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Clinical and Research News
Obstacles Complicate Research on Vets' Substance Abuse
Psychiatric News
Volume 44 Number 3 page 15-15

Research on military personnel and veterans regarding posttraumatic stress disorder (PTSD), depression, anxiety, substance use, and other disorders sometimes resulting from extended overseas deployments continues to lag behind the need, psychologist Terence Keane, Ph.D., told a conference in Washington, D.C., sponsored by the National Institute on Drug Abuse in January. Keane is with the Boston VA and Boston University School of Medicine.

"Among veterans coming into the VA for services, there is a higher rate of PTSD (79 percent) compared with Gulf War I vets (55 percent), but less alcohol misuse (21 percent vs. 34 percent), drug use (6 percent vs. 16 percent), or violence (21 percent vs. 42 percent)," said Robert Rosenheck, M.D., a professor of psychiatry, epidemiology, and public health at Yale University and the New Haven VA.

"The problems with trying to deal with alcohol use combined with PTSD, TBI [traumatic brain injury], insomnia, et cetera in military populations is that the evidence base is thin. You can't do evidence-based medicine without evidence," said Mark Willenbring, M.D., director of the Treatment and Recovery Research Division of the National Institute on Alcohol Abuse and Alcoholism.

There are rewards as well as significant challenges in conducting mental health and substance abuse research in active-duty military and veteran populations, said Keane. More funding has recently become available, but that availability is not the only reason to pursue such projects.

"Participants are motivated to take part in research, not for money, but because they are interested in helping other people who have been through what they have experienced," said Keane.

The impact of such research often spreads beyond its military subjects as well, he added. For instance, the conception of opiate addiction broadened from an emphasis on biological dependence to include contextual aspects of addiction as a result of research with Vietnam War veterans, he noted.

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Any research on military personnel and veterans must consider that the Pentagon takes a different position on drug use than it does on alcohol abuse.

There is a zero-tolerance policy toward use of illicit drugs, backed up by randomized urine testing conducted by personnel officials, not health staff. A confirmed test results in immediate separation from the service without veterans benefits. However, soldiers who admit to a problem and request help will not be prosecuted by military authorities. They may be offered treatment and are still discharged, but not with a bad-conduct designation. In contrast, soldiers whose dependence arose as a side effect of prescribed medication are seen as having a medical problem, and they are treated and retained in the service.

Alcohol consumption is not illegal in the military, except in Iraq and Afghanistan, said Navy forensic psychiatrist Capt. Edward Simmer.

"The focus is on 'responsible use,' but with severe consequences for inappropriate use, especially driving under the influence," he said." Surveys have shown that 50 percent of military personnel self-report binge drinking, so the services do a lot of education and treatment, focusing on intervening early."

Tobacco use is "strongly discouraged," he added, although nicotine use rises during deployments as former smokers react to stress and take up the habit again.

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Despite the need, there are still barriers that researchers wishing to study military populations must consider, said psychiatrist Jeffrey Pyne, M.D., a staff physician at the Central Arkansas Veterans Healthcare System in Little Rock.

Research approvals that include personnel from more than one service must, for example, go through each service branch's medical authority, he said. Often more than one institutional review board must sign off on projects. Cooperative research-and-development agreements must be hammered out between the service and the researcher. These agreements can become complex and time consuming to put together, especially when third parties, such as universities, get involved, said Pyne.

Written personnel contracts, like those governing how much time will be spent on research and how much on clinical activities, have the force of military orders and may lack the flexibility to which civilian researchers may be accustomed. Researchers also must plan ahead to allow for the reality that on-site investigators or subjects may be deployed to other bases or overseas during the course of the research.

Also, researchers must assuage the concerns of military health care providers who may be concerned that they will "lose" a patient to a research project, preventing the providers from keeping up with the requirement that they be current on a patient's clinical and administrative status. And base commanders must approve recruitment flyers but cannot apply any influence on an individual's decision to participate in a study.

That process raises the question of whether members of the military services are "vulnerable populations" in an ethical sense, analogous to children or prisoners, said David Festinger, Ph.D., director of the law and ethics research section of the Treatment Research Institute in Philadelphia and an adjunct assistant professor of psychiatry at the University of Pennsylvania.

Vulnerable populations are those whose decision to provide informed consent can be influenced by economic hardship, cognitive deficits, medical problems, social dysfunction, or coercion, explained Festinger. Military personnel may be influenced by two types of coercion. Institutional coercion is explicit pressure by superior officers, he noted, while deferential coercion is the implicit pressure that leads soldiers to believe that something negative will happen to them if they do or do not take part in a medical study.

"Many veterans seeking treatment at the VA have a variety of medical, economic, and social problems," said Festinger. "We must pay extra attention to human-risk protections for them and to increasing their understanding of informed consent."

"Members of the armed forces place their lives and the well-being of their families at risk, so it is up to us to do our best to drive our science to the table to help them," said Keane.

"Addressing Substance Abuse and Comorbidities Among Military Personnel, Veterans, and Their Families: A Research Agenda" is posted at<www.sei2003.com/nida/1014036/Agenda.doc>.

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