Joseph A. Troncale, MD, FASAM

Our veterans are special in many ways. They have made contributions to our safety and freedom in ways that are impossible to calculate or appreciate. Exposure to the trauma
of mayhem and combat creates severe problems because even the best of training cannot prepare mortals for the hell of battle. Combat veterans suffer disproportionately with regard to post-traumatic stress disorder (PTSD) and substance use disorders
(SUDs). Although PTSD has been known by various names
over the ages, such as “battle fatigue” and “soldier’s heart,” the psychological trauma is the same.

The incidence of SUD in veterans with PTSD is over 20 % which is twice what one would expect to see in the general population. Veterans with PTSD and SUDs tend to be binge drinkers if using alcohol. This is thought to represent the need to self-medicate because of the intensity of the symptoms at any given time. Binge drinking causes its own set of problems with increased problems to the liver and brain.

Opiate use disorder is seen especially in veterans who had suffered wounds or injuries of various types and then had surgeries or were for whatever reason placed on opiate therapy. Many veterans are placed on chronic opiate therapy (COT) because of the severity of their pain and injuries. This increases the chances of addiction because of the increased exposure.

Veterans with PTSD smoke more than age-matched control subjects. Cigarette smoking kills more individuals with addiction than any other substance. Smoking cessation is something that can be minimized in the face of other addictions, but it needs to be addressed with the same intensity as other addiction problems.

What is behind this phenomenon of co-occurring substance use disorder and PTSD? There are a number of factors involved. In this article, I plan to outline what I believe to be the most important issues from both the neurobiological side to the psychological aspects.

From the neurobiological side, addiction has a genetic as well as an environmental side. Not everyone has the genetic makeup for addiction, so some individuals are spared the problems of addiction simply by having the right parents. There are certain changes in the brain that have to take place to develop a substance use disorder. There is a dysregulation of dopamine in the brain’s pleasure center in a part of the brain called the limbic system, which, when triggered, causes the compulsive use of a substance. Use of addictive substances, coupled with the genetic predisposition, causes permanent changes in this part of the brain, setting up the addictive process. When a veteran with PTSD exposes himself or herself to addictive substances, the chances of developing a SUD increases dramatically.

Couple this with trauma. Another part of that same part of the brain that is responsible for addiction is directly connected to the area of the brain called the amygdala, which is the part of the brain that reacts to trauma. In animal models, if the animal is subjected to trauma and the animal’s amygdala is subsequently examined with neuroimaging techniques, that area of the brain will enlarge permanently. The amygdala is sensitized to sights, sounds and smells which bring previous experiences to the forefront of the individual’s consciousness.

In the case of the combat veteran, flashbacks, re-traumatization, or other triggers not only spark a “flight or fight” response, but it also contributes to further dysregulation of that part of the brain that is connected to the dopamine/pleasure/addiction center of the brain contributing to relapse behaviors. The affected individual is merely trying to relieve the stress, but what has occurred is a pathological way of reacting to the stress with alcohol or drugs.

From a psychological standpoint, PTSD is a breakdown of normal defense mechanisms creating chronic stress. This leaves the individual living with PTSD in a state of hypervigilance, anxiety and fatigue. Sleep comes with difficulty. Intrusive emotions interfere with day-to-day life.

Treating PTSD and SUD requires a parallel approach to handle both issues at the same time. The substance use requires detoxification and involvement in recovery programs for rehabilitation. The PTSD requires moving toward a paradoxical position psychologically. It is important for the veteran to get in touch with the feelings of fear and anxiety rather than suppress the emotions. It is the suppression of feelings that prolong and intensify the symptoms of flight and fight. This is called exposure therapy. It is giving the veteran the ability to accept the troubling emotions that drive the engine of tension. Sometimes, but not always, medications are needed to calm the brain enough to be able to engage in treatment. Such medications must be non-addictive. Unfortunately, not all practitioners providing care to veterans are aware of the addictive properties associated with certain medications, such as benzodiazepines, used for the treatment of anxiety, and the treatment can worsen the problem.

The overarching principle of treatment is to allow the veteran to understand his/her self-worth. With self-validation comes the ability to sit with uncomfortable feelings. With the ability to sit with the feelings, the veteran can then move toward his/her values and lead a meaningful life. Continued support in a supportive community is essential for ongoing stability and quality of life for the affected veteran.

The treatment of PTSD and SUDs is not only possible but essential for the survival and well-being of our veterans. They deserve the best possible care we can provide for them. The ability to do so is within our grasp. We need to be there for them as they were there for us.

Joseph Troncale, MD is Retreat’s Medical Director. Over the past 35 years Dr. Troncale has established himself as one of the premier physicians working in the field of addiction. He is both a fellow and a member of the American Society of Addiction Medicine (ASAM) and was named Outstanding Clinician by Addiction Magazine in 2010. He has publications in journals such as The Journal of Addictive Diseases and other peer-reviewed journals.