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Tuesday, March 1, 2011

Veterans and Prescription Drugs

On November 26, 2007, Veterans for Common Sense appeared on ABC News with Brian Ross highlighting the military drug abuse crisis: 
Veterans' advocacy groups charge that the problem of substance abuse is much greater than the Army wants to publicly acknowledge, and it's growing.  "I've met with veterans from coast to coast, and I will tell you that there is a catastrophe on the horizon," said Paul Sullivan, director of Veterans for Common Sense.
Three thousand fifty-seven veterans of the Iraq and Afghanistan wars were potentially diagnosed with a drug dependency from fiscal year 2005 through March 2007, according to figures provided to ABC News from the Veterans Health Administration. From 2002 through 2004, only a total of 277 veterans were diagnosed with drug dependency, the numbers show.  "The military right now can say whatever they want, but the truth on the ground is that the soldiers are in a lot of pain, emotional and physical pain, and they're turning to drugs in order to alleviate that," said Sullivan.

By estimates such as these, more than 300,000 troops have returned from Iraq or Afghanistan with PTSD, depression, traumatic brain injury or some combination of those. The Pentagon has looked to pharmacology to treat those complex problems. As a result, psychiatric drugs have been used more widely across the military than during any other war.

James Dao of The New York Times reports that those medications, along with narcotic painkillers, increasingly are being linked to a rising tide of other problems, among them drug dependency, suicide and fatal accidents. An Army report on suicide released last year documented the problem, saying one-third of the force was on at least one prescription medication.

“Prescription-drug use is on the rise,” the report said, noting that medications were involved in one-third of the record 162 suicides by active-duty soldiers in 2009. An additional 101 soldiers died accidentally from the toxic mixing of prescription drugs from 2006 to 2009. (James Dao, "Drugs Used To Treat War Veterans Pain, Depression Can Turn Deadly," The New York Times reported in Columbus Dispatch, February 13 2011)

The New York Times reviewed the cases of service members who died from what coroners said were toxic interactions of prescription drugs. All were classified as accidents, not suicides. Given the complexity of drug interactions, it’s difficult to know what killed the men, and the Pentagon declined to discuss their cases, citing confidentiality.

But there were important similarities in their stories:

1. All the men had been deployed multiple times and eventually received diagnoses of PTSD. 

2. All had five or more medications in their systems when they died, including opiate painkillers and mood-altering psychiatric drugs, but not alcohol. 

3. All had switched drugs repeatedly, hoping for better results that never arrived.
All died in their sleep.


Across all branches, spending on psychiatric drugs has more than doubled since 2001, to $280 million in 2010, according to statistics obtained from the Defense Logistics Agency by a Cornell University psychiatrist, Richard A. Friedman. A decade ago, the military came under criticism for not prescribing enough medication, particularly for pain.

Deadly Combinations

Thousands of troops struggle with insomnia, anxiety and chronic pain, and that combination is particularly risky to treat with medications. Pairing a pain medication such as oxycodone, a narcotic, with an anti-anxiety drug such as Xanax, a so-called benzodiazepine, amplifies the tranquilizing effects of both, doctors say.
Similarly, antidepressants such as Prozac or Celexa block liver enzymes that help break down narcotics and anxiety drugs, extending their effects.


Here are some alarming statistics from the National Association of Drug Court Professionals, the Substance Abuse and Mental Health Services Administration, the U.S. Department of Defense, the U.S. Department of Justice Bureau of Justice Statistics, and the U.S. Department of Veterans Affairs:

* 1 in 4 Veterans ages 18-25 met the criteria for substance abuse disorder in 2006.

* 1.8 million Veterans of any age met the criteria for having a substance abuse disorder in 2006.

* There are 140,000 U.S. Veterans in prison, and 60% of those have a substance abuse problem.

* There are 130,000 homeless U.S. Veterans, and 75% of them suffer from substance abuse problems

Surveys show that more soldiers are struggling with prescription drug addiction — and seeking help from Army doctors and counselors. Dr. Les McFarling, who heads the Army’s substance abuse treatment program, acknowledges the increased potential for abuse. "You can put soldiers at risk when you’re managing their pain," he said.

But Barbara McDonald, a civilian social worker and Army drug abuse counselor, and other critics call the military’s approach a broken system, as likely to punish or denigrate troops as to treat their addictions. (Alan Scher Zagier, "Army's Drug Abuse Policy Under Fire,", January 22 2009)

McDonald, whose son is a soldier, spent 20 years as a civilian substance abuse counselor before joining the Army’s fight against drug and alcohol abuse one year ago. She has filed a workplace complaint against her supervisor and faces disciplinary action she says stems from her criticisms. Army officials have not commented.

McDonald claims that some Army doctors and counselors point to drug dependency as a sign of weakness. Since McDonald’s complaints surfaced, she is no longer allowed to see patients.

Areas of Immediate Concern

Rather than the heroin addictions many Vietnam veterans brought back with them from Southeast Asia, today's returning soldiers are more likely to be addicted to prescription medications -- the very opiates prescribed to them by the military to ease stress or pain -- or stimulants used by soldiers to remain alert in combat situations.

One of the contributing factors to the rise in veteran prescription drug dependency could be the ease with which these drugs can be obtained in the military.  Military doctors wrote almost 4 million prescriptions for pain medication in 2009, compared to less than 1 million in 2001. ("Drug Dependency Rising Among Young Veterans,", December 10 2010)

Here are some problems that beg for immediate attention: 

1. Soldiers used opiates before they went to war while a lot of them report opiates are freely available in combat areas. ( John A. Renner Jr., M.D., associate professor of psychiatry at the Boston University School of Medicine and associate chief of psychiatry at the U.S. Department of Veterans Affairs (VA) Boston Healthcare System)

2. Soldiers in Iraq and Afghainistan often have served multiple tours in combat areas, with extended periods of time away from family and home. (Panelists at National Center for Addiction and Substance Abuse Conference, 2009)

3. Returning veterans, although screened for addiction and mental-health problems, are reluctant to admit to problems out of fear that disclosure will affect their careers inside and outside the military. (Brigadier General Loree K. Sutton, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, part of the Defense Department's Military Health Systems)

4. Women have reported high rates of sexual abuse and rape while in combat areas, but are often reluctant to report incidents to male superiors. (Alexander Neumeister, M.D., associate professor of psychiatry at Yale University and the VA Connecticut Healthcare System)

5. Many veterans feel better about coming to an office in a strip mall or a private-practice office than to a VA hospital. The prospect of going to the VA -- which is "full of men in uniform" -- is particularly difficult for female veterans who have been sexually abused. (Monica L. Martocci, clinical director of New Directions Inc., Los Angeles, a drug and alcohol treatment and co-occurring disorders program serving homeless veterans)

6. Bureaucracy prevents soldiers from getting services. (Jim McDonough, a retired U.S. Army officer and former strategy director at the White House Office of National Drug Control Policy)

7. Neither soldiers nor their family members have the knowledge to deal with addiction once they return home, and the young vets only take what their doctors tell them to take.(Conference sponsored by the National Center for Addiction and Substance Abuse)

Looking Forward
Military personnel face shortages of therapists, psychologists and psychiatrists. But, medications always have been readily available. In general, the country lacks sufficient government treatment programs. Many young veterans with drug abuse problems are not referred to the treatment programs available. The Department of Defense and other government agencies have begun research into drug abuse among veterans, but the emphasis of this research is often on prevention rather than on treatment. In the meantime, many veterans will continue to suffer from prescription drug addiction and its devastating effects.

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