Editor's note:
As service members return home from deployment to Iraq and Afghanistan and return to civilian life, community providers increasingly play a role in their care. Post-traumatic stress disorder (PTSD), mild traumatic brain injury (TBI), and other conditions may not be immediately apparent on returning home or separating from military service, and these and other clinical conditions have a complex interaction with substance abuse. In this interview, Lisa Najavits, PhD, Professor of Psychiatry, Boston University School of Medicine; Lecturer, Harvard Medical School; and Psychologist at the VA Boston Healthcare System and McLean Hospital, describes these relationships and the diagnosis and treatment of substance abuse in military service members.

Medscape: Let's talk about substance use disorders (SUDs) in service members and veterans and how they intersect with TBI or PTSD.

Lisa M. Najavits, PhD: This is an important topic as military service members and veterans have elevated rates of all 3 disorders -- PTSD, SUD, and TBI. Moreover, some have all 3 disorders, which we call a "trimorbidity." Each of the disorders, and certainly the combination of two or three of them, creates suffering and functional problems that need to be addressed. The goal is early and strong care to prevent a chronic course over time.

It is also useful to recognize that this trimorbidity affects a wide range of populations: people who are homeless, who have experienced child abuse or domestic violence, and those who have survived motor vehicle or other accidents.^[1] Indeed, military service members and veterans may also have a history of such experiences prior to their military experiences or after their service. There are many different pathways to this trimorbidity.

Many providers outside of substance abuse treatment programs may have no formal training in SUD and may not screen for it. Yet SUD is one of the most common types of psychiatric disorders in the United States -- indeed, the fourth most common with a 14.6% lifetime prevalence rate.^[2] Thus, it is key to learn about SUD, whether or not the provider ultimately treats it directly or refers the patient to specialty care for it.

Substance abuse and substance dependence are Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) terms (see Tables 1 and 2 for the specific diagnostic criteria of each disorder). Overall, "abuse" is the less severe form, and "dependence" more severe.

Table 1. DSM IV Criteria for Substance Dependence^[3]

Table 2. DSM IV Criteria for Substance Abuse^[3]

A few points may also be helpful when thinking about SUD among military service members and veterans.

First, in the current war cohorts (Iraq and Afghanistan), the military has had a much stricter policy to discourage use of substances than in prior war cohorts such as Vietnam. Thus, service members may have much less access and use while on active duty, but on returning home may be vulnerable to using when they are coping with post-deployment stressors.

Second, we know that there are gender-related factors in the development of SUD. Men outnumber women in SUD by 2 to 1 in the population at large. As men are overrepresented in military and veteran populations, SUD is thus an extremely important issue to target. However, in the United States, women's rate of SUD is increasing over time as they now have less stigma for using and more access to substances. Thus, attending to it in both genders is necessary, including in military and veteran populations as the number of women serving in the military is higher than ever before.

Third, it is key to inquire about the type of substance used. Alcohol is the most common SUD in the population at large and among military personnel and veterans as well. However, opioids prescribed for physical injuries and pain can lead to dependency, and this is increasingly recognized as a serious issue for military personnel and veterans.

Finally, from a developmental and cultural perspective, young adulthood is a prime time for experimentation with substances in the United States. This is also the age-group that represents the majority of service members and new veterans.

In short, there are many factors that combine to create vulnerability for SUD among military and veterans, and this underscores the need to address it directly as part of healthcare.

Medscape: Can you say more about the comorbidity of SUD, TBI, and PTSD?

Dr. Najavits: Yes. Comorbidity is the norm for each of these disorders. It is said that comorbidity is the "expectation, not the exception." Among people with PTSD, 80% have 1 or more co-occurring psychiatric conditions; for SUD, 60%; and for TBI, 65%.^[4] Moreover, beyond psychiatric conditions, there may also commonly be comorbid medical conditions, life problems (such as homelessness and poverty), and/or cognitive impairments. The combination of these disorders is associated with greater clinical severity and worse treatment outcomes than any of these disorders alone. Problems of aggression, legal problems, motivation, and harm to self or others may be prominent. Overall, these tend to be multiply burdened patients, and all of their problems need to be addressed as part of high-quality medical treatment.

Our understanding of the relationship between the 3 disorders is still developing, but we do know that each disorder -- PTSD, SUD, and TBI -- is a risk factor for the others. There also may be other factors, such as poverty, that create a risk for all three.^[4] We need more sophisticated models for how these disorders connect to other risk factors as well.

In terms of typical course, generally SUD precedes TBI but follows PTSD; PTSD typically follows TBI. Use of substances may be highly associated with the traumatic event that results in TBI or PTSD. For example, driving under the influence of alcohol can result in TBI and PTSD.

In the initial aftermath of TBI, SUD typically decreases.^[5-7] There are various reasons for that. It may be a "teachable moment," also called "post-TBI growth," where the individual recognizes the negative consequence that the substance use has wrought, such as a car accident. After a TBI, there is also social narrowing -- less socializing due to being in a rehabilitation setting or other controlled environment and thus less substance use. TBI patients may also have decreased substance cravings, and decreased activity generally, and substance use is one of the things that fall by the wayside. A minority of patients do increase substance use immediately after TBI, perhaps as self-medication or for other reasons. Two or 3 years post-TBI, however, there are typically increases in substance use. The patient may be renewing social ties and more active. Treating SUD at each step during recovery from TBI is important. We also need more studies of patients with no history of SUD prior to the TBI to better address the complex relationship between SUD and TBI.

For the provider, the bottom line is to routinely assess for PTSD, TBI, and SUD as well as other possible psychiatric disorders and impairments. Try to identify the time of onset of each condition, the course over time, periods of abstinence from substances and how this had an impact on the other disorders, and response to treatments (if any). Monitor the symptoms of each disorder throughout treatment. Provide treatment for all 3 disorders if each is present, or refer to appropriate providers for each. Teach the client about the risk for retraumatization and the need to contain substance use or eliminate it. Teach coping strategies in place of self-medication via substance use. Instill hope and the realistic expectation that recovery from all 3 disorders is possible. Engage them in a positive path of recovery-oriented activities and rehabilitation. Encourage social supports and positive family involvement. Educate the family as well as the patient.

Medscape: Are there ways that these factors have a particular bearing on the military population?

Dr. Najavits: The typical sociodemographic pattern of an individual with this trimorbidity is a young male from a disadvantaged background. This is also the profile of many who serve in the military. During military service, combat exposure subjects these individuals to trauma, including blast explosions, being struck by an object, experiencing an acceleration or deceleration movement, and having a foreign body penetrate the brain.

PTSD and TBI are now considered "signature wounds of war," and SUD is one of the most important consequential, related disorders.

Medscape: Let's talk about screening and diagnosis, given the overlap of these conditions.

Dr. Najavits: First, each disorder (SUD, PTSD, and TBI) has various symptom overlaps and/or may appear to mimic other psychiatric disorders. The diagnostic picture can become quite complicated. For example, stimulants such as cocaine or methamphetamine can mask depression and can mimic mania, and benzodiazepine and alcohol use can both cause and masquerade as depression. PTSD is sometimes called "the great pretender" because it can be so readily confused with other conditions such as depression, psychosis, bipolar disorder, attention deficit-hyperactivity disorder, and borderline personality. In turn, some of the symptoms of TBI, such as impulsivity, a core symptom in many TBI patients, can be interpreted as other psychiatric disorders, such as mania or one of the personality disorders.

We also know that substance use and withdrawal can increase or decrease symptoms of other comorbid disorders. For example, substance use can increase PTSD symptoms such as agitation, hypervigilance, and arousal symptoms. On the other hand, other PTSD symptoms such as sleep problems and social problems may be decreased by use of alcohol. The suggestion from a clinical perspective is to obtain a thorough history of each disorder. It is also important to use validated instruments. There are some excellent, easily accessible, free validated instruments available.^[8] The Mini-International Neuropsychiatric Interview is a structured interview for all of the key DSM-IV disorders. It is available online at www.nccpsychiatry.info/File/MINI500.pdf. Table 3 lists additional useful instruments.

Table 3. Instruments for Assessing for PTSD/Trauma and Substance Use Disorders

It is a good idea to provide the results of the assessment to patients, if possible. Many times a patient will participate in lengthy questionnaires and never be told their diagnoses. It is helpful to educate them about their conditions and symptoms, such as explain the symptoms of dissociation or substance withdrawal.

Less is more when assessing trauma in SUD patients. When providers hear that the patient has experienced a trauma, they may request a lot of detail, which can be counterproductive.^[9] For example, military sexual assault can be a key issue to address, but asking for details can trigger substantial distress when the patient is not in a treatment context, so it is better to minimize the level of trauma detail unless the detail is necessary.

It is important to ask the patient to abstain from substances the day of the diagnostic interview. Some recommend scheduling the evaluation in the morning to minimize the possibility of substance withdrawal during the interview. If someone is intoxicated at the time of the interview, do not do the assessment at that time. Kindly and compassionately tell the patient to come back. Get them a safe way to get home if needed, but do not conduct the assessment under those conditions.

It is important to be aware of reasons that a patient may or may not want to disclose these conditions. Patients may fear a number of specific consequences, such as rejection from treatment programs for active SUD or loss of custody of children. Alternatively there may be incentive to disclose. For example, reporting PTSD symptoms may be associated with financial benefit from compensation claims, so be aware of possible contingencies that may impact the assessment process.

Listen closely to patients' reasons for using substances: They may be using to feel normal, to access feeling, to socialize, or to get to sleep at night. Many reasons may connect with PTSD or TBI symptoms or with other issues in the patient's life. Ask the patient directly: "How does substance use impact you in the short term? What are your reasons for using?"

Provider training is critical. Many providers are not trained to do assessments for SUD, PTSD, or TBI.

Medscape: Let's talk about how treatment for SUD occurs with these other conditions.

Dr. Najavits: The current state of the art is a compassionate approach that recognizes SUD as a medical disorder and not a moral failing, character flaw, or lack of will. Historically, we know that the treatment of SUD patients has been rife with judgment. Even well-intentioned, compassionate providers often have no training in SUD. Providers tend to refer patients out and do not screen adequately, believing it is beyond their competency. Certainly if a provider does not have necessary training, patients should be referred to solid programs that do possess SUD expertise. The realization is growing, however, that substance use is part of the patient's overall health and the community provider should engage with patients on the topic. Many community-based providers can do basic interventions such as SBIRT (screening, brief intervention, and referral to treatment). Some may go on to learn more in-depth interventions.

The comorbidity of PTSD, SUD, and TBI may also lead to misinterpretation of symptoms. For example, domains such as memory and social skills may be impaired as a result of each of these disorders. A patient with memory problems may be perceived as treatment resistant, noncompliant, or difficult to engage, when it may be a function of the disorders.

It is also important for providers to know that each of the disorders has an optimistic prognosis and that substantial recovery is possible in many cases. Care that is provided early and strongly, coordinating among the different treatment systems of PTSD, SUD, and TBI, is key. Even patients with a chronic form of these disorders can see substantial improvement with evidence-based approaches. Providers should be hopeful, and should instill hope in their patients, even when all 3 disorders are diagnosed.

Research into treatment options is at an early stage. Most models developed so far for PTSD comorbidities have completed just 1 pilot study, but there are various studies underway. For PTSD/SUD comorbidity, the only model already established as evidence-based, effective treatment is Seeking Safety. By way of disclosure, that is a model that I developed. There are also various other models that have undergone at least 1 study, including Concurrent Treatment of PTSD and Cocaine Dependence; Substance Dependence PTSD Therapy; Collaborative Care; Transcend; and others.

Currently, just a few studies include TBI, and none include all 3 (PTSD, SUD, and TBI). Teaching coping skills and incentive-based treatments have been found helpful for TBI and SUD. It is important to recognize that treatments for one diagnosis may not be appropriate if 1 or more of the other diagnoses are present. For example, a PTSD patient could benefit from benzodiazepines, but if the patient has comorbid SUD, that may be contraindicated. Similarly, exposure-based therapies for PTSD may be too emotionally intense for a patient with SUD or too cognitively challenging for a client with TBI. Twelve-step programs are widespread and helpful, but the PTSD and/or TBI patient may need help in making use of them.

Historically, mental health, substance abuse, and TBI treatment programs have had different cultures, different staffing, different assessments, and different treatments. Convergence is occurring across treatment systems to some degree, but it still remains early.

SUD patients, especially military personnel, veterans, and younger patients, may not be willing to take an abstinence approach toward substances. Harm reduction is an approach that has gained recognition in the past 10-20 years. Moderation management -- the notion that people can recover to safe levels of use -- may be a realistic goal for some of these patients (those who are less severe). It is important for community-based providers to connect with their local VA to learn about available programs and to encourage patients to make use of VA treatments when possible. VA care is now considered some of the best in the country, based on numerous metrics. The VA has made major strides in improving its quality of care, sensitivity, and engagement of patients after the Vietnam era, when it was perceived as suboptimal.

Finally, there is now recognition that family involvement is critically important for all 3 disorders, PTSD, SUD and TBI. Providing education to the family can help them cope with changes in their loved one and offer resources for their own support and help. Destigmatizing each of the disorders and helping normalize reactions is useful. Many families focus primarily on the SUD as it typically presents the most flagrant problems, with the PTSD and/or TBI sometimes more hidden. Understanding linkages among all three is key.

Medscape: We talked about some of the principles of treatment, resources, including the VA and screening tools. Is there anything else we should be mentioning, other organizations that may be focused on this topic?

Dr. Najavits: Yes. There are some excellent, free resources on SUD, TBI, and/or PTSD, relevant for providers, patients, and family members.

Substance Abuse and Mental Health Services Administration (SAMHSA) has a lot of provider information on SUD, mental health, and trauma-informed care. SAMHSA also offers a helpline for people looking for assistance locating substance use treatment programs -- 800-662-HELP.

Addiction Technology Transfer Centers are government-funded programs. This organization helps link research and clinical practice, and it provides a lot of educational Webinars, downloadable materials, and other things related to improving addiction care.

The National Center for PTSD posts a lot of useful online materials.

SAMHSA's National Center for Trauma-Informed Care (NCTIC) promotes the implementation of trauma-informed practices in programs and services.

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury offers information to improve psychological health, combat stress, and TBI among military service personnel. This site offers a wealth of information, including Webinars, conferences, and clinical practice guidelines on topics such as SUD, TBI, and suicide prevention.

The National Institute on Alcohol and Alcoholism has a superb Website called Rethinking Drinking

Alcoholics Anonymous, and Narcotics Anonymous offer 12-step programs, and there are also numerous other 12-step programs. These organizations offer important assistance in linking up to community-based 12-step programs. Smart Recovery is an alternative for people who have concerns about the spirituality or other aspects of AA. Another helpful alternative is the Harm Reduction Coalition, which offers strategies to reduce the negative consequences of substance use.

Seeking Safety provides information on PTSD/SUD comorbidity and evidence-based care for it.

For help for families, children, and communities, the National Child Traumatic Stress Network provides a wealth of information.

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