CARLISLE PAPERS

Craig Trebilcock

Strategic Studies Institute

U.S. Army War College, Carlisle, PA 17013

A Shared Burden:

The Military and Civilian 

Consequences of Army Pain 

Management Since 2001

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A SHARED BURDEN:

THE MILITARY AND CIVILIAN CONSEQUENCES OF 

ARMY PAIN MANAGEMENT SINCE 2001

Craig Trebilcock

August 2015

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iv

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ISBN 1-58487-695-6
v

PREFACE

The U.S. Army War College (USAWC) provides an excellent environment for selected military officers and government civilians to reflect and capitalize on their career 

experience to explore a wide range of strategic issues. To ensure that the research conducted by USAWC students is available to Army and Department of Defense leaders, 

the Strategic Studies Institute publishes selected papers in its “Carlisle Papers” series.

 

 STEVEN METZ

 Director of Research

 Strategic Studies Institute 

vii

ABOUT THE AUTHOR

CRAIG TREBILCOCK is a U.S. Army Reserve officer serving in the Judge Advocate 

General’s Corps. In his civilian capacity, Colonel Trebilcock is a judge of the Court of 

Common Pleas of York County, PA, where he presides over a criminal court docket; 

he is also that county’s Veterans’ Treatment Court judge. Colonel Trebilcock holds a 

master’s degree in strategic studies from the U.S. Army War College, and a bachelor’s 

degree in political science and history and a Juris Doctor degree from the University of 

Michigan. 

ix

SUMMARY

The Army has an opioid drug problem that is not going away under current personnel policies and medical practices. The survey results recorded here indicate that senior 

officers attending the U.S. Army War College (USAWC) recognize that the opioid problem is distinct in nature and origin from those of recreational drug abuse. Yet, these officers are saddled with a legacy drug enforcement structure and outdated procedures that 

do not track opioid usage across the force and do not address the root cause of the issue. 

They are commanding units under a regulatory structure that belatedly responds to 

opioid-related misuse with the same misconduct-focused disciplinary policies as those 

for recreational drug use, rather than with a proactive medical and personnel approach 

crafted for this unique problem set that emphasizes prevention and rehabilitation. The 

USAWC officer survey responses reflect the fact that the majority of these future Army 

leaders see misuse originating out of prescribing practices, a lack of medical monitoring, 

and a lack of soldier training and education on the dangers of opioids, rather than from 

undisciplined soldiers. 

This Carlisle Paper is not meant to be the final word, but the beginning of a new 

conversation. The survey samples were not from random populations, but specifically 

chosen groups of leaders with specialized knowledge and expertise in this area. The 

samples presented do not claim to represent the views of all judges or all Army officers. 

But the trends from their responses are intriguing, as they break from past presumptions 

and perceived truths regarding opioid use. They suggest a new way of thinking about 

the Army’s opioid problem, as well as its impact on combat readiness and civil-military 

relations. 

The comparison of the two surveys reveals that, in most instances, there is not a 

significant gap between civilian judge and senior Army officer thinking as to the nature 

and seriousness of the problem. Rather, military prescription practices and the application of legacy policies that presume separation as opposed to prevention and rehabilitation are creating the cracks for a future civil-military gap to widen. Army procedures 

that continue to supply opioids on a wide scale, but then transfer the adverse long-term 

costs of those policies onto civilian society, are not in the best interest of Army readiness, 

soldier health, or civilian safety and fiscal security. Army policy and regulatory reform 

is needed to counter these trends successfully. This will require policies different from 

those in the Army’s institutional comfort zone, which have served well in countering 

recreational drug use for 40 years. To protect the readiness of its force, the Army should 

consider the path suggested by those it has trained to be innovative and strategic thinkers at the USAWC—a future focused upon increased rehabilitation, soldier education, 

medical monitoring, and unit-level opioid-readiness tracking.

1

A SHARED BURDEN:

THE MILITARY AND CIVILIAN CONSEQUENCES OF 

ARMY PAIN MANAGEMENT SINCE 2001

Military and civilian personnel are often viewed as living in separate, but parallel, 

societies. The Department of Defense (DoD) has its own housing, stores, and recreational 

facilities. A different code of conduct and higher expectations are placed upon soldiers 

and military families than on their civilian counterparts. Yet, these two societies do not 

exist immune from the activities in the other. This is an inevitable consequence of an 

all-volunteer force drawn from civilian roots, and the ultimate return of Army veterans 

to their civilian communities after finishing their service. This symbiotic relationship is 

particularly evident with the growing numbers of Operation ENDURING FREEDOM 

(OEF) and Operation IRAQI FREEDOM (OIF)/Operation NEW DAWN (OND) veterans 

who are returning to civilian life with opioid pain medicine dependency, addiction, and 

misuse issues at the time of their military discharges, resulting in public health, crime, 

social, and fiscal burdens for the communities receiving them.

There has been a substantial increase in opioid pain prescriptions1 in the U.S. Army 

since 2001, and a consequent dramatic increase in soldier prescription misuse. Opioids 

include opiates such as morphine, codeine, and opium, which are derived from the opium poppy.2

 Opioids also include synthetic pharmaceuticals prescribed to manage pain, 

which operate on the central nervous system in the same manner as opiates to block pain 

and cause a sense of euphoria and well-being.3 Common forms of opioids prescribed to 

soldiers include Percocet (oxycodone and acetaminophen) and Vicodin (hydrocodone 

and acetaminophen). All opioids can lead to dependency and addiction with ongoing 

use.4

To examine the impact of Army opioid use on the Army and civilian society, two 

parallel surveys were conducted of leaders who have experience dealing with soldiers 

and OEF/OIF veterans with opioid-related issues. The first study group comprised Veterans Court judges5

 who preside over civilian criminal courts in which former military 

personnel are facing criminal charges arising out of opioid misuse. There are 177 county 

and municipal level Veterans Courts dispersed across the country from California to 

New England. The second study group comprised 217 senior Army officers in the ranks 

of colonel and lieutenant colonel attending the U.S. Army War College (USAWC) in the 

resident class of 2015. This latter group was chosen because many of these officers have 

recently been unit commanders with disciplinary responsibility over soldiers with drug 

problems. They were also chosen because Army War College graduates have a high likelihood of being in Army policymaking or policy-influencing positions after graduation, 

providing a glimpse into future Army leadership attitudes on the opioid issue.

The goal of the survey6 was to evaluate, compare, and contrast the levels of awareness and attitudes toward opioid use and misuse between these two groups who exercise leadership and judicial and quasi-judicial7

 authority within their respective societies. Of the 31 percent survey response rate, 44.1 percent of the responding Army 

officers reported direct personal experience with a soldier who misused or was addicted 

to opioid drugs. Of those experiences, 80.6 percent were as the affected soldier’s unit 

commander, and 16.1 percent were in another role in the unit chain of command.8 One 
2

respondent noted an opioid pain prescription addiction while in a leadership position, 

and another observed his superior commander’s suffering opioid misuse or addiction 

issues, suggesting that this is not an issue merely impacting lower-ranking personnel. 

The balance of Army respondents were senior staff officers such as judge advocates or 

medical personnel, and those acting in an investigatory or court-martial/administrative 

board role.

BACKGROUND

In 2001, prior to the beginning of OEF, the Army did not have a disproportionately 

large opioid drug problem, with opioid misuse rates consistent in source and scope with 

other low-level recreational drug misuse among soldiers. However, opioid pain relief 

prescriptions written by military physicians quadrupled between 2001 and 2009—to almost 3.8 million.9

 While wounds suffered in OEF and OIF/OND accounted for some 

of this upsurge, a significant growth in deployment-related orthopedic injuries also increased the demand for more pain management.10 In addition, some military medical 

practitioners began to prescribe opioids for chronic pain of a lesser severity than the 

moderate to severe pain threshold recognized as appropriate for such use.11 With the 

expanded availability of opioids in the force, Army prescription drug misuse increased 

five-fold from 2 percent to 11 percent of soldiers from 2002 to 2008.12 During this same 

time frame, civilian prescription drug misuse also grew, but less than doubled; it remained below 4 percent of the population.13 Opioid prescription drugs, in fact, represent 

the only category of drugs for which soldier misuse exceeds that of civilians.

14

The growth of medically based opioid use in the Army is an extension of the civilian society’s approach to pain management. Of the world’s opioids, 80 percent are 

consumed in the United States, with Americans using 99 percent of the world’s hydrocodone (which when combined with acetaminophen, as stated, is popularly known as 

Vicodin).15 However, the Army now prescribes opioids at rates far exceeding those of 

the civilian medical world.

16 These do not reflect merely short term, nominal usage of 

these drugs either. Army statistics from 2012 show that of all of the soldiers to which 

military practitioners prescribed opioids, 25-35 percent of them physically depended on 

opioids at the time of their discharge.17 Accordingly, the link between Army prescription-initiated opioid use being carried into the civilian world at the time of a soldier’s 

discharge is clear. 

Prescription Opioids Impact on Readiness.

For decades, the belief embraced by Army leaders was that soldiers with prescription drug addiction and misuse issues are deficient in character and toughness, needing 

to be separated from the good soldiers to preserve good order and discipline.18 However, 

as Mark Twain observed, “It’s not what you don’t know that kills you; it’s what you 

know for sure that ain’t true.”19 The prescription opioid problem currently eating away 

at Army readiness is distinct in its origins, growth, and consequences from recreational 

drug use; yet, this problem is being addressed by the Army as if it derived from substandard soldiers choosing to begin taking opioids from a lack of discipline.
3

While illegal recreational drugs such as marijuana or cocaine historically have been 

obtained from illicit sources, opioids are being distributed by licensed military medical professionals through prescriptions. Diversion and illegal sales by drug dealers of 

opioids certainly occur. There is little doubt, however, that the growth of military opioid use that mushroomed with the beginning of OEF and OIF was medical in origin. 

In 2010, the Surgeon General briefed the Vice Chief of Staff of the Army that nearly 14 

percent of the Army (76,463 soldiers) were using some form of legally prescribed opioid 

drug, and 25,761 of those same troops were taking more than one Army-provided pain 

prescription.20 By 2013, the level of opioids being prescribed across all military branches 

was at 24 percent of the force, according to testimony before the Senate by Brigadier 

General Norvell V. Coots, Deputy Commanding General and Assistant Surgeon General 

for Force Projection.21 To understand the full scope of this challenge, it is important to 

note that this 24-percent figure captures only the legally prescribed usage and does not 

reflect the previously noted additional number of service members misusing these pharmaceuticals without authorization after they have become addicted to or dependent on 

the prescription drugs. 

Accordingly, with the Surgeon General’s data reflecting over one in seven soldiers 

was prescribed opioids in 2010, and nearly one in four military service members across 

all branches were prescribed opioids as of 2013, the scope of pain pill use among the nation’s fighting force is staggering, with a direct impact both upon Army readiness and 

opioid misuse. The growth in illegal opioid misuse from 2002-08, while the number of 

lawful prescriptions were quadrupling from 2001-09, was not merely coincidental. Researchers have indicated that the number one driver for the likelihood of opioid misuse 

is the availability of an opioid prescription, with a person having such a prescription 

being three times as likely to abuse opioids as a person who has no prescription.22

Opioids are a medicine and provide lifesaving relief to those with extreme pain. 

However, due to their addictive nature, the treatment benefit must be carefully weighed 

by physicians against health risks. A 2014 research letter from the Walter Reed Research 

Institute raised the specter that opioids are not always being prescribed within the Army 

just for serious pain cases. In a survey of a redeploying infantry brigade in 2011, the 

study determined that 15.1 percent of the brigade members were prescribed opioids by 

the Army upon their return, but that 44 percent of the soldiers given the drugs did not 

report the qualifying levels of moderate to severe pain that warrant opioid intervention 

under accepted military prescription standards.23 Some of the soldiers given opioids had 

reported pain levels ranging from zero to minimal in the previous month. 

It is not just the number of soldiers given opioids that is worrisome from a readiness 

perspective. The duration of opioid prescriptions is a source of concern due to the addictive qualities of these medicines. Some soldiers in the study were being prescribed the 

drugs past the 90-day threshold that defines chronic pain, for which opioids are often 

not appropriate because of their addictive nature and other adverse health side effects.24

The findings of the Walter Reed research study, coupled with the previously noted 25 

to 35 percent dependency levels at discharge for soldiers who were prescribed opioids, 

suggest the possibility that this is a problem the Army is growing and perpetuating 

internally through prescription practices and patterns. Former Army Surgeon General, 

Lieutenant General Eric Schoomaker, voiced concern in response to the Walter Reed 

study, noting:
4

While chronic pain and opioid use have been a long-standing concern of the military leadership, this study is among the first to quantify the impact of recent wars on the prevalence 

of pain and narcotic use among soldiers. The nation’s defense rests on the comprehensive 

fitness of its service members—mind, body, and spirit. Chronic pain and use of opioids carry 

the risk of functional impairment of America’s fighting force.25

The warning of Schoomaker, as the Army’s former top doctor, regarding the adverse 

impact of prescribing opioids for chronic pain warrants serious attention from Army 

policymakers because of the potential impact on readiness. His warning also suggests 

the need to reconsider the supposition that it is undisciplined and risk-taking soldiers 

who are the major drivers of the Army’s opioid problem. 

Schoomaker is not the only Army leader concerned with the impact of prescription 

practices upon force readiness and soldier health. Prior unit leaders now attending the 

USAWC also believe that prescription opioid use can impair their units’ readiness. An 

overwhelming 96 percent of former unit commanders and members of unit chains of 

command, responding to the survey conducted with the 2015 USAWC class, said “yes” 

when asked, “Is it important for you as a commander or member of the chain of command to know how many of your unit’s soldiers are taking opioid pain prescriptions 

at any one time?” Only 4 percent responded “no.” When also asked, “As a commander 

or member of the unit chain of command, do you believe the level of opioid use within 

a unit has an impact on unit readiness?”, 70 percent responded “yes,” 6.7 percent responded “no,” and 23.3 percent selected “I don’t know/no opinion.” 

In other words, more than two-thirds of the officers responding believe that opioid 

use impacts unit readiness. The fact that a fairly substantial 23.3 percent indicated they 

did not know, or had no opinion, may well be related to the lack of information provided to Army unit leaders about opioid use within their units. This lack of information 

is addressed in greater detail in the remainder of this paper.

The survey also sought to explore, by proposing a hypothetical, what the word 

“readiness” means to these Army leaders in the context of prescription opioid usage. 

They were asked: 

For Commanders and chain of command, would you be comfortable sending an otherwise 

‘good soldier’ on a combat mission involving performing a security role if they were taking 

an opioid pain medication at the time? 

The responses were:

Yes - 7.1 percent

No - 60.7 percent

It depends on the soldier - 25 percent

I don’t know/No answer - 7.1 percent.

Over 60 percent of unit commanders and unit leaders stated that they would not 

feel comfortable sending a soldier on a mission in a security role if he or she was taking opioids. Yet, information from the Surgeon General’s office over the past 5 years 

indicates that somewhere between 14 to 24 percent of soldiers and military personnel 
5

are being prescribed opioids. That is a huge part of the team to “bench” with the current 

operational pace. 

The preceding three questions taken together reflect the fact that the majority of Army 

commanders and unit leaders surveyed believe that prescription opioids can impair the 

effectiveness of soldiers in performing combat missions. They also want to know how 

many of their soldiers are taking opioids so that they can gauge that readiness impact. 

These responses make sense, considering that a commander’s ultimate responsibility is 

ensuring his or her unit is ready to carry out the missions it is assigned. The responses 

are also in accord with the readiness concerns expressed by Schoomaker, who warned 

that overprescribing opioids can functionally impair America’s fighting forces. Having 

such a large segment of the Army force being potentially not combat-ready in the eyes 

of commanders due to opioid consumption is a serious readiness issue.

Yet, despite the widespread scope of opioid prescriptions and the expressed concerns by commanders over their impact on readiness, when USAWC officers were asked, 

“Through what sources did you as commander or member of the chain of command receive information on unit levels of prescription opioid use when you were in that leadership position?” The responses were mixed, as noted in Table 1. The single most-frequent 

response, at 39.3 percent, was that Army unit leaders did not receive that information.

Table 1. Sources of Commander Information on Unit Opioid Use Levels. 

These results suggest that unit commanders are not being regularly and reliably informed of the medical readiness of their units when it comes to the adverse impact 

of prescription opioids. They are receiving information through a variety of uncoordinated sources, but most often they are not receiving information at all. This is a state 

of affairs that should be of concern to the Army’s top leadership. Unit leaders have 

expressed their belief that there is a causal connection between opioid consumption and 

readiness levels. Their survey responses reflect that they recognize this consumption can 

Q6. Through what sources did you as a commander or member of the 

chain of command receive information on unit levels of prescription 

opiod use when you were in that leadership position?

Answered: 28 Skipped: 40
6

adversely impact readiness, and they want to know whether their unit is medically fit 

for their mission. However, they are lacking the information to assess the extent to which 

their unit readiness is being affected by opioid prescriptions. Only 25 percent of the 

respondents indicated that they received information about their soldiers’ opioid use 

through medical channels, and 7.1 percent indicated they received information through 

metrics reports. Typically, opioid use is not a category tracked in unit metrics reports. 

This overall gap in knowledge about potentially soldier-impairing conditions is contrary to one of the most basic principles of readiness—an informed commander. In fact, 

the lack of a metrics system for opioid use is placing commanders in a position in which 

they regularly and systematically do not have access to the information they need to assess their soldiers’ readiness to deploy and fight. 

The Army has signaled that possessing such soldier medical information is indeed 

important, as it requires commanders to track dental exams, flu shots, inoculations, and 

annual physicals through unit medical metrics and report deficiencies to higher headquarters. Soldiers using opioids can experience clouded thought processes, dizziness, 

and nausea even with proper use, and die when opioid drugs are improperly used.26 The 

side effects these drugs bring, even when dependency and addiction do not occur, are 

serious and can impair readiness, yet no unit level tracking and reporting exists. This 

is an area in which greater priority is required to keeping commanders informed, and 

the Army as a whole should focus greater resources in tracking opioid-related medical 

readiness.

While health privacy laws such as the Health Insurance Portability and Accountability Act27 (HIPAA) may currently limit the identification of specific soldiers taking a 

certain drug, these laws do not preclude a commander from being kept advised of the 

overall level of opioid prescriptions in his or her unit, without individual identifying 

information. Knowing whether one’s unit has a 4-percent or 24-percent opioid prescription usage level still conveys important information regarding overall unit readiness to 

the commander, as well as signals the level of need for training and education to unit 

members on adhering to the prescribed limits in using these drugs.

Rehabilitation Policies and Community Safety.

Due to their addictive quality, opioids can cause physical dependency and psychological addiction for those who take them.28 Those who become addicted place obtaining 

more drugs to feed their addiction above all other priorities.29 That is the biological and 

psychological nature of addiction, which crosses class, branch, education, rank, and gender lines. This skewing of priorities can often lead the addicted soldier into conflict with 

his or her chain of command and law enforcement through misbehavior. Civilian judges have long recognized that individuals who might not otherwise engage in criminal 

conduct will indeed steal, prostitute themselves, sell drugs, or commit other crimes to 

sustain the drug supply to feed their addiction. Once they are addicted, their brain tells 

them they must have more of the drug to survive regardless of adverse consequences. 

In the second parallel survey, civilian Veterans Court judges were asked to respond 

to the following statement: “Opioid addiction may lead to criminal behavior in a military service member or veteran who would not otherwise engage in criminality.” See 

Table 2 for the Veterans Court judges’ responses. 
7

Table 2. Judge Responses to Opioid Addiction

Prompting Criminality in Soldiers/Veterans.

A total of 93.4 percent of the judges surveyed moderately or strongly agreed that 

an otherwise law-abiding military service member or veteran can be led to criminal 

behavior because of becoming addicted to opioids. Only 3.8 percent disagreed, with the 

balance indicating uncertainty or no opinion. This demonstrates an important principle 

recognized among criminal judges, that it is not just undisciplined people of poor moral 

character, or those predisposed to criminal conduct, but also who otherwise would be 

law abiding are recognized as susceptible to criminal behavior once they are exposed to 

and become addicted to opioids. Homemakers, college students, doctors, and businessmen appear in civilian criminal courts with opioid-related misconduct that originated 

in prescription use.

Individual soldier responsibility is a cornerstone of Army culture. Accordingly, 

USAWC students were asked to react to the statement: 

Opioid addiction may lead to criminal behavior in a soldier (e.g., shoplifting, theft, illegal 

possession and distribution of drugs, etc.) who would not otherwise engage in criminal acts.

The USAWC student responses are shown in Table 3.

Table 3. USAWC Responses to Opioid Addiction

Prompting Criminality in Soldiers/Veterans.

Strongly 

Agree

Moderately 

Agree

Moderately 

Disagree

Strongly 

Disagree

Do not know/No 

Opinion

Total

52.4%

55

41.0%

43

1.9%

2

1.9%

2

2.9%

3

105

Answer Choices Responses

Strongly Agree 14.9% 10

Moderately Agree 62.7% 42

Moderately Disagree 13.4% 9

Strongly Disagree 3.0% 2

No opinion/Do not know 6.0% 4

Total 67
8

Similar to Veterans Court judges, 77.6 percent of USAWC officer respondents moderately or strongly agreed that soldiers who would not otherwise commit crimes may 

engage in criminal acts once they become addicted to opioids. A total of 16.4 percent of 

respondents disagreed with the statement, and 6 percent selected “No opinion/Do not 

know.” While these responses reflect a slightly greater level of disagreement with the 

statement than among the judges, overall, the views in both groups indicate a general 

recognition among both civilian and military leaders that once addiction occurs, opioids 

exert a detrimental social and behavioral hold on people who are not inherently criminal 

in character. Neither set of responses means that personal responsibility does not attach 

to those who engage in drug-related misconduct, or that drug addiction should be a 

defense to criminal conduct. Determining whether the source of the broad-scale opioid 

problem lies in inherent criminal traits or medical collateral damage is important, because it helps frame whether belated punitive responses or preemptive preventative and 

rehabilitative policy responses will be most successful in combating the rise of opioid 

misuse and addiction in the Army.

USAWC students were next asked: 

Do you believe that soldiers who have become dependent upon or addicted to their opioid 

pain medication prescription have the potential to be medically treated and rehabilitated so 

that they can successfully return to Army duties?

A significant portion, 85.3 percent, responded “Yes”; 7.4 percent responded “No”; 

and 7.4 percent indicated “I don’t know/No opinion.” Thus, in addition to believing 

that otherwise law-abiding soldiers may engage in misconduct if addicted to opioids, 

this same group of officers indicated by a large margin that they believe soldiers who 

became dependent upon or addicted to prescription opioids have the potential to be 

treated, rehabilitated, and returned to duty. This response is significant, since it seems 

to suggest that soldiers who are addicted to opioid pain prescriptions may be viewed 

as qualitatively different by unit leaders from soldiers who engage in recreational drug 

use. The response is certainly contrary to Army regulatory policy, discussed in detail 

here, which assumes that soldiers with drug dependency and addiction issues should, 

in most cases, be separated from the Army.

The next question presented to both USAWC officers and Veterans Court judges concerned the impact, if any, that occurs when rehabilitation is not provided to those who 

are addicted to opioids. The USAWC officers were first asked to respond to the following statement regarding whether soldiers with an untreated opioid addiction present a 

safety and law enforcement concern for the Army. Their responses are shown in Table 4.
9

Table 4. USAWC Response on Safety and Crime Threat

to Army by Untreated Addicts.

A total of 97 percent of the officers responding either moderately or strongly agreed 

that untreated opioid addicts are a safety and law enforcement concern in the Army. 

Only 3 percent disagreed, seeing untreated opioid addiction as not presenting a safety 

and law enforcement concern. The results did not vary much when this same group of 

officers was asked what the safety impact would be on civilian communities if Army 

personnel with addictions are discharged in an untreated state. These results are shown 

in Table 5.

Table 5. USAWC Response on Safety and Crime Threat 

to Civilians by Untreated Addicts.

Q26. Army personnel with an untreated opioid addiction present a 

safety and law enforcement concern for the Army.

Answered: 68 Skipped: 0

Q27. Army personnel who are discharged with an untreated opioid 

addiction present a safety and law enforcement concern for the civilian 

communities to which they return.

Answered: 68 Skipped: 0
10

A total of 95.6 percent of the USAWC respondents expressed the opinion that soldiers discharged without treatment for an opioid addiction presented a safety and law 

enforcement concern for the civilian communities to which they return. A total of 3 percent disagreed, and 1.5 percent indicated either No opinion/I don’t know. There is apparently little disagreement, then, in the views of these Army leaders that when soldiers 

are not treated for their opioid addiction, there is a resulting safety and law enforcement 

risk to both the Army and to civilian communities. 

Veterans Courts across the country are being confronted with a growing number of 

OEF and OIF veterans who are leaving active duty with opioid addictions. Over the past 

10 years, criminal court judges have been seeing a growth in their opioid-related caseload from military personnel and veterans, during the same approximate time period 

that opioid prescriptions and misuse have been peaking in the military. A combined 

total of 77.2 percent of Veterans Court judges surveyed have seen an increase in opioid 

and opioid-related crime over the past 10 years from military personnel and veterans. 

Only 2 percent of judges have seen a decrease; for 20 percent of judges, the caseload of 

opioid offenders has remained the same. See Table 6.

Table 6. Veterans Court Opioid Crime Caseload Levels.

The discharge of soldiers with opioid issues is likewise a safety issue in the eyes of 

Veterans Court judges, who were also asked about the impact of untreated military personnel with addiction issues returning to their civilian communities. See Table 7.

Q5. Over the past ten years the relative number of military personnel 

and veterans apprearing in my criminal (VTC or traditional) court for 

opioid-related criminal conduct has:

Answered: 101 Skipped: 5
11

Table 7. Veterans Court Judges on 

Untreated Military Opioid Addicts Increasing Crime.

A total of 89.5 percent of the judges indicated either moderate or strong agreement 

with the statement that untreated military opioid addicts returning to civilian communities increase crime. Only 1 percent moderately disagreed, none strongly disagreed, and 

9 percent did not know or had no opinion. The responses from both the USAWC officers 

and judges reflect a strong consensus among civil and military leaders that untreated 

opioid addicts are a safety and law enforcement risk. The data from civilian judges indicates that the number of opioid-related crime they are seeing from military personnel 

and veterans has been increasing over the past 10 years. 

As previously noted, more than three out of four USAWC officers responding gave 

the opinion that rehabilitation can return soldiers with a prescription opioid addiction 

to duty if treated. In light of this strong alignment of views that safety decreases and 

crime risk increases for both the Army and civilian society when soldiers are not treated 

for opioid addiction, and that rehabilitation of soldiers is an effective policy option, one 

would expect that existing Army policies and regulations would seek to maximize rehabilitation for opioid-addicted soldiers and ensure that gaps in rehabilitative care are 

minimized. To be in alignment with the views of these Army leaders, one would expect 

Army regulations and policies to reflect principles that:

1. Presume soldiers are to be treated and rehabilitated from prescription opioid addiction for continued service in the force when they have future service potential;

2. For soldiers who cannot or should not be retained—since they do not have potential for future service, in the view of their commander—they will not be released from 

active duty without drug rehabilitation being first provided, so that they do not present 

a safety and crime risk to civilian communities; 

Q6. When military personnel are discharged from military service with 

an untreated addiction to opioids it increases crime in the community 

to which they return.

Answered: 104 Skipped: 2
12

3. Where soldiers are released from Army control prior to rehabilitation being completed, they will be discharged in a manner that ensures that their treatment and rehabilitation is provided through civilian channels.

The reality, in fact, is that none of these is true.

Army regulations and policies do not ensure that soldiers will receive drug rehabilitative treatment before discharge, nor do these regulations and policies minimize barriers to ensure they will get the needed help at the Veterans Administration (VA) after 

discharge; the regulations merely presume that such post-discharge help for soldiers 

may occur, but take no responsibility to ensure it will. Sometimes it occurs, but many 

times it does not. As discussed next, Army personnel practices, in combination with VA 

eligibility policies, often deny rehabilitation treatment to soldiers who leave active duty 

with prescription opioid problems. This gap in care, built upon flawed presumptions 

of later treatment that does not in fact occur, creates a recovery gap for many soldiers 

and raises potential adverse consequences to civilian society of soldiers returning home 

dependent on or addicted to and misusing30 opioids. The Army-to-civilian treatment gap 

for soldiers with opioid dependency, addiction, or misuse issues exists in part because:

1. Soldiers receiving an Other Than Honorable (OTH) discharge can be denied access 

to VA drug rehabilitation services.31 As an OTH discharge is the “presumed” discharge 

for drug abuse under Army Regulation (AR) 635-200,

32 this policy disconnect between two 

federal agencies works to pass soldiers with prescription opioid addiction and related 

misconduct issues untreated into civilian society, where they commit crimes, overdose, 

and strain civil resources. This is not an infrequent or rare occurrence. In a study of 645 

veterans seeking admission to civilian Veterans Courts, 200 of them were denied VA 

services, including rehabilitation, due to adverse discharges33;

2. Soldiers with substance abuse issues engage in denial once freed from military 

oversight and supervision, thereafter refusing to seek VA help. The addiction speaks 

louder than common sense or self-preservation, an inherent characteristic of addiction;

3. Barriers to care exist under which soldiers eligible for VA services do not access 

them after leaving the Army because of miscommunication or misunderstanding about 

their eligibility, the availability of programs, frustration over VA waiting lists, and the 

distance of the veterans in rural areas from VA hospitals.

As such, legacy policies built upon presumptions within the Army that the VA is 

waiting as a reliable safety net to take care of addicted soldiers discharged into civilian life are misplaced. The VA helps many veterans. But it also misses helping many 

veterans because of the factors mentioned earlier. When dealing with opioid addictions 

that both Army leaders and judges recognize lead to safety and security risks for veterans and the communities to which they return, an approach that works sporadically 

for many, but not all, veterans, is inadequate. Such an inconsistent system may have 

been tolerated in the past where those slipping between the cracks were undisciplined 

recreational drug abusers who voluntarily chose to use illegal drugs contrary to military law—an unsympathetic population in many eyes. However, when initial exposure 

to addictive opioids is occurring for soldiers through military medical channels, and 

early studies and data are suggesting that widespread and prolonged prescriptions are 
13

a driver of misuse and dependency issues, such a treatment gap is intolerable. While no 

system may be flawless, current Army policies increase, not minimize, the chance that 

opioid-troubled soldiers will enter the civilian world without rehabilitation.

Once a soldier becomes physically dependent on or addicted to a drug, Army regulations do not mandate rehabilitative efforts. A soldier is detoxified while on active duty 

when his or her substance abuse is discovered to ensure he does not overdose, but that 

is different than treating and rehabilitating a long-term addiction. Rehabilitation is an 

option at the commander’s discretion, with prior duty performance and future duty 

potential being considerations as to whether full rehabilitation will be provided. It is not 

purely a medical decision, but a command decision, in which the soldier’s prior goodduty performance—indicating potential for future valuable service—is important. From 

an Army resource allocation perspective this makes some sense when recreational drug 

abuse is the issue. For why should the Army expend valuable resources to rehabilitate 

poorly performing soldiers who are voluntarily using illegal drugs? However, with a 

different and broader perspective, one might ask, why is job performance a dispositive 

factor in whether one gets drug rehabilitation in the Army if the exposure to the drug 

originates in prescribed medical treatment?

One does not have to earn a reward to get other forms of medical treatment and 

therapy in the Army, but drug rehabilitation is not treated as a medical condition from 

a policy standpoint, but presumptively as an immoral act from which access to rehabilitation must be earned by showing future good-duty potential. This approach arguably 

had some weight when addictions in the post-Vietnam era resulted from recreational 

drug use, but that is not the situation confronting the Army today, with opioid misuse 

and addiction originating from pain prescriptions issued through medical channels. 

It is important to make clear that opioid misuse can occur even with the most conscientious prescription patterns and oversight by military physicians. One reason this 

problem exists is the life-saving efforts of military medicine during wartime that have 

more soldiers than ever surviving serious wounds. Different persons have different vulnerabilities to addiction because of their biological and social backgrounds, as well as 

life experiences, among other factors. It is the nature of these drugs acting on the central 

nervous system to create physical dependency, such that their use creates a high risk of 

misuse and addiction within the force. They come with great benefit in pain management, but they are also inherently dangerous. Pointing fingers at soldiers or doctors 

is not helpful. But identifying the unique source of the risk so that risk management 

policies can be crafted effectively is essential for freeing the Army from the erosion of 

readiness that is occurring under current policies.

While some substance abuse programs exist in the Army, including for opioids,34 the 

Army’s substance abuse regulation, AR 600-85, in fact presumes rehabilitation for drug 

dependency and addiction will be performed by an external civilian entity after the soldier is separated. The regulation states: 

Soldiers diagnosed as drug dependent should be detoxified and given appropriate medical 

treatment. These Soldiers generally do not have potential for continued military Service and 

should not be retained. These Soldiers will be referred to a VA hospital or a civilian program 

by the ASAP counselor to continue (or to initiate) their rehabilitation.35
14

While one of the external treatment programs noted in the regulations can be the 

VA, the Army’s personnel misconduct regulations provide for a presumed level of discharge (OTH) that is a basis for denying VA rehabilitative drug treatment. This results 

in Kafkaesque logic, in which the very condition that requires treatment is the condition 

that triggers denial of access to treatment. Drug addicts misbehave, as getting the next 

drug dose drives their mental processes while in the actively addicted stage. People 

who are addicted to a drug often steal to have resources to buy the drugs that keep 

them from suffering withdrawal symptoms; they drive impaired, and they do not fulfill 

their duty responsibilities, which can be a crime under the Uniform Code of Military 

Justice (UCMJ). So, creating a system in which the Army imposes a negative discharge 

for that misconduct and then another federal bureaucracy uses that characterization of 

discharge as the basis to deny drug rehabilitation for the same condition that triggered 

the misconduct is a Catch 22 situation that serves to deny drug rehabilitation to the persons who need it the most. When VA uses the discharge to exempt itself from providing 

drug treatment, the social and fiscal costs shift by default onto local civilian communities, which may not have the facilities or resources to absorb a complex problem that 

originated at the federal level.

The Army’s regulatory focus on removing drug-dependent and addicted soldiers is 

consistent with the Army priorities of keeping the force strong for its combat missions.

For the 40 years following the drug threat to readiness that characterized the Vietnamera Army, the Army has responded to that threat by removing undisciplined soldiers 

who engage in such conduct from the force. That is the philosophy underlying the presumptions of separation and OTH discharges contained in AR 600-85 and AR 635-200, 

Enlisted Administrative Separations. However, when such policies are applied to soldiers 

whose opioid dependency or addiction arise out of opioid prescriptions issued by military medical practitioners, these same policies may conflict with the Army’s other priorities of taking care of soldiers and military families, as well as protecting civil society 

from safety and security threats. 

Where Army prescription policies increase the likelihood of opioid misuse threefold36 for soldiers, and Army personnel policies then assume that rehabilitation will be 

provided by external civilian agencies after discharge, an environment has been created 

in which the risk of opioid dependency and addiction has been heightened within the 

Army, but the downside cost and long-term risk of those policies are often being transferred onto civilian society. Not only is this approach not good for civilian society, but 

it also unintentionally contributes to the Army’s failing to revise its policies internally, 

since the opioid-dependent and addicted soldier becomes someone else’s problem. It 

does not need to be that way; the fact that it is that way is the result of legacy Army 

enforcement policies and procedures being applied to soldiers with prescription opioid 

problems as if they were recreational drug abusers. 

The Army regulations and policies that assume someone else will deal with dependency and addiction issues are not drafted the way they are because the Army does not 

care what happens to soldiers or civilian society. They are drafted this way to promote 

good order and discipline within the Army, an organization that must demand the highest performance from its members at all times. However, these regulations were not 

drafted with the current medical and social crisis in mind; that is, that the effects of a 
15

13-year armed conflict have created a soldier population at high risk of opioid consumption, whose vulnerability to addiction and prescription misuse has been compounded 

by prescription practices and omissions in medical monitoring.37 In sum, rules drafted in 

another time for another purpose are being applied to a different set of circumstances in 

which they do not fit, and are driving poor outcomes for the Army, soldiers, and civilian 

society. 

This reliance on old policies for a new problem has occurred, in part, because on 

the surface the issues look similar—involving drugs, soldiers, and misbehavior. However, that is merely the veneer. The core of the problem, which is driving the growth 

of a military opioid culture undermining readiness and soldier health is a supply side, 

prescription-drug crisis in which soldiers are following military orders when they begin 

taking opioids, in contrast to a demand-side driven drug abuse crisis fueled by undisciplined soldiers buying drugs from illicit sources. The latter crisis requires discipline and 

enforcement. The former requires a prevention focus, soldier and doctor education, and 

regulatory reform, which promotes rather than creates barriers to rehabilitation. The fact 

that soldier drug abuse of all other types has remained at approximately 2 percent since 

2001, while prescription drug misuse has climbed to 11 percent38 of the force, reveals that 

discipline and deterrence do indeed work in the case of illegally provided recreational 

drugs. Traditional Army urinalysis screening and enforcement mechanisms have kept 

other illicit drug use at traditionally low levels despite the stressors of extended deployments over 13 years. However, these same policies have not been effective when the 

substance misuse problem is driven by medical and organizational cultural factors.39

To keep applying the same discipline-focused approach to a distinct problem in a 

manner that has proven ineffective over the past 10 years makes no sense. The Army has 

not discharged its way out of this readiness problem in over a decade, but it is swelling 

civilian courts, hospitals, and treatment centers with opioid-addicted soldiers. Perhaps 

the time for a new approach that addresses the actual underlying drivers has arrived.

Rehabilitation Can Restore Soldiers to Productive Lives. 

There are effective policy alternatives for reducing the adverse effect of opioids on 

the Army beyond merely punishing those with opioid misuse and addiction issues. 

These alternatives are recognized and embraced by both Veterans Court judges and 

USAWC officers. Veterans Courts regularly use their authority to compel recent OEF 

and OIF veterans to obtain substance abuse help from the VA, when those services are 

available, or through community programs when VA eligibility is denied. A significant 

92.5 percent of Veterans Court judges surveyed indicated a belief that Veterans Courts 

can rehabilitate veterans with opioid issues. Only 4.8 percent responded negatively to 

the proposition that Veterans Courts can rehabilitate veterans addicted to opioid drugs, 

and 1.9 percent indicated uncertainty or no opinion.

As noted, AR 600-85 indicates that civilian society, either in the form of the VA or 

other unspecified civilian entities, will provide soldiers with the rehabilitation needed 

to overcome drug dependency40 and addiction after discharge. In view of this regulatory 

presumption, USAWC students were given the following statement and asked to agree 

or disagree with it: “Due to the Army’s unique mission, Army personnel who become 

dependent on or addicted to opioid pain medication should be discharged from the 
16

service, with their drug rehabilitation left to civilian society to handle.” For these 

opinions, see Table 8.

Table 8. USAWC Opinions on Discharging Soldiers 

for Rehab in Civilian Society.

A total of 17.9 percent of the officer respondents agreed at some level with the concept of having civilian society perform the treatment and rehabilitation on those addicted to opioid pain medication. A total of 79.1 percent of the officers disagreed with the 

idea of having civilian society responsible for the rehabilitation of soldiers with opioid 

issues, and 3 percent expressed no opinion. Accordingly, in the context of opioid pain 

medication, nearly four out of five of the Army’s future senior leaders responding did 

not agree with the principles underlying AR 600-85, which assume that discharge and 

civilian rehabilitation is the appropriate disposition for soldiers with opioid dependency 

and addiction issues. This divergence in approach suggests that there is a need for considering a different policy response in the case of opioid pain medication addiction and 

dependency beyond discharging soldiers to be someone else’s problem. 

The Veterans Court judges were also asked whether, because of the Army’s unique 

mission, soldiers should be discharged and rehabilitation performed in the civilian world. Their rejection of the Army’s policy closely paralleled that of the USAWC 

officers. For the opinions of the judges, see Table 9.

Q23. Due to the Army’s unique mission, Army personel who become 

dependent on or addicted to opioid pain medication should be 

discharged from the service, with their drug rehabilitation left to civilian 

society to handle.

Answered: 67 Skipped: 1
17

Table 9. Judge Opinions on Discharging Soldiers

for Rehabilitation in Civilian Society.

A total of 77.5 percent of Veterans Court judges strongly disagreed with the policy 

of discharging soldiers for rehabilitation in civilian society. Another 5.9 percent moderately disagreed. The total favoring such a policy was 11.7 percent, with the balance of 

4.9 percent being undecided or not having an opinion. The underlying reasons behind 

these views are not indicated in the survey. However, it would be mono-dimensional to 

assume that this is merely a discussion over who foots the bill. While money and the cost 

of rehabilitating soldiers is a significant policy issue, the previously mentioned issues 

regarding gaps in service once a soldier leaves the Army are a major concern addressed 

by Veterans Court judges at their annual conferences. 

It is also not just an issue of who provides the help, but rather a concern that no one 

provides the help once the soldier is discharged until it is too late. An issue as serious 

and unforgiving as opioid addiction has no room for disconnects or miscommunication. 

It is a high-risk/high-consequence event. Failure to address opioid dependency, misuse, and addiction promptly can lead to tragedy through overdose deaths or criminal 

conduct that destroy the lives of victims, as well as tear apart military families when the 

addicted perpetrator is sent to jail. 

The survey results indicate that the assumption of the Army’s substance abuse regulations is out of alignment with the views of both senior Army officers and civilian 

judges who inherit the consequences of that policy when soldiers with opioid issues 

are discharged from the Army without full opportunity for rehabilitation first being 

provided. The Army should carefully evaluate if its discharge policies place itself at risk 

Q11. Due to the military’s unique mission, military personnel who 

become addicted to opioid pain medication on active duty should be 

discharged from the service, and their drug rehabilitation left to civilian 

society to handle.

Answered: 102 Skipped: 4
18

of widening the civil-military gap should the Army continue a policy that presumes the 

civilian world is willing to remain responsible for an opioid problem originating in large 

part in military medical practices. This reevaluation is appropriate and vital when there 

are policy alternatives in which the Army, soldiers, and civilian society all win.

Army legacy disciplinary and personnel policies were designed for recreational drug 

abuse with a focus upon post-misconduct action. Army records reflect that: 

Over 80% of Army soldiers during the Vietnam War used marijuana, and 45% tried narcotics 

(34% used heroin; 38% used opium.)41

The post-Vietnam Army was ill-disciplined as a result. Punishment and adverse discharges were employed to get rid of bad soldiers and deter future misconduct, and it 

worked: by 2001, illicit drug use Army-wide was down to approximately 2 percent. Yet, 

the opioid prescription misuse problem has grown since 2001 despite these legacy policies. If one lets opioid use and misuse expand without medical and rehabilitation countermeasures it inevitably becomes an Army disciplinary issue; the surveys have already 

reflected that an otherwise law-abiding individuals can devolve into criminal conduct 

once they become addicted. This does not mean the answer is more discipline, however. 

Rather, a policy focusing on prevention and earlier medical intervention through monitoring, to prevent prescription use from developing into a disciplinary problem in the 

first place, is required to counter a problem that is largely medical in origin. 

Unlike any other drug use in Army history, the organization knows where the supply 

is coming from—the post clinic. The Army knows who has the drugs, because soldiers 

create medical records with each prescription. So, forearmed with this knowledge as to 

who is at risk, the Army is the sole entity in the best position to intervene and preempt 

this opioid crisis in a way that neither the VA nor civilian entities can after the soldier 

has become a medical emergency and a disciplinary and safety threat. Developing new 

policies that embrace a preemptive and preventative approach is a matter of breaking 

free from familiar historical practices, setting aside past assumptions about the caliber 

of soldiers who have dependency or addiction issues, and changing the cultural focus 

from reactive to preventative. 

The Army is an environment different from civil society, with stricter rules of personal conduct and responsibility. Commanders and senior Army leaders by tradition 

and culture hold soldiers to standards of conduct and personal responsibility that are 

necessary to preserve unit cohesion in combat and preserve good order and discipline. 

Excuses and blame shifting are not tolerated in the Army, because the stakes in terms of 

lives and national defense are too high. Recognizing that personal responsibility is an 

important value within the organization, USAWC respondents were also asked whether they agreed or disagreed that, “Opioid misuse and/or addiction is a soldier’s choice 

and responsibility that is independent of Army prescription policies.” The responses are 

shown in Table 10.
19

Table 10. USAWC Opinions on Relationship between 

Misuse/Addiction and Prescription Practices.

A total of 75 percent of the USAWC officers disagreed that opioid misuse and addiction are a soldier’s choice and responsibility independent of Army prescription 

practices. A total of 23.5 percent of respondents believe that misuse and addiction are 

a soldier’s responsibility independent of Army prescription practices, and 1.5 percent 

did not know or had no answer. These answers reflect most clearly that three out of 

four senior Army officers view the opioid crisis as directly linked to Army prescription 

practices and not due to the independent conduct of soldiers choosing to engage in risktaking illegal drug behavior.

Neither group surveyed suggested, nor does this Paper suggest, that discipline is 

misplaced for those who break the law, engage in the recreational use of opioids, or 

reject the opportunity for meaningful rehabilitation . No one can rehabilitate a soldier 

once that opportunity is given other than the soldier him- or herself. Rather, the surveys 

indicate that, unlike with mere recreational drug use, prescription opioid misuse is a 

complex problem unique in its origins, which requires a nuanced and adaptive policy 

response different from that needed to counter recreational drug abuse. One size fits all 

is easy and convenient; it just happens to be ineffective and perpetuates the opioid crisis.

Shifting Army Policies on Opioid-Troubled Soldiers. 

With both civilian criminal judges and senior Army officers believing that rehabilitation programs can work with soldiers and veterans dependent on, addicted to, and 

misusing opioids, the USAWC officers were asked: “Do you believe the Army needs to 

do more to respond to opioid pain medication misuse, dependency, and/or addiction 

among soldiers?” The responses were:

Q29. Qpioid misuse and/or addiction is a soldier’s choice

and responsilbity that is independent of Army prescription policies.

Answered: 68 Skipped: 0
20

Yes - 70.6 percent

No - 13.2 percent

I don’t know/No opinion - 16.2 percent

Those responding “Yes” were then asked to elaborate what additional actions the 

Army should take to reduce the adverse impact of opioids. The AWC officers responded 

as reflected in Table 11, with more than one response being allowed to the question. 

Table 11. USAWC Officer Policy Recommendations 

to Overcome Opioid Threat.

The most often proposed responses to the opioid problem were medical and treatment oriented. An overwhelming 94.3 percent of the respondents saw preventative 

medical monitoring of soldiers who are prescribed opioids as an effective policy response. Over 71 percent of the respondents thought that reducing the number of opioid 

prescriptions was needed. Exactly 66 percent felt additional rehabilitation efforts were 

needed, and just over 60 percent believed that the Army needs to do more to train and 

inform soldiers better on the dangers of opioid pain medication. Consistent with the 

majority of other responses throughout the survey that did not view the opioid problem 

at its source as a disciplinary one, only 15.1 percent of respondents saw more UCMJ and 

administrative separation actions as a needed change; 17 percent saw the increase in 

adverse discharge characterization as being a rehabilitation failure as a needed policy 

improvement. 

These responses contrast with the 2010 policy positions of the Army on the needed 

action to overcome the prescription drug misuse problem. In the Army’s 2010 Suicide 

Prevention Report, the authors cited a lack of garrison leadership and risk-taking soldiers 

as the two primary reasons for the Army’s opioid problem.42 Medical prescription practices were noted, but not cited as a major contributing factor to soldier misuse levels.

Answer Choices Responses

Increase UCMJ and admin separations 15.1% 8

Increase discharge severity for rehab fail 17.0% 9

Reduce # of opioid medicine Rxs 71.7% 38

Increase focus on prevention by medically monitoring soldiers with opioid 

prescriptions for signs of dependency/addiction 94.3% 50

Provide drug rehabilitation programs for soldiers who become addicted to 

opioids 66.0% 35

Provide more training and information to soldiers on the dangers of opioid 

medication 60.4% 32

Other (please specify) 13.2% 7

Total Respondents: 53
21

With more than one response possible, the USAWC officers were surveyed how they 

characterized the nature of the opioid problem in the Army. They were directed to: 

“Check each of the following that you believe characterizes the use of opioids in the 

Army today.” Their responses as shown in Table 12 were:

Table 12. Characterization of the Opioid Problem

by USAWC Officers.

In contrast to the conclusions of the Suicide Prevention Report, the survey of USAWC 

officers indicates that, while nearly half recognize there is a disciplinary component to 

the opioid problem, nearly nine out of 10 consider it primarily a medical issue. Further, 

two out of three recognize the impact of the problem as a readiness issue. These responses are in alignment with this group’s prior responses, which called for increased 

reliance on solutions in the realm of prevention, medical prescription reform, and soldier training/education (Table 11), rather than in discharging opioid-troubled soldiers 

into civilian society where they create a safety and crime risk (Tables 7 and 11). 

Policy is not made in a vacuum. The Army is facing potential budget cuts through 

sequestration that may impact readiness in personnel levels, training, and weapons. In 

view of this, the survey asked USAWC respondents to react to the statement: “In this 

period of fiscal austerity, the Army should not dedicate additional funding to opioid 

drug rehabilitation programs for soldiers.”

Answer Choices Responses

It is a disciplinary issue 48.5% 33

It is a medical issue 89.7% 61

It is a readiness issue 67.6% 46

It is a civil-military divide issue 17.6% 12

It is not an issue of concern 2.9% 2

Other (please specify) 7.4% 5

Total Respondents: 68
22

Table 13. USAWC Respondents Responses to 

Drug Rehabilitation Programs for Soldiers.

Together, a total of 69.1 percent of the respondents moderately or strongly disagreed 

with the proposition that fiscal constraints mean additional funding should not be allocated to soldier rehabilitation. A total of 26.5 percent agreed that resources should not 

be increased for rehabilitation, and 4.4 percent had no opinion or did not know. The 

responses reflect that nearly seven out of 10 senior officers about to graduate from the 

USAWC view rehabilitation efforts as a priority for resource allocation, even in a period 

when personnel and equipment cuts may need to be made. Such thinking may well 

reflect the knowledge gained by these newly trained strategic leaders during their year 

at the USAWC, that having a technically skilled and well-equipped Army is of dubious 

value if its personnel readiness is eroded by prescription opioid dependency, addiction, 

and misuse. 

CONCLUSION

The Army has an opioid drug problem that is not going away under current personnel policies and medical practices. The survey results recorded here indicate that senior 

officers attending the USAWC recognize that the opioid problem is distinct in nature 

and origin from recreational drug abuse. Yet, these officers are saddled with a legacy 

drug enforcement structure and outdated procedures that do not track opioid usage 

across the force and do not address the root cause of the issue. They are commanding units under a regulatory structure that belatedly responds to opiod-related misuse 

with the same misconduct-focused disciplinary policies as recreational drug use, rather 

than with a proactive medical and personnel approach crafted for this unique problem 

that emphasizes prevention and rehabilitation. The USAWC officer survey responses 

indicate that the majority of these future Army leaders see misuse originating from 

Q24. In this period of fiscal austerity, the Army should not dedicate

additional funding to opioid drug rehabilitation programs for soldiers.

Answered: 68 Skipped: 0
23

prescription practices, a lack of medical monitoring,43 and a lack of soldier training and 

education on the dangers of opioids, not from undisciplined soldiers. 

This Paper is not meant to be the final word, but rather the beginning of a new conversation. The survey samples were not random populations, but specifically chosen 

groups of leaders with specialized knowledge and expertise in this area. The samples 

presented do not claim to represent the views of all judges or all Army officers. But the 

trends from their responses are intriguing, as they break from past presumptions and 

perceived truths regarding opioid use and suggest a new way of thinking about the 

Army’s opioid problem, as well as its impact on readiness and civil-military relations. 

The comparison of the two surveys reveals that in most instances there is not a significant gap between civilian judge and senior Army officer thinking as to the nature 

and seriousness of the problem. Rather, military prescription practices and the application of legacy policies that presume separation as opposed to prevention and rehabilitation are creating the conditions for the cracks in a future civil-military gap to widen. 

Army procedures that continue to supply opioids on a wide scale, but then transfer the 

adverse long-term costs of those policies onto civilian society, are not in the best interest 

of Army readiness, soldier health, or civilian safety and fiscal security. Army policy and 

regulatory reform is needed to counter these trends successfully; that will require policies different from those in the Army’s institutional comfort zone that have served well 

in countering recreational drug use for 40 years. To protect the readiness of its force, 

the Army should consider the path suggested by those it has trained to be innovative 

and strategic thinkers at the USAWC—a future focused upon increased rehabilitation, 

soldier education, medical monitoring, and unit level opioid readiness tracking.

ENDNOTES 

1. Opioids include morphine, codeine, and opium, which are a product of the opium poppy. But they 

also include synthetic pharmaceuticals used to manage pain that operate on the central nervous system to 

block pain and cause a sense of euphoria in the same manner as opiates. Common forms employed in the 

Army include Percocet (oxycodone and acetaminophen) and Vicodin (hydrocodone and acetaminophen).

2. Jana Burson, Pain Pill Addiction: A Prescription for Hope, Indianapolis, IL: Dog Ear Publishing, 

2010, p. 7.

3. Ibid., p. 8.

4. Ibid., pp. 9-11.

5. Veterans Courts are a new type of court founded in 2008 by Judge Robert Russell of Buffalo, NY. 

They are criminal courts under the laws of the state in which they sit. Veterans Courts, while protecting 

society and victims, also seek to ensure that veterans whose misbehavior originates in treatable conditions 

such as substance abuse or mental health issues receive that assistance. Veterans Courts have a nearly 90 

percent success rate, in terms of their participants not committing further crimes after graduation, compared to a 45 percent success rate with traditional criminal courts.

6. A 15-question survey was mailed to the presiding judges of the 177 known Veterans Courts in the 

United States on January 19, 2015. The survey focused on the experience and opinions of the judges handling the cases of OEF and OIF veterans, many of whom have opioid misuse, dependency, and addiction 

issues. Veterans Courts were selected for the survey, as opposed to all criminal courts, since defendants 
24

in these courts are typically screened as a condition of entry into these veteran treatment court programs 

as having a nexus between their military service and their substance abuse and mental health issues. Furthermore, many traditional criminal courts process defendants without ever inquiring or recording if they 

are veterans. A second survey composed of 29 questions was sent electronically and in hard copy to 216 

U.S. Army branch, resident phase, students of the USAWC, Carlisle, PA on March 3, 2015. This group 

comprised 169 active duty officers, 24 Army National Guard officers, and 23 U.S. Army Reserve officers. 

The author, who is a USAR member of this class, excluded himself from the survey. The survey sought to 

gauge the officers’ level of knowledge and opinions regarding opioid pain medication use, misuse, and enforcement policies in the Army. Both survey populations were asked the same questions, except where the 

nature of respective job duties made that impractical. A greater number of questions were asked of Army 

personnel to determine the nature of their experience, i.e., whether it was in a command or other context, 

in garrison or during deployment, and other military specific questions.

7. Army commanders exercise adjudicatory and dispositional authority for nonjudicial punishment 

over soldiers who engage in disciplinary violations, including substance abuse. They also play an active 

role in deciding whether to initiate and forward charges to court-martial in serious cases. They render the 

ultimate decision as to whether a soldier should be retained or administratively eliminated from the Army 

for drug-related misconduct, and what level of discharge the soldier should receive if separated. Army 

Regulation (AR) 27-10, Military Justice, Washington, DC: U.S. Department of the Army, October 3, 2011; AR 

635-200, Active Duty Enlisted Administrative Separations, Washington, DC: U.S. Department of the Army, 

September 6, 2011; AR 600-85, The Army Substance Abuse Program, Washington, DC: U.S. Department of the 

Army, December 28, 2012.

8. Of the respondents, 43 percent had personal or direct-duty contact with soldiers who had misused 

or were addicted to opioids since 2001, 46 percent did not have personal contact, and 11 percent did not 

know if they had.

9. National Institute on Drug Abuse, “DrugFacts: Substance Abuse in the Military,” March 2013, 

available from www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military.

10. Medication Management for Physically and Psychologically Wounded Armed Forces Members in Fiscal Year 

2011-2102: Report to Congress, Washington, DC: U.S. Department of Defense, March 14, 2012, p. 48.

11. Robin Toblin et al., “Chronic Pain and Opioid Use in US Soldiers after Combat Deployment,” JAMA 

Internal Medicine, Vol. 174, No. 8, August 1, 2014, pp. 1400-1401.

12. Ibid.

13. “Addressing Prescription Drug Abuse in the United States,” Washington, DC: U.S. Department 

of Health and Human Services, p. 10, available from www.cdc.gov/HomeandRecreationalSafety/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf.

14. “DrugFacts: Substance Abuse in the Military,” Bethesda, MD: National Institute on Drug Abuse, 

March 2013, available from www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military, accessed 

February 21, 2015.

15. “Report to Congress: Medication Management for Physically and Psychologically Wounded 

Armed Forces Members in Fiscal Year 2011-2102,” Washington, DC: U.S. Department of Defense, March 14, 

2012, p. 15.

16. Toblin et al., p. 1401.

17. Alex S. Bennett, Luther Elliott, and Andrew Golub, “Opioid and Other Substance Misuse, Overdose Risk, and the Potential for Prevention Among a Sample of OEF/OIF Veterans in New York City,” 
25

Bethesda, MD: National Development and Research Institutes (ISPR), 2013, published in final edited form 

in Substance Use Misuse Online, Bethesda, MD: National Institute of Health, Vol. 48, No. 10, July 2013, p. 894, 

available from informahealthcare.com/doi/abs/10.3109/10826084.2013.796991.

18. Army Health Promotion Risk Reduction Suicide Prevention Report 2010, Washington, DC: U.S. Department of the Army, 2010, pp. ii-iii, available from usarmy.vo.llnwd.net/e2/rv5_downloads/hprrsp/HP-RR-SPReport2010.pdf, accessed January 2, 2015.

19. See www.brilliantlifequotes.com/inspirational/mark-twain/. 

20. Army Health Promotion Risk Reduction Suicide Prevention Report 2010, p. 83.

21. Sandra Basu, “Greater Alternative Therapy Use Gradually Decreases Opioid Dependence in the 

Military,” U.S. Medicine Online, June 2014, available from www.usmedicine.com/agencies/department-of-defense-dod/greater-alternative-therapy-use-gradually-decreases-opioid-dependence-in-military/, accessed April 1, 

2015.

22. Robert Bray, Kristine Rae Olmstead, and Jason Williams, “Misuse of Prescription Pain Medications in U.S. Active Duty Service Members,” Pain Syndromes—From Recruitment to Returning Troops: 

Wounds of War IV, Vol. 91, NATO Science for Peace and Security Series E: Human and Societal Dynamics, 

Amsterdam, The Netherlands: IOS Press BV, 2012, p. 3.

23. Toblin et al., p. 1401.

24. Roger Chou et al., “The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: 

A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop,” Annals of 

Internal Medicine, February 17, 2015, available from annals.org/article.aspx?articleid=2089370, accessed April 

8, 2015. 

25. Wayne B. Jones and Eric B. Schoomaker, “Pain and Opioids in the Military: We Must Do Better,” 

JAMA Internal Medicine, August 2014, available from archinte.jamanetwork.com/article.aspx?articleid=1885985, 

accessed February 5, 2014.

26. “Pathways to Prevention: The Role of Opioids in the Treatment of Chronic Pain,” Bethesda, MD: 

National Institutes of Health, September 29-30, 2014, available from https://prevention.nih.gov/programsevents/pathways-to-prevention/workshops/opioids-chronic-pain, accessed February 16, 2015.

27. The extent to which there is a need for military specific exceptions to HIPAA laws due to the unique 

responsibility commanders have for soldiers’ lives and welfare, as well as mission accomplishment, is 

beyond the scope of this Paper to explore. It is enough to note that when commanders are being denied information essential to the performance of their mission and to the protection of soldiers placed in positions 

of personal jeopardy due to the commanders’ lack of information about their medical ability to function, 

there is a defect in the system. 

28. Burson, pp. 9-11.

29. Ibid., p. 9.

30. While dependency and addiction are medical terms, “misuse” is a legal construct that can include 

using a prescription in excess of prescribed limits, using drugs during periods not covered by the prescription, or giving or selling the drugs to another. Since opioids are a controlled substance under federal law, 

any consumption not in compliance with a medical professional’s direction is likely to constitute a crime.
26

31. Soldiers who receive an OTH discharge as the result of an adverse administrative separation are reviewed by the VHA for eligibility under VA regulations and procedures, with access to benefits, including 

drug rehabilitation, decided on a case-by-case basis. U.S. Department of Veterans Affairs, M21-1 Adjudication Procedures Manual Rewrite, Part 3, Subpart V, Chap. 1, Sec. B, Para. 5(c), February 23, 2012.

32. AR 635-200, Active Duty Enlisted Separations, Para 14-3(a), 99, and 14-12(c)(2), Washington, DC: U.S. 

Department of the Army, September 6, 2011, p. 102.

33. Evan R. Seamone, “Reclaiming the Rehabilitative Ethic in Military Justice: The Suspended Punitive 

Discharge as a Method to Treat Military Offenders with PTSD and TBI and Reduce Recidivism,” Military 

Law Review, Vol. 208, Summer 2011, p. 32, fn 92.

34. AR 600-85, Para 8, p. 54.

35. Ibid., Para. 7-1(b)(2), p, 49.

36. Bray, p. 3.

37. The medical monitoring of soldiers issued opioid prescriptions has been a suggested but optionalonly guideline for military physicians from 2001 to the present. The Surgeon General’s office is currently 

leading an initiative to make such monitoring mandatory across all Services. Colonel Paul Barras, Director, 

Office of the Army Surgeon General Comprehensive Pain Management Program, telephone interview with 

author, February 2, 2015.

38. “DrugFacts: Substance Abuse in the Military.”

39. Bennett et al., p. 1.

40. Burson, pp. 10-11. The body will chemically and physically adjust itself to require the continued 

consumption of an addictive substance, such as an opioid, in order to operate normally. This is known 

as dependency. When there is the added psychological compulsion, or obsession, to obtain the drug, in 

addition to physical dependency, this is known as addiction.

41. Mary Jo Larson et al., Military Combat Deployments and Substance Use: Review and Future Directions, 

Bethesda, MD: National Institutes of Health, February 22, 2012, p. 11. 

42. Army Health Promotion Risk Reduction Suicide Prevention Report 2010.

43. The Surgeon General’s Office is currently considering the implementation of a mandatory medical 

monitoring program as part of its Comprehensive Pain Management Program. COL Paul Barras, Director, 

Office of the Army Surgeon General Comprehensive Pain Management Program, telephone interview with 

author, February 2, 2015. This would be an extension of other reforms contained in MEDCOM Operational 

Order 10-76, which seeks to increase alternatives to pain management. LTG Eric Schoomaker, U.S. Army 

Surgeon General, “Operation Order 10-76 (USAMEDCOM Comprehensive Pain Management Campaign 

Plan),” Fort Sam Houston, TX, U.S. Army Medical Command, September 21, 2010. Unfortunately, since 

the Order was issued in 2010, there have been no data indicating that the plan has had a significant impact 

on reducing opioid prescription levels—with the testimony of BG Coots, cited earlier, noting a 24 percent 

prescription rate military-wide still existing in 2013. 
U.S. ARMY WAR COLLEGE

Major General William E. Rapp

Commandant

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