Military and substance abuse

DEFINITION: The use of alcohol and drugs among military personnel, especially those coping with combat-related trauma, is generally understood among mental health professionals as a way for service members to self-medicate. Although alcohol and drugs may bring short-term relief from the emotional and physical pain of deployment, the long-term consequences pose a threat to military morale and to the quality of life for service members and their families. The prevalence of alcohol and drug use in the military necessitates the development and implementation of best practices and programs for supporting the emotional state of service members to prevent them from turning to alcohol and drug use as a stress-coping mechanism.

Alcohol and Drugs

Mental health disorders are strongly linked to substance abuse. Post-traumatic stress disorder (PTSD) is a medically diagnosed anxiety disorder that is common and underdiagnosed among military personnel, especially those who have been in combat. A person with PTSD continually relives in their mind a highly traumatic event. This manifests itself in an involuntary flood of thoughts related to the trauma. It includes nightmares, an adrenaline rush, and spikes of anxiety when visual or audible reminders of the experience appear.

Many service members who have PTSD alleviate symptoms with alcohol and drugs, such as marijuana and prescription painkillers. These drugs slow brain activity and reduce chronic anxiety during the substance high. The National Center for PTSD in 2022 recommended that military personnel experiencing PTSD and substance abuse disorders be treated for both conditions at the same time. Evidence shows that treating PTSD and substance abuse disorders simultaneously works to treat both conditions, even if different therapy techniques are used to address the conditions separately. The most commonly used evidence-based trauma-focused treatments for PTSD include cognitive processing therapy (CPT), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR), while substance abuse disorder is best treated with relapse prevention, cognitive behavioral therapy (CBT), and contingency management. Combining these, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) gained popularity in the late 2010s and was commonly implemented in the 2020s.

PTSD and substance abuse disorders are underdiagnosed among military service members, and they carry a heavy stigma. The inclusion of such conditions as part of one’s official record often means that the service member may not be able to pursue a career in, for example, defense or law enforcement after military service. Therefore, both disorders are believed to be highly underreported by service members and their supervisors. Notably, experiencing a traumatic event that does not result in PTSD may still trigger substance abuse behaviors. Until PTSD and substance abuse disorders are addressed in a way that does not lead to stigmatization, service members will likely continue to self-medicate with substances, particularly alcohol.

The danger in self-medicating is that the method (drinking alcohol or taking drugs) used for short-term relief of the emotional pain inevitably worsens emotional conditions later. The release of dopamine in the brain triggered by alcohol or drugs results in the impairment of emotion regulation in the brain once the high wears off. Additionally, around half of suicides, sexual assaults, and intimate personal violence incidents that occur among service members are alcohol related.

According to St. Johns Recovery Place (SJRP), the culture of the military makes heavy drinking common, and drug abuse is a common obstacle that many veterans face and must work to overcome. SJRP reports that one in every ten to fifteen veterans suffers from a substance use disorder or addiction, and veterans with PTSD tend to regularly binge drink. They also use tobacco at double the rate of soldiers without PTSD. Alcohol and tobacco are the most commonly abused substances among military members because they are not prohibited. Testing positive for an illicit substance on regular drug tests may result in a dishonorable discharge, which lowers drug use. Still, illicit drugs and the abuse of prescription drugs do occasionally occur.

Veteran drug abuse most often involves heroin or cocaine use, as well as marijuana and synthetic opioids. Military veterans who struggle with substance abuse disorders are three to four times more likely to be diagnosed with a mental health issue than those who do not misuse substances. More than two out of every ten veterans with PTSD also have a substance use disorder, and one in three soldiers who seek help for their substance abuse disorder present with PTSD. According to the National Institute on Drug Abuse (NIDA), one in four veterans of Operation Enduring Freedom and Operation Iraqi Freedom who were in combat presented symptoms of a mental or cognitive disorder, and one in six veterans of these two missions showed signs of PTSD.

Alcohol and Drug Use Policy

In 2020, the US Army revised Army Regulation 600-85, which updated soldier substance abuse awareness training as well as the Policy for Voluntary Alcohol-Related Behavior Healthcare. Previous editions of Army Regulation 600-85 prescribed random drug testing and deployment restrictions on soldiers undergoing rehabilitation for substance abuse. The regulation also directs commanders to initiate separation for first-time offenses.

In 2009, an Army Times article brought to light the consequences of commander discretion trumping ASAP regulation. An investigation led by Army Vice Chief of Staff General Peter Chiarelli found that among all soldiers who tested positive for illegal drug use, only 70 percent were referred to ASAP for treatment. The most common illegal drug found through urine tests was marijuana, followed by cocaine, LSD, methamphetamine, heroin, and illicitly used prescription drugs. Brigadier General Colleen McGuire found that among 1,000 soldiers who tested positive for drug use, 372 were repeat offenders, and none had been sent to treatment. A 2022 article in Military Times noted that in the past, testing positive for substance abuse often ended a military career. However, this is changing. The article notes that veterans who were discharged because of misconduct linked to substance abuse are being given a path to honorable discharges, which qualify them for federal benefits.

Major General Anthony Cucolo, who reviews substance abuse cases for the Army, said that alcohol use is the most prevalent substance abuse concern. A commander's rejection of a standard separation policy, given the urgent need for retaining soldiers during wartime, compounds the substance abuse issue and generates a need for a case-by-case analysis of each offender’s need for treatment and level of readiness to serve.

Treatment

According to a 2010 article in the journal Addiction Professional, increasingly, more veterans are seeking treatment at the community level rather than through the US Department of Veterans Affairs (VA). There remains a degree of distrust in relying on the government to treat drug and alcohol abuse. Any diagnosis or treatment given through the VA will show up on the service member’s record.

Knowing that military personnel are more inclined to seek help outside the military structure, the VA is seeking to partner with community resources. Treatment strategies include twelve-step therapies, “stop, think, act” impulse-control programs, and “soldiers helping soldiers” programs, in which soldiers are trained to help their peers in dealing with combat-related stress. According to a June 2010 poll by Addiction Professional more than 90 percent of respondents felt that there is a shortage of community-based assistance for returning veterans, many citing the lack of PTSD treatment.

Twenty-first-century policies ensure military personnel who self-refer to a treatment program, called Voluntary Care, are not at risk of losing their security clearances, and their readiness and schooling eligibility are not limited. If an individual does not seek help, they may be subject to involuntary treatment, called Commander-Directed Care, such as after a driving under the influence arrest or a violent incident fueled by alcohol.

Intervention and Rehabilitation Outlook

Mental health and military experts agree that more investigation is needed into how to better support military personnel emotionally, particularly during and after deployment. Though recognition of depression, anxiety disorders, and substance use disorders is pervasive, more needs to be understood about wartime stress on military personnel and their families so that techniques for early intervention and treatment can be developed.

In July 2010, the US National Institutes of Health announced the approval of $6 million in federal funding to support research by institutions in eleven states specializing in substance abuse among military personnel, veterans, and their families. NIDA partnered with the VA to award the grants earmarked for investigating the links between deployment and combat-related trauma to the prevalence of substance abuse, mainly among veterans returning from the wars in Iraq and Afghanistan.

In 2010, the Army transferred its outpatient substance abuse treatment services from medical to non-medical leadership, which some argued led to substandard care from underqualified and overextended personnel. Between 2010 and 2015, ninety soldiers committed suicide within three months of receiving substance abuse treatment through the military. In one case, the soldier had been stated to be in good mental health by an unlicensed counselor hours before his death. Many soldiers who seek treatment are also turned away—in 2014, 7,000 soldiers were denied help by the military substance abuse program. This sparked an overhaul of the program, and research concerning mental health and substance abuse in the military increased.

Bibliography

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