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4/9/2004

Army Pharmacists' Roles Increase with Mass Rotation of Troops

Donna Young

Pharmacists are playing a key role in one of the largest rotations in history of U.S. military forces, said Colonel Mike Heath, pharmacy consultant to the Army Surgeon General.

On November 5, 2003, the Department of Defense (DOD) started notifying thousands of active-duty soldiers and members of the National Guard and reserves that they were being called for duty to serve in Iraq and Afghanistan to relieve military forces serving in those countries.

Some military units had already deployed a month earlier to relieve troops in Iraq.

Altogether, the current military rotation operation, which is scheduled to be completed by May 1, involves about 250,000 troops, with about half of those soldiers departing from Iraq and Afghanistan and about half going to those countries.

The maneuver is the first "full change out" of troops in Iraq and the fifth rotation of troops in Afghanistan, Heath noted.

The Army is responsible for providing medical care to all active-duty soldiers and to reserve and National Guard forces once those soldiers are called for duty.

The top priority of the Army Medical Department is "to project and sustain a healthy and medically protected force," Heath said.

A six-month supply. Because most soldiers now deploying to Afghanistan and Iraq will be in those countries for at least one year, the Army recently decided to dispense a six-month supply of medications to soldiers with chronic conditions, he said.

That decision, Heath declared, has increased Army pharmacists' and pharmacy technicians' dispensing and counseling responsibilities and their role in ensuring safe and appropriate drug therapy for deploying forces.

During previous fighting operations, soldiers with chronic conditions were typically dispensed a 30-day supply but not more than a 90-day supply of medications, he noted.

But, Heath said, some "significant" medication-use issues surfaced during Operation Enduring Freedomthe ongoing military action in Afghanistan that began in October 2001and this past year during Operation Iraqi Freedom.

Some soldiers serving in those operations had difficulties receiving refills and ran out of their medications, he said.

If soldiers do not have access to needed medications, Heath said, "they are not going to be able to do their job that they have been trained to do as soldiers."

Another problem Army medical officials discovered was a lack of medication compliance for some soldiers with chronic conditions.

"We have a responsibility from the pharmaceutical care standpoint to ensure that a soldier is compliant on his or her medication," Heath said.

More soldiers on medications. There are many more prescription drug products on the market now than when military forces deployed to the Middle East for combat actions during the Gulf War in the early 1990s, Heath noted.

"We've come to realize that a lot more soldiers than ever before are on medications," he said. "Our experience to date is that somewhere between 10-15%, or about 20,000, of all U.S. Army deployed soldiers are on at least one medication to treat chronic medical conditions."

Since the U.S. military downsized its active-duty forces in the mid-1990s, the Army is increasingly relying on its reserve and National Guard soldierspeople who spend most of their time as civiliansto augment active-duty forces during military operations.

Troops deploying to combat zones in 2004 are a "microcosm of society," Heath said.

"Soldiers have diseases just like other Americans, including diabetes and hypertension, that need to be treated with medications."

Having a chronic medical condition, such as hypertension, asthma, or narcolepsy, "may not preclude you from being on active duty" as long as the soldier's condition is under control with medication, Heath said.

But, he added, soldiers who are taking medications such as insulin or warfarin and have conditions that need consistent clinical monitoring are not typically deployed for combat operations.

"We're never going to send a soldier into harm's way who has a medical condition that . . . places them at risk for that condition being exacerbated or out of control," Heath said.

Pharmacists aid in readiness. Before soldiers are deployed to serve in combat zones, they undergo a complete medical evaluation at a soldier readiness processing (SRP) centera "one-stop shop" at military installations in which soldiers confirm that their personal and financial recordsincluding wills, powers of attorney, and family care plansand medical and dental records are in order, said Colonel George J. Dydek, chief of pharmacy at Madigan Army Medical Center at Fort Lewis, Washingtonthe Army's major West Coast regional medical center.

About 5,000 soldiers, including Fort Lewis's Stryker Brigade Combat Teama special unit of forces from the 3rd Brigade, 2nd Infantry Division that uses high-tech, eight-wheeled armored vehicles known as Strykersdeployed from Fort Lewis last fall to serve in Iraq, he said.

Some of those soldiers were the first to be dispensed a six-month supply of their medications, Dydek said.

Madigan pharmacists and pharmacy technicians assisted physicians during the SRP medical screening and counseled soldiers about their medications, he said.

A major tool used by military pharmacists and technicians when reviewing a soldier's medication history, Dydek said, is DOD's predeployment medication analysis and reporting tool (PMART)an "access" database that extracts soldiers' prescription information from the military's electronic medication profile.

The database provides "a wealth of information" that gives military pharmacists and pharmacy technicians the ability to examine prescription records of a "highly mobile group" of patients, he said.

The database does not include a full account of prescriptions for reserve or National Guard troops, he noted, because those soldiers generally fill their prescriptions at civilian locations when not serving in military operations, which poses a challenge for military pharmacists and pharmacy technicians.

One-on-one counseling. But, Dydek said, the real information about a soldier's medication history is garnered during face-to-face conversations between pharmacists and soldiers during the SRP evaluation.

Lieutenant Colonel Curt Hansen, chief of pharmacy at Tripler Army Medical Center in Honolulu, Hawaii, agreed.

During a one-on-one discussion with a patient, he said, a pharmacist may discover a potential problem with a medication that is being prescribed, such as a drug allergy that was not included in a patient's medication records.

Pharmacists are important to the SRP screening evaluation, he said, because they can help identify a soldier who is taking a medication that might require close monitoring and prevent that soldier from being "set up for failure over in a war zone."

Hansen and his pharmacy staff have been aiding physicians and other health care providers with medical reviews for about 11,000 soldiers from two brigades of the Army's 25th Infantry Division.

The division's 2nd Brigade Combat Team was deployed to Iraq in late January, and soldiers with the 3rd Brigade Combat Team are being deployed this month to Afghanistan.

Shortly after it was announced that the 25th Infantry Division would be deployed, Hansen said, his pharmacy staff began discussing with other Tripler health care providers how to best integrate pharmacy services into the SRP medical evaluation.

Many of the soldiers in the 2nd Brigade are reserve and National Guard troops from islands in the Pacific region, including Guam and Samoa, and their medication records were not included in DOD's pharmacy database, Hansen noted.

Tripler pharmacists had to special order medications for some reserve and National Guard soldiers who were taking prescription products not included on the military's formulary in cases in which there is no therapeutic alternative to ensure that those soldiers were able to continue on their prescribed medications, he said.

A few days before a soldier leaves to go to Iraq, Hansen said, "is a bad time to be switching somebody over to something that they are not used to."

But, he noted, soldiers who are taking products not considered essential to a person's overall health that would be difficult to continue in Iraq, such as the acne treatment isotretinoinwhich requires female patients to undergo monthly pregnancy tests and for which prescriptions can only be dispensed in a 30-day supplywould more than likely have to stop taking the drug and switch to another product.

Tripler began its SRP evaluations in December 2003 for soldiers who were deployed in January.

Pharmacy staff reviewed each soldier's medication profile using DOD's database, Hansen said.

Brian White, a clinical pharmacist and chief of pharmacy informatics at Tripler, created a local information tool to assist in the screening process for soldiers leaving from Hawaii, he noted.

The information tool, Hansen explained, helps Tripler pharmacy staff know exactly how many soldiers are using a specific drug, the dosages, when the drug was prescribed, and when the drug is scheduled to be refilled.

"We really know right down to every single amount how much people are on," he said.

Soldiers deployed to Iraq and Afghanistan were also dispensed a six-month supply of antimalarials, Hansen said.

Pharmacy staff at the SRP center counseled the soldiers about proper compliance with the agents and provided them with drug information sheets that describe potential adverse effects, he added.

However, soldiers were instructed not to start the antimalarials until late March or Aprilthe beginning of the rainy season in which troops were most likely to be exposed to malaria.

But, Hansen added, it was better to provide the drug products up front before troops deployed so that the soldiers would have the antimalarials when they needed them rather than wait for the agents to be delivered in Iraq.

Pharmacy staff also aided in evaluating which antimalarial, based on a soldier's medication history and laboratory test results, was the most appropriate for a soldier, he said.

Most soldiers were dispensed 500-mg chloroquine phosphate tablets, he added.

Mass refill. Pharmacists and pharmacy technicians at Tripler will begin refilling prescriptions next month for soldiers who deployed in January so that those soldiers will receive their refills before their supplies run out, Hansen said.

The refills will be for another six-month supply of products.

Physicians communicate changes in prescriptions for soldiers to pharmacists at Tripler and Madigan Army medical centers via e-mail, Dydek said.

Any prescriptions that require immediate changes are handled by pharmacists at combat support hospitals in Iraq or Afghanistan, he added.

Madigan completed its first major refill effort for soldiers in late February and began shipping the products to soldiers in Iraq in early March, Dydek said.

It was the first mass refill of prescriptions for six-month supplies undertaken by the military, he said.

"The push refill operation has gone extremely well, with the medications filled for approximately 400 identified soldiers needing refills, with a total of 786 prescriptions, and packed into 46 boxes labeled by specific unit," he said. "The boxes were further packed for shipment and then shipped via air to land bases near Iraq and recently arrived in country at the destination point where medical support personnel will distribute the medications."

Fort Lewis recently deployed about 4000 soldiers from the 81st National Guard Brigade. Soldiers with chronic medical conditions in the brigade were also dispensed a six-month supply of medications, Dydek said.

The Army's 1st Infantry Division, which has forces stationed throughout Europe, deployed soldiers to Iraq in January, Heath noted. Those soldiers, who were screened at Landstuhl Regional Medical Center in Germany, were also dispensed six-month supplies of their medications.

Soldiers with chronic medical conditions will continue to be dispensed six-month supplies of drugs as long as troops are deployed for combat duty overseas, Heath said.

"Pharmaceuticals play a greater and greater role in the health care needs of our soldiers," Heath said, "and it is important that our pharmacists ensure appropriate and safe drug therapy for those soldiers."