Veterans & Opioid Use Disorder

April 20, 2022

Table of Contents

Nearly 600,000 veterans misused opioids in 2019.[1] Around 555,000 veterans misused a prescription pain reliever in 2019, while 57,000 misused heroin.

Veterans are at high risk for opioid use disorder (OUD) as compared to the general population for several reasons. Veterans may have injuries that are chronic and are therefore likely to be prescribed opioids for chronic pain conditions. Veterans also often suffer from PTSD (post-traumatic stress disorder) and other mental health conditions such as anxiety and depression which can predispose to substance use disorders.

Veterans make up a specialty population that is prescribed opioids at high rates, yet only about two out of every three veterans with OUD are receiving the evidence-based treatment and recovery services that they require and deserve.[2]

Access to Medication for Addiction Treatment (MAT) services through the VA (Veterans Affairs) is increasing. In 2014, approximately 34% of VA patients with OUD were receiving MAT, which is a significant increase from 2004 when only 25% were receiving these services.

Expanded access to MAT can improve treatment and recovery outcomes for military veterans with OUD.

Risk Factors for OUD in Veterans

Veterans have higher rates of substance use disorders (SUDs) than the general population, as more than 1 in 10 who seek treatment at the VA meet the criteria for an SUD.[3] Opioid overdose rates are higher for veterans than the general public. As of May 2014, approximately 44,000 current VA patients were prescribed opioids and 55,000 had a current OUD.[8]

Veterans have a variety of special risk factors that can make them more likely to develop an opioid use disorder than civilians.  Veterans may have injuries that are chronic and are therefore likely to be prescribed opioids for chronic pain conditions. Veterans also often suffer from PTSD (post-traumatic stress disorder) and other mental health conditions such as anxiety and depression which can predispose to substance use disorders.  

Military veterans are prescribed opioids at rates greater than the general public. A higher rate of use, especially long-term, can lead to physical dependence.

Signs of Opioid Addiction in Veterans

Opioid “use disorder” and physical dependence are not the same thing. 

Physical dependence describes having tolerance and withdrawal to a medication. Tolerance to opioid medications means requiring higher doses to achieve the same therapeutic effect achieved prior. Withdrawal means having physical symptoms when the medication is discontinued. The presence of either tolerance, withdrawal, or both, defines the presence of physical dependence. Physical dependence on opioids can occur with regular and long-term use of a prescription opioid, even when it is taken as medically directed.

Addiction (aka “use disorder”), on the other hand, describes both physical dependence and behavioral issues leading to negative life consequences. It the negative life consequences that differentiate simple physical dependence from an actual use disorder. 


Early warning signs of opioid misuse that can lead to addiction include the following:

  • Taking more opioids than prescribed in one dose
  • Taking opioids in between doses
  • Continuing to take opioids after a prescription has run out
  • Taking opioids that are not prescribed directly
  • Using opioids in a method other than medically directed, such as chewing or crushing them 
  • Mixing opioids with other drugs or alcohol

These are signs of opioid addiction to watch for:

  • Taking more opioids at one time in order to feel the effects
  • Cravings for opioids in between doses
  • Inability to stop taking opioids despite multiple attempts
  • Social isolation and withdrawal
  • Mood swings
  • Changes in sleeping and eating habits and patterns
  • Shifts in personality
  • Less desire to do things that were previously enjoyed or important
  • Inability to consistently manage life duties, including school, work, or family obligations
  • A lot of time spent talking or thinking about the next opioid dose and where to get it, using opioids, and recovering from them
  • Withdrawal symptoms when opioids process out of the body
  • Inability to feel happy or pleasure without opioids
  • Continuing to use opioids despite knowing that they are negatively impacting relationships, finances, physical health, and mental health
  • Using opioids in potentially risky situations

PTSD & OUD in Veterans

Post traumatic stress disorder (PTSD) is a disorder that is common in military veterans, those who have been deployed, and those who have been in combat situations. PTSD is strongly associated with increased risk of substance use disorders including OUD. In one study of military veterans returning from Iraq and Afghanistan, PTSD was the most prevalent mental health disorder.[4] More than 20% of veterans with PTSD also have an SUD, and one out of every three veterans seeking treatment for an SUD also has PTSD.[5]

Chronic Pain & OUD in Veterans

Military veterans often struggle with chronic pain related to injuries sustained during active duty, so it makes sense that veterans might be prescribed opioids for these injuries and for other chronic pain conditions. Two-thirds of veterans report experiencing chronic pain, with close to 10% experiencing severe pain, putting this population at a higher risk for opioid exposure and subsequent risk of misuse.[7]

Traumatic Brain Injury & OUD in Veterans

Traumatic brain injury (TBI) is a common injury for veterans. TBI commonly co-occurs with other mental health disorders, such as PTSD and mood disorders. Veterans with more severe TBI and comorbid mental health disorders are more likely to potentially develop OUD.[9] In addition to OUD, veterans with TBI have three times the risk for opioid overdose over those without the condition.[10] Opioids should be prescribed with caution to veterans with TBI as they are at increased risk of OUD.

Treatment Options

Treatment for OUD can be lifesaving, and there are many options available to veterans with OUD. Many care options feature the use of multiple methods, including behavioral therapies and pharmacological options.

Behavioral therapies can be especially helpful for improving coping mechanisms and developing positive habits and life skills. Cognitive behavioral therapy can serve to reevaluate negative thought patterns and how they impact behaviors, working to readjust them in a positive manner.

Support groups can be vital for veterans to foster positive peer connections and help to dispel the feelings of social isolation and loneliness. Many VA facilities offer support groups and group visiting programs for veterans with OUD or other mental health disorders.

Medication for Addiction Treatment (MAT) is considered first-line treatment for veterans with OUD.[11] MAT involves using a long-term opioid such as buprenorphine, often combined with naloxone in medications such as Suboxone, to manage opioid cravings, withdrawal symptoms, and chronic pain. MAT can be administered through a variety of settings, including telemedicine, to ensure that everyone who needs it has access to care.

Access to Treatment

Around 60% of veterans are eligible for VA care, but less than half actually use these benefits.[12] Veterans often face specific barriers to treatment, such as stigma, cost, and inconvenience of veterans’ health care services.

Most veterans have additional health care benefits outside of VA care, either through private health insurance or Medicare. Access to care for veterans is continually improving. The number of veterans receiving MAT for OUD has steadily been increasing, from just over 900,000 in 2016 to nearly 1.5 million in 2019.

More veterans are able to receive care through alternative means, thanks to programs such as the Veterans Choice Program that allows eligible veterans to obtain mental health care from non-VA professionals.[13] This is especially important as VA health care facilities are not always conveniently located or easily accessible to eligible veterans who need services. Telemedicine services can enhance access to care for veterans.

Resources for Veterans

  • Veterans Crisis Line: This hotline provides free and confidential support 24/7. You don’t need to be enrolled in VA health care or with the VA to access it.[14]
  • MyHealtheVet: Use this option to find VA services, discover benefits, access health records, and manage VA health care.[15]
  • Military OneSource: This organization provides resources to maintain a healthy lifestyle and support for the military community.[16]
  • FindTreatment.gov: This link provides resources for finding treatment for a substance use disorder, hosted by the Substance Abuse and Mental Health Services Administration (SAMHSA).[17]

Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

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Citations

  1. 2019 National Survey on Drug Use and Health: Veteran Adults. Substance Abuse and Mental Health Services Administration (SAMHSA). https://www.samhsa.gov/data/release/2019-national-survey-drug-use-and-health-nsduh-releases. September 2020. Accessed February 2022.
  2. How the VA Is Battling Opioid Use Disorder. PEW. https://www.pewtrusts.org/en/research-and-analysis/articles/2018/11/09/how-the-va-is-battling-opioid-use-disorder. November 2018. Accessed February 2022.
  3. Military Life and Substance Abuse. National Institute on Drug Abuse (NIDA). https://nida.nih.gov/drug-topics/military-life-substance-use. Accessed February 2022
  4. Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan. JAMA Network.  https://jamanetwork.com/journals/jama/fullarticle/1105046. March 2012. Accessed February 2022.
  5. PTSD and Substance Abuse in Veterans. U.S. Department of Veterans Affairs (VA). https://www.ptsd.va.gov/understand/related/substance_abuse_vet.asp. Accessed February 2022. 
  6. Substance Use and Co-Occurring Mental Disorders. National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health. Accessed February 2022. 
  7. Substance Use and Military Life DrugFacts. National Institute on Drug Abuse (NIDA). https://nida.nih.gov/publications/drugfacts/substance-use-military-life. Accessed February 2022. 
  8. Veterans’ Health and Opioid Safety- Contexts, Risks, and Outreach Implications. Federal Practitioner. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363306/. June 2015. Accessed February 2022. 
  9. Chronic Effects of Neurotrauma Study Group. Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter? The Journal of Painhttps://pubmed.ncbi.nlm.nih.gov/29597083/. August 2018. Accessed February 2022. 
  10. Traumatic Brain Injury and Opioid Overdose Among Post-911 Veterans with Long-Term Opioid Treatment for Chronic Pain. The Journal of Head Trauma Rehabilitation. https://pubmed.ncbi.nlm.nih.gov/31834063/. May/June 2020. Accessed February 2022. 
  11. Opioid Use Disorder. U.S. Department of Veterans Affairs (VA).  file:///C:/Users/carls/AppData/Local/Temp/Opioid_Use_Disorder_Educational_Guide.pdf. September 2016. Accessed February 2022. 
  12. Balancing Demand and Supply for Veterans’ Health Care. Rand Health Quarterly.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158276/. June 2016. Accessed February 2022. 
  13. Protecting Veterans’ Access to Mental Health Care. National Alliance on Mental Illness (NAMI). https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Protecting-Veterans-Access-to-Mental-Health-Care. Accessed February 2022.
  14. Veterans Crisis Line. U.S. Department of Veterans Affairs (VA). https://www.veteranscrisisline.net/. Accessed February 2022. 
  15. MyHealtheVet. https://www.myhealth.va.gov/mhv-portal-web/home. Accessed February 2022. 
  16. Health & Wellness. Military OneSource. https://www.militaryonesource.mil/health-wellness/. Accessed February 2022. 
  17. Find Treatment.gov. Substance Abuse and Mental Health Services Administration (SAMHSA). https://findtreatment.gov/. Accessed February 2022.

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