War and Drugs

Alcohol and drug use by soldiers is nothing new, and at times, their use has even been sanctioned by military command. David Young takes a look at an issue that has affected every country’s armed forces, including those of New Zealand.

In September, five US infantrymen were charged with murdering Afghan civilians in Kandahar province. Prosecutors say the soldiers killed for sport, dismembered their victims and collected body parts as souvenirs.

But Geoffrey Nathan, defence lawyer for murder-accused Jeremy Morlock, says the real disgrace is a culture of “rampant” drug abuse among troops in Afghanistan that gave rise to the scandal.

Whichever version of events is to be believed, drugs – legal and illegal – are a recurring theme in the story of the ‘rogue kill squad’. The prosecution alleges the killers smoked large quantities of hashish prepared from marijuana that grows in the Kandahar countryside. The war crime allegations were made by a junior soldier who was viciously beaten after telling on his unit for smoking the drug. Morlock’s defence lawyers say that, if he was high, it was on a cocktail of prescribed sleeping pills, antidepressants and painkillers.

“This lad was all juiced up, and it was by Army doctors”, says Nathan.

In a letter to the Boston Globe, Nathan claims that, in Afghanistan, the US military suffers from “rampant and easy distribution of prescription medications without adequate warnings, supervision or proper medical training,” and, he contends, “There are no controls on troops purchasing hashish and other narcotics from interpreters who are drug dealers on the side.”

Prolonged exposure to combat increases the risk of substance abuse and mental health issues. It is 9 years since the Taliban was toppled in Afghanistan, and 7 years since a US-led coalition invaded Iraq. There are 1.4 million men and women in active service in the US military. As the withdrawal of troops draws nearer in Afghanistan – and 2 months after the last US ‘combat brigade’ left Iraq – multinational forces continue to suffer casualties in both countries.

Media accounts of Kandahar’s “hash-fuelled murder spree” have renewed focus on the US military’s complex relationship with drugs.

Treatment experts worry that drug use has increased during the wars. Researcher Thomas Kosten says that, while soldiers’ “use of [hard] drugs or stimulants seems not very common, many smoke marijuana, and usage rates have gone up as much as 500 percent in some Veterans’ Administration [areas] around the country in the last 6 years. That seems a rather alarming problem.”

Because of its size and primary role in multiple theatres of war, the US Department of Defense has dramatically larger and more serious problems with substance use and mental health issues than any of the militaries it fights alongside. But even troops from smaller defence forces have generated negative drug use headlines during the wars in the Middle East.

This year, British military police tightened border security and introduced sniffer dogs to several Afghanistan air bases after allegations that British and Canadian soldiers were smuggling heroin home in military aircraft.

The Australian military was embarrassed in late May when an elite commando in Afghanistan was found unconscious on base with a suspected opiate overdose, the morning after a function at which the commanding officer had allowed troops to drink alcohol.

“Diggers are using cocaine, heroin and other hard drugs while on tours of duty in Afghanistan and are returning home as addicts,” cried one Southern Australian newspaper, although there is no evidence that this is a trend affecting Australian forces.

And while New Zealand’s Defence Force in Afghanistan has experienced next to none of the drug-related problems of the US military, it did have its own, relatively minor brush with drugs when six junior personnel were returned home from Bamiyan province in 2008 for trial by court martial for allegedly smoking hashish.

By all accounts, hashish, opium and heroin can be found fairly easily in Afghanistan. In March, a United Nations Office on Drugs and Crime report revealed Afghanistan has become the world’s largest marijuana producer, growing between 10,000 and 24,000 hectares each year, with yields that surpass Morocco. (The verdant crops posed a unique military problem when Canadian troops complained that Taliban insurgents were hiding in “almost impenetrable forests of 10-foottall marijuana plants”. A Canadian general worried that burning the forests could cause “ill effects” for soldiers downwind). And Afghanistan has long been the world’s largest opium poppy producer, supplying more than 90 percent of the global market for opium and heroin.

Of course, drug use by soldiers did not begin with Operation Enduring Freedom.

“Historically, substance abuse has not only been present but fostered by the military,” Jim McDonough, former Strategy Director at the White House Office of National Drug Control Policy, told a health conference in New York in June 2009.

“At Agincourt, the Somme and Waterloo, soldiers got liquored up before combat. There’s been almost no break in that today.”

As long ago as during the Philippine-American War that started in 1898, enlisted US soldiers were discharged for being habitual drug users. They learned to smoke opium from Chinese and native Filipinos.

But it was the Vietnam War (1955–1975) that saw drug use become a significant problem for the US military and, to a lesser extent, other anti-Communist forces. Since then, drug use by Vietnam soldiers and veterans has been the subject of much research, with both the military and addiction researchers keen to learn lessons from the war’s experiences.

Vietnam War studies have identified two phases of drug use among anti- Communist troops. In the war’s initial stage, there was marijuana use, followed by an influx of potent heroin in 1970. Estimates of drug use have varied sharply and controversially in different research reports, but today, most experts believe that about 20 percent of all soldiers who served in Vietnam used opiates at least once – although a markedly smaller percentage developed addiction. (In fact, one lesson that many researchers took from the Vietnam War was that addiction was not nearly as inevitable for hard drug users as once thought.)

According to a 1976 study published in the American Journal of Alcohol and Drug Abuse, marijuana and opiates were seen as “serving many of the functions performed by alcohol in earlier military conflicts”. The study found the key reasons for drug use among soldiers were the need for self-medication, escape and hedonistic indulgence; the relaxation of taboos against drug use in the United States; the availability of illicit drugs at low cost; and growing disenchantment with the war.

Soldiers’ use of heroin during the Vietnam War forced the US and other militaries to actively crack down on drugs. In 1971, the US military introduced mandatory heroin urinalysis tests for every soldier leaving Vietnam. At the same time, it introduced an ‘amnesty’ policy. In theory, this meant soldiers admitting to drug use would be given help for their addiction. Within just the first 3 months of tests, more than 3,500 military personnel had tested positive for heroin use. Despite the ‘amnesty’, thousands of heroin addicts were dishonourably discharged, and follow-up treatment for troops was non-existent.

The Vietnam War was a watershed in the understanding of the psychological effects of trauma and eventually led to the introduction of a new diagnosis that is closely aligned with substance abuse: post-traumatic stress disorder (PTSD). PTSD is an anxiety disorder that can develop after a terrifying event or ordeal. Studies have found that individuals with PTSD are more likely to experience problems with alcohol and drugs.

As with estimates of drug use, research into PTSD rates has been controversial. A landmark US report in 1988 found that one in three Vietnam veterans would suffer from PTSD at some point in life; a much-debated re-analysis of the data in 2006 revised the figure downward to one in five.

Thirty-five years after the Vietnam War, some psychiatric trauma experts fear that levels of PTSD and substance abuse in soldiers from the Afghanistan and Iraq wars could turn out to be even more severe.

John Renner, Associate Chief of Psychiatry at the US Department of Veterans’ Affairs Boston Healthcare System, warned in 2009 that the longer tours of duty in Afghanistan and Iraq would bring higher rates of trauma.

“We knew in Vietnam that the limit was 1 year [of combat] if you wanted to avoid PTSD. Now, with tours of 18 to 24 months, we should expect a higher level of problems.”

Based in part on lessons from Vietnam, veterans’ organisations expect a delay before the extent of the problem becomes clear. It takes an average of 14 years for a soldier to seek help for PTSD, according to the British veterans’ treatment and support group Combat Stress.

Some of the data starting to emerge is worrying. According to a study by the Rand Corporation in 2008, 18.5 percent of US military personnel who had then returned from Afghanistan and Iraq were suffering from mental disorders that included PTSD and depression.

While several military forces – including the US – conduct comprehensive, anonymous personnel surveys of self-reported drug use and knowledge, many addiction experts believe these under-represent the extent of the problem.

One set of statistics, however, cannot be doubted: in July, a US Army report revealed that the suicide rate in troops is higher than the civilian rate for the first time since the Vietnam War.

The Times reported in July 2009 that the UK Ministry of Defence was similarly “braced for a surge in the suicide rate” after new data showed 67 service personnel who served in Iraq or Afghanistan were suspected of having killed themselves. The British Armed Forces’ suicide rate, though, remains lower than that of the general population.

“Drug and mental health problems are not new,” says Thomas Kosten, who is Research Director of the US Department of Veterans’ Affairs’ National Substance Use Disorders Quality Enhancement Research Initiative and a Professor of Psychiatry and Neuroscience at Baylor College of Medicine.

“Their contribution to the increasing suicide rates is unclear due to underreporting of these problems [but we know they] are significant risk factors for suicide.”

According to the US Army’s July report, roughly 20 out of 100,000 soldiers kill themselves, compared with 19 out of 100,000 civilians. The report said if the Army added in accidental deaths, which could often be attributed to high-risk behaviour involving alcohol and drugs, “less young men and women die in combat than die by their own actions”.

The US Army, however, has rejected the direct link some make between combat exposure and suicide.

“We have analysed this closely,” says Walter Morales, Army Suicide Prevention Programme Manager. “We just haven’t found that repeated deployments and suicide are directly connected.”

Army generals point out that about 80 percent of suicides occur among personnel who have never deployed or who have only deployed once. Suicide prevention programmes are therefore not targeted at troops in combat, but are designed to reach all service personnel.

The Army does acknowledge that lowering the standard for recruits in order to get more soldiers into battle has created “a subculture... that engages in high-risk behaviour.” Its data shows that almost 30 percent of the Army’s suicide deaths from 2003 to 2009, and over 45 percent of the non-fatal suicide attempts from 2005 to 2009, involved the use of drugs or alcohol.

There are now literally hundreds of drug awareness and abuse prevention programmes in the US military, alongside suicide prevention and mental health programmes. Their development is one major change that has occurred in the past few decades. But, in terms of the policing of drug use, not so much has changed.

The US Department of Defense – like every major defence force around the world – has a close to zero tolerance attitude toward substance use by its employees and a highly active policing programme designed specifically to root out and expel drug users.

The military is different from other employers. In the private sector, and even in many government departments, employees can usually expect confidentiality if they refer themselves to workplace-organised counselling for substance or alcohol use. But in the military, an individual’s right to confidentiality is often over-ridden by the defence force’s paramount need for “combat readiness”.

In practice, this means, if a soldier reports concerns about his or her own drug or alcohol use to medical staff, the medics have an obligation to notify his or her commander. In theory, commanders have discretion over punishment, but anecdotal evidence suggests acknowledgement of drug use most often results in discharge from service.

In April, Army Secretary Pete Geren raised the idea that soldiers should be allowed to volunteer for treatment without commanders being informed. The idea won little support.

A British Army pamphlet for troops explains the lack of tolerance for substance use:

“Soldiers do not work for their own gain or the profit of a company: soldiers are public servants responsible for the defence of the country and the protection of British interests at home and abroad. In addition, today’s professional soldier is in charge of highly dangerous weapon systems and expensive and sensitive equipment. Soldiers must be fit and ready to fight at a moment’s notice. The misuse of illegal drugs puts lives at risk.”

Since it was introduced during the Vietnam War, urinalysis has become a key weapon in the fight to deter troops from using illicit substances. Today, it is used extensively by every modern-day defence force. The British Army’s policy is that someone using drugs only needs to be caught once to face administrative discharge.

A report by the Journal of the Royal United Services Institute in late 2007 showed that the number of British Army soldiers caught using cocaine in routine urine tests had climbed four-fold in 4 years. At the time, the Army admitted it was discharging almost the equivalent of a battalion each year because of illegal drug use. (Detection rates of ecstasy and cocaine subsequently plummeted in 2009. Analysts attributed this to a shift in use to mephedrone, a drug that was then legal in the UK and undetected in the Army’s urinalysis.)

The New Zealand Defence Force (NZDF) – which has experienced only a tiny fraction of the drug and alcohol-related problems of the US military – also uses urinalysis. All military personnel are subject to random tests, as well as before and on entry to a deployment.

“There is no mandatory course of action commanders must follow in relation to a positive test,” says NZDF Surgeon Captain Alison Drewry, “but some guidance is given around the circumstances they might take into account, and this is based around security and safety.

“The security element does change things. Somebody who becomes a security liability [by using drugs] might well face a different situation than if they were just working at The Warehouse in New Zealand.”

Of the 39 New Zealand Army personnel who tested positive for cannabis use in 2009, 28 were discharged, ‘released’ from service or took ‘voluntary release’. Ten were given formal warnings, and one was fined and confined to barracks for 21 days.

In the New Zealand Navy, eight personnel returned positive drug urine tests. Two would-be naval recruits lost their chance of serving, two personnel were discharged, and four were warned that they would be dismissed if they ever tested positive again.

Nobody from the New Zealand Air Force tested positive to any drug use.

This trend – of the highest drug use in the Army, lower use in the Navy and lowest use in the Air Force – appears to exist across all of the major defence forces who collect data. Aside from the fact that air forces entrust personnel with multi-million dollar equipment and therefore have a higher incentive to deter drug use, it could suggest a variation in the socio-economic background of staff from different forces. Drewry says that, in many cases of cannabis use, other personnel step forward to report the drug use. The NZDF is small enough that she can recall the details of the handful of incidents where personnel were involved with hard drugs.

“We’re very lucky in that we’re a small country and we are very close-knit. We have our own electronic health system so it’s very difficult for anybody even to have anything prescribed without it being opened to audit, and we audit regularly.

“We only ever had one issue [of an attempt to abuse prescription drugs]. Somebody actually asked for Valium by name. We have such a different population from the normal [civilian] population where you have drug-seeking. We discovered they were a very early part of the methamphetamine distribution problem.” Drewry says the NZDF “stamped out” the problem very quickly.

In contrast, prescription drug use is a major – and growing – concern for the US military.

During the first Gulf War, the public learned that US Air Force and Navy pilots were being given amphetamines – or ‘go pills’ – to fly long distances. The pill-taking was blamed by two pilots involved in a fatal ‘friendly fire’ bombing incident and discontinued in 1992 before being reintroduced in 1996. Technically, pilots ‘volunteer’ to take the pills – although they can be grounded for refusing.

However, it is medically motivated prescriptions that cause concern today. Recall that the lawyer of one of the troops involved in the Kandahar ‘kill squad’ argues that his client was “juiced up” on 11 different prescribed medications.

The pills given to soldiers at war generally fall into two categories – medicines provided for mental health reasons (such as anti-depressants and sleeping pills) and painkilling opiates.

Until 1999, US troops were banned from using anti-depressants in combat. A uniform policy giving anti-depressants the ‘green light’ was only introduced in 2006. According to the US Department of Defense’s own survey of staff in 2008, about 12 percent of soldiers in Iraq and 15 percent of those in Afghanistan reported taking anti-depressants, anti-anxiety medication or sleeping pills. This is likely an under-reporting given the stigma attached to mental health issues.

Kosten identifies use of prescribed opiates as one of the most serious problems today.

“These are given in many cases for musculo-skeletal injuries, but then they are continued for many months and perhaps 15 percent [of these patients] or more then develop problems related to abuse of these opiates.”

This year, USA Today claimed prescriptions for painkillers to military members have gone up by four times since 2001 – from just under 900,000 in 2001 to nearly 4 million in 2009.

In part, this reflects a broader societal problem. According to the Substance Abuse and Mental Health Services Administration, more Americans abuse prescription opiates than cocaine, and the abusers far outnumber those who misuse tranquilisers, stimulants, hallucinogens, heroin, inhalants or sedatives.

But it also reflects 9 years of continued conflict, Chief of Staff of the Army General George W Casey Jr acknowledged to the House Appropriations Committee Subcommittee on Defense. He said the US Department of Defense is attempting to create a better tracking system for prescriptions, especially in combat situations. “It’s something – not a pretty thing – something we need to get on the table and deal with.”

Meanwhile, the US Department of Defense is trying to rapidly expand its provision of substance abuse treatment to soldiers and veterans. Over the last decade, the US military hierarchy has scrambled to keep up with an increase in demand for substance abuse care and recovery programmes.

The United States Department of Veterans Affairs (VA) has long been the world’s largest provider of substance abuse services, but there has been strong criticism that current and recently returned soldiers have not been able to get the help they need.

The Rand Report of 2008, suggesting that nearly one in five returning troops suffered from mental trauma, also found that roughly half of those needing treatment would actually seek it and only slightly more than half of those receiving treatment got “minimally adequate care”. It was particularly difficult for troops in Iraq and Afghanistan to access mental healthcare.

Jim McDonough, the former Strategy Director at the White House Office of National Drug Control Policy, said in 2009 that troop shortages and strains on the system meant military commanders were trying to “get men back in the fight” instead of dealing with their addictions and mental health problems.

“Between 2004 and 2006, the incidence of substance abuse went up 100 percent, while treatment referrals by commanders went up zero percent.”

And Stars and Stripes, the US military’s editorially independent but official newspaper, complained in 2009 that “hundreds of soldiers” were not being provided with counselling because commanders wanted to “keep their numbers up for combat deployments”.

This fear was underpinned by a leaked 2009 memo from General Peter Chiarelli to commanders that blasted them for allowing hundreds of soldiers involved in “substance abuse-related misconduct (including multiple positive urinalyses)” to continue to work without being processed for possible discharge. He also noted that many are not referred to the Army Substance Abuse Programme for help.

In the past year or so, however, the Department of Defense has pumped billions of dollars into programmes designed to improve war-time and post-war care. Much of that has been directed into substance abuse. Some research is specifically looking at barriers to care, including finding out why and when veterans ask for help and why many don’t.

As part of this research push, Kosten has worked on recommendations to improve treatment for returning soldiers experiencing PTSD, depression and problems with drugs and alcohol. Describing the need for change, he says, “If you went to 10 different places to get your post-traumatic stress disorder treated, you could get 10 different treatments” – and that is just within the VA system.

Now, though, “Evidence-based treatments are being standardised and implemented across the USA in the VA. That is excellent news for veterans, but it will take some time to get this as fully implemented as would be ideal.”

Veterans’ groups express quiet optimism that the slow-moving US military is making small steps in the right direction on substance abuse care, treatment and mental health.

General Casey Jr recently acknowledged that too many young Americans had been accepted to the Army without “coping skills to deal with the challenges we’re asking them to deal with” and, he said, the Army realised it needed to change.

“We want to bring mental fitness up to the same level we give physical fitness.”

Although it is now scrambling to catch up, the US military proved unprepared to cope with the inevitable, substantial increase in mental health problems and substance abuse from fighting concurrent wars in Iraq and Afghanistan.

As the Army’s July report into suicides concluded, “We are often more dangerous to ourselves than the enemy.”