Combat's other toll on veterans: increased risk of addiction

In what is described as the first study of its kind, a UConn professor has found that combat service substantially increased the risk of prescription painkiller abuse and illicit heroin use among active-duty American servicemen.

U.S. combat veterans deployed as part of the global war on terror, since 9/11, have an opioid abuse rate that is higher than servicemen who were not deployed to combat zones, the study found.

The cost of this is high not only in human terms, but in dollars and cents. The estimated health care costs of the abuse due strictly to combat exposure is $1.04 billion per year for prescription painkiller abuse, and $470 million per year for heroin use.

While it was not part of the study, more use of medical marijuana —rather than opioid painkillers, which are more likely to be addictive and lethal —might be an answer, says Resul Cesur, who was the lead author of the study.

"We are not saying that this is going to solve all the problems, but it seems like it's a viable alternative among the policy options," says Cesur, an associate professor of healthcare economics in the School of Business. "This is a sensitive issue. On the one hand people die from opioid abuse; on the other hand, people have severe pain. So, I don't have a quick fix and I don't have a magic solution."

An epidemic of opioids

The opioid crisis, of course, affects many segments of society outside of the military.

According to the National Institute on Drug Abuse:

• In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers such as Vicodin, OxyContin and Percocet, and healthcare providers began to prescribe them at greater rates. "This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive."
• Every day, more than 130 people in the United States die after overdosing on opioids.
• The total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment and criminal justice involvement.

Worse in the military

Cesur's study was published in September by the non-profit National Bureau of Economic Research. Cesur is a faculty research fellow at the bureau, which is based in Cambridge, Mass. His co-authors were Joseph Sabia, an economist at San Diego State University; and David Bradford, a professor of public administration and policy at the University of Georgia.

The authors say the study is the first to estimate the impact of combat deployments in the global war on terrorism on opioid abuse. It was based on findings from two surveys of thousands of male military veterans over a period of years done by the University of North Carolina and the U.S. Department of Defense.

Cesur says the major finding is that combat service causes a seven-percentage-point difference in the likelihood of military personnel abusing opioids.

For example: If in a given sample, one in 100 members of the military who were not deployed to combat became addicted to opioids, it's estimated that eight members of the military who were deployed to combat would become addicted —strictly due to the combat exposure.

"Combat deployments have a severe effect on the likelihood of injury, which is obvious, and also it has a severe effect on mental health. So, we are not that surprised" that combat service would cause higher rates of opioid abuse, Cesur says.

"But we also try to understand the mechanisms. Our work suggests that combat injuries and also psychological stress like PTSD (post-traumatic stress syndrome) due to combat are the reasons behind it. The biggest conclusion from our work is that it's not simply because these people would abuse opioids even if they didn't enlist; quite the contrary. The opioid epidemic in the U.S. military has a lot to do with what servicemembers went through in combat zones."

Other key findings include:

• Combat deployments increase opioid abuse because they are used to treat war injuries, but also because of PTSD and the mental health effects of exposure to battlefield trauma.
• The theater of war increases the likelihood of abuse of opioids with other antidepressants, such as benzodiazepines, which increases the risk of overdose and death.

The study does note progress in addressing the abuse problem: Since 2012, the rate of opioid prescribing by the Veterans Administration has fallen by over 40 percent.