Substance Abuse Among Veterans : Understanding the Extent of the Problem and Its Impact on Mental Health and Families

It is tough to be in military, as the life which an army person has to lead is filled with unique challenges for the person as well as their families. The deployment causes anguish due to separation from the family members and the need for adapting to a new way of life.

Many members of the military struggle to cope with the trauma of active duty, which they had done before and struggle to leave the past behind and due to this, can suffer from different problems, such as substance abuse, post-traumatic stress disorder (PTSD) and mental health problems.(1) The substance abuse which the veteran undergoes also affects their families and increases the challenges they have to face.

Extent of the Problem of Substance Abuse Among Veterans

According to research, veterans are more susceptible to suffer from substance abuse and the use of tobacco products when compared to their non-veteran counterparts with around 30% of them facing this.(2) The increased tobacco use among veterans has caused a substantial financial impact on the Veterans Health Administration (VHA) amounting to about $2.7 billion (about 7.6% of its expenditures) on ambulatory care related to smoking, hospitalization, prescription drugs and home health care.

Other than this, an increased proportion of veterans suffering from coronary heart disease are smokers when compared to civilians with similar condition.(3) For those without any heart disease, the chances of veterans being former smokers are more when compared to civilians. In recent years, the Veterans Health Administration has put in efforts for making tobacco cessation treatment options more accessible thus giving better results.

Military/Veteran Life, Substance Use and Mental Health

All the veterans have to undergo a period of readjustment when they leave the military and reintegrate back into the civilian life with family and friends and the readjustment is not always smooth as they can suffer from many mental health challenges.(4) There are many environmental stressors, which are specific to military personnel that are associated with increased risk of Substance Use Disorder (SUDs) among veterans and military personnel, such as deployment, combat exposure, and post-deployment reintegration/ civilian challenges.(3)

Veterans that are appearing for first-time care within the Veterans Health Administration system, about 11% of them meet the criteria for diagnosis of substance use disorder. Veterans having substance use disorder then often meet the criteria for co-presenting mental health disorders, such as anxiety, depression and PTSD.

Combat exposure, deployments and injuries associated with combat can cause development of substance use problems. Veterans who have suffered trauma or were injured or hospitalized during the combat are at increased risk for drug use and increased drinking. Veterans with substance use disorder are thrice or more likely to have a diagnosis of depression or PTSD.(3)

Problems Caused By Substance Abuse Disorder in Veterans

Veterans are Unable to Emotionally Connect with Anyone

Veterans suffering from PTSD tend to feel emotionally distant and have difficulty in reconnecting with their partner on a romantic level and other family members too.(5) When the veteran feels like this, they hide their issues behind substance abuse, due to which their spouse may feel hurt and rejected. If you see these changes in your family member, then it is important to seek treatment with counseling.

Personality Changes in Veterans Because of Substance Abuse

Veterans experience a drastic change in their personality when they turn to drugs and alcohol to deal their emotions, and other upheavals which they go through after getting back to normal life. The drastic personality change is more prominent if the veteran has incurred a traumatic brain injury(6), is experiencing physical pain from an injury or is suffering from PTSD.

The family members are not able to understand these changes and can start to feel depressed. When you see any such personality change in your family member, then try to understand why this is happening and how to help them.

Financial Troubles in Veterans Due to Substance Abuse

Traumatized veterans having substance abuse issues are unable to stick to any job, which not only causes frustration, but also financial instability resulting in anxiety and depression in the veteran, as well as their family members.(7)

Domestic Violence, Child Abuse and Suicide

The above mentioned combination of the factors can be deadly and if the substance abuse in the veteran is not treated, then they can become violent or self-destructive and can also contemplate suicide or engage in behaviors, such as child abuse and domestic violence.

It is important that the family members take action before things reach this level and help their loved one. The veteran can be enrolled into substance abuse treatment programs and counseling where they are taught to adopt healthy coping mechanisms and ways to successfully adjust to their new lives.

Increased Rates of Suicide in Veterans

Deaths from suicide in veterans and active duty military are more when compared to the general population. In 2014, more than 20 percent of national suicides were among veterans with an average of 20 veterans dying from suicide daily.(8) The suicide rate increased to 1.5 times more for veterans than non-veteran adults in 2016. It is observed that suicidal behavior in the military is preceded by substance use. Since 2003, around 30% of army suicides and more than 45% of suicide attempts consisted of drug or alcohol use.(3) Other than this, about 20% of deaths from high-risk behavior were due to drug or alcohol overdose.

Researchers have investigated the possible association between pain and prescription pain medications and suicide. A Veterans Affairs study done in 2017 comprising of about 124,000 veterans showed that those who were taking highest doses of opioid for pain relief had more than double the risk for dying by suicide when compared to those who were getting lowest doses.(9) However, most of these suicides were with firearms and did not involve opioids. It is also not clear if there’s a direct causal association between the suicide risk and pain medications; or if the high doses can be a marker for other factors which lead to suicide, such as untreated severe chronic pain.(10)

Homelessness in Veterans

The U.S. military veterans comprise a big part of homeless adults. A study from 2014 has shown that about 70% of homeless veterans also suffer from substance use disorder.(11) In 2011, around 1/5th of veterans with substance use disorder were homeless.(11) These homeless veterans face various barriers and challenges when seeking treatment for their substance use disorder.

Challenges Faced by Veterans: Access to Good Treatment for Substance Use Disorder

A report in 2012 from Institute of Medicine (IOM) described different challenges when it comes to treatment and management of substance use disorder among veterans and duty military personnel. These challenges include the stigma associated; limited access to treatment, fear of negative consequences; gaps in insurance coverage, and the lack of confidential services. This report also provided solutions to these problems, such as increasing the usage of evidence-based treatment and prevention interventions along with expanding the access to care.

It was also recommended to increase insurance coverage by including better equipped doctors; effective outpatient treatments and recognizing and screening for substance use problems, so the patients can be referred for correct evidence-based treatment as and when required. This report also observes that for successful treatment of substance use in the military, one needs increased confidentiality and a shift in the cultural climate where drug problems should not be stigmatized or cause fear in people suffering from them.

Challenges Faced By Veterans: Stigma Attached To Substance Use Disorder

The stigma which is very much real associated with substance use disorder in veterans also prevents them from seeking treatment and even admitting to them having any problem of such kind.

The military also has hyper-masculine culture, which gives importance to self-reliance. It is this reason, which prevents the military veterans from seeking help and makes them want to resolve their problems, such as substance use disorder and other associated mental health issues on their own. They consider getting professional treatment for their mental health as a sign of “weakness” and “unmanly.” Other than this, the veterans also feel a need to “protect” their family or friends and they thinks this can be done by not sharing or telling anyone about their struggles.

Military culture also gives importance to toughness, teamwork and self-reliance. These same values, which are beneficial on one spectrum promote stigma on the other hand. Active military personnel will hesitate in seeking care, as they think this will interfere with their effectiveness and can also be fatal for their military career.

Some of the other concerns and challenges, which the veterans feel when seeking treatment for their substance use disorder and mental health care is the fear of being treated differently by military leadership; being seen as weak or incompetent; being held responsible for the problem, the embarrassment associated with it; others losing trust or confidence in them; and how it can affect their career

The Steps Taken Thus Far For Combating Stigma and Military Concerns

Changes have been initiated by The Department of Defense to reduce the stigma and to promote seeking treatment for substance abuse and mental health disorders. Some of the efforts include instructions for developing a supportive culture when it comes to getting help for mental health and substance use services. The importance of mental well-being was also recognized as a vital component of overall health, and divided assessments of whether the person is not “ready” or “unfit/ill” is now replaced with an increased diversity of supportive personnel and preparedness for service.

The Army has started training leadership on how to develop and encourage a supportive culture and to cut down on the stigma, along with developing psychological health care services available even in non-duty hours, along with providing educational material focusing on reducing stigma.

Establishment of Embedded Behavioral Health teams is also done to increase the number of mental health staff for fostering positive relationships with leadership and also encouraging patients to speak about mental health, and encouraging positive attitudes, when it comes to seeking treatment for substance abuse and mental health.

Military Pathways is another program, which is made to improve mental health via self-directed activities present in an online portal consisting of mental health education, self-assessments and referral to services.

Combat Operational Stress Control programs also comprise of substance abuse and mental health treatment providers into the preventative and fitness services of each unit.

The Real Warriors Campaign is another program, which provides educational materials about getting treatment for veterans, military service members and family members. Materials consist of highlighting the importance of mental health and educating that substance use and mental issues are not uncommon and getting help is actually a sign of strength not weakness. Seeking treatment will not end one’s career and the patient is not alone in their journey towards better mental well-being.

Treatment for Substance Use Disorder in Veterans

Veterans suffering from substance use and mental disorders can seek treatment, which is available via military health systems. The treatment consists of medicines and behavioral interventions. The treatment should be customized according to the specific patient and should include approved medication for veterans having nicotine, alcohol and opioid use disorders.

For treating opioid addiction, there are three FDA-approved medicines available for different individual needs.(12) Methadone and Buprenorphine are opioid agonists or partial agonists.(12) Naltrexone is an antagonist for treating opioid addiction, where it prevents the effect of the opioids on the brain. Recently, the Food and Drug Administration has approved a lofexidine, which is a medicine to help manage the withdrawal symptoms in patients who are trying to stop opioids use.(13)

Veterans should receive a combination of medications with behavioral therapy to achieve the treatment goals and to reconnect relationships with family and friends along with building good life skills.

The Veterans Health Administration also approves the treatment with these medications as the first-line treatment for opioid use disorder. However, even though these medicines are effective in treating substance use disorder, they are prescribed to less than 35% of Veterans Health Administration patients with a diagnosis of opioid use disorder.

Some of the challenges to using opioid agonist medication for treating substance use disorder in the Veterans Health Administration include stigma toward the patient population, lack of perceived patient interest, and the lack of education and understanding regarding the opioid agonist treatment.

Families having veterans or other family members suffering from opioid use disorders should find out about having naloxone at home, which is a medicine used for reversing an opioid overdose. This is an easy- to- use nasal spray which can be purchased from different pharmacies without needing any personal prescriptions.

Counseling for Veterans with Substance Abuse

Studies have shown that very few service members seek counseling linked with substance use disorder due to their refusal to accept the problem or from fear of the stigma attached to these problems in veterans. Behavioral interventions for treating and managing substance use disorder consist of cognitive-behavioral therapy. In the therapy, the aim is to identify and modify the maladaptive thoughts and behaviors, such as increased use, craving or relapse. For certain drugs, such as alcohol, opioids and tobacco, behavioral counseling helps along with the right medication therapy. Substance use disorder with other drugs, such as marijuana and cocaine do not have any approved medicines for treatment as of now, which means that behavioral counseling is the mainstay treatment. The military also gives free counseling services for substance and alcohol use disorders, such as smoking cessation support.

Additionally, there are various interventions and services available to reduce substance use disorder in veterans, which consist of pharmacological as well as behavioral treatments.

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