Prescription pill dependency among American troops is on the rise
By Melody Petersen
May 19, 2009
Marine Corporal Michael Cataldi woke as he heard the truck rumble past.
He opened his eyes, but saw nothing. It was the middle of the night, and he was
facedown in the sands of western Iraq. His loaded M16 was pinned beneath him.
Cataldi had no idea how he'd gotten to where he now lay, some 200 meters from
the dilapidated building where his buddies slept. But he suspected what had
caused this nightmare: His Klonopin prescription had run out.
His ordeal was not all that remarkable for a person on that anti-anxiety
medication. In the lengthy labeling that accompanies each prescription, Klonopin
users are warned against abruptly stopping the medicine, since doing so can
cause psychosis, hallucinations, and other symptoms. What makes Cataldi's story
extraordinary is that he was a U. S. Marine at war, and that the drug's adverse
effects endangered lives — his own, his fellow Marines', and the lives of any
civilians unfortunate enough to cross his path.
"It put everyone within rifle distance at risk," he says.
In deploying an all-volunteer army to fight two ongoing wars, in Iraq and
Afghanistan, the Pentagon has increasingly relied on prescription drugs to keep
its warriors on the front lines. In recent years, the number of military
prescriptions for antidepressants, sleeping pills, and painkillers has risen as
soldiers come home with battered bodies and troubled minds. And many of those
service members are then sent back to war theaters in distant lands with bottles
of medication to fortify them.
According to data from a U. S. Army mental-health survey released last year,
about 12 percent of soldiers in Iraq and 15 percent of those in Afghanistan
reported taking antidepressants, anti-anxiety medications, or sleeping pills.
Prescriptions for painkillers have also skyrocketed. Data from the Department of
Defense last fall showed that as of September 2007, prescriptions for narcotics
for active-duty troops had risen to almost 50,000 a month, compared with about
33,000 a month in October 2003, not long after the Iraq war began.
In other words, thousands of American fighters armed with the latest killing
technology are taking prescription drugs that the Federal Aviation
Administration considers too dangerous for commercial pilots.
Military officials say
they believe many medications can be safely used on the battlefield. They say
they have policies to ensure that drugs they consider inappropriate for soldiers
on the front lines are rarely used. And they say they are not using the drugs in
order to send unstable warriors back to war.
Yet the experience of soldiers and Marines like Cataldi show the dangers of
drugging our warriors. It also worries some physicians and veterans' advocates.
"There are risks in putting people back to battle with medicines in their
bodies," says psychiatrist Judith Broder, M. D., founder of the Soldiers
Project, a group that helps service members suffering from mental illness.
Prescription drugs can
help patients, Dr. Broder says, but they can also cause drowsiness and impair
judgment. Those side effects can be dealt with by patients who are at home, she
says, but they can put active-duty soldiers in great danger. She worries that
some soldiers are being medicated and then sent back to fight before they're
ready.
"The military is under great pressure to have enough people ready for combat,"
she says. "I don't think they're as cautious as they would be if they weren't
under this kind of pressure."
Brought more than memories back
When Cataldi talks about what happened to him in Iraq, he begins with an in
incident that took place on a cold January night in 2005, when he and five other
Marines received a radio call informing them that a helicopter had disappeared.
The men roared across the desert of western Iraq and found what was left of the
chopper. Flames roared from the pile of metal. Cataldi, 20, was ordered to do a
body count.
The pilot's body was still on fire, so he shoveled dirt on it to douse the acrid
flames. He picked up a man's left boot in order to find the dog tag every Marine
keeps there. A foot fell to the ground. "People were missing heads," Cataldi
remembers. "They were wearing the same uniform I was wearing."
The final death toll from that crash of a CH-53E Super Stallion was 30 Marines
and one sailor.
For days, Cataldi couldn't escape the odor of burning flesh. "I had the smell
all over my equipment," he says. "I couldn't get it off ."
When he returned to his stateside base at Twentynine Palms, California, he knew
he'd brought more than memories back from Iraq. He would cry for no reason. He
flew into fits of rage. One night he woke up with his hands around the throat of
his wife, Monica, choking her.
"It scared the crap out of me," he says.
He went to see a psychiatrist on base. "He said, 'Here's some medication,' "
Cataldi recalls. The prescribed drugs were Klonopin, for anxiety; Zoloft, for
depression; and Ambien, to help him sleep.
Later, other military doctors added narcotic painkillers for the excruciating
pain in his leg, which he'd injured during a training exercise. He was also
self-medicating with heavy doses of alcohol.
Those prescriptions didn't stop the Marine Corps from sending Cataldi back to
Iraq. In 2006, he returned to the same part of the Iraqi desert to do the same
job: performing maintenance on armored personnel carriers known as LAVs. He also
took his turn driving the 14-ton tanklike vehicles, one of which was armed with
a 25 mm cannon and two machine guns and loaded with more than 1,000 rounds of
ammunition.
Marine Major Carl B. Redding says he can't talk about the medical history of any
Marine because of privacy laws. He says the Corps has procedures to ensure that
service members taking medications for psychiatric conditions are deployed only
if their symptoms are in remission. Those Marines, he says, must be able to meet
the demands of a mission.
But it's difficult to square those regulations with Cataldi's experience. His
medications came with written warnings about the dangers of driving and
operating heavy machinery. The labels don't lie.
One night, Cataldi took his pills after his commander told him he was done for
the day. Five minutes later, however, plans changed, and he was told to drive
the LAV. He asked the Marine sitting behind him to help keep him awake. "I said,
'Kick the back of my seat every 5 minutes,' and that's what he did."
Cataldi says he managed
on the medications — until his Klonopin ran out. The medical officer told him
there was no Klonopin anywhere in Iraq. So the officer gave him a drug called
Seroquel. That's when Cataldi says he started to become "loopy."
"I'd go to pick up a wrench and come back with a hammer," he says. "I wasn't
able to do my job. I wasn't able to fight."
Soldiers on medication
Soldiers have doped up in order to sustain combat since ancient times. Often
their chosen drug was alcohol. And Iraq isn't the first place U. S. military
doctors have prescribed medications to troops on the front. During the Vietnam
war, military psychiatrists spoke enthusiastically about some newly psychiatric
medicines, including Thorazine, an anti-psychotic, and Valium, for anxiety.
According to an army textbook, doctors frequently prescribed those drugs to
soldiers with psychiatric symptoms. Anxiety-ridden soldiers with upset bowels
were sometimes given the antidiarrheal Compazine, a potent tranquilizer.
But the use of those drugs in Vietnam became controversial. Critics said it was
dangerous to give soldiers medications that slowed their reflexes, a side effect
that could raise their risk of being injured, captured, or killed. That risk was
real. In a report supported by the U. S. Navy 14 years after the United States
withdrew from Vietnam, researchers looked at the records of all Marines wounded
there between 1965 and 1972. Marines who'd been hospitalized for psychiatric
reasons before being sent back to battle were more likely to have been injured
in combat than those who hadn't been hospitalized.
Critics of medication use in Vietnam also said that a soldier traumatized by
battle may not be coherent enough to give his consent to take the drugs in the
first place. Plus, a soldier would risk court-martial if he refused to follow
orders, they said, making it unlikely he could make a reasoned decision about
taking the medications.
After the war, the practice of liberally giving psychiatric drugs to warriors
fell out of favor. In War Psychiatry, a 1995 military medical textbook, a U. S.
Air Force flight surgeon warned about the use of psychiatric drugs, saying they
should be used sparingly.
"Sending a person back to combat duty still under the influence of psychoactive
drugs may be dangerous," he wrote. "Even in peacetime, people in the many
combat-support positions... would not be allowed to take such medications and
continue to work in their sensitive, demanding jobs."
Colonel Elspeth Cameron Ritchie, M. D., M. P. H., a psychiatrist and the medical
director of the strategic communication directorate in the Office of the Army
Surgeon General, acknowledges that writing more prescriptions for frontline
troops was a change in direction for the Pentagon. "Twenty years ago," she says,
"we weren't deploying soldiers on medications."
Today it's not uncommon
for a soldier to arrive in Iraq while taking a host of prescription drugs. The
Pentagon explained its new practice in late 2006, stating that there are "few
medications that are inherently disqualifying for deployment."
According to Colonel Ritchie, military officials have concluded that many
medicines introduced since the Vietnam War can be used safely on the front
lines. Military physicians consider antidepressants and sleeping pills to be
especially helpful, she says. Doctors have also found that small doses of
Seroquel, an anti-psychotic, can help treat nightmares, she says, even though
the drug is not approved for that use.
Two months after the new
drug policy was issued, President Bush ordered more than 20,000 additional
troops to Iraq in an attempt to quell the violence. This surge in American
military presence in Iraq increased the pressure on Pentagon officials to
quickly redeploy soldiers and Marines just back from war.
Surveys of behavioral-health professionals offer hints about what has happened
as soldiers are medicated and then sent back to fight. In last year's surveys,
carried out by teams sent to Iraq and Afghanistan by the Army Surgeon General, a
staff member reported that there had been "quite a few [evacuations for]
psychotic breakdowns."
"Many of these soldiers are sent to Afghanistan," the staff member said,
"despite a doctor saying they shouldn't go or leaders knowing they shouldn't
deploy."
To meet its needs, the army has also begun accepting more people with existing
medical or psychiatric conditions. A recent study by U. S. Army medical staff
found that 10 percent of new recruits reported a history of psychiatric
treatment.
In an article in the journal Military Medicine, Jeffrey Hill, M. D., and his
colleagues wrote about soldiers who had made suicidal or homicidal threats at a
base in Tikrit, Iraq. Of 425 soldiers evaluated for psychiatric treatment, they
reported, about 30 percent had considered killing themselves in the previous
week, and 16 percent had thought about killing a superior or someone else who
was not the enemy.
Each of these soldiers poses a dilemma for physicians, they wrote, because of
his or her duty "to conserve the fighting strength" — the motto of the U. S.
Army Medical Department. Doctors must try to avoid sending these soldiers home,
but they must also recognize the dangers of keeping them in Iraq, where weapons
are everywhere.
‘He was a good kid’
When Travis Virgadamo arrived from his army unit in Iraq for a visit with
his family in July 2007, he hesitated to tell his grandmother, Katie O'Brien,
what he had seen. "'I've seen little children killed,'" she remembers him
saying. "'You can't imagine what it's like, Grandma. You just can't.'"
Virgadamo, shy and quiet as a boy, had grown up wanting to be a soldier. "It was
his dream," O'Brien says. "He was a good kid. He would do anything for you."
Soon after entering the army, however, Virgadamo began to have problems. In boot
camp he became angry and suicidal, prompting an army doctor to write him a
prescription for Prozac, his grandmother says. Not long after that, he was sent
to Iraq. One day as men in his unit were cleaning weapons, the commander sent
Virgadamo for some gun oil, O'Brien says. When he didn't return, they went to
look for him. They found him with a gun in his mouth.
Virgadamo was sent home to Pahrump, Nevada, to be with his family for 10 days.
Then he would be returned to Iraq. O'Brien learned that he was sent to a class
meant to help him, and that he had been given a new medication instead of
Prozac. The day he supposedly completed his class, O'Brien says, his commander
gave him his gun back.
That night he used it to kill himself.
"They all knew he was in a very serious situation," O'Brien says. "He was a
danger to the other soldiers as well as to himself."
She is furious that the army gave him Prozac. She points out that the labeling
of Prozac, Zoloft, and similar antidepressants state that the drugs have been
shown to increase suicidal behavior in people age 24 and younger — a group that
includes large numbers of American soldiers.
Virgadamo was 19 when he died.
"It was so unnecessary," she says. "We can't bring him back."
The U. S. Army's suicide rate is now at an all-time high. Colonel Ritchie says
officials are studying the reasons for the increase, including the possible role
of medications. Soldiers taking antidepressants have killed themselves, she
says, but so far there is no evidence that the risk is higher for those taking
the drugs.
Instead, the army has found, soldiers who committed suicide often had personal
problems, such as troubled marriages or financial difficulties. Repeated
deployments can strain family relationships. "The army has been at war for a
long time," Colonel Ritchie says, "and everyone is kind of tired."
‘No condition to leave’
At age 26, with a new wife and child, Michael R. De Vlieger never seemed to have
enough money. He had resorted to selling his blood plasma for extra cash when he
noticed the recruiting station next door to the donation center. That was in
November 2004. Fifteen months later he was on the ground in northern Iraq, a
gunner with the 101st Airborne.
Not long after he landed in Iraq, roadside bombs blew apart two Humvees from his
platoon, killing nine soldiers, including men he knew well.
The next month, as he manned a Humvee on patrol passing through a crowded
market, grenade-throwing insurgents jumped from behind the fruit stands. One
antitank grenade landed under the vehicle. The blast didn't pierce its metal,
but the force drove De Vlieger's knee through the door.
He was later evacuated by helicopter and returned to Fort Campbell, in Kentucky,
to recuperate. But his personality had changed. He began to drink heavily, and
flew into rages. One day, he attacked his wife's dog.
"I had lost so many friends and went through a near-death experience," he says.
"I wasn't who I was when I left."
He was updating his will and preparing to return to Iraq when he broke down. His
wife, Christine, found him awake in the middle of the night, rocking while
babbling incoherently. Frightened, Christine called his squad leader, who took
him to the base emergency room. Doctors then sent him to a nearby private
psychiatric hospital, where he stayed for 16 days, receiving medications to calm
his panic and treat his blood pressure and depression. The doctors released him
with four prescriptions.
A noncommissioned officer
in charge of De Vlieger's unit's stateside operations told him that day that he
had to leave immediately for Iraq. Less than 18 hours after being released from
the hospital, De Vlieger was on a plane heading for the Middle East. "I was in
no condition to leave," he says. "I'm an infantryman. If I'm screwed up in my
head, it could cost my life or the lives of the men with me."
Pentagon policy requires that service members with psychiatric conditions be
stable for at least 3 months before they can be deployed. Colonel Ritchie says
she can't comment specifically on any soldier's medical history, but agrees that
sending someone to Iraq just hours after leaving a psychiatric hospital would
violate the policy.
DeVlieger says the medications altered his thinking — a side effect he didn't
want to deal with at war. He threw the pills away.
"I had a weapon, entire magazines filled with rounds. It's not like it would
have been difficult for me to commit suicide," he says. "I don't believe it was
safe."
Military physicians can
be swayed by the aggressive promotional efforts of the pharmaceutical industry
just like civilian doctors often are. The military has rules that limit the
handouts doctors can take from drug companies. A doctor can go to a dinner paid
for by a drug company, but the meal's value can't be more than $20, and the
value of all gifts received from a company over the course of a year can't
exceed $50.
The drug companies have devised ways of working around those limits.
When thousands of military and federal health-care professionals met in November
for the annual meeting of the Association of Military Surgeons of the United
States (AMSUS), more than 80 pharmaceutical companies and other health-care
firms were on hand. The companies helped pay for that San Antonio event in
exchange for the opportunity to set up booths in the convention hall, where
sales reps pressed doctors to prescribe their products or to use their medical
equipment and devices.
The 6-day meeting included a celebration; 15 military and federal doctors and
other health professionals received awards that included cash prizes provided by
various drug companies.
Colonel Steven Mirick, the association's deputy executive director, says the
companies didn't choose the recipients of the awards or influence the meeting's
agenda or the educational courses offered. He also said that AMSUS had followed
the strict government rules concerning the funding of those awards. Doctors
would have to pay a much higher registration fee, he says, if the companies were
not allowed to contribute.
Aggressive corporate promotion is one reason behind the army's fast-rising use
of narcotic painkillers. Manufacturers of narcotics like OxyContin and Actiq
have spent millions in recent years to convince doctors that the drugs aren't as
addictive or as dangerous as most people believe. Before such corporate
marketing campaigns, many doctors hesitated to prescribe narcotics unless a
patient was suffering from a serious, pain-inflicting condition — terminal
cancer, for instance. Drugmakers expanded the market by encouraging docs to
prescribe narcotics to people suffering from more moderate pain, and by
downplaying the drugs' addictive potential.
These same manufacturers fund organizations like the American Pain Society. The
society's noble goal of eliminating pain has made it the perfect conduit for
drug marketing.
Military doctors agreed with the American Pain Society that pain treatment
should be more accessible. In 1999, the Department of Defense and the Veterans
Health Administration began a campaign called "Pain as the Fifth Vital Sign," a
motto that had been created and trademarked by the society. Doctors treating
active-duty service members and vets were urged to test and treat pain just as
they would blood pressure and body temperature.
The Defense Department and the Department of Veterans Affairs also issued a
guideline in 2003 that directed doctors on how to prescribe narcotic painkillers
for chronic pain. Chronic pain can be related to conditions ranging from
arthritis to the phantom-limb pain experienced by amputees. "Repeated exposure
to opioids in the context of pain treatment only rarely causes addiction," the
guideline noted.
That statement is controversial. In a study at Brigham and Women's Hospital, in
Boston, 22 percent of patients taking narcotics for long-term treatment showed
signs of abusing the drugs. The army has plenty of firsthand evidence of how
addictive the painkillers can be. At Fort Leonard Wood, in Missouri, officials
charged more than a dozen soldiers with illegally using and distributing
narcotics, including drugs they'd reported picking up at the base's pharmacy for
little or no cost. Many of the soldiers had suffered injuries in Iraq or in
training but had later begun abusing the painkillers reportedly prescribed by
army doctors.
One problem is that injured soldiers in pain are often also suffering from
posttraumatic stress disorder (PTSD), which makes them vulnerable to abusing
alcohol or drugs. A soldier taking a narcotic can start using it to escape more
than his pain.
Cataldi, who's now out of active duty, says that when he returned from his first
tour of Iraq, both he and a friend were taking painkillers for injuries. They
couldn't seem to get enough of the drugs, he says.
"We'd find pills on the floor," he says, "and just take them."
Narcotics can make patients dizzy and unable to function. Their labels warn
about performing "potentially hazardous tasks."
Staff Sergeant Jack Auble took Oxy-Contin, Percocet, and Vicodin for a serious
back injury as he worked in Camp Stryker, in Baghdad. Prior to that tour, he had
been in the process of being medically discharged from the army after 20 years
of service because of severe osteoporosis in his spine. Then he was sent to
Iraq.
Auble's job in Baghdad was to monitor a computer that
showed in real time what was happening on the battlefield. But the side effects
of the drugs made his job impossible, he says. He frequently lost track of what
people said to him and the positions of troops in the field. At times, he says,
he dozed off in his chair.
"I could not do the job," Auble says. "My judgment was clouded all the time."
After 3 months in Baghdad, Auble's pain worsened. The army evacuated him to a
hospital outside Iraq. At 44, he is now retired with a permanent disability, and
walks with a cane.
According to Colonel Ritchie, painkillers can help soldiers do their jobs by
reducing pain, which allows them to concentrate. "But these medications are
lethal in overdose and can't be used carelessly," she says, adding that if side
effects interfere with a soldier's ability to perform, he or she is moved to
another job or sent back to a home base.
"It doesn't do the soldier or the army any good," she says, "if he can't do his
mission."
The army is adding safeguards to reduce the chance that soldiers will become
addicted to painkillers, she notes. And the guideline informing doctors that the
drugs rarely cause addiction is being rewritten.
Cataldi now works as a mechanic in Riverside, in Southern California. He lives
with his wife, 2-year-old daughter, and 10-year-old stepson in an apartment at
the foot of a mountain. On his living-room wall hang framed photos of his
grandfather and uncles dressed in their USMC uniforms.
Doctors at the V. A. still aren't sure how to help Cataldi. His current
diagnoses include PTSD and traumatic brain injury that might have been caused by
several concussions he suffered in training and in Iraq. He also still feels
intense pain in his leg. He shows a visitor snapshots taken at the funerals of
some of his buddies. He goes to the kitchen, bringing back four bottles of
medications, including Klonopin, the drug he blames for creating a needless
ordeal in Iraq. He fears he'll be on Klonopin for the rest of his life. When he
tries to stop taking it, he spaces out and isolates himself.
"If I had never been put on medications and just had counseling, I'd be a lot
better off ," he says.
URL: http://www.msnbc.msn.com/id/30748260/