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Problem alcohol and drug use in armed forces

Military Members & Recovery

About 1 in 15 U.S. military veterans suffer from substance use disorder.

In the United States, there is an estimated 2.2 million active service members, in addition to 23 million military veterans. About 1 in 7 U.S. soldiers currently have a opioid prescription. Members of the military have an increased risk for developing substance use disorder compared to the general population (age-adjusted), and this troubling connection is only intensified by deployment and exposure to combat.

While rates of illicit drug use by members of the military have continued to decrease overtime, alcohol and prescription opioid use remains high. Rates of substance use disorder among military veterans also varies by conflict, ranging from 3.7% among pre-Vietnam-era veterans to 12.7% among veterans of the more recent wars in Iraq and Afganistan.

Substance use disorder is associated with the development of multiple medical conditions and other co-occurring mental health disorders (e.g., depression), increased problems at home and work, increased difficulties in readjustment to civilian life, and an increase in rates of injury, suicide, and morality.

Beyond a heavy personal toll, substance use disorder has a large overall impact and financial toll on U.S. defense operations. With alcohol alone, it is estimated that the U.S. lost $1.2 billion in 2016 due to decreased productivity and medical expenditures resulting from excess alcohol consumption by members of the military.

 

MILITARY-SPECIFIC SENSITIVITIES:

DEPLOYMENT

History of deployment and combat exposure is associated with increased risk for substance use disorder development. Combat often exposes service members to the death or injury of others, threats to oneself or others, and unknown atrocities.

CHRONIC PAIN

Chronic pain is such a devastating issue. It profoundly affects Veterans, not just physically, but emotionally. It’s strongly associated with depression. It interferes with work, recreational activities and a patient’s social life.

 

–  Dr. Mathew Bair, U.S. Department of Veterans Affairs

 

  • Chronic pain affects nearly 60% of veterans returning from the Middle East and 50% of older veterans, compared to only 30% of civilians.
  • A 2012 study of more than 141,000 Iraq and Afghanistan veterans with both chronic non-cancer pain, and a mental health diagnosis (e.g. PTSD), were more likely to have an active opioid prescription and receiving riskier combinations of opioids and other drugs. Not surprisingly, veterans in this study were more vulnerable to overdose or other opioid-related negative outcomes.
  • Until recently, the U.S. Department of Veterans Affairs was treating chronic pain almost exclusively with opioid prescriptions. The Journal of Pain and Symptom Management reported in 2011 that:
    • 3% of veterans shared prescriptions to manage their pain
    • 29% of veterans reported alcohol or non-prescription drugs to treat pain
    • 35% of veterans used a combination of both alcohol and non-prescription drugs to treat pain
POST-TRAUMATIC STRESS DISORDER (PTSD)

Post-traumatic stress disorder (PTSD) is a condition of persistent mental and emotional stress resulting from injury or severe psychological shock, typically involving disturbance of sleep, constant vivid recall of the experience (e.g. flashbacks), and severe anxiety.

Personal factors such as previous traumatic exposure, age, or gender, may affect whether or not an individual soldier will go on to develop PTSD from a traumatic event.

SEXUAL TRAUMA

Military Sexual Trauma (MST) is another route by which service members may experience physical and psychological trauma, leading to the development of  PTSD. According to U.S. Department of Veterans Affairs, 55% of female veterans and 38% of male veterans have experienced sexual harassment while serving in the U.S. military.

TRAUMATIC BRAIN INJURY (TBI)

Traumatic Brain Injury (TBI) is the disruption of normal function in the brain resulting from a bump, blow, jolt to the head, or penetrating head injury. Common causes of TBI in military members include:

  • An object hitting the head, such as a bullet, flying debris, or falling object.
  • Assaults causing either blunt or penetrating trauma, or the head colliding with an object or other person.
  • Explosions in which an intense wave of pressure passes through the skull.

Traumatic brain injury is a frequent condition co-occuring with substance use disorder. While evidence is limited, neuro-chemical and behavioral evidence offers support for a causal relationship between traumatic brain injury and addiction development.

DEATHS OF DESPAIR

Deaths of despair refer to deaths by drug, alcohol, and/or suicide.

SUICIDE

Suicide rates in the military were traditionally lower than that of civilians, however, the suicide rate in the U.S. Army began to climb in 2004, surpassing the civilian rate in 2008, and reaching an all-time high in 2012, with mental health and substance use disorders being the leading cause of hospitalizations among U.S. troops.

OVERDOSE

  • 2006-2009, the U.S. Army reported that more than 45% of the 397 non-combat related fatalities were the result of an alcohol or other drug overdose. Of the 188 accidental or undetermined deaths resulting from alcohol or other drugs, 74% were caused by prescription drugs.
  • One study of military personnel found that:
    • 20% of high-risk behavior deaths involved alcohol or other drugs.
CO-OCCURING DISORDERS

Co-occurring disorders, also known as comorbidity or dual diagnosis, signify the prevalence of both a mental health condition and substance use disorder.

Common mental health diagnoses to military members with substance use disorder include:

Co-occuring disorders need to be addressed, as risk of fatal opioid overdose rates are 3x higher for those diagnosed with depression, and 6x higher for those with serious mental illness.

Addiction by branch of the military - marines, army, navy, drug addiction, alcohol

MILITARY CULTURE & STIGMA

Military members and their families are culturally unique, with distinct behavioral healthcare needs that may not be understood by the wider community or within the general population.

Military culture is widely seen as supportive of alcohol consumption, but stigmatized with regards to other drugs, and the general development of substance use disorder from alcohol or other drugs.

READJUSTMENT

Reintegration after deployment can be challenging for both servicemen and their families. Readjustment to normal life can be a difficult process after incidence of emotional or physical injury, and time apart. Research from 2013 found that 44% of soldiers returning from deployment faced challenges with the transition back to civilian life, challenges that included the onset of problematic substance use.

Reintegration and readjustment is not only difficult for military members themselves, but also for their families.

HOMELESSNESS

Military veterans make up a large portion of homeless adults in the U.S. The number of homeless veterans is expected to continue to increase as a result of current military conflicts. Overall, 70% of homeless veterans have a problem with substance use.

SUPPORTIVE MEASURES FOR MILITARY MEMBERS IN TREATMENT

MEDICATIONS

During recent conflicts in the Middle East, the military increased its use of prescription medications for the treatment of chronic pain and other health conditions, using opioids as a primary intervention. In 2009 alone, military physicians wrote almost 3.8 million prescriptions for pain management. The development of substance use related problems is found to increase with the number of opioid prescriptions per patient, so predictably, rates of opioid prescription misuse have increased. Military populations however, have seen a greater increases than in the general population, generating increasing concern among military, health, and political leaders on all levels.

Recently, the U.S. military began taking steps to address opioid use on both a national and local level.

ON A NATIONAL LEVEL:

  1. The military altered physician prescribing patterns, targeting the supply of available opioid prescriptions, in hopes of reducing the potential for substance use disorder development or medication diversion among patients.  The Army, for example, has implemented changes that include:
    • Limiting the duration of prescriptions for opioid pain relievers to 6 months.
    • Having pharmacists monitor patient medications, especially when patients are receiving multiple prescriptions.
  2. They began the Opioid Safety Initiative for the management of opioid therapy medications. This program measured key clinical indicators from 2012 to 2014, showing a 13% drop in patients receiving opioids, and a 15% drop in patients receiving long-term opioid therapy.  Also as a part of this initiative, over 70,000 more military patients were drug tested to guide treatment decisions.
  3. An ‘Opioid Dashboard” was developed by both the VA’s Office of Research and Development and the VA Office of Pharmacy Benefits Management to track and monitor prescriptions and dosages to reduce the number of veterans receiving high-dose or multiple prescriptions.

ON A MORE LOCAL SCALE:

  1. Individual medical centers have been rolling out their own programs. The VA in Minneapolis began the Opioid Safety Initiative, providing greater emphasis on non-opioid pain-management strategies, like yoga and exercise. The center witnessed a 94% decrease in oxycodone prescriptions after program implementation.

MEDICATIONS FOR TREATMENT OF SUBSTANCE USE DISORDER

Pharmacotherapy can also play an important role in the treatment and management of substance use disorders by reducing withdrawal symptoms and cravings.

There are 3 medications that are approved by the US Food and Drug Administration (FDA) for alcohol use disorders:

  1. Naltrexone
  2. Acamprosate
  3. Disulfiram.

There are 4 medications approved by the FDA for opioid use disorders:

  1. Methadone
  2. Buprenorphine
  3. Naltrexone
  4. Extended-release injectable naltrexone

There are no FDA-approved medications for the treatment of cocaine or marijuana use disorders.

PSYCHOTHERAPY

Behavioral interventions for the management of substance use disorder, generally involves short-term, cognitive-behavioral therapy (CBT) interventions, focusing the identification and modification of maladaptive thoughts and behaviors associated with addiction (e.g. craving, substance use, or relapse).

Other behavioral interventions include client-centered, motivational interviewing approaches, which focus on increasing motivation and engagement with treatment to  reduce substance use, and twelve step facilitation, which systematically links patients to, and encourages active participation in, community-based 12-step mutual-help groups.

TRAUMA-INFORMED CARE

Trauma is a contributing risk factor in developing substance use disorder. What happens directly after the traumatic event can play a critical role in whether an individual goes on to develop PTSD. Stress can make the development of PTSD more likely, while social support can decrease the likelihood.

Treatment of both substance use disorder, and any associated trauma together, have been found to increase long-term positive patient outcomes.

COMPONENTS OF TRAUMA-FOCUSED TREATMENT INCLUDE:

  • Grief or loss counseling
  • Peer support groups
  • Individual or group talk therapy (Cognitive Behavioral Therapy)
  • Exposure or desensitization work
  • Pharmacotherapy: medications to decrease symptoms
  • Holistic practice: mindfulness techniques, relaxation, yoga, meditation, acupuncture
  • Coping skill development: emotional regulation, cognitive restructuring (often gender specific coping skills)
MILITARY-SPECIFIC SERVICES

Military members and their families are culturally unique, with distinct behavioral healthcare needs that may not be understood by the wider community or within the general population. Substance use disorder services should be accessible, culturally competent, trauma-informed, with a special emphasis on reintegration.

Addiction treatment for military personnel needs to address co-occurring mental and physical conditions unique to within this population, such as the increased risk for depression, trauma, physical injury, and chronic pain.

  • A 2012 report prepared for the Department of Defense (DoD) by the Institute of Medicine recommendations that the U.S. military improve addiction treatment by increasing the use of:
    • Evidence-based treatment interventions and expanding access to care.
    • Broadening insurance coverage to include effective outpatient treatments.
    • Better equipping healthcare providers to recognize and screen for substance use problems so they can refer patients to appropriate, evidence-based treatment when needed.
CHANGING CULTURE

The 2012 IOM Report recommeded that to address substance use disorder in the military:

  • Develop a culture of confidentiality around substance use disorder, to stem the reluctance of military members to seek services and treatment out of fear.
  • Increased focus on destigmatizing substance use problems, especially from drugs other than alcohol.
  • Broadening insurance coverage to include early intervention and screening for substance use disorder.
  • Implementation of measures such as limiting access to alcohol on military bases.

RESOURCES FOR MILITARY MEMBERS 

 

CITATIONS

RESEARCH CITATIONS

INTRODUCTION TO INFORMATION AND RESEARCH ON ADDICTION TREATMENT AND RECOVERY

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