal drugs can often become mechanisms for coping with the hardships of overseas duty. When healthy recreational and personnel resources are limited, substance abuse problems on deployments and missions can easily negatively affect morale, safety, and mission success.1,3 The island of Okinawa, Japan, is a unique living environment. Clients who have presented to the Joint Substance Abuse Counseling Center and Substance Abuse Rehabilitation Depart*Psychology Department, Tripler Army Medical Center, 1 Jarrett White Road, TAMC, HI 96859-5000. †Naval Branch Health Clinic, Building 964, Jacksonville, FL 32212. We are military service members. This work was prepared as part of our official duties. Title 17, USC, §105 provides that “Copyright protection under this title is not available for any work of the United States government.” Title 17, §101 defines a U.S. government work as work prepared by a military service member or employee of the U.S. government as part of that person’s official duties. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of the Navy, Department of Defense, or the U.S. government. This manuscript was received for review in February 2008. The revised manuscript was accepted for publication in May 2008.

ment (SACC/SARD) on Okinawa reported that their alcohol use was influenced by multiple stressors, including separation from close family members and friends, geographical confines of the island, limited recreational and leisure activities, length of tour, and a high rate of military deployment. Other environmental factors include living in bachelor quarters, restriction to bases and those immediate areas outside installations, lengthy distances between installations, and reliance upon base transportation especially for younger service members. Additionally, cultural barriers, such as the lack of proficiency in the Japanese language, restrictive local laws, and an unfamiliar recreational lifestyle contribute to adjustment problems and increased psychological stress. At SACC/SARD, clients typically report problems with homesickness, isolation, loneliness, boredom, and frustration, which are consistent with published reports.3 Exacerbating the above factors are variables such as the on-andoff-base availability of alcohol and identification of the military culture as a drinking culture that may obscure the anti-alcohol message promulgated to military members.4 Although irresponsible alcohol use is openly discouraged and disapproved of, alcohol is easily and readily obtained at various retail establishments and living quarters. The Okinawa legal drinking age is 20 years old and personnel 20 years of age can obtain alcohol in the local community, despite an on-base drinking age of 21. Traditional celebrations within military culture, such as promotion ceremonies, Mess Nights, command parties, and Hail and Farewell gatherings customarily include use of alcoholic beverages. Young service members faced with a high-stress environment are frequently influenced by existing social norms that tolerate increased alcohol use for recreation and coping. Recently, this was evidenced by the on-base drinking age being changed from 21 years to 20 years following the period of data collection for this study. This investigation seeks to describe the patient population, reason for referral to SACC/SARD, and facilitate a discus-

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Alcohol Abuse Referrals in an Overseas Military Environment

sion about what interventions may best help this population adapt to their overseas environment and improve social and occupational functioning.

LITERATURE REVIEW The Department of the Navy defines “alcohol abuse” as “the use of alcohol to an extent that it has an adverse effect on performance, conduct, discipline, mission effectiveness, and/or user’s health, or Department of the Navy, or leads to unacceptable behavior as evidenced by one or more alcohol-related misconduct” (OPNAVINST 5350.4C).5 Furthermore, the instruction refers to alcoholism as “alcohol dependence,” specifically, “a chronic, progressive disease in which the individual is addicted to alcohol.” The higher rates of alcohol use problems among military populations cited below highlight the sense of urgency that the DoD assumes toward interventions for alcohol use problems.4,5 Bray et al.1 stated in a DoD report that more than threefourths of the total DoD population consumed alcohol within a 30-day interval. Bray et al.1 found that the large majority of DoD alcohol consumers use it responsibly; however, approximately 23.5% of members consumed moderately heavy levels of alcohol and 18.5% of members consumed alcohol heavily (five or more drinks in one occasion at least once a week in a 30-day period). The DoD report demonstrated that the highest rates of heavy drinking existed among Marine Corps (25.4%), followed by Army (24.5%), Navy (17.0%), and Air Force (10.3%). Furthermore, 44.5% of services members reported binge drinking, defined as drinking five or more alcoholic beverages in 2 hours once within a 30-day period. Defined as such, binge drinking was highest for Army personnel (52.8%), followed by Marine Corps (53.2%), Navy (41.7%), and Air Force personnel (33.9%). In 2005, 8.1% of service members reported one or more serious consequences related to their alcohol use and 13.2% of service members reported productivity loss associated with alcohol use.1 Comparison studies that examined military populations suggested that alcohol abuse problems may equal or exceed rates in the nonmilitary population.1,3 In 2004, the U.S. National Survey on Drug Use and Health published self-report results showing that the prevalence of heavy alcohol use among 18- to 25 year-olds was 15.3% in the surveyed civilian population and 27.3% in the military population, highlighting a higher prevalence of heavy drinking among U.S. military personnel.1,6 More specifically, the U.S. National Survey on Drug Use and Health reported that the prevalence of heavy alcohol use was 13.6% for civilian males compared to 32.2% for military males and 5.5% for civilian females versus 8.1% for military females. Wechsler et al.7 reported that approximately 80% of college students consumed alcohol in the past year, 44.4% reported binge drinking (males 48.6%, females 40.9%), and 22.8% identified themselves as frequent binge drinkers (males 25.2%, females 20.9%). Differences in rates of heavy drinking between military and nonmilitary popula-

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tions were noteworthy among the male 18 to 25 age group, where rates were higher among military members, 28.7% versus 19.7%, respectively.1 According to Bray et al.,1 moderate to heavy military drinkers most frequently cited the following reasons for consuming alcohol: (1) celebration, (2) relaxation, (3) to become more sociable, (4) to make things more fun, and (5) to enjoy party situations. Less frequently, moderate and heavy drinkers reported drinking alcohol to forget about personal problems and to improve mood.1 Many moderate to heavy drinkers believed that alcohol use was a characteristic of military culture that supervisors tolerated, and that often drinking was the only recreational activity available.1,3 Bray et al.1,8 indicated that heavy drinking in the military was more prevalent in single or unaccompanied, less-educated, younger-aged males within the lower pay grades. They showed that a larger percentage of service members between the ages of 18 and 25 (56.4%) reported binge drinking than those between the ages of 26 and 55 (34.1%).1 These researchers posited that service branches that have a larger proportion of younger, male, single, enlisted members with less education, such as the Marine Corps, will tend to have increased rates of heavy alcohol use. Similarly in a study of Army subjects, alcohol-related consequences were more likely to be associated with males, enlisted ranks, not being in an intimate relationship, being an ethnic minority, and experiencing greater levels of stress.9 Unaccompanied service members were twice as likely to be heavy drinkers as members accompanied by spouses and men were three times more likely to be heavy drinkers than women.1 Enlisted members were three times as likely as junior officers and twice as likely as senior officers to drink alcohol heavily.1 Additionally, Bray et al.1 revealed that Caucasian and Hispanic services members stationed outside of the continental United States were significantly more likely to use alcohol heavily. Heavy alcohol use has been associated with a host of negative behaviors and consequences.10 Binge drinking or heavy episodic drinking was associated with increased risk of serious health problems and injuries, poor academic and work performance, participation in unsafe sex, sexual assault, becoming the passenger of a driver under the influence of a substance, violence, and other aggressive behaviors.1,7,10 Heavy drinkers are more likely to engage in risk-taking behaviors, such as driving and operating heavy machinery after alcohol consumption, and violent behavior such as spousal abuse.1,3,11 Each year, approximately 1,400 college students die from alcoholrelated causes, and 1,100 of those deaths have been attributed to drinking and driving.10 Bray et al.1 reported that 13.2% of DoD personnel reported loss in work productivity which included being late for work, leaving work early, and performing work below normal levels, while 2.9% of personnel were identified with possible alcohol dependence. Another DoD Survey of Health-Related Behaviors among Military Personnel reported that between 1998 and 2002 alcohol abuse accounted for an increase in productivity loss in the Navy from 14.1% to 23%.12

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Alcohol Abuse Referrals in an Overseas Military Environment

The 2005 DoD rates for serious consequences, lost productivity, and possible alcohol dependence were highest among Marine Corps (14.5%, 19.8%, and 4.2%, respectively), followed by Army (10.8%, 15.4%, and 4.1%, respectively), Navy (6.9%, 13.4%, and 2.8%, respectively), and Air Force members (3.3%, 7.4%, and 1.1%, respectively).1 Studies have shown that there is a strong positive relationship between alcohol use, stress, and mental health.3,9 Bray et al.1 compared active duty military drinkers and nondrinkers and discovered that drinkers reported more stress, anxiety, suicidal ideation, and other mental health problems that interfered with performance. Gutierrez et al.9 reported that chronic stress in the workplace and home, such as high work demands and low levels of personal control, were significant predictors of substance use and alcohol-related consequences among military males. Bray, Fairbank, and Marsden13 indicated that approximately a fourth of all service members used alcohol or cigarettes to cope with stress, and that military men who reported high levels of work stress were 1.4 times more likely than men who reported low work stress to drink heavily. Interestingly, Ames and Cunradi3 found that young sailors believed drinking during the work week with their peers and shipmates was an appropriate way to deal with stress, loneliness, and the lack of recreational activities. In contrast, stress did not predict alcohol or substance use among female service members.13 Bray, Bae, Federman, and Wheeless14 posited that military members stationed in Asia may be at greater risk of becoming heavy drinkers than military members stationed at other locations, such as within the continental Unites States or Europe. Furthermore, they found that service members stationed in Asia were more likely to report experiencing a significant amount of stress due to being separated from their families and drank greater amounts of alcohol than before entering service. Consistent with other research findings on reasons for alcohol use, Bray et al.14 found that service members in Asia were more likely to endorse the following statements: (1) alcohol use was part of military culture, (2) alcohol use was encouraged at parties on base, (3) most of their peers drank, (4) it was harder to fit in if they did not drink, and (5) alcohol use was the only recreation available. Bray et al.14 suggested that the higher rates of alcohol use and productivity loss in Asia resulted from ease of access to alcoholic beverages in Asian countries and greater social tolerance of heavy alcohol use there, especially when the service member was unaccompanied by family members and experienced high levels of stress.14 The DoD fully supports interventions for alcohol abuse because the sequelae of alcohol abuse negatively impacts force numbers, produces premature attrition from active service, challenges force readiness and deployability, and affects the physical and emotional health of military members and their dependents. Okinawa presents a unique population of study because its service members and their families tend to be young, which exacerbates the challenges of an overseas environment and amplifies the inherent pressure generated by

installations with high operational tempo. Job demands and an unfamiliar cultural climate on Okinawa may intensify existing alcohol use problems. Likewise, alcohol problems may interfere with an individual’s ability to adjust to and cope with the demands of work and life overseas. Therefore, it is important to assess the client population to determine whether community interventions and health promotion strategies are meeting the population’s need for optimized readiness and health. To achieve this, our study aims to characterize our population and describe the underlying source of events that generate referrals to our overseas military substance abuse clinic. METHOD Subjects Participants in this retrospective study included all beneficiaries who presented to SACC/SARD for services from June 2004 through December 2006 (N ⫽ 1838). For this specified sampling period, the study group was comprised of 92.3% males and 7.7% females (see Table I). Age ranged from 17 to 62 years, with males and females demonstrating a mean age of 22.6 years and 23.3 years respectively. The median age among males was 21 years and among females as 22 years. Although not shown in Table I, the most representative age in the sample was 20 years, 21.5% (396 members). The sample consisted of active duty service members, family members, and U.S. civilians. Armed Forces active duty personnel presented for care from four branches of service, namely, Marine Corps, Navy, Army, and Air Force. Table II illustrates that 95.9% of the sample was made up of Marine Corps and Navy personnel, who generally reflected the population of patients empanelled to U.S. Naval Hospital Okinawa. Within our area of responsibility, the total military population was comprised of approximately 24,000 members with an additional 7,000 Air Force members. Ordinarily, Air Force members only access more intensive services at SACC/SARD through referral from the Air Force’s own substance abuse treatment program, which explains the disproportionately low number of clients from the Air Force. The Army has the smallest population of active duty members on the island, resulting in the smallest number of referrals. In addition, individuals were excluded from this study if they did not complete the initial screening assessment, or presented for their appointment under the influence, in a psychotic state, or displayed severe mental health conditions requiring alternative interventions. TABLE I. Composition of Males and Females in the Sample, Including Median, Mean Age, SD, and Percentage of Sample

Male Female

n

Median Age (years)

Mean Age (years)

SD

%

1,696 141

21.0 22.0

22.6 23.3

4.7 5.4

92.3 7.7

For a single case, gender was not adequately documented.

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Alcohol Abuse Referrals in an Overseas Military Environment TABLE II.

Representation of Service Branches in the Sample

USMC USN Army Civilian USAF

n

%

1,512 250 44 18 14

82.3 13.6 2.4 1.0 0.8

Procedure This analysis used both descriptive and qualitative methods to examine a clinically functional database that was used to track patient-demographic information, service contacts, and select historical patient data on a computer-based medical intake system. This analysis was conducted in an attempt to describe the population that obtained treatment services at this overseas substance abuse treatment clinic, as well as identify demographic factors that may contribute to alcohol use problems. This investigation did not involve administration of invasive or experimental procedures on any of the participants. Screening Instrument Participants were either self-referred, referred by unit leaders, or referred by medical providers to SACC/SARD for an initial screening. During the screening, which typically lasted from 30 to 60 minutes, general demographic information and self-reported drinking behaviors were documented. After the initial interview and paperwork were completed, a preliminary diagnosis was formulated and intervention was recommended. Outcomes generated by the screening interview included (1) no diagnosis and no intervention required, (2) no diagnosis with referral to an early intervention psychoeducational course, or (3) being diagnosed with an alcohol use disorder and referred for treatment, outpatient or residential. This study analyzed only patient data collected for the screening appointment. RESULTS Statistical analysis of the variables age, rank, branch of service, incident, source of referral, and resulting diagnosis or screening outcomes produced the following characterization of our sample. Tables III and IV delineate that most of the services at SACC/SARD were offered to enlisted Marines in the junior ranks, particularly lance corporals (E3). Age inTABLE III.

Representation of Marine Corps Ranks in the Sample

Private (E1) Private 1st Class (E2) Lance Corporal (E3) Corporal (E4) Sergeant (E5) All others

874

n

%

115 363 640 198 114 408

6.3 19.7 34.8 10.8 6.2 22.2

Mean Age (years)

SD

20.3 20.3 21.1 22.5 25.8

1.8 1.7 1.9 2.3 3.1

TABLE IV.

E1–E3 E4–E6 E7–E9

Distribution of Enlisted Ranks within the Sample, Including Mean Age and SD n

Mean Age (Years)

SD

1,247 470 29

20.9 24.8 38.5

2.11 4.33 4.00

creases with seniority, even for junior service members in the sample, and in Tables III and IV, it can be seen that a large number of referrals for substance abuse screening were generated for individuals who were below the legal age for alcohol consumption in the continental United States. The significantly disproportionate number of the clinical population falling within the E1 to E3 and 21 years old and under range strongly suggests that younger, less-mature enlisted members may need more frequent education regarding alcohol and its impact on health, safety, and mission readiness than more experienced military staff in the mid-level enlisted ranks (E4 –E6). A variety of undesirable social behaviors resulted in referrals to SACC/SARD. Table V presents specific reasons for referral of Marine Corps and Navy personnel in Okinawa. Roughly one-third of the total number of referrals resulted from illicit civil behavior. Involvement in activities, such as assault, drinking with a minor or an underage military member, use of illegal drugs, larceny, possessing an open container of alcohol, and underage drinking, were classified as unlawful civil behavior. Referrals initiated due to command or individual concern, illegal military behavior, and infractions that occurred during motor vehicle operation collectively accounted for 60% of the referrals observed. Problems related to civil behavior comprised the major reason for Marine Corps referrals (33%), and was disproportionate when compared to civil behavior problems for Navy personnel (18%). By comparison, illegal military behaviors, such as unbecoming conduct, violation of a direct order, drunk and disorderly, drunk on duty, late for muster, and unauthorized absence, comprised the largest source of referrals for Navy members (23%), conTABLE V. Underlying Social Events Resulting in Referrals with Percentage of Total Sample and Frequencies of Marine Corps and Navy Only

Illegal civil behavior Command intervention Illegal military behavior Personal intervention Driving infraction Unspecified Domestic problem International attention Medical intervention Mental health

n

%

USMC

USN

554 359 310 262 175 117 38 14 5 4

30.1 19.5 16.9 14.3 9.5 6.4 2.1 0.8 0.3 0.2

504 292 238 219 116 102 24 11 3 3 1,512

45 57 58 37 33 12 6 1 1 0 250

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Alcohol Abuse Referrals in an Overseas Military Environment

trasted with the Marine Corps (16%). Referral for problems related to vehicle operation were greater for Navy members (13%) and less for Marine Corps (8%), possibly due to policies that restrict junior Marines from obtaining driving privileges on Okinawa but did not apply to Navy personnel. Overall, the prevalence rate of SACC/SARD referrals was 112 per 1,000 for the Marine Corps and 93 per 1,000 for Navy personnel in Okinawa. In contrast, the referral rate was 49 per 1,000 for the Army, although differences in referral rates were likely the result of a substantial disparity of sample size between branches of service, as shown in Table II. An examination of the source of referral revealed that the vast majority of subjects (84%) were referred to SACC/SARD by their command. A smaller percentage of the individuals referred themselves (13%); however, self-referral is frequently prompted by the chain of command. The remaining subjects were referred by a medical provider (3%). A summary of the screening outcome data is found in Tables VI and VII. The screening procedure resulted in 63% of the clients being classified with no diagnosis, as determined by criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).15 Table VI illustrates that alcohol dependence15 was identified in almost 20% of the sample, while alcohol abuse15 was diagnosed in 16% of the group. A slightly higher proportion of female subjects (23%) met the screening criteria for alcohol dependence as compared to males (19%), whereas there was no difference between the proportion of females (16%) and males (16%) diagnosed with alcohol abuse. Less than 1% of the screened sample was diagnosed with dependence or abuse of drugs or other psychiatric disorder. Table VII represents outcomes produced at screening when viewed TABLE VI.

Frequencies for Screening Outcomes for Entire Sample and Gender

No problem Alcohol dependence Alcohol abuse Drug dependence Drug abuse Psychological disorder

n

%

Male

Female

1,168 363 292 6 4 5

63.5 19.7 15.9 0.3 0.2 0.3

1,083 330 270 5 4 4

84 33 22 1 0 1

For a single case, gender was not adequately documented.

TABLE VII.

Frequencies for Screening Outcomes across Branches of Service Branch of Service

Alcohol abuse Alcohol dependence Drug abuse Drug dependence No problem Psychological disorder

Army

Civilian

12 8 0 0 24 0 44

2 6 0 1 9 0 18

USAF USMC 5 5 0 1 2 1 14

231 298 4 4 973 2 1,512

USN 42 46 0 0 160 2 250

TABLE VIII. Cross-Tabulation of Reported Incident by Screening Outcome When Positive Positive Screening Outcomes Alcohol Alcohol Drug Drug Abuse Dependence Abuse Dependence Unidentified incident Command intervention Domestic problem Driving infraction Illegal civil behavior Illegal military behavior International attention Medical intervention Mental health Personal intervention Total count

16 64 9 23 83 44 5 3 3 42 292

27 72 7 21 73 79 0 2 0 82 363

0 0 0 0 0 3 0 0 0 1 4

0 0 0 0 0 5 0 0 0 1 6

according to branch of service. A marginally higher proportion of Navy subjects (17%) met criteria for alcohol abuse when compared to Marine Corps (15%), whereas no difference was found between the proportion of Navy (18%) and Marines (18%) identified as having alcohol dependence. The rate of alcohol dependence was 2.2% for Marines stationed in Okinawa over the sampling period. Furthermore, the prevalence rate of alcohol abuse for Marine personnel in Okinawa was 1.7%. For Navy personnel stationed in Okinawa, the prevalence rate of alcohol dependence was 1.7% for the sampling period and the rate of alcohol abuse was 1.5%. Table VIII illustrates screening results for cases found to be positive for alcohol and drug problems. Data revealed that a predominance of subjects with positive screening outcomes were diagnosed as alcohol dependent, irrespective of referral reason. Typically, someone with alcohol dependence is more likely to seek or be referred for treatment because of the greater severity in symptomology or negative consequences experienced. This was suggested by the results in Table VIII demonstrating that members who sought intervention from SACC/SARD independently, were referred by their commands, or were charged with illegal military behavior were almost twice as likely to be diagnosed with alcohol dependence than alcohol abuse. This was not the case whenever illegal civil behaviors or an international incident occurred. In those cases, there were more findings of alcohol abuse than alcohol dependence, which may suggest that incidents that draw highly negative attention from the Okinawa or Japanese government may lower the threshold for referral for substance use evaluation and treatment. Domestic and mental health problems showed a somewhat greater association with alcohol abuse referrals than alcohol dependence referrals. Finally, members referred for illegal drug use were most frequently identified through illegal military behavior. CONCLUSIONS A successful command substance abuse prevention program typically includes the following elements: (1) announcement

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of the command’s policy, (2) all hands education, (3) deglamorization of alcohol, (4) risk reduction such as limiting alcohol availability, (5) providing alternatives to alcohol, and (6) holding members accountable for illegal or harmful behaviors consistently. In 1992, the Navy announced its “Zero Tolerance” policy for alcohol use problems and a decline in alcohol incidents has been observed since. Hence, the fundamental elements of the substance abuse awareness program should be sustained. However, opportunities for program enhancement should be considered in the case of overseas military command and substance abuse clinic programs. Namely, our analysis suggests that increased efforts in community intervention and health promotion strategies targeted at younger, single service members in the junior ranks could improve mission readiness and health. Specifically, the characterization of our population and summary of the underlying events that generate referrals to the SACC/SARD suggested that interventions should focus on the negative impact and consequences of irresponsible alcohol use, such as engagement in illicit military or civil behaviors. Clinical data also suggest that a campaign for wellness and prevention of substance abuse could address the unique stressors, such as loneliness, boredom, and limited coping resources faced by the young and culturally naive military population in Okinawa. Individuals seeking services at SACC/SARD Okinawa may be generally characterized as 19 to 21 years old, male, active duty Marine Corps, with rank of E2 to E3. This finding is similar to the characterization of heavy drinkers described by Bray et al.1 Furthermore, illicit civil behavior, especially underage drinking, produced the most referrals, which were primarily generated by the member’s unit or command. Our study demonstrated that referred members are not typically diagnosed as having an abuse or dependence problem during the screening procedure, but typically benefited from intensive education regarding responsible alcohol use, coping strategies, and the negative impact of alcohol use problems. Lastly, individuals with alcohol dependence tended to have problems with adherence to military rules, whereas individuals identified with alcohol abuse problems tended to behave inappropriately in civilian situations. Prevention and health and wellness information should be designed for the young military population, beginning as early as possible in their military careers, before the stresses of military life and the demands of deployments emerge. On the whole, a wellness and prevention program would be expected to reduce the incidence of referrals for treatment of substance use disorders. In addition, prevention and education efforts should be expected to reduce illicit military and civil behavior, negative health consequences, and maladaptive family and mental health functioning. A comparison of males and females screened for substance abuse problems revealed no remarkable differences regarding diagnosis of alcohol dependence or alcohol abuse. In addition,

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no differences were found when Marines were compared to Navy personnel stationed in Okinawa. Thus, health and wellness information should be presented without bias or selection regarding gender or military branch affiliation. In summary, it appears that if a reduction of alcohol use problems could be realized, the military community in Okinawa would benefit from fewer problems with civil disobedience and negative international attention. Commands might be encouraged to be more proactive about referring service members for early identification of potential alcohol use problems. Overall, intervention efforts designed to address the unique stressors facing young, single service members and the negative consequences of alcohol use are expected to significantly improve unit morale, physical and mental health, and mission readiness of service members in overseas environments. ACKNOWLEDGMENTS We express our gratitude to the staff members assigned to the Joint Substance Abuse Program, Okinawa, especially Karrin Cotton, Mike Delepine, and Mapuana Cunningham, for their significant contributions in opening a research dialogue about the client population and in treating and caring for U.S. military service members and family members. This work was approved by the Clinical Investigation Department, Naval Medical Center, San Diego Project S-06-140.

REFERENCES 1. Bray RM, Hourani LL, Olmsted KLR, et al: 2005 Department of Defense Survey of Health-Related Behaviors among Military Personnel: A Component of the Defense Lifestyle Assessment Program (DLAP), U.S. Department of Defense. Cooperative Agreement No. DAMD1700-2-0057/ RTI/7841/106-FR). Research Triangle Park, NC, Research Triangle Institute, 2006. 2. Horgan C, Skwara KC, Strickler G: Substance abuse: the nation’s number one health problem: key indicators for policy: update (prepared for the Robert Wood Johnson Foundation). Waltham, MA, Schneider Institute for Health Policy, Heller Graduate School, Brandeis University, 2001. 3. Ames G, Cunradi C: Alcohol use and preventing alcohol-related problems among young adults in the military. Alcohol Res Health 2005; 28: 252–7. 4. Department of Defense: Rehabilitation and Referral Services for Alcohol and Drug Abusers. DoD Instruction 1010.6. Washington, DC, Department of Defense, March 13, 1985. 5. Department of the Navy, Office of the Chief of Naval Operations: Drug and Alcohol Abuse Prevention and Control. OPNAVINST 5350.4C. Washington, DC, Department of the Navy, October 15, 2005. 6. Office of Applied Studies: Results from the 2006 National Survey on Drug Use and Health: National Findings. DHHS Publication No. SMA 07-4293, NSDUH Series H-32. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2007. 7. Wechsler H, Lee JE, Kuo M, Seibring M, Nelson TF, Lee H: Trends in college binge drinking during a period of increased prevention efforts: findings from 4 Harvard School of Public Health College alcohol study surveys: 1993–2001. J Am Coll Health 2002; 50: 203–17. 8. Bray RM, Hourani LL, Rae KL, et al: 2002 Department of Defense Survey of Health-Related Behaviors among Military Personnel: Final Report (prepared for the Assistant Secretary of Defense [Health Affairs]), U.S. Department of Defense. Cooperative Agreement No. DAMD17-00-2-0057/RTI/7841/006-FR. Research Triangle Park, NC, Research Triangle Institute, 2003. 9. Gutierrez CA, Blume AW, Schmaling KB, Stoever CJ, Fonseca C, Russell ML: Predictors of aversive alcohol consequences in a military sample. Milit Med 2006; 171: 870 – 4.

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Alcohol Abuse Referrals in an Overseas Military Environment 10. Kapner, DA: Infofacts resources: alcohol and other drugs on campus— the scope of the problem, 2003. Available at www.higheredcenter.org/ pubs/factsheets/scope.html; accessed September 3, 2007. 11. Bell NS, Harford T, McCarroll JE, Senier L: Drinking and spouse abuse among U.S. Army soldiers. Alcoholism 2004; 28: 1890 –7. 12. Department of Defense: DoD Surveys of Health Related Behaviors among Active Duty Military Personnel, 1995 to 2005. Washington DC, Department of Defense, 2002–2005.

13. Bray RM, Fairbank JA, Marsden ME: Stress and substance use among military women and men. Am J Drug Alcohol Abuse 1999; 25: 239 –56. 14. Bray RM, Bae KH, Federman EB, Wheeless SC: Regional differences in alcohol use among U.S. military personnel. J Stud Alcohol 2005; 66: 229 –38. 15. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, Ed 4 (text revision). Washington, DC, American Psychiatric Association, 2000.

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