Introduction to the Special Issue: Drugs, Wars, Military Personnel, and Veterans

Abstract

This special issue examines major structural, sociocultural, and behavioral issues surrounding substance use and misuse among US military personnel and veterans who served in recent military conflicts in Iraq and Afghanistan. This introduction provides a brief historical review of the US’s experiences of the linkages between war and substance use, misuse, and abuse. It then describes how the various topics covered in this issue span the military-veteran life course and explains the significance of each contribution.

In response to the September 11, 2001, destruction of the World Trade Center, the United States initiated a War on Terror. This initiative has resulted in extended wars taking place primarily in Afghanistan as Operation Enduring Freedom (OEF) and in Iraq as Operation Iraqi Freedom (OIF) and then Operation New Dawn (OND). As of January 31, 2013, 1,934,746 US military personnel had served 3,826,591 deployments as part of OEF/OIF/OND, with many individuals serving multiple deployments (N. Chistensen, personal communication, April 18, 2013). This special issue focuses on the impact of service and its aftermath with regard to substance misuse among military personnel and veterans. The thrust of the research presented here involves a US context, though the range of focuses, methodological approaches, research designs, and findings provide useful models of inquiry and hold implications for international audiences, including researchers, policy experts, and other stakeholders.

War and drugs have a long history of intimate association (Bergen-Cico, 2011; Courtwright, 2001). This use has often served to prepare military personnel for combat; to facilitate cultural bonding; and to cope with the physical and psychological impact of service, injury, and memory. Substance use has often led to misuse and problems affecting health, family functioning, employment, and criminal justice involvement. The nature and impact of drug use reveals both continuity and change as new substances emerged due to medical innovation and technological development. Alcohol and coffee were widely consumed during the American Revolution (1775–1783, Jahiel & Babor, 2007; Pendergrast, 2010), practices that increased dramatically in the years that followed, leading Rorabaugh (1979) to label the period the “Alcoholic Republic.” Indeed, following this war-related “incubation” period, alcohol use has remained common in the US military, with the military often complicit in perpetuating a masculine, hard driving, hard drinking culture (Barrett, 1996; Finley, 2011; Poehlman et al., 2011). During the US Civil War (1861–1865), morphine, especially delivered via the newly developed hypodermic syringe, was used widely to numb pain and assist in medical procedures for wounded soldiers (Courtwright, 2001). Indeed, the use of morphine, opium, and various patent medicines became widespread in America during the late 1800s and one of the primary groups of “addicts” was Civil War Veterans who initiated use during the conflict itself. Like alcohol use during the Revolution, the Civil War functioned as an incubator, of sorts, in this case propelling the use of opiates for both medical and recreational purposes. This dope fiends paradise eventually led to state-level and federal control of potentially dangerous medicines and other psychoactive substances now considered illicit (Musto, 1987). During World War II (1935–1945) and the Korean War (1950–1953), newly synthesized amphetamines were widely distributed to military personnel as pep pills (Bergen-Cico, 2011; Miller, 1997; Rasmussen, 2008). Many became dependant while in the service and continued use after the war. During the Vietnam War (1955–1975), heroin use and abuse became more common among military personnel to cope with the challenges of conflict in a setting of dislocation and devastation (Bennett & Golub, 2012; Bergen-Cico, 2011; Courtwright, 2001; Robins, 1974). As contemporaries observed, however, most military personnel ended any use of heroin within a few months of returning to civilian life as the context of on-going destruction changed (Robins, 1974; Robins, Davis, & Nurco, 1974; Zinberg, 1984).

Recent research suggests that the use and misuse of alcohol and prescription opioids (or POs such as OxyContin, Vicodin, and Percocet) are the signature substances associated with OEF/OIF/OND military personnel and veterans; for many, the consumption of these substances is causing additional challenges both for military personnel and veteran populations (Institute of Medicine, 2012). Other reports suggest that many military personnel use various substances such as Dexedrine, NoDoz, and Red Bull as “go pills” to maintain alertness and energy and substances including Ambien, Restoril, and benzodiazepines as “no-go” pills to come down, obtain needed sleep, and suppress anxiety (Bergen-Cico, 2011; Finkel, 2009; Golub & Bennett, forthcoming; Senior, 2011). Whether or not war functions as a type of drug incubator propelling to the larger society or rather a mere reflection of prevailing patterns of consumption in society at certain timepoints and places, it is clear that some service men and women emerging from the recent engagements in Afghanistan and Iraq endure lasting problems due to their use of drugs and alcohol. It is also clear that ongoing and wide-ranging research into understanding the relationship between military service, war, civilian readjustment, and drugs is needed.

This special issue advances current research on substance use and misuse among military personnel and veterans. A central theme that ties these works together is the social, structural, and behavioral components of these phenomena over the military-veteran life span. The contributions are grouped into several general domains: etiology and prevalence; the impact of military policy; and outreach and treatment. The first two articles examine etiology. Bray, Brown, and Williams, (2013) use data from the US Department of Defense’s (DoD) extensive Survey of Health Related Behavior (HRB) collected since 1980 to identify that heavy drinking and alcohol-related consequences among military personnel have increased substantially in recent years. Further regression analysis identifies that the increase is associated with having experienced heavy combat as part of OEF/OIF/OND. Golub and Bennett (2013) present an analysis of original data collected from a street-based sample of veterans using respondent-driven sampling (RDS). This is the first study to use RDS—an important methodological advance for obtaining general population estimates—to study a veterans population. This article finds that PO misuse among veterans most often started for medical purposes while deployed, but that most PO users did not misuse their medication. These findings suggest that the root of PO misuse is iatrogenic, but limited to a subset of those prescribed. Adams, Larson, Corrigan, Ritter, and Williams (2013) examine traumatic brain injury (TBI). TBI and alcohol problems have long been associated with each other; however, the nature and even direction of the relationship has been unclear. Adams et al. found that military personnel who experienced a severe TBI involving loss of consciousness for at least 20 minutes (but not those experiencing less severe TBIs) were more likely to experience alcohol-related problems, even after controlling for the amount of alcohol they drank. These findings provide insight into the larger mental health pathway to alcohol-related problems for some military personnel.

Miech, London, Wilmoth, and Koester (2013) look at changes in military policy with regard to the use of hallucinogens. These drugs had been widely associated with the psychedelic experiences of the 1960s in the United States and with Vietnam War Era military personnel. During the 1980s, the US military implemented a zero-tolerance policy for illegal drugs. The creative and thorough age-period-cohort analysis strongly suggests that the policy was effective and that the military’s policy led to a life-long reduction in hallucinogen use among those who served. Heslin, Guerrero, Mitchell, Afable, and Dobalian (2013) examine an important possible consequence of substance misuse and the unsanitary conditions that military personnel often face that can lead to infection with the hepatitis C virus (HCV). They find that HCV infection in veterans is associated with various other readjustment challenges such as homelessness and mental illness. They also identify that HCV was more common among Vietnam era veterans.

Two articles examine untreated need for a substance use disorder (SUD). Larson et al. (2013) describe an extensive database they have assembled linking data collected at multiple points within the military system. This article describes this important resource and type of analyses that will be supported. Their initial analysis identifies that postdeployment rates of frequent binge drinking and alcohol-related problems are substantial. The article discusses the importance of early postdeployment intervention for alcohol use disorder (AUD) and how the data they are integrating from multiple sources will provide greater insight into unmet need and use of follow-up services. Vazan, Golub, and Bennett (2013) examine the treatment need among veterans in a general population sample. They find that AUD was quite common and that more than four fifths of these veterans with AUD were not receiving treatment. Both of these articles suggest that there is substantial need for alcohol misuse outreach programs.

Several articles examine various outreach programs in different contexts. Walton et al. (2013) describe efforts to address untreated SUD head on with their Warrior Check- Up Program. Some of the key lessons they learned in developing their marketing campaign were to keep the outreach low pressure (i.e., a checkup), assure nonjudgmental confidential services, and connect with the viewer by honoring their service and suggesting that they can be a good soldier even though they may need help. Bennett, Elliott, and Golub (2013) present qualitative data that highlight the pressing need for overdose prevention and response interventions for those veterans who use POs. They also illustrate the challenges to prevention efforts and barriers to help-seeking many veterans face, in the veterans’ own words. The article also describes ongoing efforts to respond to this problem and ways to advance these programs further. Slattery, Dugger, Lamb, and Williams (2013) present efforts to holistically address the complex of some veterans’ problems through veterans courts, a criminal justice diversion program. Initial findings identify positive and sustained improvement in mental health, substance use, and social integration.

The research presented in the special issue represents current dogged scholarly effort aimed at advancing the knowledge pool and crafting useful interventions regarding an exceedingly large and complex problem. It has been our great pleasure working with all of the contributors to collectively produce this special issue. All of the contributors are involved in ongoing research seeking to address substance misuse and its associated health and other consequences among US military personnel and veterans. We expect more important work, policy, and prevention programs to derive from all of the research represented here. Most importantly, we hope that our work individually and collectively will contribute to effective and cost-effective measures to help address the complex substance-misuse-related problems military personnel and veterans face.

Biographies

Andrew Golub, Ph.D., is a Principal Investigator at the NDRI. He received his Ph.D. in public policy analysis from Carnegie Mellon University in 1992. His work seeks to improve social policy and programs through research. His studies have examined trends in drug use; the larger context of use; causes and consequences of use; and the efficacy of policies and programs as well as associated issues related to violence, crime, policing, poverty, and families. Dr. Golub is currently the Principal Investigator of the Veteran Reintegration, Mental Health and Substance Abuse in the Inner-City Project funded by NIAAA (National Institute on Alcohol Abuse and Alcoholism) that examines the challenges faced by veterans returning from Afghanistan and Iraq to New York’s low-income predominately minority neighborhoods. This mixed methods study focuses on the significance of substance misuse and its relationship with other mental health problems and reintegration into family, work, and community life within the complex of problems prevailing in low-income communities.

Dr. Alexander S. Bennett, Ph.D., is a Principal Investigator at the National Development and Research Institutes, Inc. (NDRI). He received his Ph.D. in history and policy from Carnegie Mellon University in 2009. His current work focuses on veterans, overdose prevention and response, and drug use and misuse more broadly. He started work on overdose prevention and outreach services in 2002 with Prevention Point Pittsburgh, an early model for many of the overdose prevention programs that came later. Dr. Bennett continued this work on substance misuse and overdose prevention and response both in an academic and community-based setting doing research, needs assessment, program development, service delivery, and evaluation work. Dr. Bennett currently serves on the Board of Directors of the New York Harm Reduction Educators. In 2012, Dr. Bennett organized a Community Advisory Board (CAB) that includes diverse New York City organizations with a common purpose of addressing veterans substance misuse that include veterans groups, public health agencies, drug treatment providers, academic researchers, and advocacy groups. This CAB promotes awareness and personal connection between organizations and veterans, facilitates information exchange, and supports collaboration across agencies on local initiatives.