Substance use disorders (SUDs) are prevalent in the Iraq and Afghanistan military personnel populations, with an estimated 20% of active duty personnel misusing substances, particularly alcohol and prescription drugs (Armed Forces Health Surveillance Center, 2009; Eggleston et al., 2009; Milliken et al., 2007).  Using a two-item screen for alcohol misuse 3-4 months post deployment, researchers found that 27% of Army soldiers screened positive for alcohol misuse.  Those who screened positive were more likely to have engaged in drinking and driving, riding with a driver who had been drinking, reporting late or missing work, using illicit drugs, referred to alcohol treatment, and receiving a DUI (Santiago et al., 2010). Wilk and his colleagues (2010) reported similar results with 25% screening positive for alcohol misuse 3-4 months post deployment.

Pre-deployment data indicate that an estimated 9% of the reserve components (i.e., Reserve and National  Guard) engage in heavy weekly drinking, 53.6% engage in binge drinking, and 15.2% report at least one alcohol-related problem.  New onset rates for active duty personnel were 8.8%, 25.6%, and 7.1% respectively.  Those who were deployed and exposed to combat were significantly more likely to experience new-onset heavy drinking, binge drinking, and alcohol-related problems yet few were referred for alcohol treatment (Jacobson et al., 2008.  At highest risk were the youngest service members (AFHSC, 2009; Bray et al., 2009; Jacobson et al., 2008).  Factors associated with risky alcohol use included early initiation of alcohol use, tobacco use, household alcohol use or mental illness, and childhood sexual or emotional abuse (Young et al., 2006).  In a study of 350,000 Iraq and Afghanistan War Veterans, 16% received a provisional diagnosis of non-dependent alcohol or other substance abuse, 4% of alcohol dependence, and 2% of other substance dependence (Eggleston et al., 2009).

The evidentiary strength of the relationship between SUDs and mental health problems experienced by wartime combatants is growing.  Researchers have found a high correlation between substance misuse and post-traumatic stress disorder (PTSD) and other psychological disorders in service members that have been deployed (Jacobson et al., 2008).  When substance misuse is combined with PTSD (prevalence rates of 13-22%), negative consequences such as psychosocial impairment, aggression, spousal abuse, child maltreatment, impaired driving, accidents, compromised work performance, legal problems, and suicidal ideation may occur (Gibbs et al., 2008; Milliken et al., 2007).  In a sample of Iraq and Afghanistan War Veterans presenting for post-deployment Veterans Affairs (VA) health care, veterans who screened positive for PTSD or depression were twice as likely to report alcohol misuse than those who did not screen positive for these disorders (Jakupcak et al., 2010).  Furthermore, certain types of combat experiences were more strongly related to alcohol misuse and related problems. For example, personnel exposed to combat events in which they feared being killed or injured were more likely to report alcohol misuse after deployment. Those who witnessed atrocities, such as brutal treatment of non-combatants, were more likely to report post-deployment behavioral problems related to alcohol misuse.

BEST PRACTICES

While current pre-deployment and post-deployment screenings may help detect alcohol misuse among military personnel, data suggest a need to improve the referral process. In a routine post-deployment assessment of over 80,000 troops returning from Iraq, 12% of active-duty members and 15% of reserve components met screening criteria suggestive of alcohol misuse on the PDHRA. However, of those identified, only 0.2% of active duty and 0.6% of reserve components were referred for further substance abuse evaluation and treatment (Milliken et al., 2007).  Given these findings, it is important to develop more sensitive screening programs to identify possible alcohol and other drug misuse among those who return from combat deployment.  Also, providers must be sensitive to issues related to confidentiality as federal law allows military command to access health records of active duty and reserve components without consent and may serve as a barrier to engaging them in treatment.  Finally, any effective program with this vulnerable population should tailor intervention strategies based on the specific types of pre-deployment issues, wartime experiences, and post-deployment adjustment problems suffered by service members.

The VA/DoD Clinical Practice Guidelines include specific evidence-based practices for the screening, assessment, and treatment of  substance use disorders (SUDs) (http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp).  The SUDs guideline consists of the following five modules:

• Module A: Screening and Initial Assessment for Substance Use includes screening, brief intervention, and specialty referral considerations.
• Module B: Management of SUD in Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or who are seeking remission.
• Module C: Management of SUD in General Healthcare (including primary care) emphasizes earlier intervention for less severe SUD, or chronic disease management for patients unwilling or unable to engage in treatment in specialty SUD care or not yet ready to abstain.
• Module P: Addiction-Focused Pharmacotherapy addresses use of medication approved by the Food and Drug Administration for the treatment of alcohol and opioid dependence.
• Module S: Stabilization and Withdrawal Management addresses withdrawal management including pharmacological management of withdrawal symptoms.

According to the guideline, “each module consists of an algorithm that describes the step-by-step process of the clinical decision making and intervention that should occur in the specified group of patients. General and specific recommendations for each step in the algorithm are included in the annotations following the algorithm. The links to these recommendations are embedded in the relevant specific steps in the algorithm.  Each annotation includes a brief discussion of the research supporting the recommendations and the rationale behind the grading of the evidence and the determination of the strength of the recommendations.  Tobacco use should be addressed in all patients and is a major cause of morbidity and mortality among patients with non-nicotine SUDs. For management of nicotine dependence, refer to the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services (http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf) and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use (http://www.healthquality.va.gov/Management_of_Tobacco_Use_MTU.asp).”

SELECTED REFERENCES

Armed Forces Health Surveillance Center.  Alcohol-related medical encounters, active components, U.S. Armed Forces, January 2006-December 2008.  MSMR.  2009;16(5):6-9.

Bray RM, Pemberton MR, Hourani LL, Witt M, Rae Olmstead, et.al. RTI International. Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. http://www.tricare.mil/tma/ddrp/documents/2009.09%202008%20DoD%20Survey%20of%20Health%20Related%20Behaviors%20Among%20Active%20Duty%20Military%20Personnel.pdf. Published September 2009. Accessed August 14, 2010.

Elbogen EB, Wagner HR, Fuller SR, Calhoun PS, Kinneer PM, Mid-Atlantic Mental Illness Research, Education, and Clinical Center Workgroup, Beckham JC.  Correlates of anger and hostility in Iraq and Afghanistan war veterans.  American Journal of Psychiatry.  2010;167(9):1051-8.

Gibbs DA, Martin SL, Johnson RE, Rentz ED, Clinton-Sherrod M, Hardison J.  Child maltreatment and substance abuse among U.S. army soldiers.  Child Maltreatment.  2008;13(3):259-68.

Jacobson IG, Ryan MAK, Hooper TI, Smith TC, Amoroso PJ, Boyko EJ, Gackstetter GD, Wells TS, Bell NS. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA. 2008;300(6):663-675.

Jakupcak M, Tull MT, McDermott MJ, Kaysen D, Hunt S, Simpson T.  PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care.  Addictive Behaviors. 2010;35(9):840-3.

Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.  JAMA. 2007;298(18);2141-2148.

National Institute on Drug Abuse.  Principles of drug addiction treatment.  Second edition.  May 2009.

Santiago PN, Wilk JE, Milliken CS, Castro CA, Engel CC, Hoge CW.  Screening for alcohol misuse and alcohol-related behaviors among combat veterans.  Psychiatric Services. 2010;61(6):575-81.

Stahre MA, Brewer RD, Fonseca VP, Naimi TS.  Binge drinking among U.S. active-duty military personnel.  American Journal of Preventive Medicine.  2009;36(3):208-17.

Wilk JE, Bliese PD, Kim PY, Thomas JL, McGurk D, Hoge CW.  Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war.  Drug and Alcohol Dependence. 2010;108:115-121.

Young SYN, Hansen CJ, Gibson RL, Ryan MAK.  Risky alcohol use, age at onset of drinking, and adverse childhood experiences in young men entering the US Marine Corps.  Archives of Pediatric and Adolescent Medicine.  2006;160:1207-14.