"For Veterans with PTSD, A New Demon: Their Meds" article
Threat of Addiction to Prescription Painkillers Heightened With Mental Illness
November 10, 2013
NEWPORT, N.H.—Desperation drove Timothy Fazio, a former Marine, to turn up around midnight at a veterans' hospital near Boston. His post-traumatic stress disorder was causing flashbacks and blackouts. He had leapt from a balcony.
And he had overdosed, twice, on painkillers originally prescribed for a hand injury suffered in Iraq.
"I want detox," Mr. Fazio told doctors that night in 2008, his medical files say.
After a week of withdrawal, Mr. Fazio checked himself out of the Veterans Health Administration hospital—and was given 168 pills of the same opiumlike drug he was already addicted to, according to his files, which The Wall Street Journal has reviewed. The next day, the hospital gave him another 168 pills.
PTSD and painkillers are the twin pillars of a new mental-health crisis in America. Many of the more than two million Americans who served in Iraq or Afghanistan suffer, as Mr. Fazio does, from a mixture of pain and PTSD. The VA treats many of them with powerful opioid painkillers for their pain. But opioids can be a combustible mix with mental illness because of a heightened addiction risk.
Effectively, some critics say, it amounts to treating mental illness with addictive narcotics.
A study by a VA researcher found that veterans with PTSD were nearly twice as likely to be prescribed opioids as those without mental-health problems. They were more likely to get multiple opioid painkillers and to get the highest doses. Veterans with PTSD were more than twice as likely to suffer bad outcomes like injuries and overdoses if they were prescribed opioid painkillers, the study found.
In Mr. Fazio's case, between 2008 and 2011 the VA prescribed him more than 3,600 pills containing oxycodone, a narcotic painkiller from the same family as heroin and morphine, his records show. He overdosed a total of six times.
"I was always a tough kid, but I feel like this has been the toughest fight of my life," Mr. Fazio said in March, after a spell of homelessness that saw him sleeping in an ATM lobby. "I don't know if I'm going to win it."
The VA declined to comment on Mr. Fazio's treatment and said it would review his records. It said it follows uniform guidelines and procedures for veterans' pain care, adding that those are being reinforced with further training of doctors and patients in safe opioid use. "The Veterans Health Administration has worked aggressively to promote the safe and effective use of opioid therapy for veterans," it said.
The number of vets with both PTSD and pain isn't known. But some 30% of Iraq and Afghanistan veterans under VA care have PTSD, VA figures show, and more than half suffer chronic pain.
Last year, more than 50,000 veterans were treated by the VA for serious problems associated with opioid use, nearly double the number a decade earlier, according to VA data. By contrast, the total number of VA patients grew 30% over that time. The number of opioid prescriptions written by the VA has risen by 287% between 1999 and 2012, according to data obtained by The Wall Street Journal through an open-records request.
The rate of accidental drug overdoses among VA-enrolled veterans is nearly twice that of the U.S. population as a whole, according to a different study led by a VA doctor, which controlled the results for age and gender. Opioid medications were the leading cause.
The number of troops "retiring out of the Army on narcotics chronically is just absolutely unbelievable," said Andrew Kowal, director of the pain-management center at Lahey Hospital in Burlington, Mass. As "Army Pain Champion," an informal title given to him by the Army, Dr. Kowal helped develop in the late 1990s clinical guidelines for pain management used by the VA.
He now says those guidelines made doctors too comfortable prescribing the drugs. "The easiest thing for a physician to do is to simply refill the prescription," he said.
VA doctors struggling to treat a complex mix of mental and physical problems in returning veterans are prescribing opioids, suggests one study led by a VA doctor.
"It is possible that in the primary-care setting, opioids may be prescribed to treat a poorly differentiated state of mental and physical pain," the authors wrote in the Journal of the American Medical Association, "perhaps because physicians do not know how else to handle these challenging patients."
Derived from opium poppies, opioids were long shunned by doctors for their addictiveness. That changed in the 1990s when a group of cancer doctors successfully argued that opioids were wrongly stigmatized and should be used more widely to relieve patients' suffering.
The VA has since been trying to trim its reliance on the drugs for veterans in pain. In 2010 it revised its guidelines to emphasize the risks, and the VA said it would make further revisions.
"It is of great concern within the VA to try to reduce the risk of harms for veterans with chronic pain who are prescribed opioids and to potentially provide for increasing alternatives," said Robert Kerns, the VA's director of pain management.
Mr. Fazio's case embodies a problem these patients can face: The drugs prescribed for their physical pain also temporarily relieve their mental strains.
Mr. Fazio was originally prescribed narcotic painkillers after injuring his hand in Fallujah, Iraq. Once the pain subsided, he kept taking the drugs to help numb his troubled dreams and waves of anxiety. They helped "erase" his mind, he said.
He got hooked. When he couldn't get more from the VA, he moved on to street heroin. His parents say he tried to provoke police into shooting him on at least one occasion. (When asked, Mr. Fazio sometimes denies doing that, while other times he suggests it is true.)
Now 30, Mr. Fazio grew up in a close Catholic family with two brothers and two sisters in Sterling, Mass., about an hour's drive from Boston. He was a popular, scrappy hockey player who made decent grades, despite being hard-pressed to concentrate, his parents say.
In his senior year of high school, the Sept. 11, 2001, terror attacks happened. He graduated in 2002 and enlisted in the Marines. After training at Camp Lejeune, N.C., he arrived in Afghanistan in February 2004 and spent 3½ months as a machine-gunner on a grueling campaign.
The pace took a toll on the men's bodies, particularly their backs and knees. They lost up to 30 pounds each, said his former commander, Lt. Col. Asad Khan.
"They didn't let up," said Lt. Col. Khan. "We killed them until the last man. That's what it came down to."
The Iraq tour was less arduous but more dangerous. Mr. Fazio's unit relieved Marines who had taken the insurgent stronghold of Fallujah. In June 2005, a rocket-propelled grenade exploded near Mr. Fazio. A pallet he was helping to lift fell on his hand, severing a tendon.
Doctors operated and, for the first time, gave him painkillers including oxycodone, according to Mr. Fazio and his records. "That's when I started taking to liking pills," he said. "It helped with physical pain, but also emotional and mental pain, too."
Mr. Fazio was honorably discharged in August 2006. He had civilian friends back home, he said, but felt alone.
"We'd have a party and all his friends would come," said his mother, Kathy. "But he wouldn't talk about the war with anybody."
His best friend from Iraq, Eric Hall, faced a similar predicament after being injured by a roadside bomb. He also had PTSD and took opioid painkillers and antianxiety drugs. After leaving the hospital, Mr. Hall—thinking he was back in Iraq—brandished a gun at a carload of women wearing scarves, his mother said, thinking the women were tailing him.
"Eric didn't smile no more," Mr. Fazio says. "You could tell he was doped up from the pills because of the pain he was in."
Mr. Fazio started getting oxycodone for back pain from his family doctor as well as the VA. He worked as a counselor at a state facility for troubled kids but found he had little patience. After an incident in which he tackled a resident in December 2007, he left the job. "I felt myself flipping out," he said. "I thought I might hurt a kid."
In January 2008, Mr. Fazio, who had moved back in with his parents, had what his mother calls "the Rambo incident." His father woke him in the middle of the day to take him to drug treatment. Mr. Fazio went berserk. He brandished an ax, a knife and a fireplace poker, and jammed a knife into the table, saying he was ready to take on anyone who came in the house.
In February 2008, Mr. Fazio says, he realized he was addicted. According to his parents and his medical records, he flushed his drugs down the toilet and spent a week vomiting from withdrawal. His notes say he felt insects crawling under his skin.
He turned to the VA for help. "After reading online about the addiction potential," his records say, "he was determined that no medication would have control over his body."
He was released after a week. His records show that doctors, recommending that he withdraw slowly, sent him home with 30 pills containing oxycodone.
On March 9, 2008, Mr. Fazio's friend Mr. Hall was found dead inside a drainage pipe in Florida. Mr. Fazio was inconsolable.
Three weeks later, Mr. Fazio's then-girlfriend rushed upstairs at his parents' house in the middle of the night, screaming "Tim's not breathing!" His records describe an overdose of pain pills and alcohol.
He overdosed again two weeks later. Three weeks after that, he jumped from a second-floor balcony at his parents' house but escaped serious injury. Mr. Fazio's files at the time say "he doesn't want to live any longer and also wanted to kill everyone."
He later told doctors that was "a misinterpretation, it was only a little balcony." Mr. Fazio denies ever trying to commit suicide.
In September 2008, Mr. Fazio decided again he needed to come off the painkillers, and made his midnight visit to the VA hospital near Boston. A week later, he checked himself out, against doctors' advice.
At first, he was sent home without medication. But within hours, he was back with an injury to his hand, having punched a wall. "I'm withdrawing from my medication," the notes show he said. "I need my meds."
His records show he was given 28 days' supply of a drug containing oxycodone that day, and another 28 days' supply the day after. The psychiatrist appears to have agreed to issue the drugs after learning Mr. Fazio had been accepted into a mental-health program.
"I don't think the VA can help my son," the elder Mr. Fazio said when VA workers contacted him to leave a message for his son, records show. "They're the ones who got him addicted in the first place. I don't think he trusts the VA anymore, and neither do I."
VA doctors also prescribed antianxiety drugs including generic Klonopin and Ativan. According to studies and government guidelines, these drugs put patients at greater risk of overdose when used with opioids.
Several independent psychiatrists and addiction specialists asked about Mr. Fazio's treatment expressed surprise that he had been prescribed opioids after being treated for opioid addiction. Some also questioned a decision to couple his opioid prescriptions with antianxiety medications and amphetamines that also pose an addiction risk.
"Unfortunately it is typical; he's not an outlier" among vets with PTSD and pain issues, said Reza Ghorbani, medical director of the Advanced Pain Medicine Institute near Washington, D.C., after hearing details of Mr. Fazio's case. "But it's the wrong way of treating a patient."
A VA nurse-practitioner called for a review of Mr. Fazio's drugs to "protect this veteran from access to multiple—and potentially dangerous—combinations and amounts of medications." It isn't clear if that happened.
In September 2008, he crashed his mother's car into concrete barriers while high on pills and alcohol. The next month, he threw a desk phone at a nurse at UMass Memorial Medical Center. He was admitted to a PTSD and drug-detox program. A year later, his notes show, he was admitted to the Northampton, Mass., VA for PTSD, depression, panic disorder and opiate dependence.
Despite his addictions, the following month the VA resumed his prescriptions for an opioid painkiller. The VA refilled it several times a month for the next 20 months, until May 2011. The records don't detail the reason the prescription was restarted, or stopped.
In July 2011, Mr. Fazio stole his parents' TV and asked a girlfriend to report a break-in. The story fell apart. His parents didn't want to press charges, but police charged him with intimidating a witness, a felony. He pleaded guilty and spent three months in jail.
After release, he began using heroin.
This past January, Mr. Fazio's parents reached their limit. They kicked him out of their house and got a restraining order.
In March, Mr. Fazio moved in with another Marine in a needle-strewn apartment in Palmer, Mass. They sang songs about numbing themselves with drugs.
"I picture myself loading my rifle only to look down and see a needle in my vein," said Mr. Fazio, reciting one verse. "Mom, I will always be that Marine on the wall. But somewhere along the line I lost it all."
A little before his most recent overdose, last Christmas Eve, Mr. Fazio met his current girlfriend, Jennifer Dodge. A slim, blonde 32-year-old from New Hampshire, she took on a motherly role, driving two hours to the Palmer apartment with food.
In March, Mr. Fazio's roommate overdosed and later died. Mr. Fazio moved in with Ms. Dodge and her three young kids in Newport, N.H. Mr. Fazio came off the painkillers and has remained off them since, according to him and Ms. Dodge.
That, however, brought his PTSD to the fore. "I wake up, and I'm freaking out," he said in an interview in the Newport apartment in September. "I start fights. I'm really jealous."
Recently, he says he was at a drive-through Taco Bell with Ms. Dodge and the kids. Reaching the microphone, he felt himself sweating, unable to remember the orders. He felt anger and humiliation as teen staff watched him from the takeout window.
"My rage wanted me to jump through the Taco Bell window and dump my Mountain Dew all over his f— head and make him eat a Soft Taco Supreme," he recounted later.
Another time he suffered an outburst when he awoke startled one afternoon. "I had never seen him like this," Ms. Dodge said in an interview. "The look in his eye. It wasn't him, plain and simple."
In June, he was walking in the neighborhood with Ms. Dodge when he got into an argument with some local kids. They beat him with aluminum baseball bats, his records show.
He was treated at the VA for concussion, facial abrasions and a possible broken nose. He was sent home with a 10 days' supply of oxycodone. For two days he repeatedly opened the bottle, looked at the pills and put them back. Finally, he says, he dumped them down the toilet.