June 5, 2012

Veterans Struggle to Treat Addictions

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Joe Collins, a veteran of the Iraq war, sits in the living room of his mother’s home. He is staying there while recovering from drug addiction and seeking treatment for post-traumatic stress disorder.

Dylan Johnson/Oklahoma Watch

Joe Collins, a veteran of the Iraq war, sits in the living room of his mother’s home. He is staying there while recovering from drug addiction and seeking treatment for post-traumatic stress disorder.

Former Army Reservist and Iraqi war veteran Joe Collins sits in his mother’s living room in Edmond and describes his daily struggle to forget his time spent in war.

“I’ll do anything not to think about it. I don’t even have a cable box in my room,” Collins said. “It’s the psychological part of trying to live with what we’ve done, and living with what we’ve seen.”

The 28-year-old veteran now speaks with a lisp due to his dentures. In the eight years since his return from combat, Collins not only has lost his teeth and gall bladder to drug addiction, he’s also lost his job, home and self-sufficiency to post traumatic stress disorder.

Audio clip: Veterans and Addiction

A study by the Journal of the American Medical Association released in March found that veterans with PTSD were prescribed opium-based painkillers at a higher rate and higher dosage than those without mental health disorders,

and they were often taking them with other painkillers or hypnotic drugs. These soldiers, primarily veterans of Iraq and Afghanistan, had a higher rate of all adverse clinical outcomes, including overdoses and self-inflicted and violence-related injuries.

The Department of Veterans Affairs came under fire recently for how it’s handled the influx of soldiers suffering from PTSD, and just last month it announced the addition of 1,900 mental health professionals to its staff. This was just days before the release of a glaring internal report on the V.A.’s manipulation of inpatient treatment statistics.

According to VA policy, when veterans ask for mental health care, they are supposed to receive a full evaluation within 14 days. The inspector general’s report concluded that while the VA was claiming to hit that mark 95 percent of the time, in reality more than 50 percent of the veterans studied waited an average of 50 days.

Sarah Green’s son Cody Green served in Afghanistan with the Oklahoma National Guard in 2004. After his return, it was evident to those close to him that his drug use was becoming a serious problem.

He struggled with PTSD for years, and last summer Sarah tried to get Cody treatment at the VA after a series of suicide attempts. When she called after the second attempt to get Cody admitted for inpatient care, she was told her son was on a waiting list to receive treatment. He would not be admitted for a couple of months.

“I just said he needs it, and he needs it now. He’s in trouble, he needs it now,” recalled Sarah.

After pressing the Oklahoma City VA, she was finally able to get Cody’s wait time for treatment reduced from months to a couple of weeks.

It still wasn’t fast enough.

“The next day I got the call that he’ll be in the session on the 20th,” she said.

“Well, a week before that, he committed suicide.”

The War at Home

Over the last few months, the more than 3,000 soldiers in the Oklahoma National Guard’s 45th Infantry Brigade have been returning from Afghanistan and Kuwait. While the U.S. Department of Veterans Affairs’ addition of 1,900 mental health professionals represents a 10 percent increase in its mental health staff, the inspector general’s report suggests that resources at the VA still will be stretched thin. Its facilities are having trouble seeing the veterans that come in, and many more aren’t willing to seek the help they need, allowing their mental health condition to go untreated.

After serving in a war zone, it isn’t uncommon for soldiers to decline mental health care in order to process faster and get home as soon as possible. That was the case for Joe Collins, the Army Reservist who joined in 2003 and volunteered to serve in Iraq the following year.

“When we got back, we’d fill out these papers, and if you put that you saw something bad, or you were exposed to this, they’re going to keep you,” Collins said. “And, you’ll just be stuck there that much longer. So all you’re thinking is, ‘How do I get home?’”

Collins says that while the Army spent three months preparing him for deployment to Iraq, it only spent one week preparing him for civilian life.

Collins checked ‘no’ all the way down the list. As far as the VA was concerned, he had never seen or experienced any mentally damaging combat and was feeling no long-term effects.

Ask Collins today, and he’ll acknowledge that this was definitely not the case.

“When I came back I tried so hard to fit back in. I told my friends in the beginning, ‘I feel lost. What now?’”

Despite his desperation and confusion, Collins did not seek medical or mental health care immediately.

Edwina Luker is a program manager at the VA and part of a task force looking at how to meet the needs of the returning 45th. “My bigger concern is not how we’re going to handle them, but getting them here at all,” Luker said. “Typically, this age group does not want to have anything wrong with them. And, they certainly don’t want to have mental health things wrong with them or traumatic brain injuries. And so, not to find out may mean you don’t have it, which is not, of course, the case.”

However, the problem goes deeper than simply denial on the part of the veterans. Many times the stigma that comes with PTSD keeps them from seeking treatment. Many soldiers fear they may be jeopardizing a career with the military.

Again, this scenario fits Collins. He had severe depression and anxiety and was even considering suicide. He soon found himself in a series of troubling incidents. One night, while leaving a casino, he got into an argument after he backed into another man’s truck. According to Collins, both men had been drinking.

“He shot at me, he had a revolver I could tell. I got out of the truck and started screaming at him. I told him to pull it out and called him a coward. That was my moment where I thought, ‘This is going to happen. I’m finally going to get my way out.’ I was just egging him on to do it. I remember him telling his friend, ‘This guy is crazy.’”

When Collins finally did seek help, it wasn’t through the VA.

“I tried to keep everything completely quiet and away from the military, at first. I had what was called dual status with my federal employment job. So, if I lost my military position I could no longer work.”

Collins paid out-of-pocket for his care, eventually exhausting all the money he had saved from his time in the Army. Primary care doctors prescribed him higher and higher doses of prescription drugs, which left him with a severe drug addiction and even deeper withdrawal.

The JAMA study from March cited a lack of primary care clinicians, both in and outside of the VA, with specialized training on PTSD and comorbid pain as one of the reasons why veterans with mental health illnesses are being prescribed painkillers at such a high rate. The report says that “…in a sample of veterans with multiple pain problems, those with the highest-risk medical and psychiatric comorbidity were the most likely to receive the highest-dose, highest-risk opioid therapy … This paradoxical finding suggests that patient distress can drive potentially inappropriate opioid therapy, perhaps because physicians do not know how else to handle these challenging patients.”

Dr. Boyd Shook disagrees with that assertion. “ I don’t encounter a lot of primary care physicians who really don’t understand PTSD,” he said.

Shook is in private practice in Edmond as an internal medicine specialist. He was in charge of ambulatory care at the V.A. in the mid-‘90s.

“It may be that they understand it very well, but don’t have the capabilities to bring this into their practice,” Shook said. “Often it’s a matter of time. We have a tendency in this business to structure 15-, 20-minute visits. Typically my first visit with a patient with a complex chronic pain syndrome is an hour and a half. There are a lot of physicians out there who plain cannot do that.”

The Department of Veterans Affairs says it recognizes the mounting problem that PTSD and drug addiction pose. Walking through the bustling ground floor of the Oklahoma City VA complex, Public Affairs Officer Stacy Rine apologizes for the detour that was necessary due to the facility’s current expansion.

“A lot of people have a different perception of the VA, and I always tell them when they come in it’s not your father’s VA,” said Rine. “We are not the same VA we were 10 years ago, even five years ago.”

In an effort to accommodate the new generation of young soldiers who served in Iraq and Afghanistan, the VA is trying out some new tactics.

“We see a lot of younger veterans who want to communicate electronically. So we do text messaging and social media,” said Rine. “Another example is appointments. A lot of these vets have day jobs. So, we have appointments early in the morning, as well as late at night to accommodate their needs.”

The VA is also looking more into alternative and complementary medicines such as meditation and relaxation therapy. Terry Sparks is a staff chaplain at the Oklahoma City VA. She specializes in a therapy treatment called Healing Touch.

“Healing Touch is a way of working with the energy system of the body, the chi,” Sparks said. “If you’re not familiar with the chi, just think the force from Star Wars. It’s pretty close.”

Persistent physical pain from PTSD often leads soldiers to seek painkillers for relief, which in turn can lead to addiction. The department says nearly 90 percent of all VA facilities now have the option for treatments like Healing Touch as an alternative or complement to prescription drugs.

“Opioids can do good things. They can be good tools,” Sparks said. “But, a lot of younger veterans want to try something different. A lot of them have seen the downsides.”

Healing Touch is designed to dovetail with western medicine, allowing Sparks to focus on her therapy knowing the soldiers she sees are also seeing a medical doctor. Over the last few years, PTSD has become a real area of focus for her and her colleagues. “In particular with the PTSD, they want to try something different. There really is a sense within VA that we really need to do something and not let another generation of our war fighters, our soldiers, get into this bind.”

Addressing the Stigma

Flags from the graves of brothers Uday and Qusay Hussein, the sons of former Iraqi dictator Saddam Hussein, hang behind Sen. Steve Russell as he sits in his office at the Oklahoma Capitol. Russell, who represents District 45 in Oklahoma City, also served 21 years in the infantry in the U.S. Army. During that time he deployed operationally to Kosovo, Kuwait, Afghanistan, and Iraq and was among the men who captured Saddam Hussein. He says he knows firsthand how hard it can be reintegrating back into society post deployment.

“Not a day goes by that those who have borne battle don’t recall something from that time,” Russell said. “Some smell, some sight, some phrase or sequence of events.”

Russell made it one of his priorities this session to pass legislation to help veterans transition back into society. He co-authored State Bill 1863, which Gov. Mary Fallin just signed into law. The bill allows colleges and universities in the state to translate military experience into college credit. Russell is sympathetic to soldiers who avoid appropriate mental health care.

“The minute a soldier has to make the choice of getting treatment for post traumatic stress, he is immediately stigmatized in society,” Russell said. “He probably can’t hold a trusted government job. He could never enter the FBI, or he’d have difficulty doing any number of other things. Yet, as a member of the military, we can send him on tour after tour after tour. Do you see how it works against the veteran to seek treatment on things that he might need? But the minute you do, you’ve got the mark of Cain on your forehead. So, most veterans, I would say, just choose not to do it.”

For many soldiers who fear being stigmatized, the only other option is seeking public treatment through the state. But Oklahoma Department of Mental Health and Substance Abuse ServicesCommissioner Terri White says they may just get a similar response.

“To get into the public mental health system, you have struggled a long time. Because by this time you don’t have any other means to get help, that’s the only way you get here,” White said, speaking at an Oklahoma City public health forum in February.White said her department is only equipped to help one-third of those who seek mental health assistance, and usually only those in the most advanced stages. “We turn people away because of their disease, and we say as your brain gets more damaged, then you have a shot at getting in our door.”

White said the same stigma experienced at the VA happens in her sector, as well.

“As long as people believe somehow that this is a character issue or a moral issue, or that they are flawed, they’re never going to be able to stand up and ask for the help that they need,” White said. “We have to be talking about it. That in of itself is free, and it will make a huge difference.”

White contends that until addiction and mental illness are addressed as the serious medical conditions that they are, Oklahomans wont spend the time and resources necessary to treat them adequately.Oklahoma currently leads the nation in prescription drug abuse. Adding to the issue’s urgency and much to the dismay of White’s department, many of those who are turned away for treatment turn to suicide. According to the state department, not only does Oklahoma currently have the 8th highest suicide rate in the nation, one fourth of those are veterans.

State Sen. Steve Russell takes exception to such numbers. “I think a lot of those veterans statistics are unfair. They’re cherry-picked.” Russell gets at the larger issue of what role public perception plays in the problem. “Enough of the stigma. I have changed from the wars that I have fought, but I am still a competent human being. Don’t take that away from us simply by the right that we went out and did the impossible, and we went and did the hardest things that our nation asked us to do.”

He warns that asking so much of our soldiers and not taking care of them in return could have a much larger impact than the public might think. “You have to pay that price to care for those veterans,” Russell said. “With less than half of one percent going and doing it, if we expect that there will be others in the future going out and doing it? Well, then you got to keep that promise that we will take care of them until the day they die. It’s part of the bargain.”

Statistically, most of those suffering from PTSD do not act out in ways that violate the law, but Russell contends that the public often stigmatizes the disorder. He cites a Hawaii 5-0 episode he recently saw in which the crazed villain was a veteran of Vietnam. “If we think that we’re unrecoverable, then we are forever in a victim category in society,” Russell said. “I think that is a contributing factor to people self-medicating. They believe that they can’t make it, or that they can’t be made whole.”

In a time when supporting the troops is a highly idealized notion, veterans like Joe Collins wonder why the United States spends such a disproportionately small amount of the military budget on veteran care. “That is a mistake that our government is making, and it’s morally wrong,” Collins said. “The only word I can think of is disgust.”

Collins is trying to get back on his feet again, eager to re-enter the workforce and have a place of his own. He resides with his mother in Edmond, assisting her veterans care advocacy organization,Veterans’ Families United. Joe attends Yellow Ribbon events, put together by the National Guard, with her and speaks to other veterans about his ordeal.

Collins describes the years of drug addiction and mental illness he suffered as a living hell. But, even given his disappointment with the government’s handling of veterans, when asked if he would change anything, he still says no. “If I could choose between where I am now and have avoided the Army and lived a different life I think I would stick with where I am now. It puts me in a unique position to try to help at least a few people. If I help only one person I’ve done something to make a difference.”

That sentiment is not shared by Sarah Green, whose son Cody committed suicide after serving in Afghanistan. She believes that had the resources and protocol been there her son would be alive today.

It was the National Guard’s lack of compassion that she thinks did the most damage. She recalls how Cody’s fight with PTSD kept him bedridden, causing him to miss drill.

“When he finally did make it to drill, they stood him up in front of everyone and tore off his stripes,” Green said tearfully.

“The war broke his spirit, but the Army broke his heart.”