Butler Center for Research
Substance Use Disorders Among Military Populations
Butler Center for Research - May 2018
Download the Substance Use Disorder Among Military Populations Research Update.
The unique lifestyle elements and challenges of military service make both active-duty and veteran service members a distinct culture unto themselves. This cultural influence plays a significant role in health care trends, with major implications specific to mental health and substance abuse. As a result, it is critical to consider the impact of military experience on alcohol and drug use, and substance abuse, as well as its impact on best practices for prevention and treatment of substance use disorders.
Substance Abuse Prevalence and Influence
Service members have an increased risk of developing a substance use disorder (SUD), especially those who have been deployed to combat.1, 2, 3 Individuals deployed to recent conflicts in Iraq and Afghanistan have shown significantly higher rates of SUD diagnoses than civilian populations; in 2013, 44 percent of those returning from deployment had challenges with the transition, including the onset of problematic substance use behaviors.4, 5, 6 A systematic review of published research showed those recently deployed to Iraq and Afghanistan were 1.36 times more likely to develop an alcohol use disorder and 1.14 times more likely to develop a drug use disorder than non-deployed service members who served during the same time period.2 Similar post-deployment increases in substance use problems have also been seen in Reserve and National Guard personnel.6, 7, 8 Despite higher rates of substance abuse, deployed military personnel often have low rates of referral to SUD treatment services, often attributed to high levels of stigma.6, 9
Outside of combat deployment or other traumatic events, there are a number of cultural factors that can have an exacerbating effect on alcohol and drug abuse, and the development and treatment of SUDs. The availability of inexpensive alcohol at military bases is a concern because of its correlation to binge drinking and underage drinking.1, 6 Workplace culture among military personnel is also an area of concern, particularly the stigma related to problematic substance use and fear of negative consequences related to seeking help.1, 6 Perhaps the most pressing concern comes from increasing prescription rates for pain medication. Prescriptions for pain medication among military service members, generally related to combat-related injuries and strain from extreme physical exertion, have increased exponentially in the past 20 years.1, 6 In 2009, military physicians wrote almost 3.8 million prescriptions for pain medicine, which was more than four times the number written in 2001.1 As a result, prescription drug misuse and opioid use disorders have become a critical concern for military leadership.
Trauma and Substance Use Disorders
Post-traumatic stress disorder (PTSD) is a mental health condition that can occur following exposure to a traumatic event, with symptoms that include re-experiencing the trauma, avoidance of reminders of the trauma, hyper arousal and negative cognitions.10 PTSD occurs significantly more often among military veterans than civilian populations (approximately 18 percent of post-deployment Army soldiers experience PTSD,11 as compared to 6.8 percent of the general population10). The common co-occurrence of PTSD and substance use disorders is well-established, and military populations demonstrate a higher rate of comorbidity among PTSD and SUD than the general population.12 Fifty-eight percent of individuals seeking treatment for alcohol use disorder (AUD) also meet the diagnostic criteria for PTSD; among veterans who had been recently deployed to Afghanistan and Iraq and who are also seeking treatment for AUD, 63 percent meet the criteria for PTSD.12 The combination of PTSD and AUD can have serious consequences for mental health. According to a recent study comparing veterans with PTSD and AUD to veterans with AUD only, those with PTSD and AUD had significantly elevated rates of:
- major depression (36.8 percent versus 2.3 percent)
- generalized anxiety disorder (43.5 percent versus 4.1 percent)
- suicidal ideation (39.1 percent versus 7.0 percent)
- suicide attempts (46.0 percent versus 4.1 percent)12
The increase in prescriptions for pain medication and the high prevalence of PTSD among recently deployed service members has led to concerns about increasing risks for opioid use disorders (OUD). The rate of PTSD and OUD among veterans increased from 2.5 percent in 2004 to 3.4 percent in 2013.10 Reviews of opioid prescriptions by the Department of Veterans Affairs (VA) health system show that when compared to veterans without a PTSD diagnosis, veterans with PTSD are prescribed opioids more often, receive higher-dose opioids, are more likely to receive two or more opioids at the same time and obtain more early opioid refills.13 While there was an overall risk for adverse clinical outcomes for any veteran who received prescription opioids as compared to those who did not, adverse effects were more extreme among veterans who had a concurrent diagnosis of PTSD. In addition to poor clinical outcomes, military samples with co-occurring PTSD and OUD also demonstrate highly elevated rates of other SUDs, including alcohol (60 percent), cocaine (34.8 percent), marijuana (27.5 percent), sedatives (13.4 percent) and amphetamines (7.6 percent).10
Current Recommendations
As research on the increasing prevalence of SUDs continues to emerge, military leadership has begun to explore a number of policy changes to address widespread concerns related to alcohol and drug abuse, prevention and treatment in military culture. For prevention, The Institute of Medicine committee has presented recommendations to reduce access to alcohol on military sites and consistent enforcement of underage drinking rules.1 Efforts to reduce stigma related to seeking treatment for substance abuse or SUDs have also been promoted throughout the military.6, 14
Clinical directions for treating and preventing SUDs among military personnel are varied, and scientific research has provided a number of promising directions for care. Each service branch uses its own program for the delivery of treatment services to active-duty service members, and the Department of Defense advocates for the use of evidence-based practices for SUD treatment across the military as a whole.1, 6 The high prevalence of SUDs that co-occur with PTSD has led to a strong emphasis in the scientific literature to identify options that integrate treatment for both conditions simultaneously.15, 16 Recent clinical studies have found promise in the use of trauma-informed care interventions that include a concurrent focus on PTSD and SUD symptoms (for more information on trauma-informed care, see our Research Update entitled Trauma-Informed Care for Substance Abuse Counseling).17
Conclusion
Research indicates that military service members are at a much higher risk than civilians for developing a substance use disorder. It is critical that providers take their experiences into consideration when assessing the symptoms of substance abuse and treating SUDs. Providers must also take particular care to identify the potential for comorbid PTSD symptoms, which have a particularly high prevalence among those who have recently deployed to Iraq and/or Afghanistan.
The Hazelden Betty Ford Experience
In 2018, the Hazelden Betty Ford Foundation became an in-network provider for TRICARE, the insurance provider serving military service members and their families. In addition to being able to facilitate more accessible insurance options, the Hazelden Betty Ford Foundation offers a broad spectrum of clinical services that are well-matched for the unique recovery and mental health needs of our military patients. Our organization also recognizes that the high prevalence of PTSD and traumatic events among service members and veterans with substance use disorders requires a substantial focus on co-occurring treatment, in addition to recovery services. In order to properly address any co-occurring mental health disorders, Hazelden Betty Ford employs psychiatrists, psychologists, marriage and family therapists, and other mental health professionals along with substance abuse counselors and other SUD treatment professionals. Our mental health services include individual or group therapy, family therapy, diagnostic assessments and medication-assisted therapy management, which are provided to patients who present with any significant mental health or PTSD symptoms and are integrated into the overall treatment process. Mental health services at each of Hazelden Betty Ford’s facilities are evidence-based (which means there is research available to support their effectiveness), and may include psychotherapy, psychopharmacology, psychoeducation or other complementary therapies.
Questions & Controversies
Question: What are my options for treatment when the military often has a zero-tolerance policy for substance abuse or misuse of prescription drugs?
Response: Several years of research following recent combat operations has led to a number of military-driven resources for addressing substance use disorders. The Air Force’s ADAPT program, the Navy’s NADAP program (which serves the Navy and Marine Corps, and includes the SARP treatment program) and the Army’s ASAP program (which includes the SUDCC treatment program) are all developed to provide clinical resources for treating substance use disorder.6 Additionally, a number of Twelve Step peer support groups like Alcoholics Anonymous and Narcotics Anonymous are available on military installations.18
How to Use This Information
Military Service Members: The experiences related to military service can often be very stressful and may lead to increased risk of problematic alcohol or other drug use, especially for those who are deployed to combat. There is no shame in seeking help if you feel as though your drinking or substance use is affecting you negatively—even if you are currently on active duty. There are many recovery resources available to active-duty service members and veterans that are specialized for military populations; these services are meant to meet your specific needs and often can provide opportunities for support from others who have had combat or other military experience.
Providers: Military experience has such a significant impact on an individual’s mental health and substance use behaviors. While working with programs tailored to military populations may already include components to address common military issues, such as trauma, it is important to consider past military experiences for all patients, especially if they were deployed as part of their military service. Using evidence-supported techniques for trauma-exposed populations (such as trauma-informed care) is important for helping to simultaneously address any symptoms of trauma that may be presenting along with problematic substance use.
References
1. Institute of Medicine (2012). Substance use disorders in the U.S. armed forces: Report brief. Washington, DC. Retrieved from http://www.nationalacademies.org/
2. Kelsall, H. L., Wijesinghe, M. S., Creamer, M. C., McKenzie, D. P., Forbes, A. B., Page, M. J ., & Sim, M. R. (2015). Alcohol use and substance use disorders in Gulf War, Afghanistan, and Iraq War veterans compared with non-deployed military personnel. Epidemiologic Reviews, 37, 38–54.
3. Lande, R. G., Marin, B. A., Chang, A. S., & Lande, G. R. (2008). Survey of alcohol use in the U.S. Army. Journal of Addictive Diseases, 27, 115–121.
4. Lan, C. W., Fiellin, D. A., Barry, D. T., Bryant, K. J., Gordon, A. J., Edelman, E. J., … Marshall, B. D. (2016). The epidemiology of substance use disorders in U.S. veterans: A systematic review and analysis of assessment methods. The American Journal on Addictions, 25(1), 7–24.
5. Institute of Medicine (2013). Returning home from Iraq and Afghanistan: Readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.
6. Schmid, B., Tubman, D. S., Loomis, D. J., Grandela, J. E., Vernale, M. A., Messler, E. C., & Rigoglioso, J. (2017). Substance use disorders in the United States military: Current approaches and future directions. In S. V. Bowles & P. T. Bartone (Eds.), Handbook of Military Psychology (115–136). New York: Springer International Publishing.
7.Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298, 2141–2148.
8. Bartone, P. T., Johnsen, B. H., Eid, J., Hystad, S. W., & Laberg, J. C. (2017). Hardiness, avoidance coping and alcohol consumption in war veterans: A moderated-mediation study. Stress and Health, 33(5), 498–507.
9. Calhoun, P. S., Elter, J. R., Jones, E. R., Kudler, H., & Straits-Tröster, K. (2008). Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. Journal of Clinical Psychiatry, 69(11), 1686–1693.
10. Shiner, B., Westgate, C. L., Bernardy, N. C., Schnurr, P. P., & Watts, B. V. (2017). Trends in opioid use disorder diagnoses and medication treatment among veterans with posttraumatic stress disorder. Journal of Dual Diagnosis, 13(3), 201–212.
11. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13–22.
12. Norman, S. B., Haller, M., Hamblen, J. L., Southwick, S. M., & Pietrzak, R. H. (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. military veterans: Comorbidities, functioning, and suicidality. Psychology of Addictive Behaviors, 32(2), 224–229.
13. Seal, K. H., Shi, Y., Cohen, G., Cohen, B. E., Maguen, S., Krebs, E. E., & Neylan, T. C. (2012). Association of mental health disorders with prescription opioids and high-risk opioid use in U.S. veterans of Iraq and Afghanistan. Journal of the American Medical Association, 307(9), 940–947.
14. Tanielian, T., Jaycox, L. H., Schell, T., Marshall, G. N., Burnam, M. A., Eibner, C., et al. (2008). Invisible wounds of war: Summary and recommendations for addressing psychological and cognitive injuries. Santa Monica, CA: RAND Corporation.
15. Back, S. E., Killeen, T. K., Teer, A. P., Hartwell, E. E., Federline, A., Beylotte, F., & Cox, E. (2014). Substance use disorders and PTSD: An exploratory study of treatment preferences among military veterans. Addictive Behaviors, 39, 369–373.
16. Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. E. (2017). Substance use disorders in military veterans: prevalence and treatment challenges. Substance Abuse and Rehabilitation, 8, 69–77.
17. Boden, M. T., Kimerling, R., Kulkarni, M., Bonn-Miller, M. O., Weaver, C., & Trafton, J. (2014). Coping among military veterans with PTSD in substance use disorder treatment. Journal of Substance Abuse Treatment, 47, 160–167.
18. Military OneSource. (2018). Recovering from a drug or alcohol use problem. Retrieved from http://www.militaryonesource.mil/