Immigrants Sedated Without Medical Reason

by Amy Goldstein and Dana Priest | Washington Post Staff Writers

Michel Shango said he fled Congo after working as a journalist there. In America, he married and had children, but did not win asylum. Listen to Shango talk about his deportation experience.Press play to listen.

The U.S. government has injected hundreds of foreigners it has deported with dangerous psychotropic drugs against their will to keep them sedated during the trip back to their home country, according to medical records, internal documents and interviews with people who have been drugged.

The government's forced use of antipsychotic drugs, in people who have no history of mental illness, includes dozens of cases in which the "pre-flight cocktail," as a document calls it, had such a potent effect that federal guards needed a wheelchair to move the slumped deportee onto an airplane.

"Unsteady gait. Fell onto tarmac," says a medical note on the deportation of a 38-year-old woman to Costa Rica in late spring 2005. Another detainee was "dragged down the aisle in handcuffs, semi-comatose," according to an airline crew member's written account. Repeatedly, documents describe immigration guards "taking down" a reluctant deportee to be tranquilized before heading to an airport.

In a Chicago holding cell early one evening in February 2006, five guards piled on top of a 49-year-old man who was angry he was going back to Ecuador, according to a nurse's account in his deportation file. As they pinned him down so the nurse could punch a needle through his coveralls into his right buttock, one officer stood over him menacingly and taunted, "Nighty-night."

Such episodes are among more than 250 cases The Washington Post has identified in which the government has, without medical reason, given drugs meant to treat serious psychiatric disorders to people it has shipped out of the United States since 2003 -- the year the Bush administration handed the job of deportation to the Department of Homeland Security's new Immigration and Customs Enforcement agency, known as ICE.

Involuntary chemical restraint of detainees, unless there is a medical justification, is a violation of some international human rights codes. The practice is banned by several countries where, confidential documents make clear, U.S. escorts have been unable to inject deportees with extra doses of drugs during layovers en route to faraway places.

Federal officials have seldom acknowledged publicly that they sedate people for deportation. The few times officials have spoken of the practice, they have understated it, portraying sedation as rare and "an act of last resort." Neither is true, records and interviews indicate.

Records show that the government has routinely ignored its own rules, which allow deportees to be sedated only if they have a mental illness requiring the drugs, or if they are so aggressive that they imperil themselves or people around them.

Stung by lawsuits over two sedation cases, the agency changed its policy in June to require a court order before drugging any deportee for behavioral rather than psychiatric reasons. In at least one instance identified by The Post, the agency appears not to have followed those rules.

In the five years since its creation, ICE has stepped up arrests and removals of foreigners who are in the country illegally, have been turned down for asylum or have been convicted of a crime in the past.

If the government wants a detainee to be sedated, a deportation officer asks for permission for a medical escort from the aviation medicine branch of the Division of Immigration Health Services (DIHS), the agency responsible for medical care for people in immigration custody. A mental health official in aviation medicine is supposed to assess the detainee's medical records, although some deportees' records contain no evidence of that happening. If the sedatives are approved, a U.S. public health nurse is assigned as the medical escort and given prescriptions for the drugs.

After injecting the sedatives, the nurse travels with the deportee and immigration guards to their destination, usually giving more doses along the way. To recruit medical escorts, the government has sought to glamorize this work. "Do you ever dream of escaping to exotic, exciting locations?" said an item in an agency newsletter. "Want to get away from the office but are strapped for cash? Make your dreams come true by signing up as a Medical Escort for DIHS!"

The nurses are required to fill out step-by-step medical logs for each trip. Hundreds of logs for the past five years, obtained by The Post, chronicle in vivid detail deviations from the government's sedation rules.

An analysis by The Post of the known sedations during fiscal 2007, ending last October, found that 67 people who got medical escorts had no documented psychiatric reason. Of the 67, psychiatric drugs were given to 53, 48 of whom had no documented history of violence, though some had managed to thwart an earlier attempt to deport them. These figures do not include two detainees who immigration officials said were given sedatives for behavioral rather than psychiatric reasons before being deported on group charter flights, which are often used to return people to Mexico and Central America.

Even some people who had been violent in the past proved peaceful the day they were sent home. "Dt calm at this time," says the first entry, using shorthand for "detainee," in the log for the January 2007 deportation of Yousif Nageib to his native Sudan. In requesting drugs for his deportation, an immigration officer had noted that Nageib, 40, had once fled to Canada to avoid an assault charge and had helped instigate a detainee uprising while in custody. But on the morning of his departure, the log says, he "is handcuffed and states he will do what we say." Still, he was injected in his right buttock with a three-drug cocktail.

In one printout of Nageib's medical log, next to the entry saying he was calm,  is a handwritten asterisk. It was put there by Timothy T. Shack, then medical director of the immigration health division, as he reviewed last year's sedation cases. Next to the asterisk, in his neat, looping handwriting, Shack placed a single word: "Problem."
 
 

When he landed in Lagos, Nigeria, Afolabi Ade was unable to talk.

"Every time I tried to force myself to speak, I couldn't, because my tongue was . . . twisted. . . . I thought I was going to swallow it," Ade, 33, recalled in an interview. "I was nauseous. I was dizzy."

As he was being flown back to Africa, his American wife alerted his parents there that he was on his way. His father was waiting at the Lagos airport. It was the first time in three years that they had seen one another. Shocked by how woozy the young man was, his father decided not to take him home and frighten the rest of the family. Instead, he checked his son into a hotel.

Ade was in the hotel for four days before the effects of the drugs began to abate.

Part of a prominent Nigerian family, Ade asked The Post to identify him by only a portion of his name to protect their reputation. He had come to the United States as a college student in the mid-1990s. Five years later, he was in a car belonging to cousins when police found fraudulent checks in the trunk. He pleaded guilty.

After finishing his sentence, Ade was living in Atlanta, and was two semesters away from a telecommunications degree at DeVry University, when immigration officers came looking for him one day in January 2003. They wanted to deport him for the old crime. He called his probation officer to ask whether he could wait to surrender until he took his upcoming final exams. But when he went to the probation office, immigration officers were there to arrest him.

His records offer little explanation of why he was sedated. The one-page medical record in his file mentions one condition: chronic nasal allergy. The log of his trip does not mention mental illness; in the space to list current medical problems, a nurse wrote merely that Ade was anxious.

His drugging, however, fits a pattern that emerges from the cases analyzed by The Post: The largest group of people who were sedated had resisted attempts to deport them at least once before.

One summer day in 2003, deportation officers arrived at the rural Alabama jail where Ade was being held. Pack your bags, they told him. When they reached an immigration office in Atlanta, Ade recalled, half a dozen "big guys came to meet me and said I was there to be deported."

"I can't be deported," he replied. "I have a wife I love very much." Besides, he told them, he was still appealing his immigration case. He shouldn't have to leave, he protested, until the judge had ruled. That day, he was returned to Alabama. But he said that immigration officers warned him, "We'll find a way to get you on a plane."

A few weeks later, the officers came back and again took him to a holding cell in Atlanta. He was, the medical log says, becoming "increasingly anxious and non-cooperative per flt. to Nigeria." At 1:30 p.m., the log says, "Dt taken down by four" guards.

Ade was being held down, he recalled, when he noticed a nurse "with a needle and a bottle with some kind of substance in it." He said he told the guards: "Okay, fine, fine. If it's going to be like this, don't inject me. I will go on my own free will."

The nurse went ahead, the log shows, injecting him in the left shoulder with two milligrams of a powerful drug, Haldol, used to treat psychosis, and one milligram of an anti-anxiety drug, Ativan. He was injected with two more rounds, as well as a third drug, in progressively larger doses, during the trip.
The Sedation Cocktail More than 250 foreigners without mental illness have been sedated for deportation during the past five years. Most of them have been injected with a cocktail consisting of two or three drugs, although a few were given different medications in the earlier years.

During the 2007 fiscal year, ending in October, 53 people were sedated without a psychiatric reason, according to a Washington Post analysis based on government records. Fifty of them were injected with Haldol. All those people also were given Ativan, and all but three were given Cogentin as well. Two deportees received Ativan alone, and one person's medications were not clear from the records.

The effects of those injections are what alarmed Ade's father after the plane landed in Lagos. Yet the medical log says Ade arrived "alert and oriented."

His family's doctor, who visited him on each of the four days his father hid him in the hotel, had a different view. "He was groggy -- somebody under the influence of drugs or drunkenness," recalled Olakunle Adigun, a general practitioner. He couldn't figure out what sedatives his patient had been given, so he tried to detoxify him with saline infusions.

Ade's pulse was dangerously low, and when he tried to walk around the hotel room, "he leaned on the wall," Adigun said. "He was talking, but a slurred kind of speech."

* * *

Internal government records show that most sedated deportees, such as Ade, received a cocktail of three drugs that included Haldol, also known as haloperidol, a medication normally used to treat schizophrenia and other acute psychotic states. Of the 53 deportees without a mental illness who were drugged in 2007, The Post's analysis found, 50 were injected with Haldol, sometimes in large amounts.

They were also given Ativan, used to control anxiety, and all but three were given Cogentin, a medication that is supposed to lessen Haldol's side effects of muscle spasms and rigidity. Two of the 53 deportees received Ativan alone. One person's medications were not specified.

Haldol gained notoriety in the Soviet Union, where it was often given to political dissidents imprisoned in psychiatric hospitals. "In the history of oppression, using haloperidol is kind of like detaining people in Abu Ghraib," the infamous prison in Iraq, said Nigel Rodley, who teaches international human rights law at the University of Essex in Britain and is a former United Nations special investigator on torture.

For people who are not psychotic, said Philip Seeman, a University of Toronto specialist in psychiatry and pharmacology, "prescribing Haldol . . . is medically and ethically wrong." Seeman studied the drug in the 1960s and later discovered the brain receptors on which several antipsychotic drugs work.

The only circumstances in which small amounts of Haldol are appropriate for non-psychotic people, Seeman said, are when a person comes into a hospital emergency room violent and agitated from an overdose of a drug such as PCP, or when someone with severe dementia is delusional or combative. "You or I wouldn't get it if we were emotionally upset," he said.

In addition, Seeman said, typical doses to help psychotic patients accustomed to the drug are perhaps five to 15 milligrams a day. Several deportees were given a total of 30 milligrams, which Seeman characterized as "really high," especially for people who have never taken the drug before.

Even when used for its intended patients, people with psychosis, Haldol has drawn warnings from the U.S. government. In September, the Food and Drug Administration issued an alert citing "a number of case reports of sudden death" and other reports of dangerous changes in heart rhythm. It is, important, the FDA warned, to inject Haldol only into muscles, not veins, and to avoid doses that are too high.

"Pharma non grata" is the way Emergency Medicine News magazine described the drug after the FDA alert.

Beyond the specific drugs used, Rodley said, is a deeper question: "What is the least intrusive means of restraint consistent with the human dignity of the person? . . . I'd be very surprised if the injection of disabling chemicals against somebody's will that affect one's psychological well-being . . . is likely to be the least intrusive means."

Asked to explain the reason for using Haldol and other psychotropic drugs with people who are not mentally ill, ICE responded, "The medications used by Aviation Medicine are widely used in psychiatry." Agency officials said that medical escorts administer "the lowest dose possible." Combining Haldol and Ativan "allows you [to] use less of each," they said, and produces a quicker and longer sedative effect.

In the years before Ade was drugged, there had been an internal debate within the U.S. government over whether sedating deportees against their will is legal, according to confidential legal memos obtained by The Post. There was agreement that mentally ill people could be forced to take psychotropic medicine on their way out of the country. At dispute were cases in which the detainees were not mentally ill but combative -- known as "behavioral cases."

Near the end of the Clinton administration, Health and Human Services lawyers  sent around a memo that warned, "[U]sing chemical restraints in cases in which medication is not clinically indicated . . . may put the government at risk of potential liability."

Another memo went further, concluding that it could be done only if a federal judge gave permission in advance. "[R]egarding detainees who are not mentally ill," the November 2000 document said, "involuntary medication of such persons for the sole purpose of subduing them during deportation, without a court order, is not supported by any legal authority and raises ethical issues, as well.

"After the Sept. 11, 2001, attacks, and after the Bush administration assumed a tough new stance on immigration in its campaign against terrorism, the Justice Department still sounded wary about drugging deportees. In March 2002,  a Justice lawyer laid out two options. One choice, he wrote, was to "seek a court order . . . in every case where the alien's medication is not therapeutically justified." The other choice was to create a regulation to grant immigration officials explicit permission to sedate deportees, perhaps including safeguards that would give people a warning that they might be medicated -- and a chance to object.

Top immigration officials chose neither. Instead, in May 2003, just after ICE was created,  they internally circulated a new policy: "[A]n ICE detainee with or without a diagnosed psychiatric condition who displays overt or threatening aggressive behavior . . . may be considered a combative detainee and can be sedated if appropriate under the circumstances."

Here is a look at the major drugs in the government's sedation cocktail.

The Most Potent Drug

HALDOL (a.k.a. HALOPERIDOL)
Antipsychotic medication
Uses: Schizophrenia, psychosis induced by street drugs or any medical condition, persistent aggressiveness that may be a danger to patient or others, Tourette's syndrome, manic disorder
What it does: For people with severe psychiatric illness, can help them think more clearly, feel less nervous and prevent suicide in those who are likely to harm themselves. Can also reduce aggression and a desire to hurt others. Calming to psychotic people who hallucinate or are delusional. Produces a more "zombie-like" effect in non-psychotic people.
Side effects: Dizziness, drowsiness, difficulty urinating, trouble sleeping, headache, anxiety and pain at the injection site. May cause muscle spasms or stiffness, tremors, restless- ness, masklike facial expression, drooling.
Recommended daily doses: For aggressive behavior, 0.5 milligrams twice a day to 5 milligrams three times a day, although doses of up to 10 milligrams a day may be used in a hospital emergency room.

The Other Drugs

ATIVAN (a.k.a. LORAZEPAM)
Benzodiazepine
Uses: Anxiety, seizures, pre-surgery
What it does: Produces a calming effect on the brain and the central nervous system
Side effects: Dizziness, drowsiness, slurred speech, unsteadiness

COGENTIN
Anti-cholinergic agent that relaxes muscles by acting within the brain
Uses: Parkinson's disease, involuntary movements due to side effects of some psychiatric drugs, including Haldol
What it does: Helps decrease muscle stiffness, sweating and the saliva production, and helps improve walking ability in people with Parkinson's.
Side effects: Blurred vision, constipation, decreased sweating, drowsiness, dry nose, dry throat, painful urination, nausea

SOURCES: Medscape; WebMD; Philip Seeman, professor of psychiatry and pharmacology, University of Toronto