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A Guide to Addiction and Recovery for Veterans

Veterans and Addiction Article Summary

The trauma of combat, the physical pain of injuries, and the sense of disconnect in civilian life may lead many veterans to develop addiction. Many veterans are unwilling or unable to reach out for help due to a culture of toughness and a fear of discrimination, but treatment can provide veterans with hope and healing and it can help them begin working on their recovery.

Treatment can be inpatient or outpatient, depending on a veteran’s particular needs. It can consist of therapies that help the person manage cravings for drugs or alcohol and deal with mental health conditions such as PTSD.


What Causes Addiction in Veterans?

Those at greatest risk for the development of substance abuse problems are active military and veterans with multiple deployments, combat exposure, and injuries. Veterans can develop dependence on opioid pain medications given the serious nature of some of their injuries.7

Some common contributing causes of addiction in veterans are listed below.

Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) involves exposure to a traumatic event. Symptoms may include re-experiencing the event, avoidance of triggers, and hyper-arousal (fight-or-flight response). PTSD can increase the chances of developing an addiction because veterans may use alcohol and drugs to relieve the symptoms.
PTSD graphicOne study showed that PTSD is more prevalent among veterans returning from the Iraq war than the

general population, with 11.8% showing symptoms of PTSD soon after deployment and 16.7% experiencing PTSD at 6 months post-deployment compared to 3.5% among the general population.2

Deployed soldiers with combat experiences such as witnessing the death of a comrade, physical torture, and prolonged threat of death and injury are more vulnerable to PTSD compared with deployed soldiers without combat exposure, with one study claiming a 3-fold incidence of PTSD in the former.2

Veterans Diagnosed With PTSD and Addiction

Veterans diagnosed with PTSD and addiction have higher rates of substance-related relapses and related hospital admissions, more severe PTSD symptoms, shorter periods of being clean or sober (abstinence), and poor adherence to follow-up treatment.20

Sexual Assault

Sexual assault creates several kinds of pain. In addition to the trauma of the event, there is also the fear of bullying and rejection if the crime is reported.

Victims may feel that they will be perceived as weak in a culture that emphasizes strength, and they simply put up with the distress. Symptoms often worsen over time, so many military men and women may use drugs or alcohol to relieve the emotional pain.2

Female veterans report sexual assault or harassment at a rate of 10% to 30%, compared to 1% of male veterans.19

Traumatic Brain InjuryGraphic with percent of veterans with brain injury

Traumatic brain injury (TBI) is a traumatically induced disruption of brain functioning. It can lead to difficulties concentrating or remembering new information, dizziness, headaches, tiredness, sleep problems, and mood swings.37

The source of TBI for the majority of soldiers is a blast incident such as an improvised explosive device (IED). A RAND Corporation study of returning veterans found that 19.5% reported a probable TBI during deployment.4

Alcohol and drug use are known to increase the likelihood of TBI, but the reverse is also true for active-duty combatants. TBI increases the likelihood of problems with control and decision-making. Deficits in this area of the brain are associated with the development of addiction.2

Pain Medications for Injury

Men and women in military service are particularly vulnerable to dependence on and addiction to opioid drugs due to equipment-related or combat-related injuries.

Needing to maintain fitness for military service and not wanting to be left behind in the field, many of them “just suck it up” and don’t give the injury time to heal. This increases the need for more and more of the drug.

Alcohol Use During and After Deployment

Workplace culture in the military can be a risk factor for developing addiction. The culture allows heavy drinking and binge drinking, which increases overall consumption.5 Drug use has decreased with random drug testing begun in 1981, but binge drinking has increased. The military is trying to change this culture.18

Among military personnel, there is growing evidence linking combat stress and alcoholism. U.S. Reserve and National Guard personnel who have been exposed to combat in Iraq and Afghanistan are at higher risk of developing problems with alcohol.5

Among veterans seeking treatment, alcohol misuse (e.g., binge drinking) is very common, particularly among veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) (11.5%-35.4%), with the highest rates of alcohol misuse among those in the Army and Marines.17

Return to Civilian Life

A soldier can be in combat today and tomorrow be released into civilian life without a job. Many have trouble reintegrating back into society. They have spent years, even decades, assimilating into military culture, and it can be hard to make the shift into a less structured environment.

The lack of shared experience and understanding can create a divide between civilians and veterans. Veterans may turn to alcohol and drugs to cope with the isolation they feel.6

How Does Addiction Affect Those in the Military?

Addiction has numerous physical, psychological, and social consequences.It’s not just about dependence on a drug but also how drug use affects family, relationships, and physical and mental health.

    • One of the most common causes of incarceration for veterans is substance abuse/addiction.9 As of 2004, 46% of veterans in federal prison were there for violation of drug laws, and 61% of all incarcerated veterans met criteria for drug dependence/addiction.10
    • Health problems associated with drug use are HIV and hepatitis C, heart and lung disease, and liver disease.11 Chronic use of drugs can also lead to mental health problems such as depression, anxiety, paranoia, aggression, and hallucinations.38

Graphic of relationship between homeless vets and substance abuse

  • Many veterans struggling with PTSD and substance use are homeless. One review of the available research found that the most consistent risk factors for homelessness were substance abuse and mental health problems.12
  • Multiple deployments are associated with more emotional difficulties among children and spouses of veterans.1 When alcohol or other drugs are added to that dynamic, the results may be much more critical, given that children of addicted persons have higher rates of emotional and behavioral disorders as well as poor coping skills. Conflict with partners/spouses is more likely, as well as greater marital dissatisfaction.11
  • Addiction can cause greater absenteeism, loss of work productivity, more on-the-job injuries, and workplace violence. Eventually, these behaviors can lead to termination. Veterans’ skills in the military may not translate into civilian employment, and they may need further education and training. The use of alcohol and other drugs can compromise brain function needed to train for the transition to the civilian workforce.11
  • The suicide rate among male and female veterans exceeds the suicide rates in the civilian population. Veterans make up 20% of national suicides, with 22 veterans dying each day by suicide.40 PTSD and TBI are risk factors for suicide attempts, with one study asserting that veterans with these conditions should be closely monitored for suicidal behavior.14 Increased suicide risk from drug addiction appears to be greater among female veterans.15

What Are the Signs of Addiction and Mental Health Disorders?

Signs of addiction in veterans include:16

  • Lack of control over use.
  • Social or interpersonal problems caused by drug use.
  • Risky use, such as driving while impaired.
  • Cravings to use.
  • Continued use despite physical or psychological problems due to use.
  • Other activities are neglected in favor of drug use.
  • Tolerance (needing more to get the same effect).
  • Withdrawal (can include nausea, vomiting, seizure, anxiety, or irritability, depending on the drug).

PTSD Symptoms

Common signs of PTSD, following exposure to one or more traumatic events, include:16

Veterans with PTSD

  • Recurrent, involuntary, and intrusive distressing memories of the event(s).
  • Recurrent, distressing dreams relating to the event(s).
  • Flashbacks, in which the person feels or acts as if the traumatic event were re-occurring.
  • Intense reactions to internal or external triggers that remind the person of the event.
  • Avoidance of external and internal reminders (people, places, things, internal cues) of the event(s).
  • Inability to remember an important aspect of the event.
  • Feelings of detachment from others.
  • Diminished interest or participation in activities.
  • Inability to experience positive emotions.
  • Heightened arousal or reactions in response to the event, such as angry outbursts or self-destructive behavior.

Depression Symptoms

Symptoms of depression include:16

  • Lack of interest in most activities for most of the day, nearly every day.
  • Loss of appetite and weight loss, or increase in appetite and weight gain.
  • Not sleeping or sleeping more than usual.
  • Fatigue.
  • Feelings of worthlessness or guilt.
  • Trouble concentrating.
  • Thoughts of death and/or suicide.

Depression is more common in women than in men.16 About 2% to 15% of individuals with this disorder die from suicide. Those most at risk include people who are hopeless about the future, those just discharged from the hospital, and those who have a family history of suicide.39


How Can They Overcome Stigma and Get Help?

A significant number of military personnel, veterans, and their families seek help from community and state services rather than through the Department of Defense because of the stigma or lack of confidentiality attached to seeking help within the system. Many veterans believe that mental health or addiction treatment may impact their careers or the careers of their spouses.1

They may also be concerned that a diagnosis of substance abuse or PTSD will lead to stereotypes and problems finding employment, or they may not understand the types of treatment available or how treatment works. Some may simply think that they can take care of themselves or they will get better without help.

Given that addiction is a progressive illness, the cost of not seeking help can have a devastating impact on a veteran’s family and employment, as well as on their own physical and psychological health. Even though it takes a lot of courage to face combat, sometimes the greatest obstacle an addicted veteran may have to face is being able to admit that they have a problem and seek help.

What Treatment Approaches Are Used for Veterans?

In cases where the veteran has an addiction and a mental health disorder such as PTSD, both conditions must be treated for the person to fully recover. If the mental health disorder is not treated, the person is likely to relapse to self-medicate when symptoms of the mental health disorder return.

There is now wider understanding of the high incidence of trauma in both men and women in treatment for substance use disorders. This has resulted in the integration of trauma-informed care into addiction treatment.

Therapies

  • Cognitive behavioral therapy (CBT) focuses on recognizing thoughts and behaviors that cause problems in your life, restructuring the thoughts, and learning new behaviors.
  • Many programs incorporate meetings of 12-Step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These groups offer a step-by-step approach to recovery that involves surrendering to a higher power and working with a sponsor. Some programs use 12-Step facilitation therapy, in which a therapist helps a patient to accept the need for abstinence and surrender, and develop a desire to participate in the 12-Step program.24
  • Motivation enhancement therapy (MET) tries to help you find your own internal motivation to begin the process of change.
  • Prolonged exposure therapy helps you re-experience and engage with the reminders or cues of the trauma, rather than avoiding them. It is done in a safe way and in a safe place. It has been shown to reduce PTSD symptoms.25
  • Contingency management attempts to reduce substance use and minimize the impact of cravings by increasing the availability of alternative rewards, such as vouchers, which you receive for staying clean and sober.
  • Eye movement desensitization and reprocessing (EMDR) is an option for PTSD treatment. EMDR involves re-experiencing unpleasant memories or cues with the addition of eye movement exercises intended to reduce anxiety.
  • Couples counseling is intended for married or cohabiting couples. Its purpose is to build support for abstinence and to improve relationships.

Medications

A number of medications are used to treat alcoholism. They include the following:

  • Naltrexone (Vivitrol) aims to reduce alcohol consumption by blocking the pleasant or euphoric effects of alcohol.
  • Disulfiram (Antabuse) interrupts the process of metabolizing alcohol, making you feel very ill if you drink it.
  • Acamprosate (Campral) can reduce cravings, as well as reduce unpleasant effects of alcohol withdrawal.

Medication-assisted treatment (MAT) for addiction to opioids such as heroin or oxycodone includes the following medications, which are often combined with behavioral therapies:

  • Buprenorphine + naloxone (Suboxone) is a partial opioid agonist that helps with drug cravings but does not give you the “high” associated with full opioids, such as oxycodone. The naloxone remains inactive unless you try to dilute and inject the medication, at which point the buprenorphine is ineffective. It also blocks the effects of other opioids.
  • Methadone is a synthetic opioid, and it prevents symptoms of withdrawal and craving.
  • Naltrexone blocks the effects of opioids by attaching to the part of the brain stimulated by opioids.

Antidepressants are medications shown to be effective for the treatment of depression, and many of them have been shown to help reduce anxiety as well. They are not addictive substances, but they can have some uncomfortable side effects. Talk to a physician if you feel that a particular medication is not agreeing with you.

Here is a list of common antidepressant medications:

  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
  • Bupropion (Welbutrin)
  • Citalopram (Celexa)

What Kinds of Programs Are Available?

  • Inpatient treatment provides a high level of patient safety and supervision. These programs generally last from 30 to 90 days and include individual and group therapy, medical treatment as needed, education, and family support programs. One study of homeless female veterans found that residential/inpatient treatment can reduce psychiatric symptoms and improve employment, housing status, and social support, while increasing a sense of safety and stable living.31
  • Outpatient treatment may be a good option if you have a good support system at home and/or in your community. You attend treatment during the day while living at home. In some outpatient programs for veterans, trauma management therapy helps the veteran to practice skills in dealing with exposure to triggers.33
  • AA and NA meetings can be easily located in most communities. They foster social interaction and a spirit of welcome. In some areas, there are AA and NA meetings for veterans, where the need for social interaction with comrades can be met.
  • The Veteran Treatment Courts (VTCs) were created to address issues unique to U.S. veterans and, where possible, avoid punishing veterans for crimes that may have been committed as a direct result of their mental conditions (e.g., PTSD and addiction).34 A screening is done to assess eligibility. Normally, only those veterans with non-violent crimes and who are in need of mental health or substance abuse treatment may go to the treatment court.

How Do You Find a Program?

VA wait times for service can be extensive, and there is still a stigma in some areas around drug addiction/substance use disorder. Fear of discrimination and perceived confidentiality issues may prevent some veterans from seeking treatment.

Care is available in the private medical sector. Check with local providers about cost and insurance coverage. Outpatient programs are also available, and many programs will help through Medicaid or set up a payment plan.

In areas where there is not a VA facility within a reasonable distance, you may be able to seek private sector care, covered by the VA or by your employer.29


How Can You Stay Sober After Rehab?

Although some people with addiction are able to achieve long-term recovery after treatment without any assistance, for many people addiction is characterized by periods of being clean followed by relapse and re-entry into treatment.

The primary goal of aftercare programs is to help maintain and build on the successes made in treatment. Most aftercare programs consist of group therapy sessions and participation in self-help programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).

Self-help programs such as AA and NA are widely available in large and small communities, and people can attend for extended periods. These programs provide a supportive social network of people who do not use drugs, and they explicitly discourage drug use.35

Sober living homes or halfway houses are another aftercare option for people who are not ready to return to their living environment. The person lives with other people who have completed a rehab program and participates in recovery activities, such as attending support groups, looking for a job, or finding housing.


What Help Is Available for Families?

Addiction is a “family disease.” When one family member is addicted, other family members may adjust to the addiction through anger, disappointment, silence, workaholism, or fear.36

Rehab programs for veterans may offer the following options for family members:

  • Patient education about how addiction impacts the family.
  • Family education about the interplay between the family and addiction.
  • Family education about addiction, drugs of abuse, treatment, and recovery.
  • Family therapy sessions.
  • Participation in 12-step groups for families of persons with substance use disorders, such as Al-Anon and Nar-Anon.36

Most people are “coaxed” into treatment because of legal, family, or medical problems. In situations where family members feel helpless about getting through to their loved one, an intervention may be warranted. This is a professionally planned process in which family members lovingly yet firmly speak to the addicted family member about how addiction has affected them.36


Resources and Hotlines For Veterans

Resources and Hotlines For Families

  • VA Caregiver Support Program. This VA program offers support services for caregivers, such as a caregiver support line, medical in-home help for your loved one, and tips for managing medications and caring for yourself.
  • Al-Anon/Alateen/Nar-Anon. These support groups allow family members of alcohol/drug-addicted persons to share their “experience, strength and hope” in order to solve their common problems. Al-Anon is for families of alcohol-addicted people, Alateen for teenaged family members and friends of alcohol-addicted persons, and Nar-Anon for families of those addicted to other drugs.