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The Pentagon is moving to limit off-label use of powerful anti-psychotic drugs for post-traumatic stress disorder — a practice some say may contribute to accidental drug overdoses among troops.
Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson sent a letter to the services in February asking military treatment facilities to monitor prescriptions of atypical antipsychotics like risperidone and quetiapine, marketed under the brand name Seroquel.
The drugs, used to treat severe mental illnesses like schizophrenia and bipolar disorder, are sometimes prescribed to troops in lower doses to alleviate symptoms associated with PTSD and anxiety, including nightmares and irritability.
But when mixed with other prescriptions, they can be dangerous and sometimes fatal.
The Food and Drug Administration in 2011 added a warning label to quetiapine, saying its use with some synthetic opiates, including methadone, can increase the risk of a heart-stopping overdose.
In his letter, Woodson said the number of prescriptions for these antipsychotics jumped tenfold from 2002 to 2009, from 0.1 percent to 1 percent.
In fiscal 2010, 1.4 percent of all soldiers and 0.7 percent of Marines received prescriptions for Seroquel.
Side effects for these medications can include slow heart rates and high blood sugar levels. When combined with other medications that slow respiration and heart rate, including opiates and alcohol, they can exacerbate the problem.
The FDA said in a one-year period, 34 drug overdoses involved quetiapine, although none were fatal. Of those, 17 involved other medications.
Military death records obtained by Military Times in 2011 showed there were at least 68 accidental drug deaths among troops in 2009, up from 24 in 2001.
At least 430 troops have died from drug or alcohol use in the past decade.
At least one antipsychotic commonly prescribed for PTSD, risperidone, has fallen out of favor for off-label use. In 2011, VA researchers determined it worked no better than a placebo for PTSD symptoms.
VA and the Defense Department subsequently removed it from their list of recommended medications for PTSD, saying its potential harm outweighed the benefits.
The other atypical antipsychotics, including quetiapine, have not been tested for their efficacy in treating PTSD. In their guidelines, VA and DoD said care providers who use them for PTSD "must clearly document their rationale for concluding that the potential benefits outweigh the known risks."
Woodson's office is moving to ensure physicians account for prescribing these medications, especially for disorders outside the FDA recommendations.
In his memo, Woodson said military treatment facility commanders should monitor prescription and utilization patterns and flag providers who prescribe them the most for off-label use.
He suggested the services consider limiting prescription authority for anti-psychotics to psychiatrists.
"While off-label drug use is legal and has been an accepted and beneficial practice within the standard of care for many years, atypical antipsychotics are not Food and Drug Administration-approved treatments for anxiety disorders (including PTSD) or sleep disturbances," Woodson wrote. "Providers should use caution when these agents are used as sleep aids in service members substance use disorders."
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