Substance abuse is gaining ground in our military. Here's a look at the problem.
By Kelly O’Rourke Johns
“An individual who has been to war will always come back as a changed individual,” says Richard Suchinsky, associate chief consultant for addictive disorders for the U.S. Department of Veteran Affairs, in a 2006 webcast sponsored by the Center for Substance Abuse Treatment, Recovery and the Military: Treating Veterans and Their Families.
Certainly, the current conflicts in which the U.S. is involved have caused thousands of soldiers to return home changed by physical and mental injuries. Although the government and medical communities are prepared to heal their bodies, our military personnel suffer silent wounds that may be far more challenging to mend.
A 2010 study of U.S. service members conducted by the American Journal of Public Health reports that deployed soldiers are nearly three times as likely as non-deployed soldiers to have visited a mental health professional and more than six times as likely to have received substance use disorder treatment. The cost to society of caring for veterans with mental health disorders is expected to surpass that of the Global War on Terror, estimated at $600 billion.
“There is a disturbing trend happening in this country,” said Barry Karlin, CEO and founder of CRC Health Group, in a September 2010 news conference in Wilmington, N.C., to kick off National Recovery Month. “As many as 30 percent of returning military from the Iraq and Afghanistan war have reported symptoms of a mental health disorder. Over 7 percent of veterans—almost 2 million adults—met criteria for a past-year substance use disorder.”
The very nature of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) offers some insight into why post-traumatic stress disorder (PTSD) and substance use disorders are emerging among military personnel. Too, the makeup of those personnel—unique to these conflicts—also plays a factor. According to top government and healthcare officials, the current level of services cannot keep up with the growing needs of our returning soldiers, and barriers to care exist. Meanwhile, the emotional toll on our troops persists, and those returning home from active duty find their internal conflicts far from over.
A Growing Problem
We’ve witnessed the toll war wreaks on the mental health of our veterans. Flashback to the Vietnam era, during which the military experienced horrific conditions and confrontations and returned home to a prevailing anti-war sentiment. Cases of post-traumatic stress and substance abuse skyrocketed.
“In ’64 when I was commissioned, I had never seen drugs in my life,” says retired Gen. Barry R. McCaffrey, former director of the Office of National Drug Control Policy (ONDCP). “Then I went into the armed forces, and Vietnam became this giant, terrible, excruciating issue in America.”
McCaffrey witnessed the surge of alcohol and drug use that’s become a trademark of the Vietnam War. “The entire armed forces turned their attention to that problem, and in the space of a decade, we ended up with damn-near drug-free institutions,” he says. Though implementing mandatory drug testing helped the turn-around, McCaffrey also points to a no-tolerance stance adopted by military brass. “The message was, in our ship, in our squadron, in our battalion, we’re not going to smoke pot or get fall down drunk or inject heroine,” McCaffrey recalls. “And if you do, we’re not going to prosecute you; we’ll make you leave the Army.”
Now an adjunct professor of International Affairs at the U.S. Military Academy at West Point and an advisor and board member to CRC Health Group, McCaffrey remains on the front lines of substance abuse treatment advocacy, particularly for military personnel.
“Now we have the problem [that] drug abuse rates have increased dramatically [in the armed forces]. To put it in context, dramatically from an almost nonexistent base,”
McCaffrey says. “But it is, unmistakably, a dramatic increase in drug abuse, and a lot of it is the continuing problem of alcohol, which is the worst drug of abuse in the military, combined with other drugs.”
H. Westley Clark, director of the Center for Substance Abuse Treatment for the Substance Abuse and Mental Health Services Administration (SAMHSA), concurs. “Individuals returning from Iraq and Afghanistan are at increased risk for PTSD, traumatic brain injury as well as substance use disorders,” he says.
Current director of the ONDCP, R. Gil Kerlikowske, sees the overall rise in prescription drug abuse in the U.S. to be of particular concern and notes that the military is not immune to the trend.
“Oftentimes the people that are having problems with them started out quite legitimately with pain medication,” he says. “That is the stealth problem that we’re seeing with prescription drugs in the military.”
The Nature of the Beast
Part of the increase in substance use disorders in the military may stem from the nature of the conflicts in which the U.S. is engaged. The length of these conflicts, number of deployments experienced by military personnel, length and uncertainty of those deployments and lack of any reprieve from counter insurgency all produce a toxic mix of mental stressors.
“The nature of the conflict is different,” Clark says. “We have a war that’s nine years old now. It’s persisted for a long period of time.”
Says Kerlikowske, “We’ve had the multiple tours. We’ve also had the issues where people within the National Guard and Reserve often thought they would do two weeks a month in the summer and a weekend a month in training, and now you look at National Guard and Reserve troops who’ve done multiple-year tours over a number of years. It’s very disruptive.”
Suchinsky comments in the Recovery and the Military webcast, “There is no front line in this war, and even when the people are in what’s called ‘the Green Zone,’ which is supposedly a safe area, they are still subject to bombardment with car bombs and mortars and what have you. For the individual in the active duty war zone, there is no respite from the stress.”
And because of technological advances, disjointed emotions can result from an increased accessibility to loved ones back home. “This conflict is very different from others,” says Patricia B. Getty, supervisory public health advisor for the Center for Substance Abuse Prevention. “A soldier may experience a car bombing, go back to his facility, get on email and talk to his wife. There is that conflict between still being tied with what’s going on at home and at the same time, experiencing war zone.”
Even the nature of the physical damage caused by these conflicts may influence the rise in substance abuse and addiction. John P. Allen, associate chief consultant for addictive disorders for the Office of Mental Health Services for the Veterans Health Administration, points to the types of injuries associated with these conflicts as a source of the problem.
“These injuries need to be treated with medications that reduce pain,” Allen says, “and of course the problem is the individual could become psychologically or physically dependent on the pain medications that they need.”
B. Diane Vchulek, PTSD tract coordinator for Twelve Oaks Alcohol and Drug Treatment Center in Navarre, Fla., ironically attributes a higher quality of medical care to the larger number of soldiers returning home alive but mentally and physically altered. “We’re getting a lot of people back,” Vchulek says. “They’re well cared for at the time of injury, so there’s a higher percentage of survivors.” Vchulek, who developed the center’s tract ASPIRE for military and civilian patients in need of addiction and PTSD treatment, sees military personnel’s need for treatment ongoing. “We’re going to have a lot of catching up to do over the next five years. We’ve never had to address things like this before.”
A Complex Military Makeup
Another contributing factor to the increase in chronic mental health illnesses among U.S. military personnel may have to do with the very makeup of the military. “We’ve got many more people from the Guard and Reserve who have been mobilized,” Clark says.
“When people have readjustment issues, they complain of trouble finding work, places to live, strained relationships due to long deployment. If you’re a plumber or carpenter or teacher and you’re in combat where people die or are wounded and you come back and you’re thrust back into civilian [life], you’ve got adjustment issues that need to be addressed. You’ve got a tendency for alcohol problems to develop as well as other substances, and there’s the increased problem with depression.”
Allen concurs. “National Guards and reservists do have unique problems because they’re activated for a certain period of time, and then they return to their civilian lives.”
Barriers in the Barracks
Abel Moreno, co-founder and deputy director of Vets4Vets, a nonprofit organization that offers peer-to-peer support, focuses on helping fellow veterans heal once home. One difficulty he faces in providing that service has to do with a prevailing “boot straps” mentality in the military that facilitates stigma and shame regarding mental health issues. “I think there is a sense, and it works against itself, to maintain a show of force and strength by virtue of you being a service member,” Moreno says. “That’s ingrained in you.”
Clark offers hard figures. “Forty-five percent of military personnel who report that medication might help them report that they’re afraid it will have side effects,” he says. “Another 44 percent fear that seeking mental health treatment could hurt their careers; 44 percent report they fear they could be denied security clearance; 39 percent feel family and friends would be more helpful than a mental health professional; 38 percent feel that their coworkers would have less confidence in them if they found out they were in behavioral healthcare. We’re dealing with stigma on the part of the larger society as well as on the part of the affected individual.”
McCaffrey recognizes that the military culture is not one that embraces substance use disorders. “It’s very difficult to go in and tell your chain of command you have an issue,” McCaffrey says. “It’s probably easier to tell them you have PTSD than [to] discuss alcohol or OxyContin. We’ve got to address that.”
Treating Invisible Wounds
Along with the barriers to care associated with mental health disorders, service men and women seeking treatment must navigate available support programs. Every branch of the armed forces has systems in place to address mental health issues including substance use disorders.
Active duty military personnel often have access to mental health offices on base. Those who require treatment are referred by that office to treatment providers. After treatment, soldiers return to base and the substance abuse programs provided there, which could include outpatient programs after an inpatient/residential stay. Recommendations from the treatment facility can include Twelve Step meetings and continued counseling.
Veterans in need of substance abuse treatment have different avenues of support to include VA hospitals and clinics across the country. Allen believes treatment services are sufficient to meet the needs of returning OEF/OIF veterans.
“We have over 2,000 personnel in our hospitals and clinics who are providing substance abuse disorder services,” he says. “There’s an entire continuum of care going all the way from detoxification through outpatient sessions through what we call intensive outpatient treatment.”
Still, veterans may reside in remote areas and have little or no access to VA support. And Guard and reservists have their own access issues. “The reservists and the Guard, who generally return to civilian life, may fall through the cracks if we don’t have a seamless system,” Clark says. “The DOD [Department of Defense] while you’re active duty—whether you’re Guard, Reserve or traditional military—the VA and the civilian delivery system all need to be working in concert so that we can address these issues.”
Though effective treatments for substance abuse disorders for military personnel generally follow civilian models, those that involve peer-to-peer support and provide staff trained in military issues have proven highly successful. “I’ve been astonished at how the power of getting a bunch of veterans together in a vets program adds to the effectiveness of the program,” McCaffrey says. “The military culture is unique. It has its own unique jargon and community and makes it a challenge for behavioral health professionals who may not be adequately trained to work with returning military personnel. We want to make sure that our providers are more sensitive to that unique military culture and that they’re sensitive to the transition needs.”
Is It Enough?
Though the government and civilian sectors have vowed to ramp up treatment services to care for the mentally wounded, some say there are too few programs in place. “I think uniformed leadership has always said, when you are acutely wounded, we’ll go 300 percent to take care of you,” McCaffrey says. “But when you get into the chronic care category, which of course substance abuse and PTSD are both essentially … I don’t think the uniformed military got there. I think Secretary [of Defense Robert] Gates energized the system, Congress is aware, but now you’ve got to build something to scale that meets the problem.”
Kerlikowske recognizes the gravity of the issue and believes military substance abuse problems are a government priority. “I know that in my discussions with the VA and with Secretary Gates and also a number of other people at the DOD, [that] it’s really very high on their radar screen. I know that they’re working very hard to address the problem,” he says.
The resources needed to handle the complicated mix of service members in need of care must be addressed. “Since 2004, the Army has added 500 primary care providers including military personnel, civilian employees and contractors and more than 270 behavioral health providers to help meet the needs in that field due to stresses associated with combat deployment,” Clark says. “The commitment is there; the issue is the matter of resources both financial and professional in terms of workforce development so that we can address these issues.” He adds, “Resources are not unlimited.”
Certainly, there are a multitude of variables that factor into the mental health disorders that plague our soldiers and ultimately our ability to adequately treat them. Though the conflicts are unique, one thing remains discouragingly consistent. “Since who knows when, the first war that’s ever been fought, individuals will try to escape their trauma by using substances,” says Moreno. The result is a population of returning soldiers with chronic mental wounds and a system of care hard-pressed to keep up. That we do keep up and continue to address the problem long after current conflicts resolve remains to be seen.
“When we say combat operations are over, we mislead our citizens to say the fight for our soldiers is over,” said Rep. Patrick Kennedy in a speech last November at the Rosalynn Carter Symposium on Mental Health. “Why are we leaving our soldiers prisoners of war?”
Military Recovery Quick Reference
Here are a number of resources for service men and women in need of support for substance addiction treatment and recovery. Many of these providers also serve individuals with co-occurring disorders such as post-traumatic stress disorder and other mental health issues.
Army Center for Substance Abuse Programs
The Army Substance Abuse Program mission is to strengthen the overall fitness and effectiveness of the Army´s workforce, to conserve manpower and enhance the combat readiness of soldiers.
Department of Defense National Resource Directory
The NRD provides access to services and resources at the national, state and local levels that support recovery, rehabilitation and community reintegration.
Give an Hour
Give an Hour is a nonprofit organization that provides free mental health services to U.S. military personnel and loved ones affected by the current conflicts in Iraq and Afghanistan including members of the National Guard and Reserves who have not yet deployed.
National Military Family Association
The mission of the NMFA is to educate military families concerning their rights, benefits and services available to them and the issues that affect their lives.
Operation Healthy Reunions
Operation Healthy Reunions helps to bust the stigma of mental health issues among soldiers to ensure that a greater number of military families receive the prompt and high-quality care they deserve.
TRICARE is the healthcare program serving active duty service members, National Guard and Reserve members, retirees, their families, survivors and certain former spouses worldwide.
TurboTAP.org is Department of Defense’s official website providing information for service members on transitioning from military service.
Warrior Transition Command
The WTC’s mission is to develop, coordinate and integrate the Army’s Warrior Care and Transition Program for the wounded, ill and injured soldiers, veterans and their families or caregivers in order to promote future success in the force or civilian life.
Coalition for Iraq + Afghanistan Veterans
The CIAV is a national nonpartisan partnership of organizations committed to working with and on behalf of all military, veterans, families, survivors and providers to strengthen the existing system of care and support for all those affected by the wars in Iraq and Afghanistan.
Disabled American Veterans
Disabled American Veterans is an organization of disabled veterans who are focused on building better lives for disabled veterans and their families.
Grace After Fire
Grace After Fire is a place for women veterans, and their loved ones, to connect to one another and professional partners to find resources.
Iraq and Afghanistan Veterans of America
IAVA’s mission is to improve the lives of Iraq and Afghanistan veterans and their families. IAVA is dedicated to educating the public about the wars in Iraq and Afghanistan, advocating on behalf of those who have served and fostering a community for troops, veterans and their families.
National Veterans Foundation, Inc.
The NVF operates the nation’s only tollfree helpline for veterans and their families, raises public awareness about veteran issues, and outreaches to veterans and their families.
Swords to Plowshares
Swords to Plowshares is a community based, nonprofit organization that provides counseling and case management, employment and training, housing and legal assistance to veterans in the San Francisco Bay Area.
Veterans Advantage is a national program that partners with corporations that want to do their part to honor and thank all who serve our country by providing preferred pricing on their goods or services every day.
Vets4Vets is a nonpartisan veterans’ peer support organization dedicated to helping Iraq and Afghanistan veterans heal from any negative aspects of service and war. Vets4Vets pays ALL expenses for OIF/OEF vets to fly to weekend peer support workshops.
For more resources for active duty and veteran service men and women, click on the Resources section.