Identification of Contributing Factors to Alcohol Abuse in Korean and Vietnam War Veterans

Project Title: Identification of Contributing Factors to Alcohol Abuse in Korean and Vietnam War Veterans Background: It is known that alcohol use is prevalent among American military personnel. There is little research on whether or not alcohol abuse in the military today can also be applied to Korean and Vietnam era war veterans. Objective: This study aims to discover if risk factors for alcohol abuse patterns from Korean and Vietnam War veterans match a more recent predictive model for veteran alcohol abuse. Method: A Retrospective descriptive study, using existing medical record data, drawn from a total record set of 400 veterans, 59 of which met inclusion criteria for alcohol abuse. Cases were then drawn that had both alcohol abuse diagnostic codes and a Post Traumatic Stress Disorder (PTSD) code, resulting in 13 of 59 cases meeting inclusion criteria for the model. Results: Of the 13 men who had an inclusion diagnostic code for alcohol abuse and a diagnostic code (309.81) for PTSD, eight also had a diagnostic code (311), for depression. Retrospectively this theoretical model seems to fit Veterans from the Korean and Vietnam War era. ALCOHOL ABUSE IN KOREAN AND VIETNAM WAR VETERANS 3 Introduction The use of alcohol is prevalent in American society today. Unfortunately, drinking alcohol is directly related to a higher risk of health problems and unintentional injuries or death (CDC, 2012). One specific population with rates of high alcohol use and abuse are veterans and military personnel. The strain put on military personnel and their families can evidence itself in many ways, but substance abuse may be on the rise (Volkow, 2009). The National Institute of Drug Abuse found that in 2011, 27% of soldiers returning from Iraq met criteria for alcohol abuse. It is clear alcohol abuse is a current problem that requires continued work by the military and Veterans Affairs, but what about our retired veterans? Those who served during the Korean and Vietnam Wars are now older adults, still suffering from mental illnesses and alcohol abuse issues that were not well understood in the context of their war experience. This study takes a retrospective look at Veterans from the Korean and Vietnam era to see whether the variables predictive of alcohol abuse patterns noted among more recent war veterans can also be found among the earlier war veterans. Literature Review The scientific literature on alcohol use and abuse related to combat exposure in veterans from the Korean and Vietnam wars is limited. However, more and more research is available about veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) related to alcohol use rates among soldiers (Eisen, Schultz, Vogt, Glickman, Elwy, Drainoni, & . Martin, 2012; Hawkins, Lapham, Kivlahan, & Bradley, 2010; Jacobson, et al., 2008; Jakupcak, Tull, McDermott, Kaysen, Hunt, & Simpson, (2010); McDevitt-Murphy, Williams, Bracken, Fields, Monahan, & Murphy, (2010). A number of themes are apparent in ALCOHOL ABUSE IN KOREAN AND VIETNAM WAR VETERANS 4 these studies that can potentially help in the treatment of veterans from previous wars. Researchers found several variables that forecast alcohol abuse including gender, branch of service, Post Traumatic Stress Disorder (PTSD) status, and depression (Jakupcak, et al., 2010). This pattern is supported by other studies. Branch of service in the military was identified as one of the risk factors for alcohol abuse (Eisen et al., 2012). Eisen et al. (2012) found that Army and Marine soldiers screened positively for alcohol use almost two times more often than Air Force and Navy respondents with the difference being statistically significant. They noted that service branch was an important factor in evaluating risk for alcohol abuse. Jakupcak et al. (2010) confirmed that alcohol abuse was more common among Veterans who served in the Army or Marine Corps. By realizing which branches of service correlate to higher rates of alcohol abuse, greater efforts can be made for alcohol abuse prevention and interventions in these specific branches of service. Additional risk factors for alcohol abuse are younger age and male gender (Jakupcak, et al., 2010). Eisen (2012) confirmed that men reported higher substance abuse scores than women specifically in regard to alcohol abuse. This was found to be statistically significant using the AUDIT-C as the tool for assessment. Hawkins et al. (2010) found that men under the age of thirty are at highest risk for alcohol abuse. The OEF/OIF veterans were found to have a statistically significant higher rate of alcohol abuse correlated to age. These two factors should be included when studying veterans. Direct combat exposure was found to be a serious risk factor for alcohol abuse. Among present day soldiers, Jakupcak et al. (2010) found that those who screened positive for alcohol abuse were more likely to report direct combat experience while deployed (Jakupcak, et al., 2010). Knowing whether or not a soldier has direct combat experience could be a contributor to ALCOHOL ABUSE IN KOREAN AND VIETNAM WAR VETERANS 5 their risk for alcohol abuse as a result of the traumatic experience. The final risk factors identified for alcohol abuse in present-day studies is PTSD status and depression. Positive associations found between PTSD, depression, and alcohol abuse are consistent among OEF/OIF Veterans (Seal et al., 2009). Another study found that hazardous drinking mediated the relationship between PTSD symptoms and global ratings of mental health (McDevitt-Murphy et al., 2010). The research clearly identifies PTSD as a major risk factor for alcohol abuse, one that subsequently affects overall mental health. It is important to remember that PTSD was not an actual psychiatric diagnosis until 1980, when it appeared for the first time in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Andreason, 2010). The veterans who came home from war prior to 1980 could not be diagnosed with PTSD at the time of service separation but may now, as older adult veterans, have the PTSD diagnosis. However, it is unclear whether the medical records of all older veterans have been updated to include a PTSD diagnostic code when relevant. The Context of War There are five key factors that make the Vietnam War unique and are important to note. First, the Vietnam War was the first armed conflict that the United States lost. It was also a guerrilla war, where boundaries were blurred and citizens could be innocent victims or the attackers. At home, there was controversy about the War that resulted in negative public reactions toward returning soldiers. Different from World War II, and in part due to the draft, soldiers were rotated individually rather than in units, potentially lowering their sense of social support. Finally, soldiers returned home to a slow economy with high rates of unemployment. All of these features contribute different pieces to how soldiers who survived reacted to their ALCOHOL ABUSE IN KOREAN AND VIETNAM WAR VETERANS 6 experiences in war. One important characteristic of the Vietnam soldier is that the average age was only 19. This was six years younger than the average age of World War II Veterans (VVA Veteran, 2005). A large number of soldiers were drafted for the Vietnam War, possibly indicating that not enough people in the country wanted to fight. Many Americans who qualified for the draft were poor and racial minorities were disproportionately selected to serve. This is likely because the upper class Americans who were eligible were able to defer the draft for reasons such as attending a university or even knowing a doctor who would certify real or fictitious ailments that made them ineligible to fight. Lawyers could also help find loopholes to prevent them from being called to military service. Returning home was more difficult for those who were poor and/or a minority. In fact, a disproportionate percent of those who left service with a less-than-honorable discharge were black, 21%, or Spanish speaking, 3.5%, which made it even more difficult for them because of social and employment discrimination at home (Calhoun, 1980). The social, political, demographic, and economic features of this war contribute to the effect it had on the soldiers who fought in it. One study found that 36% of Vietnam army veterans demonstrated “alcoholism or significant alcohol-related problems which could develop into alcoholism” (VVA Veteran, 2005). As discussed above, PTSD is a risk factor for alcohol abuse. Vietnam veterans are at risk for PTSD, especially those involved in combat, even though they may not have been diagnosed when they initially returned to the U.S. Bremner’s (1996) study found that the onset of alcohol abuse was associated with symptoms of PTSD and that patients found alcohol and heroin helpful for the intrusive and hyper arousal categories of PTSD. Alcohol abuse in terms of days of abuse per month was found to be highest over the abuse of heroin, marijuana, benzodiazepines, and cocaine two years after the war, measured every two years for 24 years, post war. McFall’s ALCOHOL ABUSE IN KOREAN AND VIETNAM WAR VETERANS 7 (1992) study also noted that veterans of Vietnam with PTSD experienced greater drug and alcohol abuse problems than those veterans without PTSD. Berger noted that sixty to eighty percent of Vietnam veterans seeking treatment for PTSD also have alcohol-use disorders. These studies all point to the fact that PTSD and alcohol-abuse are far too common among Vietnam veterans. Each war is different and soldiers are exposed to different types of combat, different climates, and a different era of war altogether. These different settings and experiences undoubtedly result in different variables influencing study results. However, because of the lack of research conducted at the time the veterans in this study returned home from war, results of studies condu