Rachel Sayko Adams

Military Combat Deployments and Substance Use: Review and Future Directions

Iraq and Afghanistan veterans experience extreme stressors and injuries during deployments, witnessing and participating in traumatic events. The military has organized prevention and treatment programs as a result of increasing rates of suicide and posttraumatic stress disorder among troops; however, there is limited research on how to intervene with alcohol misuse and drug use that accompany these problems. This review presents statistics about postdeployment substance use problems and comorbidities, and it discusses the militarys dual role (a) in enforcing troop readiness with its alcohol and drug policies and resiliency-building programs and (b) in seeking to provide treatment to troops with combat-acquired problems, including substance abuse.

Frequent binge drinking after combat-acquired traumatic brain injury among active duty military personnel with a past year combat deployment

Objective:To determine whether combat-acquired traumatic brain injury (TBI) is associated with postdeployment frequent binge drinking among a random sample of active duty military personnel. Participants:Active duty military personnel who returned home within the past year from deployment to a combat theater of operations and completed a survey health assessment (N = 7155). Methods:Cross-sectional observational study with multivariate analysis of responses to the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, an anonymous, random, population-based assessment of the armed forces. Main Measures:Frequent binge drinking: 5 or more drinks on the same occasion, at least once per week, in the past 30 days. TBI-AC: self-reported altered consciousness only; loss of consciousness (LOC) of less than 1 minute (TBI-LOC <1); and LOC of 1 minute or greater (TBI-LOC 1+) after combat injury event exposure. Results:Of active duty military personnel who had a past year combat deployment, 25.6% were frequent binge drinkers and 13.9% reported experiencing a TBI on the deployment, primarily TBI-AC (7.5%). In regression models adjusting for demographics and positive screen for posttraumatic stress disorder, active duty military personnel with TBI had increased odds of frequent binge drinking compared with those with no injury exposure or without TBI: TBI-AC (adjusted odds ratio, 1.48; 95% confidence interval, 1.18–1.84); TBI-LOC 1+ (adjusted odds ratio, 1.67; 95% confidence interval, 1.00–2.79). Conclusions:Traumatic brain injury was significantly associated with past month frequent binge drinking after controlling for posttraumatic stress disorder, combat exposure, and other covariates.

Association of military deployment of a parent or spouse and changes in dependent use of health care services.

Background:U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. Objective:To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. Design:A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. Measures:Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors’ deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). Results:Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P<0.01) adjusting for group differences. Deployment was consistently associated with increased use of purchased care services, partially, or fully offset by decreased use of military treatment facilities. Conclusions:These results suggest that emotional or behavioral issues are contributing to increased specialist visits and reliance on medications during sponsors’ deployments. A shift to receipt of services from civilian settings raises questions about coordination of care when families temporarily relocate, family preferences, and military provider capacity during deployment phases. Findings have important implications for the military health system and community providers who serve military families, especially those with children.

Alcohol Use After Combat-Acquired Traumatic Brain Injury: What We Know and Don't Know

Military personnel engage in unhealthy alcohol use at rates higher than their same-age civilian peers, resulting in negative consequences for the individual and jeopardized force readiness for the armed services. Among those returning from combat deployment, unhealthy drinking might be exacerbated by acute stress reactions and injury, including traumatic brain injury (TBI). Combat-acquired TBI is common among personnel in current conflicts. Although research suggests that impairment due to TBI leads to an increased risk for unhealthy drinking and consequences among civilians, there has been little research to examine whether TBI influences drinking behaviors among military personnel. This article examines TBI and drinking in both civilian and military populations and discusses implications for clinical care and policy.

Missed opportunity for alcohol problem prevention among army active duty service members postdeployment

OBJECTIVES We identified to what extent the Department of Defense postdeployment health surveillance program identifies at-risk drinking, alone or in conjunction with psychological comorbidities, and refers service members who screen positive for additional assessment or care. METHODS We completed a cross-sectional analysis of 333 803 US Army active duty members returning from Iraq or Afghanistan deployments in fiscal years 2008 to 2011 with a postdeployment health assessment. Alcohol measures included 2 based on self-report quantity-frequency items-at-risk drinking (positive Alcohol Use Disorders Identification Test alcohol consumption questions [AUDIT-C] screen) and severe alcohol problems (AUDIT-C score of 8 or higher)-and another based on the interviewing providers assessment. RESULTS Nearly 29% of US Army active duty members screened positive for at-risk drinking, and 5.6% had an AUDIT-C score of 8 or higher. Interviewing providers identified potential alcohol problems among only 61.8% of those screening positive for at-risk drinking and only 74.9% of those with AUDIT-C scores of 8 or higher. They referred for a follow-up visit to primary care or another setting only 29.2% of at-risk drinkers and only 35.9% of those with AUDIT-C scores of 8 or higher. CONCLUSIONS This study identified missed opportunities for early intervention for at-risk drinking. Future research should evaluate the effect of early intervention on long-term outcomes.

Rationale and methods of the Substance Use and Psychological Injury Combat Study (SUPIC): a longitudinal study of Army service members returning from deployment in FY2008-2011.

The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.

Gender differences in substance use treatment utilization in the year prior to deployment in Army service members

Although military men have heavier drinking patterns, military women experience equal or higher rates of dependence symptoms and similar rates of alcohol-related problems as men at lower levels of consumption. Thus, gender may be important for understanding substance use treatment (SUT) utilization before deployment. Military health system data were analyzed to examine gender differences in both substance use diagnosis (SUDX) and SUT in 152,447 Army service members returning from deployments in FY2010. Propensity score analysis of probability of SUDX indicated that women had lower odds (AOR: 0.91, 95% CI: 0.86-0.96) of military lifetime SUDX. After adjusting for lifetime SUDX using propensity score analysis, multivariate regression found women had substantially lower odds (AOR: 0.61; 95% CI: 0.54-0.70) of using SUT the year prior to deployment. Findings suggest gender disparities in military-provided SUT and a need to consider whether military substance use assessment protocols are sensitive to gender differences.

When addiction co-occurs with traumatic brain injury

The study by Miller and colleagues in this volume reminds us that, while the military has strong messages that discourage alcohol abuse, it has been unsuccessful in deterring harmful drinking. An age-old warrior culture belief persists -- that frequent binge drinking is acceptable, normative, and rational because warriors “work hard and play hard.” Other contributors to ongoing excessive drinking are negative attitudes toward help-seeking, and stigmatizing beliefs that seeking alcohol treatment is career-ending (1). Because of the prevalence and consequences of substance abuse, a recent committee of the Institute of Medicine named alcohol and prescription drug abuse in the military a public health crisis (1). Miller and colleagues have provided important additional insight into the emerging evidence on the misuse of substances by injured military service members. Their findings expand growing evidence that substance misuse and substance use disorders are likely to co-occur with mild traumatic brain injury (TBI). At the same time, their findings require contextualization of the relationship between injury onset and identification of substance use disorders, as well as what is known about combat-related TBI and its relation to post-deployment substance misuse. It is both remarkable and puzzling that service members in the first 30 days following a mild TBI were significantly more likely to receive an initial diagnosis for all but one addiction-related disorder (ARD) when compared to others who received treatment for a different injury. While the occurrence of a TBI is systematically associated with subsequent ARD diagnosis in a way that other injuries are not, a causal relationship between mild TBI and onset of dependence would not appear plausible as the behavioral patterns leading to a dependence diagnosis rarely manifest in just 30 days. Clearly, the injury is occurring during a period of maladaptive substance use. Perhaps the diagnosis and treatment of behavioral symptoms from mild TBI facilitates the identification of co-existing substance problems in a way that treatment for other bodily injuries does not. Another possibility that leads to differential identification of a person with emerging substance dependence is if the consumption pattern of those with dependence was more likely to result in a TBI versus other injury. Indeed, at least one large population study found that the likelihood of an injury event including a TBI increased dramatically with increased blood alcohol content (2). It is plausible that across all drugs, consumption patterns consistent with ARD creates more risk for incurring an injury that affects the brain, whether that is due to poorer decisions, greater disinhibition, and/or more impaired motor control. Such a conclusion complicates the roles of risk and consequence, obfuscating an easy public health implication. Even though Miller and colleagues focused on service members during the years overlapping with Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), it is unclear to what extent the ARD diagnoses in this study occurred during months immediately post-deployment. The TBI diagnoses examined come from Military Health System data that do not typically contain medical records from combat zones; thus the TBIs likely occurred during non-combat activities (e.g., stateside car crashes or sports injuries). As such, the TBIs in this study had more opportunity to be associated with an alcohol-related event than those occurring in combat zones where the prohibition of alcohol significantly reduces the opportunity to drink excessively. Thus, Miller and colleagues have identified important issues about the likelihood of receiving an ARD diagnosis after a non-combat acquired TBI, however, the contribution of either combat-acquired TBI or post-deployment binging is not clear. Two studies have examined the risk of harmful alcohol use post-deployment after experiencing a combat-acquired TBI. A recent study used a 2008 Department of Defense (DOD) population-based survey of service members to assess the association of self-reported, combat-acquired TBI with post-deployment binge drinking. For those returning from a combat deployment in the past year, having experienced a TBI was associated with increased odds of past-month frequent (at least weekly) binge drinking after controlling for demographics, lifetime combat exposure, and post-traumatic stress disorder (3). Another self-report survey study of returning United Kingdom OEF/OIF service members found that those who experienced a mild TBI were 2.3 times more likely to report possible alcohol misuse than those without a TBI (4). The findings of these two studies demonstrate a link between combat-acquired TBI and actual drinking behavior. A third study of OEF/OIF veterans in Veterans Administration medical clinics measured diagnoses rather than consumption behaviors, as did the present study, and reported that those with ongoing postconcussive symptoms from a TBI were twice as likely to have ARD diagnoses compared to veterans without a TBI (5). None of these studies measured precisely how much time had elapsed after the injury event, nor were TBI patients compared to others with injury events. Thus, Miller and colleagues make a contribution in focusing on the immediate period post-TBI and comparing TBI patients to others with injuries. There are several implications of this study for military policy development as well as for civilian and military medical providers who care for service members, particularly those with TBI. Clearly, more research is needed to examine how combat-acquired TBI relates to post-deployment excessive substance use and the later development of ARD (6). The presence of TBI should trigger substance use screening and brief intervention that are designed, implemented, and evaluated with military populations. Given the heightened risk of TBI and the high prevalence of binge drinking in the military, research on what constitutes effective tertiary substance use prevention programming for those with TBI is warranted. Also, to reduce consequences of substance abuse among those with TBI will require more effective early interventions in primary care and better access to acceptable treatment options. The IOM committee found a lack of consistent implementation of evidence-based prevention, screening, early intervention and treatment services among the DOD (1). Effective environmental prevention strategies (e.g., partnerships between base commanders and local communities around sales to underage drinkers) are important because most service members are at peak ages for alcohol use disorder. The military should mount proven prevention efforts for those with TBI, including mandatory use of a validated alcohol screening tool in primary care accompanied with medical provider education on evidence-based brief counseling and intervention (7). The military’s current screening program centers around deployment events, and referrals for care associated with alcohol use are rare (8). Effective alcohol dependence pharmaceutical treatments (naltrexone and extended release naltrexone) are recommended in the VA/DOD Clinical Practice Guidelines, (9) which could be used for those with TBI, but these treatments are rarely utilized (1). A recent memo clarified that current DOD policy permits primary care clinicians to provide confidential counseling for emergent alcohol problems without notification of the patient’s commander (1), however, to de-stigmatize alcohol treatment will require new DOD policy permitting confidentiality. A pilot program permitting confidential access to the Army Substance Abuse Program found that participants highly valued this option (10), and other preliminary data found increased referrals and volunteers for treatment including officers who otherwise rarely enter treatment (1). Miller and colleagues’ findings not only underscore the need for continued attention to ARD among service members, but adds to the growing evidence that TBI may co-occur with substance misuse and abuse. Preventive and ameliorative interventions will not only need to be efficacious for ARD, but must also be proven effective for those service members who have a history of TBI.

Traumatic Brain Injury Among US Active Duty Military Personnel and Negative Drinking-Related Consequences

This study used the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel to determine whether traumatic brain injury (TBI) is associated with past year drinking-related consequences. The study sample included currently drinking personnel who had a combat deployment in the past year and were home for ≥6 months (N = 3,350). Negative binomial regression models were used to assess the incidence rate ratios of consequences, by TBI-level. Experiencing a TBI with a loss of consciousness for more than 20 minutes was significantly associated with consequences independent of demographics, combat exposure, posttraumatic stress disorder, and binge drinking. The studys limitations are noted.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.

Objective:To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). Methods:Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. Main Measures:The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD–positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. Results:The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. Conclusion:Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.