Demographic and Psychosocial Predictors of Early ...

MILITARY MEDICINE, 181, 11/12:e1540, 2016

Demographic and Psychosocial Predictors of Early Attrition for Drug Use in U.S. Marines Martin R. White, MPH; Christopher J. Phillips, MD, MPH; Kartavya J. Vyas, MA; Lauren Bauer, MPH ABSTRACT Objective: The objective of this study was to determine demographic and psychosocial predictors of early attrition for drug use in a cohort of U.S. Marines and the resulting lost person-days. Method: The study included data from 35,193 male Marines who completed a life history questionnaire during their first week of basic training. Associations between demographic and psychosocial variables with subsequent discharge for drug use were analyzed using logistic regression. Results: The strongest predictors of early attrition because of drug use were being a smoker, African American race, moving around often as a child, not having a high school diploma, joining the military to leave problems behind, and having a prior arrest record. The results also indicate that approximately 3.1 million person-days were lost in this cohort because of early discharge for drug abuse. Conclusions: Despite effective policies that prohibit drug use, these findings suggest that a significant loss in manpower and training costs still occurs because of early attrition for drug use. Postenlistment interventions for those recruits at higher risk for drug abuse may help to reduce this attrition.

INTRODUCTION Substance abuse has well-known negative health consequences and detrimental effects on military readiness, levels of performance, and discipline. It remains a concern for the military, despite having policy directives in place that prohibit illicit drug use and strongly discourage alcohol abuse and tobacco use by members of the military. Recent trend data— from 131,961 new Marine Corps accessions starting in 2001–2010—revealed that 27% were current cigarette smokers, 14% used smokeless tobacco, 4% had alcohol-related problems, and 13% were binge drinkers.1 Self-reported Department of Defense (DoD) Health Related Behavior Surveys (HRBSs) found the prevalence of any illicit drug use, including prescription drug misuse during the past 30 days before taking the surveys, declined sharply from 28% in 1980 to 3% in 2002. There were several methodologic changes for the 2005, 2008, and 2011 HRBS, which obfuscate direct comparisons to prior surveys, but illicit drug use and prescription drug misuse were both 1.3% in the past 12 months for those active duty service members completing the 2011 HRBS.2 Without using self-reported data, instead using medical and pharmacy claims data and drug screening results from FY 2010, Jeffery et al3 found the rate of prescription and illegal drug abuse to be 1.14% of the total active duty force, essentially the same result as the 2011 HRBS. Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106. This study was supported by the Department of Defense under work unit 60002. The views expressed in this article are those of the authors and are not intended to represent the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Approved for public release; distribution is unlimited. This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research. U.S. Government work (17 USC 105). Not copyrighted in the United States. doi: 10.7205/MILMED-D-15-00507

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Currently, the Defense Department tests approximately 60,000 urine samples each month as part of their Drug Demand Reduction Program, which began in the early 1980s to discourage drug use in the services. This program currently tests for THC (marijuana), cocaine, opiates (morphine, codeine, oxycodone, oxymorphone, hydrocodone, hydromorphone, and heroin), amphetamines (methamphetamine and ecstasy), barbiturates (amobarbital, butalbital, and pentobarbital), benzodiazepines (lorazepam, diazepam, temazepam, alprazolam, and ozazepam), phencyclidine (PCP), and lysergic acid diethylamide (LSD).4 By regulation, each active duty service member must be tested at least once per year. This is done by means of “random testing,” where a commanding officer orders all or a random selected sample of his/her unit to be tested at any time.4 Overall, positive drug urinalysis rates for active duty personnel across each of the military services have continued to decline according to a recent DoD report. Of the total number of service and component members tested from 2007 to 2011, only 0.97% tested positive for illicit drug use—the lowest level in the history of the program.5 Although the Drug Demand Reduction Program has been very effective, the results from urinalysis tests tended to underestimate the true incidence of drug abuse in the services. The discrepancy between these estimates of drug use may be a result of an increase in the use of synthetic and prescription drugs, which is a relatively new occurrence.6–8 These novel hallucinogenic drugs, also known generically as “spice” and “bath salts,” have become readily available in the United States during the past decade. Spice, a synthetic cannabinoid that acts on the body similar to marijuana, is used as an alternative to marijuana because of a similar “high.” Bath salts are a general name given to a group of cathinone-containing hallucinogens that produce sympathomimetic effects when consumed.7 Because these drugs are banned for U.S. military personnel and synthetically made, they are more difficult to detect using standard drug tests and MILITARY MEDICINE, Vol. 181, November/December 2016

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Predictors of Early Attrition for Drug Use in U.S. Marines

have become popular among those individuals seeking a chemical “high.” Also, these synthetic drugs are not currently included in routine urinalysis testing in the services. Individuals who use spice or bath salts may be discovered by their commanding officers through routine inspections, unusual behavior, poor performance, or they may be reported by their peers. If someone is suspected of using any of these synthetic drugs, their commanding officer can then make a request to have their urine sample tested specifically for these drugs.9 Prescription drug misuse of pain relievers, tranquilizers, sedatives, and stimulants has also increased in the past decade among military service members.10,11 As a consequence, the DoD did expand the prescription drug urinalysis testing by screening for commonly abused prescription drugs, such as hydrocodone and benzodiazepines.12 Early discharge for illicit drug use accounts for a significant portion of early discharges across the services. The costs associated with early discharge are substantial because many of the discharges occur after considerable investment and training has taken place. Although there are some drug rehabilitation programs available to service members on active duty, the most common response to illicit drug use in the military is to receive an “other than honorable discharge,” or court-martial if sales or distribution are involved. To our knowledge, few studies have examined the associations between demographic and preservice psychosocial predictors and subsequent early discharge for illicit drug use in a large cohort of Marines. METHODS Study Population This study utilized two data sets: (a) archival data from the Recruit Assessment Program (RAP) and (b) career discharge data from the Defense Manpower Data Center (DMDC). Both data sets are maintained by the Naval Health Research Center (NHRC), San Diego, California. Baseline data were extracted from the RAP questionnaire for all active duty Marine participants who entered service between January 1, 2003, and December 31, 2008. Only those individuals who had a satisfactory completion of required service, referred to as end-of-active-service (EAS) (n = 31,508), or individuals who were discharged before their full term of service because of drug use, referred to as non-end-of-active-service (nonEAS) (n = 3,685), were included in this study. Military career information regarding discharges was obtained from the DMDC database, which compiles detailed career history on individuals in the military. The outcome variable of interest was having an early discharge for drug abuse based on the 32 separate DoD drug-related discharge codes used by the Marine Corps. The study was conducted in compliance with all applicable federal regulations governing the protection of human subjects in research and was approved by the Institutional Review Board of NHRC (protocol NHRC.2000.0003). MILITARY MEDICINE, Vol. 181, November/December 2016

RAP Questionnaire The RAP questionnaire is a self-administered instrument that assesses Marine recruits’ preservice medical and psychosocial histories. This survey was developed by the DoD and other government agencies to evaluate the health effects of military service. Since June 2001, this questionnaire has been administered to the majority of Marine recruits at the Marine Corps Recruit Depot (MCRD), San Diego, California, during the first week of their 12-week basic training program. Because only male recruits are trained at MCRD, data were collected for male recruits only. Participation was voluntary, and military unit commanders were not present during the administration of the questionnaire. Response rates have consistently been above 95%. All data were confidentially maintained, and all participants provided informed consent. Variables Variables were selected from the RAP questionnaire based on theoretical or empirical reasons for expecting an association with drug abuse. The following were placed into seven risk categories: (a) demographic factors included age, education, Armed Forces Qualification Test (AFQT) score, race, and marital status; (b) household/residence factors included questions regarding one’s family’s ability to provide for you while growing up and whether one was raised in a small rural town or large city; (c) health factors included smoking status, alcohol-related problems defined by the CAGE (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers) questionnaire,13 and a history of attention deficit hyperactivity disorder; (d) family psychosocial issues addressed adverse childhood experiences (ACE) using a modified version of the original ACE questionnaire,14,15 which adapted questions from the Childhood Trauma questionnaire16 and sexual abuse questions.17 Respondents were asked about incidents of physical and emotional neglect or abuse, domestic violence, and child sexual abuse; living with someone who was depressed, mentally ill, or had alcohol-related problems; (e) issues with authority comprised negative experiences with authority, including being arrested by police, fired from a previous job, school suspension, and number of traffic tickets; (f ) stress related including witnessing the death of a friend or family member, any death of a friend or family member, history of being raped, and history of deliberately cutting or burning oneself; and (g) reasons for joining the Marine Corps including to travel, to earn money, leave problems at home, for a career, to serve the country, or other unspecified reasons. All data from RAP represent preservice information collected at the start of Marine Corps recruits’ military careers. Variables were scored or dichotomized as described below. Education level was coded into two categories—no high school diploma and high school or more. Smoking was based on the question, “In the year before entering the military, did you smoke cigarettes?” Those who responded “not at all” were coded as nonsmokers, and those who responded “some days” or “every day” were coded as smokers. e1541



Using the CAGE13 questionnaire, alcohol-related problems were coded yes if participant answered “yes” to two or more items (e.g., feel the need to cut down, feel annoyed, feel guilty, or need for a morning first drink). Family psychosocial issues were based on responses to the modified ACE study questions: “The following are statements about you when you were growing up, before you were 17 years old.” The individual statements included (a) “There was someone to take care of you and protect you,” and (b) “You felt loved.” If participant responded “sometime true,” “often true,” or “very often true,” the item was coded as “yes.” If the response was “never true” or “rarely true,” the item was coded as “no.” The other questions were (c) “How often did a parent or adult living in your home swear at you, insult you, or put you down?” (d) “How often did a parent or other adult living in your home push, grab, shove, slap, or throw something at you?” (e) “How often did a parent or other adult living in your home push, grab, shove, slap, or throw something at each other?” and (f ) “How often did an adult ever touch you sexually or try to make you touch them sexually?” Response options for these four items included “never,” “once/twice,” “sometimes,” “often,” and “very often.” If the respondent answered “never” or “once/twice,” the variable was coded as “no.” Responses for the last two questions—“Did you live with someone who was depressed or mentally ill?” and “Did you live with someone who was a problem drinker?”—responses were coded as “yes” or “no.” DMDC Military career data for Marine Corps service members are compiled from Marine Corps Headquarters electronic files and stored at the DMDC. Discharge data, total days of active service, and AFQT scores were obtained from DMDC data extracts. The AFQT, a test taken by all individuals in the United States who hope to join the military, is used by all U.S. military branches to help determine eligibility.18 This test is a measure of general cognitive ability and correlates well with various standardized tests of intelligence.19 AFQT scores are reported as percentiles and standardized to have a mean of 50 and a standard deviation of 10. Scores on the AFQT reflect an applicant’s standing relative to a statistical sample from the national population of males and females between the ages of 10 and 23 years. A score of 32 is the minimum AFQT score requirement for entry into the Marine Corps without a waiver. Statistical Analysis Univariable descriptive statistics using χ2 tests were used to examine covariates from all seven risk group categories among Marines who were discharged for drug abuse, nonEAS, and those who successfully completed their service term EAS, with p < 0.05 considered statistically significant. A multivariable logistic regression was used to model demographic and psychosocial factors that were associated with e1542

early discharge from the Marine Corps for drug abuse. All demographic and psychosocial variables that were significant in the univariable analysis (p < 0.05) were entered as candidates into the multivariable model. The intercorrelations between the variables and their variance inflation factor were examined. Multicollinearity diagnostics were performed; no condition index was greater than 1.6, and no variance inflation factors were greater than 1.2. Odds ratios (ORs) were estimated with 95% confidence intervals (CIs). Data management and statistical analyses were performed using SAS 9.3 software and Enterprise Guide 4.2 (SAS Institute, Cary, North Carolina). RESULTS A total of 3,685 (10.5%) Marines received an early service discharge as a result of drug abuse during the 72-month observation period. Of the 32 DoD discharge codes for drug abuse used by the Marine Corps, nine codes accounted for all discharges in our study population. One code indicated erroneous or fraudulent entry for preservice drug use and accounted for approximately 18% of the total discharges. This code likely reflects new information for drug use—before entry and not revealed during the enlistment process—that was discovered after the individual entered the Marine Corps and was then subsequently discharged typically within the first 90 days. The demographic characteristics and AFQT scores of the two study populations are shown in Table I. All participants TABLE I.

Demographic Characteristics of Male Marine Corps Recruits, (N = 35,193) EASa

Characteristics Demographics Age (years)* 17–20 ≥21 Education* Does Not Have High School Diploma High School or More AFQT* Score >65 Score ≤ 65 Race* White, Non-Hispanic Black, Non-Hispanic Hispanic Other Marital Status Single Married Divorced, Separated, Widowed

Non-EASb

n = 31,508

n = 3,685

n

n

(%)

(%)

25,225 (80.1) 2,793 (75.8) 6,283 (19.9) 892 (24.2) 1,978

(6.3)

432 (11.7)

29,530 (93.7) 3,253 (88.3) 13,370 (42.4) 1,328 (36.0) 18,138 (57.6) 2,357 (64.0) 25,432 (80.7) 2,926 (79.4) 892 (2.8) 226 (6.1) 3,581 (11.4) 368 (10.0) 1,603 (5.1) 165 (4.5) 30,781 (97.7) 3,593 (97.5) 666 (2.1) 80 (2.2) 61 (0.2) 12 (0.3)

a Marines who had an honorable completion of required service. b Includes individuals who were discharged before their full-term commitment because of drug usage. *p < 0.05.

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were male, enlisted Marines; those under 20 years of age accounted for 80.1% in EAS and 75.8% in non-EAS. The majority of participants had a high school diploma or greater (93.7% EAS; 88.3% non-EAS). A larger proportion of EAS than non-EAS received AFQT scores ≥ 65 (42.4% and 36.0%, respectively). Approximately 80% of both populations were White non-Hispanic; African Americans represented 2.8% of EAS and 6.1% of non-EAS. Those who were divorced, separated, or widowed represented 2.1% of EAS and 2.2% of non-EAS; the majority were single (>97%). The largest ORs from the univariable and multivariable logistic regressions to predict drug discharge outcomes are shown in Table II. Overall, 29 of the 31 variables examined as predictors were significant in the univariable analysis, with the strongest association for drug abuse in smokers (OR = 2.82, 95% CI [2.62, 3.03]); African Americans (OR = 2.20, 95% CI [1.89, 2.56]); history of being raped (OR = 2.04, 95% CI [1.25, 3.32]); history of police arrest TABLE II.

(OR = 2.03, 95% CI [1.76, 2.34]; without a high school diploma (OR = 1.98, 95% CI [1.78, 2.21]; moving around often as a child (OR = 1.91, 95% CI [1.63, 2.22]); and joining the military to leave problems behind (OR = 1.90, 95% CI [1.68, 2.14]). Other variables in the univariable analysis with a predictive association of being discharged for drug use were being 21 years or older; AFQT score ≤ 65; usually had to struggle financially while growing up; alcohol-related problems; no one to take care of you; did not feel loved; parents insulted you; parents pushed or slapped you; parents pushed or slapped each other; having lived with someone with depression or who was mentally ill; having lived with someone with a drinking problem; having been fired from a job; suspended/expelled from school; receiving more than three traffic tickets; history of cutting/burning oneself; witness to death of a family member or close friend; any death of a family member or close friend and five of the six reasons reported as reasons to join the military.

Selected Results of Logistic Regression to Predict Drug Related Discharges, Male Marines 2003–2008 Univariable

Characteristics Age (years) 17–20 ≥21 Education High School or More Does Not Have High School Diploma AFQT Score Greater Than 65 Score of 65 or Less Race White, Non-Hispanic Black, Non-Hispanic Hispanic Other Lived Most the Time as A Child Farm, Ranch, or Country Small Town Less Than 10,000 People Small City 10,000 to 100,000 People Lived Most the Time as A Child In A Large City Over 100,000 People Moved Around Often Smoking Status Nonsmoker Smoker Parents Pushed or Slapped You No Yes Ever Arrested by Police No Yes Suspended From School No Yes Saw Family/Friend Killed No Yes

Multivariable

OR

(95% CI)

OR

(95% CI)

1.00 1.28*

(1.18, 1.39)

1.00 1.19*

(1.08, 1.31)

1.00 1.98*

(1.78, 2.21)

1.00 1.63*

(1.43, 1.87)

1.00 1.31*

(1.22, 1.40)

1.00 1.30*

(1.19, 1.42)

1.00 2.20* 0.89 0.90

(1.89, 2.56) (0.80, 1.00) (0.76, 1.06)

1.00 2.12* 0.99 0.81*

(1.76, 2.56) (0.86, 1.13) (0.66, 0.99)

1.00 1.12 1.24*

(0.97, 1.28) (1.09, 1.41)

1.00 1.17 1.32*

(0.99, 1.38) (1.13, 1.53)

1.36* 1.91*

(1.20, 1.55) (1.63, 2.22)

1.39* 1.70*

(1.19, 1.62) (1.42, 2.05)

1.00 2.82*

(2.62, 3.03)

1.00 2.53*

(2.33, 2.76)

1.00 1.53*

(1.39, 1.68)

1.00 1.18*

(1.05, 1.33)

1.00 2.03*

(1.76, 2.34)

1.00 1.49*

(1.26, 1.77)

1.00 1.39*

(1.28, 1.52)

1.26*

(1.11, 1.42)

1.00 1.72* 1.00 1.54*

(1.39, 1.70)

*p < 0.05.

MILITARY MEDICINE, Vol. 181, November/December 2016

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Predictors of Early Attrition for Drug Use in U.S. Marines TABLE III. Days of Active Service Before An Early Drug Discharge, Active Duty Marines 2003–2008 Non-EASa Days of Active Service 1460

N = 3,685

Cumulative

n

(%)

%

442 210 339 216 609 756 682 431

12.0 5.7 9.2 5.9 16.5 20.5 18.5 11.7

12.0 17.7 26.9 32.8 49.3 69.8 88.3 100.0

a

Marines who were discharged before fulfilling their term commitment because of drug usage.

The six variables with the strongest association with receiving a discharge for drug use in the multivariable analysis were the same as in the univariable analysis, with only slight changes to the ORs and CIs: being a smoker (OR = 2.53, 95% CI [2.33, 2.76]); being African American (OR = 2.12, 95% CI [1.76, 2.56]); moving around often (OR = 1.70, 95% CI [1.42, 2.05]); not having a high school diploma (OR = 1.63, 95% CI [1.43, 1.87]); joining the military to leave problems behind (OR = 1.56, 95% CI[1.34, 1.81]); and previous police arrest (OR = 1.49, 95% CI [1.26, 1.77]). Table III shows the days of active service before a drug use discharge. Approximately 12% were discharged in the first 90 days; however, an estimated 70% were discharged after serving at least 3 years. The mean length of time served by those who received an early discharge for drug use was 780 days; those who finished their 4-year commitment or more had a mean length of service of 1,613 days. On average, 833 potential days were lost for each of the 3,685 individuals who were discharged early for drug use. This equates to approximately 3,069,605 (833 × 3,685) potential person-days lost due to a discharge for drug use in this cohort of Marines entering active duty service between January 2003 and December 2008. This loss equates to approximately 5.74% of the total person-days for this cohort. DISCUSSION This study uses objective discharge data to examine the association of demographic and preservice psychosocial risk factors as predictors of early attrition for drug use in a cohort of 35,193 male Marines between January 2003 and December 2008. Approximately 3.1 million person-days were lost over this period as a result of drug abuse, accounting for 5.74% loss in total person-days in this cohort. The mean length of time served by those who received an early discharge was 780 days. Losing individuals with this level training is not only costly to the Marine Corps, but negatively impacts military readiness to recruit and train replacements to meet personnel end strength requirements. e1544

Thirty-one potential risk factors were chosen based on theoretical or empirical reasons for expecting an association with drug abuse or early attrition and were placed into seven categories for logistic regression analysis. From univariable analysis, 29 of the 31 risk factors were statistically significant across the seven risk categories. Historically, pre-enlistment drinking, smoking, and drug use have been prevalent behaviors in young military recruits.20 However, a number of characteristics stand out in this population as risk factors for an early discharge for drug abuse. In the multivariable model, Marines are more than twice as likely to have been discharged for drug abuse if they are African American. Not having a traditional high school diploma increases the risk by 63%, and scoring 65 or below on the AFQT increases the risk by 30%. Those 21 years or older had a slightly increased risk of 19%. Among smokers, there was a 2.5-fold increase in the risk of a non-EAS for drug use, and having an alcohol-related problem increased the risk for a non-EAS by 14%. Elements of early family life that reflected any emotional or physical neglect or abuse increased the risk for a non-EAS increased by 14 or 18% respectively. This finding is consistent with a recent finding that childhood trauma exposure has been associated with increased drug use in later life.21 Individuals who reported ever being arrested were at a 49% increase for a non-EAS; suspended from school by 39%, or joined the service to leave problems at home by 56%. For those Marines whose reason to join was to serve their country, risk of non-EAS decreased by 11% compared to those who listed all other reasons. A number of study limitations should be noted. Data were not available to determine the criteria that were used for early dismissal (other than a discharge code for drug abuse) or whether there was any selection bias in this process. Also data were not available to determine if the drug discharges were for illicit drugs or abuse of prescription drugs. In addition, it was not known if anyone who was discharged for drug abuse enlisted on a moral waiver; those who enter under a moral waiver, other than minor traffic offenses, tend to show higher attrition rates.22,23 Also, we did not look at deployment or combat history, and studies have shown that individuals who have been deployed and experienced combat are at a higher risk for psychiatric illness or posttraumatic stress disorder, which, in turn, increases their risk for alcohol and drug abuse.24–29 A primary strength of this study was the use of discharge data, which is an objective measure of determining the magnitude of drug abuse in the Marine Corps because it is not susceptible to survey bias or self-reported drug use. CONCLUSIONS Enlisted personnel entering the Marine Corps are committed to active duty tours ranging from 3 to 5 years. Separation or discharge before tour completion, referred to as attrition, has major implications for the Marine Corps since substantial costs are incurred in recruiting, processing, and training recruits who are discharged before fulfilling their term. This study was MILITARY MEDICINE, Vol. 181, November/December 2016



unique because it was able to look at a number of preservice recruit characteristics to determine what role they may play in early service attrition due to drug use, and it provided an indication of the number of lost person-days as a result. Postenlistment interventions for those recruits at higher risk for drug abuse may help to reduce this attrition. Further studies should evaluate attrition rates for illicit drug use looking forward from FY2013 when testing for hydrocodone and benzodiazepines were instituted, with an additional focus on determining what proportion are being discharged for prescription drug misuse.

12. 13.

14.

15.

ACKNOWLEDGMENTS The authors thank Dennis Hernando, Elizabeth Markowitz, and Michelle Stoia from the Naval Health Research Center, San Diego, California. We also thank the U.S. Army Medical Research and Material Command, especially those from the Military Operational Medicine Research Program, Fort Detrick, Maryland, and the U.S. Marines at Marine Corps Recruit Depot, San Diego, California.

16.

17.

REFERENCES

18.

1. Horton JL, Phillips CJ, White MR, LeardMann CA, Crum-Cianflone NF: Trends in new U.S. Marine Corps accessions during the recent conflicts in Iraq and Afghanistan. Mil Med 2014; 179: 62–70. 2. Barlas FM, Higgins WB, Pflieger JC, Diecker K: 2011 Health Related Behaviors Survey of Active Duty Military Personnel. Available at http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA582287; accessed December 21, 2015. 3. Jeffery DD, May L, Luckey B, Balison BM, Klette KL: Use and abuse of prescribed opioids, central nervous system depressants, and stimulants among U.S. active duty military personnel in FY 2010. Mil Med 2014; 179: 1141–8. 4. DOD Urinalysis (Drug Test) Program. Available at http://usmilitary .about.com/od/theorderlyroom/l/bldrugtests.htm; accessed March 23, 2015. 5. Status of Drug Use in the Department of Defense Personnel Fiscal Year 2011 Drug Testing Statistical Report. Available at http://prhome.defense .gov/Portals/52/Documents/RFM/Readiness/DDRP/docs/6b%20FY% 202011%20Annual%20Drug%20Use%20Status%20Report.pdf Washington, DC: accessed March 23, 2015. 6. Bebarta VS, Ramirez S, Varney SM: Spice: a new “legal” herbal mixture abused by young active duty military personnel. Subst Abus 2012; 33: 191–4. 7. Berry-Caban CS, Kleinschmidt PE, Rao DS, Jenkins J: Synthetic cannabinoid and cathinone use among US soldiers. US Army Med Dep J 2012; 19–24. 8. Loeffler G, Hurst D, Penn A, Yung K: Spice, bath salts, and the U.S. military: the emergence of synthetic cannabinoid receptor agonists and cathinones in the U.S. Armed Forces. Mil Med 2012; 177: 1041–8. 9. Synthetic Drug Urinalysis Operating Guide. Milington, TN: Navy Alcohol and Drug Abuse Prevention Program; 2012. Available at http://www .public.navy.mil/bupers-npc/support/21st_Century_Sailor/nadap/policy/ Documents/OPGUIDE%20Spice%20Testing%20Update%20V%203% 20Final.pdf; accessed March 23, 2015. 10. Jeffery DD, Babeu LA, Nelson LE, Kloc M, Klette K: Prescription drug misuse among U.S. active duty military personnel: a secondary analysis of the 2008 DoD survey of health related behaviors. Mil Med 2013; 178: 180–95. 11. Ramirez S, Kennedy J, Bebarta V, Varney S, Porter J, Ganem V: Misuse of prescribed pain medication and prescribed stimulants in a military

19.

MILITARY MEDICINE, Vol. 181, November/December 2016

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

population—is there a correlation with deployment or combat illnesses and injury?: DTIC Document ADA575882; 2013. Available at http:// www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD= ADA575882; accessed March 23, 2015. Servies T, Hu Z, Eick-Cost A, Otto JL: Substance use disorders in the U.S. Armed Forces, 2000–2011. MSMR 2012; 19: 11–6. Mayfield D, McLeod G, Hall P: The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974; 131: 1121–3. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH: Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001; 286: 3089–96. Felitti VJ, Anda RF, Nordenberg D, et al: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14: 245–58. Bernstein DP, Fink L, Handelsman L, et al: Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry 1994; 151: 1132–6. Wyatt GE: The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507–19. Orme DR, Brehm W, Ree MJ: Armed Forces Qualification Test as a measure of premorbid intelligence. Mil Psychol 2001; 13: 187. Herrnstein RJ, Murray C: Bell curve: intelligence and class structure in American life. New York, Simon and Schuster, 2010. Ames GM, Cunradi CB, Moore RS: Alcohol, tobacco, and drug use among young adults prior to entering the military. Prev Sci 2002; 3: 135–44. Kelley ML, Brancu M, Robbins AT, et al: Workgroup. Drug use and childhood-, military- and post-military trauma exposure among women and men veterans. Drug Alcohol Depend 2015; 152: 201–8. Etcho LL: The Effect of Moral Waivers on First-Term, Unsuitability Attrition in the Marine Corps: DTIC Document ADA309309;1996. Available at http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc= GetTRDoc.pdf&AD=ADA309309; accessed March 23, 2015. Fitz CC, McDaniel MA: Moral Waivers as Predictors of Unsuitability Attrition in the Military: DTIC Document ADA210160;1988. Available at http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc .pdf&AD=ADA210160; accessed March 23, 2015. Hoge CW, Auchterlonie JL, Milliken CS: Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295: 1023–32. Jacobson IG, Ryan MA, Hooper TI, et al: Alcohol use and alcoholrelated problems before and after military combat deployment. JAMA 2008; 300: 663–75. Mills K, Teesson M, Ross J, Peters L: Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being. Am J Psychiatry 2006; 163: 652–8. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR: Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. Am J Public Health 2009; 99: 1651. Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, KritzSilverstein D: New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 2008; 336: 366–71. Wilk JE, Bliese PD, Kim PY, Thomas JL, McGurk D, Hoge CW: Relationship of combat experiences to alcohol misuse among US soldiers returning from the Iraq war. Drug Alcohol Depend 2010; 108: 115–21.

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