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Inability to track prescriptions adds to Marine drug abuse problem, IG finds

This is the fifteenth story in an ongoing series.

Leaders of the Marine Wounded Warrior Battalion at Camp Lejeune, N.C., consider combating the abuse of both illegal and prescription drugs their No. 1 priority, but they cannot track the use of these drugs due to problems with the Defense Department's electronic health record system, the Defense inspector general reported last week.

Camp Lejeune Wounded Warrior managers also told the IG that they wanted to control the use of prescription drugs with an electronic pill-dispensing machine, but the Navy Bureau of Medicine nixed the idea because it is a proprietary system.

The IG visited the Camp Lejeune Wounded Warrior Battalion in the fall of 2010. Unit leaders reported that prescription and illegal drug abuse resulted in "inadequate order and discipline and risks to physical health and safety, [which] may have negatively impacted the warriors' recovery and prolonged their transition time."

The battalion commander said drug dealers in nearby towns preyed on members of the unit. Another senior leader said the command was working with local authorities to prosecute five cocaine cases. The battalion commander told the IG that he believed only 10 out of the 400 Marines in the unit had drug problems.

But the IG reported the commander expressed concern that most if not all Marines in the battalion were on "serious medications" as a result of their wounds, illnesses or injuries. He believed many Marines were predisposed to addiction and although Navy medicine was trying to "catch up" with this state of affairs, there were still a number of Marines needing assistance with pain management and addiction counseling.

Read the entire Broken Warriors series.The problem was compounded by "the perception from Washington" that combat-wounded Marines should be given a break, the leadership of the Wounded Warrior unit told the IG.

Naval Hospital Camp Lejeune did not have specific medication management policies or procedures in place to manage medications, the IG reported. Marines were prescribed multiple medications, some of which were controlled substances. As a result, Marines were at risk of having adverse reaction from these medications interacting with each other, which could derail their health and recovery, the IG said.

A Wounded Warrior case manager told the IG it was difficult to track multiple drug prescriptions since Marines in the unit obtained prescriptions from off-base providers, which amplified the polypharmacy problem. The battalion instituted a policy to have pharmacists produce a written report listing patients who were prescribed five or more controlled medications in a two-month period.

A pharmacist said it was difficult to reconcile prescriptions from off-base providers with the Composite Health Care System electronic medical record module in the Defense Armed Forces Health Longitudinal Technology Application. AHLTA is the electronic health record used in the hospital.

Dr. Karen S. Guice, principal deputy assistant secretary of Defense for health affairs, in a Feb. 10 reply appended to the IG report, acknowledged the disconnect between CHCS and AHLTA.

Currently, she said, Defense clinicians are able to document medication orders by "DoD providers, but are unable to do so for non-DoD providers, to include VA and civilian providers."

Accomplishing this would require two system changes to AHLTA and CHCS, which Guice said are expected to be funded in fiscal 2014.

An Army doctor who declined to be identified told Nextgov, "the AHLTA medication module is a mess. Most clinicians have given up relying on automated tools in AHLTA to track and document medication use and have resorted to free-texting this information." As a result, he said, "when I need to, I manually type in the list of medications the patient is taking. This is time-consuming and is a reversion to the free-text note format that [Defense Health Affairs] has been unsuccessfully trying to wean physicians from with the failed AHLTA architecture."

He added: "The main problem is that AHLTA is now fed by so many systems that the interface appears to have become broken. While the system used to work reasonably well when AHLTA was being fed only by local CHCS hosts at [military hospitals], now it appears that it is getting fed by some civilian pharmacy feeds, VA and possibly some theater data. I believe it really broke with the latest upgrade to AHLTA, which was otherwise a pretty good update."

Stan White, a retired high school teacher whose son Andrew, a Marine Iraq veteran, died in his sleep due to what White views as an overdose of prescription drugs supplied by the Veterans Affairs Department, said while the IG report shows Defense finally is acknowledging there is a problem with overprescribing and tracking drugs, he cannot comprehend why it still cannot track prescriptions. "I do not understand with the modern electronic technology why it is so difficult to maintain and track the medical record of our troops." White said.

Dr. Peter Breggin, an Ithaca, N.Y., psychiatrist who questions the use of psychotropic drugs, said the IG report shows "that overmedicating and polydrug prescription is out of hand. It does not get at the root problem, which is stopping psychiatrists from prescribing all these drugs."

To control the use of prescription drugs, senior leaders in the Wounded Warrior Battalion recommended installing an Electronic Medication Management Assistant system, a computerized medication dispenser for either inpatient or outpatient use. The Army at Fort Bragg, N.C., uses EMMA.

Despite potential benefits, the battalion was unable to get approval to use EMMA from the Navy Bureau of Medicine because it was concerned the system might not be compliant with the 1996 Health Insurance Portability and Accountability Act known as HIPAA, the IG reported.

Vice Adm. Matthew Nathan, the Navy surgeon general, said in a Jan. 31 response to the IG report that EMMA is a vendor-specific system and there are other electronic and nonelectronic ways to manage drug dispensing in the wounded warrior barracks.

Lt. Col. N.E. Davis, commander of the Camp Lejeune Wounded Warrior Battalion, said in a Dec. 22, 2011, reply to the IG report that in order to control drug abuse the unit issued a new prescription reconciliation policy in October 2011 focused on medication inventory, pain management, and identification of and assistance to high-risk patients.

This policy bars personnel in the unit from going to medical providers or clinics in the civilian community unless they are authorized by the unit or the detachment's primary care manager.

The Wounded Warrior Battalion also has established a urinalysis screening program to test for drug use, Davis said, and has tapped the Naval Criminal Investigative Service to search for drugs in the barracks.

Breggin said military leaders must do much more. "There needs to be a complete overhaul from the top down of military psychiatry to stop the current policy of pouring drugs into our soldiers as if they were a combination of experimental guinea pig and marketing bonanza for the drug companies," he said.

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