Coping with the invisible wounds of war is the new front line for hundreds of thousands of soldiers returning from multiple deployments in Iraq and Afghanistan. Sleepless, on high alert, and waiting in fear for something terrible to happen, countless veterans turn to alcohol or drugs to try and keep the nightmares at bay. The behavioral health community must be prepared to help veterans cope.
While it doesn’t garner as much media attention as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI), the abuse of alcohol is one of the most prevalent problems that veterans face. Twenty-seven percent of Army soldiers screened three to four months after deployment to Iraq, met criteria for alcohol abuse and were at increased risk for related harmful behaviors, including driving intoxicated or using illicit drugs. In addition, prescription drug abuse doubled among U.S. military personnel from 2002 to 2005 and almost tripled between 2005 and 2008. Drugs or alcohol were involved in 30% of the Army’s suicide deaths from 2003 to 2009 and in more than 45% of non-fatal suicide attempts from 2005 to 2009. Of returning veterans from the war in Afghanistan who have been treated at a VA hospital for drug addiction, 27,000 veterans have been diagnosed with “nondependent use of drugs,” and 16,200 have been diagnosed with Alcohol Dependence Syndrome. In New York State alone, programs that are certified by the Office of Alcoholism and Substance Abuse Services treated nearly 14,000 veterans in the past year, but the Substance Abuse and Mental Health Services Administration reported that there are over 75,000 New York veterans suffering from alcoholism or chemical dependence.
Historically, excessive drinking has been associated with military culture, and was considered just a facet of ‘being a man.’ One in eight soldiers returning from Iraq and Afghanistan between 2006 and 2008 were referred for alcohol counseling. The National Household Survey on Drug Abuse reported that more than half of the male veterans in the U.S. use alcohol, 23% binge drink, and 7% drink heavily. Female veterans drink less, with 41% using alcohol, 14% binge drinking, and 2% drinking heavily.
Fortunately, more active duty soldiers and veterans are seeking help than ever before. From 2007 to 2012, the number of soldiers enrolled in treatment after being diagnosed with alcohol problems increased by 56%. Despite this increase, far too many soldiers are not getting the treatment they need. In fact, of the 12% of soldiers who reported an alcohol problem post-deployment, less than 1% percent are being referred to treatment. This could be due to the fact that in the military, referrals for alcohol treatment are not confidential. The military’s current policy requires that “accessing alcohol treatment triggers automatic involvement of a soldier’s commander,” which can impact their career prospects. According to the military’s Mental Health Task Force, “Concerns that self-identification will impede career advancement… may lead service members to avoid needed care, even at early stages when problems are most remediable.” It is likely that the policy of automatic command notification is the most significant barrier to troops’ receiving alcohol abuse treatment.
In addition to alcohol, drugs have long been part of the military during conflict. While many soldiers returning from Vietnam brought heroin addictions home from war, today we find returning soldiers more at risk from the drugs given to them legally. A 2010 Army study found that one-third of its soldiers were on prescription meds, and nearly half of those — 76,500 soldiers — were taking powerful and addictive opiate painkillers. Last year, researchers at the San Francisco VA Medical Center published a paper that found VA doctors prescribed significantly more opiates to patients with PTSD and depression than to other veterans – even though people suffering from those conditions are most at risk of overdose and suicide.
Advances in medicine have also meant that many more military personnel are surviving serious injuries, further increasing the demand for drugs to control pain. In 2009, military doctors wrote 3.8 million prescriptions for narcotic pain pills — four times as many as they did in 2001. The Army also reported the number of amphetamine prescriptions doubled between 2006 and 2009. More drugs have meant more drug problems among service members. Last year, a study of more than 450,000 Iraq and Afghanistan veterans found that 4.5 percent had a substance use disorder diagnosis — more than double the civilian rate — adding that the rate was likely to be even higher because of the VA’s poor screening process. The same study noted that VA funding for chemical dependency services had declined in comparison to other healthcare services. It also noted the military continued to do a poor job screening patients whose mental conditions put them at greater risk of drug abuse.
We know that drugs and alcohol frequently co-occur with many mental health disorders. Six out of ten people with a substance use disorder also suffer from a mental illness. Even in soldiers whose comorbidities do not occur simultaneously, research shows that mental disorders can increase vulnerability to subsequent drug abuse and that drug abuse constitutes a risk factor for subsequent mental disorders. Therefore, diagnosis and treatment of one disorder will likely reduce risk for the other, or at least improve its prognosis. The need to develop effective interventions to treat both conditions concurrently is strongly supported by research but has been difficult to implement in practice. Health care systems in place to treat substance use disorder and mental illness are typically disconnected, dis-coordinated and inefficient.
For some veterans, the use and abuse of drugs brings them into contact with the justice system. Sometimes mental illness plays a role in the crimes committed by veterans, often because it’s untreated. More than 33% of troops who were convicted of criminal acts in Afghanistan or Iraq had committed offenses while under the influence of alcohol or other drugs.
In the past five years, new community solutions have arisen to address this in the form of special courts. The courts are similar to drug and mental health courts, but designed specifically for veterans, who have both substance use and mental health issues. There are now about 88 veterans’ courts in 26 states. It makes a big difference for veterans to have a community wrap itself around them, help them adhere to treatment and gently hold them accountable for their actions. On the day the veteran’s case is heard, the courtroom is filled with people to help him sort out his problems—physical health, mental health, legal and practical. Additionally, peer-based services, which expand the continuum of services available to veterans with co-occurring disorders, provide veterans with a unique opportunity to develop linkages and relationships with other veterans who have similar lived experience and develop options for involvement in new communities of hope.
One of the most critical aspects to mitigate and prevent substance use and abuse is to stabilize important elements of the veteran’s life. This includes employment, housing and community supports. The unemployment rate among veterans ages 20-24 is 15%, three times the national average for this age group. Younger veterans who may have joined the service immediately after high school express difficulty transferring their military skills to the civilian work force. These veterans may have limited education and no civilian work experience. Some veterans are re-enlisting because they are discouraged by the lack of opportunity in their local job markets. By stabilizing employment, we reduce the abuse of substances and ensure that they have successes in other areas.
A number of employers have committed to hire and support veterans in the workplace. Over 100 major U.S. firms have pledged to hire 100,000 veterans and military personnel over the next several years. The Veterans on Wall Street initiative, a partnership of five banks, provides career development, support, and retention of veterans throughout the financial industry. President Obama established a Veterans Employment Initiative in order to transform the federal government into a model of veterans’ employment. We all must do our part. As members of the behavioral health community, we must join together to address the complex mental health and substance abuse challenges among our nation’s heroes by promoting:
- Increased access to comprehensive recovery oriented civilian based mental health and substance abuse supports that are competent in military culture. Availability of community-based resources is critical for veterans who cannot or will not use the VA for care.
- Expanded use of peer-to-peer supports that have proven effective with helping veterans recover and reintegrate
- Support for families of veterans and service members
- Enhanced outreach and public education to provide information about mental and substance abuse problems and sources of help for veterans and their families
- Expanded suicide prevention efforts to build awareness of signs of suicide risk among veterans and how to respond
- Expanded supports in educational and employment settings to increase veteran retention and success
- Enhanced confidentiality of soldiers and veterans seeking alcohol counseling in the DOD and VA care systems
To help advance these policy and practice recommendations, join the Veterans Mental Health Coalition of New York City, a diverse group of over 950 stakeholders united and committed to improving care for veterans, service members and their families. Veterans have sacrificed on our behalf, now it’s our turn to ensure that they get the help they need and deserve so they can lead successful lives and contribute to our communities.