Introduction

Context: Substance use disorders among US military Veterans

The high costs of substance use disorders (SUD) to individuals, communities, and to the nation are well documented (1). They span all areas of life including physical and mental health, family, loss of income and productivity, healthcare costs and involvement in illegal activities. The cost of drug use to the nation has been estimated at $193 billion annually (2), which does not include the costs of alcohol use disorders or the many unquantifiable costs of substance use both to the individual and to communities. Although historically poorly documented, there has recently been a growing interest in understanding substance use and other mental health concerns among military personnel, especially among the estimated 21.5 million US military Veterans (3, 4). After widespread drug use during the Vietnam war era and well-publicized post-war military accidents, the Department of Defense (DoD) adopted a “zero tolerance” policy for drugs and started a program of mandatory, routine urinalysis testing for opiates, barbiturates, amphetamines, and cocaine that could result in serious sanctions including possible discharge (5). Since then, use of these substances among military personnel has declined significantly and has remained around 3%, although self-reported misuse of prescription medications has recently escalated (6).

Men and women in the US Military face many challenges during their service including combat exposure, multiple deployments, physical injury, and psychological trauma. These challenges are risk factors for substance use, and may persist after active service ends (7). Currently, SUDs are among the most common and costly conditions among Veterans, adversely affecting their health, occupational and personal functioning (8). Of Iraq and Afghanistan veterans who were new Department of Veterans’ Affairs (DVA) patients, 10% had a diagnosed alcohol use disorder, and 5%, a drug use disorder (9).

Accordingly, the DoD has made efforts to screen for SUDs and other mental health concerns post-deployment (10, 11). Perhaps not surprisingly, studies show more frequent SUDs among Veterans than non-Veterans. Specifically, military personnel and combat Veterans have higher rates of problematic substance use than their age peers in the general population (5). In particular, there is a high rate of alcohol use and abuse following combat that is comorbid with relationship and aggression problems, with depression, PTSD, homelessness, and criminal justice system involvement (12–15). The proportion of soldiers who meet screening criteria for alcohol misuse is significantly higher after than before deployment (12) and alcohol use is consistently higher among active duty military personnel than among civilians (16). However, although soldiers endorse alcohol problems at rates similar to those of other mental health concerns, referral to alcohol services and use of these services is dramatically lower than for other mental health concerns. Specifically, in one study, of 56,350 active soldiers, 11.8% endorsed alcohol misuse, 0.2% were referred, and only 29 of these were seen within 90 days (10).

Help seeking for substance use disorders

Low rates of SUD services utilization are not unique to veterans. In the most recent National Survey on Drug Use and Health (NSDUH) which includes veterans but excludes active military personnel, only 2.3 million of the 21.6 million persons aged 12 or older who needed treatment for an illicit drug or alcohol use problem in the past year (10.65%) received help in that year (16). Across studies, about one quarter of individuals with alcohol dependence and 38% of those with drug dependence ever receive treatment (17, 18). The overwhelming majority of SUD affected persons who do not seek help do not perceive any need for help (16), a regrettable fact sometimes referred to as ‘the denial gap.’

Findings across the relatively few studies on ‘untreated remission’ suggest that the majority of SUD-affected persons - as many as three-fourths - attain and sustain remission (‘recovery’) without treatment (19–22). Much less is known about this ‘hidden’ population than about persons enrolled in treatment because, since, until recently, the bulk of addictionresearch has been conducted almost exclusively among treatment samples (23). Overall then, it appears that in spite of the high rate of under utilization for SUD treatment, SUD affected persons can and do remit- i.e., ‘recovery’ is a reality. A recent study estimated that 23.5 million Americans are in SUD recovery (24).

Knowledge is lacking about recovery experiences

While there is a rich and detailed knowledge base about the course of SUDs and how SUDs affect people’s lives, much less is known about how people experience recovery, a broad construct that has been defined as ‘“a voluntarily maintained lifestyle comprised of sobriety, personal health and citizenship” (25)p. 222. A handful of long-term studies have

documented changes (improvements) in broad areas of functioning including employment, involvement in illegal activities, physical and mental health as a function of abstinence duration (26); however the generalizability of findings from these studies is typically limited by restricted geography (i.e., studies were conducted in one city), and sample characteristics (e.g., data were collected among individuals recruited in or seeking treatment). Moreover studies have generally focused on outcome domains of concern to society (especially criminal involvement, work) while the priorities of persons in recovery are much broader, including for instance, family and social functioning (27). Finally, we lack knowledge about individuals in stable recovery (i.e., >5 years), and persons who initiated recovery without SUD treatment, as discussed above.

As the broad construct of recovery is increasingly guiding SUD services and policy in the United States and abroad (28–32), documenting recovery experiences in key life areas using large, diverse sample of individuals becomes more critical to informing service development, evaluation and policy. In addition, although the issue of substance use in the military and among veterans is becoming more widely discussed and systematically examined, research has understandably focused on the problem –i.e., substance use. Thus at this writing, we know little about how veterans fare in recovery and whether that differs from civilian populations. The information is needed to identify areas where additional services and/or referrals may be needed as well as to inform vets and their loved ones of what to expect as recovery unfolds.

Survey Objectives

We capitalize on a large national dataset of persons in recovery recruited for a study that examined the costs and consequences of active addiction as well as life experiences in recovery. The Life in Recovery survey, was sponsored by Faces and Voices of Recovery, the largest nationwide grassroots organization dedicated to promote, advocate for and inform the public about recovery from alcohol and drug problems. The survey was designed as a first step to documenting psychosocial functioning in key life areas in a large sample of persons with diverse experiences in terms of addiction, recovery path, and duration. Findings for the overall sample as well as gender subgroup comparisons were presented elsewhere (33, 34). The aim of this study is to compare life experiences in active addiction and since entering recovery between veterans (i.e., individuals who had served in the U.S. military) and non-veterans, with the ultimate goal of informing service development, evaluation, research, and policy. We examined three research questions: 1) Do vets and non vets differ in terms of their substance use and recovery history (e.g., duration of active use, primary substance problem, age initiated recovery)?; 2) Do vet and non-vets have similar or different experiences in active addiction (e.g., were they affected in similar areas and to the same extent)?; and 3) Are there differences in functioning in key life areas among veterans and non-vets once in recovery?

Methods

Participant recruitment and Data collection

The survey link was disseminated via Faces & Voices’ biweekly electronic newsletter sent to over 30,000 subscribers consisting of diverse stakeholders groups including individuals in recovery, loved ones of persons in recovery, recovery advocates, and service providers. The following text summarized the survey for prospective participants:

What’s your life like in recovery? Faces & Voices wants to know!

Faces & Voices is excited to conduct the first nationwide survey designed to document key aspects in the lives of people in recovery from addiction to alcohol and other drugs. While much is known about the many costs of addiction, we know very little about what happens in a person’s life in recovery.

WHO SHOULD TAKE THE SURVEY? We ask anyone who considers themselves in recovery from alcohol and other drugs problems to take the survey.

A link to the survey was also displayed on Faces and Voices’ website and on their social media sites pages (e.g., Facebook, Twitter), with postings “shared” (e.g., retweeted) by followers to their own social network. Survey data were collected between November 1 and December 31, 2012. The anonymous survey was administered online through SurveyMonkey® and took between 10 and 15 minutes to complete. Individuals completing the survey were offered a 10% discount at the Faces & Voices’ online store. A total of 3,176 surveys were completed. Survey data were imported into a statistical software package for analysis.

Measures

The survey consisted of standard background and demographic questions. Veteran status was determined by a positive answer to the question: “Have you ever served in the U.S. military (active or reserve)?” Yes/no. The instrument also consisted of items assessing the following domains:

Physical health

(a) Currently under a physician’s care for a chronic/ongoing physical health problem in the past year (yes/no); and (b) Use of tobacco products (yes/no); and (c) Physical health self-rating on a scale ranging from 1 (poor) to 5 (excellent).

Currently receiving help or treatment for emotional or mental health problems (yes/no); (b) if not currently, ever received help or treatment for emotional or mental health problems (yes/no); and (c) Mental health self rating on a scale ranging from 1 (poor) to 5 (excellent).

Substance use and recovery

(a)  Primary problem substance class (alcohol only, drugs only or both drugs and alcohol);

(b) Duration of substance use; (c) Age initiated recovery (d) Ever participated in professional treatment for drug or alcohol problems (yes/no); and (e) Ever attended 12-step meetings (e,g., Alcoholics Anonymous) to deal with drug or alcohol problems (yes/no); and (f) Ever attended non 12-step meetings (e,g., LifeRing, SMART Recovery,) to deal with drug or alcohol problems (yes/no).

Life experiences in addiction and in recovery

Survey Items development. The overarching goal of this survey was to document life experiences both during active addiction and once in recovery to begin examining changes in broad life domains. Literature searches and consultation with expert colleagues revealed that no standardized measure was available that meet our study goals. What follows is a summary of our survey development process. Based on the extant scientific literature, on current conceptualizations of recovery (25, 35) and on the documented experiences of persons in recovery (27), a large pool of items was developed by the first and third authors to reflect events and experiences in key life domains typically affected by active addiction or occurring in recovery: Finances, family, social and civic functioning (e.g., voting), physical and mental health, legal status and involvement, and employment/school. The pool of items consisted of both positive (e.g., ’pay bills on time’) and negative experiences (e.g., ‘frequently miss work or school’); 44 items was retained at the end of an iterative review process by the authors, Faces & Voices’ board of directors and other stakeholders. To minimize reporting bias, positive and negative items were presented in mixed order. The 44 item list was to be completed twice: participants first answered whether they had experienced each of the 44 events/situations ‘while in active addiction’ using a dichotomous (yes/no) format; then they completed a parallel list of 44 items ‘since you came into recovery’.

Data analyses

Bivariate analyses (ANOVAs and chi-square) were conducted to compare sociodemographics and background as well as addiction and recovery experiences between individuals with veteran status and those without, we conducted.

Results

Description of survey participants

Fifteen percent (15.1%) of survey participants (N = 481) had served in the military and constitute the study’s veteran sample. Table 1 presents individual characteristics comparisons between veterans and non veterans (NV). Starting with sociodemographiccharacteristics, Table 1 shows that as may be expected, the veteran sample consisted of nearly three times fewer women than the non-veteran sample (23% vs. 62.6%). Relative to NV, veterans clustered in the older age groups; for instance, three times as many were 66 and over compared to NVs (15.6% vs. 5.5%). In terms of race, more than twice as many veterans as NV were African Americans (15.4% vs. 6.6%). A significantly greater percentage of veterans than NV were married, had children, were retired and lived in rural settings.

Turning to health, overall, most participants rated their physical health as ‘good’ or better than good, with no subgroup differences observed. Consistent with the older age of the veteran subgroup, a significantly greater percentage reported being currently under medical care for a chronic condition such as diabetes or hypertension (55.2% vs. 46%); a third of the sample reported using tobacco products, with no subgroup difference. As with physical health, most participants rated their mental health as ‘good’ or better than good; here, however, a subgroup difference emerged whereby a greater percentage of veterans than NV rated their mental health as ‘excellent’ (22.8% vs. 17.8%). Consistent with this finding, fewer veterans than NV report past or current treatment for mental health issues (56.3% vs. 64.6%, and 30.6% vs. 40%, respectively). Seven out of ten survey participants rated their quality of life as very good or excellent, with no subgroup difference.

Substance use history and recovery

Asked about their primary problem substance(s), over half of the sample selected drugs AND alcohol and slightly less than a third selected ‘alcohol only’; significantly fewer veterans than NV selected ‘drugs only’ (9.7% vs. 14%). The mean duration of active addiction was close to two decades, with veterans reporting a significantly longer period of addiction (21.9 years vs. 17.75); veterans also initiated recovery later in life than did NV (42.5 years of age, vs. 35.4). The sample was skewed toward individual in very long term recovery, with over half reporting 10 or more years of recovery; consistent with their older age, a greater percentage of vets than NV reported being in recovery for twenty years or over (42.4% vs. 30%). No subgroup difference was noted in terms of paths to recovery or utilization of recovery services: about seven out of ten participants had received professional treatment of their substance use problem, slightly fewer than 20% had been prescribed medications to deal with substance use problems, nearly all (95%) had attended 12-step addiction recovery meetings, and about one out of five had attended non 12-step addiction recovery support groups.

Life Experiences in active addiction

Overall survey findings document the heavy costs of active addiction to the individual in all areas of life, as well as to the nation’s health and economy. Table 2 presents a comparison of life experiences in active addiction between veterans and non veterans. For the sake of concision, only statistically significant results (p≤.05) are noted in this section. In the Finance area, over two thirds of respondents experienced problems (e.g., difficulty pays bills, bad credit) and this was especially true among veterans: 75% of vets reported financial difficulties, compared to 69% of non-veterans. A greater percentage of veterans than NV also reported owing back taxes (29.9% vs. 20.9%). While three quarter or more of theoverall sample had a bank account while in active addiction, fewer veterans than NV did so (77% vs. 84.1%). In terms of family functioning, fewer vets than non-vets reported having been a ‘victim or perpetrator of domestic violence (32.8% vs. 42.4%); the item regrettably did not separate victimization from perpetrating domestic violence. Fewer vets reported having participated in family activities while in active addiction (57.9% vs. 65.6%). This finding may of course be due to being away from home while deployed. Turning to health, only one subgroup difference emerged whereby significantly fewer vets than NV had experienced untreated emotional health problems (62.2% vs. 68.8%). A significantly greater percentage of vets than NV reported involvement with the criminal justice system; this includes more reports of arrests (63.5% vs. 50.7%), incarceration (42.4% vs. 32%) as well as driving infractions (DWIs 37% vs. 27.5%, and lost/suspended license, 42.5% vs. 34.2%). Not surprisingly, a greater percentage of vets than of non vets also reported resolving legal issues including getting off probation or parole (27.5% vs. 19.5%) and getting their driver’s license back (32.2% vs. 21.7%). Finally in terms of employment, the only subgroup difference was that a greater percentage of vets than NV reported having started their own business while in active addiction (19.5% vs. 14.1%).

Life Experiences in Recovery

Overall, findings about life experiences in recovery document the significant improvements people experience in all areas of their lives relative to when they were in active addiction (Table 3): Surveyed participants reported fewer negative experiences and more positive experiences across study domains. Comparisons between veterans and non veterans since entering recovery generally yield fewer subgroup differences than were found for the active addiction period. Contrary to findings obtained for the addiction period where greater percentages of vets than non vets reported financial problems and fewer reported signs of financial health (e.g. paying bills on time), in recovery, a significantly greater percentage of vets than NV report financially healthy experiences: paying taxes and back taxes (84.1% vs. 79.6%), and paying pack personal debts (86.1% vs. 81.3%); this may of course be in part due to the greater degree of financial problems including owing back taxes, reported by vets during active addiction. In the family area, as reported in active addiction, fewer vets than non vets reported being a ‘victim or perpetrator of domestic violence (5.8% vs. 9.4%) and fewer vets reported participating in family activities (92.5% vs. 95%). In terms of health, fewer vets than NVs reported having no health insurance (16.1% vs. 20.5%), not a surprising finding as many vets likely have access to health services through the Department of Veterans Administration (DVA) system; the finding is noteworthy however, since the opposite pattern was observed in active addiction, though not attaining statistical significance. Turning to legal matters, as in active addiction, significantly more vets than NVs reported resolving legal issues -getting their driver’s license back (57.4% vs. 43.8%), restoring a professional license (21.4% vs. 15.8%) and getting off probation or parole (29.8% vs. 24.6%); as noted earlier, this is likely due to the significantly greater percentage of vets reporting legal problems in active addiction. Finally, more vets reported positive experiences in the employment area, including being steadily employed (86.9% vs. 81.8%), getting good job performances (91.1% vs. 88.7%), furthering their education or training (82.8% vs. 77.4%), and starting their own business (32.3% vs. 26.4%).

Discussion

Reprise of Key Findings

We examined three research questions: 1) Do vets and non vets differ in terms of substance use and recovery history?; 2) Do veterans and non vets have similar or different experiences during active addiction?; and 3) Are there differences in functioning in key life areas between veterans and non-vets once in recovery?

With respect to the first question, several subgroup differences were noted in terms of substance use and recovery history between vets and non vets. Fewer vets than non vets reported drugs only as their primary substance problem. Vets were in active addiction for an average of four years longer than non vets and initiated recovery seven years later than non vets. Even though vets initiated recovery on average, seven years later than NVs, a greater percentage of vets than NV reported being in recovery for twenty years or longer, consistent with their older age. Turning to experiences during active addiction, first, we note a similarity between subgroups in that large percentages of both vets and non vets reported negative experiences in all life domains under study, from financial and legal issues to health, employment and family functioning. Greater percentages of veterans reported financial problems (e.g., unpaid debts) and involvement with the criminal justice system, while fewer reported family participation and untreated emotional health issues. Third, data on life experiences since the initiation of recovery highlight the dramatic improvements in functioning across domains in both subgroups relative to the active addiction period: participants report fewer negative experiences and more positive experiences across study domains. Most of the subgroup differences observed during addiction leveled off in recovery; to wit, while significant differences emerged in fifteen of the 44 items in addiction, only five endured in recovery. Moreover, the differences observed in recovery typically emerged in areas where the obverse was noted in addiction. For example, greater percentages of vets than non vets repaid debts in recovery, consistent with the findings that they reported more debt during addiction; the same pattern abides in the legal area where greater percentages of vets reported experiences aiming at rectifying legal issues such as getting off probation or getting one’s driver’s license back.

4.3 Study Strengths and Limitations

This study has several strengths: We draw on the largest national sample of persons at various stages of recovery recruited thus far, an under-investigated population, especially persons in long-term recovery (i.e., > 5 years). We collected information on key areas of psychosocial functioning bearing both on the active addiction period and since recovery was initiated. The latter is especially important because we included domains that persons in recovery cite as challenges and priorities -e.g., family and social functioning, and community/civic involvement (27)- that are rarely included in addiction studies. Although we did not purposely oversample veterans, the study benefits from a relatively large percentage of veterans relative to the general population (15% here vs. 8.8%) including a larger percentage of women veterans than does the general veteran population (i.e., 23% here vs. 9.8% of the veterans population) according to government figure (36). Data for this study were obtained in the context of a low budget online survey (the Life in Recovery Survey) designed primarily to begin documenting the benefits of recovery from alcohol and other drugs of abuse to individuals and to the nation. Several methodological limitations must be considered when interpreting findings.

First, data bearing on the active addiction phase were retrospective and may therefore be subject to reporting bias, especially one whereby respondents may have over-reported negative experiences in active addiction and/or positive ones in recovery. We had taken several steps to minimize this potential bias when designing and disseminating the survey: We used a parallel list of 44 life experience items to be answered for periods of active addiction and recovery and within each, the positive and negative items were randomly ordered. In describing the purpose of the survey, we did not state we sought to document the benefits of recovery but rather, ‘key aspects in the lives of people in recovery from addiction to alcohol and other drugs’; nor did we imply a ‘before and after’ comparison. Respondents were therefore not informed when beginning to report on experiences in active addiction, that the same items were also asked later on for the recovery period as the survey was administered sequentially (i.e., first, the 44 items were presented for active addiction, then for the recovery period). Finding trends bearing on both active addiction and on recovery are generally consistent with the few smaller, geographically constrained studies examining broad changes in functioning as a result of ceasing drug and/or alcohol use (26, 37), affording us a strong level of confidence that our findings are minimally subject to reporting bias. Second, with respect to the veterans subsample, we lack information about the chronology of their substance use and recovery in relationship with their active military service; therefore we cannot address important questions such as whether recovery was initiated or treatment sought during or after military service. This information would be useful to elucidate in the future. Finally, a note about sample representativeness: As described earlier, the study was conducted exclusively online with the survey link disseminated through web and social media. While online data collection is increasing in health research, we do not currently know about some of the barriers to this methodology, including how to determine response rates.

Implications and Conclusions

Veterans used drugs and alcohol for a longer period than did non-vets and initiated recovery at an older age. Although vets and NV did not differ in recovery support utilization (i.e., treatment and self-helps groups), a number of barriers to help seeking specific to military personnel may explain the longer active addiction period – i.e., help may have been sought and recovery been initiated after active service ended. Despite high SUD rates among active duty military and veterans, many do not seek help (Lande et al., 2007). Research has documented unique aspects of military organizations and culture that may affect help-seeking and utilization of services. During active duty, assuming a sick role is contrary to the military’s warrior ethos, and may predispose individuals to avoid seeking help for a substance use or psychological problem (5). While drug use is likely to be sanctioned, alcohol use is also prohibited during military deployments; fear of the loss of deployment and/or military status due to disciplinary action thus also may impede help-seeking (5). Unlike in civilian settings where seeking help can be a private decision, military leadership may determine when a possible problem will be professionally evaluated to determine if treatment is needed, when someone will receive help for a psychological or substance use problem, and, when the service member can return to duty. While on active duty, using SUD treatment, even when a soldier self-refers, may not be confidential. Accessing alcohol treatment may initiate involvement of a soldier’s commander and can have negative career ramifications if the soldier fails to comply with the program (10). In addition to the stigma of having a problem and discomfort with help-seeking for substance use problems (38), another barrier to help seeking among Veterans may be their negative beliefs about treatment (12, 39). In light of the high prevalence of substance use, especially alcohol, among active military personnel, it is important that military policies become more conducive to encouraging self-referral, referral from medical professionals, and confidential treatment before alcohol-related behaviors necessitate formal involvement of the soldier’s commander (10). This can also contribute to reducing the stigma veterans that perceive is attached to seeking help. For both veterans and active duty personnel, a potential strategy to aid problem drinkers is self-help, especially Web-based interventions (40, 41) and support that may be more anonymous, therefore perceived as ‘safer’ from the fear of exposure.

The longer period of active addiction among vets may in part explain the higher rates of negative experiences vets reported relative to NVs, especially in the areas of finances and criminal involvement. With respect to these two domains however, we note that studies have documented high rates of criminal involvement among substance abusing vets (42) as well as an association between vets’ criminal involvement and financial difficulties (43). In turn, financial difficulties in covering basic needs are associated with several post-deployment adjustment problems including criminal arrests, homelessness, and aggression. Finally, regardless of income, poor money management (e.g., incurring significant debt, writing bad checks) is related to maladjustment, emphasizing the need to enhance financial literacy and to promote meaningful employment among returning veterans (43). Regrettably we did not obtain detailed income-related information that would have informed conclusions in this area.

A somewhat unexpected finding was the consistently lower report of mental health problems and treatment by veterans compared to non veterans. This included not only a greater percentage of veterans than NVs rating their current mental health as excellent but also lower reports of current and lifetime mental health treatment and lower reports of untreated emotional health issues during active addiction. This is somewhat surprising in light of evidence for a high prevalence of mental health issues among vets, especially depression, PTSD and traumatic brain injury (44). A recent study noting the underutilization of mental health services in veterans concluded that ‘Veterans Affairs may further improve engagement by attending [mental health services] to time since separation’ (45)p. 1183.

A possible explanation for the lower rates of mental health problems and treatment reported by our veteran subsample may be the perception that reporting or seeking help for ‘problems’ (perhaps especially mental/emotional health problems) is inconsistent with being ‘a soldier’ – i.e., the same general dynamic that is believed to be central to so many veterans not seeking help for SUD (see above). An alternative explanation, however, may lie in findings that Veterans, even those who have endured a high number of lifetime traumas, are frequently psychologically resilient as they reach middle and older age (46). Such resilience may aids in recovery from substance misuse (47, 48) and may also in part, account for our findings on mental health among veterans.

Overall, substance use, especially heavy alcohol use, remains high among military personnel and veterans. While both veterans and non veterans experienced numerous negative consequences of substance use during active addiction; vets are especially likely to experience financial problems and to become involved in criminal acts; this is only exacerbated by their tendency to be actively addicted for longer periods than are non veterans. Although veterans in this study received addiction treatment at the same rate as non veterans in this study, the longer active addiction period and more severe consequences reported by vets are consistent with their documented reluctance to seek help, especially for mental health/substance use problems as reviewed earlier. It is our hope that the growing recognition of and openness about discussing substance use problems in the military will translate into destigmatizing these problems and encouraging active military personnel and vets who need it to seek help. In terms of research, additional information is needed to develop and evaluate strategies that promote help seeking; we also need to learn more about the circumstances surrounding military and vets’ involvement with criminal behavior and how that relates to both substance use and to any financial difficulties they may be experiencing.

Acknowledgments

Funding for this study was provided by Private Donations to Faces & Voices of Recovery. Dr. Timko was supported by the Department of Veterans Affairs (VA) Office of Research and Development (Health Services Research & Development Service, RCS 00-001).

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