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)

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.

In every war, we see a drug culture attached with the conflict. During the WW1 as a part of a daily ration, a British soldier received a half-gill of rum. The German soldiers had a daily ration that included a pint of beer, half a pint of wine and a quarter pint of spirits. In the WW2, the German soldiers frequently used   methamphetamine.  The drug of choice of American soldiers during the Vietnam War was marijuana. Marijuana was widely and cheaply available in Indochina, and various sources estimate that anywhere from 20-50% of American servicemen were at least occasional users, despite efforts by the military to crack down on the drug. The recent Iraq War has increased drug abuse among the US combatants. As Gregg Zoroya of the USA Today reports the US Army records show 2.38% of all soldiers had positive results on routine drug urinalysis screening, a 10-year record. In 2004, when combat troops returned from Iraq in large numbers, 1.72% had positive results.

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 consume 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, displace ruminations on hurtful thoughts, minimize hyper -arousal reactions, and to achieve a combat nightmare free 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 – 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. 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 were 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, the enemy ambushed his team.  He saw the deaths of fellow soldiers and their final outcry. Another member of his team 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 in Jaffna.  He was troubled by the war trauma that he experienced there. He saw terrifying     clashes between the rebel forces and the SLA. Several of his buddies died in front of his eyes. Despite fear and uncertainty, they retaliated and destroyed the enemy strongholds.  At the end of the battle, Lance Cpl. RXC143 was exhausted and cried for his friends. After the Mandathive incident, he  became more and more isolated and took to smoking. He became a chain smoker and couldn’t be without a cigarette. As revealed by his wife Lance Cpl. RXC143 used to smoke 30 -40 cigarettes per day. After the initial trauma counseling as a part of his treatment plan Lance Cpl RXC143 was referred to Dr. Manaoj Fernando- Chief Medical Officer of the Mel Medura Tobacco, Alcohol and Drug Treatment Center. With the tobacco abuse, prevention counseling   Lance Cpl. RXC143 was able to reduce the harmful usage of tobacco smoking.

Warrant Officer AXE86 joined the Military in 1973 and from 1987 to 1993 participated in all the major combat operations that were conducted by the SLA. During these operations, he witnessed numerous traumatic combat events.  He actively participated in overpowering the 1988 -89 insurrection and witnessed a number of atrocities. On one occasion, they arrested a group of JVP rebels who robbed a boutique and killed the shop owner. The rebels were taken to a coconut estate and then pushed to an abandon well. After that, they put a few grenades in to the well.

After committing these acts, Warrant Officer AXE86 became emotionally overwhelmed. While on duty, he started smoking day and night. After the retirement, his behavior changed drastically and Warrant Officer AXE86 became abusive to his wife and children. The family members could not tolerate him anymore. He was diagnosed with Adjustment Disorder and Nicotine Addiction. Warrant Officer AXE86 smoked over 30 cigarettes per day, which 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, the 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 survey on drug abuse in the SLA revealed that cannabis (Cannabis sativa) was the most frequent substance that was often used by the Sri Lankan combatants. There are many reasons for wide spread cannabis abuse. Although Cannabis is an illicit and a dangerous drug, many consider cannabis is a harmless stimulant also an Aurvedic preparation that causes no harm to the human body. There are many serious adverse effects of Cannabis have been reported. Among the adverse effects dependence on Cannabis, permanent cognitive impairment as well as development of psychosis are evident. Prolonged use of cannabis can lead to depression, lack of volition and a history of gradually deteriorating social ability and contact with others.  Cannabis use may also precipitate a latent psychosis. Cannabis use can trigger psychotic episodes in a person who already has a mental illness. We have treated a considerable numbers of Sri Lankan combatants with CAS (Cannabis Amotivational Syndrome) that is characterized with apathy,   disinhibition, cognitive impairments decreased motivation, and social performance.

Cpl.WXC45 who was an experienced combatant who participated in major military operations in the North 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 the 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 Borella , Maradana, Slave Island etc.  Only problem was to smuggle it to the Northern war front. If we traveled by air through Ratmalana Airport, the Air force guys used to search us. If you get caught, you are in a real trouble. One of my friends was caught at the Ratmalana Transitional Camp and he had to face disciplinary charges. Therefore, we were extremely careful. We used several methods to traffic cannabis. The popular method was to put the stuff in to a condom and then insert it deep in to the anal cavity. Sometimes the civil workers (labourers attached to the Palali airfield, civil cooks) brought the stuff for us.  

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. It is like a toffee a sticky substance. When some of our group mates went for the operations, they kept Madana Modaka preparation in the hard palate. 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 mental stimulant.

Heroin usage was not in abundance among the Sri Lankan combatants according to our experience. From 2002 to 2006, we systematically interviewed 824 soldiers and we found only three heroin users. Heroin is a highly addictive opiate, which is processed from morphine. Although it is illegal in Sri Lanka, the addicts know the places where it can be bought.   The local heroin addicts usually sniffed or smoke it and intravenous injection of heroin is not popular among them. Why we had minimal number of heroin addicts among the soldiers that we interviewed during 2002-2006?  One reason is heroin is expensive and the soldiers cannot afford the frequent use. Also in the Army camps heroin uses, find it extremely difficult to use it inside the billets and bunkers without being noticed by others. Often they become AWOL and continue their addiction with heroin.

Alcohol and substance abuse in the military has caused a wide range of problems from health issues to family and social problems. It has drastically reduced the productivity of the soldiers. On the other hand, the drug abuse among the deserters and ex-servicemen are increasing. The Police reports indicate that the Army deserters committed many crimes under the influence of alcohol or cannabis. Therefore, the health authorities should take Island wide effective measures to prevent alcohol and drug abuse with the help of other agencies. The MOH Officers can do a lot in this regard.

The Military authorities must take effective actions to prevent alcohol and substance abuse among the combatants. In the post war era there is a possible risk that is prevailing and   urgent action has to be taken.  There are many examples from other counters that indicate the excessive use of alcohol and other substances among the combatants especially in the post war era. 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.

Dr Ruwan M Jayatunge