PTSD & Substance Abuse in Veterans

Post-traumatic stress disorder (PTSD) is a mental health disorder that can occur after exposure to trauma. It can happen if you witnessed or directly participated in the traumatic event.¹ PTSD is common in veterans because of the nature of their work. During military service, veterans may be exposed to violent, life-threatening events and experiences. The National Center for PTSD explains that around 7-8 people out of 100 in the general population develop PTSD at some point; the number of veterans who develop PTSD varies by service era but is higher than in the general population.²

PTSD commonly co-occurs with substance use disorder and research has shown that a person with PTSD may be up to 14 times more likely than people without PTSD to have an SUD.²¹ People who have PTSD are more likely than others to use substances as a way of coping with their PTSD symptoms.⁴ Keep reading to learn more about PTSD, PTSD and substance abuse, and PTSD facts and treatment that can help you start the path to recovery.

What is PTSD?

PTSD can occur in anyone who has witnessed or experienced significant trauma, which may explain its high prevalence in veterans who have seen combat. It is a psychiatric disorder that can involve mentally re-experiencing the event (e.g., flashbacks), avoidance behaviors, hyperarousal and reactivity, and cognitive and mood symptoms.^{3, 5} Many people with PTSD use alcohol or drugs to cope with or manage the condition. This may alleviate symptoms temporarily, however, if a person develops a dependency on a substance, withdrawal symptoms (which often mimic symptoms of PTSD) could further reinforce the cycle of self-medication, and those with PTSD may therefore be at increased risk for developing a substance use disorder.³

A medical professional who is experienced in mental illness, such as s psychiatrists or psychologist, uses certain screening tools to assess and subsequently diagnose a patient with PTSD.³ There are a variety of screening tools, such as the Clinician-Administered PTSD Scale (CAPS) or Structured Clinical Interview for DSM (SCID), and self-administered questionnaires such as the PTSD Checklist (PCL) and the Impact of Events Scale-Revised (IES-R). Each has different features that can make them useful for helping to assess PTSD.^6,7

All VA medical centers employ mental health professionals to provide screening, diagnosing and treatment for PTSD.⁸

What Causes PTSD?

PTSD may occur in anyone following exposure to one or more traumatic events, such as combat, witnessing death or the horror of war. The clinical presentation of PTSD varies and may include components of fear and horror, but also feelings of helplessness and even feeling guilty or powerless in an inability to take action to influence events. Not all veterans who experience potentially traumatic episodes of combat will develop PTSD. Some people never experience PTSD symptoms at all and others recover from symptoms relatively quickly after trauma. Still others, however, continue to experience the persisting symptoms of PTSD.⁴

Risk factors can influence your chances of developing PTSD, such as the duration of your exposure to trauma or sustaining injuries during the event, as well as personal characteristics like your age, gender, history of trauma, whether you have another mental illness, having an addiction, dealing with added stress after the event (such as the death of a loved one), and whether you had social support after the event.^{3 risk factors and 4}

PTSD & Substance Abuse Amongst Veterans

Co-occurring PTSD and substance use are common within veteran populations. Each disorder can influence the other. As previously mentioned, veterans often use substances to cope with symptoms of PTSD.⁴

The VA National Center for PTSD provides statistics for veterans with PTSD, which vary by service era. This includes:²

• Operations Iraqi Freedom and Enduring Freedom. An estimated 11-20 out of every 100 (11-20%) veterans who served in these missions develop PTSD each year.
• Gulf War. Around 12 out of every 100 (12%) veterans develop PTSD in a given year.
• Vietnam War. An estimated 15 out of every 100 (15%) veterans were diagnosed with PTSD as of the most recent study in the 1980s. Researchers believe around 30 out of every 100 (30%) Vietnam veterans have had PTSD during their lives.

The National Institute on Drug Abuse (NIDA) says that more than 1 in 10 veterans receives a substance use disorder (SUD) diagnosis at some point, and that 11% of veterans who come to the VA for the first time meet the criteria for SUD.⁹  In addition, 63% of Afghanistan and Iraq War veterans who received an SUD diagnosis also met the criteria for PTSD.⁹ Veterans with an SUD are 3-4 times more likely to have a co-occurring PTSD diagnosis.⁹ 

PTSD & Alcoholism

PTSD and problematic alcohol use are closely linked in veterans. Alcoholism and PTSD can worsen symptoms of each other, and either disorder can develop first; people who drink alcohol can have PTSD, and people who have PTSD often abuse alcohol.^{10 top} In fact, experiencing trauma, whether a person develops PTSD or not, can lead to problematic alcohol use. The National Center for PTSD explains around three-quarters of people who are involved in abuse or survive traumatic accidents, illness, or disasters report drinking problems.^{10 2nd half}

Binge drinking, which means that someone drinks 4-5 drinks over the course of 1-2 hours, is a common alcohol-related problem in veterans with PTSD.¹⁰ If you’re a combat veteran who experienced trauma, additional risk factors can affect your chances of developing alcoholism, including having chronic pain and/or having persistent health problems.⁹

PTSD & Drugs

PTSD coupled with drug use is also common in veterans; NIDA reports that rates of illicit drug use among veterans increases once they leave active duty. Marijuana appears to be the most commonly used drug, with 3.5% of veterans saying they used the substance, while 1.7% used other illicit drugs.⁹ Opioid misuse is another major concern among veterans, especially since many veterans are prescribed opioid medication to deal with chronic pain. Opioid overdose rates in veterans rose from 14% in 2010 to 26% in 2014.⁹ The mortality rate for opioid overdose is 1.5 times greater in veterans vs. the general U.S. adult population.

Symptoms & Triggers of PTSD

Symptoms of PTSD can vary from person to person and can be influenced by specific triggers. Symptoms of PTSD often show up soon after the trauma, but they can also begin months or years after the event. People can have ongoing and persistent symptoms that come and go for years.⁵ 

Common symptoms of PTSD include:^{3, 5}

• Re-experiencing the event. You may feel like you are reliving the trauma (flashbacks or nightmares), especially if you are exposed to a trigger that reminds you of the event.
• You avoid things, people, or places that remind you of the traumatic event. You might avoid talking about the event or your feelings about it with others.
• Cognitive and behavioral symptoms. You might feel numb, depressed, mistrustful of others, think the world is dangerous, or feel shame or guilt about the event. You might feel like you should have done more or that you could have prevented the event from happening. You could have increased negative feelings about yourself. Many people feel unable to experience pleasure.
• Hyperarousal and reactivity. You may feel “keyed up” or “on edge,” like you must always be on the lookout for danger even when there’s no apparent threat. You might feel angry or irritable, have trouble sleeping, or be easily startled.

You may not always be consciously aware of triggers that elicit a PTSD reaction. Common triggers of PTSD can include anything that reminds you of the event, such as:^{3, 12}

• Words and phrases.
• Objects.
• Situations.
• People.
• Sounds.
• Thoughts, memories and feelings.
• Recent traumatic events.

How is PTSD Treated?

PTSD treatment usually involves medication, psychotherapy (i.e., talking to a licensed therapist), or a combination of the two.³ Antidepressants are the most studied type of medication for treating PTSD symptoms. This includes selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft) and paroxetine (Paxil) and serotonin-norepinephrine reuptake inhibitors (SNRIs), such as fluoxetine (Prozac) and venlafaxine (Effexor).⁵ They are commonly used to alleviate feelings of sadness, anxiety, anger, and numbness. You may receive other medications to help with sleep problems, nightmares, or other hyperarousal symptoms.³ 

Talk therapy can involve different approaches that have been found to be useful for PTSD. This includes trauma-focused therapies such as:^{5, 13}

• Cognitive Processing Therapy (CPT), which involves changing how you think about the trauma to help change the way you feel.
• Prolonged Exposure (PE), which involves talking about the trauma until you no longer feel upset about it.
• Eye Movement Desensitization and Reprocessing (EMDR), which works by helping you think about the trauma as you focus on the hand movements of the therapist. It helps your brain reprocess, or work through, the traumatic events.
• Cognitive Behavioral Therapy for PTSD (CBT for PTSD), which includes elements of PE and CPT as well as other specific strategies to help you find helpful ways of dealing with feelings and behaviors related to the trauma.

How Long Does PTSD Treatment Take?

The exact duration of PTSD treatment can vary widely from person to person. Factors that can influence treatment duration include the severity of the disorder, the intensity of the treatment, and other physical or mental health problems you may be facing. Treatment that works for one person may not work for another, so it can take time and a few tries to find the right treatment for you.³ 

Is PTSD Treatment Effective?

Several treatments have demonstrated efficacy in treating PTSD. In particular, research has shown strong evidence supporting the effectiveness of PE, CPT, and CBT for PTSD.¹³ Additionally, a clinical review of 24 studies on EMDR showed it to be an effective form of treatment for PTSD, with 7 out of 10 reviewed studies demonstrating it to be superior to CBT for PTSD, and 12 studies indicating that it helped produce a quick reduction in negative feelings and traumatic images.¹⁴ 

How to Find PTSD Treatment Programs

It’s a good idea to talk to your primary care physician as a starting point for PTSD treatment. If you are a veteran, you can find a PTSD treatment program through the VA. All of the VA’s medical centers offer PTSD treatment.⁸ If you wish to find a treatment program for PTSD and addiction, you may also search for a rehab in your area on the Substance Abuse and Mental Health Services Administration’s Behavioral Health Treatment Services Locator.

VA PTSD Ratings & Benefits for Veterans

The VA issues disability ratings for PTSD that refer to the percentage that you are disabled by the condition. These ratings for PTSD can vary depending on the severity of the condition and includes graduating ratings of 0%, 10%, 30%, 50%, 70%, or 100%.^{15 p.11 and 16 background} The VA states that your rating is based on different criteria, including:¹⁷

• The proof you give them (which can include reports from your physician or results from medical tests),
• The results of your VA claim exam (also called a compensation and pension, or C&P, exam), if they decide that you need this exam, and
• Additional information from other sources (like federal agencies).

According to the VA, you may be eligible for disability coverage if you have PTSD, but you must meet specific requirements, namely:¹⁸

• The stressor happened during your service,
• Your symptoms have decreased your level of functioning, and
• You have received a PTSD diagnosis from your physician.

You can get free healthcare from the VA for any condition related to service (like PTSD).¹⁹  Provided that you meet the necessary criteria, your PTSD treatment should be covered by the VA.¹⁵ For non-service-related conditions, you can use VA coverage in addition to additional healthcare coverage you may have (such as Medicaid or private health insurance), but you will need to provide information about your other coverage to the VA. The VA says that while you may have a copay for those services, you won’t be billed for any balance that is unpaid by your insurance company.²⁰ Consult the VA at 877-222-8387 to find the right resources for your needs, to determine your specific coverage, or for any additional questions you may have.¹⁸ 

How Effective is Rehab at Treating PTSD and Addiction?

As PTSD often co-occurs with conditions like addiction, many facilities offer treatment that addresses both. This is known as dual diagnosis treatment or treating co-occurring PTSD and substance use disorder. Veteran-specific treatment programs can be effective for treating veterans with both PTSD and addiction. Trauma-focused therapies and, in many cases, medications, are offered by drug rehabs that provide these services. These treatments have been demonstrated effectiveness in reducing the frequency or intensity of symptoms in helping people recover from addiction and PTSD.⁵