Police officers, firefighters and paramedics run toward danger while others flee. Firefighters charge into burning buildings to rescue strangers; police confront the wreckage of violent crashes and crime scenes; paramedics race to stabilize the critically injured. Meanwhile, dispatchers shoulder the invisible burden from afar, listening to every scream, every moment of silence and every desperate plea for help. Together, these first responders carry humanity’s darkest moments. Yet, the toll is often invisible: More die from suicide than in the line of duty.
Due to chronic exposure to trauma and high stress, these professionals are at risk of developing post‑traumatic stress disorder, a complex biopsychosocial condition. In search of short‑term relief from troubling images and intrusive memories, some turn to alcohol or drugs. This can lead to substance use disorder, a chronic, relapsing medical condition characterized by the compulsive use of drugs or alcohol despite harmful consequences. When left untreated, the effects of frequent or repeated exposure to intense trauma can be life‑altering or deadly.
It is important to understand the nature of these conditions and recognize warning signs that an individual may be struggling and in need of assistance. PTSD is both a complex and persistent condition. Disrupting the nervous system, it can make daily functioning difficult by causing sleep disturbances, the onset of extreme anxiety and depression, and exacerbation of chronic pain. First responders often experience nightmares, flashbacks or uncontrollable thoughts related to a particular event or multiple traumas.
PTSD can make it hard for someone to control or manage emotions, and interactions with other people can become challenging. Angry outbursts, aggressive confrontations and increased social isolation and substance use can become common behaviors.
Further, PTSD can be difficult to treat because of its potential for delayed onset. Symptoms may not appear immediately but rather surface weeks, months or even years later, and it can be triggered by a seemingly innocuous incident.
A first responder struggling with the effects of PTSD might feel defeated. With nowhere to turn, the person may seek the temporary relief through alcohol or drugs. This can lead to the development of SUD, creating harmful consequences.
SUD in first responders rarely arises as a singular condition. Instead, the disorder is frequently intertwined with other complex physical and mental conditions that affect overall health and well‑being. These factors make it harder to stop without intervention.
To identify SUD in first responders, it is essential to look beyond substance use and assess patterns of emotional distress, increasing isolation, declining work performance and withdrawal from meaningful activities. These may reflect deeper unresolved trauma as well as SUD.
The co‑occurrence of PTSD and SUD, known as a dual diagnosis, creates a vicious cycle: Trauma intensifies substance use, and substance use worsens the effects of trauma. Unaddressed, this cycle can cause severe psychological and physiological damage.
Unfortunately, a stoic workplace culture, a strong stigma around asking for assistance and an unwavering desire to serve others often make it difficult for first responders to seek help for themselves. By the time someone reaches out, he or she is often already in a state of profound disrepair.
When SUD combines with PTSD, chronic pain or traumatic brain injuries, standard treatments are rarely sufficient, and underlying conditions often go undertreated. When residual barriers to recovery are not identified and addressed, some first responders lose hope and abandon treatment, which can cause conditions to quickly worsen and steadily escalate.
A highly advanced treatment approach has evolved over recent years showing that effective treatment requires medical providers and clinicians to understand the full depth of a first responder’s experience with the condition or injury. This concept of cultural competence on the part of the medical staff is essential for first responders to fully engage with a treatment program.
Furthermore, a first responder’s health should be approached holistically. This is best achieved through a biopsychosocial approach to care rather than treating conditions separately and in isolation.
Additionally, complex cases of PTSD, SUD and other trauma‑related conditions require treatment from a transdisciplinary team of specialists. This includes neurologists, psychiatrists, psychologists, physical therapists, behavioral health specialists, addictionologists and clinical nutritionists, among others.
Employing a transdisciplinary team that eliminates barriers among disciplines allows clinicians and specialty providers to address pain and injury on multiple levels in a highly coordinated fashion. Team members collaborate and develop a single treatment plan for an individual first responder, with progress and updates shared in real time.
Moreover, providing care within a therapeutic community of first responders designed to recover from similar experiences helps support treatment effectiveness and accountability. Both intensive outpatient settings and brief inpatient detox and trauma recovery are sometimes needed to achieve functional improvement and reintegration back into their personal and professional lives.
The city of San Diego adopted what has become known as a transdisciplinary, biopsychosocial, therapeutic community care model (TBTC) developed by the Institutes of Health, and the ensuing partnership enabled the program to be implemented rigorously. Central to its success, the workers compensation team worked with departmental leaders to raise awareness of trauma‑related conditions and fostered an environment that encouraged members in need to seek assistance. The team also physically vetted clinical programs with an eye toward rapid access to evidence‑based, multidisciplinary care.
Of the city’s first responders who have completed the IOH programs, more than 93% no longer met diagnostic criteria for PTSD by the end of treatment, and an equally high percentage returned to duty. Those treated also saw significant decreases in opioid use, polypharmacy and disability duration across the board. Clinically validated improvements were reported in sleep, cognition, emotion regulation and pain.
Importantly, San Diego is not alone. An increasing number of agencies and municipalities are seeking to replicate these results. Across multiple program evaluations, the TBTC model has repeatedly delivered what less sophisticated levels of treatment have struggled to achieve: systematic reductions in PTSD with the vast majority no longer meeting diagnostic criteria; high rates of return‑to‑duty; substantial decreases in anxiety among first responders with PTSD; measurable improvements in disability and activities of daily living among patients with traumatic brain injuries and severe pain; marked reductions in depression; and a significant drop in pain catastrophizing, a key psychological barrier to recovery. Across cohorts, gains in sleep, cognition, emotional regulation and pain management have been consistently observed, underscoring TBTC’s ability to restore function, rather than just reduce symptoms.
PTSD and SUD are serious conditions and a potent threat to our first responders. The good news is that the TBTC model offers hope for an employee population where results were highly elusive or non‑existent. When the alarm sounds, signifying a call for help, first responders can now access resources designed to help them recover and reclaim their purpose in life. Indeed, it is time to confront the challenges posed by PTSD, SUD and other trauma‑related conditions and extend an offer of assistance in their hour of need.
Dr. Tomer Anbar is CEO of Institutes of Health. For more information, visit www.institutesofhealth.org.