Highlights
- Veterans with co-occurring alcohol use disorder (AUD) and opioid use disorder (OUD) face significantly higher risks of positive IPV screening and high-lethality violence exposure.
- Female veterans with dual SUD diagnoses are particularly vulnerable to lethal IPV subtypes, including strangulation and escalation of violence.
- Despite high prevalence, screening rates for IPV in VHA clinics remain around 22%, with extremely low referral rates to specialized family or relationship services.
- Neurobiological evidence suggests structural alterations in the limbic system, specifically the amygdala-hippocampus complex, are associated with IPV perpetration in veterans with PTSD and TBI.
Background
Intimate partner violence (IPV) is a pervasive public health crisis with profound implications for the military veteran population. Characterized by physical, sexual, or psychological harm by a current or former partner, IPV is inextricably linked to severe psychiatric morbidity, including posttraumatic stress disorder (PTSD), depression, and anxiety. For veterans, the transition from military to civilian life often brings unique stressors—combat exposure, military sexual trauma (MST), and traumatic brain injury (TBI)—that exacerbate the risk of both IPV victimization and perpetration.
Substance use disorders (SUDs), specifically alcohol use disorder (AUD) and opioid use disorder (OUD), are frequent comorbidities in this population. While the association between SUDs and IPV is well-recognized in general clinical settings, there is a significant research gap regarding the nuances of screening, disclosure, and the specific risk of lethality among veterans seeking care for addiction. Understanding these intersections is vital for developing integrated, evidence-based treatments that address the cyclical nature of trauma and substance misuse.
Key Content
Screening Efficacy and Disclosure Rates
A landmark cohort study by Mandavia et al. (2026), analyzing electronic health records of 790,384 veterans, revealed that while IPV is a known risk factor in SUD populations, only 22.36% of veterans with AUD or OUD were actually screened for IPV within the Veterans Health Administration (VHA). Of those screened, 12.24% disclosed IPV.
Research indicates that female veterans are more likely than their male counterparts to be screened and to disclose IPV. However, the low overall screening rate suggests a critical missed opportunity for intervention. Furthermore, evidence from the first year of national IPV screening adoption showed that while 7.4% of patients reported IPV, only 0.1% received a referral to couple and family services within 90 days, highlighting a significant “screening-to-referral” gap (PMID: 40839446).
The Synergistic Effect of Co-occurring SUDs
The type of substance use disorder significantly influences IPV risk. Mandavia et al. (2026) found that veterans with co-occurring AUD and OUD were significantly more likely to screen positive for IPV compared to those with either disorder alone. This suggests a synergistic effect where poly-substance use may reflect greater underlying psychological distress or environmental instability, increasing vulnerability to interpersonal conflict.
Data from the National Health and Resilience in Veterans Study (PMID: 41106619) corroborated these findings, showing that lifetime physical IPV perpetration was strongly associated with current AUD, nicotine dependence, and a history of military sexual trauma. These findings underscore that SUDs often serve as markers for complex trauma profiles that manifest as violence within intimate relationships.
Gender-Specific Risks and Lethality
One of the most concerning findings in recent literature is the high risk of lethality among female veterans. Mandavia et al. (2026) demonstrated that female veterans, especially those with co-occurring AUD and OUD, were more likely to report “high-lethality” indicators. These indicators include violence escalation, strangulation (a primary predictor of future homicide), and the victim’s belief that they might be killed.
In contrast, male veterans with AUD only were less likely to report these high-lethality markers compared to females in the same diagnostic category. This disparity emphasizes the need for sex-disaggregated risk assessments in clinical practice. For women veterans, the presence of SUD may not only be a consequence of IPV-related trauma but also a barrier to escaping high-danger situations.
Psychiatric and Neurobiological Correlates
Advancements in neuroimaging have begun to identify structural brain correlates of IPV. A 2024 study (PMID: 38882690) investigated male veterans and found that IPV perpetration was associated with microstructural abnormalities in the right amygdala-hippocampus complex (higher fractional anisotropy). This suggests that alterations in the limbic system—often driven by PTSD, depression, or TBI—may impair emotional regulation and increase the propensity for aggressive outbursts.
Additionally, insomnia has emerged as a meaningful predictor of violence. Among veterans in substance use treatment, sleep disturbances were found to moderate the relationship between cocaine use and non-partner aggression, while also predicting physical injury to partners (PMID: 34022495). This points to the necessity of addressing basic physiological regulation as part of violence prevention strategies.
Social Determinants: Housing and Food Insecurity
IPV does not occur in a vacuum; it is influenced by social determinants of health. Research shows that a positive IPV screen increases the odds of housing instability by a factor of three among women veterans (PMID: 29433952). Risk factors for housing instability in this group include being African American, having an SUD, or a history of MST.
Furthermore, vulnerable subpopulations such as LGBQ+ veterans face even higher burdens. LGBQ+ veterans are 2.5 times more likely to experience food insecurity than heterosexual veterans, with IPV being a significant contributing risk factor (PMID: 39495510). These findings necessitate a holistic approach to care that integrates psychosocial support with clinical treatment.
Evidence-Based Interventions: Strength at Home
Addressing IPV within the VHA requires effective intervention models. The “Strength at Home” (SAH) program, a 12-week trauma-informed cognitive-behavioral group intervention, has shown significant promise. A large-scale quality improvement study (PMID: 36917105) involving 1,754 veterans demonstrated that SAH was associated with significant reductions in the use of physical and psychological IPV, as well as improvements in PTSD symptoms and alcohol misuse. This suggests that trauma-informed care can simultaneously address both the behavioral health needs and the relational safety of veterans.
Expert Commentary
The current evidence base reveals a complex, multi-directional relationship between SUD, trauma, and IPV. The high prevalence of high-lethality IPV among female veterans with dual AUD/OUD is a clinical red flag that requires immediate attention. From a mechanistic perspective, the overlap of SUD and PTSD creates a state of chronic hyperarousal and impaired executive function, which may be mediated by limbic system alterations.
Clinicians should view SUD not just as a primary diagnosis but as a potential indicator of ongoing or past interpersonal trauma. The USPSTF’s recent hesitation to recommend routine screening for older women is challenged by VHA data showing that IPV remains prevalent and morbidity-associated well into middle and older age (PMID: 32315066). The primary clinical controversy remains the lack of integrated care; too often, SUD and IPV are treated in silos, leading to fragmented care and poor follow-through on referrals.
Conclusion
Significant progress has been made in identifying the risk factors and neurobiological markers of IPV among veterans with substance use disorders. However, systematic screening remains underutilized, particularly for male veterans and older populations. The association between co-occurring AUD/OUD and high-lethality IPV suggests that these patients require intensified safety planning and integrated trauma-informed care. Future research should focus on optimizing the transition from screening to specialized referral and evaluating the long-term impact of programs like Strength at Home on preventing domestic lethality. Integrated care models that address addiction, mental health, and relationship safety concurrently are no longer optional—they are a clinical necessity.
References
- Mandavia AD, et al. Differences in Intimate Partner Violence Screening, Violence Exposure, and Risk of Lethality Among Veterans with Substance Use Disorders. J Gen Intern Med. 2026. PMID: 42082854.
- Creech SK, et al. Intimate partner violence in United States military veterans: Results from the National Health and Resilience in Veterans Study. J Affect Disord. 2026. PMID: 41106619.
- Portnoy GA, et al. Maintaining relationship safety while promoting relationship health: Family service referrals among veterans screened for intimate partner violence. Psychol Serv. 2025. PMID: 40839446.
- Taft CT, et al. Evaluation of the Strength at Home Group Intervention for Intimate Partner Violence in the Veterans Affairs Health System. JAMA Netw Open. 2023. PMID: 36917105.
- Iverson KM, et al. Association of Health Conditions and Health Service Utilization With Intimate Partner Violence Identified via Routine Screening Among Middle-Aged and Older Women. JAMA Netw Open. 2020. PMID: 32315066.
- Zou S, et al. Intimate partner violence perpetration among veterans: associations with neuropsychiatric symptoms and limbic microstructure. Front Neurol. 2024. PMID: 38882690.
