Polypharmacy: Veterans and Substance Abuse

Authored by: Ariana Desai

Art by: Carla Hu

“These drugs were killing me,” recalled Doug Gresenz, a former U.S. Marine Corps Assaultman who was prescribed over a dozen medications before he lost the ability to walk and was left with permanent brain damage [1]. However, it is not just Doug who is left ruined by these prescriptions, but thousands of other veterans across the country. According to the National Institute of Health, more than 1 in 10 veterans are diagnosed with a substance use disorder. Furthermore, the rate of suicide among veterans was 34.7 per 100,000, compared with 17.1 per 100,000 for nonveterans [2]. Polypharmacy, the simultaneous prescription of powerful psychiatric drugs, continues to become more prevalent within the Veteran community and has had severe side effects. Patients are tranquilized to the point of numbness, gain weight, and experience a heightened amount of suicidal thoughts [3]. Furthermore, polypharmacy is sometimes associated with poor clinical outcomes, especially in older adults, including falls, frailty, impaired cognition, increased hospital admissions, and adverse drug reactions [4]. The most worrisome consequence of polypharmacy is the occurrence of therapeutic failures, adverse drug withdrawal events, and drug–drug interactions leading to hospitalization [5]. The VA has long been aware of the risks of overprescribing, and has internal research since at least 2016 showing the potential harms, including increased risk of suicide. The internal polypharmacy data “was pretty concerning,” said Dr. Shereef Elnahal, who headed the VA health system until early this year. He recalled a veteran advocate who told him about three veterans on more than five psychiatric drugs each who died by suicide, one after the other. [6]. The most prominent reason for why this problem has gone unaddressed for far too long is the VA’s inability to implement proper oversight in how these drugs are prescribed [7]. Doctors have failed to inform patients about drugs with suicide risk, and often offer psychiatric medications without referrals to therapy or other forms of rehabilitation. The best policy solution would be for the VA to invest more heavily into safer rehabilitation programs so that patients are able to recover without being dependent on prescription drugs. There should also be stricter regulations imposed on physicians so that drugs are prescribed in moderation and with transparency. One of the options that should be considered is implementing Prescription Drug Monitoring Programs (PMDPs) on a widescale basis. PMDPs are used to collect and facilitate information on prescription practices [8]. However, PMDPs often do not capture when a veteran receives medication through VA and Medicaid simultaneously. Since they are state-run, there is often uneven coverage since many states do not exchange data. Beyond its prescription-tracking mechanism, PMDPs also do not provide alternative forms of treatments. When clinicians feel pressured by PMDP alerts, they abruptly cut patients off medications; This leads to withdrawal symptoms, higher suicidality rates, and an increased risk of veterans obtaining them illicitly. Another option was enhancing transparency in prescription drug pricing by requiring disclosure slips to come with drugs. Veterans are often unaware of the disruptive side-effects of certain high-risk drugs, thereby making them more susceptible to harm and addiction [9]. Thus, providing additional information helps veterans to reclaim autonomy in making decisions about their health. Recommendations to improve this solution would be to both caution against harmful prescribing behaviors and taking action to prohibit them. By subjecting providers to penalties for noncompliance, these warnings will have more enforceability. Opioid overdoses are not simply a problem within our nation, but rather an epidemic. Through informed and meaningfully planned action, veterans can get the care they deserve. 

References:

1. Bohnert, Amy S. B., et al. “Accidental Poisoning Mortality among Patients in the Department of Veterans Affairs Health System.” Medical Care, vol. 49, no. 4, 2011, pp. 393–396.

2. “Drug Overdose Deaths in the U.S.” Centers for Disease Control and Prevention, 2023.

3. Finley, Erin P., et al. “Evaluating the Impact of Prescription Drug Monitoring Program Implementation.” Addiction Science & Clinical Practice, vol. 12, no. 1, 2017.

4. Fisher, Marc. “VA Polypharmacy and Its Risks.” 2024.

5. Gnjidic, Danijela, et al. “Polypharmacy Cutoff and Outcomes: Five or More Medicines Were Used to Identify Community-Dwelling Older Men at Risk of Different Adverse Outcomes.” Journal of Clinical Epidemiology, vol. 65, no. 9, 2012, pp. 989–995.

6. Maher, Robert L., et al. “Clinical Consequences of Polypharmacy in Elderly.” Expert Opinion on Drug Safety, vol. 13, no. 1, 2014, pp. 57–65.

7. Mark, Tami L., et al. “Association between Prescription Drug Monitoring Program Policies and Opioid Prescribing.” Health Affairs, vol. 39, no. 6, 2020.

8. “National Veteran Suicide Prevention Annual Report.” U.S. Department of Veterans Affairs, 2023.

9. “Prescription Drug Monitoring Programs (PDMPs).” Centers for Disease Control and Prevention, 2022.