Alcohol and substance abuse among the combatants

by Dr Ruwan M Jayatunge

"Life, as we find it, is too hard for us; it brings us too many pains, disappointments and impossible tasks. In order to bear it we cannot dispense with palliative measures... There are perhaps three such measures: powerful deflections, which cause us to make light of our misery; substitutive satisfactions, which diminish it; and intoxicating substances, which make us insensible to it." - Sigmund Freud (Civilization and Its Discontents)

(July 28, Ontario, Sri Lanka Guardian) Alcohol and substance an abuse is sometimes an observable condition among the combatants especially those who suffer from combat stress. These negative stress coping methods are often used to displace the intrusions and negative thoughts. Alcohol and other substances give a temporary stimulation but in long term, it causes an enormous damage to the soldier both in physically and psychologically.

Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. It is differentiated from alcohol dependence by the lack of symptoms such as tolerance and withdrawal. Traditionally alcohol has become a part in the Military culture. Alcoholic beverages are offered in the Officers Mess and sometimes the officers are indirectly encouraged to have alcohol.

Rise in alcohol and Substance Abuse among the Sri Lankan combat veterans suffering from PTSD have been observed. The veterans consume alcohol and other substances to suppress traumatic war-related memories, escape flashbacks and to achieve a combat nightmareless sleep.

A number of reports indicate that individuals meeting diagnostic criteria for Post Traumatic stress disorder (PTSD) are likely to also meet DSM-3 R criteria for alcoholism and /or drug abuse. Among Vietnam Veterans seeking treatment for PTSD 60-80% exhibit concurrent diagnoses of drug or alcohol abuse or dependence. (Alcoholism and Drug Abuse in patients with PTSD – Lial Kofoed Matthew J. Friedman and Robert Peck- Psychiatric Quarterly – Springer Netherlands Publishers 31st January 2005)

Alcohol dependence, as described in the DSM -4 is a psychiatric diagnosis describing an entity in which an individual uses alcohol despite significant areas of dysfunction, evidence of physical dependence, and/or related hardship. Chronic Alcoholism has serious consequences on a person's health and personal life, on family and friends, and on society.

Combatants suffering from combat stress easily go in to negative stress coping methods like alcohol abuse. Alcohol and substance abuse is evident among the combatants suffering from war trauma. Those veterans who experienced prolonged exposure to heavy combat are especially vulnerable. Soldiers abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons. When we interviewed 56 Sri Lankan combatants with full blown symptoms of PTSD we found 8.9% of them are severely addicted to alcohol. They were found positive with alcohol related symptoms and their liver function were seriously affected following the misuse of alcohol. They consumed a large amount of alcohol in order to avoid sleep disturbances and
eliminate scary nightmares. The heavy drinking may also seem to relieve anxiety and block out intrusive memories associated with combat events. But the truth is excessive drinking can disturb the natural sleep process, interrupting REM dream patterns; the veteran may become more vulnerable to the symptoms of PTSD.

Capt NX453 served in the Army for over 16 years and exposed to heavy combat situations. In an incident near Paranthan, his team was ambushed by the enemy. He saw the death of fellow soldiers and their final outcry. Another member was shot at the abdomen and his bowels were out. Although they made an unsuccessful attempt to resuscitate him, the soldier died in Capt N’s arms. For number of years he blamed
himself for taking his men to the enemy’s jaws.

He was disturbed over the incident and he increased his alcohol intake in order to get a better sleep and disassociate with the horrific combat event. Hence, he could not sleep without alcohol. Gradually Capt NX453 had long periods of being drunk, he started drinking alone. He was neglecting his official duties and the senior officers could not trust his capabilities anymore. Several times, he was reprimanded for being drunk on working hours. In 2004, he was diagnosed with Harmful Use of Alcohol.

Tobacco addiction is another unseen factor, which has serious health related consequences. Nicotine dependence is an addiction to tobacco products caused by the drug nicotine. Nicotine can produces physical and mood-altering effects and frequent usage can increase risk of numerous health problems. The common symptoms of nicotine dependence are inability to stop smoking, experiencing strong withdrawal symptoms such as anxiety, irritability, restlessness, difficulty concentrating and sometimes headaches.

The relationship between alcohol consumption, cigarette smoking and post-traumatic stress disorder (PTSD) was studied in 147 male former members of the civilian resistance against the Nazi occupation of Holland during World War II by Wybrand op den Veldeand and the colleagues of the Department of Psychiatry, St Lucas Andreas
Hospital, Amsterdam. They found that Cigarette smoking was more prevalent in those with current PTSD. The researchers hypothesized that, in trauma survivors, current substance use is associated with peri-traumatic patterns of psychological tension–reduction modes.

Jean C. Beckham’s 1995 study (Duke University Medical Center, USA) was conducted to investigate smoking patterns in 445 Vietnam veterans with and without posttraumatic stress disorder (PTSD). Combat veterans with PTSD reported similar occurrence of smoking (53%) compared to combat veterans without PTSD (45%). For those who smoked, combat veterans with PTSD reported a significantly higher rate of heavy smoking (≥25 cigarettes daily): 28% of combat veterans without PTSD were heavy smokers and 48% of combat veterans with PTSD were heavy smokers.

Lance Cpl RXC143 met with traumatic combat events at Mandathive. He was troubled by the war trauma that he experienced there. He became more and more isolated and took to smoking. He became a chain smoker and couldn’t be without a cigarette. According to his wife Lance Cpl RXC143 smokes 30 -40 cigarettes per day.

Warrant Officer AXE86 joined the Military in 1973 and participated in all the combat operations until 1999. During these time he witnessed numerous traumatic events especially in 1988 -89. He was diagnosed with Adjustment Disorder and Nicotine Addiction. Warrant Officer AXE86 smoked over 30 cigarettes per day brought series vascular obstruction in his lower extremities and in 2003, he underwent below knee amputation.

Substance abuse is another issue that has to be dealt effectively. Substance abuse refers to the overindulgence in and dependence on a stimulant, depressant, chemical substance, or herb leading to effects that are detrimental to the individual's physical health or mental health, or the welfare of others.

Unlike the US and other combatants, Sri Lankan combatants do not indulge in a wide variety of substances. Some fractions in the Red Army in Afghanistan frequently used highly concentrated tea, which was called Chifer that gave sedation and toxic effects. During the Vietnam War, some US combatants abused atropine - a parasympatholytic that lowers the parasympathetic activity of all muscles and glands regulated by the parasympathetic nervous system. Sri Lankan veterans never knew about Chifer or atropine as addictive drugs.

Our 2005 study revealed that cannabis was the most frequent substance that was often used by the Sri Lankan combatants.

Cpl WXC45 who was an experienced combatant diagnosed with Cannabis intoxication described how he became addicted to cannabis . The narration below is based on his testimonial.

I was first posted to Nadunkarni , our team consisted of young fearless soldiers. We knew our days were numbered; the death was several inches ahead of us. To evade the nostalgic feelings and homesickness we smoked cannabis. When you take the puff inside, you feel that you are disconnected with the reality. No enemy, no bullets, no mortar attacks make you frighten. In an attack, you can advance like a wind. You don’t feel the heaviness of your backpack, you don’t feel pain even you sustain a gun shot injury.

The supply was a problem. We used to buy the stuff in Colombo. There were many joints where you could buy it. There were a number of places in Boralla , Maradana, Slave Island etc. Only problem was to bring it to the Northern war front. If we travel by air through Ratmalana , the Air force guys used to search us. If you get caught you are in a real trouble. We used several methods to traffic it. The popular method was to put the stuff in to a condom and then insert it inside the anal cavity.

Although there were many restrictions, our guys used to bring it and we smoked it. When we did bunker duties cannabis cigars kept us awake. Thus, we were on guard all night long.

We often used Madana Modaka ( Aurvedic cannabinoid product) as well. Its like a toffee. When some of our group mates went for the operations, they kept it in the pallet. Madana Modaka gave a sensational feeling. You can run, jump and move your body like a rubber when the effect comes. We feel no pain even we sustain injuries. Some said it prologs your ejaculation and we used to take it home when we got duty leave.

After long usage of cannabis, Cpl WXC45 had low motivation,aimlessness apathy and sluggishness in mental and physical responses. He presented with poor self-care and transient disorientation, as well as impaired memory. Today he knows the negative effects of cannabis that gave him a wrong picture as a stimulant.

Heroin usage was not in abundance among the Sri Lankan combatants according to our experience. From 2002 to 2005, we systematically interviewed 824 soldiers and we found only three heroin users. Heroin is a highly addictive opiate, which is processed from morphine. Although its illegal in Sri Lanka the addicts know the places where it can be bought. Sri Lankan heroin addicts usually sniffed or smoke it and intravenous injection of heroin is not popular among them. Why we had very minimal number of heroin addicts among the soldiers that we interviewed? When strict rules and regulations are applied to the soldiers in the Army camps heroin uses, find it extremely difficult to obtain and use it. Often they become AWOL and
continue their addiction with heroin.

The effective measures have to be taken to prevent alcohol and substance abuse among the combatants. In the post war era there is a possible risk that is prevailing and we have to take urgent measures. There are many examples from other counters that indicate the excessive use of alcohol and other substances among the combatants.

According to the 2000 and 2001 NHSDA report on illicit drug use among the US Veterans, an estimated 6 percent of all veterans living in the United States used an illicit drug in the past year. Of the 256,000 veterans in need of treatment for illicit drug use in the past year, 20 % had received treatment during the past year. These studies show that we too are at risk.