Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
Recent DoD reports on medication use among active duty service members deployed in support of conflicts in Iraq and Afghanistan indicate potentially problematic use of central nervous system (CNS)-acting drugs. According to the Army Institute of Public Health, 46% of those who completed suicides, 90% of those who attempted suicide, and 87% of those with suicidal ideation received a CNS-acting prescription in the year preceding the event. Prior studies in VA have tended to focus on individual classes of CNS drugs. This study examined the prevalence of CNS polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Investigators identified 303,716 Veterans who had served in Iraq and/or Afghanistan in support of post-9/11 conflicts, and who had received inpatient or outpatient VA healthcare from October 2009 through September 2011. Investigators then assessed the number of unique CNS medications dispensed from VA pharmacies during FY2011. Demographic and clinical characteristics, such as comorbid conditions associated with CNS polypharmacy (e.g., pain, PTSD, TBI, depression, anxiety, substance use disorder) also were examined.
- Of the 303,716 Veterans in this study, 25,546 (8%) had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors.
- Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy.
- The definition of CNS polypharmacy used for this study (five or more drugs) may be considered conservative compared to studies in elderly adults using two or more CNS drugs.
- Investigators did not examine the simultaneous use of medications, dosing, adherence – or whether medications were scheduled or used as needed.
- ICD-9 codes were used to identify suicidal ideation and attempts, which results in a conservative asessement, as data on completed suicides were unavailable.
- Data suggest that CNS polypharmacy may be used as a "trigger tool" to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
This study was funded through HSR&D (DHI 09-237). Drs. Pugh and Finley are part of the South Texas Veterans Healthcare System.
Collett G, Song K, Jaramillo C, Potter J, Finley E, and Pugh MJ. Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011. Drugs: Real World Outcomes. March 2016;3(1):45-52.