Substance Abuse and Veterans
By Robert J. Caffrey, M.A.
The characteristic act of war is not dying, it is killing. For politicians, military strategists, and many historians, war may be about the conquest of territory or the struggle to recover a sense of national honor but, for the man on active service, warfare is concerned with the lawful killing of other people. Its peculiar importance derives from the fact that it is not murder, but sanctioned bloodletting, legislated for by the highest civil authorities and obtaining the consent of the vast majority of the population.
Joanna Bourke, “An Intimate History of Killing” (1999)
It happened some time later that God put Abraham to the test…”Take your son,” God said, “your only child, Isaac, whom you love and go to the land of Mariah. There you shall offer him as a burn offering on a mountain I will point out to you.”…Then he bound his son Isaac and put him on the altar on top of the wood. Abraham stretched out his hand and seized the knife to kill his son.
Genesis 22: 2, 9-10 I.
In 2002 and 2003 an estimated 27 million male and female military veterans were living in the United States (NHSDA, 2004). These are the men and women who our nation has trained to kill. The archetypical American warrior is viewed as stoic, resilient, and high functioning by many segments of American society. The expectation is that our warriors perform their missions successfully, and then return home to reintegrate seamlessly into civilian society. The truth, however, is far different. Much as was Isaac, they are chosen for their task by fate, and are the least well prepared for its consequences.
It is within this cultural dissonance of the idea of the invincible warrior and the reality of the oft times psychologically fragile soldier, that the seeds for the neglect of the substance abuse issues confronting our veterans are often sown. In many ways, a significant number of veterans are actually less resilient and more fragile than their civilian counterparts, even before their exposure to warfare.
Many possess trauma histories, substance abuse histories arising from pre-existing familial structures, and other factors that predate their enlistment that make them more, as opposed to less, likely to suffer from substance abuse issues after the completion of their military careers (Schnurr, et. al., 2007). The exposure to combat, as well as the sexual assault and harassment that occurs all too frequently in the military, also serve to increase the likelihood of substance abuse among this already fragile population (Benda & Belcher, 2006; Suris, et.al., 2004).
This paper will examine the historical context of substance abuse among veterans, and the factors that both identify this population and also render them more likely to suffer from this disorder. Methods of treatment addressing issues of both chronicity and co-morbidity will be identified, as well as challenges in working with this population.
II. Demographics of the Veteran Population
There are approximately 27 million veterans in the United States who are over the age of 18 (NHSDA, 2004). This represents 14% of the U.S. population. This group is 94% male, 54% are over the age of 55, 44% between the ages of 26 and 54 and 2% are between the ages of 18 and 25 (NHSDA, 2001). Of this total, 85% are white, 9% are black, 4% Hispanic and 1% Asian (NHSDA, 2001).
III. Current Statistics Regarding Substance Abuse Among Veterans
In early 2001, before the inception of the “War on Terror,” statistics obtained by the Substance Abuse and Mental Health Services Administration (SAMHSA) documented significant alcohol and marijuana abuse trends in the then existing veteran population. “Binge drinking,” defined as drinking 5 or more alcoholic beverages on one occasion within the last 30 days, was reported by 22% of veterans, with 7% also reporting “heavy” alcohol use (NHSDA, 2001). Binge drinking was reported by 23% of the males and 14% of the females, while heavy alcohol use was reported by 7% of the males and 2% of the females, respectively (NHSDA, 2001). Rates were similar for whites and blacks. By way of comparison 50.1% of male veterans between the ages of 18-25 reporting binge drinking, as compared to 47.1% of non-veterans in the same age group.
The overall rates for heavy drinking in veterans in 2003 was 7.5% as opposed to 6.5% in the civilian population (NSDUH, 2005). Marijuana use during the same period was 3.5% by veterans versus 3% by non-veterans (NSDUH, 2005).
The rates of substance abuse, however, appear to be increasing as the war continues. The Department of Veteran Affairs reports that among Iraq & Afghanistan veterans receiving care between 2001 and 2005, 20% were diagnosed with substance abuse disorder (“SUD”) and 33% were diagnosed with mental and psychological problems (NSDUH, 2007). When combining data from 2004 through 2006, an annual average of 7.2% of veterans met the criteria for SUD in the preceding year in the following age categories: 25% in the 18 to 25 group; 11.3% of those ages 26 to 53; and 4.4% of those 55 years or older. (NSDUH, 2007). The statistical difference reported between men (7.2%) and women (5.8%) was deemed statistically insignificant (NSDUH, 2007).
The use and misuse of alcohol, marijuana, and opiates by U.S. combat veterans is not a recent phenomenon. In fact, substance abuse by combat veterans has been recorded throughout history.
Recent studies, however, and a more comprehensive understanding of the pre-service psychological make up of war veterans, suggests that pre-existing conditions such as trauma history, pre-existing personality disorder, the occurrences of sexual abuse or harassment prior to or during service, and familial substance abuse history, may also play a role in the etiology of substance abuse. Potentially, due to the existence of these factors, our military may be sending those least capable of dealing with extreme stress into combat. As did Abraham, we also must answer the question whether the selection and deployment of these individuals is a “service” that is required by a higher calling, or the simple sacrifice of innocents incapable of protecting themselves from what is to pass.
A. Substance Abuse and Combat
Historically, veterans have turned to alcohol and drugs as a way to manage or medicate the trauma they have experienced in combat (Shay, 2002). The most well documented studies of veteran substance abuse arose from the Vietnam War, although evidence of alcohol and drug abuse by veterans has been a historical and cultural constant for generations (Shay, 1994). By way of example, in a study of Indiana Civil War veterans from 1861 to 1919, 22.4% reported abusing alcohol and 5.2% had abused drugs such as morphine, opium, chloral hydrate, and cocaine, in numbers consistent with modern day rates (Dean, Jr., 1997).
Much as their Civil War forefathers used alcohol and drugs to assuage the impact of combat trauma, a number of modern veterans also abuse substances. By way of example, Vietnam era veterans meeting the American Psychiatric Association’s criteria for dependence or abuse, totaled 45.6% for alcohol and 8.4% for drugs, while comparable demographic groups of civilians suffered at much lower rates of 26% and 3.4%, respectively (Shay, 2002). The rate of co-morbidity for posttraumatic stress disorder (“PTSD”) was significant with 73.8% of those diagnosed for alcoholic dependence and 11.3% of those with drug dependence also being diagnosed with this disorder (Shay, 2002). Other studies have documented the co-existence of PTSD in the ranges of between 41% and 85% in veterans diagnosed with substance abuse (Steindl, et.al., 2003). In one in-patient treatment program, between 51% and 61% of veterans with combat related PTSD were also diagnosed with alcohol dependence or abuse (Boudewyns, 1991). Of the participants in that study, 91.2% suffered from alcohol or drug abuse of sufficient severity to qualify for a lifetime diagnosis of some form of substance abuse (Boudewyns, 1991).
Although the historic drugs of choice for combat veterans have been alcohol and marijuana, Vietnam veterans also demonstrated an unusually high rate of heroin use. Studies indicate that of the Army enlisted deployed in the Vietnam theater from September1970 to September 1971, 35% used heroin while “in country” (Robins & Slobodyan, 2003). This extraordinarily high rate of use, however, has not been replicated in any post-Vietnam conflict (Robins & Slobodyan, 2003).
Recent studies of Iraq and Afghanistan veterans confirm the link between present day exposure to combat and increased alcohol use and misuse. A study of active duty, national guard and army reserve personnel demonstrates that post deployment heavy weekly alcohol use, binge drinking and alcohol related problems all increase with initial or repeated exposure to combat (Jacobson, et.al., 2008). Reserve and national guard soldiers with initial combat experience reported pre-deployment alcohol abuse at the following rates: heavy weekly drinking (9%); binge drinking (53.6%); and alcohol related problems (15.2%). After redeployment from another combat tour rates were effected in the following manner: heavy weekly drinking increased from 9% to 12.5%; binge drinking remained essentially the same at 53%; and alcohol related problems decreased from 15.2% to 11.9% (Jacobson, et.al., 2008). For reserve/national guard and active duty soldiers completing their first combat tour, the reported rates were respectively as follows: (1) heavy weekly drinking 8.8% for reserve and national guard and 6.0% for active duty; (2) binge drinking 25.6% and 26.6% respectively; and (3) alcohol related problems 7.1% for reservists and national guardsmen and 4.8% for active duty members (Jacobson, et.al., 2008).
It is theorized that the reason for the use and abuse of depressants by veterans involves the hyper-activation of the “flight/fight” response created by combat. Combat is an extreme example of the life stress human beings are required to manage. It is increasingly recognized that substance abuse disorders are often a dysfunctional attempt to respond to life stress (Bonn-Miller, et. al., 2007). In this respect, emerging empirical work is identifying a causal link between traumatic event exposure and marijuana use (Bonn-Miller, et.al., 2007).
Likewise, alcohol is often used by veterans to manage the effects of post-combat stress that, in its most extreme form, can manifest as PTSD. Studies suggest veterans self medicate with alcohol to ameliorate the effects of hyper-arousal, nightmares, intrusive memories when awake, and avoidance of anxiety producing situations (Steindl, et.al., 2003; Calhoun, et.al., 2000). In fact, use of alcohol and marijuana has been directly identified by veterans diagnosed with PTSD, as being beneficial in their managing their symptoms (Calhoun, et.al., 2000; Ouimette, Finney & Moos, 1999).
Studies also suggest that increased combat exposure also increases the probability of long-term substance abuse by veterans of any war (Boudewyns, et.al., 1991). This is supported by the pattern of substance abuse often identified in combat veterans.
In one study, 64% of those Vietnam veterans using drugs did so for the first time while in the service, and 47% evidencing significant problems with substance abuse post combat had not used substances prior to combat (Boudewyns, et.al., 1991). Finally, some studies show little evidence that non-combat related PTSD increases substance abuse, thereby suggesting that combat related PTSD and substance abuse are intertwined in most cases (Boudewyns, et.al., 1991). Thus, the relationship between substance abuse and combat exposure appears undeniable.
The correlation between substance abuse and ever increasing combat exposure abuse appears well demonstrated. With the present day reality of repetitive deployments to combat environments by both active duty and reserve and national guard troops, increased alcohol abuse by an ever growing number of veterans appears virtually guaranteed.
B. Pre-existing Trauma History
Although service-related combat exposure appears to be the dominant factor in the etiology of veteran’s substance abuse, studies also indicate that military personnel often have significant pre-existing trauma history that may, potentially, pre-dispose them to substance abuse when they are then also exposed to trauma in military service. By way of example, although female veterans have significantly less exposure to combat than their male counterparts, rates of substance abuse by women as opposed to men are almost the same, 7.2% for men and 5.8% for women (NSDUH, 2007). A significant contributing factor appears to be a history of sexual and physical assault both prior to, and during, military service (Schnurr, et.al., 2007). By way of example, 69.1% of women veterans suffering from PTSD symptoms reported pre-enlistment sexual and physical assault (Schnurr, et.al., 2007). Incredibly, 73% also reported sexual trauma such as sexual assault or rape while serving in the military (Schnurr, et.al, 2007). This is consistent with other Veterans Administration health care reports, suggesting that 23% of female users of VA services reported at least one sexual assault while in the military (Suris, et al., 2004).
The potential impact of pre-existing childhood abuse was also documented in a study of 625 homeless alcohol and drug abusing veterans (Brenda &Belcher, 2006). Of the 310 women participants, 75% reported a history of childhood physical and sexual abuse and 67% of the men reported a similar history (Brenda & Belcher, 2006).
C. Pre-existing Axis II personality disorders
It has been noted that the relationship between Axis II personality disorders and alcoholism is significant, although it has not been possible to establish the causal relation between the two with any high degree of certainty (Scheidt & Windle, 1994). It is theorized that the interplay between Axis II characterological tendencies such as defenses and coping strategies may predispose such an individual to substance abuse, but whether personality disorders develop concurrently with or subsequent to an Axis I substance abuse disorder is, as yet, undetermined (Scheidt & Windle, 1994).
In a study of 4,462 Vietnam Army veterans who served between January 1965 and December, 1971, however, it was determined that personality disorder syndromes were highly prevalent among alcoholic individuals, especially among alcoholics with co-morbid disorders such as depression (Scheidt & Windle, 1994). Although the study did not allow the researchers to establish a temporal sequence between alcoholism and personality disorders, the role of Axis II pathology appeared significant in elevated score levels on 8 (Paranoid, Schizotypal, Anti-Social, Borderline, Dependent, Avoidant, Obssessive-Compulsive, Passive-Aggressive) of the 11 DSM-III scales, as opposed to those not diagnosed as alcoholic (Scheidt & Windle, 1994).
At the present time, however, none of the armed services require recruits to take the MMPI or any other battery of psychological tests designed to identify potential personality disorders. Although the causal connection is not definitive, the result of the aforementioned study indicates that some correlation between Axis I and Axis II disorders exists and can be identified through existing testing procedures. To the extent such testing is no undertaken, the military cannot identify those soldiers that might potentially be more susceptible to alcohol abuse if Axis II disorders are, in fact, an indicator or predictor of future alcohol problems.
D. Gender and Socio-cultural factors
The majority of our military is comprised of young men and women from the ages of 18 to 25, the age group most likely to engage in binge drinking and heavy alcohol use (NHSDA, 2001). In addition to this demographic factor mediating in favor of heavy alcohol use, it is also likely that the “warrior” culture and hyper-masculinity of the military exacerbates this propensity.
In a 1998 sample of 4 infantry battalions of Marines, those between the ages of 18 to 25 were two times as likely to engage in heavy drinking and binge drinking for 4 or more days in a 30 day period than were their civilian counterparts (Schuckit, et.al., 2001) Of this sample of 1,320 Marines, 24% reported blacking out when drinking in the prior 6 months, 21% reported themselves as unable to stop drinking, and 18% reported drinking in the morning (Schuckit, et.al., 2001).
It is noteworthy that this level of alcohol consumption occurred ostensibly in peacetime, and a full 3 years before U.S. troops invaded Afghanistan and Iraq. Thus substance abuse is not only a dysfunctional method of coping with stress or trauma, but may also be a cultural aspect of this warrior society as well.
E. Alcohol and depressant abuse and PTSD
A characteristic of soldiers struggling with PTSD is their experience of cycling between over-excitement and numb withdrawal (Shay, 2002). As PTSD is best understood as valid survival adaptations to combat persisting into civilian life, drinking and drugs also can be understood as the veteran’s method of regaining some semblance of control over memories and body responses that are tied to his past combat experiences (Shay, 2002).
Thus, alcohol and drug abuse in a veteran with PTSD is often motivated by attempts to ameliorate emotional and psychic vulnerability (Bonn-Miller, et.al., 2007). Marijuana use among veterans with high levels of posttraumatic stress also has been linked to a self-directed attempt by the veteran to regulate his emotional experience (Bonn-Miller, et.al., 2007).
In much the same way as marijuana, alcohol is also a means of managing the present day re-experiencing of combat trauma (Steindl, et.al., 2003). The veteran’s goal in coping with nightmares, intrusive memories, and reducing anxiety may, at first, appear resolved with initial alcohol use. Misuse may increase anxiety in the veteran, however, and the increasing intensity of PTSD symptoms may then exacerbate alcohol use. In the end, both disorders may work together in a vicious cycle, perpetuating one another with ever increasing intensity and severity (Steindl, et.al., 2003).
Additionally, some studies suggest that alcohol abuse may also serve to facilitate the impact of PTSD on the hippocampus (Woodward, et.al., 2006). Neurobiological models indicate that both alcohol addiction and PTSD alter a veteran’s limbic activity (Woodward, et.al, 2006). Addiction develops as limbic neurons are re-wired through the increased dopaminergic neurotranmission from high doses of drugs and alcohol on the brain (Woodward, et.al., 2006). Likewise, PTSD causes neural alterations in the amygdala and hippocampus, resulting in the clinical symptoms of hyper arousal and the “fight/flight” response (Woodward, et.al., 2006).
In examining the hippocampal volume of veterans with a history of alcoholism, the impact of those suffering from PTSD from combat exposure was significant. In those cases where alcoholism was co-morbid with PTSD, veterans’ hippocampal volumes were 9% smaller than those alcoholic veterans without PTSD (Woodward, et.al., 2006). Whether the reduction was the result of PTSD, or those with reduced volumes are predisposed to combat exposure PTSD through a genetic vulnerability, remains unanswered. The negative synergistic effect of PTSD and alcoholism, however, appears undisputed.
F. Treatment of Substance Abuse in Veterans and its’ Challenges
The greatest challenge to working with substance abusing veterans is the presence of co-occurring disorders. To the extent alcohol and marijuana are used as a means of regulating a hyperaroused nervous system, treating the substance abuse alone without addressing the other disorder appears futile. The results of recent treatment programs appear to bear out this truth.
Initially, the need for a multi-disciplinary approach appears manifest. In one such program, veterans diagnosed with PTSD and alcoholism were treated by an interdisciplinary team comprised of psychiatrists, psychologists, social workers and psychotherapists (Steindl, et.al., 2003). The treatment involved a 6 to 8 person group cohort which focused on CBT principles, but also provided individual therapy, PTSD psycho-education and diazepam over a five (5) day period when detoxification was required (Steindl, et.al., 2003).
The study noted that improvement in drinking during treatment was accompanied by improvement in PTSD symptoms. The study evidenced the fact that early alcohol use changes were predictive of later PTSD change, whereas those who were unable to moderate their consumption reported ongoing PTSD arousal symptoms (Steindl, et.al, 2003). It was noteworthy that reduction in PTSD symptoms did not result in later changes in drinking behaviors. (Steindl, et.al., 2003) This suggests, somewhat contrary to common sense expectations, that in a substance abusing PTSD sufferer, it is the substance abuse that must be addressed initially, or improvement in either disorder is unlikely.
This conclusion, however, is by no means accepted by all clinicians. A study of the first VA in-patient facility addressing an alcoholism-PTSD dual diagnosis, emphasized CBT techniques to allow a participant to discriminate between combat and civilian life and, only later in the process, focused on behaviors that led to not drinking (Seidel & Gusman, 1994). The drawback to this program, aside form its de-emphasis of the role of alcoholism in perpetuating PTSD, was that it was in-patient, limited to 30 individuals and lasted, on average, for 3 to 4 months.
The funding for programs of this type simply does not exist at this time. Moreover, it is unlikely that most alcohol or drug abusing veterans who are gainfully employed can, or would, commit themselves to an in-patient program of this type. Aside from the most severe of cases, this treatment protocol appears inappropriate.
Twelve-Step and CBT treatment for substance abuse appears to have significant success rates (Ouimettte, Finney & Moos, 1997). After attending a month long Twelve-Step and CBT program, 22% of the participants were in remission and 19% remained abstinent one year later (Ouimette, Finney & Moos, 1997). Interestingly, the results were essentially the same for those who received CBT only, and slightly higher for those participating in the Twelve-Step program exclusively.
The efficacy of Twelve-Step programs was further demonstrated in a subsequent study by the same researchers. Attendance in a Twelve-Step program was positively associated with 5-year remission of those veterans dually diagnosed with PTSD and alcoholism (Ouimette, Moos & Finney, 2003). Although the exact factor mediating this change (positive association with abstinence, psychological functioning, and/or social networks) offered by Twelve-Step programs was not identified, the salutary aspect was undisputed (Ouimette, Moos & Finney, 2003).
In terms of dealing with substance abusers suffering from sever anxiety and arousal symptoms attributable to PTSD, benzodiazepine has been relied upon as a method of reducing the need for “self-medication” with alcohol and marijuana (Hermos, et.al., 2007). Unfortunately, evidence suggests that patients with PTSD and substance abuse are receiving benzodiazepines in doses and/or in combinations presenting increased risks for toxicity and dependence (Hermos, et.al, 2007). Especially in the VA healthcare system, despite its contraindication for treating core PTSD symptoms, long-term, high dose benzodiazepines are being prescribed to PTSD patients with prior diagnoses of alcohol or drug abuse or dependence at alarming rates (Hermos, et.al, 2007).
It appears undisputed that a multi-disciplinary approach and etiological orientation must underpin working with veterans suffering from substance abuse. The neurobiological aspects of substance abuse and other factors (PTSD, Axis II disorders, family history, attachment disorders, sexual and physical trauma) must continue to be examined. Practitioners working with this population must remain current with research literature and studies in these areas. New information received must be considered and then integrated into treatment modalities.
Medication must be considered, albeit with great caution, in those veterans whose trauma symptomology overwhelms their existing psychic defenses. To the extent that substance abuse is an attempt by the veteran to ameliorate these symptoms, chemical assistance may be necessary. At the same time the danger of, and tendency towards, overmedication by some clinicians must be monitored with great care.
The efficacy of Twelve-Step programs needs to be re-enforced, and the reasons for their success should be a continued source of study. Many veterans may be resistant to identifying themselves as likely participants in such a program, especially those who abuse alcohol through binge drinking. The cultural pressure to engage in this behavior, both in the military and male and female youth culture, needs to be addressed by clinicians and the military and social hierarchy.
Many combat veterans feel isolated and separate from society (Shay, 1994). Many of us feel betrayed by those who sent us to fight, but refused to support us on our return. The reconnection with other veterans who shared the same experience, whether in a Twelve-Step program or through group therapy, often proves incredibly healing (Shay, 2002). In this regard, both individual and group therapy needs to be offered to veterans struggling with substance abuse issues.
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Copyright © 2009, Robert J. Caffrey, M.A., Hartford, CT 06105