First responders are specially trained people who intervene to save lives in dire situations, like natural disasters or terrorist attacks. Medical personnel, police officers, and firefighters all put their lives at risk to save others. The nature of a first responder’s job means that this person experiences intense stress and sees horrific events up close, far more often than an average citizen.

However, first responders tend to view themselves as more emotionally durable and resilient, even when this is not true. Although they respond to trauma, like overdoses or suicide attempts, they are often less able to see symptoms of substance abuse and mental health problems in themselves. Culturally, first responders are less likely to seek treatment for these conditions, even when they have concerns because getting help is viewed as a weakness. Unfortunately, the combination of consistent mental strain, higher incidence of post-traumatic stress disorder (PTSD), and greater risk of substance abuse puts first responders at greater risk for long-term health consequences and death.

Treatment Options for First Responders

Signs of Substance Abuse Trouble

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a page of Tips for First Responders to recognize substance abuse. Behavioral and cognitive indicators include:

  • Wide mood swings
  • Panic attacks or appearing fearful and anxious
  • Impatience, agitation, or irritability, bordering on physical violence
  • Increasing anger or defiance
  • Talks about getting high or drunk, or uses language typical among drug users
  • Behaves impulsively or inappropriately
  • Covers up, denies, or lies about drug abuse
  • Takes unnecessary risks or acts recklessly
  • Bends or breaks rules, or cheats
  • Misses appointments or interviews, or arrives to meetings late or intoxicated
  • Fails to comply with program requirements without a legitimate reason
  • Trouble concentrating
  • Appears distracted or disoriented
  • Trouble making decisions
  • Short-term memory loss or blackouts after substance abuse
  • Trouble recalling details of events
  • Needs repeated assistance with tasks like paperwork

Although this list was designed to help emergency responders quickly diagnose a potential substance abuse problem in a person involved in an emergency situation, the list can also apply to first responders themselves.

First Responders at Greater Risk for Substance Abuse

Due to the intense, stressful job, and the volume of trauma they are exposed to, first responders are at a higher risk of developing a substance abuse condition.

People who are employed consume 75 percent of illicit drugs, and 10 percent of that substance abuse is believed to occur in the workplace. Intoxication significantly reduces productivity, and impairs both physical and cognitive skills. For people whose job requires being in danger, like first responders, being intoxicated on the job endangers their lives as well as the lives of their coworkers and the public they aim to serve.

First Responders at Greater Risk for Substance Abuse

Among police officers, 20-25 percent are chemically dependent on drugs or alcohol. While most police officers will not take illicit drugs like cocaine, heroin, or marijuana, many struggle with prescription opioid addiction and alcoholism. Until recently, alcohol use disorder was the most prevalent form of substance abuse among police officers; now, as the opioid addiction epidemic ravages the US, injured police officers are more likely to become addicted to prescription narcotic painkillers.

Cigarette smoking is also a big problem among first responders, including firefighters. USFA estimates that 1,800 members per year die from health issues induced by smoking cigarettes.

Psychological Distress and Substance Abuse

An older survey of firefighters found that about 40 percent experienced psychological distress, and around 30 percent experienced problematic alcohol ingestion. These rates are close to other American adults who experience post-traumatic stress disorder (PTSD); 30-50 percent of men and about 25 percent of women who struggle with PTSD develop a troubled relationship with alcohol, which is twice the rate of alcohol difficulties occurring in the general population.

Psychiatric Quarterly published an article in 2015 noting that 5.9-22 percent of first responders develop psychological trauma and PTSD. In spite of these high rates of trauma and associated problems including violence and substance abuse, interventions and treatments are inadequately provided.

PTSD is highly correlated with substance use disorders. For example, 21-43 percent of people with a lifetime prevalence of PTSD also struggle with addiction. Vice versa, those with a lifetime prevalence of substance abuse have a 26-52 percent incidence of PTSD. The psychological trauma can cause a person to self-medicate with intoxicating substances, or the substance abuse can lead to experiencing a situation that is traumatic.

SAMHSA notes that first responders are at greater risk of chronic emotional stress and disturbances because of:

  • Longer separation from loved ones due to job requirements
  • Being in life-threatening situations
  • Previous deployments that caused disruptions at home or work
  • Trauma from witnessing others’ trauma

Trauma experienced by first responders is inherent to the job and sometimes is unique to their working situation. Professional trauma can stem from a perceived threat to personal safety or to the safety of others in a specific situation. The professional trauma first responders may experience includes:

  • Line-of-duty trauma: This involves experiencing the death or near-death of other professionals, those in the community, or oneself.
  • Line-of-duty death: This is trauma associated with the death of a fellow while working in a crisis event.
  • Post-shooting trauma in law enforcement: Usually specific to police officers, this is the kind of trauma experienced after the person or their fellow police officer shoots a suspect.

These traumas are unique to first responders’ work, and they can occur in addition to regular trauma associated with a natural disaster, fire, or other devastating event.

Work-Related Injuries and Addiction

Opioid painkillers effectively ease pain, but they can also be highly addictive. They induce both relaxation and euphoria, which can release neurotransmitters like serotonin and dopamine. Painkiller prescriptions are also designed to help the person feel better, enough to attend doctors’ appointments and physical therapy; however, in a cultural structure that pressures a person to be resilient, such as working as an emergency responder, feeling better may lead the person to go back to work before they have fully recovered. When they do not fully recover, they may use prescription painkillers as a temporary way to feel good enough to work. This leads to dependence and addiction.

Barriers to Mental Health and Substance Abuse Treatment among First Responders

There are three common factors that are often found in first responders’ work culture, which may prevent these professionals from seeking the help they need.

Work-Related Injuries and Addiction
  1. Stoicism: The expectation that first responders are not impacted by the devastating and dangerous events to which they respond. Instead, they are expected to cope with humor, emotional distance, or, too often, heavy drinking or other legal substance abuse.
  2. Depersonalization: This may be unintentional, but the first responder begins to experience events as though they are happening to someone else. When recalled, the first responder does not have emotions associated with the traumatic event they responded to.
  3. Derealization: Similar to depersonalization, derealization involves feeling like the traumatic event is not real.

These three conditions put the first responder in a position where they are more likely to deny symptoms of PTSD, other emotional trauma, and substance abuse when they appear. They believe they must force themselves to work because lives truly rely on them responding to events. They cannot let anyone down, and there is great pressure to maintain the appearance of high performance. However, experiencing greater amounts of trauma means that first responders actually need more extensive, thorough, and effective treatment for mental health conditions, substance abuse, and co-occurring disorders.

Additionally, many first responders may become involved in criminal or civil litigation related to the traumatic event. For example, police officers involved in stopping a violent incident may be called to testify in court; firefighters may be asked to testify as expert witnesses if an arson occurs. Many first responders may choose to delay or avoid treatment because they do not want to leak key details of a case before it can legally be disclosed, even with guarantees of privacy from the therapist or medical professional.

Recommendations for Better Treatment

To better serve first responders, a few steps can be taken to reduce the impact of mental health conditions and substance abuse.

  • Mental health screenings: Offering first responders more extensive access to mental health professionals after a traumatic event can help to reduce the severity of PTSD, anxiety, depression, and substance abuse among these officers. Requiring these screenings may have a detrimental effect among these professionals, but providing the resources for voluntary, anonymous access may improve problems related to addiction or suicide. This may include working with departments and their chiefs or commanders to coordinate access to services just after a traumatic event and ensure consistent care between responses.
  • After Action Reviews (AARs): This is a term used widely among military, first responders, and law enforcement; these professionals gather after responding to an event and discuss what occurred and how their actions could be improved. Part of the discussion for improvement could focus on resources available to those who may have suffered mental or emotional trauma, or whose substance abuse may have affected their job performance.
  • Workers’ compensation coverage for mental health and substance abuse: If state-mandated workers’ compensation programs do not cover mental illness and substance abuse, lawmakers should consider changing these laws. Time and money are two large barriers for anyone to access substance abuse treatment and mental health services, and this is just as true of first responders as the general population.
  • Better coverage through Employee Assistance Programs: Many jobs offer substance abuse interventions, referrals, and case management through EAPs, or Employee Assistance Programs. However, there are gaps in coverage among different professions. Lawmakers, department chiefs, and others can ensure that first responder EAPs cover mental health and substance abuse services, so participants can at least get appropriate referrals and assistance managing resources like insurance.
  • Privacy guarantees: Because of legal considerations, a therapist, doctor, or rehabilitation specialist working with a first responder must ask if there are any legal considerations that would prevent the first responder from discussing a traumatic incident in detail. This could impede the flow during therapy sessions, but this guarantee of privacy can make a first responder more comfortable with discussing emotional details without worry about accidental disclosure of case information.

Resources for First Responders to Get Help

Some organizations that provide education and treatment for first responders are outlined below:

  • Blue Wall Institute: This organization provides training and resources to help first responders, particularly police officers, understand how stress and trauma affect mental health and rates of substance abuse.
  • Code Green Campaign: This organization aims to raise awareness of mental health and substance abuse issues among first responders, provide education and prevention tools, eliminate stigma around seeking treatment, and help first responders gain access to mental health and substance abuse services. The campaign was founded in 2014 by a group of EMS responders who became aware of high rates of suicide among all first responders.
  • Code 9 Project: This group provides education, support, and self-help tools for public safety personnel and their families.
  • Safe Call Now: this confidential crisis hotline and referral service was designed specifically for public safety employees and first responders who may be in crisis due to substance abuse, suicidal thoughts, or other issues.
  • Serve and Protect: This resource helps first responders find services to help them understand and overcome trauma and invisible, emotional scars related to their high-stress occupations.