How Substance Abuse Research - Military Personnel, Veterans & Their Families: is Effecting Positive Change
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Military Personnel, Veterans & Their Families:
How Substance Abuse Research
is Effecting Positive Change
Wilson M. Compton, M.D., M.P.E., M.D.
Director, Division of Epidemiology, Services and Prevention Research
National Institute on Drug Abuse
Research Shows that Social Stressors Can Have
Profound Effects on Illicit and Licit Drug Use
1. Facilitate
Initiation
2. Increase Risk
of Addiction
3. Trigger Relapse
Iraq and Afghanistan Wars
• Since September 11, 2001, more than
two million service members have
deployed to Iraq and Afghanistan
• Many of these service personnel have
or will experience multiple deployments
• A high number of military personnel survive severe injuries
that in previous wars would have resulted in death
• Long deployments and intense combat conditions require
optimal support for the emotional and mental health needs
of our service members and their families
IOM (Institute of Medicine). 2010. Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members,
and Their Families. Washington, DC: The National Academies Press.
Combat Exposure Is the Key Driver of
Mental Health Problems Across Outcomes
Soldiers who report high levels of combat are significantly more
likely to screen positive for acute stress (PTSD symptoms)
80
Stress Score
70
Score
60
Stress
50
Acute
40
Acute
30
20
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Number of Combat Experiences
Number of Combat Experiences
Adapted from presentation by: MAJ Jeff Thomas, Walter Reed Army Institute of Research.
Research Shows that Social Stressors Can Have
Profound Effects on Illicit and Licit Drug Use
Who else is affected?
Spouses
Families
Communities
Complexities Regarding Substance Use
in the Military
• Typical problems related to illicit drug use
• Compounded by zero tolerance regarding illicit drug use
– Possibility of discharge
– Reduced confidentiality of medical records
• Potential consequences of treatment on military career
• Stigma related to treatments for drug abuse
Weinick RM, et al. Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families.
Santa Monica: RAND Corporation, 2011.
IOM (Institute of Medicine). 2012. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press.
Substance Use, Past 30 Days,
DoD Services: 1980 -- 2008
100
Heavy Alcohol Use
Any Cigarette Use
80 Any Illicit Drug Use Including Prescription Drug Misuse
Any Illicit Drug Use Excluding Prescription Drug Misuse
Percentage
60
40
2005 & 2008
20 survey had
question
change
0
1980 1982 1985 1988 1992 1995 1998 2002 2005 2008
Year of Survey
Source: RM Bray, et al., 2008 Department of Defense Survey of Health
Related Behaviors Among Active Duty Military (Published Sept. 2009)
Smoking in Military Personnel
• Smoking rates are higher in the military
than in the general population (32.2%
vs 24.9% in 2005).
Bray & Hourani. Addiction 2007;102:1092-1101; NSDUH, SAMHSA.
• $130 million are spent annually by the
military on excess training alone due to
smokers that are prematurely
discharged. Klesges et al., 2001, Tob Control, 10, 43-47.
• Service members who smoke have
lower fitness levels and are at greater
risk for physical injury.
Smoking has been shown to be a coping mechanism
for those exposed to stress. Smith et al., Am J Preventive Medicine 2008.
Excessive Alcohol Drinking & Related Harms
are Common Among Military Personnel
35
Non-binge 1-2 episodes
Binge 3+ in year 3 or more episodes
30 Binge 1-2 in year
43.2% of
Non- binge
active duty Percent 25
military
reported at 20
least one 15
episode of
binge drinking 10
in the past
5
month vs
26.1% for 0
Worked below
comparable Didn’t get
promoted
Got into fight,
hit someone normal
Drinking and
driving
age civilians performance level
Risk Behavior/Consequence
N=16037, anonymous self-administered survey. Source: Stahre, MA et al. (2009) Am J Prev Med , 36(3):208-217.
Standardized Comparisons of Civilians and
All Services “Heavy Alcohol Use”
By Age Group, 2008
100
All Services Civilian
80
Percentage
60
40
26*
20 20*
16 18*
14
11 10 8 9
0 4*
18-25 26-35 36-45 46-64 All Ages
Age GroupIllicit Drug Use in Past 30 Days
3 2002
Any Illicit Drug Use
Including Prescription 5 2005
Drug Misuse
12 2008
Any Illicit Drug Use 2
Military physicians wrote nearly 3.8 million
Excluding Prescription 2
Drug Misuse prescriptions for pain medication in 2008,
2 more than quadruple the number of such
prescriptions written in 2001.
2
Any Prescription
Drug Misuse 4
11
0 10 20 30
Percentage
Source: DoD Survey of Health Related Behaviors Among Military Personnel, 2008.Use of Illicit Drugs, Past 30 days, DoD Services: 2002,
2005, 2008
Prescription
Drugs
Source: RM Bray, et al., 2008 Department of Defense Survey
of Health Related Behaviors Among Active Duty Military
(Published Sept. 2009)New-onset PTSD Symptoms or Diagnosis
7.6% - 8.7% deployed with combat
1.4% - 2.1% deploy without combat
2.3% - 3.0% did not deploy
• Army OR=3.59
• Air Force OR=3.38
• Marine Corps OR=2.78
• Navy or Coast Guard OR=2.48
PTSD three-fold higher among
deployed with combat exposures
Smith TC et al. for the Millennium Cohort Study Team. New onset and persistent symptoms of posttraumatic stress disorder
self-reported after deployment and combat exposures: prospective population-based US military cohort study.
British Medical Journal. 2008 Feb;336(7640):366-71.Alcohol Misuse & Relationship to PTSD
Hoge, et al. N Engl J Med. 2004;351:13-22.Traumatic Brain Injury Veterans (OEF
and OIF)
• Mild Traumatic Brain Injury (TBI) has been
reported in 12-18% of soldiers evacuated from Iraq
and Afghanistan (Carson study: 1 in 6 shows TBI symptoms.
Associated Press. April 11, 2007).
• Mild TBI occurring among soldiers deployed in
Iraq is strongly associated with PTSD and poorer
physical health 3 to 4 months after returning home
(Hoge CW et al., NEJM 2008).Brain Areas Affected by TBI
Diffuse Axonal Injury
Subdural Hemorrhage
Contusions
Orbitofrontal Cortex
Taber et al., J Neuropsychiatry Clinical Neuroscience 2006.
The orbitofrontal cortex is disrupted in addicted subjects and
this may contribute to their vulnerability for SUD
Volkow et al., Neuropharmacology 2009.Additional Problems in Veterans from
the Iraqi and Afghanistan Wars: PAIN
• As a result of improvements in
battlefield medicine 90% of
severely wounded soldiers survive
and face additional challenges
imposed by significant PAIN.
• Chronic pain increases the risk of
mental health disorders including Peoples et al., NEJM 2004.
substance abuse disorders.
• Exposure to opiate medications for the
treatment of chronic pain can results in opiate
addiction.Post-Deployment Health Consequences
2,863 Iraq War returnees one-year post-deployment
60
PTSD
50 No PTSD
40
30 Twice as many
sick call visits
20
10
0
15+ on limb pain back pain 2+ sick 2+ missed
PHQ-15 call work
visits/mo days/mo
Hoge et al., AJP 2007;164: 150-153.Alcohol and other drug use in the
armed forces remain unacceptably
high, constitute a public health crisis,
and both are detrimental to force
readiness and psychological fitness
Recommendations:
• Increasing emphasis on efforts
to prevent substance use disorders
• Developing strategies for identifying,
adopting, implementing, and
disseminating evidence-based programs
and best practices for SUD care
• Increasing access to care
• Strengthening the SUD workforceThe White House
Office of the Press Secretary
For Immediate Release
August 31, 2012
EXECUTIVE ORDER
IMPROVING ACCESS TO MENTAL HEALTH SERVICES FOR VETERANS,
SERVICE MEMBERS, AND MILITARY FAMILIES
Sec. 5. Improved Research and Development (a) ….establish a National
Research Action Plan within 8 months of this order.
(b) The National Research Action Plan shall include strategies to establish surrogate
and clinically actionable biomarkers for early diagnosis and treatment
effectiveness; develop improved diagnostic criteria for TBI; enhance our
understanding of the mechanisms responsible for PTSD, related injuries, and
neurological disorders following TBI; foster development of new treatments ..;
improve data sharing between agencies …; and make better use of electronic
health records ... In addition, .. research to address suicide prevention.MH Problems in Veterans from
Iraqi and Afghanistan Wars
• Specific concerns have been centered on
• post-traumatic stress disorder
• traumatic brain injury
• suicide
• substance use disordersNIDA Response • Understanding the risks for and trajectories of comorbid problems • Development and testing of prevention and treatment interventions • Working with Key Partners in HHS, DOD, VA and elsewhere
NIDA Initiatives/Activities
• January 2009 Interagency Meeting
• Substance Use and Abuse among U.S. Military Personnel,
Veterans and their Families -- $6 million in grants funded
in 2010 by NIDA, NIAAA, NCI and VA
• Research on Children in Military Families…Standing
funding opportunity announcements issued July 2012 with
NICHD, OBSSR & ORWH
• Prevention and Health Promotion Interventions…RFAs
issued January 2013 with NIAAA, NCCAM and OASD/HA
• Responding the Executive Order
– Working with HHS partners, under leadership of SAMHSA
– Focusing on addressing research needs through the National Research
Action Plan (with NIMH, NIAAA, DOD, VA and others)Purpose: • To develop a multi-agency collaboration (NIDA, other NIH ICs, DoD, VA) • To identify cross-agency expertise on substance abuse and comorbid problems Areas of Research Gaps: • National Guard and Reservists • Combat wounded • Pain and prescription drugs • Co-morbidities • Stigma • Military families
NIDA Grants • BACK, SUDIE E -- Integrated Treatment of OEF/OIF Veterans with PTSD and Substance Use Disorders • GEWIRTZ, ABIGAIL -- Effectiveness of a Web-enhanced Parenting Program for Military Families • HUDSON, TERESA JO -- Use and Abuse of Prescription Opioids Among OEF/OIF Veterans • LARSON, MARY JO -- First Longitudinal Study of Missed Treatment Opportunities Using DOD and VA Data • MCGOVERN, MARK P -- Integrated CBT for Co-Occurring PTSD and Substance Use Disorders
NIAAA and NCI Grants
NIAAA & NCI Grants
• AMSTADTER, ANANDA B -- Stress-induced Drinking in OEF/OIF
Veterans: The Role of Combat History and PTSD
• GOLUB, ANDREW L -- Veteran Reintegration, Mental Health and
Substance Use in the Inner-City
• ARTENS, MATTHEW P -- Personalized Drinking Feedback
Interventions for OEF/OIF Veterans
• ROSENBLUM, ANDREW BRUCE -- Web-based CBT for Substance
Misusing and PTSD Symptomatic OEF/OIF Veterans
• MALONE, RUTH E -- Enhancing Civilian Support for Military
Tobacco ControlDept. of Veterans Affairs
Grants
• DESAI, RANI A -- Gender Differences in Post-deployment Addictive
Behaviors Among Returning Veterans
• CURRAN, GEOFFREY -- An Ethnographic Study of Post-Deployment
Substance Abuse and Treatment Seeking
• BOYKO, EDWARD J -- Tobacco Use and Alcohol Misuse among
Participants of the Millennium Cohort Study
• OSLIN, DAVID W -- Integrated vs. Sequential Treatment for Post
Traumatic Stress Disorder and Addiction Among Operation Enduring
Freedom/Operation Iraqi Freedom VeteransPrevention and Health Promotion Interventions to
Prevent Alcohol and Other Drug Abuse and Associated
Physical and Psychological Health Problems in U.S.
Military Personnel, Veterans and their Families
(R01) RFA-DA-13-012, (R34) RFA-DA-13-013
With NIAAA, NCCAM and OASD/HA
Accelerate research on health promotion and
prevention interventions
• reduce onset and progression of alcohol, tobacco, and other drug
use and abuse (including illicit and prescription drugs) and
associated mental and physical health problems
• promote health-enhancing behaviors among active-duty or
recently separated (e.g., Iraq and Afghanistan) military troops,
Veterans, and their families.Where Do We Need
to Go From Here?
We Need to…
Advance the SCIENCE
in order to …
Help our Military Friends and their Familieswww.drugabuse.gov
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