Butler Center for Research | May 2018 Download the Substance Use Disorder Among Military Populations Research Update The unique lifestyle elements and challenges of military service make both active-duty and veteran service members a distinct culture unto themselves. This cultural influence plays a significant role in health care trends, with major implications specific to mental health and substance abuse. As a result, it is critical to consider the impact of military experience on alcohol and drug use, and substance abuse, as well as its impact on best practices for prevention and treatment of substance use disorders. Substance Abuse Prevalence and Influence Service members have an increased risk of developing a substance use disorder (SUD), especially those who have been deployed to combat.1, 2, 3 Individuals deployed to recent conflicts in Iraq and Afghanistan have shown significantly higher rates of SUD diagnoses than civilian populations; in 2013, 44 percent of those returning from deployment had challenges with the transition, including the onset of problematic substance use behaviors.4, 5, 6 A systematic review of published research showed those recently deployed to Iraq and Afghanistan were 1.36 times more likely to develop an alcohol use disorder and 1.14 times more likely to develop a drug use disorder than non-deployed service members who served during the same time period.2 Similar post-deployment increases in substance use problems have also been seen in Reserve and National Guard personnel.6, 7, 8 Despite higher rates of substance abuse, deployed military personnel often have low rates of referral to SUD treatment services, often attributed to high levels of stigma.6, 9 Outside of combat deployment or other traumatic events, there are a number of cultural factors that can have an exacerbating effect on alcohol and drug abuse, and the development and treatment of SUDs. The availability of inexpensive alcohol at military bases is a concern because of its correlation to binge drinking and underage drinking.1, 6 Workplace culture among military personnel is also an area of concern, particularly the stigma related to problematic substance use and fear of negative consequences related to seeking help.1, 6 Perhaps the most pressing concern comes from increasing prescription rates for pain medication. Prescriptions for pain medication among military service members, generally related to combat-related injuries and strain from extreme physical exertion, have increased exponentially in the past 20 years.1, 6 In 2009, military physicians wrote almost 3.8 million prescriptions for pain medicine, which was more than four times the number written in 2001.1 As a result, prescription drug misuse and opioid use disorders have become a critical concern for military leadership. Trauma and Substance Use Disorders Post-traumatic stress disorder (PTSD) is a mental health condition that can occur following exposure to a traumatic event, with symptoms that include re-experiencing the trauma, avoidance of reminders of the trauma, hyper arousal and negative cognitions.10 PTSD occurs significantly more often among military veterans than civilian populations (approximately 18 percent of post-deployment Army soldiers experience PTSD,11 as compared to 6.8 percent of the general population10). The common co-occurrence of PTSD and substance use disorders is well-established, and military populations demonstrate a higher rate of comorbidity among PTSD and SUD than the general population.12 Fifty-eight percent of individuals seeking treatment for alcohol use disorder (AUD) also meet the diagnostic criteria for PTSD; among veterans who had been recently deployed to Afghanistan and Iraq and who are also seeking treatment for AUD, 63 percent meet the criteria for PTSD.12 The combination of PTSD and AUD can have serious consequences for mental health. According to a recent study comparing veterans with PTSD and AUD to veterans with AUD only, those with PTSD and AUD had significantly elevated rates of: major depression (36.8 percent versus 2.3 percent) generalized anxiety disorder (43.5 percent versus 4.1 percent) suicidal ideation (39.1 percent versus 7.0 percent) suicide attempts (46.0 percent versus 4.1 percent)12 The increase in prescriptions for pain medication and the high prevalence of PTSD among recently deployed service members has led to concerns about increasing risks for opioid use disorders (OUD). The rate of PTSD and OUD among veterans increased from 2.5 percent in 2004 to 3.4 percent in 2013.10 Reviews of opioid prescriptions by the Department of Veterans Affairs (VA) health system show that when compared to veterans without a PTSD diagnosis, veterans with PTSD are prescribed opioids more often, receive higher-dose opioids, are more likely to receive two or more opioids at the same time and obtain more early opioid refills.13 While there was an overall risk for adverse clinical outcomes for any veteran who received prescription opioids as compared to those who did not, adverse effects were more extreme among veterans who had a concurrent diagnosis of PTSD. In addition to poor clinical outcomes, military samples with co-occurring PTSD and OUD also demonstrate highly elevated rates of other SUDs, including alcohol (60 percent), cocaine (34.8 percent), marijuana (27.5 percent), sedatives (13.4 percent) and amphetamines (7.6 percent).10 Current Recommendations As research on the increasing prevalence of SUDs continues to emerge, military leadership has begun to explore a number of policy changes to address widespread concerns related to alcohol and drug abuse, prevention and treatment in military culture. For prevention, The Institute of Medicine committee has presented recommendations to reduce access to alcohol on military sites and consistent enforcement of underage drinking rules.1 Efforts to reduce stigma related to seeking treatment for substance abuse or SUDs have also been promoted throughout the military.6, 14 Clinical directions for treating and preventing SUDs among military personnel are varied, and scientific research has provided a number of promising directions for care. Each service branch uses its own program for the delivery of treatment services to active-duty service members, and the Department of Defense advocates for the use of evidence-based practices for SUD treatment across the military as a whole.1, 6 The high prevalence of SUDs that co-occur with PTSD has led to a strong emphasis in the scientific literature to identify options that integrate treatment for both conditions simultaneously.15, 16 Recent clinical studies have found promise in the use of trauma-informed care interventions that include a concurrent focus on PTSD and SUD symptoms (for more information on trauma-informed care, see our Research Update entitled Trauma-Informed Care for Substance Abuse Counseling).17 Conclusion Research indicates that military service members are at a much higher risk than civilians for developing a substance use disorder. It is critical that providers take their experiences into consideration when assessing the symptoms of substance abuse and treating SUDs. Providers must also take particular care to identify the potential for comorbid PTSD symptoms, which have a particularly high prevalence among those who have recently deployed to Iraq and/or Afghanistan.