Julie Kroviak, MD, Principal Deputy Assistant VA Inspector General
WASHINGTON, DC — Recent reporting by the Wall Street Journal has raised concerns about VA treating patients with multiple central nervous system medications, a mixture some veterans referred to in the article as “combat cocktails.” Combining medications of these kinds can result in significant mood changes, as well as other serious side effects. This has left lawmakers wondering how widespread the practice is and what oversight and accountability mechanisms are in place.
VA watchdog groups and veterans service organizations testified to the Senate VA committee that the practice is not uncommon and is frequently medically necessary for patients suffering from complex trauma. They also described the robust safety measures in place to prevent adverse reactions.
However, they acknowledged that those measures have been known to fail, and some fall entirely away when veterans are referred to community care.
“The risk of polypharmacy is real, but it does not always mean a patient is receiving poor care,” explained Julie Kroviak, MD, principal deputy assistant VA inspector general. “Veterans are at higher risk of psychotropic polypharmacy. That is being prescribed more than two medications that affect mind, mood or behavior. This can occur because of their distinct military experiences that lead to complex, treatment-resistant mental health diagnoses.”
A 2023 VA-supported study found that 28% of post-9/11 veterans with a history of TBI met the criteria for central nervous system polypharmacy, and 90% had diagnoses of at least one comorbidity, such as PTSD and depression, any of which might be treated with a separate medication.
Medication reconciliation is supposed to occur at multiple points during a patient’s care, most notably when they change facilities, change caregivers or receive new medications. In the VA electronic health record system—both the legacy version and the Oracle-designed system currently being rolled out—alerts will pop up describing the risk level of any new medication being prescribed a patient.
“Every time you see a patient, this medication reconciliation process should be happening between provider and patient,” Kroviak said. “The software they’re using will run it against the inventory of what’s already being prescribed.”
Used properly, this should mitigate the risk of adverse interactions or at least give the provider and patient a chance to talk about them. Still, OIG has documented multiple failures to follow proper procedure. One report looking at the Philadelphia VA found that only 37% of electronic health records included clear discharge instructions for patients leaving an acute mental healthcare setting.
“This is essential to prevent medication errors,” Kroviak said.
Another OIG report examined the case of a young veteran prescribed an antidepressant without being educated of its risks or being provided timely follow-up care to examine how he responded to the drug. He later died by suicide.
The most significant area that troubles Kroviak is the oversight of community care providers, especially when it comes to prescribing opioids.
“VA is required to ensure community providers review and acknowledge VA’s opioid safety initiative guidelines. However, we found inadequate oversight of VA’s third-party administrators’ certification that community providers review those guidelines,” she told the committee. “When community providers are not even aware of VA’s expectations of safe opioid prescribing, VA cannot guarantee the safety of those veterans referred to the community for chronic and acute pain management.”
Of the reporting in the Journal, Kroviak said, “I was very disappointed at the suggestion that VA providers were handing our medications to avoid providing adequate care. That’s not what we’ve seen. We are seeing compassionate, dedicated providers managing incredibly complicated patients.”
According to Erin Fletcher, PsyD, of the Wounded Warrior Project, many veterans her organization speaks with feel differently. They describe a medication-first approach where prescriptions are offered before therapy and that they feel rushed through visits and medication management conversations.
“Overmedication can be one of the many challenges veterans face on their road to recovery,” Fletcher said. “Poor access to therapy, canceled appointments and stigma can also frustrate even those who are most motivated to find care. We can frame strategies for improvement around stopping overmedication, increasing access to care and embracing overmedication.”
Veterans, she said, are willing to do the harder work required of therapy.
“What we hear from our veterans is they want to spend more time with their providers. They want to process through their trauma,” she said. “They also want to be informed about the medications that they’re being prescribed.”
Lawmakers also raised “credible reports” from providers that some VA psychologists have been instructed to cap the number of sessions they can offer a veteran, regardless of what they believe is clinically necessary. While VA officials denied that this was a national policy, both Republican and Democrat leaders on the committee urged them to investigate the matter further.