The Impact of War Deployments on Opioid Abuse

Nearly 50 percent of all combat veterans suffer from chronic pain, often stemming from war injuries for which opioid-based treatment is common (Clancy 2015). Opioid-use disorders among war veterans have risen by over 50 percent in the last five years, with veterans facing opioid-related mortality rates that are 100 percent higher than civilians (Bohnert et al. 2011). Approximately 70,000 are classified as having an opioid use disorder and recent evidence from the public health literature suggests that opioid abuse is more common for those with mental health conditions such as Post-Traumatic Stress Disorder (PTSD) and depressive symptomatology (Seal et al. 2016; Shiner et al. 2017), both of which are common among those deployed to combat (Cesur et al. 2013; Tanielian and Jaycox 2008). Treatment is often difficult due to barriers to access to psychotherapy, stigma service members face in seeking treatment for addiction, and complications from dual diagnoses (Teeters et al. 2017). In the face of this problem, policymakers have argued for further regulation of prescription drug policies at the Department of Veterans Affairs (VA). Senator John McCain (R-Arizona) introduced the Veterans Overmedication Prevention Act to better monitor prescriptions as well as identify high-risk abuse cases.

While descriptive studies have found that opioid misuse is greater among war veterans than civilians (Bohnert et al. 2011), this association may be explained, at least in part, by difficult-to-measure personal or family background characteristics associated with selection into military service. No study of which we are aware has examined the causal impact of combat deployments on use of opioid use or abuse. This paper is the first to estimate the impact of combat deployments on prescription pain reliever abuse and heroin consumption among active duty servicemen deployed during the Global War on Terrorism (GWOT) era. We exploit the conditional random assignment of active duty servicemen to deployment duties to identify the causal effect of combat. That is, conditional on military rank and occupation (within branch), servicemen’s assignments to units and assignments of those units to deployment duties, are orthogonal to opioid use. Our analysis uses data from two sources: the National Longitudinal Study of Adolescent and Adult Health (NLSAAH) and the Department of Defense Survey of Health and Related Behaviors Among Active Duty Personnel (HRB).

Across the NLSAAH and HRB data, our results show that combat exposure is associated with substantial increases in the probabilities of prescription painkiller use and abuse, as well as increases in heroin use. Estimated effects are largest for enlisted servicemen under age 25, a population found to suffer the largest adverse psychological effects from combat (Cesur and Sabia 2016). Among the potential channels at work include (i) war-related injuries, which lead to medical and then non-medical use of opioids, and (ii) PTSD, which may lead combat veterans to turn to opioids as a coping mechanism. Finally, we uncover some evidence that combat may lead to abuse of non-opioid prescription drugs designed to treat anxiety, depression, and sleep disorders.