How Do Morally Injurious Experiences Affect Substance Use in Combat Veterans?

What you need to know

• Different types of morally injurious experiences are linked to different substance use disorders in combat veterans
• Feeling responsible for harming others is associated with lifetime alcohol use disorder
• Witnessing morally injurious events is linked to current drug use disorder
• Betrayal by others is connected to current alcohol use disorder
• Assessing moral injury may be important when treating substance use in veterans

Understanding moral injury and substance use in veterans

Combat veterans face many challenges when returning from deployment, including the risk of developing substance use problems. While we know that trauma exposure can increase this risk, less is known about how moral injury - distress from actions that violate one’s moral beliefs - impacts substance use in veterans. This study examined how different types of morally injurious experiences relate to alcohol and drug use disorders in a large sample of U.S. combat veterans.

What is moral injury?

Moral injury refers to the psychological, social, and spiritual impact of events that violate one’s core moral beliefs. For combat veterans, this could involve:

• Perpetration: Taking actions that harm others or violate one’s own moral code
• Witnessing: Seeing others engage in acts considered morally wrong
• Betrayal: Having trust violated by leaders or others

These experiences can lead to feelings of guilt, shame, anger, and a loss of meaning or purpose. While related to post-traumatic stress disorder (PTSD), moral injury is considered a distinct issue that can occur even without PTSD.

How the study was conducted

Researchers surveyed 1,321 combat veterans from all eras who were representative of the U.S. veteran population. The veterans answered questions about:

• Exposure to potentially morally injurious events
• Symptoms of alcohol use disorder and drug use disorder
• PTSD and depression symptoms
• Combat exposure and other trauma history

The study looked at both current substance use disorders (in the past year) and lifetime history of these disorders. This allowed the researchers to examine both immediate and long-term connections between moral injury and substance use problems.

Key findings on moral injury and substance use

The study revealed several important links between moral injury and substance use disorders in veterans:

Perpetration and lifetime alcohol problems

Veterans who reported more experiences of perpetration - feeling responsible for harming others or violating their own moral code - were more likely to have a lifetime history of alcohol use disorder. This suggests that the guilt and shame from these actions may contribute to alcohol problems over time.

Witnessing and current drug use

Exposure to morally injurious events through witnessing was associated with higher odds of current drug use disorder. Veterans who saw more morally troubling acts were more likely to be struggling with drug use in the present.

Betrayal and current alcohol use

Experiences of betrayal by others were linked to current alcohol use disorder. Veterans who felt their trust had been violated were at higher risk for problematic drinking in the past year.

Relative impact on substance use

The researchers also examined how much each type of moral injury contributed to substance use problems compared to other risk factors:

• Betrayal accounted for nearly 39% of the risk for current alcohol use disorder - more than depression or PTSD
• Witnessing explained about 26% of the risk for current drug use disorder
• Perpetration explained over 5% of lifetime alcohol use disorder risk

These findings suggest moral injury may play a larger role in veteran substance use than previously recognized.

Why moral injury may lead to substance use

There are several reasons why moral injury could increase the risk of substance use problems in veterans:

• Numbing emotions: Alcohol and drugs may be used to cope with guilt, shame, and other painful emotions related to moral injury
• Avoidance: Substances can help veterans avoid memories or thoughts about morally injurious experiences
• Self-punishment: Some veterans may use substances as a form of self-harm due to feelings of worthlessness
• Loss of meaning: Moral injury can lead to a loss of purpose that substances temporarily fill

Different types of moral injury may also have unique pathways to substance use:

• Perpetration may lead to long-term guilt that increases alcohol use over time
• Witnessing traumatic events could cause distress that leads to drug use for relief
• Betrayal may erode trust and increase isolation, contributing to problematic drinking

Implications for veteran care

These findings highlight the importance of assessing moral injury when treating veterans for substance use disorders. Some key implications include:

• Screening for moral injury: Clinicians should ask about morally injurious experiences when evaluating veterans for substance use problems
• Targeting treatment: Different types of moral injury may require different treatment approaches for associated substance use
• Addressing underlying issues: Simply treating the substance use without healing moral injury may lead to relapse
• Expanding research: More studies are needed on how to effectively treat co-occurring moral injury and substance use disorders

Importantly, most existing treatments for moral injury have excluded veterans with significant substance use problems. There is a need to develop and test integrated treatments that address both issues simultaneously.

Conclusions

• Different types of moral injury are associated with distinct patterns of substance use disorders in veterans
• Moral injury may play a larger role in veteran substance use than previously recognized
• Assessing and treating moral injury is likely important for effective substance use treatment in veterans
• More research is needed on the connections between moral injury and substance use over time

While this study provides important insights, there are still many questions to explore about moral injury and substance use in veterans. Continuing to study these issues can help improve care for the many veterans struggling with the psychological wounds of war.