Why are American veterans at significant risk of addiction ?
More importantly, what can be done to help?
Members and veterans of the United States Armed Forces experience a very specific set of challenges and responsibilities not usually encountered by the rest of the civilian population.
- Regular deployment – moving from place to place
- Extended separation from family – frequently for months at a time
- Unique culture – drinking is often seen as a way to bond
- Combat service – needing to constantly be on alert
- Life or death situations – split-second decisions that impact the rest of their life
- Injuries and pain – wounds and scars in battle; service-related disability
- Survivor’s guilt – secondary trauma from witnessing fellow soldiers’ injuries and deaths
- Alienation – experiences that non-veterans may not understand
And here’s the thing – added to all of these vet-specific issues is the fact that Soldiers, Sailors, Marines, Airmen, and Coast Guardmen are just as vulnerable as civilians to the same genetic predispositions, traumas, family histories, and stresses that lead to problematic substance abuse.
A Zero-Tolerance Policy with Immediate Consequences
“Any person subject to this chapter who wrongfully uses, possesses, manufactures, distributes, imports into the customs territory of the United States, exports form the United States, or introduces into an installation, vessel, vehicle, or aircraft used by or under the control of the armed forces (an illicit substance) shall be punished as a court-martial may direct.”
~ Article 112a of the Uniform Code of Military Justice
Make no mistake – ALL illicit substances are prohibited by military law. This is enforced by random drug screens that are conducted at the individual unit level. Any servicemember who tests positive for any banned substance faces immediate discipline. This can include any combination of the following:
- Administrative, or unit-level punishment
- Extra duty
- Forfeiture of pay
- Restriction to barracks
- Reduction in rank
- Barred from reenlisting
- Cancellation of upcoming promotions, schools, transfers, or temporary duty assignments
- Loss of security clearance
- Articles of discipline that become a permanent part of their military record
- Mandatory substance abuse education and treatment
- Dishonorable discharge
Even the misuse of otherwise-legal substances can damage or end a career.
- Alcohol—DUI, Public Intoxication, Drunk on Duty, Conduct Unbecoming an Officer and a Gentleman, etc. In certain instances, a Drunk on Duty charge can carry the death penalty, per Article 13 of the UCMJ.
- Prescription Medication—The UCMJ prohibits “Prescription or over-the-counter medications when used in a manner contrary to their intended medical purpose or in excess of the prescribed dosage.”
- Marijuana— Article 112 of the UCMJ bans marijuana, regardless of any state law legalizing its medical or recreational use.
What Substances Are Being Abused by Veterans?
According to statistics posted by the University of California San Diego, these are the most-common substances appearing in VA substance abuse diagnoses, and their use increased across the board:
- Alcohol: 303,488 admissions, increasing to 362,737 (+19.5%)
- ANY Drug: 182,003 to 216,173 (+18.8%)
- Cocaine: 74,995 to 80,348 (+7.1%)
- Cannabis: 53,516 to 73,687 (+37.7%)
- Opioids: 35,240 to 43,332 (+23%)
- Amphetamine: 9,430 to 11,972 (+27%)
Veteran Substance Abuse Statistics
Generally speaking, the use of illegal drugs among active duty servicemembers is lower than it is in the civilian sector. However heavy alcohol abuse – particularly binge-drinking – is far more prevalent, and the misuse and/or abuse of prescription medications is on the rise.
Per the National Institute on Drug Abuse:
- Just 3% of active-duty servicemembers report using an illegal drug within the previous 30 days, compared with 12% of the civilian population.
- Within the 18-25-year-old demographic – the group most likely to use drugs – only 9% of servicemembers reported the use of an illicit drug within the previous month, compared to over 17% of civilians.
- However, 25% of veterans within that age bracket meet the clinical criteria for a diagnosis of ANY past-year Substance Abuse Disorder (SUD), which includes alcoholism, illicit drug abuse, or the misuse of
- That is more than double the rate for veterans between the ages of 26 and 54.
- It is five times the rate for those veterans age 55 or older.
- Substance abuse and homelessness among vets are closely linked.
- 70% of homeless vets abuse alcohol or drugs.
- Conversely, 21% of vets in substance abuse treatment programs are homeless.
Veteran Alcohol Abuse Statistics
“Most people who drink this way do not consider themselves binge drinkers,” said Jones. “Binge-drinking behavior really tends to be your weekend drinkers who hit it hard. What happens over time though, is that binge drinking develops into something more.”
~ Susan Jones, Army Substance Abuse Program
- 2008: 47% of active-duty military self-reported episodes of binge-drinking.
- A decade earlier, the rate was 35%.
- Approximately 20% of servicemembers binge-drank every week during the previous 30 days.
- 27% of combat veterans engage in weekly binge-drinking.
- Among soldiers 18-35, the rate of binge-drinking is 50% higher than it is among civilians.
- Nearly 60% of Marines binge-drink.
- 2011: 1 in 4 soldiers serving overseas self-reports a drinking problem.
Veterans Prescription Drug Abuse Statistics
“We use prescription drugs because it is a quick fix. It started because our military was strained, and it was just keeping more people propped up to do their jobs. But the long-term danger is we made people too dependent on it.”
~Brigadier General Becky Halstead (Ret.)
The misuse of prescription medications is a hidden epidemic in the armed forces.
- 2002-2011: Drug spending in the military swelled from $3 billion to $6.8 billion.
- 2008: 1 out of every 9 servicemembers misused a prescription medication.
- That equates to almost 12%
- In 2005, that number was “only” 5%.
- In 2002, it was even lower – 2%.
- For comparison, 4.4% of civilians misuse prescription medication
- 2001-2009: Department of Defense orders for antipsychotic drugs like Risperdal or Seroquel spiked 200%.
- During that same time period, orders for benzodiazepine tranquilizers like Ambien or Valium jumped 170%.
- In 2011 alone, 54,581 Seroquel prescriptions were written for active-duty servicemembers.
- Seroquel is commonly prescribed off-label to treat stress-induced insomnia.
- 2009: Nearly 17% of the active-duty military took some kind of psychiatric drug.
Veterans, Pain, and Opioid Painkiller Abuse
“The description that I’ve been given, they get injured somehow — most of the injuries come from training, not actually deployment — they’ll get prescribed a painkiller, then when they become discharged, they’ve become addicted.”
~ John Bigger, Corporate Director, Cape Fear Valley Medical Center
During the combat operations in Iraq and Afghanistan, more than 51,000 service members were injured. A survey concluded that:
- 44% suffered chronic pain lasting at least three months.
- Of those, nearly 56% experienced pain almost daily, or even worse, constantly.
Similarly, in a survey of veterans in the Western New York VA Health System:
- 71% self-reported pain.
- 35% said the pain was constant.
- 85% said the pain had been going on for years.
Opioid painkillers are the prescription medications most-frequently-abused by active-duty servicemembers and discharged/retired veterans. Part of the reason for this is the fact that the military lifestyle lends itself injuries and chronic pain complaints.
But the over-prescription of opioid pain meds is also a very real concern. Too often, rather than ordering a lengthy non-opioid treatment regimen, military doctors will turn to painkillers as a first option. This is especially true for active-duty patients, because lengthy treatments affect units’ combat readiness.
For example, look at two representative military hospitals in North Carolina, the Fayetteville Veterans Affairs Medical Center and the Womack Army Medical Center.
- 2001: the Fayetteville VA prescribed hydrocodone to “only” 1130 patients.
- 2012: 47,586 patients received hydrocodone.
- That represents an increase of 4100%!
- At the Womack Medical Center, over 18,000 soldiers were given 46,870 opioid painkiller prescriptions.
- That means that roughly 1 out of every 3 soldiers was prescribed an opioid.
This is indicative of military medical care at the time. Between 2004 and 2012, the number of VA patients receiving opioid painkillers jumped nearly 77%. In 2014, the Department of Veterans Affairs treated approximately 650,000 veterans with opioids.
The Special Problem of Warrior Transition Units
Each branch of the service operates a program that takes care of severely wounded, ill, or disabled servicemembers and veterans. The goal is to support the patient as they transition back to active duty or civilian life.
- The Army Wounded Warrior Program
- The Marine Corps Wounded Warrior Regiment
- The Air Force Wounded Warrior Program
- The Navy Safe Harbor Program
Servicemembers/veterans treated in one of these programs are considered significantly disabled if they have any of the following conditions:
- Post-Traumatic Stress Disorder (PTSD)
- Traumatic Brain Injury (TBI)
- Severe vision loss or blindness
- Severe hearing loss or deafness
- Limited life expectancy due to a fatal disease
- Loss of a limb
- Spinal Cord Injury (SCI)
- Severe burns
- Permanent disfigurement
But these same conditions make it much more likely that the person with also struggle with a Substance Use Disorder (SUD). A 2011 USA Today article quoted statistics estimating that up to 35% of program participants have a drug problem—especially to opioid painkillers, benzodiazepine tranquilizers, or antidepressants.
PTSD and Substance Abuse among Combat Veterans
1 out of every 4 combat veterans returning from Afghanistan or Iraq exhibits symptoms of a cognitive or mental disorder. 1 out of 6 shows signs of PTSD.
According to the Veterans Administration, PTSD and SUD have high rates of comorbidity:
- Nearly one-third of veterans seeking substance abuse treatment also have PTSD.
- Over one-fourth of veterans with PTSD also abuse alcohol and/or drugs.
Among combat veterans, the problem is even more widespread:
- 50% of veterans who saw combat in Iraq self-report PTSD.
- Of special relevance, 66% of veterans who are treated for PTSD experience chronic pain.
- Up to 87% of returning veterans experiencing psychological problems do not receive proper care.
- 40% of those combat vets report problematic alcohol use.
When these two disorders co-occur, each makes the other worse. This often creates a self-perpetuating negative cycle:
- One of the major symptoms of PTSD is poor sleep – insomnia, wakefulness, etc. Sufferers might self-medicate with drugs or alcohol, but these remedies actually worsen sleep quality.
- Veterans with PTSD are often locked into “fight or flight” mode. They battle feelings of anger, irritability, fear, and depression. Substance abuse feeds those negative emotions.
- All PTSD sufferers – and especially veterans – feel cut off from those around them. Because they feel so alone, they turn to intoxicants. But alcoholics and addicts tend to feel even more alienation than the rest of the general population.
- Excessive drinking and drug use allows PTSD sufferers to avoid the bad dreams and painful memories so often experienced. But when avoidance becomes the primary coping method, it can interfere with successful recovery and healing.
- Substance abuse can serve as a distraction from the pain of PTSD and the problems associated with it. But drinking and drug use also cause their own complications, making it even harder to enjoy a happy, productive, and well-adjusted life.
- Finally, people who abuse drugs and alcohol very often experience new trauma as a result – violence, accidents, sexual assault, divorce, homelessness, etc.
Substance Abuse and Suicide among Veterans
“We hope these findings will help clinicians and health systems care for people with substance abuse disorders, with mental health conditions, and with both – and focus suicide prevention efforts accordingly.”
~Dr. Kipling Bohnert, researcher, Veterans Administration Center for Clinical Management Research
The suicide rate among current and ex-servicemembers is significantly higher than that of the civilian population. Every day in America, 20 veterans take their own lives. That is one suicide every 65 minutes.
Now, recent research published in Addiction has uncovered that the suicide risk becomes far greater when alcohol or drug abuse is also present. 4.4 MILLION vets were evaluated over a period of 6 years.
Male veterans with drug or alcohol problems are over twice as likely to kill themselves than vets without an active SUD. Among substance-abusing female veterans, the suicide risk is 6 times greater.
The study delved even deeper – examining how specific substances could affect the rate of suicide in different ways. Of special relevance, prescription sedative abuse quadruples the suicide risk among male vets and creates a suicide risk among females that is ELEVEN times greater.
In fact, substance abuse seems to impact the suicide risk among female vets to a greater degree:
- Opioids –8-fold greater risk
- Amphetamine/Stimulants –6-fold greater risk
Dr. Rajeev Ramchand, PhD, a behavioral scientist and expert on mental health and suicide among the military, says, “We knew that a diagnosis of a substance abuse disorder increased risk for suicide, but this paper illustrates that not all substance abuse disorders are the same.”
Barriers to Active-Duty Military Substance Abuse Treatment
Only about half of combat veterans who need mental health treatment seek help, and of those, a little over half actually receive adequate care. In fact, there are serious concerns about the quality of SUD treatment in the military.
- 2010-2015: 90 soldiers took their own lives within three months of receiving treatment via the Army’s substance abuse program.
- The Army maintains 54 substance abuse clinics worldwide. 50% fail to meet the established professional standards for treating alcohol and drug abuse.
- 2014: Approximately 7000 soldiers were turned away from treatment programs after screening. Subsequent evaluations by senior staff revealed that half should have been treated.
- Specific problems cited include:
- Poor focus on treatment mission
- Insufficient continuity of care
- Low morale and motivation among the staff
But there are four barriers that make it difficult for active-duty personnel to even seek treatment in the first place:
FIRST, there is the fear that admitting to a substance abuse problem could damage—or even end—their military career. A dishonorable discharge follows a veteran for the rest of his or her life.
SECOND, within the social culture of the military, drug use is frowned upon, but drinking is so commonplace as to almost expected. A servicemember may feel that they will miss out on good times with their buddies if they give up drinking.
THIRD, as there is with civilians, there is a decided stigma associated with addiction. Servicemembers can be stuck in denial because of overwhelming feelings of shame and guilt.
FOURTH, military culture is unique. Servicemembers are hesitant to show any weakness around their peers, and they are even more reluctant to admit that personal problems have affected their performance of their duty.
Barriers to Veterans Substance Abuse Treatment
But as hard as it is for active-duty servicemembers, it is exponentially more difficult for discharged veterans to receive proper treatment for an addictive disorder. Compared to most civilians, veterans have higher rates of:
- Family instability
- Financial problem, especially early in the transition
- Lack of higher education
- Joblessness, because military skills do not always transfer to civilian occupations
- Lingering physical and mental health problems
Receiving adequate care from the VA for those health issues can also be problematic, because:
- To receive VA benefits, the veteran must have either an Honorable or General discharge. In other words, a Dishonorable, Bad Conduct, or Other Than Honorable discharge disqualifies them from receiving VA health benefits.
- Veterans serving after 1980 must have served 24 continuous months.
- The waiting list for drug or alcohol abuse treatment can be lengthy due to a shortage of providers. As recently as late 2014, the VA was trying to fill 400 vacant primary care physician positions.
- Overburdened facilities: The nation’s estimated 22 million veterans are served by just 151 medical centers, 300 veterans centers, and 820 outpatient clinics.
- A limited federal means a rationing of care. Veterans with service-connected disabilities receive top priority.
What Can Be Done to Help the Problem of Addiction among Veterans?
By far, the biggest thing that can be done to help US veterans struggling with addictive disorders is an expansion of the availability of necessary services. To completely address the unique issues facing substance-abusing veterans, drug and/or alcohol rehab treatment must be comprehensive and may include any or all of the following:
- Individual psychotherapy
- Cognitive Behavioral Therapy (CBT)
- Trauma counseling – both primary and secondary
- Peer group therapy
- Couples/family counseling
- Medication-Assisted Therapy (MAT)
- 12-Step support groups
- Coping strategies
- Non-opioid pain management
- Suicide prevention
- Nutritional guidance
- Art or Poetry therapy
- Equine therapy
- Service animals
- Life skills coaching
- Resources for basic needs – housing, employment, healthcare
If the VA cannot provide the necessary treatment services in a timely manner, then the veteran and their family should contact an accredited rehab program for a detailed assessment and to discuss available options.