By Bob Brewin
August 5, 2011
A Defense Department health advisory group in June backed the controversial practice of prescribing multiple psychotropic medications for individual troops, but also acknowledged the Military Health System lacks a unified pharmacy database to track prescription drug use.
"The use of multiple psychotropic medications may be appropriate in select individuals. Polypharmacy can constitute a balanced approach to optimize functioning," the Psychotropic Medication Work Group and Complementary and Alternative Medicine Work Group of the Defense Health Board said in a presentation at a June 14 board meeting.
But, in the same paragraph, the group reported the MHS does not have the ability to track the effects on patients using multiple psychotropic drugs, including adverse reactions that can occur from mixing medications. "However, individual clinical and population-level MHS data systems do not comprehensively detect polypharmacy, adverse drug-drug interactions or potential for abuse, particular[ly] in theater."
The Defense Health Board is a federal advisory group chartered to provide independent advice to the secretary of Defense to "maximize the health, safety and effectiveness of the United States Armed Forces" and the psychotropic medication work group was formed to examine and provide recommendations on prescription practices and use.
Military and private clinicians and the families of troops who died due to multidrug toxicity told Nextgov they viewed these recommendations by the Defense Health Board panel as potentially deadly.
The work group, chaired by Charles Fogelman, who runs an executive coaching firm in Silver Spring, Md., also said in its presentation that Defense does not have a pharmacy database that tracks medication use before, during and after deployment to combat. "DoD currently lacks a unified pharmacy database that reflects medication use across predeployment, deployment and postdeployment settings," the work group reported.
The presentation added, "MHS data systems are inadequate to understand and detect important clinical and pharmacy data in a timely fashion."
Read the entire Broken Warriors series.The work group also said that Defense's multibillion-dollar AHLTA electronic health record system lacks adequate links with data systems maintained by the Defense PharmacoEconomic Center, which manages prescription drugs for the military. "The AHLTA system is not sufficiently linked with pharmacy information. The [Military Health System PharmacoEconomic Center] has identified these areas as limiting and is working to identify a data structure for improved in-theater data collection."
Marianne Coates, a spokeswoman for the Defense Health Board, characterized the June 14 work group report as preliminary, and said it could contain some "inaccuracies and may or may not change" when the work group delivers its final report at the Aug. 8 meeting of the Defense Health Board.
Nextgov reported in its Broken Warrior series earlier this year that 20 percent of 1.1 million active-duty troops surveyed by the PharmacoEconomic Center, or 213,972 troops, took some form of pyschotrophic drug as of June 2010. In a July 2010 report, the Army said these prescription drugs have contributed to an epidemic of suicides.
When the suicide report was released, Gen. Peter Chiarelli, the Army's vice chief of staff, said the service needed to develop better controls for prescription drugs: "Let's make sure when we prescribe that we put an end date on that prescription so it doesn't remain an open-ended opportunity for somebody to be abusing drugs." The suicide report said prescription drugs were involved in one-third of the 162 suicides by active-duty soldiers in 2009. Another 101 soldiers died accidentally from the toxic mixing of prescription drugs from 2006 to 2009, the report said.
Congress has directed the Pentagon to improve its drug-tracking systems for the past two years. In June 2010, the Senate Armed Services Committee faulted Defense for its inability to monitor psychotropic drug use in combat zones and directed it to quickly develop "a reliable method to track and manage the prescription and use of pharmaceuticals, to include psychotropic medications, by deployed service members."
This June, the House Appropriations Committee noted that the department still cannot track prescription medications, particularly in combat zones. Defense must examine the feasibility of electronically transmitting such data, the committee said, so patient use and physician prescribing patterns can be monitored and tracked.
Capt. Nita Sood, a Public Health Service pharmacist who serves as chief of staff for the TRICARE Management Activity Pharmaceutical Operations Directorate, which falls under the Military Health System, said in an email response to a query from Nextgov that MHS is "actively working on the development of an interface" that will support transmission of pharmacy information from combat zones to the Pharmacy Data Transaction Service, the department's central prescription data repository.
Sood said she expected the pharmacy data exchange to be completed by Dec. 31.
An Army doctor, who declined to be identified, said the fact that Defense still cannot account for drug use in deployed settings "is a violation of law, which requires all treatments be recorded in a standardized manner both for clinical and for public health and epidemiological purposes." He added, "This is a deficiency that requires urgent action and one that should have been addressed years ago -- as early as 2007 -- when reports surfaced that this was a problem."
Dr. Allen Frances, former chief of psychiatry at the Duke University Medical Center, said he found it "incredible" that MHS cannot track prescriptions, since it deals with a finite and closely managed population. "One of their highest priorities should be a drug-tracking system," Frances said.
Frances likened polypharmacy treatment to "pure alchemy" because determining the effects of multiple psychotropic drugs is "scientifically impossible" due to the mass of data. As a result, he said, polypharmacy has not been studied adequately.
Doctors use multiple drug combinations to treat "symptoms rather than syndromes," Frances said, and if one drug does not work, they prescribe another. Then they prescribe yet another medication to treat the side effects of the other drugs, he added.
If military clinicians do prescribe multiple psychotropic drugs, MHS needs to monitor patients with a quality assurance program, Frances said.
Frances said advertising campaigns by pharmaceutical companies bear part of the blame for the explosion in the use of psychotropic drugs over the past several decades. "They're selling the illness to sell the pill," he said.
Dr. Peter Breggin, a psychiatrist in Ithaca, N.Y., said the worst cases he sees are patients prescribed multiple psychotropic drugs and he views the endorsement by the Defense Health Board for such an approach -- particularly in a combat environment -- as unethical. "There is no scientific basis for polypharmacy," Breggin said, adding that multiple drug cocktails "are potentially deadly."
Underscoring the scientific uncertainty surrounding psychotropic drug use The Journal of the American Medical Association reported Tuesday that a drug widely used by the Veterans Affairs Department as well as Defense proved ineffective in the treatment of post-traumatic stress disorder. That drug, risperidone, is the second most widely prescribed drug used by VA to treat the disorder, and the journal article said there was "no statistically significant difference between risperidone and [a] placebo" in the treatment of PTSD. The study included 193 Vietnam veterans and 63 Afghanistan veterans.
Jerry Bachus Jr. of Westerville, Ohio, knows well the deadly effects of multiple drug cocktails on troops. His brother, Marine Gunnery Sgt. Christopher Bachus, a 17-year veteran who served a full tour in Iraq in 2003 followed by an abbreviated tour in 2007, died in 2008 due to the combination of drugs in his system.
Bachus was found dead in his quarters at Camp Lejeune, N.C., on March 10, 2008, with 26 containers of prescription medications, many of them psychotropic drugs or pain medicines, found in his room and another in his car, according to the autopsy report. The medications included oxycodone, a powerful opiate painkiller; four separate prescriptions for lorazepam, a benzodiazepine tranquilizer; propanol, a beta blocker used to treat anxiety; divalproex for migraines; and Ambien a sedative used for sleep. Other medications found in Bachus' room included citalopram and risperidone, both used to treat depression.
The autopsy report by the Armed Forces Medical Examiner ruled the death of Christopher Bachus an accident due to multidrug toxicity. Jerry Bachus, who says he has great respect for the Marine Corps, called his brother's death "negligent homicide."
Jerry Bachus said his brother was first prescribed medications to treat PTSD after an Iraq tour in 2005. According to a review of his medical history attached to the autopsy report, these drugs included clonazepam, a benzodiazepine tranquilizer, along with citalopram and risperidone.
The medical history said Christopher Bachus was taken off his medications from January to July 2006, when he asked to be put back on due to continued anxiety. He was again prescribed citalopram, Seroquel, intended to treat bipolar depression, and trazodone, another antidepressant.
He was allowed to deploy with his unit to Afghanistan in 2007, but was soon ordered back to Camp Lejeune after it was discovered he was still taking multiple psychotropic drugs. According to his medical history, Christopher struggled to return to his unit and grew more depressed. Jerry Bachus said his brother, a social creature, became increasingly isolated, and "showed no signs of his former, extroverted self."
Christopher Bachus made one last visit to the Naval Mental Health Clinic at Camp Lejeune a week before his death. There he told a psychiatrist and psychologist he was on "the verge of breaking." As that point, Jerry Bachus said, his brother should have been hospitalized. Instead, he returned to his quarters alone. His body was discovered three days later.
The original version of this story incorrectly said the Military Health System's pharmacy data exchange was expected to be completed in September. The estimated completion date is actually Dec. 31. The story has been corrected.
By Bob Brewin
August 5, 2011