By Asiya K. Kazi, MSPH
Feb. 2, 2022

U.S. Army Photo by Sgt. Gillian McCreedy (OR-5)

Substance use disorders affect active duty service members' health and ability to perform their duties. Substances used by service members include, but are not limited to, alcohol, prescription medication, tobacco, and illicit drugs.¹ While service members use illicit substance at lower rates than the general population, binge drinking rates in the military exceed those among the general population.^2,3 A significant portion of active duty service members will experience a substance use disorder during their enrollment in the military, yet they may not seek out treatment due to stigma, lack of knowledge, or lack of access to high quality treatment.^3,4

Factors that place service members at risk of substance use disorders include young age, high demands in the line of service, and military sexual trauma.^3,5–7 While deployment in the military creates situations of acute and chronic stress, it also offers some protective factors against the development of substance use disorders.^3,8 For example, the prospect of dishonorable discharge, criminal prosecution, and adverse consequences on one's military career in response to a positive drug test can serve as deterrents to engaging in substance use.^3,8 In contrast, combat exposure which may involve witnessing or experiencing mental, emotional, and physical trauma is associated with increased rates of PTSD, depression, traumatic brain injury, and generalized anxiety among service members.^4,8–11 In turn, these conditions increase the risk of developing a substance use disorder.⁸

To reduce the risk of substance use disorders, military leaders should ensure that clear policies exist to address alcohol and drug use among service members.⁸ Moreover, establishing positive morale in one's unit and strong camaraderie with fellow service members can offer protection against substance use disorders.⁸ Leaders should strengthen existing programs and invest in new programs that teach coping skills for the stressors of deployment and increase resiliency among service members.⁸ Preventative programs can offer education around healthy alternatives to substance use and alternative entertainment activities, such as team sports and community engagement opportunities.¹² Military leaders should receive education on how to identify substance use disorders, where to refer service members experiencing substance use disorders for treatment, and how to serve as sources of non-judgmental support for them.¹² Tailoring response to substance use disorders in service members requires sensitivity to national cultural norms around specific substances and military cultural understandings which may differ across ranks, services, and occupations.^8,13,14 The 'Where to Seek Help' section below contains some military and government resources on substance use disorder for military leaders and service members.

It is important for military leaders to learn how to recognize common signs that may indicate unhealthy substance use among service members, as well as to take steps to guide service members with suspected substance use disorders to treatment. Since the military environment involves close interaction and in-person communication, leaders can make the most of their proximity to service members as they monitor potential substance use issues. The following symptoms, particularly when appearing together, may point to a substance use disorder:¹⁵

• Trouble with the law
• Violent behaviors, such as physical or sexual assault
• Work performance issues, such as chronic tardiness or absences
• Mood disturbances, such as irritability, anxiety, depression, and memory lapses
• Unexplained and/or frequent injuries
• Relationship problems

Military leaders and health care providers may consider screening for substance use disorders by judiciously using urine and blood tests and mental health evaluations for both active-duty service members and military applicants.¹² Urine and blood testing can be particularly useful for screening for alcohol use disorders whereas alternative or conjunctive methods should be used for drug use screening.^16,17 Moreover, mandatory random drug testing should be avoided as it can contribute to stigma and lead to treatment avoidance.³ Instead, military leaders should encourage self-identification of substance use disorders and refrain from wielding self-disclosure as means for reprimand or punishment.¹² Self-disclosure should be followed by appropriate referral to health care assessment and/or treatment.¹²

Similarly, when assessing service members, military health care providers should refrain from reporting provision of substance use disorder education and mental health treatment until the point of definitive diagnosis to unit leadership, unless there is concern for safety or mission impact.¹² Often, confidential, brief, and early intervention can prevent the development of more severe substance use disorders.^12,18 Finally, limiting the prescription of medications that may be abused, such as opioid substances, can reduce the prevalence of substance use disorders.^12,19

Service members can take heart in knowing that many avenues have proven effective to help with recovering from substance use disorders. Specific procedures for obtaining assessment and treatment vary depending on a service members' branch. The TRICARE health system offers intensive outpatient programs for service members in need of more in-depth substance use disorder treatment.³ Service members struggling with many types of substance use disorders, such as binge drinking and tobacco use, can often avail themselves of free counseling or mental health treatment through programs at their base.³

Regardless of which avenue service members take to seek help with substance use disorder, military health care professionals will guide them to an individualized treatment plan appropriate for their needs. This may include behavioral interventions, such as short-term cognitive behavioral therapy (CBT).³ CBT teaches individuals how to become aware of distorted thinking patterns that may contribute to a substance use disorder and restructure them to create a healthier mindset.³ Medication-assisted therapy may be used in cases of alcohol, tobacco, or opioid-related substance use disorders, likely in conjunction with behavioral intervention.³ Service members may also find 12-step support groups, such as Alcoholics Anonymous or Narcotics Anonymous, helpful to receive and provide support to others struggling with similar issues.^20,21

The intense nature of the military environment underscores the importance of prevention and recognition of substance use disorders to allow for early intervention and optimized recovery for active-duty service members. By continuing their education on substance use disorders, military leaders can improve their ability to guide service members suffering from substance use disorders to treatment and dismantle stigma around substance use disorders in the military. Service members' health and performance depend on an effective, proactive pathway of prevention, assessment, and treatment, one that incorporates evidence-based policy changes, sustainable programs, and military-wide cultural shifts.⁶

Where to Seek Help

Army Substance Abuse Program (ASAP)

Marine Corps Substance Abuse Program

Navy Alcohol Abuse Prevention (NAAP)

Air Force Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program

National Cancer Institute's Smokefree.gov

SAMHSA's National Helpline

National Opioids Crisis- Help and Resources

Psychological Health Resource Center

References

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2. Meadows SO, Engel CC, Collins RL, et al. 2015 Health Related Behaviors Survey: Substance Use Among U.S. Active-Duty Service Members. RAND Corporation PP - Santa Monica, CA; 2018. doi:10.7249/RB9955.7
3. Substance Use and Military Life DrugFacts. National Institute on Drug Abuse (NIDA). Published October 23, 2019. Accessed January 8, 2022. https://www.drugabuse.gov/publications/drugfacts/substance-use-military-life
4. Hoge CW, Castro CA, Messer SC, et al. Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. http://dx.doi.org/101056/NEJMoa040603. 2009;351(1):13-22. doi:10.1056/NEJMOA040603
5. Ames G, Cunradi C. Alcohol Use and Preventing Alcohol-Related Problems Among Young Adults in the Military. Alcohol Res Heal. 2004;28(4):252. Accessed January 10, 2022./pmc/articles/PMC6601669/
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13. Federman EB, Bray RM, Kroutil LA. Relationships Between Substance Use and Recent Deployments Among Women and Men in the Military. APA. 2009;12(3):205-220. doi:10.1207/S15327876MP1203_3
14. Meyer EG, Wynn GH. The Importance of US Military Cultural Competence. Mil Veteran Ment Heal. Published online 2018:15-33. doi:10.1007/978-1-4939-7438-2_2
15. Understanding and Identifying Substance Use Disorders. Military One Source. Published May 18, 2020. Accessed January 9, 2022. https://www.militaryonesource.mil/health-wellness/mental-health/substance-abuse-and-addiction/understanding-and-identifying-substance-use-disorders/
16. Hawkins EJ, Grossbard J, Benbow J, Nacev V, Kivlahan DR. Evidence-Based Screening, Diagnosis, and Treatment of Substance Use Disorders Among Veterans and Military Service Personnel. Mil Med. 2012;177(suppl_8):29-38. doi:10.7205/MILMED-D-12-00125
17. Saitz R, Alford DP, Bernstein J, Cheng DM, Samet J, Palfai T. Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed. J Addict Med. 2010;4(3):123. doi:10.1097/ADM.0B013E3181DB6B67
18. Management of Substance Use Disorders Working Group. VA/DoD Clinical Practice Guideline for Management of Substance Use Disorders (substance use disorder).; 2009.
19. US Government Accountability Office. Prescription Drug Control: DEA Has Enhanced Efforts to Combat Diversion, but Could Better Assess and Report Program Results. J Drug Addict Educ Erad. 2011;7(2):101-132.
20. Substance Abuse and Addiction- The Essentials. Military One Source. Accessed January 11, 2022. https://www.militaryonesource.mil/health-wellness/mental-health/substance-abuse-and-addiction/substance-abuse-and-addiction-the-essentials/
21. Magaletta PR. Facilitating 12-Step Approaches to Change for Service Members with Problematic Drinking. Health.mil Clinician's Corner Blog. Published April 16, 2019. Accessed January 13, 2022. https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Clinicians-Corner-Blog/Facilitating-12-Step-Approaches-to-Change-for-Service-Members-with-Problematic-Drinking

Asiya K. Kazi, MSPH is a contracted Senior Program Analyst in the Clinical Care- Prevention and Early Intervention team at the Psychological Health Center of Excellence. She has experience conducting research and evaluation for opioid use disorders, equitable mental healthcare delivery, and trauma-informed programs