John S. McCain National Defense Authorization Act for Fiscal Year 2019 (PL 115-232)

The Policy

Synopsis

The John S. McCain National Defense Authorization Act authorizes monetary appropriations for the United States military and the Department of Energy. This bill also limits and/or prohibits military spending in defined areas such as weapons allocations or the discontinuance of specific vehicle production. In addition to monetary allocations, this bill gives authority to branches of the military to procure and/or develop military equipment and vehicles.

Section 226 stipulates the procurement of existing personal equipment to prevent injuries, particularly traumatic brain injuries (TBIs), caused by blasts in combat and training. Blasts that can leads to TBIs in exposed populations occur in both combat and training through the use of explosives. The military shall partner with governmental, industrial, and academic entities to develop requirements for the procurement of protective equipment and mechanisms for its deployment to military personnel. The military must also develop appropriate methods to test protective equipment for efficacy in preventing TBI. In addition, the Secretary of Defense will identify areas of research where there is potential to improve personal protective equipment. The goal of Section 226 of the Act is to both enhance survivability of personnel exposed to blasts during combat and training and to further prevent brain damage, including chronic brain dysfunction, that occurs due to blasts. For this purpose, ten million dollars was appropriated for the 2019 fiscal year.

Section 702 mandates the creation of a pilot program to assess the efficacy of using intensive outpatient programs to treat military servicemembers with post-traumatic stress disorder (PTSD) resulting from military sexual trauma. This program includes treatment for substance abuse, depression, and other conditions related to PTSD. Each organization that partners with the military on the pilot program is required to carry out short-term intensive outpatient programs for military members with PTSD, to use evidence-based treatment strategies, to share best practices with other participating groups of the pilot program, and annually assess outcomes of the pilot program based on the treatment of PTSD. These organizations include public, private, and non-profit healthcare organizations and universities. The Department of Defense (DOD) must establish metrics to evaluate the efficacy of the pilot program prior to its commencement. Upon cessation, a final report outlining the success of the program will be submitted to appropriate Congressional committees and used to determine whether the pilot study should be extended or made permanent. This program may not continue past three years from the Act’s enactment date (2021).

Section 716 authorizes the creation of a pilot program to assess ways in which opioid exposure, misuse, and abuse could be minimized among military populations. The Defense Health Agency is charged with the identifying likely mode for opioid medication misuse or abuse, such as military, retail network, and home delivery pharmacies. This pilot program will focus on beneficiaries of TRICARE, military sponsored healthcare for military personnel, retirees, and dependents. The program is charged with the education of TRICARE beneficiaries to prevent opioid misuse. In addition, specialist pharmacists are charged with identifying potential abuse of opioid medications in military servicemembers. Also, predictive analytics will be used to identify potential abusers of prescription opioids prior to beginning an opioid regimen. The program is set to last three years, and the DOD is required to submit a report to the Committees on Armed Services outlining a description of the ability of the pilot program to reduce misuse and abuse of prescription opioids. This report should also contain a description of the ability of predictive analytics to identify potential abuse of opioid medications among military servicemembers. If the program is successful, the DOD may carry out the program on a permanent basis.

Context

Section 226 was mandated to address the prevention of TBI in the military. TBI is clinically measured by severity ranging from mild to severe. From 2000-2018, 383,947 servicemembers were diagnosed with TBI. TBI in the military is most often caused by Improvised Explosive Devices, or IEDs. IEDs are bombs constructed and deployed by persons or entities outside of the military. Within a military context, these explosives are often used to destroy buildings or disable military vehicles. In 2007, the US government established the Psychological Health and Traumatic Brain Injury Research Program to address TBI and psychological health issues for military servicemembers. Since 2007, $978.2 million have been appropriated to address brain injury and mental health in the military.

Section 702 addresses the prevalence of sexual assault in the military. In May 2018, the DOD released its Annual Report on Sexual Assault in the Military. According to the document, reporting of sexual assault increased by about 10% over 2016 rates, with 6,769 reports in 2017. This number includes those who reported a sexual assault that occurred prior to joining the military. PTSD is highly correlated with experiencing sexual assault. This bill seeks to address the treatment of PTSD in sexual assault victims who are military members.

Section 716 of the Act was developed in response to the opioid crisis. In the United States, nearly 20,000 people died due to opioid overdoses in 2016. Expanding from opioid pain medication to also include opioid analgesics, such as heroin and illicit synthetic opioids, the number increases to 42,249 Americans who died. In response, the Military Health System created an Opioid Registry in 2016 to reduce opioid prescriptions and rates of addiction in both civilian and active-duty populations. In 2017, the Army implemented the Comprehensive Pain Management Program which monitors and develops best practices regarding pain medicine, specifically opioids. Parts of the Act serve as a continuation of the military’s efforts to curb the opioid crisis within military populations.

The Science

Science Synopsis

Traumatic brain injury (TBI) occurs when functioning of the brain is disrupted by sudden trauma or head injury. TBI is usually caused by a blow or jolt to the head, but can also be caused by an object penetrating the brain. In its most severe form, TBI can cause deficits in speech, sensation, vision, and cognition including difficulties with attention, memory, concentration, and impulsiveness. This can lead to permanent physical and psychological changes.

Generally, sexual assault is defined as sexual contact or behavior that occurs without consent. This form of violence is often emotionally charged for victims. 94% of victims experience post-traumatic stress disorder symptoms in the first two weeks after the assault, and 50% of those who were assaulted continue to have problems long-term. Sexual assault is chronically underreported in the military; however, reporting of sexual assault in the US military increased by 10% in 2017.

Substance use disorder is a medical condition in which the use of one or more substances leads to significant impairment. In 2008, 11% of servicemembers reported misusing prescription drugs. The most commonly reported misused drug are opioid pain medications. In addition to opioids, alcohol is commonly abused drug within the military. In 2008, 20 percent of military personnel reported binge drinking every week in the past month. For those who had high combat exposure, the rate was 27%.

Scientific Assumptions

  • Sexual assault can cause Post-Traumatic Stress Disorder (Section 702): Researchers have thoroughly investigated the link between sexual assault and PTSD, and it is commonly agreed that sexual assault predisposes one to PTSD.
  • Blasts from explosives can cause traumatic brain injury (Section 226): Researchers have thoroughly investigated the link between explosives and traumatic brain injury, and researchers agree that the concussive force of explosives can cause traumatic brain injury.
  • The over-prescription of opioids leads to opioid dependence and addiction (Section 716): Researchers have thoroughly investigated the link between the over-prescription of opioids and opioid dependence, and it is commonly agreed that dependence and addiction are correlated with the over-prescription of opioids.

The Debate

Scientific Controversies / Uncertainties

Section 226 calls for increased efforts in the procurement of efficacious combat helmets. Combat helmets are used for protection against high pressure explosives (i.e., IEDs) and penetrating injuries (i.e., bullet wounds). However, there are indications that blast pressure in areas of the body other than the head can lead to brain injury. A study conducted in 1999 found that 51% of servicemembers who experienced explosive injuries in lower extremities had symptoms consistent with TBI.  Section 226 is controversial as it directs funding to combat helmet procurement, however, it is not clear that combat helmets are will prevent TBI entirely.

There is controversy surrounding the manner by which sexual assault-induced PTSD is treated. Although the pilot program does not specifically outline the way in which individuals with this condition will be treated, there are debates over whether cognitive-behavior therapy or exposure therapy is the correct method for treatment in outpatient settings.

Endorsements & Opposition

  • Senator Roy Blunt (R-MO), statement, December 13th, 2018: “[The Act] … includes the largest pay raise in nearly 10 years and provides our service members with the resources, equipment and training they need.”
  • Vice President Mike Pence (R), statement, August 13th, 2018, “…President Trump signed into law the largest increase in our national defense in a generation. Under President Donald Trump, the days of arbitrary budget cuts to our national defense are over.”