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mental health mondays :: the war at home

what's worse than being sent off to war when you're barely old enough to order a drink in a bar? making it home only to get poisoned by the government that sent you there. 


although it's certainly not a secret, i don't find that the opiate/ opioid crisis happening in america gets nearly the attention it deserves. at least, what attention it gets just seems to repeat "thousands of people are dying, it's terrible", without ever explaining how things got to the state they are now. there's mention of heroin becoming cheaper, of shameful over-prescriptions and dumping of pills in poorly regulated states/ counties, etc. but too much of the media coverage seems content to say that there's a problem and leave it at that.

one of the things that might be hindering debate is that a very big problem likely has a lot of different causes, which means that it's important to break it down into smaller problems to deal with it. and one of those problems connects opiates, mental health and the military. because the addiction epidemic wasn't difficult enough to talk about on its own.

the wars in afghanistan and iraq have given us far greater visibility of the effect of combat on troops than any other conflict in history. and what it's told us isn't pretty: soldiers frequently return home irreparably damaged, requiring treatment that's too often hard to get, treatment that often involves managing a permanent condition rather than fixing a temporary one. america is hardly the only nation to distinguish itself through shitty treatment of its veterans, but it is the one that's doing so in the full light of what we now know about chronic conditions and mental disorders.

the mental condition most associated with combat is undoubtedly post-traumatic stress disorder. the condition was basically discovered by observing soldiers after world war i, although at that point they called it "shell shock". in fact, there are reports of "melancholy" affecting soldiers since we started killing each other in an organised fashion, but it's only in the last century that we've started to study it. strangely enough, there isn't a solid estimate as to rates of ptsd in the military, because there are too many contradictory studies. the prevalence in the overall population seems to be a little over 6%, which includes both short and long term causes. a study of iraq war veterans [second iraq war] found that 13.8% met the criteria for ptsd. an earlier study showed the prevalence was higher among vietnam war vets. studies that look at other studies peg the incidence of ptsd at between 5 and 20% among iraq war vets, between 10 and 30% for vietnam vets. so let's agree to this: ptsd among current or former military personnel is at least as common at any given time as it is in the population as a whole, and most likely higher. over the course of a lifetime, a person who has served in the military in an active combat theatre is far more likely than average to experience ptsd. [side note :: there are perfectly good reasons why prevalence is difficult to establish; some studies only recognise ptsd when it is severe enough to keep someone from resuming their duties; there is a difference between those who are currently suffering from ptsd and those who will experience it during their lifetimes; there may be other conditions that mask or override ptsd.]

but ptsd isn't the only problem people bring home with them: one in ten comes back with a substance abuse problem; 20% of veterans with ptsd have a substance abuse disorder; one third of veterans seeking treatment for substance abuse also have ptsd. one of the biggest issues that psychiatrists have to deal with when treating ptsd is the insistence of the patient on avoiding the most painful memories and most powerful triggers. self-medication through alcohol and other drugs is one of the most powerful tools that a veteran can use to avoid these things.

so, when treating ptsd in a veteran, the very last thing that you'd want to do would be to give them something with a high potential for addiction, right? right? you see where i'm headed here.

the u.s. department of veterans affairs and the department of defense maintain a guide for medical professionals on how to deal with ptsd in former military personnel. the guide specifically recommends that it be treated first and foremost with individualised, trauma-centred therapy. if that doesn't work [or if there isn't anyone available in a veteran's geographical area, or if it's going to take months or years to assign someone's case to an expert...], they cautiously recommend monotherapy [one drug only] with ssri's or snri's. more specifically, they recommend fluoxetine [prozac], paroxetine [paxil] and venlafaxine [effexor]. those are literally the only three drugs they recommend, after reviewing fifty-five different studies with over six thousand participants, because they're the only ones where there's sufficient evidence of even moderate success in treating ptsd. if those don't work, they cautiously suggest the use of tricyclic antidepressants, with the caveat that these have a nasty side effect profile and are associated with other problems.

their guide specifically says that benzodiazepines, with their addictive potential, should never be used. nonetheless, as of 2012, 30% of veterans with ptsd were still being treated with benzos. and despite the fact that treatment with multiple drugs, "polytherapy" has been connected with increased rates of suicide and addiction, a study conducted on texas veterans in 2016 found that ptsd sufferers were more likely than other groups to be taking five or more medications for their condition.

which brings us to the opioids. no doctor in their right mind would ever prescribe opioids to a person with ptsd, because they are depressants, because they are addictive, and because they are conducive to accidental and deliberate overdose. but veterans don't just see doctors about their ptsd. [in fact, veterans are often unwilling to seek treatment for mental disorders because of the social stigma associated with admitting to one, but that's another post.] the most common complaint among veterans is pain. many of us suffer from chronic pain. about one in three, actually. but the rate is nearly double that among veterans, which means that a veteran's primary concern is reducing the pain that they're in every single day. pain itself can trigger mental health problems like depression, so things can get complicated very quickly.

it's at this point that the system really seems to break down. opioids have become the first-line treatment for pain, with prescriptions increasing forty-fold between 2000 and 2011. and doctors have been more than willing to hand them out to veterans in vast quantities, without checking for the possibility of problems beyond the physical pain. a 2012 study conducted in texas [not the same one linked above] showed that the rate of overdose deaths among veterans was more than five times that of the general population, and of all veterans who died by overdose, nearly 45% had ptsd.

when the complicity of the medical establishment in prescribing addictive opioids came to light in 2012, the reaction was to immediately make the drugs harder to get. prescriptions dropped by 56%, which sounds awesome until you think about what going cold turkey with no support system usually does to an addict.

for their part, veterans have started to speak up on the issue and their message is clear:

give us some fucking pot.

a petition to the u.s. federal government to allow disabled veterans [including those disabled by mental disorders] access to medical marijuana garnered eight thousand signatures, and veterans have become one of the most vocal groups calling for marijuana laws to be relaxed. twenty-eight states and the district of columbia now have some form of legalisation, but many "red states", home to a disproportionate number of america's veterans, do not.

there are other methods that have shown some promise: eye movement desensitisation reprocessing [emdr, future post imminent] helps some, as does meditation, and distance healthcare that allows veterans to use artificial intelligence. [apparently, vets are more comfortable talking to a computer algorithm about their mental health issues, because the computer doesn't judge them.] but the biggest push is for pot.

and it's no wonder. marijuana's [ridiculous] classification as a class i controlled substance in the united states means that not only is it legally dangerous, but that it's almost impossible to conduct proper studies on its efficacy. nonetheless, there are reports that it is effective in as many as 75% of ptsd cases. if confirmed [big "if"], that number would be enough for it to be recommended as the only pharmacological treatment for ptsd. the results are that much better than anything else.

the added benefit is that marijuana has also shown strong benefits in pain management, so that it could be used as therapy for complex cases involving multiple health concerns. we just don't know that, because current law doesn't allow american labs to conduct proper testing.

veterans, however, don't seem to need more testing to be convinced. go look through the reviews of any strains on leafly and see how many of them come from wounded warriors. and since these people have already sacrificed so much for their country without really asking why, maybe it would be a nice gesture to listen to them for once.

p.s. :: the image at the top of this post is taken from a project called "operation trapped", conducted by veteran and marijuana advocate david bass. read more about it here

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