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Role of the SUD Treatment & Recovery Field

We do not yet know how many veterans with post-combat stress effects will seek substance use disorder (SUD) treatment through civilian rather than military systems in the months to come.  We do know that some VA centers already have waiting lists, and that significant numbers of veterans may be avoiding treatment for fear of the stigma associated with post-deployment stress effects (Tanielian and Jaycox, 2008).  We know even less about the extent of the challenges that the civilian SUD field will face as veterans begin to return in high numbers from Iraq and Afghanistan, and about the long-term demands on civilian treatment systems. 

In general, though, the connection between post-trauma effects and substance use disorders is well known to the treatment field. 

  • Between one third and one half of people seeking treatment for SUDs may also have posttraumatic stress disorder, with greater prevalence in people with drug dependency.
  • Having PTSD has been associated with a more severe course and worse outcomes for substance use disorders.
  • Drug dependence is frequent in war veterans with posttraumatic stress disorder (Alcoholism:  Clinical & Experimental Research, 2008)

One preliminary study of Department of Defense prevalence surveys shows that “this generation of veterans has been much closer to trauma, has completed or may complete multiple tours of duty, and experience a greater prevalence of mental health issues (40%) and of those upwards of 60% also have an SUD” (Danforth, 2007, p. 11).  And our experience with Vietnam veterans has revealed that significant long-term problems can follow the stress of war, including chronic substance use disorders and a host of complicating factors (Kulka et al., 1990;  Schnurr et al., 2003).

The role of the substance use disorder (SUD) treatment field in mobilizing to meet these challenges is an essential one, for several reasons:

  • When the human stress system responds to intense or unrelenting stress or threat, it often creates chemical imbalances that people instinctively seek to remedy with alcohol, street drugs, or misuse of prescription medications.  The risk of abuse and dependence rises.
  • Many of the other aftereffects of war—from the neurological effects of trauma to the psychological and spiritual effects of exposure to death and destruction—can be very painful.  Veterans who are hesitant to seek professional services for these effects may be drawn to self-medication through alcohol or other drugs.
  • If the alcohol and drugs that have “medicated” combat stress effects leave the system, unconscious stored memories and other symptoms of trauma begin to emerge at higher levels of intensity.
  • Injured veterans with pain-management needs are often prescribed opioid pain relievers.  Even in the absence of combat stress effects or prior histories of substance use problems, their injuries can leave them more vulnerable to dependence on those medicines.
  • Young male veterans with traumatic injuries may be more vulnerable to a number of risk-taking behaviors, including the misuse of alcohol, and less likely to seek or accept help (Good et al., 2008).
  • Veterans who are successful at hiding or rationalizing their post-trauma effects may be less successful at hiding the effects of their self-medication with alcohol and other drugs and the dependence that often follows.  OIF/OEF veterans have begun seeking services from civilian SUD treatment facilities, and their numbers may rise significantly in the years to come.  In some cases, SUD clinicians and recovery support staff may be the only sources of help they encounter.

The SUD treatment field has begun to mobilize toward a focus on recovery, recovery management and recovery-based systems of care.  In many cases, the needs that make recovery management so essential for clinical populations with substance dependence disorders are linked to clients’ experiences of hardship and trauma (White, 2006).  The concept of recovery-based care is in many ways a bridge between our responses to substance use disorders and our responses to trauma.  As more and more new veterans return, the needs of those with substance dependence disorders will be important considerations in building new recovery-oriented systems of care.

The standard of care for co-occurring SUDs and post-trauma effects is simultaneous, co-located treatment of both illnesses.  In a recovery-based, trauma-informed model of care, SUD clinicians both refer to and coordinate closely with mental health and trauma specialists (White, 2006).  However, that model will not succeed unless SUD clinicians and recovery support service providers also receive all appropriate training in:

  • The nature of trauma
  • The circumstances under which trauma has occurred
  • The needs and realities of the individuals who have experienced it
  • Any issues specific to clients’ cultures—including the military culture

The effects of trauma reach throughout the human being.  Anyone providing services to someone affected by trauma—even if those services seem unconnected to the post-trauma symptoms—is in effect working with trauma, an often-volatile condition.  As the SUD field has learned in its work with survivors of childhood abuse, a failure to understand and respect the complexities of trauma can derail the treatment process and drive the trauma deeper into the human body, mind, and spirit (White, 1998).  An understanding of trauma can elevate the safety and effectiveness of SUD treatment and make ongoing recovery far more likely, and far more complete.

Next: Overview of Clinical Challenges


The material on all of the Clinical Pages is taken directly from the clinicians' manual Finding Balance:  Considerations in the Treatment of Post-deployment Stress Effects, published by the Great Lakes Addiction Technology Transfer Center and Human Priorities.  This manual is copyright © 2008, Pamela Woll.  Reprint permission is universally granted, but attribution is requested. Click here for References and Other Resources.
Click the following links for PDFs of materials in the Finding Balance series:   Clinicians' Guide <> Workbook for Service Members and Veterans <> Quick Guide for Service Members and Veterans <> Workbook for Military Families <> Suggestions for Facilitators (Counselors, Trainers, Mentors) using the workbooks

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