Some of the accusations that led to the withdrawal of White House physician Ronny Jackson as Donald Trump's nominee to run the Department of Veterans Affairs raised serious questions that were relevant to his fitness for the job. But the complaints about his distribution of sleeping pills and stimulants revealed more about our culture's hypocrisy and inconsistency on the subject of performance-enhancing drugs.
In a CNN interview on Tuesday, Jon Tester, the senior Democrat on the Senate Veterans' Affairs Committee, said Jackson, a Navy rear admiral who has directed the White House Medical Unit since 2013, would "hand out the prescription drugs like they were candy" during international flights. Jackson reportedly would offer journalists and White House staffers traveling with the president Ambien to help them sleep and Provigil to keep them awake and alert the next day.
Although Tester found this practice shocking (or at least pretended to find it shocking), White House Chief of Staff John Kelly called it "standard operating procedure." As CBS News noted, "Both officials and journalists have used sleep aids on overseas flights for practical reasons—in order to help them adjust to time zone differences more quickly in what is usually a compressed travel schedule. And Jackson is neither the first nor the only administration doctor offering sleeping aids to officials and journalists traveling on long overseas trips."
Politico interviewed "nearly a dozen current and former officials," including "some who were treated by Jackson while working in the Obama White House," who said "Jackson is being unfairly labeled as a 'candy man' and that casual use of some prescription drugs is an established fact of life at the highest echelons of government." Some of those sources said that without sleeping pills and stimulants, "it's impossible to keep up with the physical demands of working a full day off a long-haul flight, which is expected when U.S. officials travel overseas." Several of Tester's Senate colleagues, including Richard Durbin (D-Ill.), John Cornyn (R-Texas), and Marco Rubio (R-Fla.), agreed that Jackson's distibution of Ambien and Provigil was perfectly appropriate.
Tester was having none of it. "These are called controlled substances for a reason," he told CNN. "We have a prescription drug problem in this country," he told The New York Times, "and if we have doctors at the highest levels who are just handing them out like candy, we have a problem."
Yet there is no evidence that the sleeping pills and stimulants Jackson or his predecessors distributed caused any problems. To the contrary, they helped government officials and the reporters accompanying them sleep when they needed to sleep, stay awake when they needed to stay awake, and do the jobs they needed to do. So what's he problem? The problem is that such utilitarian, work-oriented use of psychoactive substances does not fit very neatly into our system for dispensing prescription drugs, which is based on the premise that doctors are using medicine to treat diseases.
Politico notes that "use of Provigil to help people stay awake in stressful situations or after long travel is not an FDA-approved use," although "doctors can legally prescribe medicines for unapproved uses." The FDA says Provigil "is indicated to improve wakefulness in adult patients with excessive sleepiness associated with narcolepsy, obstructive sleep apnea (OSA), or shift work disorder (SWD)." Although that last one sounds promising in the context of hard-working, hard-flying, jetlagged White House personnel and members of the press, shift work disorder is supposed to be a chronic problem rather than a one-time issue related to a particular trip or project.
How about "acute shift work disorder"? If Jackson had uttered that phrase or written it on a piece of paper while handing out Provigil, would that have made his prescriptions more ethical or legitimate?
The FDA's description of Ambien's function is more flexible. It says "Ambien is indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation." If you have trouble getting to sleep, you have insomnia, which is a disease your doctor can treat with sedatives like Ambien.
What if you don't actually have insomnia but anticipate that you will, as presumably was the case with most of the people who got sleeping pills from Jackson during presidential trips? No problem: Ambien also can relieve insomnia anxiety disorder, which certainly sounds like a credible off-label use, even if the condition is one I just invented.
Although Jackson's distribution of sleeping pills and stimulants seems perfectly defensible, it is still a bit jarring to see John Kelly defend it. After all, this is the former Marine Corps general who, according to Attorney General Jeff Sessions, refused to take prescription opioids after he had hand surgery, despite the fact that he was in considerable pain. I'm not sure what principle Kelly thought he was defending by rejecting drugs that could have safely and effectively relieved his pain. But apparently that principle is consistent with relying on drugs to sleep while off duty and stay alert while working. In fact, as Politico notes, the military has a long history of relying on "go" and "no-go" pills.
To some extent, the perceived propriety of using performance-enhancing drugs depends on who you are. While it is pretty common for Americans to take sedatives like Ambien while traveling, obtaining prescription stimulants is harder and may require discovering a hitherto undiagnosed case of attention deficit hyperactivity disorder. Air Force pilots do not have that problem, and neither do people who work "at the highest echelons of government."
Special exceptions aside, we prefer to think that people who use prescription stimulants are treating a disease or compensating for a disability, as opposed to hitting a deadline, cramming for an exam, impressing their bosses, or beating the competition. Medicalizing drug use is reassuring, since it puts the experts in charge and certifies that "controlled substances" are not being abused. But the difference between use and abuse depends on costs and benefits, not the presence or absence of a doctor's note.