A DEADLY MIXTURE: DISTRESSED VETERANS AND HANDFULS OF PRESCRIPTION DRUGS

In his last months alive, Senior Airman Anthony Mena rarely left home
without a backpack filled with medications.

He returned from his second deployment to Iraq complaining of back
pain, insomnia, anxiety and nightmares. Doctors diagnosed
post-traumatic stress disorder and prescribed powerful cocktails of
psychiatric drugs and narcotics.

Yet his pain only deepened, as did his depression. "I have almost
given up hope," he told a doctor in 2008, medical records show. "I
should have died in Iraq."

Airman Mena died instead in his Albuquerque apartment, on July 21,
2009, five months after leaving the Air Force on a medical discharge.
A toxicologist found eight prescription medications in his blood,
including three antidepressants, a sedative, a sleeping pill and two
potent painkillers.

Yet his death was no suicide, the medical examiner concluded. What
killed Airman Mena was not an overdose of any one drug, but the
interaction of many. He was 23.

After a decade of treating thousands of wounded troops, the military's
medical system is awash in prescription drugs -- and the results have
sometimes been deadly.

By some estimates, well over 300,000 troops have returned from Iraq or
Afghanistan with P.T.S.D., depression, traumatic brain injury or some
combination of those. The Pentagon has looked to pharmacology to treat
those complex problems, following the lead of civilian medicine. As a
result, psychiatric drugs have been used more widely across the
military than in any previous war.

But those medications, along with narcotic painkillers, are being
increasingly linked to a rising tide of other problems, among them
drug dependency, suicide and fatal accidents -- sometimes from the
interaction of the drugs themselves. 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.

"I'm not a doctor, but there is something inside that tells me the
fewer of these things we prescribe, the better off we'll be," Gen.
Peter W. Chiarelli, the vice chief of staff of the Army who has led
efforts on suicide, said in an interview.

Growing awareness of the dangers of overmedicated troops has prompted
the Defense Department to improve the monitoring of prescription
medications and restrict their use.

In November, the Army issued a new policy on the use of multiple
medications that calls for increased training for clinicians, 30-day
limits on new prescriptions and comprehensive reviews of cases where
patients are receiving four or more drugs.

The Pentagon is also promoting measures to prevent troops from
stockpiling medications, a common source of overdoses. For instance,
the Navy, which provides medical care for Marines, has begun pill
"give back" days on certain bases. At Camp Lejeune, N.C., 22,000
expired pills were returned in December.

The Army and the Navy are also offering more treatments without drugs,
including acupuncture and yoga. And they have tried to expand talk
therapy programs -- one of which, exposure therapy, is considered by
some experts to be the only proven treatment for P.T.S.D. But
shortages of mental health professionals have hampered those efforts.

Still, given the depth of the medical problems facing combat veterans,
as well as the medical system's heavy reliance on drugs, few experts
expect the widespread use of multiple medications to decline
significantly anytime soon.

The New York Times reviewed in detail the cases of three service
members who died from what coroners said were toxic interactions of
prescription drugs. All were classified accidents, not suicides.

Airman Mena was part of a military police unit that conducted combat
patrols alongside Army units in downtown Baghdad. He cleaned up the
remains of suicide bombing victims and was nearly killed by a bomb
himself, his records show.

Gunnery Sgt. Christopher Bachus had spent virtually his entire adult
life in the Marine Corps, deploying to the Middle East in 1991, Iraq
during the invasion of 2003 and, for a short tour, Afghanistan in
2005. He suffered from what doctors called survivor's guilt and came
back "like a ghost," said his brother, Jerry, of Westerville, Ohio.

Cpl. Nicholas Endicott joined the Marines in 2003 after working as a
coal miner in West Virginia. He deployed twice to Iraq and once to
Afghanistan, where he saw heavy combat. On one mission, Corporal
Endicott was blown more than eight feet in the air by a roadside bomb,
medical records show. He came home plagued by nightmares and
flashbacks and rarely left the house.

Given the complexity of drug interactions, it is difficult to know
precisely what killed the three men, and the Pentagon declined to
discuss their cases, citing confidentiality. But there were important
similarities to their stories.

All the men had been deployed multiple times and eventually received
diagnoses of P.T.S.D. All had five or more medications in their
systems when they died, including opiate painkillers and mood-altering
psychiatric drugs, but not alcohol. All had switched drugs repeatedly,
hoping for better results that never arrived.

All died in their sleep.

Psychiatry and Warfare

The military medical system has struggled to meet the demand caused by
two wars, and to this day it still reports shortages of therapists,
psychologists and psychiatrists. But medications have always been
readily available.

Across all branches, spending on psychiatric drugs has more than
doubled since 2001, to $280 million in 2010, according to numbers
obtained from the Defense Logistics Agency by a Cornell University
psychiatrist, Dr. Richard A. Friedman.

Clinicians in the health systems of the Defense and Veterans Affairs
Departments say that for most patients, those medications have proved
safe. "It is important not to understate the benefit of these
medications," said Dr. Robert Kerns, the national director of pain
management for the Department of Veterans Affairs.

Paradoxically, the military came under criticism a decade ago for not
prescribing enough medications, particularly for pain. In its
willingness to prescribe more readily, the Pentagon was trying to meet
standards similar to civilian medicine, General Chiarelli said.

But the response of modern psychiatry to modern warfare has not always
been perfect. Psychiatrists still do not have good medications for the
social withdrawal, nightmares and irritability that often accompany
post-traumatic stress, so they mix and match drugs, trying to relieve
symptoms.

"These decisions about medication are difficult enough in civilian
psychiatry, but unfortunately in this very-high-stress population,
there is almost no data to guide you," said Dr. Ranga R. Krishnan, a
psychiatrist at Duke University. "The psychiatrist is trying
everything and to some extent is flying blind."

Thousands of troops struggle with insomnia, anxiety and chronic pain
-- a combination that is particularly treacherous to treat with
medications. Pairing a pain medication like oxycodone, a narcotic,
with an anti-anxiety drug like Xanax, a so-called benzodiazepine,
amplifies the tranquilizing effects of both, doctors say.

Similarly, antidepressants like Prozac or Celexa block liver enzymes
that help break down narcotics and anxiety drugs, extending their effects.

"The sedation is not necessarily two plus two is four," said Cmdr.
Rosemary Malone, a Navy forensic psychiatrist. "It could be
synergistic. So two plus two could be five."

Commander Malone and other military doctors said the key to the safe
use of multiple prescriptions was careful monitoring: each time
clinicians prescribe drugs, they must review a patient's records and
adjust dosages to reduce the risk of harmful interactions. "The goal
is to use the least amount of medication at the lowest doses possible
to help that patient," she said.

But there are limits to the monitoring. Troops who see private
clinicians -- commonly done to avoid the stigma of seeking mental
health care on a base -- may receive medications that are not recorded
in their official military health records.

In the case of Sergeant Bachus of the Marines, it is far from clear
that he received the least amount of medication possible.

He saw combat in Iraq, his brother said, and struggled with
alcoholism, anxiety, flashbacks, irritability and what doctors called
survivor's guilt after returning home.

"He could make himself the life of the party," Jerry Bachus recalled.
"But he came back a shell, like a ghost."

Sergeant Bachus received a diagnosis of P.T.S.D., and starting in
2005, doctors put him on a regimen that included Celexa for
depression, Klonopin for anxiety and Risperdal, an antipsychotic. In
2006, after a period of stability, a military doctor discontinued his
medications. But six months later, Sergeant Bachus asked to be put on
them again.

According to a detailed autopsy report, his depression and anxiety
worsened in late 2006. Yet for unexplained reasons, he was allowed to
deploy to Iraq for a second time in early 2007. But when his
commanders discovered that he was on psychiatric medications, he was
sent home after just a few months, records show.

Frustrated and ashamed that he could not be in a front-line unit and
unwilling to work behind a desk, he applied in late 2007 for a medical
retirement, a lengthy and often stressful process that seemed to
darken his mood.

In early March 2008, a military doctor began giving him an opiate
painkiller for his back. A few days later, Sergeant Bachus, 38, called
his wife, who was living in Ohio. He sounded delusional, she told
investigators later, but not suicidal.

"You know, babe, I am really tired, and I don't think I'll have any
problems falling asleep tonight," he told her. He was found dead in
his on-base quarters in North Carolina nearly three days later.

According to the autopsy report, Sergeant Bachus had in his system two
antidepressants, the opiates oxymorphone and oxycodone, and Ativan for
anxiety. The delirium he experienced in his final days was "most
likely due to the interaction of his medications," the report said.

Nearly 30 prescription pill bottles were found at the scene, most of
them recently prescribed, according to the report.

Jerry Bachus pressed the Marine Corps and the Navy for more
information about his brother's death, but received no further
explanations. "There was nothing accidental about it," he said. "It
was inevitable."

Self-Medicating

The widespread availability of prescription medications is
increasingly being linked by military officials to growing substance
abuse, particularly with opiates. A Defense Department survey last
year found that the illegal use of prescription drugs in the military
had tripled from 2005 to 2008, with five times as many troops claiming
to abuse prescription drugs than illegal ones like cocaine or marijuana.

The problem has become particularly acute in specialized units for
wounded troops, where commanders say the trading of prescription
medications is rampant. A report released last month by the Army
inspector general estimated that up to a third of all soldiers in
these Warrior Transition Units are overmedicated, dependent on
medications or have easy access to illegal drugs.

Some of that abuse is for recreational purposes, military officials
say. In response, the Army has taken several steps to tighten the
monitoring of troops on multiple prescriptions in the transition units.

But in many cases, wounded troops are acquiring drugs improperly
because their own prescriptions seem ineffective, experts say. They
are self-medicating, sometimes to death.

"This is a huge issue, and partly it's due to the availability of
prescription drugs among returning troops," said Dr. Martin P. Paulus,
a psychiatrist at the University of California, San Diego, and the
V.A. San Diego Medical Center. "Everyone knows someone who'll say,
'Hey, this worked for me, give it a try.' "

Corporal Endicott, for instance, died after adding the opiate
painkiller methadone to his already long list of prescribed
medications. His doctors said that they did not know where he got the
narcotic and that they had not authorized it.

Corporal Endicott, who survived a roadside bomb explosion, was in
heavy fighting in Afghanistan, where he saw other Marines killed.
After returning from his third deployment, in 2007, Corporal Endicott
told doctors that he was having nightmares and flashbacks and rarely
left his house. After a car accident, he assaulted the other driver,
according to medical records. Doctors diagnosed P.T.S.D. and came to
suspect that Corporal Endicott had a traumatic brain injury.

Over the coming year, he was prescribed at least five medications,
including the antidepressants Prozac and Trazodone, and an
anti-anxiety medication. Yet he continued to have headaches, anxiety
and vivid nightmares.

"He would be hitting the headboard," said his father, Charles. "He
would be saying: 'Get down! Here they come!' "

On Jan. 29, 2008, Corporal Endicott was found dead in his room at the
National Naval Medical Center in Bethesda, Md., where he had checked
himself in for anger management after another car accident. He was
26.

A toxicologist detected at least nine prescription drugs in his
system, including five different benzodiazepines, drugs used to reduce
anxiety or improve sleep. Small amounts of marijuana and methadone --
a narcotic that is particularly dangerous when mixed with
benzodiazepines -- were also found in his body.

His death prompted Marine Corps officials at Bethesda and Walter Reed
Army Medical Center to initiate new procedures to keep Marines from
inappropriately mixing medications, including assigning case managers
to oversee patients, records show.

Whether Corporal Endicott used methadone to get high or to relieve
pain remains unclear. The Marine Corps concluded that his death was
not due to misconduct.

"He survived over there," his father said. "Coming home and dying in a
hospital? It's a disgrace."

Trying to Numb the Pain

Airman Mena also returned from war a drastically changed
man.

He had deployed to Iraq in 2005 but saw little action and wanted to go
back. He got the chance in late 2006, when sectarian violence was
hitting a peak.

After coming home, he spoke repeatedly of feeling guilty about missing
patrols where a sergeant was killed and where several platoon mates
were seriously wounded. Had he been driving on those missions, he told
therapists, he would have avoided the attacks.

"On my first day, I saw a total of 12 bodies," he said in one
psychological assessment. "Over there, I lost faith in God, because
how can God allow all these dead bodies?"

By the summer of 2008, he was on half a dozen medications for
depression, anxiety, insomnia and pain. His back and neck pain
worsened, but Air Force doctors could not pinpoint a cause. Once
gregarious and carefree, Airman Mena had become perpetually irritable.
At times he seemed to have hallucinations, his mother and friends
said, and was often full of rage while driving.

In February 2009, he received an honorable discharge and was given a
100 percent disability rating by the Department of Veterans Affairs,
meaning he was considered unable to work. He abandoned plans to become
a police officer.

Now a veteran, his steady medication regimen continued -- but did not
seem to make him better. His mother, Pat Mena, recalls him being
unable to sleep yet also listless, his face a constant shade of pale.
Shocked by the piles of pills in his Albuquerque apartment, she once
flushed dozens of old prescriptions down the toilet.

Yet for all his troubles, he seemed hopeful when she visited him in
early July 2009. He was making plans to open a cigar store, which he
planned to call Fumar. His mother would be in charge of decorating
it.

The night after his mother left, he put on a new Fentanyl patch, a
powerful narcotic often used by cancer patients that he had started
using just five weeks before. The Food and Drug Administration issued
warnings about the patches in 2007 after deaths were linked to it, but
a private clinic in Albuquerque prescribed the medication because his
other painkillers had failed, records show.

With his increasingly bad memory, he often forgot what pills he was
taking, his mother said. That night when he put on his new patch, he
forgot to remove the old one. He died early the next day.

Was the Fentanyl the cause? Or was it the hydromorphone, another
narcotic found in his system? Or the antidepressants? Or the sedative
Xanax? Or all of the above?

The medical examiner could not say for sure, noting simply that the
drugs together had caused "respiratory depression."

"The manner of death," the autopsy concluded, "is accident."