Publicly Released: April 8, 2021
The objective of this audit was to determine whether DoD medical treatment facilities (MTFs), dispensed the appropriate number of days supply for Schedule II amphetamines, in accordance with Defense Health Agency (DHA) guidance.
Amphetamines are stimulants that speed up the body’s systems. They are prescribed commonly to treat attention-deficit hyperactivity disorder and narcolepsy. Controlled drugs are categorized by Schedule I through V and are classified according to their abuse potential and psychological effects. Many amphetamines, such as Adderall and Ritalin, are Schedule II, which means that they have a high potential for abuse, with use potentially leading to severe psychological or physical dependence. Using amphetamines can lead to addiction. According to the Drug Enforcement Administration, stimulants can be diverted from legitimate channels and are also clandestinely manufactured exclusively for the illicit market.
On December 20, 2019, the DHA issued guidance for the Military Departments, the DHA, and the MTFs, stating that medications to treat attention-deficit hyperactivity disorder may be filled for quantities up to a 90-day supply with no refills. According to the Acting Chief of the DHA Pharmacy Operations Division, the DHA allowed the Military Departments until April 14, 2020, to implement the 90-day supply requirement. Also, the DHA guidance states that active duty service members requiring resupply of medication while deployed will be enrolled in the TRICARE Deployment Prescription Program. The Program fills and mails the maintenance medications to the deployed active duty member. Each Military Department has its own guidance on the number of days that medications can be prescribed for deployed active duty service members.
Overall, most DoD MTFs dispensed the appropriate number of days supply for Schedule II amphetamines. Specifically, according to data from the Military Health System Data Repository, from April 15, 2020, through August 13, 2020, DoD MTFs dispensed 89,356 Schedule II amphetamines, of which 86,074 (or 96 percent) were equal to or less than a 90-day supply, as required by the DHA guidance. Therefore, the majority of MTFs complied with DHA guidance, reducing the chances of drug addiction and diversion.
However, 65 MTFs, mostly located on Navy and Air Force installations, dispensed a total of 2,967 Schedule II amphetamines prescriptions that were for a 100-day supply. Of these prescriptions, 1,281 (or 43 percent) were for active duty service members, leaving 1,687 (or 57 percent) for family members of active duty service members, and retired service members and their family members. Therefore, this indicates that the majority of prescriptions for 100-day supply are not for deployed active duty service members. This occurred because the Navy and at least one MTF did not revise their guidance to conform to DHA guidance to dispense only up to a 90-day supply of Schedule II amphetamines to conform to DHA guidance. For example, Navy guidance allows for up to a 100-day supply of stimulant medications to include amphetamines. As a result, although several MTFs only dispensed 10 more days supply than the DHA guidance, these MTFs dispensed Schedule II amphetamines to beneficiaries in a manner that was inconsistent with DHA policy and may have increased the risk of overdose and diversion from legal sources to the illicit market.
We recommend that the Director of the DHA ensure that DoD MTFs and the Navy Bureau of Medicine and Surgery revise their guidance to limit Schedule II amphetamines prescriptions used to treat attention-deficit hyperactivity disorder to no more than a 90-day supply, except for applicable deployments.
Management Comments and Our Response
The DHA Director agreed with the recommendation. The Director stated that the DHA procedural instruction is in place on pharmacy operations, which supersedes any Service policy publications for DHA-specific functions including clinical and health delivery services. The Director stated that Service policy publications will continue to address Service readiness activities and deployed and operational units and settings. The Director also stated that the Navy Bureau of Medicine and Surgery will update its Service policy to reflect DHA policy at MTFs. The Director further stated that there are advantages to dispensing these medications in the original unopened 100-count bottles; however, initial standardization efforts led to the selection of the 90-day supply guidance.
Comments from the Director partially addressed the recommendation; therefore, the recommendation is unresolved. We agree that the DHA procedural instruction should supersede any Service policy publications for DHA-specific functions including clinical and health delivery services. However, DoD MTF personnel were not consistently following the DHA procedural instruction; therefore, until MTF guidance is revised, MTFs may continue prescribing over the limit of a 90-day supply regardless of whether DHA guidance supersedes the MTF guidance. Additionally, we recognize the potential advantages of dispensing unopened 100-count manufacturer bottles. However, we used a 90-day supply as the standard for our testing because the DHA established a 90-day supply as the DoD standard. If the DHA changed the policy to a 100-day supply, we would have used that standard for our testing instead of the 90-day supply. We request that the Director reconsider the DHA’s position on ensuring that MTFs revise their guidance to limit Schedule II amphetamines prescriptions to no more than a 90-day supply and provide additional comments to the report.
This report is the result of Proj. No. D2020-D000AW-0011.000.