Michelle N. Cleary, M.A., Senior Project Associate and Philip Paty, Project Assistant, SAMHSA’s Service Members, Veterans, and their Families Technical Assistance Center, Policy Research Associates
During the month of November, we celebrate Veterans Day (11/11) and the Marine Corps birthday (11/10). We also recognize it as the Month of the Military Family. This spotlight on those who have served causes us to pause and acknowledge the sacrifices made by our service members, Veterans, and their families (SMVF). Unfortunately, our SMVF experience risks that can increase their likelihood of having a substance use or co-occurring disorder.
SMVF with substance use disorder (SUD), including opioid use disorder (OUD), may also come in contact with the criminal justice system. In 2015, the Bureau of Justice Statistics estimated that Veterans make up approximately 8 percent of our country’s inmate population.[i] In some of these instances, substance use is a contributing factor.
Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are widely recognized as risk factors among Veterans, increasing the likelihood of SUD. A 2011 statewide study on public health found 46.4 percent of patients with PTSD also had SUD.[ii] Another frequent but lesser-known risk factor among Veterans is physical pain: studies have found that Veterans are about 50 percent more likely to experience severe pain than the civilian population.[iii] This indicator is particularly concerning given the shift that occurred in the medical community during the 1990s, which encouraged the use of prescription opioids for non-cancer-related pain. Further, the Veteran population faces an increased likelihood of long-term exposure to opioids, which can begin during their military service if they are administered opioids on the battlefield. After they leave service, use of these drugs may continue, as Veterans may experience acute or chronic pain as a result of injuries sustained in battle or as a result of the physical demands of serving in the military. Long-term exposure, their strong addictive nature, and the prevalence of pain can result in many veterans becoming dependent on opioids. This can lead to the non-medical use of prescription drugs, and from there, can then lead to use of heroin and fentanyl.
Efforts are now underway to educate providers on strategies to more safely prescribe opioids. When using opioids for long-term treatment of pain, it is best to involve a pain specialist in the treatment planning process, so that a coordinated treatment plan that incorporates other evidence-based strategies is established to help the Veteran best manage his or her chronic pain. It is also important to note that in the long term, opioids may not be the most effective approach to address pain.
In our work at SAMHSA’s SMVF Technical Assistance Center, we are charged with helping states, cities, and counties better coordinate behavioral health resources across their service system for SMVF. As communities across the United States work to address the opioid crisis, coordinated efforts to develop person-centered approaches will need to consider the specialized needs of SMVF. When working with service members and Veterans in the criminal justice system, military culture-informed approaches can be a critical aspect of reducing recidivism and helping SMVF connect with the care they need. To be most effective, efforts to support Veterans should incorporate a broad-based biopsychosocial approach. A biopsychosocial approach considers the biological, psychological, and social aspects in the lives of SMVF and includes the use of military culture-informed behavioral therapies, medication-assisted treatment, and peer models as needed. Military culture plays an important role in care. The U.S. Department of Veterans Affairs’ (VA’s) Community Provider Toolkit notes, “Knowledge and understanding of military culture can lead to:
- Increased ability to relate to and support your Veteran client resulting in a stronger therapeutic alliance – the strongest determinant of treatment outcome.
- Deeper understanding of the context for mental health symptoms and conditions.
- Improved treatment planning that is informed by increased military cultural knowledge.
- Increased appreciation for military service.”[iv]
The VA’s Pain Management Opioid Safety Guide outlines chronic pain treatment strategies for Veterans that can reduce the risk of addiction to opioids.
Veterans treatment courts (VTCs) have been shown to be a promising military culture-informed model in helping Veterans overcome addiction, while offering an alternative to incarceration. Throughout the country, many communities have established specialized courts to support justice-involved service members and Veterans. In New York State, Judge Robert Russell’s Buffalo VTC led the way in establishing one of the first courts that builds upon Veterans’ deeply ingrained military culture and uses the strengths inherent in that culture to foster a process that allows Veterans alternatives to incarceration and recovery-oriented supports. Through a combination of military culture-informed practices that include a strong peer support component, Buffalo’s VTC has seen a significantly reduced recidivism rate compared to the general population in Erie County. During the first 4 years of the Buffalo VTC’s operation, the first 71 graduates of the program experienced zero recidivism.[v] In a 2012 study published in the Journal of Criminal Justice, an analysis of 154 independent evaluations of drug court programs throughout the country found a 12 percent reduction in the rate of recidivism.[vi]
A variety of approaches are needed to address the opioid crisis. When working with SMVF in the criminal justice system, military culture-informed approaches—along with safer opioid prescribing practices, non-narcotic medications, and alternative therapies—are critical to helping SMVF connect with the care they need.
Guidance on Opioids and OUD
SAMHSA – Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use
Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders
Treatment Improvement Protocol (TIP) Series, No. 54
SAMHSA’s Service Members, Veterans, and their Families Technical Assistance Center Webinar Archive: Strategies for Pain Management, and the Prevention of Opioid Misuse Among
Service Members, Veterans, and their Families
Stop the Addiction Fatality Epidemic Project
Pain Management Resources
Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain
US Department of Veterans Affairs (VA)/US Department of Defense Clinical Practice Guidelines for Opioid Therapy for Chronic Pain
VA Pain Management Opioid Safety VA Educational Guide (2014)
Military Culture Resources
U.S. Department of Veterans Affairs Community Provider Toolkit
Military Culture Training for Community Providers
Uniformed Services University, Center for Deployment Psychology
[i] Bureau of Justice Statistics (2015). Veterans in Prison and Jail, 2011-12.
[ii] Nahin, R.L. (2016). Severe Pain in Veterans: The Impact of Age and Sex, and Comparisons to the General Population. The Journal of Pain, 18(3).
[iii] Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from wave 2 of the National Epidemiologic Survey on alcohol and related conditions. Journal of Anxiety Disorders, 25(3), pp. 456–465.
[iv] United States Department of Veterans Affairs (n.d.). Understanding Military Culture—VA Community Provider Toolkit.
[v] Russell, R.T. (2014). Veterans Treatment Courts. In B. D. Hunter & R. C. Else (Eds.), Attorney’s Guide to Defending Veterans in Criminal Court, pp. 515-527. Veterans Defense Project.
[vi] Mitchell, O., Wilson, D. B., Eggers, A., & MacKenzie, D. L. (2012). Assessing the effectiveness of drug courts on recidivism: A meta-analytic review of traditional and non-traditional drug courts. Journal of Criminal Justice, 40, 60–71.