Central nervous system and musculoskeletal medication profile of a veteran cohort with blast-related injuries

INTRODUCTION AND BACKGROUND Many wounded veterans from combat theaters in Iraq and Afghanistan exhibit severe polytrauma from blast-related injuries (BRIs) sustained via conventional explosives and improvised explosive devices (IEDs). Direct exposure to the blast results in tremendous forces on tissues and organs. Blasts can create flying debris (shrapnel) and displacement of objects, resulting in polytrauma. While not all blast exposure will result in observable injuries (e.g., burn, tissue loss, puncture wounds), the general exposure to shock waves may damage organs and systems of the body, such as the central nervous system (CNS). The Centers for Disease Control and Prevention (CDC) provides an overview of blast and explosive type injuries [1]. Many of these types of injuries can affect the digestive system (e.g., bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism) and, of course, the nervous system (e.g., concussion, closed and open brain injury, stroke, spinal cord injury, air embolism-induced injury). The medication management of BRIs is complex, because these patients are prescribed antidepressants, anticonvulsants, benzodiazepines, and analgesics (both opioids and nonopioids) to manage the pain and resulting mental health effects, such as depression, frequently associated with these injuries [1-7]. While treating chronic nonmalignant pain is important, the treatment of depression or cognitive/behavioral symptoms associated with BRIs may necessitate the prolonged use of these multiple drug regimens. These drug combinations merely reflect the complex medication conditions being treated [5-7]. Our previous analysis of CNS medication utilization in 60 patients with combat-related blast injuries treated at the James A. Haley Veteran's Hospital in Tampa, Florida, found that all but one patient (59/60) were prescribed at least one medication from the Department of Veterans Affairs (VA) CNS medication classification and 95.0 percent (57/60) were identified as being on multiple CNS medications [2]. In our cohort, the types of injuries included traumatic brain injuries, fractures, spinal cord injuries, and ocular injuries, which frequently result in chronic pain as evidenced in the civilian population [7]. The most common complications documented in this cohort were skin ulcers, late effects of injuries to the nervous system (e.g., concussion, closed and open brain injury, spinal cord injury, air embolism-induced injury), and bladder disorders. To our knowledge, our previous study is the only one containing benchmark data on CNS drug use for veterans with BRIs [2]. The intent of this article is to provide a more detailed description of the CNS and musculoskeletal (MS) drug utilization profile for a larger cohort of veterans with BRIs identified from additional data. METHODS Polytrauma patients were identified from two sources: (1) the Joint Theater Trauma Registry (JTTR) based at the U.S. Army Institute of Surgical Research at Fort Sam Houston, Texas, and (2) the Tampa Polytrauma Registry (TPR) maintained and housed at the Level 1 Polytrauma/Blast-Related Injury Center at the Tampa VA. The JTTR provided us with a current list of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/ OEF) veterans treated at the Tampa and Orlando Florida Veterans Health Administration (VHA) medical clinics for complications from BRIs in combat theaters [8]. Both registries contain information on the mechanism of injury and a unique patient identifier but do not have information on injury severity or injury date. BRIs in combat theaters are usually caused by direct fire from IEDs and by indirect fire, such as mortar attacks. Cohort Identification We performed manual chart reviews of the Computerized Patient Record System at the Tampa VA to confirm blast exposure by using text from the medical record including, but not limited to, the words "blast," "bomb," "explosion," "grenade/rocket propelled grenade," "improvised explosive device," "land mine," "mortar," "shrapnel," and "vehicle improvised explosive device. …