A Research Update from the National Institute on Drug Abuse —
July 2009

Scope of the problem

The operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have placed tremendous strain on military personnel and their families. Some have experienced devasatating consequences, including family disintegration, mental health disorders, and even suicide. Research conducted by RAND has shown that 25 to 30 percent of Iraq and Afghanistan war veterans have reported symptoms of a mental disorder or cognitive impairment. Post traumatic stress disorder (PTSD) is the most common, and traumatic brain injury may be a causal factor in some reported symptoms. Although less common, substance use is also a large concern, with aggregated data from the Substance Abuse and Mental Health Services Administration's annual household survey revealing that from 2004 to 2006, 7.1 percent of veterans (an estimated 1.8 million persons 18 or older) met criteria for a past-year substance use disorder.

Problems with alcohol and nicotine abuse are the most prevalent and pose a significant risk to the health of veterans as well as to Reserve component and National Guard soldiers. At greatest risk are deployed personnel with combat exposures, as they are more apt to engage in new-onset heavy weekly drinking, binge drinking, and to suffer alcohol-related problems; as well as smoking initiation and relapse. Within this group, Reserve and National Guard personnel and younger service members are particularly vulnerable to subsequent drinking problems. And although alcohol problems are frequently reported among veterans, few are referred to alcohol treatment.

Drug Abuse Research and Military Personnel

To gain a fuller understanding of these burgeoning issues, the Millennium Cohort Study– the largest prospective study in military history– is following a representative sample of U.S. military personnel from 2001 to 2022. Early findings highlight the importance of prevention in this group, given the long-term effects of combat-related problems and the ensuing difficulties experienced in seeking or being referred to treatment, likely because of stigma and other real and perceived barriers. To fill this need, a host of government agencies, researchers, public health entities and others are working together to adapt and test proven prevention interventions, as well as drug abuse treatments, for potential use with military and veteran populations and their families.

To address the social problems both caused by and contributing to drug use, the Department of Defense and partners are developing and testing novel treatment approaches with veterans. For example, Rosen's Money Management Intervention trains those in drug treatment to better manage their money by linking access to funds to treatment goal completion. For relapse prevention, McKay's telephone treatment approach delivers counseling at home for several months once a veteran has completed an initial face-to-face treatment episode.

While NIDA is striving to expand its portfolio of research related to trauma, stress, and substance use and abuse among veterans and their families, a number of promising projects are already being funded. These include studies on: smoking cessation and PTSD, behavioral interventions for the dually diagnosed, substance use and HIV progression, and virtual reality treatment of PTSD and substance abuse. Additionally, NIDA's National Drug Abuse Treatment Clinical Trials Network (CTN) is developing, in conjunction with researchers from the Veterans Administration, a protocol concept on the treatment of PTSD/SUD in veteran populations.

Further, efforts are under way to make it easier for veterans to access treatments. Research on drug courts, for example, is now being applied to developing courts for veterans, the former having demonstrated their effectiveness in addressing nonviolent crimes by drug abusers and ushering them into needed treatment instead of prison. Because the criminal justice system is a frequent treatment referral source for veterans, such specialized courts may give them the opportunity to access the services and support they may not otherwise receive. While New York has the only court that exclusively handles nonviolent crimes committed by veterans, other states are considering establishing such courts.

Advancing the Research

NIDA, in collaboration with the Department of Defense, Veterans Administration, and other Institutes within the National Institutes of Health, held a 2-day meeting in January 2009 that focused on addressing substance abuse and associated mental health problems in military personnel, veterans, and their families. The goals of the meeting were to:

• Learn about the intervention needs of military personnel, veterans, and their families regarding substance abuse and associated difficulties;
• Review existing efficacious drug abuse prevention and treatment interventions that may be appropriate for adapting and testing with military and veteran populations and their families; and
• Understand how to successfully conduct research in systems serving these populations.

In collaboration with other federal agencies, NIDA plans to release a Request for Applications (RFA) on the topic of Substance Use and Abuse among U.S. Military Personnel, Veterans and their Families, focusing on service in Afghanistan and/or Iraq. The RFA will invite research on the epidemiology/etiology, screening, and identification of substance use disorders, as well as the prevention and treatment of substance use and abuse and co-occurring problems (e.g., PTSD, traumatic brain injury, sleep disturbances, relationship violence) among U.S. military personnel, veterans, and their families.