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.
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