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It happens on average once every five days — an active-duty service member is found dead from an accidental drug or alcohol overdose.
And the number has roughly tripled since 2001, a Military Times investigation has found.
The fatalities, mostly involving prescription medications, come at a time when military prescription drug use is soaring. Many troops are taking multiple drugs simultaneously. Orders for common pain and psychiatric medications nearly doubled from 2001 through 2009, according to Defense Logistics Agency data. And the Army on July 29 reported that the amount of stimulants prescribed to soldiers more than doubled from fiscal 2006 through 2009.
Death records show the military reported at least 68 accidental drug deaths in 2009, up from 24 in 2001. In total, at least 430 troops have died from drug use — or, in a small number of cases, alcohol use - during the past decade.
These figures are based on a Military Times analysis of more than 14,000 casualty records maintained by the Defense Manpower Data Center and provided in response to a Freedom of Information Act request.
Military officials say they do not systematically track fatal overdoses involving prescription drugs across the force.
Overall, the rate of accidental drug deaths among active-duty troops remains well below the civilian population at large. The military data show a rate of less than 5 such deaths per 100,000 people, while the Centers for Disease Control and Prevention recently estimated the rate for the general population to be about 9 per 100,000.
But that's an apples-to-oranges comparison, some say. The military maintains much tighter controls, on the job and off, of service members than civilians are subjected to, including regular and random drug testing.
Painkillers top the list
While the death records released to Military Times offer insights into the cause and manner of deaths, they lack details and make it difficult to draw conclusions about the names or types of drugs involved.
For example, dozens of records list only generic descriptions for cause of death, such as "mixed drug toxicity" or "drug intoxication."
Still, at least a third of the accidental overdose deaths specifically involved some type of narcotic painkiller, the investigation reveals.
Topping the list is methadone, a synthetic narcotic popularly known as a medication prescribed to help heroin addicts kick the habit but now widely prescribed as a painkiller. It has contributed to at least 60 military deaths — more than any other drug, legal or illegal, according to the data.
These painkillers belong to a family of medications known as opioids, synthetic versions of opium. With names such as methadone and oxycodone (brand name OxyContin), these drugs have found wide use in the past decade in the treatment of chronic pain.
Opioids in high doses, or when mixed with alcohol or other drugs, can depress the central nervous system, sometimes fatally.
About one in seven soldiers is currently prescribed some form of opiate, according to the Army.
Opioids are particularly dangerous, experts say, when combined with another class of drugs called benzodiazepines, or "benzos." With names like alprazolam (brand name Xanax) and diazepam (Valium), these drugs are commonly prescribed to treat anxiety, including post-traumatic stress disorder.
However, benzodiazepines increase the respiratory-depressant effect of narcotics. Taken together improperly, they can stop the respiratory system entirely.
According to the military data, at least two dozen deaths involved a combination of opioids and benzodiazepines.
"One thing we've learned in the last decade is that the effect of opioids, like methadone, is enhanced when it's co-ingested with a benzodiazepine," said Dr. Bruce Goldberger, a professor and director of toxicology at the University of Florida.
Some experts peg the spike in prescription-drug use to the tens of thousands of physically and mentally wounded returning from two war fronts over the past decade. They are being prescribed drugs to which they often become addicted or abuse either willfully or through lack of proper medical oversight.
Goldberger pointed to the challenges of treating those returning from the war zones.
"PTSD patients suffer from anxiety disorders, so they would be prescribed drugs like Xanax, but also may be seeking treatment for pain, so they're being prescribed drugs like methadone," he said. "It's really a very complicated medical situation."
Dr. Lynn Webster, medical director of Lifetree Clinical Research and Pain Clinic in Salt Lake City, who has written extensively about safe prescribing practices, encouraged family members to be extra vigilant and closely monitor loved ones on these medications, particularly at night. Be on the lookout for heavy snoring or long pauses between breaths, he said.
"These are signs that happen prior to dying," he said. "Family members can fail to recognize that this is an impending calamity."
Military doctors respond
Drug deaths have become an urgent concern for the Army in recent years.
The Army has recorded a spate of drug-related deaths in the Warrior Transition Units, the specialty-care units created to provide troubled soldiers with close supervision. At least 30 soldiers in the WTUs have died since 2007.
An Army report released July 29 on suicides and the health of the force found that 74 soldiers died of drug overdoses in 2009 alone, a rate of 13 per 100,000 active-duty soldiers, somewhat higher than the civilian rate.
A key risk factor, Army officials say, is the simultaneous use of numerous drugs at once, known as "polypharmacy."
In 2009, Army Surgeon General Lt. Gen. Eric Schoomaker issued a sweeping new policy to overhaul how the Army prescribes, distributes and monitors the riskiest drugs.
"Closer oversight of polypharmaceutical use by our patients can be life-saving," Schoomaker added in a hand-written note at the bottom of a policy memo dated April 2009.
One Army official said a servicewide policy change to further improve oversight of polypharmacy is expected in August.
However, the entire military medical community does not share the same view of the problem of treating the war wounded. The Navy's top doctor, Vice Adm. Adam Robinson, said his primary concern is that some wounded troops may be under-treated.
"Many physicians feel that we have undertreated pain for many years due to concerns that a patient might become addicted to the pain medicine," Robinson said a recent meeting with Military Times reporters. "We have men and women in theater who are being hurt and who need pain medication to gain control of their pain to help them to get better. I don't think there is any evidence that there is any overusage of pain medication in most of those individuals."
But Noel Koch, former deputy undersecretary of defense for wounded warrior care and transition policy at the Pentagon, said he saw "repeated evidence of excessive drug use" at military treatment facilities across the country during his brief tenure.
Koch, who was asked to resign his post in April for reasons that remain unclear, said he spent hours with soldiers and Marines in medical hold units on more than a dozen trips to Warrior Transition Units and Wounded Warrior Battalion detachments.
Koch said he briefed senior military leaders on his concerns about drug use among troops.
"You'd be staring at kids, you'd get this 50-meter stare. You'd have to raise your voice to get their attention," he said. "In Vietnam, the enemy turned our people into drug addicts. This time, caregivers are doing it."
A NOTE ON THE NUMBERS
To establish militarywide figures for accidental drug overdose deaths, Military Times staff members analyzed casualty data from the Defense Manpower Data Center. The figures in the story reflect active-duty deaths categorized as accidental, undetermined or pending that involved drugs and/or alcohol.
Because of the focus on accidental overdoses, the analysis did not include suicides, or deaths from at-risk behaviors such as inhaling chemical solvents or cleaning products. Military Times excluded deaths in which the cause was unclear and could not be verified as drug- or alcohol-related.