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Ms. Adams is supported by a predoctoral fellowship from a Ruth L. Kirschstein National Research Service Award from the National Institute on Alcohol Abuse and Alcoholism (F31 AA021030). Drs. Corrigan and Larson report no financial relationships with commercial interests. Dr. Freedman has reviewed this editorial and found no evidence of influence from these relationships.
The content is the sole responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health.
From the Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus; and the Heller School for Social Policy and Management, Brandeis University, Waltham, Mass.
Address correspondence to Dr. Corrigan (email@example.com).
Copyright © 2013 by the American Psychiatric Association
The study by Miller et al. (1) in this issue of the Journal reminds us that, while the military presents strong messages that discourage alcohol abuse, it has been unsuccessful in deterring harmful drinking. An age-old warrior culture belief persists—that frequent binge drinking is acceptable, normative, and rational because warriors “work hard and play hard.” Other contributors to ongoing excessive drinking are negative attitudes toward help-seeking and stigmatizing beliefs that seeking alcohol treatment is career-ending (2). Because of the prevalence and consequences of substance abuse, a recent committee of the Institute of Medicine named alcohol and prescription drug abuse in the military a public health crisis (2). Miller et al. have provided important additional insight into the emerging evidence of the misuse of substances by injured military service members. Their findings expand the growing evidence that substance misuse and substance use disorders are likely to co-occur with mild traumatic brain injury (TBI). At the same time, their findings require contextualization of the relationship between injury onset and identification of substance use disorders, as well as what is known about combat-related TBI and its relation to postdeployment substance misuse.
It is both remarkable and puzzling that service members in the first 30 days following a mild TBI were significantly more likely to receive an initial diagnosis for all but one addiction-related disorder when compared with others who received treatment for a different injury. While the occurrence of a TBI is systematically associated with subsequent diagnosis of addiction-related disorders in a way that other injuries are not, a causal relationship between mild TBI and onset of dependence would not appear plausible because the behavioral patterns leading to a dependence diagnosis rarely manifest in just 30 days. Clearly, the injury is occurring during a period of maladaptive substance use. Perhaps the diagnosis and treatment of behavioral symptoms from mild TBI facilitates the identification of coexisting substance use problems in a way that treatment for other bodily injuries does not. Another possibility that leads to differential identification of a person with emerging substance dependence is if the consumption pattern of those with dependence was more likely to result in a TBI compared with other injury. Indeed, at least one large population study found that the likelihood of an injury event including a TBI increased dramatically with increased blood alcohol content (3). It is plausible that across all drugs, consumption patterns consistent with addiction-related disorders creates more risk for incurring an injury that affects the brain, whether that is due to poorer decisions, greater disinhibition, and/or more impaired motor control. Such a conclusion complicates the roles of risk and consequence, obfuscating an easy public health implication.
Even though Miller et al. focused on service members during the years overlapping with U.S. operations in Iraq and Afghanistan, it is unclear to what extent the diagnoses of addiction-related disorders in this study occurred during the months immediately postdeployment. The TBI diagnoses examined were from Military Health System data that do not typically contain medical records from combat zones; thus, the TBIs likely occurred during noncombat activities (e.g., stateside car crashes or sports injuries). As such, the TBIs in this study had more opportunity to be associated with an alcohol-related event than those occurring in combat zones, where the prohibition of alcohol significantly reduces the opportunity to drink excessively. Thus, Miller et al. have identified important issues about the likelihood of receiving an addiction-related disorder diagnosis after a noncombat-acquired TBI; however, the contribution of either combat-acquired TBI or postdeployment binging is not clear.
Two studies have examined the risk of harmful alcohol use postdeployment after a combat-acquired TBI. A recent study used a 2008 Department of Defense (DOD) population-based survey of service members to assess the association of self-reported combat-acquired TBI with postdeployment binge drinking. For those returning from a combat deployment in the past year, having experienced a TBI was associated with increased odds of past-month frequent (at least weekly) binge drinking after controlling for demographic characteristics, lifetime combat exposure, and posttraumatic stress disorder (4). Another self-report survey study of service members from the United Kingdom returning from Iraq and Afghanistan found that those who experienced a mild TBI were 2.3 times more likely to report possible alcohol misuse than those without a TBI (5). The findings of these two studies demonstrate a link between combat-acquired TBI and actual drinking behavior. A third study of veterans from these wars in Veterans Administration (VA) medical clinics measured diagnoses rather than consumption behaviors, as did the Miller et al. study, and found that those with ongoing postconcussive symptoms from a TBI were twice as likely to have addiction-related disorder diagnoses compared with veterans without a TBI (6). None of these studies measured precisely how much time had elapsed after the injury event, nor were TBI patients compared with others with injury events. Thus, Miller et al. make a contribution in focusing on the immediate period post-TBI and comparing TBI patients with others with injuries.
There are several implications of this study for military policy development as well as for civilian and military medical providers who care for service members, particularly those with TBI. Clearly, more research is needed to examine how combat-acquired TBI relates to postdeployment excessive substance use and the later development of addiction-related disorders (7). The presence of TBI should trigger substance use screening and brief intervention that are designed, implemented, and evaluated with military populations. Given the heightened risk of TBI and the high prevalence of binge drinking in the military, research on what constitutes effective tertiary substance use prevention programming for those with TBI is warranted. Additionally, to reduce consequences of substance abuse among those with TBI will require more effective early interventions in primary care and better access to acceptable treatment options.
The Institute of Medicine committee found a lack of consistent implementation of evidence-based prevention, screening, early intervention, and treatment services in the DOD (2). Effective environmental prevention strategies (e.g., partnerships between base commanders and local communities around sales to underage drinkers) are important because most service members are at peak ages for alcohol use disorder. The military should mount proven prevention efforts for those with TBI, including mandatory use of a validated alcohol screening tool in primary care accompanied with medical provider education on evidence-based brief counseling and intervention (8). The military’s current screening program centers on deployment events, and referrals for care associated with alcohol use are rare (9).
Effective pharmaceutical treatments for alcohol dependence (naltrexone and extended-release naltrexone) are recommended in the VA/DOD Clinical Practice Guidelines (10), which could be used for those with TBI, but these treatments are rarely applied (2). A recent memo clarified that current DOD policy permits primary care clinicians to provide confidential counseling for emergent alcohol problems without notification of the patient’s commander (2); however, to destigmatize alcohol treatment will require new DOD policy permitting confidentiality. A pilot program permitting confidential access to the Army Substance Abuse Program found that participants highly valued this option (11), and other preliminary data revealed increased referrals and volunteers for treatment, including officers who otherwise rarely enter treatment (2).
The findings of the Miller et al. study not only underscore the need for continued attention to addiction-related disorders among service members but add to the growing evidence that TBI may co-occur with substance misuse and abuse. Preventive and ameliorative interventions will not only need to be efficacious for addiction-related disorders but must also be proven effective for those service members who have a history of TBI.
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