The U.S. could face a wave of addiction and mental-health problems among returning veterans of the Iraq and Afghan wars greater than that resulting from the Vietnam War, according to experts at the recent Wounds of War conference sponsored by the National Center for Addiction and Substance Abuse (CASA*) at Columbia University (Join Together is a project of CASA).
Rather than the heroin addictions many Vietnam veterans brought back with them from Southeast Asia, however, today's returning soldiers are more likely to be addicted to prescription medications -- the very opiates prescribed to them by the military to ease stress or pain -- or stimulants used by soldiers to remain alert in combat situations.
"I think there's a lot more [soldiers addicted to] pharmacological opiates than the data show," said John A. Renner Jr., M.D., associate professor of psychiatry at the Boston University School of Medicine and associate chief of psychiatry at the U.S. Department of Veterans Affairs (VA) Boston Healthcare System. "A lot of them were using opiates before they went, and a lot are reporting that opiates are freely available in combat areas."
Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA), noted that while many soldiers receive prescription opiates for traumatic injuries and pain, the drugs also are effective in relieving stress. "So, even if you don't take it for that, it will work," she said.
Prescription drug abuse may be a top concern among conference participants, but experts noted that excessive drinking remains a huge problem among soldiers, sailors and airmen despite being banned from combat zones in Muslim countries.
Historically, substance abuse has "not only been present but fostered by the military," said keynote speaker Jim McDonough, a retired U.S. Army officer and former strategy director at the White House Office of National Drug Control Policy. "At Agincourt, the Somme and Waterloo, soldiers got liquored up before combat ... There's been almost no break in that [tradition] today."
In the U.S., "drinking heavily was part of military culture until the mid-1980s, when we had a series of reforms that just pushed it underground," said McDonough. "The Officer's Clubs closed, but that moved the drinking into the homes and private parties."
A recent study found that 43 percent of active-duty military personnel reported binge drinking within the past month, and researchers say that returning veterans of the Iraq and Afghan wars are at especially high risk of binge drinking and suffering alcohol-related harm.
"There's nothing new under the sun with the current experience except that the nature of the substances is different," McDonough said.
Long Tours a Major Source of Stress
Panelists at the May 20 conference, held at CASA's conference center in New York, said that while combat may have been more intense in Vietnam, tours of duty were limited. Soldiers in Iraq and Afghanistan, by contrast, often have served multiple tours in combat areas, with extended periods of time away from family and home.
"In the history of the Republic, never has so much been placed on the shoulders of so few for so long," said Brigadier General Loree K. Sutton, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, part of the Defense Department's Military Health Systems. As a result, she said, "We have no reference population" to compare with the addiction and mental-health problems facing today's military personnel.
Unsurprisingly, the strains on the system have led military commanders to "get men back in the fight" rather than confronting addiction and mental-health problems in the ranks, said McDonough. "Between 2004 and 2006, the incidence of substance abuse went up 100 percent, while treatment referrals by commanders went up zero percent," he said.
Renner predicted that the rate of Post Traumatic Stress Disorder (PTSD) "will be much higher than in Vietnam."
"We knew in Vietnam that the limit was one year [in combat] if you wanted to avoid PTSD," he said. "Now, with tours of 18 to 24 months, we should expect a higher level of problems."
Gen. Sutton noted that the military has ended the "stop-loss" policy of involuntarily retaining personnel in the service beyond the end of their enlistment. "In terms of tour length, tour repetition, and dwell time in between we are moving in the right direction, but we know that 12-15 months in combat takes its toll," she said.
News from Home Can Help and Hurt
The Internet and cell phones may help keep soldiers more in touch with the home front than in past wars, but access to instantaneous communication also can be a double-edged sword, experts said. Gulf War veteran and Texas Tech psychology professor M. David Rudd, Ph.D., said that today's soldiers are more exposed to family-related stress over finances, children, and other issues. Robert Bazell, chief medical correspondent for NBC News and a conference panel moderator, said its "definitely not a de-stressor" when soldiers chat online with family members who may be terrified about harm coming to those serving in combat.
Nor does short-term leave do much to alleviate problems like addiction or PTSD, especially among those with underlying drinking problem who come from an essentially alcohol-free zone back to home communities with a bar or liquor store on every corner.
"I'm hearing from returnees that, 'If I'm going to be home for two weeks then I'm going to be drunk for two weeks,'" said Rudd. Added Fred Gusman, executive director of the California Transition Center for Care of Combat Veterans: "Young wives tell us all their husband wants to do is come home, have sex, eat pizza and drink beer."
Many soldiers return to their families with an array of problems that make it very difficult for them to pick up their old lives and reintegrate with civilian society. Addiction and exposure to traumatic incidents literally cause changes in the brain, experts note, so it's not surprising that family members often say that their loved ones are different people when they return from combat. "They've been trained to get the mission done and not to have feelings, because that gets you killed," said Monica Martocci, clinical director of New Directions, a Los Angeles based program for troubled veterans and their families.
"They've done and witnessed terrible things, and can't talk to anyone about it," said Martocci. "They are supplied with meds while in the military, so they don't know they have a problem ... a lot don't realize they need meds to function until they get home."
Martocci noted that many soldiers are barely out of their teens when they return from combat. "They go from high structure to none -- some can't even write a check," she said. Long separation from spouses and children can cause estrangement, and young veterans face the highest risk of problems because they are the most likely to misuse alcohol and other drugs, least experienced in dealing with the stress of being parents and running a household, and reluctant to reach out to professionals or even fellow veterans for help.
Conference panelists said that the VA and other healthcare providers need to engage the families of servicemembers in getting those who need help into treatment, as well as providing support and counseling for families dealing with a veteran who comes home with addiction and mental-health problems.
Stigma, Fear for Career are Barriers
Returning veterans are screened for addiction and mental-health problems like PTSD, but many soldiers are reluctant to admit to problems out of fear that disclosure will affect their careers inside and outside the military, experts said. In many cases, "The reality is that if you come forward and get help ... it will be in your record," said Gen. Sutton.
Most soldiers who get treatment "get better" and return to duty, Gen. Sutton said. On the other hand, "It you have a problem and don't get intervention, I can promise you things won't go well for as well for your career as they could," she added.
However, Defense Secretary Robert Gates recently approved policy reforms that allowed soldiers to answer "no" when asked about past mental-health treatment episodes if they were related to combat stress and certain other circumstances. "That's an important step forward," said Gen. Sutton. "... We're on a journey, but we haven't gotten to the promised land yet."
Female Vets Face Special Challenges
Female soldiers are technically barred from serving in most combat-related positions, but in conflicts like Iraq and Afghanistan there are no real front lines, and women often come under fire and face the existential threat of roadside bombings alongside their male colleagues.
Women also have reported high rates of sexual abuse and rape while in combat areas, but are often reluctant to report incidents to male superiors. "Many prefer to live with the trauma than the address it," said Alexander Neumeister, M.D., associate professor of psychiatry at Yale University and the VA Connecticut Healthcare System.
The combination of combat stress and abuse puts women at particularly high risk of PTSD and drug problems, according to panelists. Yet some are so traumatized by their experiences that they won't even identify themselves as veterans.
Noting that only 1/4 to 1/3 of veterans ever seek help from the Veterans Administration, panelists called on the VA to do more outreach to returning veterans and to increase spending on treatment, noting that only about one-third of soldiers needing addiction or mental-health care actually get help.
"Many veterans feel better about coming to an office in a strip mall or a private-practice office than to a VA hospital," said Martocci. The prospect of going to the VA -- which is "full of men in uniform" -- is particularly difficult for female veterans who have been sexually abused, added Martocci.
"It's a national disgrace how un-barrier-free access to early intervention services is in the VA" and the Defense Department's TriCare program, said McDonough. "There's a perfect storm of bureaucracy that prevents soldiers from getting any services."
Panelists also called on military leaders to break down the stigma surrounding addictions and mental illness among service members. "The top-level brass is saying the right things, but it takes time to filter down," said Gusman.
Tours of duty also need to be limited to limit the stress on soldiers and their families, many panelists agreed. "We need to start there," said Neumeister.
* The National Center on Addiction and Substance Abuse at Columbia University is neither affiliated with, nor sponsored by, the National Court Appointed Special Advocate Association (also known as "CASA") or any of its member organizations with the name of "CASA."
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