The medically evacuated Viet-Nam narcotic abuser: a follow-up rehabilitative study

Sections

Method
Results - DEMOGRAPHIC DATA
REHABILITATION DATA
TABLE 4 - Rehabilitation data based on three criteria of success/failure
Discussion

Details

Author: William J. DESS , F. Conrad COLE
Pages: 55 to 65
Creation Date: 1977/01/01

The medically evacuated Viet-Nam narcotic abuser: a follow-up rehabilitative study 1

William J. DESS 2
F. Conrad COLE
Madigan Army Medical Center 3

Vast amounts of money, manpower, and effort have been poured into investigations of problems related to drug abuse within the United States military (1, 4, 5, 7, 8, 10, 13, 14, 16). The major thrust of most of these studies has been directed toward description of the characteristics of soldiers most likely to abuse drugs and delineation of the type of psychotropic agents most commonly abused. Almost without exception, prior studies have utilized anonymous questionnaires as their predominant mode of information gathering (4, 5, 8, 10, 16). Sample sizes have varied from less than 100 to over 5,000 and the troops studied have been from both combat and support units stationed overseas and in the United States. The present investigation represented in at least three major ways a rather different approach to the study of drug abuse in the military.

First, the present study differed in its basic objective. While earlier studies represented surveys of patterns of drug abuse, the objective of the present study was an evaluation of the degree of success or failure of the Army's attempts to assist identified drug abusers in rehabilitating themselves and becoming productive members of both the Army and society.

The second major difference was in the nature of the subject population studied. Whereas former investigations have utilized blanket surveys of all troops on a certain post whether the troops were abusers of drugs or not, the present investigation utilized as subjects identified drug abusers. Almost the entire population studied in this investigation were abusers of opiates or "hard" drugs and all were involved in a military drug rehabilitation programme.

The third major difference was in the methodology utilized to obtain information. Rather than obtaining data from anonymous questionnaires given in blanket fashion to large numbers of troops, the information upon which the present study was based was derived from the impressions of medical personnel, line unit commanders, and professional mental health staff. These impressions were compared with the feelings of the soldiers themselves about the Army's rehabilitation efforts.

1

This investigation was funded and supported by the Clinical Research Service, Madigan Army Medical Center, Tacoma, Washington, 98431.

2

Requests for reprints should be sent to William J. Dess, Neuropsychiatric Institute, The Center for the Health Sciences, 760 Westwood Plaza, Los Angeles, California 90024.

3

The authors were assigned to the Mental Hygiene Consultation Service (MHCS) on adjoining Fort Lewis. MHCS served only in a consultative and evaluative capacity to the drug rehabilitative effort. The first author was appointed to evaluate the rehabilitation progress of all evacuees for drug abuse to the northwestern United States and report the results to the Surgeon General of the Army.

Method

The sample investigated in this study was composed of identified drug abusers who were air-evacuated for drug abuse from the Republic of Viet-Nam (RVN) to Madigan Army Medical Centre, Tacoma, Washington, where they were subsequently placed into the Fort Lewis drug rehabilitation programme. The following section delineates the process by which this took place.

In July, 1971, the Department of the Army initiated a programme whereby all troops leaving Viet-Nam were to undergo a mandatory urinalysis screening for drug abuse. Eighty-eight per cent of the sample were identified in this manner; only 12 per cent voluntarily admitted their drug abuse and requested treatment.

Regardless of the identification process, all soldiers were routinely placed on a drug detoxification ward in the Republic of Viet-Nam, detoxified, and categorized by physicians in that country as drug dependent or misusers of drugs. Once detoxified, an attempt was made to air-evacuate the drug abusers to military hospitals nearest their home of record. Data indicated that 38 per cent of the sample were from the states of Washington, Oregon, Idaho, Montana, and California.

Immediately upon arrival at Madigan Army Medical Center (MAMC), all identified drug abusers were placed on a drug detoxification/observation ward for 3-5 days. During this period they were medically examined, their drug involvement categories re-evaluated and changed if appropriate, and psychosocial data collected. All soldiers were then assigned to a duty unit on adjoining Fort Lewis.

Each major unit of Fort Lewis had its own command-oriented drug rehabilitation programme with at least one civilian "outreach" drug counsellor and one military rehabilitation programme co-ordinator (officer rank) to assist the drug abuser in his rehabilitative effort. Not all unit programmes were identical, but all were co-ordinated through the post-wide Coordinating Center for the Prevention of Alcohol and Drug Abuse (CCPADA), approved personally by the Commanding General, and designed to be 180-day observation, evaluation, and rehabilitation efforts. The rehabilitation programme for most units consisted almost exclusively of educational, individual, and group counselling on an outpatient basis, initially mandatory, and then voluntary.

Each soldier, regardless of unit assigned, was required to report to medical facilities twice each week for urinalysis testing. When eight consecutive negative tests were recorded, the soldier was released from this requirement and subject only to random testing at the discretion of his commander and/or higher authority. If any test proved positive for non-prescription drugs, or if the subject missed a scheduled test, he was required to begin the series all over again until he reached eight consecutive negative tests. Additionally, each soldier was evaluated at 60-day intervals and at the time of his termination with the rehabilitation programme, both by the Mental Hygiene Consultation Service (MHCS) staff (in personal interviews) and by his unit commander. These evaluations were reported on standardized forms developed by the first investigator of this study. Data from these forms, plus hospital and Viet-Nam records, comprised the bulk of all information gathered on the sample.

The present investigation hoped to study the entire population of drug abusers evacuated to MAMC who completed or otherwise left the rehabilitation programme within one calendar year. The subject population, beginning with the initial evacuee in July, 1971, and continuing through July, 1972, represented a total of 242 soldiers. Due to misplaced or incomplete records, demographic data were available on a total of 231 of the original sample. Rehabilitation data were available on 226 of the remaining subjects. Therefore, in all, data on 16 subjects were lost or incomplete, which represents 7 per cent attrition.

Results - DEMOGRAPHIC DATA

The following tables represent various demographic characteristics gathered from personal interviews and hospital records by the Mental Hygiene Consultation Service.

TABLE 1 - General demographic data

Variable and level

Number

Percentage

Age
   
17-19
45 19
20-23
160 69
24-28
21 9
29 5 3
  231 100
Race
   
Caucasian
167 72
Negro
54 23
Other
10 5
  231 100
Marital status
   
Single
170 74
Married
45 19
Sep./Div.
16 7
  231 100
Education
   
High school
85 37
High school graduate
127 55
Some college
19 8
College graduate
0 0
  231 100
Religion
   
Protestant
96 42
Catholic
41 18
Jewish
1 0.5
Other
7 3
None claimed
86 37
  231 100

TABLE 1 - (continued)

Variable and level

 

Number

Percentage

Family constellation (by siblings)
     
Only child
(0) 22 10
Small family
(1-2)
75 32
Medium family
(3-4)
71 31
Large family
(5+)
63 27
    231 100

TABLE 2 - Military demographic data

Variable and level

Number

Percentage

Rank
   
E-1 E-4
190 82
E-5 higher enlisted
41 18
Officer
0 0
  231 100
Service component
   
RA (enlistees)
211 91
AUS (draftees)
20 9
  231 100
Career plans
   
Yes
13 5
No
200 87
Undecided
18 8
  231 100
Time in service
   
0-12 months
1 1
13-18 months
14 6
19-24 months
72 31
25-36 months
104 45
36 months 40 17
  231 100
Republic of Viet-Nam
   
duty assignment
   
Combat
49 21
Support
155 67
Unable to rate
27 12
  231 100
Articles 15 during entire service a
   
One
62 28
Two
43 19
Three
14 6
Four or more
21 9
None
84 38
  224 100
a

Information not available on 7 subjects.

Table 1 represents general demographic data of the population studied. Of particular interest are the facts that the overwhelming majority of the total sample were between the ages of 17 and 23 (88 per cent), Caucasian (72 per cent), single (74 per cent), and had received high school educations or less (92 per cent). There were no college graduates in the sample. A large percentage (37 per cent) claimed no religious affiliation.

Demographic data not shown in this table indicated that 37 per cent reported their parents were not living together for various reasons and that the largest occupational category of the father was "blue collar" (41 per cent). Ninety-two per cent of the sample reported no history of mental illness, alcoholism, or other emotional disturbance in their families; likewise, the same percentage (92 per cent) reported that they themselves had not received professional help for drug abuse or emotional disturbance prior to being placed in the Fort Lewis programme.

Table 2 represents military demographic variables of the sample. The table indicates that an overwhelming majority of the subjects had enlisted into the service (91 per cent as opposed to being drafted and 87 per cent did not plan to make the service a career; 62 per cent had spent over two years on active duty when last interviewed, and 82 per cent were between the lower enlisted ranks of E-1 and E-4. No officers were reported to MHCS as having been medically evacuated for drug abuse. Thirty-four per cent of the sample reported receiving two or more Articles 15 (military disciplinary action), with 62 per cent reporting having received at least one. Those serving primarily in support roles in Viet-Nam as opposed to active combat roles comprised 67 per cent of the sample.

TABLE 3 - Drug abuse history

Period and type of drug abuse

Number

Percentage

Prior to Viet-Nam service
   
Marijuana only
33 14
Amphetamines only
2 1
Barbiturates only
1 0.5
Multiple (exclude opiates)
34 15
Multiple (include opiates)
9 4
Other
0 0
None
84 36
Insufficient data available
68 29
  231 99.5
During Viet-Nam service
   
Heroin and marijuana only
91 39
Opium only
0 0
Heroin only
66 29
Multiple (include opiates)
70 30
Amphetamines only
2 1
Barbiturates only
0 0
Multiple (exclude opiates)
2 1
  231 100

Table 3 represents the drug abuse history of the sample prior to being placed on the rehabilitation/observation programme. Of interest in this table are the facts that while virtually every soldier was detected for using opiates or their derivatives while serving in Viet-Nam (98 per cent), only 4 per cent reported using opiates or their derivatives before being sent to Viet-Nam. Approximately one-third of the sample reported using drugs of some kind before Viet-Nam (34 per cent); however, insufficient information accounted for 29 per cent of the sample.

Related data not shown on this table indicated that only 11 per cent of the sample used a needle as their main or only mode of drug usage while in Viet-Nam. The most common mode of usage by far was through smoking or sniffing.

REHABILITATION DATA

The following table represents the rehabilitation status of all individuals in the sample at the time of their termination with the Fort Lewis drug rehabilitation programme. Three criteria were selected to represent the medical, the command, and the mental hygiene viewpoint regarding success or failure: (1) urinalysis results, (2) adjustment to duty as rated by the individual's command, (3) Mental Hygiene Consultation Service final evaluation and prognosis.

Urinalysis "total success" was represented by completing the urinalysis requirement (see Method section); partial success indicated those individuals who never completed the requirement, but had at least over half of all urinalysis results negative; failure represented those individuals who had half or more of their urinalyses positive for psychotropic agents.

The "adjustment to duty" rating was made by the individual's commander or drug rehabilitation officer and based on a scale of excellent to poor. "Excellent" and "good" were considered total success, "fair" and "uncommitted" were considered partial success, and "poor" was considered failure. Although there were no standardized criteria upon which this judgement was made, it was nevertheless felt that this rating represented the command's reaction to the individual concerned.

The MHCS rating represented an over-all diagnostic rating based on urinalysis results, command reaction, the individual's attitude, and the subjective prognostic impression of MHCS staff. The rating was based on a scale of total success, partial success, and failure. It should be noted that unless an individual completed the urinalysis requirement and was rated at least "fair" in his adjustment to duty, he could not be rated a total success by MHCS.

Table 4 indicates that a large majority (76 per cent) of the sample was able to successfully complete the urinalysis requirement. Similarly, a large majority (65 per cent) were judged totally successful in their adjustment to duty. Mental Hygiene Consultation Service tended to be more conservative in their over-all final evaluation and rated just a slight majority (54 per cent) as totally successful. Those rated as failures composed a small percentage of all three criteria, with the major fluctuations taking place between total and partial success. When total and partial success categories are combined, drug rehabilitation efforts appear to have been of benefit for 96 per cent, 87 per cent and 89 per cent of the sample in each criterion respectively. Data relevant to table 4 indicated that abrupt changes in drug use occurred. Of all urinalyses recorded on the sample population, only 9 turned positive for opiates or their derivatives, and only 122 positive tests were recorded in total, mostly for amphetamines and barbiturates. It is presumed that opiates and other drugs were readily available to the subjects, although certainly not in the quantity, quality nor at the price as in Viet-Nam; subjects were not confined to Fort Lewis, having relatively easy access to the surrounding communities of Tacoma, Olympia, and Seattle.

TABLE 4 - Rehabilitation data based on three criteria of success/failure

 

Total success

Partial Success

 

Rating component

Criterion

Number

Percentage

Number

Percentage

Number

Percentage

Total

Medical
Urinalysis
175 76 42 20 9 4 226 100
Command
Adjustment to duty
146 65 49 22 31 13 226 100
Mentalhygiene
MHCS final evaluation
123 54 79 35 24 11 226 100

It is interesting to note that while, over-all, an overwhelming majority of the sample was rated partially or totally successful in their rehabilitative effort, on self-evaluative reports only 26 per cent of the sample felt the programme had benefited them. Thirty-eight per cent felt the programme was either not needed or "nothing but a hassle". The remaining 35 per cent were uncommitted as to any benefit they had received from the rehabilitation programme. It is hypothesized that the generally lower "total success" MHCS rating was due at least in part to the subtle influence of the large percentage of negative and uncommitted individual reaction (see table 5). Additionally, subjective impressions indicated that the low positive reaction to the rehabilitation effort may have been largely due to the soldiers' feelings that: ( a) once back in the U.S. they did not require any further rehabilitation, i.e., they were situational users, ( b) the command structure, despite its expressed desire to do otherwise, tended to single-out the identified soldiers as special people to keep a close watch over, i.e., they had less freedom and were allowed fewer mistakes.

Only 77 persons participated in rehabilitation efforts for a full 180 days. Approximately two-thirds of the sample (66 per cent) left the Army or Fort Lewis between 60 and 180 days, almost exclusively the result of their service obligation being completed. As might be expected, those who completed the entire 180-day programme tended to be rated more successful in all success/failure criteria. It should be noted that special provisions were made so that a soldier could voluntarily remain in the Army to continue/complete his 180-day rehabilitation programme - few individuals chose this option. Individuals who were still rated drug dependent when they completed their service obligation, and who did not wish to remain in the Army for rehabilitation, were automatically transferred to a Veterans Administration hospital for further treatment.

When rehabilitation outcome was evaluated both according to whether an individual was originally drug dependent or a misuser of drugs, and whether he completed or did not complete the 180 days, it was found that the percentage of failures in all success/failure criteria remained relatively small and consistent. Apparently, any fluctuations in success rate due to these variables occurred between total and partial success, in part due to the fact that many individuals opted to leave the Army early, before becoming eligible for recategorization. For example, a review of the data indicated that many soldiers had no positives on urinalysis testing, but due to a missed appointment or other administrative reasons they did not obtain the required number of negative tests to officially merit a successful rating. It was felt by MHCS staff that a significant number of those soldiers rated "partially successful" could have received a "totally successful" rating had they elected to remain in the programme long enough to simply take a few more urinalysis tests.

A stepwise discriminant function analysis was performed with the data in an attempt to identify demographic and/or historical variables which would help predict success or failure. In all cases, no clear discrimination was found, leading to the conclusion that there was little chance of predicting the success or failure of any individual based on demographic/historical information available at the time of his entry into the programme.

Table 5 represents the results of an X [ 2] analysis completed with the data. Statistically significant findings indicate that those individuals who were not originally classified drug dependent and those who gave more favourable reactions to the rehabilitation programme were likely to receive more successful MHCS final evaluation and prognosis ratings. Additionally, those soldiers who were successful in completing the urinalysis requirement tended also to receive more favourable adjustment to duty ratings.

TABLE 5 - X 2 analysis of success/failure criteria with relevant variables

Variables

df

X2

Urinalysis results x
   
Original category
1
.099
Unit assigned
7 3.85
Est. rehab. potential, Republic of Viet-Nam
4 1.28
Individual's assessment of rehab. programme
4 2.59
Adjustment to duty x
   
Original category
4 6.99
Unit assigned
28 31.04
Urinalysis results
4 12.82a
MHCS final evaluation x
   
Original category
5 23.40 b
Unit assigned
35 41.93
Est. rehab. potential, Republic of Viet-Nam
20 9.82
Individual's assessment of rehab. programme
9 19.11a

a p .05 bp .01

Important statistically non-significant findings show that the urinalysis results were not significantly associated with any variable except adjustment to duty; the estimated rehabilitation potential rating made by Army Medical Department staff in Viet-Nam was not associated significantly with either urinalysis results or the MHCS final evaluation and prognosis rating; and the military duty unit assigned was not significantly associated with any success/failure criterion. This last finding would indicate that although no unit rehabilitation programme was identical, there apparently was no significant difference in rehabilitation outcome based on this factor.

Discussion

The results of this study support the contention of the White House Special Action Office, under the direction of Dr. Jerome Jaffe (1, 11) that the military Viet-Nam narcotic user was not the "typical" narcotic user studied so often in civilian research. As opposed to the findings of various studies on the domestic narcotic user (9), often with a recidivism rate of 90 per cent or greater, the Viet-Nam narcotic user was able to "kick" his narcotic use in virtually every case - at least for the time he was monitored by the Fort Lewis programme, indicating that perhaps the military Viet-Nam narcotic user incurred a "situational addiction". Mandatory urinalysis testing revealed abrupt changes in extent and pattern of drug use, with opiates detected only rarely. It should be noted that urinalysis results were subject to the reliability of the laboratory doing the analysis and that essentially only amphetamines, barbiturates, and opiate drugs were detectable. Therefore, it is possible that nondetectable drugs (marijuana, LSD, cocaine) were being used by the subjects but were not discovered in their urine samples.

Despite the fact that urinalysis testing was the only concrete criterion available to measure rehabilitation success or failure, it was felt that this variable alone did not accurately represent the soldier's total adjustment and reaction to the rehabilitation effort. Such questions as laboratory reliability (noted above), the possibility that soldiers were able to somehow "fake" their urinalysis tests, and whether or not some individuals merely stayed "clean" until they could leave the Army remained unaswered. For these reasons, two other indices of success and failure were used, and the qualifications noted above may partially explain why these two ratings were substantially lower. The "adjustment to duty" rating, higher than the MHCS rating, may have reflected some tendency on the commander's part to inflate ratings in order to put his unit's rehabilitation programme in a favourable light with the Commanding General. However, it was felt by some MHCS staff that some commanders may have been conservative in their ratings in prejudice to the identified user, thus partially correcting for any inflation. Even so, differences between the two largely subjective ratings occurred primarily in fluctuations between total and partial success ratings - not in failure. The Mental Hygiene Consultation Service final evaluation and prognosis rating (independent of the Fort Lewis command structure) was accomplished by trained mental health staff and, while dependent to some extent on the other two ratings, was considered as reliable an over-all evaluation as could reasonably be made. The fact that this rating was an over-all rating and partially dependent on the other two ratings may explain why it was substantially lower. It is further recognized that the aims of the Army and those of the individual may have differed significantly and thus possibly prejudiced the results in some cases.

In this light and with the reservations noted, the results indicated that the Army's attempt to rehabilitate the Viet-Nam narcotic abuser at Fort Lewis appeared to have been successful with this sample. The Mental Hygiene Consultation Service final evaluations and prognoses judged 89 per cent of the sample either partially or totally successful in their rehabilitative effort. The data suggest, however, that factors other than the rehabilitation programme itself may have been operating in the rehabilitation process. Since almost three-fourths of the sample claimed the rehabilitation programme was of dubious or no benefit to them, and since small differences in failure rates were observed between those who completed the programme and those who did not, perhaps merely evacuating the individual from the Viet-Nam environment and returning him to the "real world" (as the G.I.s called the U.S.) was the single most important factor in their rehabilitation. In any case, whether due solely to the change in environment, the rehabilitation programme (including the pressure of urinalysis testing), the desire to simply clear their record, or a combination of the above, it appeared that few, if any, individuals who used narcotics in Viet-Nam, and who participated in the rehabilitation programme, returned to civilian life physiologically dependent on opiates, amphetamines, or barbiturates. A review of urinalysis records showed that these drugs were used by a small percentage of the sample, and then only rarely or sporadically. The extent to which individuals may have been psychologically drug dependent is unknown. Further follow-up in the civilian environment is required to determine if in fact the soldiers represented in this sample remained relatively drug-free.

Finally, a factor of political and strategic importance suggested by the data to be considered by the all-volunteer Army is that enlistees appeared significantly more likely (91 per cent of sample) to experiment with drugs in an overseas setting than those drafted into the service. If it is contended that enlistees were simply "caught" more often, the question then becomes: Why were enlistees not able to "clean-up" before urinalysis screening as well as draftees? In either case, it appears evident that there are differences between the enlistee and the draftee. Whether the differences suggested by the data have implications for such qualities as motivation and over-all effectiveness under stress is an important question for future research.

References

001

A follow-up of Vietnam drug users. Drug Abuse Prevention Report, 1 (1) 1973, prepared by the Strategy Council under the direction of Dr. Jerome Jaffe, Director of the White House Special Action Office, and Myles Ambrose, Director of the Office of Drug Abuse Law Enforcement.

002

Alleged Drug Abuse in the Armed Services, Hearings by Special Subcommittee on Alleged Drug Abuse in the Armed Services of the Committee on Armed Services, House of Representatives, Ninety-First Congress, Second Session, September 22, 30, October 6, 13, November 17, 18, 19, December 2, 7, 8, 15, 1970. Briefings and Interviews, Southeast Asia Inspection Trip, January 2-19, 1971.

003

Biomedical Computer Programs Developed at U.C.L.A. (BMDOTM), Stepwise Discriminant Function Analysis, revised 6-1067, 214a-412t.

004

Black, S., K.L. Ownes and R.P. Wolff, Patterns of drug use: a study of 5,482 subjects, Am. J. Psychiatry, 127, 420-423, 1970.

005

Callan, J.P. and C.D. Patterson, Patterns of drug abuse among military inductees, Am. J. Psychiatry, 130, 260-264, 1973.

000

The evacuated Viet-Nam narcotic abuser: a follow-up study 65

006

Campbell, B., Extent of drug use and addiction in the armed forces appears wider than Pentagon's statistics show, The New York Times , Monday, June 8, 1970.

007

Drug and Alcohol Abuse in the Military, Hearings before the Special Subcommittee on Alcoholism and Narcotics of the Committee on Labor and Public Welfare, United States Senate, Ninety-First Congress, Second Session on Examination of Drug Abuse and Alcoholism in the Armed Forces , November 17 and 18, December 2 and 3, 1970.

008

Drug Research Project: Summary of Preliminary Findings , Mental Hygiene Consultation Service, Irwin Army Hospital, Fort Riley, Kansas. Fort Riley Publication, February, 1971.

009

Drug Use in America: Problem in Perspective , Second Report of the National Commission on Marijuana and Drug Abuse, March, 1973.

010

Greden, J.F. and D.W. Morgan, Patterns of drug use and attitudes toward treatment in a military population, Archives of General Psychiatry, 27 , 113-117, 1972.

011

Harris, G., As far as heroin is concerned, the worst is over: a conversation about the drug epidemic with Jerome Jaffee, Psychology Today , 7(3), 68-86, 1973.

012

Inquiry into Alleged Drug Abuse in the Armed Services in the 91st Congress, 2nd Session, Report of a Special Subcommittee of the Committee on Armed Services, House of Representatives, Ninety-Second Congress, First Session , April 23, 1971.

013

Maillet, E.L., Drugs, race and the counter culture: a perspective from Vietnam, Proceedings of the U.S. Army Current Trends Conference, Drugs, Race, the Counter Culture and the Soldier , Fitzsimmons General Hospital, Denver, Colorado, 1970.

014

Military Drug Abuse, 1971, Hearings before the Subcommittee on Alcoholism and Narcotics of the Committee on Labor and Public Welfare, United States, Ninety-Second Congress, First Session on Military Drug Abuse , June 9, 22, 1971.

015

Patterns of drug use of men entering army active duty, men on active duty with no overseas experience, and men on active duty with overseas experience. Unpublished manuscript, Fort Riley Publication, Fort Riley, Kansas.

016

Stanton, M.D., Drug use in Vietnam, a survey among army personnel in the two northern corps, Archives of General Psychiatry, 26 , 279-286, 1972.

Acknowledgement

The authors wish to thank Dr. Jerry Stoler and Dr. Bruce Fariss of Madigan Amry Medical Center, Dr. Donovan Thompson and Mr. Frank deLibero of the Department of Biostatistics, University of Washington, and Douglass Fee, William App, and the staffs of MHCS and CCPADA, Fort Levwis, Washington, for their invaluable assistance in making this project possible.