August 25, 2008 – Strain of duty surfaces
Military officials say there is no way to track how much pain and behavioral medication is being consumed by soldiers at war in Iraq and Afghanistan, in part because soldiers and military doctors often bring medication from home when they’re sent overseas.
Annual surveys by a military mental- health advisory team, however, have asked soldiers whether they have taken medicine for mental health, combat stress or sleep problems. The number who said yes jumped from 8 percent in 2004 to 14 percent in 2005, then dipped to 12 percent in 2006. Last year, one in eight soldiers surveyed in Iraq and one in seven in Afghanistan said they had taken sleeping pills or antidepressants.
If those surveys are accurate, nearly 20,000 soldiers in Iraq and Afghanistan took mental-health or sleep medication last year. According to Ritchie, about half of those soldiers took antidepressants.
By comparison, roughly one in 20 American men and one in 10 American women reported taking an antidepressant in the most recent survey by the Centers for Disease Control and Prevention.
For three straight years, the mental- health advisory team has reported that multiple deployments are affecting the Army’s mental health. This year it reported that 27 percent of noncommissioned officers with three or more deployments had mental-health problems, compared with 12 percent on their first tour.
Alcohol use increased with second deployments, and soldiers deploying for the third or fourth time were “significantly more likely” to report they had stress or emotional problems that worried their supervisors and limited their ability to do their jobs.
The mental-health surveys do not ask how many soldiers go to war with physical pain or are regularly taking narcotics.
A prescription overload?
Some soldiers deployed from Fort Carson in December with injuries or recent surgeries took pain and anxiety medicines as well — Imitrex, morphine, Demerol, Klonopin.
Waltz’s medication profile shows he was taking a prescription painkiller — the generic equivalent of Percocet — during his second combat tour in Iraq.
When he came back to Fort Carson in November 2006, “he was really sick,” his widow, Renea, said.
She said he was diagnosed with PTSD and a TBI, and after 10 years of marching with heavy gear, “he had degenerative disc disease, so they were giving him pain medication for that.”
In his last month of treatment, he filled 10 different prescriptions from the Army for narcotic painkillers and other drugs. He was given Topamax, the antidepressant Effexor, and generic versions of Vicodin, Percocet and Dilaudid.
Finally, on Friday, April 27, 2007, “he was prescribed methadone and rapid-release morphine,” his wife said, and “he wasn’t monitored” during the weekend.
Her husband acted odd that weekend, and she asked whether he wanted to go to an emergency room. He didn’t want to. Sunday night, she went downstairs to watch a movie with her husband and found him already sleeping on a couch. At 4 a.m. one of their children got up and heard him snoring there. When she awoke at 7:30, he was dead.
The coroner’s report cited the mixture of methadone and morphine as the cause of death but did not list all the medication Waltz had been taking. It did note that five others were detected in his urine.
Robert Valuck, an associate professor of clinical pharmacy at the University of Colorado Denver, reviewed Waltz’s autopsy and medication list for The Post.
He said the pattern of prescriptions was “not reckless” but a “stepped, phased progressive treatment” that tried nearly every nonsteroidal pain medicine on the market.
Valuck also said it would be difficult to prove whether morphine and methadone alone, or those drugs in combination with other painkillers, caused a fatal reaction.
“Those are the last two on board, and they’re the most powerful,” he said. Unfortunately, he said, deaths are “not unheard of with these medicines.”
Some soldiers say they are frustrated that the Army plies them with medicine but does not treat the underlying cause of the pain.
Robey Covel, 33, a soldier from the 2nd Brigade, 4th Infantry Division who was training to become a Green Beret, was prescribed 1,110 Percocets over the course of six months, medical records he provided show.
Covel said an Army physician’s assistant prescribed the painkillers for broken ribs, and knee, neck and back injuries. In August 2007, an initial MRI showed he had a bulging disc in his spine, yet it wasn’t until February that Covel saw a medical doctor for the injury. The doctor found that Covel’s condition had worsened. While taking Percocet, Covel worked as a safety officer on a range with live machine-gun fire.
“They tell you, ‘Don’t drive a motor vehicle,’ but you can go shoot a machine gun on Percocet,” Covel said.
Sgt. 1st Class Chuck Clamon also is frustrated by the number of drugs he has been prescribed since he was injured March 29 during his third tour in Iraq.
An improvised explosive device hit a truck filled with ammunition a few feet ahead of Clamon’s truck. When the ammunition blew, his head smacked into the windshield. His spine slammed into the radios behind him. His shoulder dislocated.
Now he is one of more than 16,000 people who have entered new Warrior Transition Units, where injured soldiers are transferred to recover. At 33, he walks with a cane and occasionally falls on the floor when his legs give out. Pounding headaches form behind his eyes. His short-term memory is gone. His hands shake uncontrollably.
“They think I’ve developed a seizure disorder in my left hand where it does what it wants to when it wants to, from my fingertips all the way up to my shoulder. It bounces all over the place,” he said.
He takes Seroquel and Ambien to sleep; Vicodin, Migranal, Naproxen and Neurontin for pain; plus an antidepressant and a muscle relaxer.
He said the Army’s drugs are helping — but haven’t gotten to the root of his medical issues.
His wife walks the dogs, mows the lawn, takes out the trash. “I feel helpless,” he said. “I don’t feel like an active person. I could care less about actually leaving the house now.”
Soldier goes “over the edge”
Other families are asking whether the cocktails of medication prescribed for combat stress, head injuries and body pains are lethal.
Chad Oligschlaeger “was completely different” when he returned from his first tour in Ramadi, Iraq, in 2006, his mother, Julie, said. He was 19, but “he looked older. He was drinking. At night he told me horrific stories. Then he’d go to bed, and I’d just sit there and cry.”
On a rescue mission, the young Marine had seen his mentor, “Fitz” — 2nd Lt. Almar Fitzgerald — fatally wounded by a roadside bomb. “I think that was the catalyst that threw Chad over the edge. Body parts of friends, the women and the kids he killed, that got him,” his mother said.
In March 2007, Oligschlaeger told a substance-abuse counselor he was drinking a liter of whiskey in two to three hours every day. His mother said he also divulged his mental-health problems to a sergeant, who accused him of faking illness to avoid his next tour.
Oligschlaeger was sent back to Ramadi the next month. When he left Iraq in November, the nightmares and hallucinations were getting worse. Sometimes he would awaken and see Fitz sitting beside him.
He entered a substance-abuse program in April, then was referred to a PTSD-treatment facility. But it had a waiting list, and “they kept pushing the date out,” his mother said.
In the meantime, he was ordered back to the Twentynine Palms base in the Southern California desert. He was given an assortment of medication: a sleeping pill, a sedative, an antidepressant and Seroquel. He also began taking Chantix, an anti-smoking drug the Federal Aviation Administration recently forbade pilots to use because it had been linked to seizures, loss of consciousness and other serious side effects.
Oligschlaeger’s roommate had moved off base, so he was alone. When he returned home for a visit on Mother’s Day, May 11, his family noticed he seemed confused about how many pills he was taking and when he had taken them.
Back at the base, he made his last phone call at 12:48 a.m. May 17. Two days later, his fiancee, Adrianna Avena, called to tell him her wedding dress had arrived, but she got his voice mail. She called the next day and again got his voice mail. Finally, at 5:30 p.m. May 20, after frantic calls and text messages from Chad’s fiancee and others, two Marines went to check his room. They found him alone — and dead — on the floor.
His mother suspects her son accidentally took too many pills. She also found a receipt for a six-pack of beer he had bought on the base.
“I believe he had been lying there for three days,” she said. “The barracks are supposed to be checked daily.”
Three months later, she is waiting for a formal report on her son’s death.
Pill combinations can be fatal
In West Virginia, 23-year-old Andrew White, a Marine reservist, died suddenly this year while taking the antidepressant Paxil along with Klonopin, an anti-anxiety medicine, and massive doses of Seroquel.
His father, Stan, said Andrew’s mental health deteriorated after his brother was killed in Afghanistan, and the Marines subsequently told him he would be going for a second round of combat in Iraq.
“He started having nightmares. Everything went downhill from there,” Stan White said.
Seroquel, an antipsychotic drug, is dispensed in doses as small as 25 milligrams for anxiety and insomnia. A doctor with the Department of Veterans Affairs and then a private psychiatrist both prescribed much larger doses to Andrew White — up to 1,600 milligrams a day. When his mother came home from work Feb. 12 and found her son unresponsive, he was also taking Paxil and Klonopin.
Stan White said the state medical examiner ruled that his son’s death was accidental due to intoxication from Paxil and Seroquel.
Ritchie said she did not want to comment on an individual case.
But in general, 1,600 milligrams of Seroquel would be “an enormous dose,” she said. “The normal maximum dose would be about 800 milligrams a day.”
She said the Army maintains an electronic medical record that can “put up red flags” when a soldier is taking a combination of drugs that can have dangerous side effects.
But that safeguard gets complicated by the reality that soldiers sometimes seek to avoid the stigma of taking behavioral medication by getting them from civilian doctors. And the Army counts on its soldiers to take medicines as prescribed.
“The soldier is an adult,” Ritchie said. “We don’t want to be Big Brothers.”
Andrew White was one of four young veterans in West Virginia who died this year while taking similar combinations of medicine for PTSD.
Eric Layne was another. “He was taking a lot of medicines,” his wife, Janette, said. “Paxil and Seroquel. He had been taking Klonopin. He was taking pain medicines. You should not die from taking pain medicine with PTSD.”
His symptoms had worsened gradually after he came home from Iraq in 2005. As a young West Virginia National Guardsman, “he was physically fit. He had a clear head. He was calm. He was easygoing. He was funny. Everyone wanted to be around him,” his wife said. Postwar, he had grown angry and withdrawn even from his best friends. “It got to the point where he wouldn’t even pick up the phone when they called.”
Finally he began going to a VA hospital for intensive PTSD treatment. The medication and camaraderie with other veterans helped him mentally, “but physically he was deteriorating,” his wife said. “Everything from slurred speech to excessive weight gain, inability to urinate. He would shake, developed tremors in his hands. Every weekend he came home, it was something more noticeable.”
In January, 29-year-old Layne came home from the hospital for the last time. He died in his sleep that night.
His wife said the death certificate listed a combination of four drugs as the cause: paroxetine (generic Paxil), morphine, Seroquel and the painkiller Tramadol.
VA, Army investigate deaths
This month, the VA’s inspector general issued a report on the deaths of White and Layne, referring to them as Patient A and Patient B. It said both had taken medication besides those prescribed to them, reflecting “a tendency of young, returning veterans to self-medicate using nonprescribed prescription medication obtained from friends, family members and co-workers.”
The report found “no apparent signal to indicate increased mortality” among other patients taking the generic equivalents of Seroquel, Paxil and Klonopin, and noted the daily Seroquel dose for Patient A (White) had been reduced before he died.
Stan White said he believed his son’s doctors advised he could take extra Seroquel if he “was having a bad day and it’s not working.”
The inspector general’s report did question why a residential PTSD program in West Virginia had refused to accept White and other veterans who were prescribed the class of drugs that includes Klonopin. It recommended re-examining that policy.
In the Army, Ritchie said all soldier deaths are reviewed by the armed forces medical examiner, and her office also watches for any emerging patterns of problems associated with medicine use.
“There is no question that overdoses of the combination of multiple medications, often combined with narcotics, alcohol or illegal drugs, can result in death,” she said. “Some of the deaths have been ruled suicides and others accidental overdoses. We are not aware of deaths that have occurred when soldiers were taking their medicines as prescribed.”
Renea Waltz disagrees.
After her husband’s first combat tour, he told a sergeant he felt sick and was having nightmares, and he was advised to “just keep it under wraps,” she said. “I felt like they treated him like he was a malingerer, that there was nothing wrong with him, that he was just a pain in their ass, to be honest with you.”
After his second combat tour, he took the drugs prescribed to him, she said, and he died.
The Army is “100 percent” responsible for his death, she said.
“He’d still be alive had they not given him that crap, and he would have been medically retired, and he probably would have lived a comfortable life,” she said. “It really upsets me that nothing’s been done about it.”