Health
3:29 pm
Fri July 11, 2014

Veterans Kick The Prescription Pill Habit, Against Doctors' Orders

Originally published on Sun July 13, 2014 3:28 am

For many people with post-traumatic stress disorder, sleeping can return you to the worst place you've ever been, at the worst possible moment.

"I always see his face," says Will, who did tours in Iraq and Afghanistan with the Army. "And in my dreams it's the same thing. ... I always walk over to him, and instead of this Afghani kid that's laying there, it's my little brother."

The memory that triggers Will's nightmare happened during his tour in Afghanistan. Will, 33, who asked that NPR not use his last name, was on patrol when a kid came up to the Humvee asking for water. Then he bashed Will's medic in the face with a rock. The boy's father appeared with a gun and started shooting. Amid a scuffle, the child picked up the gun and Will shot him at close range.

"After I did that, all I remember is that I was shaking," Will says. "And one of my soldiers took my weapon away and said: 'It's OK primo [cousin]. It's gonna be OK.' "

Troops coming home from war, like Will, are often prescribed drugs for PTSD and other conditions. Hundreds of thousands of veterans are on opiates for pain, and 1 in 3 veterans polled say they are on 10 different medications.

While there is concern about overmedicating and self-medicating — using alcohol or drugs without a doctor's approval — there are also some veterans who are trying to do the opposite: They're kicking the drugs, against doctor's orders.

Long Lists Of Drugs

Will has other upsetting stories. They're noteworthy not for the intensity of the firefight or the size of the bombs, but for the bad pictures they conjure up in his head.

He remembers pulling a friend out of a river in Iraq, only to find there was nothing left of him below the waterline. He recalls discovering his buddy is dead by finding a huge scrap of his tattoo.

And there's guilt: "Those guys had wives and kids. You know, everybody in my Humvee, we were all single. I felt guilty. It should have been us; it shouldn't have been them."

Will came away, he says, with "only" two ruined knees, a wrecked back, a piece of bone fragment that sort of floats on his hip, a mild traumatic brain injury and PTSD.

And for all those things, Will has been prescribed medications — lots and lots of medications. It takes him about six minutes to list all his pills.

There are other veterans with similarly long lists. On average, servicemen and women are prescribed narcotic painkillers three times more often than civilians. But despite the pain and PTSD, some of them have decided, without telling their doctors, to stop taking their medications.

Leo Kalberg served in the Army for six years. His medication list includes escitalopram, Prozac, Klonopin, morphine, Percocet, Vicodin, tramadol, Motrin, cortisone, lidocaine and Seroquel, among others. At points, it adds up to 20 or more pills a day.

He realized he was addicted to Percocet because he'd get nervous if he only had a few pills left. Plus, Karlberg says the side effects make him feel like a zombie.

"I'd take all my medication, and I'd sit down, and a whole entire day would pass, and I would just get up and go to bed," Karlberg says. That's when he decided to quit taking his medications.

Nancy Bryant, who served in the Air Force for almost 15 years, was in a similar situation. Cymbalta, Maxalt, trazodone, tizanidine, dicyclomine, hydrocodone — and her list goes on.

Bryant came upon the idea of stopping her medications by accident. She got the stomach flu and couldn't keep any food or medications down.

"After a few days of that — those medications clearing my system — I just realized, wow, I felt like a totally different person," she says.

Rachel Stokes was in the Army, and she too has a long list crowded with similar medications. She started looking into what all those medications are really designed to do.

She was prescribed Seroquel to help her sleep. "But it's not even for sleep," Stokes says. "Seroquel is for people that have bipolar [or] schizophrenia. And I'm like, that is not me."

Using Drugs 'Way, Way, Way Off Label'

Dr. Richard Friedman, director of the Psychopharmacology Clinic at Weill Cornell Medical College, has heard this before. "They're using psych drugs off label — way, way, way off label," he says. "Obviously, they are not using them to treat the major disorders for which these drugs are designed."

Friedman researched the military's use of antipsychotics like Seroquel, and stimulants like Adderall and Ritalin. He says those drugs have no official purpose that fits a combat zone. He figures the military was using whatever drugs they could to keep troops sleeping, waking up and functioning during wartime.

"They were in a different situation, where they had unprecedented levels of stress in a group of otherwise healthy people," Friedman says. "So, I think they resorted to psychopharmacology as a means to keep people in active duty."

Friedman says it's like giving a football player painkillers so he can finish the game: It gets him back on the field, but might hurt him worse in the long term.

The Pentagon says it has safeguards to prevent overprescription or the use of drugs in harmful combinations, and the Department of Veterans Affairs' guidelines warn about using many of these drugs off-label.

Off-label use is common in medicine, and Friedman says doctors do it with good intentions. He also says stopping medications without a doctor's guidance can be dangerous.

But Rachel Stokes says she's sick of doctors and their pills.

"The medications — I hate all the medications," she says. "If the scientist actually went through and did research, and then really found out what really worked, then that's different. But it doesn't seem like they're doing that."

She may have a point. A study by the Institute of Medicine last month concluded that the VA and the Pentagon do a poor job tracking what happens when they treat PTSD with drugs — although there is a brand-new effort at the VA to educate its doctors.

Gavin West, who heads the Opioid Safety Initiative at the VA, says, "We've undertaken a psychopharmacologic safety initiative, where we're looking across the board at more safe and more effective use of medications."

Flushing The Drugs Down The Toilet

Will, the veteran whose list of medications takes six minutes to read, has stopped taking those drugs.

"I always keep at least one month on supply," Will says. "My next month's supply comes next week, so as soon as they come in, I take those and I flush them. And then I just scrape my name off all the pill bottles and throw them all away."

Will, who is in the process of medically retiring from the Army, keeps that month's supply of pills on hand for a reason: He gets drug-tested to make sure he is taking his medications. That's to ensure he's not selling his drugs on the street — which isn't uncommon.

So every few months, when he has an appointment coming up, Will gets himself back on his drugs. He gradually works up to the dose he's supposed to be on. He recently cycled himself off the medications again after a doctor's appointment.

"I'm actually feeling pretty good," Will says. "I've now been fully off the meds for nine days. The first three days of being off them were really bad; just real bad nausea, diarrhea, shaky."

Will hopes he'll be out of the Army soon and can stop the roller coaster of getting on and off the drugs. But for now, he says, it's worth it. When he was on the medications, he was a shut-in, he says, depressed and too doped up to drive.

As for dealing with his PTSD without the drugs — he's still working on it.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

MELISSA BLOCK, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block. Troops coming home from war are prescribed drugs at a staggering rate. Hundreds of thousands of veterans are on opiates for pain, and yesterday we heard about the risk of addiction. Those opiates are among many drugs that vets are taking for everything from pain to PTSD. 1 in 3 vets polled say they're on 10 different medications. Today, we're going to hear how some veterans are rebelling. NPR's Quil Lawrence met some veterans who are kicking drugs against doctors' orders. And a quick word of caution - there are descriptions in this story that some listeners may find disturbing

QUIL LAWRENCE, BYLINE: For a lot of people, PTSD is knowing that if you sleep, you return to the worst place you have ever been at the worst possible moment.

WILL: I always see his face. And in my dreams it's the same thing, but I always walk over to him and instead of this Afghani kid that's laying there, it's my little brother.

LAWRENCE: Will is 33 years old. He did one tour in Iraq, one tour in Afghanistan with the Army.

WILL: In Afghanistan there was a real bad incident. We'd just finished this humanitarian aid mission. And we were getting ready to roll out, and this kid runs up to a Humvee. The kid's yelling, water, water, water. And so the medic reaches down to a case of water on the floor. And we turn around - the kid bashed him in the face with a rock. And kid runs off, and I mean we were like a hive of angry bees. And a guy comes out with an AK and, you know, it was the kid's father, we found out later - and start shooting. And they shot the father. The kid ends up picking up the AK. I mean he was 13 - 14 years old. And the driver that had shot the father just froze, and I ended up shooting the kid from - couldn't have been 50 feet away. And after I did that, all I remember is that I was shaking. And one of my soldiers took my weapon away and said it's OK primo. It's going to be OK.

LAWRENCE: Will has other stories, and they're some of the worst I've ever heard - not for the intensity of the firefight or the size of the bombs, but just for the bad pictures he's got stuck in his head - like pulling a friend out of a river in Iraq only to find that there's nothing left of him below the waterline - like realizing your buddy is dead because you find nothing but a huge scrap of his tattoo.

WILL: Those guys had wives and kids, you know? Everybody in my Humvee - we were all single. And it was just - I felt guilty. You know, that should've been us. It shouldn't have been them.

LAWRENCE: Will came away with only, only two ruined knees, a wrecked back, and a piece of bone fragment that sort of floats on his hip, and a mild traumatic brain injury and PTSD. And for all of those things, Will has been prescribed meds - lots and lots of meds.

WILL: For migraines and whatnot due to TBI, topiramate - 10 milligrams of Ambien daily...

LAWRENCE: We'll hear more about Will in a bit. It'll take him about six minutes to list all of his pills. But there are other vets in the same boat. On average, veterans get prescribed narcotic painkillers three times more often than civilians, like these three.

LEO KALBERG: Leo Kalberg. I served in the United States Army.

NANCY BRYANT: My name is Nancy Bryant and I served in the Air Force.

RACHEL STOKES: My name is Rachel Stokes. I was in the Army.

LAWRENCE: They have their lists as well.

BRYANT: I've been on tizanidine.

KALBERG: Citalopram.

BRYANT: Trazodone.

STOKES: Trazodone.

KALBERG: Prozac.

BRYANT: Ambien.

KALBERG: Klonopin.

BRYANT: Dicyclomine.

STOKES: Xanax, Seroquel, and Zoloft.

BRYANT: Hydrocodone.

KALBERG: Tramadol.

STOKES: Tramadol.

KALBERG: Percocet, Vicodin.

BRYANT: Compazine.

STOKES: Oh, naproxen sodium. (Laughing) Everyone has that for every reason.

LAWRENCE: Besides getting the same drugs, these folks have something else in common. Despite the pain and PTSD, they've decided, without telling their doctors, to stop taking their meds. They say the side effects make them feel like zombies. Nancy Bryant came on the idea by accident. She got a stomach flu and she couldn't keep any food or her meds down.

BRYANT: After a few days of that, you know, those medications clearing my system, I just realized - wow, I felt like a totally different person.

LAWRENCE: Leo Kalberg says he realized he was addicted to Percocet. He used to get nervous when he only had a few left. And Rachel Stokes started looking into what the meds she takes are really designed to do, like the ones to help her sleep.

STOKES: Seroquel is for sleep, but it's not even for sleep. Seroquel is for people that have bipolar schizophrenia. And I'm all like, that is not me.

RICHARD FRIEDMAN: They were using antipsychotic drugs off label - way, way, way off label. Obviously, they're not using them to treat the major disorders for which these drugs are designed.

LAWRENCE: Richard Friedman is the director of psychopharmacology at Cornell Medical College. He researched the military's use of antipsychotics like Seroquel and stimulants like Adderall and Ritalin. He says those drugs have no official purpose that fits a combat zone. He figures the military was using whatever drugs they could to keep troops sleeping, waking up and functioning at war.

FRIEDMAN: They were in a difficult situation when they had unprecedented levels of stress in a group of otherwise healthy people. So I think they resorted to psychopharmacology as a means to keep people in active duty.

LAWRENCE: Friedman says it's like giving a football player painkillers so he can finish the game. It gets him back on the field, but it might hurt him worse in the long-term. The Pentagon says it has safeguards to prevent over prescription or the use of drugs in harmful combinations, and the VA's guidelines warn about using many of these drugs off label. Now, using drugs off label is common in medicine, and Friedman says doctors do it with good intentions. He also says stopping taking the meds without a doctor's guidance can be dangerous. Maybe, but Rachel Stokes is sick of doctors and their pills.

STOKES: The medications - I hate all the medications. If a scientist actually went through and did research and they really found out what really worked, then that's different. But it doesn't seem like they're doing that.

LAWRENCE: She may have a point. A study by the Institute of Medicine last month concluded that the VA and the Pentagon do a poor job tracking what happens when they treat PTSD with drugs. There is a brand-new effort at the VA to educate its doctors. Gavin West is with the VA.

GAVIN WEST: We've undertaken a psychopharmacologic safety initiative where we're looking across the board at more safe and more effective use of medications.

LAWRENCE: Which brings us back to Will. Remember Will? He's almost done reading out his prescriptions.

WILL: We've got tramadol, baclofen...

LAWRENCE: Will's also not taking his meds. He's still in the process of being medically retired from the Army, so he asked that we only use his first name.

WILL: I always keep at least one month on supply. My next month's supply comes next week, so as soon as they come in, I take those and I flush them. And then I just scrape my names off the - all the pill bottles and throw them all away.

LAWRENCE: Will keeps a month's supply of pills because he's getting drug tested. That's right - tested to make sure he is on drugs. That's to make sure he's not selling his drugs on the street, which isn't uncommon. So every few months when he has an appointment, Will gets himself back on drugs. He gradually works up to the dose he's supposed to be on. When we met, he had just cycled himself off the meds again, after a doctor's appointment.

WILL: I'm actually feeling pretty good. I have now been fully off the meds for nine days - the first three days of being off them were really bad. I just - real bad nausea, diarrhea, shaky.

LAWRENCE: Will hopes he'll be out of the Army soon and he can stop the roller coaster of getting on and off the drugs. He says it's worth it for now. When he was on the meds, he was a shut-in - too doped up to drive, depressed. Dealing with his PTSD without the drugs - he's still working that. Quil Lawrence, NPR News. Transcript provided by NPR, Copyright NPR.