By Bob Brewin
January 18, 2011
Army leaders are increasingly concerned about the growing use and abuse of prescription drugs by soldiers, but a Nextgov investigation shows a U.S. Central Command policy that allows troops a 90- or 180-day supply of highly addictive psychotropic drugs before they deploy to combat contributes to the problem.
The CENTCOM Central Nervous System
Drug formulary includes drugs like Valium and Xanax, used to treat depression, as well as the antipsychotic Seroquel, originally developed to treat schizophrenia, bipolar disorders, mania and depression.
Although CENTCOM policy does not permit the use of Seroquel to treat deploying troops with these conditions, it does allow its use as a sleep aid, and allows deployed troops to be provided with a 180-day supply, even though the drug has been implicated in the deaths of two Marines who died in their sleep after taking large doses of the drug.
The Army endorsed Seroquel as a sleep aid in the May 2010 report of its Pain Management Task Force, which, among other things, called for a reduction in the number of prescription drugs given to troops. An appendix to that report recommended taking Seroquel in either 25- or 50-milligram doses for sleep disorders.
A June 2010 internal report from the Defense Department’s Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other controlled substances.
Dr. Grace Jackson, a former Navy psychiatrist, told Nextgov she resigned her commission in 2002 “out of conscience, because I did not want to be a pill pusher.” She believes psychotropic drugs have so many inherent dangers that “the CENTCOM CNS formulary is destroying the force,” she said.
Dr. Greg Smith, who runs the Los Angles-based Comprehensive Pain Relief Group, which treats chronic pain and prescription drug abuse through an integrative medical approach called the Nutrition, Emotional/Psychological, Social/Financial and Physical program, said he was shocked by CENTCOM’s drug policy for deployed troops. “If I was a commander I’d worry about what these troops would do,” as a result of their medications, Smith said.
Dr. Peter Breggin, an Ithaca, N.Y., psychiatrist who testified before a House Veterans Affairs Committee last September on the relationship between medication and veterans’ suicides, said flatly, “You should not send troops into combat on psychotropic drugs.” Medications on the CENTCOM CNS formulary can cause loss of judgment and self-control and could result in increased violence and suicidal impulses, Breggin said.
The Army implicated prescription drugs as contributing to suicides in a July 2010 report, which said one-third of all active-duty military suicides involved prescription drugs.
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,” Chiarelli said.
But when it comes to the CENTCOM CNS formulary — which for some drugs allows a 180-day supply when troops deploy, followed by a 180-day refill in theater, according to an October 2010 update to the psychotropic drug policy — neither the Army nor CENTCOM sees a need for change.
In an e-mailed statement to Nextgov, Col. John Stasinos, chief of addiction medicine for the Army surgeon general, and Col. Carol Labadie, pharmacy program manager in the Directorate of Health Policy and Services for the surgeon general, said soldiers are supplied with up to 180 days of medications because they “serve in remote areas without easy access to pharmacies. It is important that soldiers on chronic medications do not run out of them during combat operations, because not taking the medications can be as dangerous as taking too much medication.”
Abuse of prescription drugs, Stasinos and Labadie said, can be prevented by improved communication among health care providers, soldiers and commanders. Comprehensive reviews of soldiers’ medication profiles by pharmacists are another way to prevent abuse, they said.
The statement from Stasinos and Labadie added that it is possible that troops could receive a 180-day supply of more than one psychotropic medication.
Navy Lt. Cmdr. William Speaks, a CENTCOM spokesman, echoed comments from the Army. He said the drug-supply policy for deployed troops was “established to ensure personnel who required these medications had an adequate supply before deployment to last through pre-deployment activities and training as well as travel to theater and initial deployment phase.”
He added, “Some of these medications can cause duty-limiting side effects if they are withdrawn abruptly [i.e. if the individual runs out]. This policy prevents that from occurring.”
Speaks said, “Abuse is always a possibility the prescribing clinician must consider … demonstration of clinical stability, medication quantity limits and in-theater review of prescriptions reduces the potential for abuse.”
Suicide and Drug Abuse
The Army’s suicide report drew a link between a significant increase in prescription drug use among troops and the service’s rising suicide rate. It also raised serious concerns about troops trafficking in prescription drugs.
Jackson, the former Navy psychologist, now has a civilian practice in Greensboro, N.C. She said at least one drug on the CENTCOM formulary — Depakote, an anticonvulsant, which military doctors prescribe for mood control — carries serious physical risks for troops. Depakote is toxic to certain cells, including hair cells in the ears, and can lead to hearing loss. Troops in a howitzer battery who already run the risk of hearing loss should not take Depakote, she said.
The medication also can cause what she calls “cognitive toxicity,” also known as Depakote dementia, impairing a person’s ability to think and make decisions. Jackson said that while Depakote has been investigated as an adjunct therapy for cancer, its use has been limited due to the drug’s effects on cognition.
The antidepressant Wellbutrin, also on the CENTCOM formulary, likely poses a long-term risk of Parkinson’s disease, especially for older troops, said Jackson, author of Drug-Induced Dementia: A Perfect Crime (AuthorHouse, 2009).
Jackson and Breggin both expressed deep concerns about Xanax, perhaps the most addictive of all benzodiazepines, a class of depressant medications used to treat anxiety, on the CENTCOM formulary.
Breggin, author of Medication Madness: The Role of Psychiatric Drugs in Cases of Violence, Suicide and Crime (St. Martin’s Griffin, 2009), called Xanax “solid alcohol” and said all the benzodiazepines on the CENTCOM formulary “amount to a prescription for abuse.” He also said there is no rationale for prescribing multiple psychotropic drugs to troops.
Smith said he was “flabbergasted” that military doctors prescribed Seroquel as a sleep aid, as the Food and Drug Administration has not approved such a use and other drugs are more effective. Breggin agreed, calling Seroquel “very dangerous, expensive and not proven to be more beneficial than other drugs.”
Jackson noted Seroquel has the addictive potential of opioids, such heroin.
CENTCOM’s allowance of Seroquel as a sleep aid also seems to fly in the face of a high-level Defense policy set in November 2006. In a memo titled “Policy Guidance for Deployment Limiting Pyschiatric Conditions and Medications,” William Winkenwerder, then assistant secretary of Defense for health affairs, said psychotropic medications that would prohibit troops from deployment included those used to treat chronic insomnia.
Asked if prescribing Seroquel to aid sleep violated this policy, Stasinos and Labadie said in an e-mail, “Seroquel is not prescribed for chronic insomnia. Lower doses have been used to aid soldiers with troubled sleep for anxiety-related nightmares.” They added while other sleep medications are on the CENTCOM formulary, none appears to relieve nightmares as effectively as Seroquel.
Laura Woodin, a spokeswoman for the U.S. division of London-based AstraZeneca, which makes Seroquel, said the drug is not approved by the FDA as a sleep aid or to treat post-traumatic stress disorder. But, she added, mental health professionals often prescribe it to treat conditions not approved by the FDA. “Like patients, we trust doctors to use their medical judgment to determine when it is appropriate to prescribe medications,” Woodin said.
Stan White, a retired high school teacher who lives in the small town of Cross Lanes, W.Va., has observed the effects Seroquel can have. When his son Andrew returned from a tour in Iraq with the Marine Reserve 4th Combat Engineer Battalion in 2007, he was diagnosed with post-traumatic stress disorder and was prescribed three psychotropic drugs, including Seroquel, by the Huntington Veterans Affairs Medical Center, White said.
VA started Andrew on 25 milligrams of Seroquel a day and upped the dose to 1,600 milligrams a day (the CENTCOM-approved dose is 25 milligrams a day). Andrew White died in his sleep Feb. 12, 2008, six months after seeking help.
White said Andrew was so befuddled by his drug cocktail, which included Klonopin, a benzodiazepine, and hydrocodone, an opiate, that his wife, Shirley, had to dole them out forAndrew. White said Seroquel did not diminish Andrew’s nightmares at even such a high dosage.
While talk therapy is widely viewed as one of the most effective treatments for some mental health problems, including PTSD, White said Andrew had only a few such sessions, primarily with a local veterans’ peer therapy group. It was not until the week Andrew died that a VA psychiatrist decided to begin intensive sessions with him.
Stan White says his mission in life today is to expose the dangers of Seroquel. The drug, he said, “turns people unto zombies. I cannot imagine going into battle on Seroquel.”
MEDS AND MREs
Some of the drugs on the CENTCOM Formulary of CNS Medication Restrictions require patients to follow restricted diets, a tall order for deployed troops operating in remote areas and eating a steady round of Meals Ready to Eat field rations, according to Dr. Peter Breggin, a psychiatrist.
At least three of the antidepressant drugs on the CENTCOM formulary are monoamine oxidase inhibitors, which also exist in the intestine and help break down a substance in food know as tyramine.
MAOIs on the formulary include Marplan, Nardil and Parnate, and patients taking these drugs should avoid foods that contain significant amounts of tyramine, which interferes with the action of natural tyramine in the intestines. If not, too much of the MAOI could enter the bloodstream, which could cause a hypertensive crisis due to elevation of blood pressure.
Foods in MREs that contain tyramine include pepperoni and cheese and, among the favorite snacks, raisins and peanuts.
MAOIs also increase the amount of norepinephrine, a hormone, neurotransmitter and blood vessel constrictor, and patients taking these medications should not be prescribed other drugs that could also increase norepinephrine levels. These include amphetamines, dextroamphetamine and Ritalin, which are also on the CENTCOM formulary.
Read article here: http://www.nextgov.com/nextgov/ng_20110118_8944.php?oref=topstory