Case Study: Malaria drug causes brain damage that mimics PTSD (MilitaryTimes)
The case of a service member diagnosed with post-traumatic stress disorder but found instead to have brain damage caused by a malaria drug raises questions about the origin of similar symptoms in other post-9/11 veterans. According to the case study published online in Drug Safety Case Reports in June, a U.S. military member sought treatment at Walter Reed National Military Medical Center in Bethesda, Maryland, for uncontrolled anger, insomnia, nightmares and memory loss. The once-active sailor, who ran marathons and deployed in 2009 to East Africa, reported stumbling frequently, arguing with his family and needing significant support from his staff while on the job due to cognitive issues. Physicians diagnosed the service member with anxiety, PTSD and a thiamine deficiency. But after months of treatment, including medication, behavioral therapy and daily doses of vitamins, little changed. The patient continued to be hobbled by his symptoms, eventually leaving the military on a medical discharge and questioning his abilities to function or take care of his children. It wasn’t until physicians took a hard look at his medical history, which included vertigo that began two months after his Africa deployment, that they suspected mefloquine poisoning: The medication once used widely by the U.S. armed forces to prevent and treat malaria has been linked to brain stem legions and psychiatric symptoms. … Case reports of mefloquine side effects have been published before, but the authors of “Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine” say their example is unusual because it shows that symptoms can last years after a person stops taking the drug. And since the symptoms are so similar to PTSD, the researchers add, they serve to “confound the diagnosis” of either condition. “It demonstrates the difficulty in distinguishing from possible mefloquine-induced toxicity versus PTSD and raises some questions regarding possible linkages between the two diagnoses,” wrote Army Maj. Jeffrey Livezey, chief of clinical pharmacology at the Walter Reed Army Institute of Research, Silver Spring, Maryland. Once the U.S. military’s malaria prophylactic of choice, favored for its once-a-week dosage regimen, mefloquine was designated the drug of last resort in 2013 by the Defense Department after the Food and Drug Administration slapped a boxed warning on its label, noting it can cause permanent psychiatric and neurological side effects. At the peak of mefloquine’s use in 2003, nearly 50,000 prescriptions were written by military doctors. That figure dropped to 216 prescriptions in 2015, according to data provided by the Defense Department. According to DoD policy, mefloquine is prescribed only to personnel who can’t tolerate other preventives. But Dr. Remington Nevin, a former Army epidemiologist and researcher at the Johns Hopkins Bloomberg School of Public Health in Baltimore, said any distribution of the drug, which was developed by the Army in the late 1970s, is too much. “This new finding should motivate the U.S. military to consider further revising its mefloquine policy to ban use of the drug altogether,” Nevin told Military Times. No data is available on the prevalence of adverse symptoms among those who take mefloquine. One randomized study conducted in 2001 — more than a decade after the medication was adopted by the military for malaria prevention — showed that 67 percent of study participants reported more than one adverse side effect and 6 percent of users needed medical care for a side effect. Yet mefloquine remains on the market while Walter Reed Army Institute of Research conducts research on medications in the same family as mefloquine, including tafenoquine, hoping to find a malarial preventive that is less toxic but as effective. Mefloquine was developed under the Army’s malaria drug discovery program and approved for use as a malaria prophylactic in 1989. Shortly after commercial production began, stories surfaced about side effects, including hallucinations, delirium and psychoses. Military researchers maintained, however, that it was a “well-tolerated drug,” with one WRAIR scientist attributing reports of mefloquine-associated psychoses to a “herd mentality.” … Mefloquine was implicated in a series of murder-suicides at Fort Bragg, North Carolina, in 2002, and media reports also tied it to an uptick in military suicides in 2003. A 2004 Veterans Affairs Department memo urged doctors to refrain from prescribing mefloquine, citing individual cases of hallucinations, paranoia, suicidal thoughts, psychoses and more. The FDA black box warning nine years later led to a sharp decline in demand for the medication. But while the drug is no longer widely used, it has left damage in its wake, with an unknown number of troops and veterans affected, according to retired Navy Cmdr. Bill Manofsky, who was discharged from the military in 2004 for PTSD and later documented to have mefloquine toxicity. He said the Defense Department and VA should do more to understand the scope of the problem and reach out to those who have been affected. … The patient in the case study written by Livezey continues to see a behavioral therapist weekly but takes no medications besides vitamins and fish oil. He sleeps just three to four hours a night, has vivid dreams and nightmares and vertigo that causes him to fall frequently, and continues to report depression, restlessness and a lack of motivation. The sailor’s experience with mefloquine has been “severely life debilitating” and Livezey notes that the case should alert physicians to the challenges of diagnosing patients with similar symptoms.
VA predicts emergency care claim tsunami if ruling is upheld (Stars and Stripes)
More than two million claims for private sector emergency healthcare services provided to VA-enrolled veterans since February 2010 could be eligible for VA reimbursement if a recent ruling by the U.S. Court of Appeals for Veterans Claims is allowed to stand, the VA general counsel has warned. The counsel also has warned in court documents that over the next decade VA could be swamped with an estimated 68.6 million additional claims for emergency care reimbursements, which could drive up VA health costs over that period by as much as $10.6 billion. Despite these alarms, and VA introducing a new legal argument, a full panel of judges on the claims court voted six-to-one last month to deny VA’s motion to rehear the case, and instead made final its ruling of last April in the case of Richard W. Staab v. Robert A. McDonald. VA has 60 days, until September 20, to appeal the decision to the U.S. Court of Appeals for the Federal Circuit, a near certainty given what’s at stake. Meanwhile, VA officials say they are unable to begin to pay any of the emergency healthcare claims that the Staab decision requires until they can prepare new regulations to support the complex review process. “Even if the Staab decision is upheld,” VA officials explained in a statement Wednesday, “the statutory authority [cited by the court] does not set forth a payment methodology or payment limitations necessary for VA to implement the decision. Therefore, VA must follow legal procedures to [draft, publish for public comment and] implement regulations that would allow it to process payments for claims impacted by Staab.” In Staab, the court agreed with lawyers for an 83-year Air Force veteran that the Department of Veterans Affairs wrongly ignored “plain language” of a 2010 statute meant to protect VA-enrolled veterans from out-of-pocket costs when forced to use outside emergency care. So VA should not have turned down Staab’s claim for roughly $48,000 in healthcare costs he was forced to pay following open-heart surgery in December 2010. For many years VA has maintained that, by law, it can reimburse VA-enrolled veterans for outside emergency care only if they have no alternative health insurance. That includes Medicare, Tricare, employer-provided health insurance or contracted health plans of any kind. The practical effect is that veterans with other health insurance often are stuck paying hefty out-of-pocket costs that their plans won’t cover, while veterans with no other insurance see VA routinely pick up their entire emergency care tab. The logic of this offended some lawmakers and in 2009 they persuaded Congress to clarify the law on VA coverage of outside emergency care. A single provision was changed to say VA could “reimburse veterans for treatment in a non-VA facility if they have a third-party insurance that would pay a portion of the emergency care.” To ensure colleagues understood the change, Staab’s attorneys noted, Sen. Daniel Akaka, then-chairman of the Senate Veterans Affairs Committee, said in a floor speech that it would “modify current law so that a veteran who has outside insurance would be eligible for reimbursement in the event that the outside insurance does not cover the full amount of the emergency care.” The change took effect Feb. 1, 2010. But in preparing new regulations, VA officials interpreted the revised law as still preserving its way of screening most emergency care claims. The revised regulation said VA would continue to cover outside emergency care only if the “veteran has no coverage under a health-plan contract.” That was wrong, a three-judge panel on the appellate claims court ruled last April, citing the “plain language” of the revised statute. It deemed the revised regulation as invalid and vacated a Board of Veterans’ Appeals decision that had upheld VA denial of Staab’s claim. The board, it said, had relied on a faulty rule rather than the revised statute. VA’s general counsel immediately asked the three-judge panel to reconsider its decision but also asked the full appellate court to review the case. Reconsideration was denied in late June. On July 14, while a decision on full court review was pending, VA filed a motion to “stay the precedential effect” of Staab, that is, to not require payment of previously denied emergency claims given the “strong likelihood” the decision will be reversed. In the same motion, VA argued that the claims court erred by not focusing on language in the statute Congress didn’t change in 2010, which VA believes still bars reimbursement if the veteran has a separate health-plan contract. Instead, the claims court based its decision on changes to another section of the statute. VA argues the intent of that change was only to address situations where veterans benefit from third party insurance coverage, not their own alternative health plans. VA appears to be saying that the 2010 law was intended to allow VA only to cover emergency costs not fully covered, for example, by the insurance of a driver at fault in an accident that injured a veteran. But to be eligible, the veteran still can’t have other health insurance. This was not an argument VA previously had made, said Bart Stichman, one of Staab’s attorneys. VA declined interview requests about the case and gave only limited written responses to questions, noting Staab is active litigation that could be overturned. But documents filed since we first reported on this decision last April show VA wants judges to know the magnitude of the burden on VA if the decision is allowed to stand. From April through July 6, VA has had to suspend consideration of almost 85,000 claims for emergency care that it previously would have denied. They can’t be adjudicated “until VA has promulgated payment regulations necessitated by the Court’s decision and established the technological or other means to confirm the amounts paid by the veterans’ health-plan contracts,” VA lawyers explained in their filing. VA estimates that, looking back six years, more than two million claims could be impacted by Staab, and 68 million more claims could be eligible for reimbursement over the next 10 years. Numbers are so large, VA reported, because emergency room visits generate multiple claims, given the acuity of care required. The averages are four claims per outpatient emergency room visit and eight per emergency hospital admission. The administrative costs alone of handling these claims, which would require more employees, new technology and other support needs, would be $182 million over the next 10 years, raising total VA costs to $10.8 billion. Within a week of receiving these estimates, six of seven judges on the claims court still signaled it was VA that erred in interpreting the 2010 law.
VA officially reviewing circumstances of vet’s suicide (WQAD)
In a letter to Iowa Sen. Chuck Grassley, the inspector general of the Department of Veterans Affairs said the circumstances surrounding the suicide of Davenport veteran Brandon Ketchum are officially under review. Grassley, as well as other members of the Iowa congressional delegation, have demanded answers from the VA in the wake of Ketchum’s death last July. The veteran’s family has claimed he was turned away from the VA hospital in Iowa City, despite having a history of suicidal thoughts and drug use. According to the letter sent by Michael Missal, the VA’s inspector general, upon completion of the review, the department will “make every effort to share whatever information we can in accordance with applicable law.” In a media release, Grassley stressed the importance of independent reviews. “This is a good example of why we have independent watchdogs at federal agencies. Inspectors general review agency work and point out problems that need to be fixed or confirm that policies and procedures are fine as is. In a tragic situation like a veteran’s suicide, an independent review is especially important so the VA and Congress will be better informed to give veterans the care they need and deserve.” U.S. Rep. Dave Loebsack has also been working on the issue of veterans mental health. He was hosting a town hall meeting in Davenport Thursday at the American Legion Post on 35th Street to hear veterans’ concerns about mental health treatment. “As I have long said, the loss of any veteran to suicide is one too many,” he said. “This tragedy, combined with the fact that over 20 veterans commit suicide every day, means that something must be done to address this crisis.” Iowa Sen. Joni Ernst joined Grassley’s call for an investigation into the events surrounding Ketchum’s suicide. “The tragic loss of Brandon underscores how critical it is that every veteran is receiving quality and timely care from the VA,” Ernst said. “I am pleased that the VA OIG has answered our calls for an investigation into the circumstances surrounding Brandon’s death, including the alleged denial of urgent treatment, so we can determine what went wrong and take the steps necessary to ensure this never happens again.”
Sen. Moran blasts VA for poor treatment of veterans (The Hays Daily News)
Just up the road from the Kansas Veterans Cemetery and with several veterans in the audience, Sen. Jerry Moran, R-Kan., on Wednesday criticized the agency tasked with overseeing veterans’ health care. Approximately 20 people gathered to hear and question Moran at the Western Electric Cooperative community room at the Trego County stop of his listening tour while Congress is on break. Two years after a scandal showing negligence within the Veterans Administration, Moran said the department still is mismanaged. “I believe the VA is allowing too many veterans to slip between the cracks,” he said. “If you need proof that big government doesn’t work well, the VA is a pretty good example,” he said. Veterans’ health care is the No. 1 complaint his office receives now, he said. Moran said Congress is focused on implementing the Veterans Choice Act, a law passed in 2014 in response to the discovery the VA was lying about wait times for veterans to see doctors. Internal investigations that year showed at least 35 veterans had died while waiting for care in the Phoenix Veterans Health Administration, and nationwide, thousands of veterans waited 90 days or more to see a doctor, if they saw one at all. The Veterans’ Access to Care through Choice, Accountability and Transparency Act of 2014 provides veterans who live more than 40 miles from a VA health facility or who have to wait more than 30 days for treatment from a VA facility can seek care at a non-VA facility, such as their own doctor or local hospital. “That, in my view, is a really, really good thing for veterans,” Moran said. “It is also a good thing for our health care delivery system in our home towns. Just like our schools need every student, our hospitals need every patient.” But, he said, the VA is fighting the law. “The VA doesn’t like this at all,” he said. “They’re making it difficult for veterans to qualify. They’re slow in paying the bills. “The VA has testified that veterans don’t want this law,” Moran said. “That can’t be true. If they don’t like it, it’s because of the experiences they’ve had in trying to get in it and getting the services they need.” The senator told the audience his office had been contacted by a veteran from Moran’s hometown of Plainville who needed a colonoscopy. The veteran wanted it done at the hospital there, but the VA told him he could not because there is a clinic less than 40 miles away in Hays. However, colonoscopies are not among the services in the Hays outpatient clinic, so the VA told the veteran he had to go to its hospital in Wichita. A veteran in the audience suggested the VA hospital system be done away with and veterans be allowed to choose their medical providers. “If we can prove this works, that’s the direction I think that this can go,” Moran said. “There may be specialized services that only the VA can provide,” such as mental health care for veterans suffering from PTSD, he said. “But there is a lot of opportunity for us to downsize the big volume of VA and put people at home.” He urged those in attendance to help make sure veterans are using the Choice Act, even if that person is ready to give up on it. He said veterans facing difficulty with getting care at home should contact his office or officials with the VFW or American Legion for help. “Make sure someone connects with this veteran so that if they’re willing, we force the VA to do what they’re supposed to do and care for these people,” he said.
Afghanistan veteran battling for a ‘War on Terror’ memorial in DC (Stars and Stripes)
Andrew Brennan’s life shifted as he watched the motorcycles roaring around him. Brennan, a former Army captain who flew Blackhawk helicopters in Afghanistan, stood rapt as hundreds of veterans from Rolling Thunder passed by on their annual trek to the Vietnam Veterans Memorial. Mixed in with the gray beards of the Vietnam soldiers were youthful faces, dozens of post-9/11 vets like him. The younger vets were welcomed with open arms, yet to Brennan it was never so apparent that they lacked their own ride — their own spot to grieve. Brennan, who lost several friends in one of the deadliest helicopter crashes of the Afghanistan war, felt a sudden sense of purpose: build a memorial on the Mall for post-9/11 vets. “I wanted my generation to have that same healing that the Wall gave to Vietnam Vets,” Brennan said, recalling that day in 2014. Brennan, 31, quickly formed a nonprofit group, the Global War On Terror Memorial Foundation, and started assembling a team that includes former military commander and CIA director Gen. David Petraeus, and Jan Scruggs, the man who conceived the idea to build the Vietnam Veterans Memorial in Washington. He is also rallying support in Congress. Brennan has been lobbying lawmakers, military officials and others for what some say is an uphill battle: a new memorial on the nation’s front lawn, even though there is a law banning new memorials there. Memorials are built to remember people and events, but the nation’s efforts to ferret out and eliminate terrorist networks are ongoing. In fact, there is a law that requires a conflict be over for 10 years before a national commemorative work can be considered. The group wants to change the law to allow for the consideration of a memorial in the case of conflicts that extend beyond a decade. There are other complications, as well. The phrase “War on Terror” is contentious. Coined and popularized by President George W. Bush, the name has been derided by those who say the U.S. fight is with specific terror networks. The Obama administration largely retired the phrase. Brennan, however, notes that the phrase “Global War on Terrorism” is written on service medals authorized by the Department of Defense. And he says the men and women who fought deserve recognition. In many ways, this is a war of firsts: the country’s first all-volunteer military campaign, the first time American women have served in combat, the first time service members have faced so much upheaval in their lives, enduring multiple redeployments. It is the first time U.S. service members have fought abroad in response to terrorist attacks on U.S. soil, on 9/11. U.S. casualties in Iraq and Afghanistan, according to Department of Defense records, total nearly 7,000 dead and more than 50,000 wounded. Petraeus, the retired general who commanded forces in Iraq and Afghanistan, supports the memorial. “I understand the criticism of the term ‘war on terror’ very well. And I am certainly not wedded to it,” he said in an email. “The key is to have a memorial to the service and sacrifice of those who served in the wars of the post-9/11 period.” Brennan knows this sacrifice. As he went through training in Fort Polk, La., a warrant officer told him that the trauma of war is different for the aviation community than it is for ground troops. Aviators often do not witness death in the same way; they wake one morning to suddenly find the guy in the cot next to them isn’t there. Sure enough, many months later, in August 2011, Brennan left his tent one morning to find the U.S. flag flying at half-staff. Then someone told him: After midnight, a Chinook helicopter had been shot down. Thirty Americans died that day, along with seven Afghan soldiers and an interpreter. One of them was pilot Bryan Nichols, one of Brennan’s friends whom he had worked with to plan raids and supply missions. “I wear a KIA, Killed In Action bracelet for him,” said Brennan. “Every day.” Within a few weeks of starting a campaign for the memorial, Brennan had called old West Point classmates, vets he’d fought beside, anyone he could think of, to make the new memorial a reality. But the key figure he encountered was Scruggs, the founding member of the team that got the Vietnam Veterans Memorial built in just a few years. As soon as he had the idea, he started trying to reach Scruggs directly. No luck. But about a year later, Scruggs wrote an article in the Military Times saying someone should build a memorial commemorating the post-9/11 conflicts: “Who will step forward?” he wrote. Brennan, a West Point grad now studying for an MBA at the University of Pittsburgh, had already built a full ops plan, 10 years out, describing everything from forming his nonprofit and its board, through the moment the National Park Service would take ownership of the memorial. Scruggs was impressed, and started serving as Brennan’s mentor. He advised the younger vet to start seeking higher-ranking names for his board, people like Petraeus, retired Army Gen. George W. Casey and retired Marine Gen. James T. Conway, and even supplied their email addresses. “Write them,” Scruggs suggested, “and CC me.” Today, all three serve on Brennan’s advisory board. The process to build a memorial is long. The National World War II Memorial on the Mall opened roughly 60 years after that war ended. Korean war vets waited 42 years. But in hindsight, those waits seem grossly long, Brennan said. He hopes his effort will not take as long to become a reality. His group has the backing of, among others, Rep. Ryan Zinke, R-Mont., a former Navy Seal who fought in Iraq. Zinke is also a member of the House Natural Resources Committee, which oversees national parkland. … Legislators have declared the Mall to be a “substantially completed work of civic art,” preventing the approval of new memorials there. But organizers say placing the memorial on the Mall is important. Visitors to the Vietnam Veterans Memorial can’t help but understand that war’s cost — in the list of names of the dead, spanning the Wall’s length, and in the offerings that are left there, from teddy bears to letters for the deceased. Visitors coming to the Mall to see a post-9/11 Memorial should come face-to-face with veterans and families and witness the depth of their grief, they said. As Brennan and all deployed soldiers know, coming home isn’t easy. After being in combat, many soldiers find civilian life difficult. For many, the word “service” takes on a spiritual quality, as a guidepost. Brennan came home from Afghanistan in October 2011, and tried to get on with civilian life as best he could. But he had, as he puts it, “re-entry issues.” At 26, he’d already served as an Army captain, responsible for the lives of his soldiers and significant military assets, like Blackhawk helicopters. He’d plotted and planned supply drops and assaults on the enemy. But back home, his days were consumed by planning logistics for Best Buy, where he’d been recently hired. “It didn’t exactly move the needle for me,” he said. He didn’t feel the same passion he felt in the military until that day he saw Rolling Thunder come through Albuquerque in 2014, when he saw the many Iraq and Afghanistan vets riding with Vietnam veterans on their way to the Vietnam Memorial.