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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." Cohort identification and verification of BRIs are critical in a study of this nature, because both registries contain many non-combat-related (primarily motor vehicle accidents) and nonblast (generally gunshot wound) patients. We retained only patients we could confirm by cross-walking the registry data with the electronic medical record data for a definitive cohort of 210 veterans with BRIs as of April 1, 2008.

We converted the 210 patient Social Security numbers to a scrambled Social Security number format to track inpatient and outpatient pharmacy service use via national VHA data sets. We were unable to identify scrambled Social Security numbers for 2 patients, resulting in a potential study cohort of 208 patients. In order to enable our analysis using existing data, we further limited our cohort of 208 patients to those who received VHA care in fiscal year (FY) 2007 (October 1, 2006--September 30, 2007), resulting in 148 unique patients.

National medication records for this cohort were extracted from the VHA Decision Support System (DSS). The DSS allowed tracking of all VHA medications dispensed from any VHA clinic or hospital for this cohort at any VA facility in the United States. We obtained pharmacy data for FY 2007 by using the scrambled Social Security numbers for the cohort. The DSS did not contain the medication records for 15 of the 148 patients. Hence, our final study cohort consisted of 133 BRI patients who received medications during FY 2007.

Statistical Analysis

We used descriptive statistics to analyze inpatient and outpatient medication utilization categorized according to VHA CNS and MS drug classes, similar to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification System [9]. To assess the duration of use of these medications over the study period, we used the variable "day supply" within the individual pharmacy claims and structured query language (SAS, Proc SQL) to calculate the total days of CNS or MS medication use per patient. All analyses were conducted with SAS version 9.1 (SAS Institute Inc; Cary, North Carolina). This study was approved by the James A. Haley Veterans' Hospital Research and Development (R&D) Committee and approved by University of South Florida Institutional Review Board (IRB 104159) for human subject protection standards.

RESULTS

The average age of our study cohort (N = 133) was 30 (standard deviation [SD] = 8.0, range 20-52) and all were male. Female soldiers are prohibited from deployment in combat units but do sustain BRIs, albeit infrequently, via indirect fire. Table 1 summarizes the inpatient and outpatient pharmacy claims by the major VHA drug classes. Over the 12-month period (FY 2007), a total of 15,143 pharmacy claims were found across various drug classes, averaging 9.5 pharmacy claims per patient per month. The top five major VHA drug classes accounted for more than 64 percent of the total pharmacy claims. In descending order, these were CNS medications (27.9%), gastrointestinal medications (14.5%), new drugs not yet classified (8.5%), therapeutic nutrients (7.6%), and blood products (6.0%).

Of the 15,143 pharmacy claims, 82.8 percent were related to inpatient treatment (12,544/15,143) and 17.2 percent to outpatient treatment (2,599/15,143). The 12,544 inpatient claims involved 44.4 percent (59/133) of our study population, while the 2,599 outpatient claims included 85.0 percent (113/133). The average day supply related to inpatient and outpatient pharmacy claims was 11.2 days (SD = 4.7 days) and 42.3 days (SD = 26.6 days), respectively.

The CNS medications comprised 27.9 percent (4,225/15,143) of the total pharmacy claims and were dispensed to 90.2 percent (120/133) of our cohort. Of the 4,225 CNS pharmacy claims, 73.9 percent (3,122/4,225) were for inpatient treatment and 26.1 percent (1,103/ 4,225) were for outpatient treatment (Table 1). Among BRI patients, the CNS medications were generally prescribed for the entire FY. Of the 120 patients taking CNS medications, 78.3 percent (94/120) had been dispensed multiple CNS medications.

Table 2 presents the CNS medication profile for the cohort and examples of the most commonly prescribed CNS medications. Approximately one-half (48.9%) of the patients were treated with opioid analgesics (e.g., morphine, oxycodone, fentanyl). Nearly 60 percent received antidepressants (e.g., buproprion, citalopram, fluoxetine, mirtazepine, sertraline). More than one-half were given anticonvulsants (e.g., gabepentin, oxcarbazepine, topiramate). Finally, benzodiazepines (e.g., alprazolam, diazepam, temazepam) and antipsychotics (e.g., quetiapine, risperidone) were prescribed to 17.3 and 15.8 percent, respectively.

For MS medications (nonopioid analgesics and skeletal muscle relaxants), we found 804 pharmacy claims for 48.1 percent (64/133) of patients. Table 3 presents the MS medication profile and examples of the most commonly prescribed medications. Nearly one-fourth (24.8%) of the cohort was treated with skeletal muscle relaxants (e.g., baclofen, cyclobenzaprine, dantrolene, methocarbamol, tizanidine), and similar to the duration of CNS medication, the use encompassed the entire FY. All patients using MS medication also used CNS medications at some time during the study period.

DISCUSSION

This study updates a previous study that describes CNS (including opioids) and MS medication use in OIF/ OEF veterans with BRIs. Compared with our earlier study, we found similar overall use of CNS and MS drugs. However, in this study, we found lower use of opioids: approximately 48.8 percent compared with 81.6 percent [2].

Several potential reasons exist for this difference in opioid use. Although we had no information on the types and severity of injuries for these patients, the pain center at the Tampa Polytrauma Rehabilitation Center (PRC) has greatly expanded its pain management services, which include alternatives to medication [3].

The types of injuries for our cohort upon receiving care in the VHA included traumatic brain injuries, fractures, spinal cord injuries, and ocular injuries. Main complications for 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. The injuries sustained in our cohort were consistent with our previous study and were similar to those described by the CDC [1]. While we could not quantify the severity of the BRIs sustained in our cohort, the medication profiles of these patients suggests a high degree of medical complexity.

A retrospective analysis primarily of pharmacy data has limitations. We used the electronic medical record only to confirm BRIs. We also could not determine from the JTTR or the TPR registries the onset or severity of BRIs for individual patients. Therefore, we could not determine whether medication use varied by injury severity or time since injury. Furthermore, we do not know the specific reasons why the medications were prescribed or which providers prescribed these medications. No physician profiling of board certification or treating specialty type exists in VHA data sets to evaluate individual provider prescribing behaviors, information that is available in the American Medical Association (AMA) Physician Master File [10]. However, care for OIF/OEF polytrauma patients involves a multidisciplinary team of physiatrists, psychologists, trauma surgeons, pharmacists, and physical and occupational therapists. The specialized and multidisciplinary care provided at PRCs was highlighted by Dr. Steven G. Scott, MD, Director of the Tampa PRC, in a statement before the House Committee on Veterans' Affairs at a "Roundtable Discussion of Issues Concerning our Veterans" on November 19, 2008 [11]. Regardless, future research in this subject matter may benefit from the purchasing of the AMA Physician Masterfile and a merging with the various Austin Automation Center databases for future descriptive and outcome-based studies.

CONCLUSIONS

This study is exploratory and provides benchmark data on the medication use of a vulnerable population. This study provides insight into the complex medical management involved in the care of veterans with BRIs. By providing some benchmark data on the medication profiles of patients with BRIs as they transition from inpatient rehabilitation to the community, we may help guide clinicians' medical decision-making related to CNS and MS medication usage.

Abbreviations: AMA = American Medical Association, BRI = blast-related injury, CDC = Centers for Disease Control and Prevention, CNS = central nervous system, DSS = Decision Support System, FY = fiscal year, IED = improvised explosive device, JTTR = Joint Theater Trauma Registry, MS = musculoskeletal, OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, PRC = Polytrauma Rehabilitation Center, R&D = Research and Development, SD = standard deviation, TPR = Tampa Polytrauma Registry, VA = Department of Veterans Affairs, VHA = Veterans Health Administration.

ACKNOWLEDGMENTS

Author Contributions:

Procured, staged, and analyzed all VA data: D. D. French.

Conceptual layout: D. D. French, M. J. Bair, E. Bass, R. R. Campbell.

Methodological layout: D. D. French.

Drafted and revised manuscript (after consultation with coauthors): D. D. French, K. Siddharthan.

Literature review: M. J. Bair, E. Bass, R. R. Campbell.

Interpretation of data: M. J. Bair, E. Bass, R. R. Campbell.

Assisted with "Discussion" section: E. Bass, R. R. Campbell.

Provided JTTR data: K. Siddharthan.

Financial Disclosures: The authors have declared that no competing interests exist.

Funding/Support: This work was supported by the VA, VHA, Health Services R&D grant DHI 05-264 ("Treatment and Costs of Blast-Related Injuries in the VHA"). The views expressed in this article are those of the authors and do not necessarily represent the views of VA.

Submitted for publication September 8, 2008. Accepted in revised form January 16, 2009.

REFERENCES

[1.] CDC Home [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; c2009. Explosions and blast injuries: A primer for clinicians; 2006 Jun 14 [cited 2008 Dec 17]; [about 9 screens]. Available from: http://www.bt.cdc.gov/masscasualties/explosions.asp/.

[2.] French DD, Siddharthan K, Bass E, Campbell RR. Benchmark data on the utilization and acquisition costs of central nervous system and muscular skeletal drugs among veterans with combat-related injuries. Mil Med. 2008;173(7): 626-28. [PMID: 18700594]

[3.] Clark ME, Bair MJ, Buckenmaier CC 3rd, Gironda RJ, Walker RL. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: Implications for research and practice. J Rehabil Res Dev. 2007;44(2):179-94. [PMID: 17551872] DOI:10.1682/JRRD.2006.05.0057

[4.] Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med. 2003;163(20):2433-45. [PMID: 14609780] DOI:10.1001/archinte.163.20.2433

[5.] Board on Population Health and Public Health Practice, Institute of Medicine, Committee on Gulf War and Health: Brain Injury in Veterans and Long-Term Health Outcomes. Gulf war and health: Long-term consequences of traumatic brain injury. Vol. 7. Washington (DC): National Academies Press; 2008.

[6.] Graham DP, Cardon AL. An update on substance use and treatment following traumatic brain injury. Ann N Y Acad Sci. 2008;1141:148-62. [PMID: 18991956]

[7.] Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury: A systematic review. JAMA. 2008; 300(6):711-19. [PMID: 18698069] DOI:10.1001/jama.300.6.711

[8.] VA Information Resource Center (VIReC) [Internet]. Washington (DC): VIReC. Data sources outside the VA; [updated 2008 Aug 5; cited 2009 Jun 8]; [about 9 screens]. Available from: http://www.virec.research.va.gov/Non-VADataSources/ NonVADataNames.htm#JTTR/.

[9.] VA Home [Internet]. Washington (DC): Department of Veterans Affairs; c2009. Pharmacy benefits management services: National formulary; 2009 Mar 17 [cited 2008 May 23]; [about 2 screens]. Available from: http://www.pbm.va.gov/NationalFormulary.aspx/.

[10.] AMA [Internet]. Chicago (IL): American Medical Association; c1995-2009. About AMA: AMA Physician Masterfile; 2009 [cited 2009 Jan 6]; [about 3 screens]. Available from: http://www.ama-assn.org/ama/pub/category/2673.html/.

[11.] House Committee on Veterans' Affairs [Internet]. Washington (DC): House Committee on Veterans' Affairs; c2009. Hearings: Servicemembers' seamless transition into civilian life--The heroes return: Statement of Dr. Steven G. Scott, MD; 2007 Mar 8; [cited 2009 Jan 6]; [about 4 screens]. Available from: http://veterans.house.gov/hearings/Testimony. aspx?TID=13357&Newsid=10&Name=D/.

Dustin D. French, PhD; (1-3) * Matthew J. Bair, MD, MS; (1-3) Elizabeth Bass, PhD; (4) Robert R. Campbell, JD, MPH, PhD; (5) Kris Siddharthan, PhD (5)

(1) Richard L. Roudebush Department of Veterans Affairs Medical Center, Center of Excellence on Implementing Evidence- Based Practice, Indianapolis, IN; (2) Regenstrief Institute, Inc, Indianapolis, IN; (3) Indiana University School of Medicine, Indianapolis, IN; (4) Congressional Budget Office, Washington, DC; (5) James A. Haley Veterans' Hospital, Health Services Research and Development Research Enhancement Award Program, Tampa, FL

* Address all correspondence to Dustin D. French, PhD; Richard L. Roudebush VA Medical Center, Center of Execellence on Implementing Evidence-Based Practice, Health Services Research and Development, 1481 West 10th Street, 11H, Indianapolis, IN 46202; 317-988-3485; fax: 317-988-3222.

Email: Dustin.French2@va.gov or Drddfrench@yahoo.com

DOI: 10.1682/JRRD.2008.09.0117
Table 1.
Inpatient and outpatient utilization by major Veterans Health
Administration (VHA) drug class headings for patients with
blast-related injury (N = 133).

                                               Pharmacy Claims
Major VHA Drug Class Heading
                                          Inpatient    Outpatient

Antidotes, Deterrents, and Poison               35           16
  Control (AD)
Antihistamines (AH)                            229           67
Antimicrobials (AM)                            780           95
Autonomic Medications (AN)                     521           17
Blood Products/Modifiers/Volume                791           55
  Expanders (BL)
Cardiovascular Medications (CV)                358          151
Central Nervous System Medications (CN)      3,122        1,103
Dental and Oral Agents, Topical (OR)            21           10
Dermatological Agents (DE)                     431          139
Diagnostics Agents (DX)                          5            6
Gastrointestinal Agents (GA)                 2,082          107
Genitourinary Drugs (GU)                        55           57
Hormones/Synthetics/Modifiers (HS)             256           32
Immunological Agents (IM)                       17            1
Irrigation/Dialysis Solutions (IR)               2            6
Musculoskeletal Medications (MS)               627          177
Nasal and Throat Agents, Topical (NT)           65           11
New Drugs, Not Classified (NC)               1,099          191
Ophthalmic Agents (OP)                         198           26
Otic Agents (OT)                                 1            3
Pharmaceutical Aids/Reagents (PH)              128           11
Prosthetics/Supplies/Devices (XA)               25          166
Rectal, Local (RS)                              58           18
Respiratory Tract Medications (RE)             215           54
Therapeutic Nutrients/Minerals/              1,118           34
  Electrolytes (TN)
Vitamins (VT)                                  305           46
Total                                       12,544        2,599

                                           Pharmacy
                                            Claims
Major VHA Drug Class Heading                             No. of
                                            Total       Patients

Antidotes, Deterrents, and Poison               51          13
  Control (AD)
Antihistamines (AH)                            296          48
Antimicrobials (AM)                            875          54
Autonomic Medications (AN)                     538          13
Blood Products/Modifiers/Volume                846          35
  Expanders (BL)
Cardiovascular Medications (CV)                509          48
Central Nervous System Medications (CN)      4,225         120
Dental and Oral Agents, Topical (OR)            31           8
Dermatological Agents (DE)                     570          64
Diagnostics Agents (DX)                         11           6
Gastrointestinal Agents (GA)                 2,189          57
Genitourinary Drugs (GU)                       112          18
Hormones/Synthetics/Modifiers (HS)             288          23
Immunological Agents (IM)                       18           8
Irrigation/Dialysis Solutions (IR)               8           5
Musculoskeletal Medications (MS)               804          68
Nasal and Throat Agents, Topical (NT)           76          21
New Drugs, Not Classified (NC)               1,290          64
Ophthalmic Agents (OP)                         224          21
Otic Agents (OT)                                 4           4
Pharmaceutical Aids/Reagents (PH)              139          18
Prosthetics/Supplies/Devices (XA)              191          31
Rectal, Local (RS)                              76          14
Respiratory Tract Medications (RE)             269          24
Therapeutic Nutrients/Minerals/              1,152          37
  Electrolytes (TN)
Vitamins (VT)                                  351          29
Total                                       15,143         133 *

Note: For complete list of all 570 VHA drug classes and 97,763
medications by generic, trade, and manufacturer names that
comprise VHA drug classes, please refer to freely downloadable
VHA National Drug File (Microsoft Access Database):
http://www.pbm.va.gov/NationalFormulary.aspx/.

* Patients used multiple drug classes and numbers do not
add up.

Table 2.
Central nervous system (CNS) drug utilization for patients
with blast-related injury (N = 133).

                                                 Pharmacy    No. of
VHA CNS Drug Classes                              Claims    Patients

CN101 Analgesics (e.g., morphine, oxycodone,        532         65
  fentanyl)
CN102 Opioid Antagonist Analgesics (e.g.,             1          1
  naloxone)
CN103 Nonopioid Analgesics (e.g.,                   145         41
  acetaminophen, aspirin)
CN104 Nonsteroidal Anti-Inflammatory                 22          9
  Analgesics (e.g., etodalac)
CN105 Antimigraine Agents (e.g.,                     25          7
  zolmitriptan)
CN204 Local Anesthetics, Injections (e.g.,            6          2
  bupivacaine, lidocaine)
CN302 Benzodiazepine-Derivative Sedative            144         23
  Hypnotic (e.g., alprazolam, diazepam,
  temazepam)
CN309 Sedative Hypnotics, Other (e.g.,               55         14
  bupirone, chloral hydrate, zolpidem)
CN400 Anticonvulsants (e.g., gabepentin,           1704         68
  oxcarbazepine, topiramate)
CN500 Antiparkinson Agents (e.g.,                    53          2
  pramipexole)
CN550 Antivertigo Agents (e.g., meclizine)          171          9
CN601 Tricyclic Antidepressants (e.g.,               90         19
  amitriptyline, nortriptyline)
CN609 Antidepressants, Other (e.g.,                 784         79
  buproprion, citalopram, fluoxetine,
  mirtazepine, sertraline)
CN709 Antipsychotics (e.g., quetiapine,             120         21
  risperidone)
CN802 Amphetamine-like Stimulants (e.g.,            156          5
  methylphenidate)
CN809 CNS Stimulants, Other (e.g., modafinil)       206          5
CN900 CNS Medication, Other (e.g.,                   11          2
  donepezil, strattera)

                                                  Claims
                                                   per        % of
VHA CNS Drug Classes                             Patient    Patients

CN101 Analgesics (e.g., morphine, oxycodone,        8.2       48.9
  fentanyl)
CN102 Opioid Antagonist Analgesics (e.g.,           1.0        0.75
  naloxone)
CN103 Nonopioid Analgesics (e.g.,                   3.5       30.8
  acetaminophen, aspirin)
CN104 Nonsteroidal Anti-Inflammatory                2.4        6.8
  Analgesics (e.g., etodalac)
CN105 Antimigraine Agents (e.g.,                    3.6        5.3
  zolmitriptan)
CN204 Local Anesthetics, Injections (e.g.,          3.0        1.5
  bupivacaine, lidocaine)
CN302 Benzodiazepine-Derivative Sedative            6.3       17.3
  Hypnotic (e.g., alprazolam, diazepam,
  temazepam)
CN309 Sedative Hypnotics, Other (e.g.,              3.9       10.5
  bupirone, chloral hydrate, zolpidem)
CN400 Anticonvulsants (e.g., gabepentin,           25.1       51.1
  oxcarbazepine, topiramate)
CN500 Antiparkinson Agents (e.g.,                  26.5        1.5
  pramipexole)
CN550 Antivertigo Agents (e.g., meclizine)         19.0        6.8
CN601 Tricyclic Antidepressants (e.g.,              4.7       14.3
  amitriptyline, nortriptyline)
CN609 Antidepressants, Other (e.g.,                 9.9       59.4
  buproprion, citalopram, fluoxetine,
  mirtazepine, sertraline)
CN709 Antipsychotics (e.g., quetiapine,             5.7       15.8
  risperidone)
CN802 Amphetamine-like Stimulants (e.g.,           31.2        3.8
  methylphenidate)
CN809 CNS Stimulants, Other (e.g., modafinil)      41.2        3.8
CN900 CNS Medication, Other (e.g.,                  5.5        1.5
  donepezil, strattera)

Note: For complete list of all 570 Veterans Health
Administration (VHA) drug classes and 97,763 medications by
generic, trade, and manufacturer names that comprise VHA drug
classes, please refer to freely downloadable VHA National
Drug File (Microsoft Access Database):
http://www.pbm.va.gov/NationalFormulary.aspx/.

Table 3.
Musculoskeletal (MS) drug utilization for patients with
blast-related injury (N = 133).

VHA MS Drug Classes                             Pharmacy    No. of
                                                 Claims    Patients

MS110 Salicylates (e.g., salsalate)                32          4
MS120 Nonsalicylates, Nonsteroidal                234         50
  Anti-Inflammatory Drugs (e.g., ibuprofen,
  indomethacin, naproxen)
MS200 Skeletal Muscle Relaxants (e.g.,            538         33
  baclofen, cyclobenzaprine, dantrolene,
  methocarbamol, tizanidine)

                                                 Claims
VHA MS Drug Classes                               per        % of
                                                Patient    Patients

MS110 Salicylates (e.g., salsalate)                8.0        3.0
MS120 Nonsalicylates, Nonsteroidal                 4.7       37.6
  Anti-Inflammatory Drugs (e.g., ibuprofen,
  indomethacin, naproxen)
MS200 Skeletal Muscle Relaxants (e.g.,            16.3       24.8
  baclofen, cyclobenzaprine, dantrolene,
  methocarbamol, tizanidine)

Note: For complete list of all 570 Veterans Health
Administration (VHA) drug classes and 97,763 medications by
generic, trade, and manufacturer names that comprise VHA drug
classes, please refer to freely downloadable VHA National Drug
File (Microsoft Access Database):
http://www.pbm.va.gov/NationalFormulary.aspx/.
COPYRIGHT 2009 Department of Veterans Affairs
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2009 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:French, Dustin D.; Bair, Matthew J.; Bass, Elizabeth; Campbell, Robert R.; Siddharthan, Kris
Publication:Journal of Rehabilitation Research & Development
Article Type:Report
Date:Jul 1, 2009
Words:3711
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