Veteran Substance Use Dependence and Department of Veterans Affairs Rehabilitation Options

By Summer 2020 M-VETS Student-Advisor Cameron Williams

Military veterans have struggled trying to overcome substance use disorders (SUDs) for over two centuries of American conflicts. Beginning after the Revolutionary War soldiers consumed two substances we consider relatively benign today, alcohol and caffeine[1]. After the Civil War, many veterans were addicted to medications and drugs such as morphine and opium, with many of the veterans’ first contacts with the drugs occurring during the war[2]. This movement continued during both World War II and the Korean War, as many veterans returned home addicted to amphetamines given to them as “pep pills” to reduce soldier fatigue[3][4]. During the Vietnam War, many veterans returned addicted to heroin and alcohol[5]; and during the most recent conflicts in the Middle East, many veterans have returned with addictions to both prescription opioids and alcohol[6]. As part of the Department of Veteran’s Affairs (VA) mission is “to care for him who shall have borne the battle”, helping veterans overcome their addictions is of primary concern to the military.

The Diagnosis and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recognizes SUD in ten different categories of drugs[7]. SUD can manifest itself in eleven different ways[8]. For all categories of drugs, a patient that shows two to three symptoms has mild SUD, a patient that shows four to five symptoms has moderate SUD, and a patient that shows six or more symptoms has severe SUD.

Determining the prevalence of SUDs in veterans is difficult. Prior to the DSM-5’s release in 2013, the VA used The International Classification of Diseases, Ninth Revision (ICD-9) to determine if a veteran had SUD. Studies that use the DSM reported higher rates of veterans suffering from SUD than VA backed studies that used the ICD-9 Criteria for the disorder[9]. Additionally, because not all veterans utilize all VA healthcare options, there are more than likely veterans who are suffering in silence[10].

Approximately 11% of veterans diagnosed by the VA meet the criteria for a SUD diagnoses using the DSM-5.[11] The most common substances that cause young[12] veterans to have SUD are alcohol and tobacco. Though veterans mainly struggle with SUD for legal substances, veterans struggle with illicit drug use as well, with 29% and 38% of young male and female veterans respectively using illicit drugs[13]. The primary illicit drug used by veterans is cannabis, and from 2002 to 2009 cases of cannabis use disorder increased by over 50%[14].

Opioid abuse is also rising for veterans. In 2009, 24% of veterans utilizing VA health care had a prescription for an opioid[15]. 4.5% of young veterans use opioids for at least six months, and over 17% of veterans diagnosed with Post Dramatic Stress Disorder also have a prescription for opioids[16]. With research suggesting people with mental health disorders (MHD) are more susceptible to SUD, the number of veterans with MHD receiving prescriptions for opioids is troubling.

The structure and demographics of the military leads to veterans developing SUDs. SUDs generally occur more in young males, which is a demographic that makes up a significant portion of the military[17]. Environmental stressors that are occur in the military have also been shown to increase the risk for development SUDs among veterans, including deployment, combat exposure, and reintegration challenges[18].

The military has realized since the Vietnam War that SUDs were problematic for veterans, and since the 1970’s the Department of Defense (DoD) has released several directives to help servicemembers with substance issues[19]. Though the DoD has released these directives, the implementation of the directives has been haphazard. Discipline for alcohol abuse and drug abuse is handled differently, there is no standardization for the directives from the DoD, and the policies are not fully informed by scientific evidence for finding and treating SUDs[20].

The VA offers over two hundred treatment programs across the country for veterans to receive help for SUDs[21]. The Warrior Check-Up program is one such program, where low-pressure tactics are used to reach out to veterans who believe they may have a SUD[22]. Additionally, the VA encourages veterans to use groups such as Alcoholics Anonymous and Narcotics Anonymous[23]. Though the VA makes these efforts, one could argue they could do more to find servicemembers and veterans with SUDs. Four fifths of veterans who have a SUD with alcohol do not receive treatment for their SUD[24].

For veterans that receive treatment for SUDs through the VA, the VA provides two main types of treatment. For alcohol or opioid based SUDs, the VA offers psychotherapy treatment[25]. For this treatment, the VA uses short-term cognitive treatment to determine behaviors that increase the use of the substances[26]. The VA offers this treatment both in person and online, and it has been proven to lower drinking rates for veterans who suffer from alcohol-based SUD[27]. The VA also offers pharmacotherapy treatment for some veterans who suffer from SUDs[28]. When using pharmacotherapy treatment, the VA prescribes medications to veterans who suffer from withdrawal symptoms of alcohol and opioids, as well as medications that can decrease cravings[29]. Pharmacotherapy is done in conjunction with psychotherapy treatment[30]. Besides psycho- and pharmacotherapy. The VA also offers veterans the Alcohol and Drug Dependence Rehabilitation Program. This program provides veterans with intensive outpatient treatment, residential treatment, medically managed detoxification, or relapse prevention depending on the veteran’s needs[31].

Between the demographics of the military and military stresses, veterans experience SUDs at a higher rate than the general population. The VA and DoD recognize these issues that veterans deal with, and over the past decades have been making strides to help veterans and servicemembers overcome these lifelong issues. Though there are still improvements to be made to the programs, one can hope that eventually the DoD will be able to find a solution to help all veterans that suffer from dependence issues after serving the country.

[1] See Andrew Golub & Alexander S. Bennett, Introduction to the Special Issue: Drugs, Wars, Military Personnel, and Veterans, in PMC 2013 Nov. 3, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3815474/.

[2] Id.

[3] Id.

[4] This trend continues today, as the military has approved the use of Modafinil, a drug which works similar to amphetamine.

[5] Golub.

[6] Golub.

[7] The ten categories are alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances.

[8] The eleven symptoms of SUD are: 1) Taking the substance in larger amounts or for longer than you’re meant to; 2) Wanting to cut down or stop using the substance but not managing to; 3) Spending a lot of time getting, using, or recovering from use of the substance; 4) Cravings and urges to use the substance; 5)Not managing to do what you should at work, home, or school because of substance use; 6) Continuing to use, even when it causes problems in relationships; 7) Giving up important social, occupational, or recreational activities because of substance use; 8)Using substances again and again, even when it puts you in danger; 9) Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance; 10) Needing more of the substance to get the effect you want (tolerance); and11) Development of withdrawal symptoms, which can be relieved by taking more of the substance.

[9] Jenni B. Teeters, et al., Substance Use Disorders in Military Veterans: Prevalence and Treatment Challenges, Substance Abuse and Rehabilitation, 30 Aug. 2017 at 70.

[10] Id.

[11] Id.

[12] Under 25 years old.

[13] Teeters at 70.

[14] Id.

[15] Id. at 71.

[16] Id.

[17] Id. at 70.

[18] Id.

[19] Institute of Medicine, Substance Use Disorders in the U.S. Armed Forces Summary, https://www.ncbi.nlm.nih.gov/books/NBK207266/

[20] Id.

[21] Todd H. Wagner et al., Prevalence of Substance Use Disorders Among Veterans and Comparable Nonveterans from the National Survey on Drug Use and Health, 2007 Psychological Services Vol. 4, Number 3, at 149.

[22] Golub

[23] Teeter at 72.

[24] Golub

[25] Teeter at 72.

[26] Id.

[27] Id.

[28] Id.

[29] They cannot offer this treatment for cocaine or marijuana-based SUDs because there is no FDA approved treatment for these SUDs.

[30] See Teeter at 72.

[31] US. Department of Veteran Affairs, https://www.mentalhealth.va.gov/res-vatreatmentprograms.asp (last visited Aug. 22, 2020).