Memorial Day just passed, and I reflected on those in my extended family who were lost in battle. My stepfather’s two brothers, whose names are carved in the World War II monument of a nearby small town, are most prominent in my mind. If I remember correctly, one died in Germany and the other in the Pacific. My stepdad was so affected by the loss of his older brothers that he actually lied, probably for the first time in that sainted man’s life, and said he was of age to fight. He served in the Pacific but survived to come home to live his life and help raise me after my biological father’s car went over a cliff.

These thoughts led me to think about the definition of heroism and what it takes to be one. Charging into battle against heavy fire is clearly an example. Every person brave enough to leave their amphibious vehicle and advance across the beaches of Normandy or Tarawa definitely qualifies. But for the majority of our most celebrated heroes, the end is quick. A single bullet, grenade, or bomb, and their terror and suffering are over in an instant. We who exist because of their sacrifices salute the flag-draped coffins when they return, engrave their names in granite, and honor their sacrifice on this day of remembrance.

But not every warrior wears a uniform, and not every loss is remembered. There are many battles that we all face in life, and all kinds of ways to be a hero. And to die. One of those heroes, to me anyway, was a man named Jay Lawrence. Jay’s life was not easy on the day of his death. He had been driving a truck back in the 1980s when his brakes failed. This happens occasionally, and steep inclines will sometimes have a specially constructed deceleration system, sometimes water-filled barrels, while others have gravel-covered inclines. None of these were available to Jay.

Anyone driving a large commercial truck would know that this means you need to find a safe place to stop the vehicle. Sometimes, this is by running it against a guardrail. Jay was on a bridge, and impacting the steel supports at high speed could kill him or send his truck over the side. It was a tough decision. Seeing a baby seat in the car ahead of him clarified things for him, and he jerked the wheel to the right, impacting the steel girders at full speed and determining the course of protracted suffering he would experience for the rest of his life.

It is easy to withstand pain, even severe pain, for brief periods of time. I have laughed after breaking a bone and stitched up my own forehead without lidocaine after cracking it with a crowbar while working on a car. Note to self: some CV joints have retaining pins that must be removed before they will slide out, no matter how hard you pull on a crowbar. I stitched it up myself so I wouldn’t have to get laughed at by my peers in the ER, where I worked as a physician. I’m not tough. Just lucky. Jay was not so lucky, and the severe injuries he sustained would cause him to constantly suffer debilitating pain.

Unlike the pain I experienced, which was intense but brief, Jay had suffered severe back injuries that required surgical intervention and fusions of the lower back and neck. This is very different, and let me make something clear. Unless we are talking about a laminectomy or spinal cord stimulator placement, your back surgery is not intended to relieve your pain. We all hope it will, but most people hurt worse after back surgery than before. Back surgery aims to stabilize the spine, to keep you mobile and not paralyzed. No way cutting through muscle and screwing metal into bone won’t hurt.

But Jay was luckier than most, for now, tolerating this well and continuing with his life, and here’s another point. While acute injuries heal, severe chronic pain does NOT get better with time. Nor should it be expected to resolve after surgery. Jay had been prescribed opiates for his pain after surgery but recovered to where he could get by without them, routinely working sixty-hour weeks to support himself and his family. In 2005, Jay met and married his wife, Meredith, and together, they worked on having a happy, healthy life together, giving up drinking entirely and focusing on building their lives.

Jay still had some pain, which the alcohol had helped, but now depended on NSAIDs and over-the-counter medications if it flared. Despite this pain, he was constantly helping others. Then, around 2007, something changed. Over time, as we age, the intervertebral discs separating our vertebrae start to shrink. This is not noticeable at first, but by the time we are aged, we are usually at least an inch and often several inches shorter than when we were young. The nerves to our legs, arms, and our entire bodies come out between these vertebrae, and disc degeneration can cause problems here.

As the vertebrae get closer, they can start to press on these nerves. This is most common in the neck and lower back, as these more mobile spine areas seem to wear out sooner. For Jay, it started with a loss of feeling in his legs, and he started falling. And there was also pain. No one who has not experienced severe nerve pain can understand the realities of this condition, where the very pain reporting system is coopted to send a constant signal at maximum volume. Sometimes inversion tables and stretching can give some relief, but often not. When these fail, it is time to see the doctor again.

The first-line therapy for someone with structural back pain, as Jay had, would be physical therapy and medications. NSAIDs are used cautiously as they have serious side effects and risks; then stronger medications, perhaps tramadol if there is no history of seizures, codeine if the patient is able to metabolize it effectively, about 16% of the population cannot, and gabapentinoids specifically for nerve pain as well as some antidepressants. The spinal interneurons in the descending pain inhibitory pathways use serotonin; boosting serotonin in the substantia gelatinosa might relieve some.

None of these medications come without risk, and this seems to be something the DEA just does not understand. They are adamantly opposed to the use of opiates, although NSAIDs kill more people than heroin. Or that the gabapentinoids’ side effects frequently include low back pain and muscle aches, the exact symptoms we are trying to treat. Or that antidepressants can increase the risk of suicide, as can gabapentinoids, or that alcohol is often used to moderate pain in the untreated and is much more dangerous than any of these. The DEA does not have the expertise to understand this.

The doctors in Jay’s case tried everything reasonable. From 2008 to 2011, he had steroid shots, nerve blocks, and a spinal cord stimulator. He was also prescribed opiate medications, which helped ease his pain and make it more tolerable, giving him some quality of life. One of the other problems with chronic back pain is that it limits our mobility and activities, which leads to postural muscle atrophy and weight gain, removing structural support while adding extra stress to the spine when it’s already failing under its current load. Jay’s pain got worse despite these interventions, and he had a third back surgery.

Despite this, his pain continued to worsen as time went by, and a morphine pump was installed. Morphine pumps, also called intrathecal pumps, are placed under the skin with a catheter leading into the spinal canal. The very first intrathecal injection was back in the late 1800s and used cocaine mixed with morphine, which is not as crazy as it sounds, as cocaine is an excellent local anesthetic, still used today for nasal surgeries. The first implantable one was placed in 1981 for a cancer patient, and their use has increased over the decades if a trial shows that they would be effective.

These are now battery-powered with an injection port to refill the medication, and they work well for some. Even if the pump works for baseline pain control, chronic pain fluctuates with sleep quality, activity, mood, and a thousand other things, including the weather. Jay was on breakthrough pain medications to control this well-known, studied, and documented issue. The constant level of severe pain was taking a toll on Jay in many ways, but mainly on his mental state. There are many theories on why this might be the case, but I think that it is the result of severe chronic sleep deprivation.

It is well known that the human brain cannot continue to function well without sleep. And that low-quality sleep, while keeping us alive, can still lead to mental problems. Toxins that are not removed build up, and stress hormones spike, creating a neurotoxic environment that inhibits neuroplasticity and neurogenesis. No one does well without sleep, and sleep deprivation, dementia, and even death are well-documented. In any event, the severe stress from the pain began to take a toll on Jay’s mind. Jay developed the confusion we would all have if we stayed up just two nights in a row, and it got worse.

Over time, he developed what was called trauma-induced dementia, but not all his doctors agreed on this diagnosis. A better term might be chronic stress-related dementia, but I think we should call it what it is: dementia as a result of unrelieved suffering. I’ll even abbreviate it DUS so doctors take it seriously. Jay had also been suffering from anxiety and PTSD and had been on alprazolam as well as 120 mg of morphine daily through the pump. That’s 120 MMDE and twice the CDC recommendation for opiate-naïve patients starting opiate therapy by primary care doctors. None of these apply to Jay.

The 2016 CDC guidelines clearly state that they were not meant for patients like Jay; that doesn’t stop the DEA. You can see where this is going. Now, being on benzodiazepines and opioids was very common for about a half-century. Many people with severe chronic pain have severe anxiety, often from whatever process caused their pain but sometimes from stewing in stress hormones released because of the pain. The mechanism is simple. Pain is reported to the amygdala from the insula and thalamus. The amygdala sends a distress signal to the hypothalamus, which activates the sympathetic nervous system.

Epinephrine levels rise, the heart rate goes up, the respiratory rate goes up, norepinephrine is released in the periaqueductal gray matter, and we become more awake and alert, and we can then escape whatever is hurting us. Except in the case of severe chronic pain. That we cannot escape. When we experience chronic pain, a signal goes out to the locus ceruleus to avoid sleep and to the hypothalamus again to release corticotropin-releasing hormone (CRH), which travels to the pituitary and triggers the release of ACTH, releasing longer-acting stress hormones that keep our bodies on high alert.

But over time, like constantly revving a car engine, we increase the risk of breakdown. When the CDC came out with its guidelines, it made clear they were voluntary and a single factor of consideration for the doctors alone. That didn’t stop local and federal governments from enforcing those recommendations for a few as mandates for everyone. With state medical boards and the VA suspending pain specialists for “exceeding the CDC’s mandatory maximum,” it did something much, much worse. It gave the DEA another false metric they could use to target pain doctors and patients.

If a patient died in their sleep for any reason while on more than 90 MMDE, or even less in some cases, a jury would be told that the doctor was an “overprescriber,” defined as anyone who exceeded the “usual” or the CDC recommendation. This included all doctors who treated patients with the highest levels of pain. Then, those prescribing benzodiazepines and opiates together were excoriated and even prosecuted for “prescribing dangerous medications in dangerous combinations,” a totally invented crime, and for “ignoring the risk of overdose.” (Prescription medications cause less than 7% of these.)

A patient dying while on a medication does not mean that they died because of the medication. But the authorities had a new “tool” in the war on drugs, and doctors were a lot safer to target than real drug dealers, who sometimes shoot back. Medical offices started being raided by black-clad DEA stormtroopers, and every doctor treating pain was terrorized, watching their colleagues hauled away. I remember this time well and recall telling my patients that I would have to adjust their medications because of new state and federal mandates, but still, I tried to do so with compassion and reason.

But that’s not what happened to Jay. His pain specialists weaned back his alprazolam, not because they thought it was best for him to do so, but because they felt it was safer for them. Jay ended up on one a day to help him sleep, but the worsened anxiety made this almost impossible, and he would stay up until the early morning hours, exhausted but unable to rest. His wife began sleeping in another room because of his tossing and turning, but they still enjoyed watching television and walking their dogs on good days. On bad days Jay had to stay in his chair with tears running down his face.

In January of 2017, Jay’s doctors decided it was too risky for them to continue his dose of morphine. They also said they would not continue treating him as a patient if he stayed on alprazolam, even though it was prescribed by a different doctor. Jay’s wife begged them to reconsider, but they would not, and I understand why. They were scared. Scared people make poor decisions, and they do not want to go to prison. The doctor said, “My patient’s quality of life is not worth losing my practice over.” I understand how he felt, and I cannot say that he was wrong in his assessment.

I can say that he failed his most sacred obligation to his patient. Medicine is a special calling, and to those who have sacrificed years of their lives in study and student loans, its practice is a special privilege and reward. Or at least it used to be. I cannot say that it is now. Doctors are retiring or just quitting in droves, and I don’t blame them either. How smart is it to stay on the battlefield when the enemy has all the guns and ammunition? What point is there in fighting to the bitter end if you know that you will lose? And that is where my greatest personal vulnerability exists. The Marines did not teach me to quit.

In almost identical circumstances as those doctors treating Jay, I made the decision to continue my patient’s medications, diazepam, and oxycodone in that case, and for that, I am looking at prison time. The government said that I “prescribed a dangerous combination” and that I “ignored the risk of overdose.” And when my patient died alone and terrified in a jail cell after being denied medical care for eight hours, not having taken his medications in twenty, the family was told he died of an overdose. The DEA tried to give me life in prison on this premise, and while they failed at that, I could still get twenty.

Despite the coroner’s report clearly saying that, while a contribution from overdose or withdrawals cannot ever be completely excluded, the death was from a cardiac problem, in this case, heart failure. I had long thought that the stress of my patient’s pain and anxiety, if untreated, would increase his risk of death more than continuing the medications. The police proved me right when they took these from him, and he died. But Jay’s doctors did the safe thing. For them anyway, and reduced his medications, even claiming when challenged that too many patients were “making up” their pain complaints.

Jay and his wife got in their car to leave, and he told her this might be it for him; he didn’t think he could continue to live if the pain was worse. Jay’s Xanax was stopped, and over the next month, February, his morphine was decreased. Immediately, his pain and suffering increased. Despite this, Jay did not forget Valentine’s Day, buying jewelry for his wife for the first time since their engagement and taking her out to dinner. His medications were scheduled to be decreased again in March. The night before that appointment, Jay decided that his personal battle of a quarter-century was over.

He woke up his wife to say goodbye and discussed how he would end his suffering. He did not have enough pills to do the job, but he did have, as most Americans do, a gun. They drove to the park where they had renewed their vows in 2015 and parked. With Meredith holding his hand, he pointed the gun at himself and pulled the trigger. His wife’s immediate reaction was horror but also relief, knowing that his ordeal was over and that he could finally rest. The authorities saw things differently and decided to arrest and prosecute Meredith for “assisting a suicide.” She was put on probation.

Packed away for safekeeping, I have several uniforms. One is a Marine dress uniform that I hope to be buried in when the time comes. Another is my Air Force dress uniform and the blue missileer’s flight suit I wore when I had command and control of nuclear weapons. Back in my Strategic Air Command and Space Command days, that now seems like another lifetime. On those uniforms are not a few ribbons, badges, and medals; among others, there is one for national defense service, another for air force achievement, and a presidential unit citation.

They mean a lot to me, but I can tell you right now I have never faced an ordeal or suffered as much as Jay in the battle he fought. If I ever do, I hope to be as strong as he was for all those years. None of us know how long we could stand up to the agony of severe chronic pain. Doctors who’ve never felt it will doubt it, and the sadists and psychopaths among us, and we have not a few, will even laugh at the suffering. Not long ago, one of these laughed about women being traumatized in childhood, and another said, “Dead is dead,” to a colleague lecturing about the increase in chronic pain-related suicides.

Dead, as many veterans suffering chronic pain would affirm, is indeed dead, doctor. And that should matter to you. I would also like to point out that often, in our consideration of the fallen, we neglect to remember the other casualties of war. Those who earn the military’s most feared honor: that of being a “gold star” mother, father, or widow. This appellation grants you nothing but a reminder of what was taken from you. With that thought in mind, let me speak for a moment about the courage, dedication, and absolute strength of Meredith Lawrence. While Jay was a true warrior, her strength was divine.

L. Joseph Parker is a distinguished professional with a diverse and accomplished career spanning the fields of science, military service, and medical practice. He currently serves as the chief science officer and operations officer, Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity into the realms of space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions for the complex challenges of space travel, including space transportation, energy storage, radiation shielding, artificial gravity, and space-related medical issues. 

He can be reached on LinkedIn and YouTube.