Walden University Domestic Violence in Military Families Discussion: Sociology Answers 2021

Walden University Domestic Violence in Military Families Discussion: Sociology Answers 2021

Walden University Domestic Violence in Military Families Discussion: Sociology Answers 2021

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Walden University Domestic Violence in Military Families Discussion

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Journal of Social Work Practice in the Addictions, 12:6–27, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: 10.1080/1533256X.2012.647586
ARTICLES
Military Combat Deployments and Substance
Use: Review and Future Directions
MARY JO LARSON, PHD, MPA
Senior Scientist, The Heller School for Social Policy & Management, Institute
for Behavioral Health, Brandeis University, Waltham, Massachusetts, USA
NIKKI R. WOOTEN, PHD, LCSW-C
Assistant Professor, School of Social Work, Boston University,
Boston, Massachusetts, USA, and Major, District of
Columbia Army National Guard, Washington, DC, USA
RACHEL SAYKO ADAMS, MPH, MA
Doctoral Candidate, The Heller School for Social Policy & Management, Institute
for Behavioral Health, Brandeis University, Waltham, Massachusetts, USA
ELIZABETH L. MERRICK, PHD, MSW
Senior Scientist, The Heller School for Social Policy & Management, Institute
for Behavioral Health, Brandeis University, Waltham, Massachusetts, USA
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 military’s dual role (a) in enforcing troop
Received April 8, 2011; revised July 25, 2011; accepted August 11, 2011.
This study was supported in part by a grant from the National Institute on Drug Abuse
(R01DA030150).
Address correspondence to Mary Jo Larson, Senior Scientist, Heller School, Institute for
Behavioral Health, Brandeis University, 415 South Street, Mailstop 035, Waltham, MA 02254,
USA. E-mail: larson@brandeis.edu
6
Military Combat Deployments and Substance Use
7
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.
KEYWORDS combat exposures, military deployments, military
health care system, substance use, veterans
Since 2001, over 2 million U.S. service members have deployed to the wars
in Iraq and Afghanistan (Institute of Medicine [IOM], 2010b). These wars
are fundamentally different from previous military operations in numerous
ways, including the sociodemographics of troops deployed, frequency and
duration of deployments, the nature of combat, number of deaths, and types
of injuries (Tanielian & Jaycox, 2008). The problem of unhealthy substance
use, ranging from risky use to substance use disorders (Jackson, Alford,
Dube, & Saitz, 2010; Saitz, 2005) among service members must be understood in this context. This review focuses on substance use problems among
veterans of Operation Enduring Freedom (OEF; Afghanistan) and Operation
Iraqi Freedom (OIF; Iraq). We present an overview of current knowledge
on prevalence and risk factors for unhealthy substance use and cooccurring
conditions, and programs to address these problems. We also describe facilitators and barriers to help seeking, and conclude with a discussion of
implications and future directions for social work professionals.
The environment and length of OEF and OIF has led to unusual work
demands for military personnel, and contributed to high rates of cooccurring
physical, psychological, and substance use problems among returning veterans (Hoge, 2011). Deployed service members might experience blasts
from improvised explosive devices (IEDs); contend with suicide bombers or
snipers; receive incoming artillery, rocket, or mortar fire; engage in hand-tohand combat; sustain serious injuries; or witness death or injury of comrades,
combatants, or civilians (Mental Health Advisory Team IV [MHAT–IV], 2006;
Tanielian & Jaycox, 2008). With a 10% mortality rate for serious injuries
(Holcomb, Stansbury, Champion, Wade, & Bellamy, 2006), a record number of combat veterans are surviving serious burns, amputations, and other
physical and psychological injuries (Melcer, Walker, Galarneau, Belnap, &
Konoske, 2010). Consistent with low mortality and increased survival rates,
OEF and OIF have resulted in unprecedented attention to the “signature
injuries” or “invisible wounds” of these conflicts: posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and depression (Hoge et al.,
2004; Lapierre, Schwegler, & LaBauve, 2007; Seal, Bertenthal, Miner, Sen, &
Marmar, 2007; Tanielian & Jaycox, 2008). Substance use and misuse can
be comorbid with any of these conditions. Additional symptoms associated
with OEF and OIF experiences include subthreshold posttraumatic stress
symptoms, helplessness, insomnia, shame, and survivor’s guilt, which could
8
M. J. Larson et al.
also contribute to substance use problems (Campise, Geller, & Campise,
2006).
Reserve component members (i.e., National Guard, Reservists) and
women have been deployed in unprecedented numbers. By October 2007,
more than 620,000 National Guard and Reservists had been activated, and
women represented 15% of troops in Iraq and Afghanistan (Albright et al.,
2007; U.S. Government Accountability Office [GAO], 2008). Women are
currently employed in over 90% of military occupations, are at risk for
combat exposure, and serve multiple, lengthy deployments similar to men
(Manning & Wight, 2000; Murdoch et al., 2006). Female soldiers are more
likely to screen positive for PTSD and depressive symptoms, but are less
likely to develop substance use problems (Luxton, Skopp, & Maguen, 2010;
Tanielian & Jaycox, 2008). Thus, service component and gender are relevant
to the impact of deployments on substance use.
Although both psychological injuries and unhealthy substance use
are common, it is important to consider that onset of symptoms might
be delayed, and that multiple deployments can have a cumulative effect.
For instance, service members on their third and fourth deployments
report significantly more problems than those on their first or second
deployments—more acute stress, psychological and marital problems, and
higher rates of using medication for combat stress (MHAT–IV, 2006).
Since 2003, the nation’s response to the health care needs of OEF and
OIF veterans has been evolving. The Department of Defense (DoD) and
Department of Veterans Affairs (VA) have increased their attention to prevention and resilience, outreach and assessment, and counseling of service
members, veterans, and families. There is a growing public health awareness
that more services for unhealthy substance use and cooccurring problems
must be made available (American Psychological Association, 2007). Social
workers will play a vital role in providing these services. Although each military service has a DoD-mandated substance abuse program (IOM, 2010b;
U.S. Department of Defense, 1997), unhealthy alcohol use and smoking
rates remain high (Bray et al., 2010), and there are increasing rates of
amphetamine and narcotic prescriptions among active duty members, some
of which might reflect substance abuse (Wagner et al., 2007).
POSTDEPLOYMENT SUBSTANCE USE PROBLEMS
AND SYMPTOMS
Service members returning from deployments often engage in unhealthy
substance use. These problems can be exacerbated by cooccurring psychological problems. In this section, we describe use of common substances
and examine the most common cooccurring conditions. Table 1 presents
summary findings from five recent population-based studies that examine
9
2008 DoD Health Related
Behaviors Survey Among
Active Duty Military
Personnel: 28,546 active
duty service members
Sample
Anonymous Air Force
Community Assessment
Survey: 56,137 active duty
Air Force members
Anonymous survey of
1,120 soldiers from brigade
combat infantry teams
returning from OIF
Heavy alcohol use was higher among service members who
had been combat deployed since September 11, 2001,
compared to those who had not been combat deployed (21%
vs. 18%). Smoking in the past month was higher among
service members who had been combat deployed since
September 11, 2001, compared to those who had not been
combat deployed (31.7% vs. 27.8%).
Reserve/National Guard service members who deployed with
combat exposures were significantly more likely to report
new onset heavy weekly drinking (OR 1.63, 95% CI [1.36,
1.96]); binge drinking (OR 1.46, 95% CI [1.24, 1.71]); and
alcohol-related problems (OR 1.63, 95% CI [1.33, 2.01]).
Smoking initiation was 2.3% among deployers (compared to
1.3% among nondeployers). Smoking recidivism was 39.4%
among deployers (compared to 28.7% among nondeployers).
Smoking levels increased among 57% of deployers (compared
to 44% among nondeployers). Further, those deployed with
combat exposure were at 1.6 times greater odds of smoking
initiation and 1.3 times greater odds of recidivism than those
deployed without combat exposure.
For each increase in deployment frequency, problem drinking
odds increased by 14%. Each additional year spent deployed
was associated with 23% increased odds of problem drinking.
Heavy alcohol use in the past
30 days; any cigarette use in
the past 30 days
Smoking initiation (among
baseline nonsmokers);
smoking recidivism (among
baseline past smokers);
increased and decreased
daily smoking levels
Alcohol Use Disorders
Identification Test (AUDIT)
to identify problem drinking
(scores of 8+)
Alcohol misuse (2-item screen) High rates of exposure to the threat of death or injury were
associated with positive screens for alcohol misuse. Exposure
and alcohol-related
to atrocities was associated with alcohol misuse and
problems
alcohol-related problems.
New onset heavy weekly
drinking; binge drinking;
alcohol-related problems
Results
Outcome Measures
Notes. OR = odds ratio; CI = confidence interval. All results were significant at the p ≤ .05 level or better.
Wilk
et al.
(2010)
Spera
et al.
(2010)
Jacobson Millennium Cohort
Longitudinal Study:
et al.
48,481 service members
(2008)
(26,613 active duty and
21,868 Reserve/National
Guard)
Millennium Cohort
Smith
Longitudinal Study:
et al.
48,304 service members
(2008)
Bray
et al.
(2010)
Source
TABLE 1 Key Recent Studies Regarding the Association of Substance Use and Deployment or Combat Experiences
10
M. J. Larson et al.
the association of tobacco or alcohol use with deployment and combat
exposure.
Alcohol Use
Cumulatively, deployment duration and frequency have been associated
with higher rates of heavy alcohol use among active duty service members
(Ong & Joseph, 2008; Spera, Thomas, Barlas, Szoc, & Cambridge, 2010).
Unhealthy drinking rates and alcohol-related consequences are also correlated with intensity of combat exposure, specifically among Reserve and
National Guard personnel and younger service members (Jacobson et al.,
2008). As shown in Table 1, a study based on longitudinal data gathered on National Guard and Reservist members estimated increased odds
of alcohol-related problems using three measures, ranging from 1.46 to
1.63 in association with deployment with combat exposure (Jacobson et al.,
2008). A study of Air Force members reported a smaller range of odds
increase (14% to 23%) of problem drinking, measured using the World
Health Organization’s Alcohol Use Disorder Identification Test (AUDIT),
associated with deployment frequency and duration, respectively, independent of combat exposure (Spera et al., 2010). Finally, a study of one brigade
of Army soldiers found that seeing death or injury as well as witnessing
atrocities during combat in Iraq were associated with increased positive
alcohol misuse based on a two-item screen (Wilk et al., 2010). The association of alcohol-related problems with deployment and combat exposure
is complicated by the long-standing culture of unhealthy drinking in the
military. Service members, while stationed at their permanent bases or installations, report using alcohol to cope with stress, boredom, and loneliness
(Ames & Cunradi, 2004). Binge drinking rates are high: 20% report binge
drinking at least once per week in the past 30 days (Bray et al., 2010).
During nondeployment periods, young enlisted, unmarried service members report the highest rates of unhealthy drinking (Ferrier-Auerbach et al.,
2009).
Smoking and Tobacco Use
Although there has been an overall decrease in cigarette smoking in the
military (Bray et al., 2010), young service members remain more likely to
be smokers than their civilian counterparts (Nelson & Pederson, 2008), and
deployment appears to increase smoking initiation and recidivism (Smith
et al., 2008) and smoking in the past month (Bray et al., 2010). Combat exposure as well as longer length and number of deployments are associated
with increased prevalence of smoking and smoking recidivism according
to analysis of longitudinal data that reports increased odds of smoking
Military Combat Deployments and Substance Use
11
initiation (1.6) and smoking recidivism (1.3) for deployment with combat
exposure compared to deployment without combat exposure (Smith et al.,
2008; see Table 1). During deployment, service members report smoking
helps cope with stress, boredom, and sleep problems; endorse a belief that
the dangers of smoking are insignificant compared to those of combat; and
perceive smoking as socially acceptable in military culture (Poston et al.,
2008). Further, use of cigars and smokeless tobacco have been increasing
among military recruits (Vander Weg et al., 2008).
Other Drug Use
Illicit drug use among military personnel has varied during previous U.S.
wars and combat situations, likely due to ease of access, personal stress,
and the nation’s cultural norms related to specific substances (Federman,
Bray, & Kroutil, 2000). Over 80% of Army soldiers during the Vietnam
War used marijuana, and 45% tried narcotics (34% used heroin; 38% used
opium; Robins, 1993). Drug use on return from deployment decreased
significantly and only 5% of service members who had been addicted
to drugs in Vietnam remained addicted immediately after deployment
(Robins).
Widespread Vietnam-era drug use and well-publicized postwar military accidents led the DoD to adopt a “zero tolerance” policy for drugs
and to start a program of mandatory routine urinalysis testing for opiates,
barbiturates, amphetamines, and cocaine that could result in serious sanctions including possible discharge (Bachman, Freedman-Doan, O’Malley,
Johnston, & Segal, 1999). Since then, use of these substances among military personnel has declined significantly and has remained around 3%
(Bray et al., 2010). However, self-report misuse of prescription medications has escalated, matching anecdotal evidence that more service members
are experiencing problems with or dependence on narcotics, benzodiazepines, and other prescription medications (Army Suicide Prevention Task
Force, 2010).
Self-report of nonmedical use of prescription drugs increased from 4%
in 2005 to 11% in 2008 (Bray et al., 2010). Improved wording on the survey
might have contributed to this increase, but the trend matches the dramatic
rise in the prescription of narcotics among the U.S. general population (Bray
et al., 2010). Self-reported misuse in the past 30 days was 10% for pain
relievers and 3% for tranquilizers and muscle relaxers (Bray et al., 2009). It is
suspected but unknown to what extent combat veterans misuse these prescription drugs as part of maladaptive coping with combat-acquired wounds,
pain, or psychological injury (Dao & Frosch, 2010).
12
M. J. Larson et al.
Other Comorbidities with Substance Use Disorders
PAIN
Veterans with cooccurring substance use disorders (SUDs) and chronic pain
(Gironda, Clark, Massengale, & Walker, 2006; Kline et al., 2010) might turn
to drugs to self-medicate the pain, creating challenges for effective pain
management (Larson et al., 2007; Rosenblum et al., 2003; Trafton, Oliva,
Horst, Minkel, & Humphreys, 2004). The Army’s Pain Management Task
Force recommended providing appropriate pain management and clinical
prescription drug oversight in Warrior Transition Units (WTUs; Office of the
Army Surgeon General, 2010). The impact of pain medication use in the
military has not been comprehensively studied (Army Suicide Prevention
Task Force, 2010).
SUICIDE
RISK
Substance use often precedes suicidal behavior in the military, as indicated
by the 30% of Army suicides and over 45% of suicide attempts since 2003 that
involved alcohol or drug use (U.S. Army Center for Health Promotion and
Preventive Medicine, 2010). Further, the Army Suicide Prevention Task Force
(2010) reported that approximately 20% of 188 high-risk behavior deaths
from 2006 to 2009 that were not combat-related were due to a drug or
alcohol overdose. In 2008, the active duty Army suicide rate (20.2 per
100,000) surpassed the civilian population rate (19.6 per 100,000; Kuehn,
2009). Rates of suicide attempts and suicidal ideation are also increasing;
almost 5% of service members reported seriously considering suicide within
the past year, and 2.2% reported attempting suicide within the past year, an
increase from 0.8% in 2005 (Bray et al., 2009).
POSTTRAUMATIC
STRESS DISORDER
Deployment intensity and multiple deployments also increase the risk of
developing PTSD (Shen, Arkes, & Pilgrim, 2009), and OIF and OEF veterans
who screen positive for PTSD or depression are twice as likely to report alcohol misuse as those without a positive screen (Jakupcak et al., 2010). Data
from DoD postdeployment health assessments (PDHAs) completed within
30 days of return, and postdeployment health reassessments (PDHRAs)
completed 90 to 180 days postdeployment, indicate that 7% of active duty
service members endorsed PTSD symptoms immediately on return and 9%
at follow-up (Armed Forces Health Surveillance Center, 2010). Rates are
higher among Reserve component service members than among those on
active duty. Further, mild traumatic brain injury (mTBI) and PTSD symptoms are strongly correlated (Friedemann-Sanchez, Sayer, & Pickett, 2008;
Military Combat Deployments and Substance Use
13
IOM, 2008), making it difficult to clinically discern the etiology of insomnia,
irritability, fatigue, and hyperarousal symptoms (Hoge, Goldberg, & Castro,
2009; Stein & McAllister, 2009). Unhealthy substance use can complicate
these conditions.
Behavioral Health Treatment When Deployed or Reintegrating
After Deployment
In responding to substance use, military organizations have dual roles—
they enforce discipline in part to maintain force readiness and they promote
resilience, optimal health, and well-being of service members as part of their
public health mission. DoD policies distinguish use of legal substances (alcohol and prescriptions) from illicit substances (cocaine) and unauthorized
or illegal behaviors (e.g., bringing into barracks, use without prescription,
sharing) in its response to substance use.
IN-THEATER
SERVICES
Behavioral health personnel deploy as part of combat stress units, combat support units, or as support personnel in combat units (Hoge, 2011).
Although a recommended ratio of one behavioral health professional for
every 700 soldiers was adopted, the MHAT–IV (2006) reported this ratio is
not maintained in all areas. Service members experiencing combat stress
reactions in-theater can be referred to a “restoration program,” a structured
3- to 5-day curriculum designed to maximize the return-to-duty rate of those
who are temporarily impaired or incapacitated. Over 90% of behavioral
health providers surveyed by the MHAT–VI reported that they felt confident in their ability to assess and treat soldiers with suicidal ideation, combat
stress reactions, acute stress disorder, or PTSD; however, only 63% felt confident in their abilit…

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