[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
BETWEEN PERIL AND PROMISE: FACING THE DANGERS OF VA'S SKYROCKETING USE
OF PRESCRIPTION PAINKILLERS TO TREAT VETERANS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, OCTOBER 10, 2013
__________
Serial No. 113-39
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Jon Towers, Staff Director
______
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE MCLEOD, California
VACANCY ANN M. KUSTER, New Hampshire
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
October 10, 2013
Page
Between Peril And Promise: Facing The Dangers Of VA's
Skyrocketing Use Of Prescription Painkillers To Treat Veterans. 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Prepared Statement of Hon. Benishek.......................... 51
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on
Health......................................................... 3
Prepared Statement of Hon. Brownley.......................... 52
Hon. Jeff Miller, Chairman, Committee on Veterans Affairs, U.S.
House of Representatives....................................... 4
Prepared Statement of Hon. Miller............................ 52
WITNESSES
Heather McDonald, Spouse of Scott McDonald, SPC (deceased)....... 5
Prepared Statement of Ms. McDonald........................... 53
Kimberly Stowe Green, Spouse of Ricky Green MSGT (Ret) (deceased) 6
Prepared Statement of Ms. Green.............................. 54
Joshua Renschler, Sgt. (Ret)..................................... 8
Prepared Statement of Mr. Renschler.......................... 58
Justin Minyard, LSgt. (Ret)...................................... 10
Prepared Statement of Mr. Minyard............................ 60
Pamela J. Gray, M.D.............................................. 26
Prepared Statement of Ms. Gray............................... 63
Claudia J. Bahorik, D.O.......................................... 29
Prepared Statement of Ms. Bahorik................................ 66
Steven G. Scott, M.D., Chief of Physical Medicine and
Rehabilitation Service, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 30
Prepared Statement of Mr, Scott.................................. 80
Robert L. Jesse, M.D., Principal Deputy Under Secretary for
Health, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 41
Prepared Statement of Mr. Jesse.................................. 82
Accompanied by:
Robert Kerns, Ph.D., National Director for Pain Research,
Veterans Health Administration, U.S. Department of
Veterans Affairs; Kathleen M. Chard, Ph.D., Director,
Cognitive Processing Therapy Implementation, Director,
Trauma Recovery Center, Cincinnati VA Medical Center,
Veterans Health Administration, U.S. Department of
Veterans Affairs
STATEMENTS FOR THE RECORD
The American Legion.............................................. 90
Iraq and Afghanistan Veterans of America......................... 94
National Association for Alcoholism and Drug Abuse Counselors.... 97
Wounded Warrior Project.......................................... 97
Vietnam Veterans of America...................................... 102
American Psychiatric Association................................. 104
BETWEEN PERIL AND PROMISE: FACING THE DANGERS OF VA'S SKYROCKETING USE
OF PRESCRIPTION PAINKILLERS TO TREAT VETERANS
Thursday, October 10, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:59 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Huelskamp, Wenstrup,
Brownley, Ruiz, Negrete McLeod, Kuster.
Also present: Representatives Miller, Bilirakis, Harris.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. Good morning. Thank you for being here today.
The Subcommittee will come to order.
Before we begin, I want to ask unanimous consent for our
colleague from Maryland, Dr. Andy Harris, to sit at the dais
and participate in today's hearing. Without objection, so
ordered.
And I am happy to see we have Mr. Miller here this morning,
the Chairman of the Full Committee. Thank you for being here,
Mr. Chairman.
With that, I would like to welcome you all to today's
hearing, ``Between Peril and Promise: Facing the Dangers of
VA's Skyrocketing Use of Prescription Painkillers to Treat
Veterans.''
Today's subject is one of the most serious and significant
we will discuss all year, and it is one that is particularly
poignant and personal to me. I have spent 20 years serving our
veterans as a physician at the Oscar D. Johnson VA Medical
Center in Iron Mountain, Michigan. And in that capacity, I
understand all too well what it means for a veteran and a
patient to be in pain.
Pain can be an unrelenting enemy, one that thwarts an
individual's ability to work and enjoy the activities they once
loved, hinders their relationship with their family and
friends, and impacts their capacity to be comfortable in their
own home. On a daily basis, my veteran patients would confide
in me about the pain they were in, and many ways in which they
were hurting, and more than anything else their desperate
desire to find relief.
Perhaps no where else is that more clear than in the
heartbreaking testimony that we will hear shortly from two
surviving spouses, Heather McDonald and Kimberly Green. Their
husbands, Scott McDonald and Ricky Green, honorably served our
Nation in uniform and came home, as far too many of our
returning veterans have, hurting and in pain. These men sought
treatment from the department charged with caring for them, the
VA, hoping to get the help they needed so they could once again
take full and successful ownership of their lives without pain
as their constant companion. Sadly, rather than getting the
best care anywhere, Scott and Ricky were prescribed a
disturbing array of pain, psychiatric, and sleeping medications
without any clear consideration or special attention paid to
how these powerful drugs were interacting with each other or
affecting Scott and Ricky's physical and mental well being. The
combined effects of these multiple medications ultimately took
their lives.
We also will hear from two veterans, Joshua Renschler and
Justin Minyard, who will give us a firsthand account of the
struggles they faced with VA's apparent over-reliance on
opiate-based medications for pain management. At one time,
Joshua was prescribed 13 different medications. Despite his
pleas that the medications were not working, he was never
referred to a pain specialist. Justin was prescribed enough
opiate pain medications on a daily basis to treat four
terminally ill cancer patients. He eventually sought care
outside of VA to find an effective treatment to manage his
pain.
To say that I am disturbed by these accounts and by the
multiple reports we hear everyday about the skyrocketing use of
prescription painkillers, particularly opiates, to treat
veterans in pain would be a major understatement. VA's band-aid
approach to suppressing the symptoms of pain rather than
treating their root cause must stop. VA maintains a pain
management treatment model that makes primary care rather than
specialty care the predominant treatment setting for veterans
suffering from pain. Yet as I know from personal experience,
the multifaceted nature of chronic pain, particularly when
multiple medications are being prescribed, should not be
managed by a primary care physician, but rather by a qualified
pain specialist who is trained to understand the complexities
of treating these conditions.
I want to be very clear that this hearing is not intended
to vilify the many hardworking primary care providers working
everyday to care for patients in pain at VA facilities across
the Nation. I have been in their shoes. I know the challenges
they face in providing the high quality care our veterans
deserve. Rather, our intent here today, is to initiate better
provider practices and most importantly better care
coordination for our veterans and their loved ones so that no
other family has to experience the pain, the suffering, or the
loss that our witnesses on the first panel have already
experienced.
It is critical for VA to take responsibility for its
failures and rise to the challenge to change and take immediate
action to adopt effective pain management policies, protocols,
and practices.
We have already lost too many veterans on the homefront to
battles with chronic pain. The stakes are too high for VA to
continue to get it wrong.
This is a really important matter to me. In my own personal
practice, I realized that I just do not know everything there
is to know about pain. And that we always, always send people
with chronic pain to a specialist. To not do that is just
inconceivable to me.
I will now yield to our Ranking Member, Julia Brownley, for
any opening statement she may have.
[The prepared statement of Hon. Dan Benishek appears in the
Appendix]
OPENING STATEMENT OF HON. JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chair. And good morning. I
would like to thank everyone who is in attendance today for
being here.
Chronic pain is a debilitating condition that affects
veterans at a much higher rate than the civilian population.
According to the Department of Veterans Affairs, in the newest
cohort of veterans, chronic pain is the most common medical
problem reported in veterans returning from the battlefield
with estimates as high as 60 percent of those who seek
treatment in the VA.
Modern warfare often leads to serious but survivable
physical and neurological injuries, such as amputations, spinal
cord injury, traumatic brain injury, gunshot wounds, and many
more. Oftentimes, these same veterans experience mental health
issues as well, such as Post-Traumatic Stress Disorder and
depression. And while advances in medical technology have saved
the lives of many wounded soldiers, many veterans of our armed
forces are forced to live a life that is dominated by acute and
chronic pain.
Providing safe, effective, adequate pain management is a
crucial component of improving veterans health care. The
treatment of chronic severe pain often involves physicians
prescribing highly addictive painkillers, that if not properly
monitored can lead to death. Testimony from our first panel
highlights the dangers of prescription drugs and just how
quickly veterans get trapped in a rapid downward spiral of
addiction and pain.
I know that VA has a national pain management strategy, and
I look forward to hearing from Dr. Jesse regarding the ramping
up of pain clinics and services throughout the Veterans Health
Administration. I am also very interested in progress being
made with the Department of Defense on transitioning
servicemembers and the management of medications between the
agencies.
Finally, VA recognizes that chronic and acute pain among
our veterans is a serious problem and in fact is a priority. I
applaud them for taking the lead on this issue. But I am
concerned that comprehensive pain care is not consistently
provided throughout the VA's health care system.
I look forward to hearing from our witnesses. I thank you
again for being here. It is important for this panel, and
Members, and the public to hear your stories. Thank you, Mr.
Chairman, and I now yield back.
[The prepared statement of Hon. Julia Brownley appears in
the Appendix]
Mr. Benishek. Thank you, Ms. Brownley. I would like to
yield to Chairman of the Full Committee, Mr. Miller from
Florida.
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you, Dr. Benishek and Ms. Brownley both
for having this very important hearing. And as you have already
said, many of our servicemembers are returning home with
serious injuries from the battlefield and very acute pain. And
as they transition to veterans status, the pain often lingers
and leads to chronic illness.
For these veterans, it is the pain level, not the veteran
that sets the agenda for the day. It sets the tone for their
families. And it keeps the veteran in many cases from fully
participating in their daily lives and activities that they may
have once had.
Yet when these veterans reach out and entrust the VA to
relieve their pain, the treatment they often receive is the
systemwide default of prescribing prescription painkillers. CBS
News has recently reported that based on VA data, over the past
11 years, the number of patients treated by the VA is up 29
percent, while the narcotic prescriptions written by VA doctors
and nurse practitioners are up 259 percent.
Look, veterans depend upon VA to uphold its mission of
restoring the health of those who have borne battle. But
instead of helping them manage their battles with pain, VA has
opted instead to use a treatment that has the power to destroy
rather than to restore their lives.
VA can and must change course and act now to reduce their
reliance on the use of prescription drugs. The veterans and
their loved ones must be listened to, must be followed up with
closely, and supported with a treatment that can best help them
regain happy and healthy lives. Anything less is unacceptable.
And I yield back.
[The prepared statement of Hon. Jeff Miller appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Chairman. I would like to now
formally welcome our first panel to the witness table. As I
mentioned earlier, joining us is Heather McDonald from South
Vienna, Ohio; and Kimberly Stowe Green from Fort Smith,
Arkansas. Mrs. Green is a veteran of the United States Air
Force. Thank you, ma'am, for your service. And thank you both
for being here to deliver what I know is going to be very
difficult testimony for you.
Mrs. McDonald and Mrs. Green are joined by Joshua Renschler
from Olympia, Washington; and Justin Minyard and Orlando
Florida. Mr. Renschler and Mr. Minyard are both veterans of the
United States Army and both continue to serve today as
advocates for their fellow veterans. Thank you both for your
service and for all the hard work that you continue to do.
We appreciate you all being here with us today to tell your
stories. Mrs. McDonald, please proceed with your testimony. We
like to keep it around five minutes so that everyone has an
opportunity to be heard.
STATEMENTS OF HEATHER MCDONALD, SPOUSE OF SCOTT MCDONALD, SPC
(DECEASED); KIMBERLY STOWE GREEN, SPOUSE OF RICKY GREEN, MSGT
(RET)(DECEASED); JOSHUA RENSCHLER, SGT. (RET); AND JUSTIN
MINYARD, 1SGT. (RET)
STATEMENT OF HEATHER MCDONALD
Mrs. McDonald. First and foremost, I want to thank you all
for inviting us here today to speak. This is a cause that I
know that we are incredibly passionate about.
After graduating from Belpre High School in 1995, Scott
Alan McDonald took an oath to uphold the dignity and the honor
of the United States Army. For 15 years, he served honorably in
the uniform of his country and was proud to serve as a UH-60
Black Hawk mechanic and crew chief for a medevac unit. Bosnia,
Panama, Iraq, and Afghanistan are only a few of the war torn
countries he dedicated his life to changing. In his career, he
experienced heartache, unimaginable violence, death, and the
overall devastating effects of war. He saw many of his fellow
soldiers give the ultimate sacrifice, narrowly escaping many
times himself. He loved his country and what the American Flag
stands for. He was a brother in arms to thousands of fellow
soldiers, and a truly remarkable man that never met a stranger.
Scott had larger than life expectations for his children and
because of his commitment and honor in January of 2011 we
married.
On April 30, 2011, Scott's career with the Army came full
circle and he hung his uniform up for good. He began seeking
the treatment from the VA for back pain and mental illness. The
Chalmers P. Wylie Ambulatory Care Center in Columbus, Ohio
immediately starting prescribing medications. Beginning with
Ibuprofen, Neurontin, and Meloxicam, and graduating to Vicodin,
Klonopin, Celexa, Zoloft, Valium, and Percocet. This is where
the roller coaster began.
My husband was taking up to 15 pills a day within the first
six months of treatment. Every time Scott came home from an
appointment, he had different medications, different dosages,
different directions on how to take them. And progressively
over the course of a year and a half of starting his treatment,
the medications had changed so many times by adding and
changing that Scott began changing. We researched many of the
drugs that he was prescribed online and saw the dangerous
interactions that they cause. Yet my husband was conditioned to
follow orders. And he did so.
On September 12, 2012, Scott attended another of his
scheduled appointments. This is when they added Percocet. This
was a much different medication than he was used to taking, and
which they prescribed him not to exceed 500 milligrams of
Acetaminophen. Again, my husband followed orders.
Approximately 01:00 hours on the 13th of September, I
arrived home from my job. I found Scott disoriented and very
lethargic. I woke him and asked him if he was okay. He told me
he was fine and that he just took what the doctors told him to
take. At approximately 07:30 I found my husband cold and
unresponsive. At 35 years old this father of two was gone.
I ask myself why everyday. And when I asked the VA why more
tests were not performed to make sure he was healthy enough,
they responded by saying, it is not routine to evaluate our
soldiers' pain medication distribution. A simple, ``I am in
pain,'' constitutes a narcotic and, ``This is not working,''
constitutes their change of medication.
I was sickened and disturbed by their response, and I
decided at that point, no one else should die. I have no doubt
that if the proper tests were being performed on our men and
women, I would not be here today because my husband would be. I
have no doubt that thousands of the soldiers that have fallen
since coming home from War would be here today.
As the silent soldiers and the spouses of our military
members, we almost expect the possibility they will not come
home from War. But we cannot accept that they fight for their
country, and after the battle is over, they come home and die
in front of their children and their loved ones and this has
got to stop.
When our men and women signed that contract they gave their
bodies to their country. And I ask now, as the people that have
the power and the ability to make these changes happen, to
force regulations to change on behalf of all of the veterans
out there that have died. And for their families, I beg you to
reopen this issue and reevaluate the distribution of narcotics
to our men and women when they come home. Because you do not
only take the lives of these men and women, but you tarnish the
lives of their families forever. They selflessly chose to wear
the uniform the United States military, and when they come
home, they should not be treated as numbers, nor should they be
labeled as if they are no longer a productive or useful part of
society. Thank you.
[The prepared statement of Heather McDonald appears in the
Appendix]
Mr. Benishek. Thank you very much, Mrs. McDonald. I truly
appreciate you being here and testifying. Mrs. Green, would you
please begin?
STATEMENT OF KIMBERLY STOWE GREEN
Mrs. Green. Chairman Benishek, Ranking Minority Member
Brownley, and all the distinguished Members of the
Subcommittee, my name is Kimberly Green and I am honored to
have been invited to speak to you today at this hearing. I am
accompanied here today by my attorney Brad Miller, who is also
a medical doctor. I respectfully request that my written
statement be incorporated into the official records of this
hearing.
I live in Fort Smith Arkansas. I served my country for 21
years in the United States Air Force serving both on active
duty and reserve status. I retired as a Master Sergeant from
the Arkansas Air National Guard. I am the widow of Ricky Green.
My husband served his country for 23 years, serving both on
active duty status and in the Reserves. He was a military
policeman and a paratrooper and he served with distinction in
Desert Storm. He retired as a Sergeant First Class.
My husband Ricky Green died as a result of the VA's
skyrocketing use of prescription painkillers. On behalf of my
husband, myself, and our two grieving sons, I want to ask this
Committee to do all that it can to prevent other veterans from
dying in the same manner that my husband died.
My husband died on October 29, 2011 at the age of 43, four
days after lower back surgery. The Arkansas State Crime Lab and
its medical examiner performed an autopsy and determined that
the cause of death was mixed drug intoxication, complicating
recent lumbar spine surgery. My husband died because of the
prescription pain and sleeping medications that the VA and his
doctors prescribed for him and dispensed to him out of the VA
pharmacy.
In treating Ricky's service-connected back pain, the VA
doctors wrote prescriptions for the following drugs: Oxycodone,
Hydrocodone, and the generic versions of Valium, Zoloft,
Ambien, Gabapentin, and Tramapol, among others. Ricky trusted
the VA doctors and followed their orders.
The VA already has written guidelines for prescribing
painkillers but these are not being followed. The clinical
practice guidelines which have been in place since May of 2012
require physicians to closely monitor and evaluate patients who
are being prescribed prescription painkillers for chronic pain
and warn physicians about the dangers of drug interactions that
can cause death. The guidelines also warn physicians to take
special care in prescribing pain medications for patients such
as my husband who had sleep apnea.
Unfortunately again, no such special precautions were taken
for Ricky, who got a legal drug cocktail that included
Oxycodone and Diazepam, which were reviewed by the VA and
filled by the VA pharmacy on October 26, 2011.
I strongly believe that my husband was entitled to receive
the quality of care that the VA and Department of Defense set
forth in their guidelines. However, last year the VA's national
program director for pain management admitted that VA has not
fully implemented the guidelines.
I know that statistics show in Fayetteville, Arkansas where
my husband was treated there is a high incidence of over-
prescribing pain medications for veterans. In my husband's
case, he asked the VA to reduce the opiate pain medications he
was taking, but the VA did not listen.
I am proud of my husband. After serving his country for
over 20 years in the military he went back to school and earned
his college degree in criminal justice. Ricky survived serving
in combat zones in his over 20 years of military service, but
he could not survive the VA and its negligent treatment of him.
I have heard excuses. The guidelines are not standards of
care, and some veterans who have died of overdoses were
suicidal. These are excuses that the VA is making because it
has failed to take the action needed to fully implement and
follow its own written guidelines that have already been
published. Let me be clear, the VA knew that Ricky was not
suicidal. The VA knew that Ricky did not display drug seeking
behavior. The VA knew that he wanted to reduce the amount of
pain medication he was taking. It is all documented in Ricky's
medical records.
Humana and the VA have teamed up on a program called
Project Hero. Last year, this Committee heard the testimony of
Brad Jones, Chief Operating Officer of Humana Healthcare
Services. Mr. Jones contended that Humana and Project Hero
provided a strong care coordination element. This did not
happen in my husband's case. No one at the VA or Humana
monitored his drugs to ensure safety, nor questioned why he got
all of the medications when he had a diagnosis of sleep apnea.
I would like this Committee to use its powers of
investigation to uncover why Humana and Project Hero did not
protect my husband Ricky from the lethal cocktail of drugs that
killed him. Why cannot the powerful computer systems at both
the VA and Humana that process the medical records of our
veterans be programmed to monitor the kind of drug interactions
and dangerous conditions like sleep apnea to alert both doctors
and pharmacists when dangerous prescribing occurs, like that
that killed Ricky?
It is my understanding that when unexpected death occurs,
the VA does an analysis to find out why the death occurred. I
want to know if such an analysis was ever done in my husband's
case, and whether or not the VA will investigate my husband's
death so that other veterans will not suffer the same fate?
I hope the VA, and if not the VA, then this Committee, will
ask these questions, learn something to save the lives of our
veterans in the future. This is the one way, the only way, that
my husband will not have died in vain.
I will not be silent about any of this. My husband does not
have a voice, therefore I am his voice. I want to see that this
overdrugging of our veterans stops and that there is
accountability for these physicians' actions. I respectfully
request that this Committee demand that the VA follow its own
written guidelines, demand that the VA put in place procedures
that punish VA doctors and staff who do not follow the written
guidelines and demand that the VA and its doctors put a stop to
this epidemic of the VA's skyrocketing use of prescription
painkillers to treat veterans. Thank you.
[The prepared statement of Kimberly Stowe Green appears in
the Appendix]
Mr. Benishek. Thank you so much, Mrs. Green. I really
appreciate your being here. Mr. Renschler, could you proceed?
STATEMENT OF JOSHUA RENSCHLER
Mr. Renschler. Chairman Benishek, Ranking Member Brownley,
and Members of the Subcommittee, I am honored for the
opportunity to speak to you today about my own experiences with
the VA's pain management system, or lack thereof.
Not only am I retired from the United States Army in which
I proudly served as an infantryman for five and a half years,
but as stated earlier I currently walk alongside of other
veterans struggling to navigate the difficult systems in trying
to find a new normal life.
After I was medically retired from injuries sustained from
a mortar blast in 2004, I left the Army in 2007 and entered
immediately into the care of the VA in 2008. I was on eight
different medications from the Department of Defense that took
three years for Army doctors to balance a safe mix with limited
side effects to allow me to have an opportunity to try to
function. I entered into work at the only thing I knew how to
do as an infantryman, I started working corrections.
With the VA care, my first practitioner informed me that
many of the medications I was on were not on the VA's formulary
and they had to find a new mix. They began experimenting on me.
Despite the urging of my wife telling them that many of the
medications they wanted to try again already failed through
DoD, they did it anyway. Within 12 months of VA care, I was on
13 medications, many of which were to counter the effects of
other medications, and I began to backslide in my recovery. It
ended with me having a severe panic attack for the first time
in my life while at work, resulting in the loss of my job,
resulting in my family losing our house and our vehicle, and
being virtually homeless, if it was not for our family stepping
up and taking care of us.
It 2009, I began to suffer from debilitating back pain as a
result of my injuries. The VA's answer to that was to add
narcotics into the mix of my medications that I was on at the
time. I was on Percocet, and what happened was, as I took that,
the more I took it, the less it worked because my body became
tolerant to it.
I continued to ask my VA doctors to find a proactive
solution for the back pain rather than more medications, and
the answer was an increase in the dosage to a level of 12 to 15
five-milligram tablets a day. When that was no longer
effective, I finally saw a neurosurgeon who sent me to a
physical therapist. I was excited for a proactive solution.
However, when I received that care, it entailed me sitting in a
chair while the physical therapist asked me questions about the
pain and printed off a package of papers that included
instructions on stretches to do at home on my own, and asked me
to follow up in two weeks. That made me feel hopeless and
infuriated.
When I began advocating strongly for my care at that point,
my dosages maintained at the levels that they were, but they
were augmented by other medications such as Morphine and
Methadone. I began to not function well at all. I had children
at the house and things were not going well at home. Finally, I
was able to get an EMG and an MRI, which determined that I had
severe nerve damage and resulted eventually in a fee service
referral to a private hospital. When I went to that private
neurosurgeon he asked me how long I had experienced the
symptoms, and I had told him it had been over a year since it
was that bad, and he was infuriated at the VA for allowing it
to take place that long. He scheduled an urgent surgery that
took place three days later and the result of the delay in my
care meant that I have permanent nerve damage. I still have no
feeling in my left leg to this day.
I continued to take this cocktail of medications that the
VA prescribed me less the narcotics following the surgery. And
there was no oversight. It took me three months to get an
appointment with a primary care doctor that usually changed who
the person was that I saw every three months when I got in
there.
Finally I had a new prescriber in 2011, three years after I
entered the system, who said many of these drugs are harmful to
kidney and liver, let us get some blood work. The blood work
determined that I had elevated liver enzymes to lethal levels.
I immediately saw a hematologist who performed a biopsy and
determined I had scarring of the liver and diagnosed me with
non-alcoholic steatohepatitis. This prompted my wife and I to
remove myself from all of my medications, save the seizure
medications and as needed migraines.
This makes life very difficult. But within six months my
liver enzymes had returned to a high normal level. And I would
rather be pill free and in pain than to die.
I continued to have struggles. In 2011, the back pain
returned and I began pleading again for my own care and I was
denied everywhere I went. I went back through the hoops of
physical therapy, occupational therapy, who, by the way offered
me a device to help me put my socks on in the morning. I was
denied any other care that I was asked for. I turned to
spending $15,000 out of my own money to buy a therapeutic hot
tub and a massage chair just hoping to find a way of managing
my pain. I lived next door to a very nice lady who was a
massage therapist who worked on me for free. These were the
only ways I could manage my pain without the drugs.
There is no happy ending to this account, I apologize. I am
currently taking narcotics again. I am prescribed levels that
allow me to take six five-millimeter Oxycodone a day. I cannot
take Percocet because of my liver.
Let me emphasize I did not make this trip here today to
gain an advantage for myself. But I have walked alongside of
countless veterans and I know this to be true: it is a hopeless
situation when you are encountered with this type of
debilitating pain. The VA is very quick to drop statistics on
22 soldiers a day ending their lives. But they do not really
look internally and realize that the hopelessness that comes at
the very end for a veteran is when he reaches a level of
debilitating pain that puts him into a hopeless situation at
home. Being 30 years old and having to rely on a cane and a
wheelchair and not being able to hold my child without physical
pain is a hopeless situation. And when I cry out to the VA, my
only source of medical care, to help me with this situation and
I am hit with a brick wall and a bottle of pills that does not
end the hopelessness, and in fact it makes it a more hopeless
situation and results in the loss of life of countless of our
veterans.
I thank you for your time and your oversight on this
matter, and I urge the VA to start looking internally for a
solution to this epidemic.
[The prepared statement of Joshua Renschler appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Renschler, for your
testimony. I truly appreciate your comments. Mr. Minyard,
please begin.
STATEMENT OF JUSTIN MINYARD
Mr. Minyard. My name is Justin Minyard and I would like to
thank you for the opportunity to appear before the Committee
and address this vital subject.
I am a medically retired member of the United States Army.
Before retiring due to a series of spinal injuries, I was a
first responder at the Pentagon on 9/11, and a special
operations interrogator. I struggled with years of dependence
on the opioid therapy, that was my only option made available
to me for my chronic debilitating back pain. Finally after
years of searching, I found lasting pain relief through spinal
cord stimulation, or SCS. Today, I am proud to say that I am
not taking a single dose of opioid pain pills in the last two
years. No veteran should have to struggle for as long as I did.
Early access to interventions in the VA is critical.
I first developed chronic back pain when I was serving as a
member of the Presidential Escort Third U.S. Infantry Old Guard
stationed at Fort Myer. On 9/11, my unit was one of the first
responders at the Pentagon. For the next 72 hours we searched
for survivors, working on adrenaline to move huge pieces of
rubble. As a result of these efforts, I sustained a serious
back injury, damaged discs and ruptured vertebrae.
My back pain drastically impacted my life from September
11th onwards. In 2004 and 2007, I was deployed in the Middle
East and reinjured my back during subsequent combat operations.
When home on R&R, Army doctors told me my spine was rapidly
deteriorating and I needed reconstructive back surgery. Despite
knowing I should have the surgery, I wanted to complete the
mission with my unit. My doctor responded, ``If you insist on
going, this is the only way that you will be able to make it
through.'' Then he handed me a bottle of prescription opioid
pain pills.
My pain fluctuated daily somewhere between a four and a
nine on a one to ten pain scale. But I was able to mask that
due to the high dose of pain pills. It was a very double edged
sword. The pills allowed me to keep working, but they also
allowed me to do further damage to my back.
August 4, 2008 was my breaking point. I came back to our
team hour in Iraq after an extremely challenging three-day
mission. I stepped out of my HUMVEE and my right leg simply
gave out. I could not take another step and it was terrifying.
I was subsequently Medevac'd on a helicopter to Balad Air Force
Base.
Returning home, my life was not my life. I was in a great
deal of pain, confined to a wheelchair, and struggling with
severe PTSD. I also started an intense opioid pain medication
management regimen. My life revolved around when is my next
pill? When is my next dosage increase? And when can I get my
next refill? At my worst point, I was taking enough pills daily
to treat four terminally ill cancer patients.
I had enormous physical and mental effects on me. I was so
high on the opioids that my eyes would often roll in the back
of my head and if I was not babbling incoherently, I was
drooling on myself.
My wife stayed by my side throughout the entire process,
but for years I went without even telling her thank you for
taking care of me. I was not the husband my wife deserved and I
was not the father my daughter deserved, and it was a very dark
and difficult part of my life, one of which I am extremely
ashamed and regret today.
With no options offered by the medical services and after
seeing a video of myself passed out with my daughter in my lap,
I started to look for treatment on my own. I had a spinal
fusion procedure that helped me regain some mobility, but did
nothing to lessen my pain or dependence on opioid medication.
It was a major challenge navigating the bureaucracy of the
VA and DoD health care systems. My wife had to advocate for me,
never taking no for an answer. Finally we found an
interventional pain specialist at Fort Bragg conducting a trial
study of SCS therapy. I credit both with turning my life
around. My specialist explained how an implantable device could
stop my brain from receiving pain signals. After a test drive,
I had the permanent device implanted in less time than it takes
to have a cavity filled. When the device was turned on, I was
floored. With each adjustment to the device, I could feel the
impulse moving through my body and hitting my targeted pain
areas. All of a sudden, to push a button and have my pain drop
significantly was life changing.
The relief that I felt from SCS allowed me to start
tapering my medications. That process took time and was
extremely difficult, but it was worth it. I am now at the point
where I have not taken an opioid-based pain pill in more than
two years.
The bottom line is that I consider myself extremely lucky
that I was able to push through the maze of providers and find
a doctor knowledgeable about SCS. The majority of soldiers are
not so lucky. Soldiers who lack the resources and awareness to
advocate for alternatives to opioids are left with the crushing
reality of lifelong opioid dependence, or worse. A recent VA
study spotlighted the horrific epidemic of suicide among
veterans, 22 per day. We must increase awareness about
alternatives to opioid medication in the VA system. The VA must
work to create access to interventional pain specialist
knowledgeable in state of the art pain management treatment. We
must train more doctors in these techniques and devote more
resources to raising awareness.
We should also be collecting data on long term outcomes of
interventional therapies versus opioid therapies so we have the
numbers to show that the techniques that helped me will help
other soldiers as well. The VA is a great place to start
because so many veterans come home and struggle just as I did.
I continue to struggle with the VA in getting timely
appointments with the specialist to manage my SCS therapy. But
my hope is that in the future, policies will be in place to
help people like me manage their SCS therapy, and to help
shield soldiers and their families from the devastating effects
of opioid dependance.
Thank you very much for your time and for listening to my
story.
[The prepared statement of Justin Minyard appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Minyard. We truly appreciate
your comments.
I yield myself five minutes for questions. Thank you all
once again. I guess I have a question, let me just start with
Mrs. McDonald. Did your husband see the same person every time
he went to the VA?
Mrs. McDonald. No, sir.
Mr. Benishek. So was that person their regular primary care
physician that they saw?
Mrs. McDonald. Both his pain management and his mental
health management prescription bottles had the same doctor's
name on them. But it was a rarity that he either saw them, it
was a rarity that he saw the same doctor twice. Many times he
came home from appointments frustrated because he, especially
in mental health, had to basically relive the last 15 years and
five deployments over, and over, and over again. And he never
felt like that was ever going to be treatment for his PTSD. You
know, like I said, almost immediately after seeking treatment,
he was diagnosed with severe PTSD. In July of 2011, just months
before he died, he was awarded 80 percent disability after
never having an MRI, x-rays, nothing to prove where this pain
came from.
Mr. Benishek. Mrs. Green, let me ask you the same question.
Did your husband see the same person over and over again?
Mrs. Green. My husband had an assigned neurologist, a VA
doctor, and then he also had a civilian doctor. So he had two
neurologists. But he had other doctors that he did see at the
Fort Smith VA Clinic. And he would see different health
practitioners. So it could be a number of, a different number--
--
Mr. Benishek. Were you ever involved in asking the
physician, did you ever go with him to his appointments and ask
about all these medications?
Mrs. Green. I had, yes sir, I had attempted to go with him.
They would not let me back with him into the room. Now I did
see his----
Mr. Benishek. They would not let you go with him to see the
doctor? Is that what you are saying?
Mrs. Green. No sir, they would not. Now I did see his
doctor with him when he was, he had a spinal fusion in May of
2011, and I did see the doctor with him, and then the back
surgery, I saw the doctor with him for the back surgery.
Mr. Benishek. So you never did, neither one of your
husbands actually saw a pain specialist about----
Mrs. Green. No sir, my husband had never been referred to a
pain specialist.
Mrs. McDonald. I had, actually, just prior to my husband's
death, when he went for his appointment on the 12th, I
suggested to him that he talk to his doctor and allow me to
talk to them. Because I feared that the amount of medication
that he was on was what was preventing us from conceiving.
Because he had completely deteriorated, not just as a person,
but his health was going downhill. My husband was in stage two
liver failure, which was only discovered by the coroner.
Mr. Benishek. Unbelievable. Mr. Renschler, is that your
experience as well? Did you see the same person?
Mr. Renschler. No sir, I did not see a pain specialist. And
primary care, often as the deployment health team was
attempting to shift focus, the primary care provider would
often change from one appointment to the next.
Mr. Benishek. Mr. Minyard?
Mr. Minyard. Sir just prior----
Mr. Benishek. I just want to know if you, did you see a
regular, I mean, did you end up going, was this within the VA
system, this pain----
Mr. Minyard. My chronic pain treatment both was in with the
DoD and the VA. I can tell you that before I was referred to an
interventionalist pain specialist, I was already at the point
where I was daily taking 240 milligrams of Oxycontin, 60
milligrams of Oxycodone, and 40 milligrams of Valium a day
prescribed by my general practitioner, the same doctor that
prescribed medicine if I have a cold or the strep throat. And
that also alternated between sometimes she decided to go with a
100 microgram Fentanyl patch, again which is typically used for
patients that are not long for this world. So it was a long
time----
Mr. Benishek. Did it seem, did any of you have the
experience where the physician, or maybe you were not aware,
that they were looking to get you to someone that could manage
this better than they could and they just could not get the
appointment? Or they just decided that they were going to do
the management? Was there any, do any of you remember any----
Mr. Minyard. In my situation, sir, my primary care provider
made it clear to me that she was my primary care provider and
it was her responsibility to manage my medication.
Mr. Benishek. All right.
Mr. Minyard. If that can answer your question.
Mr. Benishek. All right. I think I am out of time now. I
will yield to Ms. Brownley for five minutes in questions.
Ms. Brownley. Thank you, Mr. Chair. And thank you all for
being here, and thank you for your service to our country. And
I think we all owe you, each and every one of you, a deep
apology for not responding to your needs the way you have
defended our country. And Mrs. McDonald and Mrs. Green, I
include you in thanking you for your service to our country and
being married to your spouse and supporting him through this
process. That you, too, need to be thanked for your service. So
thank you all. I think this is obviously a very, very important
topic, and hearing your individual stories, I think is
important for the American people to hear.
I wanted to ask a question, my first question anyway, and
this question is more directed to Mr. Minyard and Mr.
Renschler. And I was wondering about your experiences and maybe
experiences from other wounded warriors that you may, more
regarding the continuity of treatment from the Army to the VA,
and perhaps from one VA facility to another VA facility?
Mr. Renschler. I will answer that to the best of my
knowledge. Again, I have walked alongside of countless veterans
over the last several years in a volunteer capacity and walked
them through, attempted to navigate the VA health care system
to get the best care possible. In my experience, it takes quite
often a door kicker mentality to get veterans the care that
they need. We, I have hand walked them to a physician's door,
to a social worker's door, to a mental health practitioner's
door and said, ``This person needs help today.'' And that is
the way we have been able to make things happen in people's
lives.
To answer as quick as possible, no. There is not good
continuity of care from one facility to another. There is not
good continuity of care from DoD to VA. You know, as I spoke on
my specific experience leaving DoD and entering VA care, my
medications were not only the VA formulary. So they completely
changed my medication regime, put me on more harmful
medications, which ended up causing me a backslide in my
recovery which took the Army three years to establish.
As far as, there is a veteran that I work with currently
that has left Portland VA facility in Oregon and moved into
Washington State. And upon entering Washington State American
Lake VA Hospital, he was told that his medications are not able
to be purchased through the American Lake VA Hospital because
they do not have the budget for the non-formulary medication
that the other facility had. And this was, again, a medication
that took six years to figure out the best thing for him. And
they are not going to purchase it anymore, which is causing him
a backslide in his pain management as well. So the short answer
is no, there is not good continuity of care.
Ms. Brownley. Thank you. And I think I said Mr. Green, I
apologize. I meant Mr. Minyard, if you had any additional
comments in terms of continuity of treatment?
Mr. Minyard. Ma'am, with all due respect, I would not, in
my opinion and through my experience, I would not place the
word continuity anywhere in a sentence that contains the other
nouns DoD and VA. To give you a quick answer. The systems to
me----
Ms. Brownley. Yeah. I hear you.
Mr. Minyard. --do not work.
Ms. Brownley. Thank you.
Mr. Minyard. Yes, ma'am.
Ms. Brownley. And then really to anyone who would like to
respond, you know, can you talk a little bit to, about to what
extent and with the VA facilities, has there been any kind of
sort of comprehensive interdisciplinary approach to your
situation or to others that you might, we talk about a primary
provider, therapist, others who are working as a team?
Mrs. McDonald. I guess I can say one thing about that.
After my husband's death I did contact the VA almost
immediately. I was, the VA itself told me that I needed to
immediately start the process to claim my husband's death
pension to help my family. What doing that immediately does, I
do not know. I took 11 months to start receiving any
retroactive pay from my husband's pension. I lost my home. I
lost my car. When I asked them during the filing of the claim,
the VA asked me whether I felt my husband's death was service-
connected or not. First, that is not my decision. Every pill he
put in his mouth was due to an ailment or injury he received
either in theory due to his service for his country, so yes,
that makes it service-connected. Why it took nine months for
them to make a decision and a rating on that? No, I was simply
told, ``I am sorry, Mrs. McDonald, this is the process. It
takes time.'' There is a huge backlog. I feel like the VA right
now is proud of themselves because they are saying the backlog
is going down. The amount of claims are lessening. Well, of
course they are. Because they are dying. They are not receiving
treatment anymore because they are not here to receive it.
You know, when I asked the VA, you know, why? Why was his
health care not well managed? And the response they gave me was
that there was nothing else that they could have done, and that
his health care was well managed and properly maintained. No.
Ms. Brownley. Thank you very much. And I yield back.
Mr. Benishek. Mr. Huelskamp?
Mr. Huelskamp. Thank you, Mr. Chairman. I would like to
also apologize, as my colleague has done, for what has occurred
here. I have a couple of follow up questions. The Chairman was
asking, I think in terms of continuity of care. And I was also
struck by the denial of Mrs. McDonald's for the ability to walk
in with your husband and participation in those appointments.
Is that what I understood correctly? That you requested and the
VA would say no, you cannot come back and visit with----
Mrs. McDonald. Many times I would go to the appointments
with my husband in the very beginning of his treatment. I
wanted to, first of all he was in denial that he even had PTSD,
like most soldiers and veterans I think battle with that.
Probably more than the pain itself is the denial behind the
fact that they may actually have a mental health issue
underlying a lot of the war that they have experienced. Once I
was able to get him convinced that he needed, it actually took
the help of another veteran to convince him he needed help. I
did go for the first several months and I had to wait in the
waiting room. I was told that due to privacy issues, I was not
allowed to be there with my husband. Now in the civilian
sector, doctors normally will allow a spouse to go back there
just because, especially prescribing medication, once they have
received that medication, they might not remember the orders
that the doctor gave them afterwards of taking the medication.
It was frustrating. I finally stopped going.
Mr. Huelskamp. Did your husband request that you come in
there, and they denied that? I am just curious what the VA
policy is.
Mrs. McDonald. On the September 12th appointment, the day
before he died, he requested that I be allowed to go with him
to his, he was finally being scheduled to see a pain specialist
at the Ohio State University Neurological Surgery Center for
his back pain. A consultation, and they were going to allow me
to be there. That would have been September 24, 2012, but Scott
was deceased by the 13th.
Mr. Huelskamp. Okay. Mrs. Green, was it a similar
experience?
Mrs. Green. Somewhat. I was denied the right to go in with
my husband, and he did want me in there. But they refused
because of privacy issues.
Mr. Huelskamp. Mr. Chairman, it sounds, I look forward to
hearing what VA has to say.
Mrs. Green. This is going on, mm-hmm.
Mr. Huelskamp. Because you want to be in there, the patient
would like to see you in there, and the VA, do you think it was
a preference of the physician or the provider? Or do you think
that was just their policy?
Mrs. Green. Sir, I cannot answer, I cannot speak, I do not
know.
Mr. Huelskamp. All right, thank you. How big were these
clinics in terms of how many providers were there? Were these
pretty massive clinics, or were they small where you were
receiving care?
Mrs. Green. The clinic at the VA in Fort Smith is not a
huge facility. But they do, we do have a lot of returning
servicemen and women, and it is utilized frequently from the
Guard, a lot of transitioning soldiers. So, but it is not a
very big facility.
Mr. Huelskamp. Mm-hmm. And Mrs. McDonald, when you were
concerned on PTSD, what was the, how would they have handled
that? You have to go see someone separately? Or you could bring
it up to the primary care physician if your husband was
willing? And do you know how they would have handled that?
Mrs. McDonald. I do not know how they would have handled
it. You know, my primary concern of telling him, look, flat
out, ``I am going with you,'' my husband never accused me of
having the ability to keep my mouth shut. I was going with him,
regardless of what they said, because I had watched his
medications fluctuate in such a way, especially for his PTSD,
my husband was no longer Scott McDonald. I did not know who the
man was that I was married to.
Mr. Huelskamp. Thank you.
Mrs. McDonald. He would become angry and violent. And in
the months prior to his death, we had finally thought we had
found a remedy, that he was back to himself. He was back to
being a father and a husband. But he had been labeled 80
percent disabled.
Mr. Huelskamp. Okay.
Mrs. McDonald. Or he jokingly would say he did not mind
being a soccer dad.
Mr. Huelskamp. All right.
Mrs. McDonald. But I could see that he was broken.
Mr. Huelskamp. Okay. All right. Thank you. I yield back,
Mr. Chairman.
Mr. Benishek. Thank you, Mr. Huelskamp. I call upon Dr.
Ruiz.
Mr. Ruiz. Thank you, Mr. Chairman. Thank you for your
service. Thank you for all those days that you went wondering,
and thank you for finding hope in your struggle to make sure
that other people do not get treated like you did.
I am an emergency medicine doctor and I treat patients who
come in when they are at their last wits, when they just cannot
take it any more. When that pain is unbearable, they cannot see
their doctor, or it is just relentless. Can you tell me about
the experiences, have you, did you ever have those moments
where you sought care for acute pain, acute on that chronic
pain, at a different facility in the emergency department that
was not affiliated with the VA?
Mrs. McDonald. As far as with my husband?
Mr. Ruiz. Yes.
Mrs. McDonald. No, because we quite frankly could not
afford it. We utilized the VA because it is free health care
for the first five years after separation from the military.
Mr. Ruiz. Okay.
Mrs. McDonald. And it is what we could afford.
Mr. Ruiz. How about the others?
Mr. Renschler. The same answer. We honestly cannot afford
for that to happen. We, it took us a long time to recover from
the financial hardships of losing my job. And once my benefits
started, I could not afford to seek treatment elsewhere. We had
to put together, as I said, a pain management regime that
worked for us. We paid out of pocket for a while for
chiropractic care and we found somebody through church who
would work on me chiropractically for free, and our neighbor is
a massage therapist. And we found things that worked for us
just to get by. But you know, it would be really cool if the VA
would take care of some of that too.
Mrs. Green. My husband always said that when he enlisted
into the military the VA had promised him his free, or his
health care. And when he was VA service-connected, he said he
trusted the VA and that he was going to use the VA. And so his
facilities that he utilized was the VA.
Mr. Ruiz. My understanding is that the VA will not cover
acute emergencies outside of the VA in what they cover? Is that
true or not true?
Mrs. Green. I cannot answer that.
Mr. Ruiz. Okay. My question also is referring to all those
times that you mentioned that there was a doctor that would add
a new medicine, or that would change the dose, and that there
was no continuity of care, like it is not the same doctor.
Sometimes that may occur outside of a VA system or not, or
inside. I know in this case, it did occur on the inside. And
sometimes that does occur on the outside. What was it like to
get information from the VA to those doctors in terms of
knowing what the medications they were on, and what is the
dose, and what is the regimen that was prescribed? Because
sometimes when you do not have that information, they see you
for the very first time, and there is no continuity, there is
no history. They just look at a list of maybe what you have
been on before, and so they will prescribe you, just to handle
that specific situation. How is the ability to acquire records
or call your physician from the VA?
Mr. Minyard. Sir, I can try to answer that. I think it
would be easier if everybody in this room, we all worked
together to try to raise the Titanic, than try to get my
medical records from the VA to a civilian hospital. And to have
a doctor from the VA call my civilian provider, that would be
unheard of, sir. In my experience, it is extremely difficult to
get. It is kind of a chain link process. It is extremely
difficult for me to get my DoD records into the VA. If that
happens in piecemeal, once they do get to the VA, and I do need
to go see a civilian provider, I have yet to receive documents
that I asked for 12 months ago. And I volunteered to come to
the VA where the records are kept, take time from work, and
photocopy them myself. And we are at 12 months and counting,
sir. It is extremely difficult.
Mrs. McDonald. I think for me, I was only able to obtain,
and we are still in the process of obtaining my husband's full
medical docket after the estate hearing, in which I was
appointed the executor. I think the bigger question is, is why
is there not more continuity between the doctors at the same
VA? Why is my husband being prescribed the same medication and
two weeks later sees another doctor who says, ``do not take
that,'' but then the same medications show up in our mailbox?
My husband was just receiving pills left and right, that it
seemed like with every months that passed the plastic bowl,
mixing bowl that we kept all his meds in, had to become bigger.
Because they just become so abundant. And nobody ever said,
``stop taking this one, switch to this one.'' It was, ``this
does not come in that milligram, okay, so-and-so has you on,''
nobody was going through his records and saying, ``this doctor
already gave you this, so I am not going to go and do this.''
So I think there needs to be a lot more communication amongst
the doctors who work in the exact same area, in the exact same
field, and treat the exact same patient.
Mr. Ruiz. I absolutely agree with you, and I think that is
the primary question here is, what kind of safety mechanisms
are in place to ensure that a prescription cannot be prescribed
until they have a consultation with the appropriate pain
specialist, which we know that they have, you have a lack of,
in the VA, and the pharmacy, to start to have a different
ability to look at the interactions between drugs.
There is a big push now, I know in the hospital that I work
in at Eisenhower Medical Center, where every patient, the
nurses, and the doctors have to get together and they have to
look at the interactions and identify those interactions for
every single drug that they take. I think these are approaches
and policies that the VA may have, like you mentioned there are
clinical guidelines. But it is the implementation, and what are
the quality control measures that also look, not only at the
actual science of those interactions but the patient/doctor
relationship.
Not allowing the next of kin, the spouse, to be seen with
the patient for privacy reasons, is one of the biggest hog
washes I have ever heard. And the other thing is to make sure
that we look at pain in a holistic manner. To look at the
complexity of pain not only on the science, but also the
effects of the interactions with family, their ability to
function, their mental health, like you mentioned, and the
perception of who they are as a human being. And I think that
these are questions that we will be asking the VA and we will
be looking thoroughly into.
So I thank you for giving voice to the voiceless. Although
they are not voiceless, their voice lives in you. And I know
that. Because I feel like your spouses are here, and I feel
like all of your friends that are doing that are here with you.
So thank you very much.
Mr. Benishek. Thank you, doctor. Now we will have five
minutes from Dr. Wenstrup.
Mr. Wenstrup. Thank you, Mr. Chairman. And I, like the
others, applaud you for being here, and to have the courage to
be here and to take up this new mission in life. Basically, the
things that I was going to bring up my colleague, Dr. Ruiz,
really pretty much covered. And as a caregiver, and as one that
has given care in the DoD, I am an Army Reservist, I understand
that side of it, and the complexities there with it. And it
bothers me when we hear what we just heard, because this could
not go on, I do not think very well in the civilian side, the
things that are taking place.
And so my question to sort of piggyback on Dr. Ruiz is,
when you went to the doctor, you or your spouse, did they ever
take the time to review the current medicines while prescribing
something new that you are aware of?
Mrs. Green. My husband went to the VA doctor in September,
a month before his death, to request that his medications be
reviewed. And how the VA, how the health care provider reviewed
it was to tell him that he should continue taking all of his
medications. And wrote that in the medical summary. And it is
clear in the medical summary of his medical records. And he
followed the orders of the doctor.
Mr. Wenstrup. Is that similar for all of you? I would
imagine that----
Mr. Renschler. I think she paints a pretty good picture of
what it feels like and the transition I had to take for myself
in learning how to advocate, and I learned it pretty good from
my wife. She is about 5'5'' but she is a pistol. When we would
go into the hospital and the doctors would say, ``you are going
to take this pill,'' I would be like, ``yes, sir, it is going
to help me.'' As far as reviewing the medications, every visit,
they would print off at the nurse's station a current list of
medications. Not necessarily to go over them or to ask how they
are doing, but I am sure that this comes down to a policy
issue, this is how they are executing the policy to review
those medications. At each visit, the doctor prints off a
current list of medications and hands it to me as we are
walking out the door.
You know, I think a big issue that I would like to raise as
we are talking about this specifically is the oversight. You
know, many of these medications have harmful side effects. And
the problem that arises, I am sure in the civilian community,
that primary care providers change and they move. But this
happens really frequently at our VA facilities. It happens,
they go from team to team. And when you are put on a new
medication with harmful side effects and there is no oversight
to say, ``hey, how is this doing for you?'' three days later,
that is a dangerous practice.
Mr. Wenstrup. That goes to my next question. When you were
receiving your medications, was there ever a consultation with
a pharmacist to discuss the medications that you are on?
Mr. Renschler. That is another practice, at least at our
facility, is that when you pick up your medications, if it is a
new or renewal, we have to sit in front of the pharmacist who
looks it up, and at our facility they say, ``this is the
medication that you are getting and these are some of the known
side effects.'' And they print, for me, they have printed off a
fact sheet for the medications and then prescribe them to me.
So.
Mr. Wenstrup. Were you ever offered a consultation with
pain management specialists?
Mr. Renschler. No.
Mr. Wenstrup. Mr. Minyard?
Mr. Minyard. Sir, I took it upon myself to try to track
down the pain specialist in our VA. Nobody could tell me what
office he was in. So I literally walked the three or four
floors of the VA, office to office, asking who the pain
specialist was.
Once I got there, I quickly realized it was an exercise in
futility. Because his answers for my condition and my injuries
were either go back on long term opioid-based treatment
regimen, or he could do lumbar epidural shots. I mentioned that
I had a spinal cord stimulator already implanted and it helped
me, it was instrumental in stopping a dose of opioids that
would have killed me very shortly. And he, this is, now to put
this in perspective, this is the interventionalist pain
specialist in charge of one of the largest VAs in Florida. The
guy that we all are supposed to go to for pain management. He
had never heard of a spinal cord stimulator. That blows my
mind. That to me is beyond unacceptable. And for me, as a
patient to have to pull out a brochure and say, ``This is what
it does, doctor.'' And I did it very tactfully and very
respectfully. But for me, I am an Army guy. And I am having to
talk to a medical professional and explain a device that is
used to treat pain, the field in which he has gone above and
beyond to become educated in? And the most absurd part of it
is, I was thrown out of the office.
The reception I got from him was, again, you are an Army
guy, I am the pain specialist, how are you going to teach me
anything? Here is your brochure. Thank you very much. Have a
nice day. That was my situation. Which is absurd, sir, in my
opinion.
Mr. Wenstrup. I agree. Well my time is expired. I want to
thank you all very much. I appreciate it.
Mr. Benishek. Thank you, doctor. Ms. Kuster?
Ms. Kuster. Thank you very much, and thank you Mr. Chairman
for holding this hearing. And to our colleagues, particularly
our doctor colleagues, I want to say that we are fortunate to
have their expertise on this panel.
I just want to say in addition to thanking you all for your
courage to come forward today, and please know that you are
giving voice to your spouses. And for you all, for your
service, thank you, and for coming forward. I have been married
for 27 years to a man who lives with chronic pain, not from
military purposes, but I very much understand the story that
all four of you have told, and it is something that I have
lived with everyday and the psychological impact and the
physical impact.
But I want to focus on, Mr. Minyard, your experience with
this spinal cord stimulator. And just for me to understand as a
new Member of Congress, how that type of answer to your prayers
could be made available to more people in the VA system? And I
know it is complicated managing pain. For my husband, he has
tried every treatment that you have described and many that you
have not. He now is getting hip replacement surgery, where
people had talked about major back surgery. And in fact, this
is one of the first times that I have seen him pain free. So I
think it is complex in terms of the connections. But how to get
from this opportunity that you had for more people across the
spectrum, to have these types of cutting edge therapies that
could make a tremendous difference in people's lives, do you
have any suggestions for that?
Mr. Minyard. Yes, ma'am. And I am very grateful for the
question, and I will try to answer it as best as I can as a
patient with the device that it works. I am obviously not an
industry expert or anything like that, or a policy maker.
Ms. Kuster. Sure, mm-hmm.
Mr. Minyard. But the biggest stumbling block to getting
this medical innovation, technology like this, that I have seen
and when I deal with other veterans and other people that are
dependent and addicted, as I was, to Oxycontin, is, or opioid
pain medication, is that providers, as well as patients have to
be educated. That is, for me, if I ran the world, that is where
I would start. Because if you do not know about it, you cannot
teach somebody about it. So if more doctors were made aware and
learned about the technology, and it does not just have to be
what I have, but it is medical innovation. Looking for a
better, more effective way to treat veterans and other chronic
pain sufferers, not just veterans. So it is, in my opinion,
again ma'am, it is not being satisfied with the status quo of
we have been doing opioid pain medication for long term chronic
pain treatment. It seems to be going okay, so let us stick with
that. Why not strive to do something better?
And the ramifications of long term opioid-based pain
medication, if you look at the, I spoke about this yesterday, a
lot of times you hear the argument there is a cost benefit
ratio. Pain pills are, I am assuming, much cheaper than
technology like this. But cost benefit analysis is, that is not
really realistic when you are looking at, if you want to do
cost benefit analysis, we can do that. Let us go ahead and put,
what cost are you going to put on my marriage? My ability to
now know my daughter, who I did not know for three years
because I was stoned and I was deployed? What value is there
for me to be excited to read a book with my daughter at story
time, at bedtime? What value do you place on me being happy and
excited about my ten-year anniversary on Saturday? I, I did not
think there was any way I could make it to ten years. If I was
my wife, I would have divorced me 20 times ago.
But the point is, it has to, in my opinion, it has to start
with education and the desire to look beyond the standard and
the status quo. It seems to me every other, car industries for
example, they do not settle for this year's model, is the best
we are going to do, and we are good with it. They constantly
strive to look for new innovations, better ways to sell their
product. Why do we not do the same thing with patients? Look
for more effective ways for them to live well, have a family,
be a productive member of society, and manage their pain as
opposed to their pain managing them, ma'am?
Ms. Kuster. Thank you very much. My time is up. But in the
civilian side there is a process, and I am sure Dr. Wenstrup is
familiar with the quality assurance, and it is something that
we could look into of trying to get to a place where these
situations did not happen. So thank you so much for coming here
today and sharing with us.
Mr. Benishek. Thank you. Mr. Bilirakis?
Mr. Bilirakis. Thank you, doctor. I appreciate it very
much. And I want to thank you all for your service. I
appreciate it. Thank you for your willingness to testify as
well.
Mr. Minyard, I have one question. I understand that at one
point you went to VA with a list of private sector providers in
your area who were able to see you and could provide the
treatment you needed, and were told by the VA that you could
not access care in the community and would instead need to
travel to another VA facility hours away. Is this true? And
again, it would take months for you to get the next available
appointment, which I think is unacceptable. Please describe
that experience for us. And why did the VA tell you that you
could not be seen in the community? I think this is a very
important question. So please, if you will, thanks.
Mr. Minyard. Yes, sir. Part of the technology I have and
the pain therapy I have is treated by spinal cord stimulation.
The Orlando VA, as I said earlier, the pain doctor there was
not even aware of this treatment. And I went on Google Maps,
looked up 60 providers within a ten-mile radius of the Orlando
VA, civilian providers, that could give me the support I needed
to maintain the device I use to manage my pain without opioids.
I went to the highest, I went, I started at the bottom and
went up the chain of command at the Orlando VA, and then asked
for the appeal to be sent up to Gainesville, saying why can I
not, why with bonuses being paid to VA CEOs for outstanding
performance when people are dying in the hospitals, why with
big, you know, conventions being thrown that cost millions of
dollars, why cannot somebody pay for me just to go down the
street and get my device fixed? And they said no. It costs too
much. We have a doctor in Gainesville, I live in Orlando, that
deals with this type of thing.
So I said okay, can we get an appointment? And this was
last May. They said, okay, we will put you on the list.
Mr. Bilirakis. So you have a doctor at the VA in
Gainesville, that is affiliated----
Mr. Minyard. In Gainesville.
Mr. Bilirakis. Okay.
Mr. Minyard. I will see that doctor in June of 2014.
Mr. Bilirakis. June----
Mr. Minyard. I made that appointment in May of 2013. So I
am eagerly looking forward to it next year, sir.
Mr. Bilirakis. So in other words there are several, you
said close to 60 providers, private sector providers in the
area that could see you almost immediately?
Mr. Minyard. Last count. And on top of that, sir, I know
our time is getting short, but due to multiple TBI injuries,
you know, one too many times being blown up, I have seizure
disorder. The result of that is I have fairly frequent
seizures, typically three to four every five months. So my
license gets revoked every six months I have a seizure. So that
was another case I brought up with the VA, saying you would
rather me try to arrange a ride from Orlando to Gainesville, at
the same time I have a full-time job which I was subsequently
fired from because the VA kept canceling my appointments and
that is another story. But knowing I did not have a drivers
license, they still insisted that I was not allowed to go five
miles from my home to a civilian doctor. Instead, I would wait
until an appointment was available. And then, they actually
called me and their words were, ``We need you to arrange some
transportation. Do you not have a wife?'' My wife is a VP for a
Fortune 500 company. She is taking care of me, my daughter, and
progressed in her career unbelievably. So yes sir, I do have a
wife. But I am not asking her to take time off to drive me to
Gainesville when you can send me five minutes away. And that
was that situation you are referring to, sir. If it did not
happen to me, I would have trouble believing it, sir.
Mr. Bilirakis. All right, thank you. Anyone else want to
comment on that on the panel? But also I would like if you do
not mind, I would like to talk to you further after the
hearing?
Mr. Minyard. Yes, sir. It would be my pleasure.
Mr. Bilirakis. Okay. Please. Please. Anyone else want to
comment on this particular issue?
Mrs. Green. My husband was referred for a sleep apnea test
and there is a sleep facility in Fort Smith. And he, the
referral was for Missouri. We had to take him to Missouri for
his sleep apnea test. Not once, but twice, when there is a
sleep facility in Fort Smith, Arkansas. Twice.
Mr. Bilirakis. Thank you very much. I yield back the
balance of my time. Thank you.
Mr. Benishek. Dr. Harris?
Mr. Harris. Thank you very much. I want to thank the Chair
and the Ranking Member and other Members of the Committee to
let me sit in on this. As you know, I am an anesthesiologist.
So pain management, although not my subspecialty, is certainly
related. And I have a couple, just a couple of very brief
questions. Sergeant Renschler, let me ask you a question about
the denial by the formulary of Lyrica. Which I find
fascinating, because you know, Federal employees can get
Lyrica. I mean, you can go on all kinds of health coverage to
get Lyrica. But my question is very specific. My understanding
is about your testimony the Chief of Neurosurgery said you
should get Lyrica. And then it was denied by the pharmacy, by
someone in the, did someone examine you from the pharmacy? Sit
down, take a history, go over the indications, possible
indications? Or was this just a paper denial as far as you
know?
Mr. Renschler. Sir, it is a disgusting situation and it
went down like this. I went up to visit the Chief of
Neurosurgery in the Seattle Medical Center. She came up with
this medication option, said it might be a really great thing
to improve my quality of life and reduce my dependence on
opiate-based medications which is something that was a big goal
for me. And it had very few side effects and it certainly was
not damaging to the liver, so it was a great thing for me and
my wife. When she put in, she did tell me it was non-formulary
and it might be a battle to get it, but she was pretty
confident that her rank would allow us to get this. It was
denied. And she called me on the phone and told me it was
denied but she was gathering the signatures from two other
department heads to resubmit a request back to the pharmacy
because when they responded to her they told her, ``he should
try things such as Lidocaine ointment and Gabapentin.'' And----
Mr. Harris. And again, just, because I think you have
answered the question. It was recommended by someone who never
met you----
Mr. Renschler. Never met me, never evaluated me.
Mr. Harris. --did not know the specifics?
Mr. Renschler. And did not know the specifics.
Mr. Harris. And my belief is, as I am sure you share, this
was because Lyrica actually costs more than other medications,
right? So this is a cost saving measure. It is just
fascinating, that is fascinating to me. And just very briefly,
Sergeant Minyard, let me just ask you because, you know, part
of your testimony was pretty, as you have found out pain
management can get pretty specific, require a lot, we require a
high level of training.
Mr. Minyard. Yes.
Mr. Harris. Because you could not find someone in the VA
system who actually, nearby who could do what you had, which as
you found out is pretty standard in the outside world.
Mr. Minyard. Yes.
Mr. Harris. I mean, six or seven years ago, when I was
giving anesthesia for people like you who were getting spinal
cord stimulators implanted. When you were in overseas, though,
were you getting epidural steroid injections in a tent in Iraq?
I mean, I am an OB anesthesiologist. I have given thousands of
epidurals to patients in labor. I would never dream of doing
epidural steroids on a pain patient because you actually need
some special training to do it properly. But is that what you
were getting? Were you getting epidural steroid injections?
Mr. Minyard. Yes, sir. I----
Mr. Harris. I mean, and again----
Mr. Minyard. I do not want to sound----
Mr. Harris. --this is a VA hearing. It is not on DoD,
obviously.
Mr. Minyard. Yes, sir.
Mr. Harris. The DoD was responsible for delivering that.
But I think the appreciation is, is that perhaps even
systemwide, not even just the VA, maybe in the DoD, I mean
there may be no appreciation for how very, for how the
treatment of pain has changed over time. Multimodality. I mean,
epidural steroids may well have been indicated in your case.
But doing it in a tent in Iraq? I mean this----
Mr. Minyard. Not even a tent, sir.
Mr. Harris. Oh, I am being generous----
Mr. Minyard. Yes, sir.
Mr. Harris. --this was a tent.
Mr. Minyard. I mean, what would happen, sir----
Mr. Harris. But you know what I mean? I am sure you did not
have an interventional pain management specialist doing that
intervention?
Mr. Minyard. Sir, the docs that performed those, what would
happen is, we would have, I would have my team's trucks rolled
up outside the team house ready to go. As soon as all pre-
combat checks were done, I went around the corner to a small
enclosed area, three walls enclosed, and the RN that was
attached to our trauma team would give me my epidural. And we
would wait a few minutes to make sure everything was good, and
then I would put on my combat kit, and roll on that mission.
And I had eight of those.
Mr. Harris. I am going to apologize for the way the U.S.
government handled that. Thank you very much, Mr. Chairman.
Mr. Benishek. Thank you, doctor. Well it was particularly
frustrating to me to hear your many stories, one after another.
But the challenges that you have addressed here seem to be
remarkably similar for each of you. I hope that the
administration officials that are here listened as closely as I
did to the testimony. And if there are no further questions,
the first panel is now excused. Thank you all so very much.
Now I will welcome the second panel to the witness table.
Joining us on the second panel is Dr. Pamela Gray. Dr. Gray is
a former provider at the Hampton VA Medical Center. Also in our
second panel is Dr. Claudia Bahorik. Dr. Bahorik is a provider
with VA's interim staffing program. In that capacity, she has
worked at 13 different VA medical facilities across the
country. She is also a disabled veteran, so thank you ma'am for
your service. We are also joined by Dr. Steven Scott, the Chief
of Physical Medicine and Rehab Services at the James A. Haley
Veterans Hospital in Tampa, Florida. Thank you all for being
here and for your hard work on behalf of our servicemembers and
veterans.
We will begin with Dr. Gray. Dr. Gray, please proceed with
your testimony.
STATEMENTS OF PAMELA J. GRAY, M.D.; CLAUDIA J. BAHORIK, D.O.;
AND STEVEN G. SCOTT, M.D., CHIEF OF PHYSICAL MEDICINE AND
REHABILITATION SERVICE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF DR. PAMELA J. GRAY
Dr. Gray. Thank you. At the outset, I would like to thank
the Members of this Committee on Veterans' Affairs for offering
me this opportunity. I am grateful for your time. I must also
tell you that I am most honored to be in the presence of the
four individuals who occupied these seats ahead of us. I would
beg of this Committee to hear their stories and realize that
they represent tens of thousands of similar stories. Tens of
thousands.
I have included for your review today, a letter that I
wrote to my State Senator. I do not mean at all for you to be
bored by the trivial details of that letter. I use it as a
jumping off point for you to hear the physician's side of what
it was like, at least at one VA center in Hampton, Virginia,
between 2008 and 2010 when I tried to work through the system
and failed. As a result of trying to work through the system,
and realizing the gravity of these complaints and the validity
of my concerns, I offered myself up as a sacrificial lamb.
When you are employed as a physician, you are prohibited at
a VA medical center from speaking out to the general public.
You are to work through chain of command. I did so, and it fell
on deaf ears. I went to my State Senator, knowing that the
inevitable outcome would be to be terminated, which was indeed
the case. But it was only through doing that, that my story was
discovered. And I would like you to understand how I am here
today.
I went through appropriate chain of command, went to
service chiefs, chief of staff, director of the center,
represented my VA as a VISN 1 through 11 conference on pain, I
went through all the appropriate channels and failed. I am here
because of the investigative reporting of a CBS News producer.
And for that I am grateful.
I would pray of this Committee, no I would beg, I would beg
of you to offer constructive intervention. Your flowery words
of praise, thanks, condolence are heartfelt, I am quite sure.
And they are eloquent. But if true change and action does not
come out of this Committee, all here have failed.
With that in mind, I am going to just some highlights of my
letter to my Senator. Not for details, and yes, there are names
in that letter. And I chose to let them stay. I see no point in
mentioning them in this testimony but they are in the written
form. I do that because I spoke the truth then, and I speak the
truth now.
I am a physician with 30 years experience. I am an
internist and a rheumatologist. I closed my private practice
and went to the VA in 2008. I never misrepresented myself. I am
an internist, and a rheumatologist, and I was, had a dual
appointment with internal medicine 30 percent, and primary care
70 percent. In the first hour of my first day, I was informed
that I was head of pain management. In my ten years of post-
graduate training, I had no pain management training. It is an
entity unto itself. And it is a subspecialty that has
subspecialty training. I was never asked if I was willing to
assume this role, I was informed. So to those observations and
questions that came before, I was pain management with zero
training.
My concern about that was, it is not standard of care. If
you are going to portray yourself as an obstetrician, you
should have OB/GYN training. A surgeon should have surgical
training. That is common sense. The VA in Hampton obviously did
not realize that.
I tried to do what was asked of me. I thought it would be
reasonable. They had no pain management, no rheumatologist. And
so I decided to try and work through the system. I went through
service chiefs, clinic nurses, telecare nurses, supervisors,
when I found abberances in the way of treatment,
musculoskeletal pain syndromes. I pointed out that ten to 20
percent of opioid users become addicted, we were creating
addicts. All of this fell on deaf ears. The Chairman of the
Department of Internal Medicine gave me this response to my
query as why we were writing so many prescriptions for opioids,
``think twice before refusing to write these narcotics. It is a
time of economic downturn.'' I do not know if that was a threat
of the loss of my job, or if it alluded to the possible
diversion of narcotics. I do not know.
During my two-year period, I was coerced to writing drugs
that I knew in my medical experience were wrong. When I would
object, I was simply told to do it or else. The physicians are
given three choices. One is acquiesce and keep your job. Two is
quit; and three physicians quit during my two years there, one
within 30 days of being hired due to objection to writing these
massive amounts of opioids. I chose to work within the system,
which led to termination, the third choice.
I documented in my notes, in 30 years of practice, I know
how to write a note, I know how to be complete, I included the
facts. I was being coerced by non-medical employees, non-M.D.s,
to write for large amounts of opioids. When that was discovered
in my medical note, which was an electronic medical record, I
was ordered to delete the note or alter the note. I had
reported the truth and I refused. The Chief of the Department
of Primary Care altered my note, buried the note which
documented the truth. And I had the proof, I had the original
note, and then the subsequent note that was entered into the
chart. And I reported that to the Office of Regional Counsel at
McGuire in Richmond, Virginia. Nothing came of it. Again, I was
trying to work through the system which was what was
appropriate.
Upon representing my VA at the National Pain Conference,
which was in 2009, I brought all of that information back to
both Service Chiefs, the Chief of Staff, the Director. And in
the two years after that timeframe, nothing was implemented,
absolutely nothing.
I became an advocate for several of the patients. There are
patients who are smart enough to know about spinal stimulators,
about alternate treatments. And as a result of trying to be a
patient advocate, I was threatened with further action may
result in disciplinary action to include removal. So again, the
system failed me. I received death threats from patients. I was
called before a probationary review board, not told of the
charges against me, not allowed to review my records. And my
Chief denied knowing anything about this review board when she
herself had called for it.
So during my two years, I was forced to do work for which I
had no professional training. I was ordered by supervisors to
write large amounts of Schedule 2 narcotics for inappropriate
medical circumstances. I had my medical records altered to hide
factual documentation. I received sexual harassment by a male
nurse, who would come to my office during lunch hour and
threaten me if I did not write for the opioids. And when I
reported it, I was asked if there were any other witnesses.
Since there were no witnesses but the two of us during lunch
hour, ergo it did not happen.
I was reprimanded for standing up for the rights of a
patient. I was threatened to be reported to the National Data
Bank, which is a mechanism for egregious complaints against
physicians. And you have to reach a certain level of severity
to be reported, and I did not. But they gave me that threat.
And I was subjected to situations of entrapment, trying to get
me to admit to things that were not true in an effort to build
the case against me.
I underwent that board. I was never apprised of the
findings. I was called to my boss' office and terminated.
I can see that I am over time. But I would like to beg, if
I may offer the 11 patients that are at the end of this letter.
And I will go through them quickly. The bottom line in all of
them are they are on massive amounts of medication. You do not
have to know anything about medicine, you do not have to know
the difference between Morphine and Tramadol and Percocet, all
you have to do is hear the quantities.
There was a 55-year old man, the first patient I saw in
this musculoskeletal clinic, who had carpal tunnel. I bet you
everyone here has had carpal tunnel symptoms. If you flex your
hand for too long, these fingers will go a little numb. It is
fixable with surgery. This gentleman has the surgery. He had
none of the findings of chronic entrapment of the nerve. He had
Morphine, Fentanyl patch, Tramadol, Percocet, he had been
getting it since 2004, he had not been seen since 2004. He had
had no labs checked since 2004. He had the opioids mailed to
him. He did not even have to come in.
You had two veterans tell you about liver dysfunction as a
result of these drugs. You must check the labs. There is not a
civilian pain management, musculoskeletal clinic,
rheumatologist, primary care, anything that would do this to a
patient.
I can go through them all. I am over my time. This is
representative.
[The prepared statement of Pamela J. Gray appears in the
Appendix]
Mr. Benishek. I truly appreciate your testimony, Dr. Gray.
But time is a precious thing here in Congress----
Dr. Gray. I understand.
Mr. Benishek. --and I just want to make sure that everyone
has the opportunity to testify. We will certainly include the
statement, your written statement in the record.
Dr. Gray. Thank you.
Mr. Benishek. I appreciate your efforts here. Dr. Bahorik?
STATEMENT OF CLAUDIA J. BAHORIK
Dr. Bahorik. I am here because no one else will speak out.
My colleagues are afraid for their jobs. I am here as a
physician who is concerned about the health and welfare of our
vets. I also happen to be a physician acupuncturist, and a
licensed physical therapist. I am here, too, because as he
said, I am a disabled vet.
We have been asked to discuss the problem of narcotic
prescriptions within the VA. I am here to tell you that the
system is broken, that it is a set up for catastrophe, at least
on the part of the veterans who get caught up in the pain game.
As a traveling physician, I have worked in 13 VA facilities
from Guam to Maine, including the notorious VA in Jackson,
Mississippi. Jackson serves as a perfect example of a system
gone haywire. This was a system so cavalier that this VA
facility did not think the Drug Enforcement Agency rules
applied to it. So when they, DEA, stopped all the nurse
practitioners from writing narcotics, the VA traveling docs
were asked to help and I volunteered. I arrived to discover
that I had been assigned the job of writing narcotic
prescriptions for the vets that needed their monthly renewals.
The first thing the head administrator told us was that we only
had to review the charts, make sure they were stable, and write
the prescriptions. He said he could do 30 charts a day while he
was still playing top dog.
He did not understand why I objected, why I insisted I
needed time to take a history, to examine the vets, and to
review the chart. This is the same administrator that thought
his own staff should write narcotic prescriptions on patients
they never saw. He also paid medical residents at night to
review charts on patients sight unseen so the pill mill could
churn out more narcotics.
So they stuck me in a tiny exam room with no exam table, so
I could not examine the vets. They gave me a nurse and we set
out to screen the vets. What I found was a disgrace. I
discovered that veterans' narcotic prescriptions were being
renewed month after month, months on end, sometimes for one to
two years without an examination of the body part that was in
pain. They had been seen for routine medical problems, but the
pain evaluation amounted to merely asking them to rate the pain
on a scale of one to ten.
This was not just a few of the nurse practitioners whose
patients I saw, it was the rule rather than the exception.
Often, there were no x-rays, no recent MRIs, no tests, no
specialist consultations for the pain problem. Just more and
more narcotics on top of other medications.
There was no true attempt to screen for misuse or drug
diversion. I found that urine tox screens were infrequently
done and often they were positive for substances like cocaine
and pot, or negative when they should have been positive. Many
of the vets were misdiagnosed. Some had potentially serious
conditions. Pain contracts were not being completed. When urine
drug screening was done, no one even checked to see if the
specimen was body temperature, or if the specimen was even from
the veteran. No one was bothering to call the state databanks
to see how many providers in the state were giving the people
narcotics. I am here to tell you that this is not just a
problem at Jackson, it is endemic throughout the VA where quick
and cheap is rewarded over good and thorough.
Furthermore, it is uncommon for a doctor to refuse to write
a narcotic prescription, only to have the vet go to the
administration. What happens? The administrators call another
doc and tell them to write the prescription. Or the vet will go
to the emergency room to get their narcotics. Worse yet,
doctors are being verbally abused, attacked, or injured when
veterans who are on dangerous concoctions of mind altering
substances are cut off. In Jackson, a doctor was shot and
killed. Another had acid thrown in her face. In Delaware, two
mental health workers were attacked. A vet who was denied
narcotics ran his truck into the VA clinic in Lincoln, Maine.
Another vet in Maine attempted to enter the VA with a gun to
shoot the administrator. He became a case of suicide by cop.
Why is this happening? Unfortunately, we have given the
veterans the impression that for whatever problem they have, we
have a pill to help it. One or two pills for depression, one
for anxiety, one or two for sleep, one for PTSD, then add a few
more pills for problems like hypertension or diabetes, asthma,
then add one or two or three prescriptions for narcotics. What
happens if the vet adds some over the counter medications, or
if he drinks alcohol? We have a prescription for chemical
lobotomy, a veteran who is at risk for fatal interactions.
Someone whose brain is bathed in a chemical soup.
The VA will show you guidelines and resources available to
providers showing how much they are doing. These are the same
administrators that create regulations, mandates, requirements
that are so mind boggling that physicians are no longer captain
of their ships. Basic principles of medicine are abandoned.
Primary care providers are struggling to stay afloat in a
system bogged down with mismanagement, bonuses that reward
cheap care, not true quality care, and policies that make it
nearly impossible to adequately and safely monitor the health
care given to the brave men and women who served our country.
Thank you.
[The prepared statement of Claudia J. Bahorik appears in
the Appendix]
Mr. Benishek. Thank you for your testimony. Dr. Scott,
would you please begin?
STATEMENT OF STEVEN G. SCOTT
Dr. Scott. I just want to begin by expressing my sincere
sympathy to Mrs. McDonald and Mrs. Green who were here. And to
you and your families, I just want to express that before I
begin my testimony.
Good morning Chairman Benishek, Ranking Member Brownley,
and Members of the Committee, thank you for the opportunity to
participate in this oversight hearing and to discuss
specifically the Department of Veterans, James A. Haley
Veterans Hospital Chronic Pain Rehabilitation Program in Tampa,
Florida that treats veterans experiencing acute and chronic
pain. VA's chronic pain rehabilitation program was established
in 1988. Our involvement in this program over the last 25
years, is a demonstration of our commitment to addressing pain
management. We, recognizing that chronic pain can be very
disabling and these veterans need our help.
Chronic pain is pain that does not resolve within three to
six months. When chronic pain causes significant psychosocial
dysfunction, then it is called chronic pain syndrome. Chronic
pain syndrome is defined as chronic pain with significant
psychosocial dysfunction. While pain may be the cause of these
psychosocial problems, there is evidence that once established,
these related problems linger even if the underlying pain is
substantially reduced.
Unfortunately, many individuals with chronic pain syndrome
attempt to fight these problems using increasing amounts of
opioid analgesics. But these efforts are rarely successful. Due
to the complexity of the syndrome, no single treatment approach
is the answer. A multidisciplinary and multimodality approach
is almost always necessary.
Tampa VA has both an inpatient and an outpatient chronic
rehabilitation program, and has the only VA chronic pain
program. The program is specifically designed to treat veterans
and active duty military personnel with chronic pain. The
program is evidence based, intensive, interdisciplinary, 19-day
inpatient chronic pain treatment program that targets not only
the pain intensity but also all the symptoms of chronic pain
syndrome. The core philosophy of this program recognizes the
complex interactions between the pathological, physiological,
emotional, social, perceptual, cultural, situational components
of chronic pain. Approximately half the patients submitted to
this program are taking opioids and approximately half are not.
The program teaches pain self-management principles, where
the participants assume responsibility for their daily
functioning and learn to actually manage their pain. For most
participants, this includes increasing their level of
independent functioning; increasing their activity levels;
reducing their emotional distress associated with chronic pain;
eliminating their reliance on opioid analgesics or muscle
relaxers; reducing pain intensity; improving marital, family,
and social relationships, improving vocational and recreational
opportunities; and improving their overall quality of life.
A unique aspect of this program is that all participants
who take an opioid analgesic at admission are tapered off these
medications during the course of the treatment. We have found
that patients taken off these opioids, experience similar
improvements to patients who are not taking opioids in all
areas of treatment outcomes over time, including pain severity;
activities of daily living; mobility; and all other
psychosocial problems.
In its 25 years of existence, the program and its staff
have received numerous awards. The program has been recognized
as a two-time Clinical Center of Excellence by the American
Pain Society. It has also received the prestigious Secretary of
Veterans Affairs Olin Teague Award for Clinical Excellence, and
has been accredited six times by the Commission of
Accreditation of Rehabilitation Facilities, or CARF. Their
programs leaders have been actively involve in promoting
systemwide enhancement of VA pain care. As the most specialized
chronic inpatient pain treatment option in the VA health care
system, the program has already accepted and treated referrals
from all 50 states, Puerto Rico, and the United States Virgin
Islands, and military installations from around the world.
In 2009, the Chronic Pain Program was selected to serve as
VA's trading site for interdisciplinary pain programs. To date
we have hosted 30 teams from across the country to observe the
Tampa VA model system, and learn how to enhance pain treatment
services at their facilities. The training program helps meet
the 2009 VHA Pain Management Directive, mandating an
interdisciplinary CARF accredited pain programs in each of the
VISNs' integrated supported network. The positive effects of
these training are seen in the increase from two CARF-
accredited programs in 2009 to eight CARF-accredited programs
in 2013, and it is anticipated that an additional 14 VA chronic
pain programs will achieve CARF accreditation.
Mr. Chairman, VA is committed to providing a high quality
of care that our veterans have earned and deserve. I appreciate
the opportunity to appear before you today to discuss the Tampa
VA chronic pain rehabilitation program, and I am grateful for
your support in identifying and resolving challenges as we find
new ways to care for veterans. I am prepared to respond to your
questions that you may have.
[The prepared statement of Steven G. Scott appears in the
Appendix]
Mr. Benishek. Thank you very much, Dr. Scott. I am going to
yield myself five minutes to ask some questions. Dr. Gray, it
is my understanding that each VA medical center is supposed to
have a pain specialist. So I guess the pain specialist at your
VA medical center was you, then, right? I mean, you were the
one that was called the pain specialist even though you had no
experience, is that correct?
Dr. Gray. Correct.
Mr. Benishek. And now was it you that testified that your
records were changed?
Dr. Gray. Correct.
Mr. Benishek. You know, that is very much a fear that I
have about the electronic medical records. Because I know
myself at the VA, I experienced that as well. You know, I had a
path report that said it was benign, and then the patient, that
is why I sent the patient home for six weeks. And then when
they came back, the same path report had mysteriously changed
and become malignant. And yet, I had no evidence that there was
a path report six weeks ago that said benign. So, you know, it
makes you look bad. And this situation, where you are saying
how the medical record is changed, was there any evidence in
the medical record, that it had been changed without your
consent?
Dr. Gray. Absolutely. Not that it was changed without my
consent. Because I had been ordered by my superior to alter my
notes, and I had documented the truth, I refused. I took it
upon myself to print my note.
Mr. Benishek. Good idea.
Dr. Gray. The electronic medical records cannot be entered
into other than the treating physician or someone who has a
pass level, and it could be a medical records person. My Chair,
who ordered me to change my record, was Chief of Medical
Records. She deleted the entire segment that she had ordered me
to change. So the note started with my verbage, ended with my
verbage, was signed with my signature. There was no record, and
then reprinted, entered into the record as such. I printed that
one, too.
Mr. Benishek. So you have a record of the----
Dr. Gray. Yes, sir.
Mr. Benishek. --pre and the post?
Dr. Gray. Yes, sir.
Mr. Benishek. Well I wish I would have copied that path
report. To tell you the truth, this is a real scary thing for
me because of the fact that, here we have got government
controlled health care, where administrators are going to be
changing the physician's notes to make themselves look good is
a pretty scary situation in my estimation.
Dr. Bahorik, you relate a very similar story about being
told how to treat patients by people that are not physicians,
is that correct?
Dr. Bahorik. Yes, it certainly is. Administrators that are
not physicians are often in positions to supervise us and tell
us what to do. Not only that, she was talking about pain
specialists. For instance, at Wilmington in Delaware, the pain
specialist is not a physician, it is a nurse practitioner who
tells us what to do. And the other problem with a pain
specialist is, if the person does get sent to a pain specialist
they, once they start them on narcotics, they actually dump
them back on primary care and expect us to continue the
prescriptions. They just want to do their procedures and
injections, and they do not want to bother with the mundane
work of, or the day to day monitoring people on narcotics.
Mr. Benishek. Dr. Scott, let me ask you this question. It
sounds as if you have a pretty dynamic pain specialty service
there in the VA at Tampa. Do you have any experience with the
way they manage pain elsewhere in the VA? I mean, it seems to
me like you should be an example to the VA, as how pain
management should occur. But it does not seem from the
testimony we have had today that that is actually happening.
Dr. Scott. We are trying to, because we set up this, we are
trying to get other centers to come and educate them at our
center, sort of team to team like interactions. And we have had
30 of them that have actually come. This program is real unique
because I actually have seen individuals, I have been in this
program long enough, you know, it is 25 years so you can
imagine, I have been 23 years at this program, that I have
actually seen veterans from D-Day, you know, that have had
chronic pain. I have seen veterans that have had chronic pain
from Korea from frostbite and that. I have seen veterans from
Vietnam. I have seen veterans from Gulf War I. I have seen
complex veterans that have polytrauma, chronic pain from this
War. And in some of those invisible type wounds where they, you
know, we have seen those too. And they have all been successful
in this. And they have all done well. And we have a program
that, when you do this CARF stuff, it is an outcome based. So
we are constantly, everyday, everybody in the team is trying to
improve. Improve the process, improve the program.
And over 25 years this thing has been polished off and is
really a fine, I guess you would say, program that you could
really try to model after. And that is what we are attempting
to do, to educate more people out in the VA or elsewhere, by
coming. We also try to do some research. We also try to do
educational. We just do our best as we can. And but it has
definitely a 25-year track records of excellent outcomes.
Mr. Benishek. Thank you, Dr. Scott. I am out of time. Ms.
Brownley?
Ms. Brownley. Thank you, Mr. Chair. And thank you to all of
you for your testimony.
Dr. Gray, I wanted to ask you if you have any evidence at
all that the story that you have told by trying to work through
the system and do the right thing, if at the end of the day do
you know if there was any kind of investigation by the VA to
determine both sides of the story in your situation?
Dr. Gray. No, ma'am. If I tell you the grounds for my
dismissal were that I did not say good morning to a nurse.
There was no addressing my issues. The Office of Inspector
General, when I asked for a copy of the report as a result of
my queries about physicians being bullied into overwriting
opioids, they found that the waiting times for physical therapy
were not excessive. That had never been my complaint. That had
nothing to do with prescribing opioids.
So no, to my knowledge the issues were covered up, not
addressed. And the entrapment issues that I alluded to were
these trivial, trivial things that were used against me. They
did not want to address the facts.
Ms. Brownley. What happens in the VA when we know a patient
is now an addict to their drug? I have heard over and over
again today it is just different cocktails, more drugs. Is
there a point in which that stops and ceases?
Dr. Gray. No. No, ma'am.
Ms. Brownley. Dr. Bahorik, you said in your opening
comments you had background in both acupuncture and physical
therapy?
Dr. Bahorik. Yes, I am glad you brought that up. I have
been an acupuncturist for a little over two years. And every
facility I have gone to I have asked to be credentialed to do
acupuncture, particularly for pain patients. And I have been
denied. Not because I do not have credentials. I am licensed as
a physician acupuncturist. Just because they do not want to
open up a can of worms because patients are going to find out
that the service is valuable, and then they would have to pay
for someone. Same thing with chiropractors. They do not have
enough chiropractors. They do not do alternative things like
massage, or anything to that respect. Mr. Renschler mentioned
that when he went to physical therapy they did nothing. Well as
a physical therapist and after having been to 13 facilities I
can tell you that that is the absolute truth. Not only do they
not do anything, patients cannot get in.
Ms. Brown. Thank you. Dr. Scott, do you use acupuncture at
all or massage therapy in any of your----
Dr. Scott. Yes, we credential people in acupuncture, and we
also use massage, and we also use, have a chiropractor. We also
have alternative things. And I also submitted some new research
on CAM stuff, too, so we believe in that, too. And we believe
it. We use it as part of our overall holistic approach to pain
management. And I think that it is part of that whole, looking
at this thing in more of a total thing than just a separate
thing. So we do all of those things. And if the physical
therapy, if we cannot, we use a lot of, if there is sometimes,
if it is closer to home we use non-VA care. I mean, we
basically use what is best for the patient. The----
Ms. Brownley. You had mentioned about the training that you
do. Do you train across the country in acupuncture so that
others are licensed? Or massage therapy? Or----
Dr. Scott. We currently at the present time do not have a
manual or I guess you would say a training program in those
areas. We do have residency education, you know, and residency
programs like neurology and physical medicine rehab that we
train individuals or we can send them to places that get that
training, too. But we do not have train the trainers, if that
is what you mean, at our place.
Ms. Brownley. And is the training, it sounds to me the way
you have described it, the training is voluntary. That if
people want to come and get trained, they come to your center.
But you are not sort of overseeing centers across the country
saying, trying to look at where they need to be trained, if
people are up to speed in where they need to be?
Dr. Scott. Right. The 2009 pain directive says that every
VISN should have what they call a tertiary and
interdisciplinary team for pain. And we are trying to offer our
25 years of experience to facilitate that in the VISN area. But
I do not have a, I am just a local pain director. I do not have
any kind of a say on who comes and when they come. Except they
are always invited.
Ms. Brownley. Thank you. I have run out of time. I yield
back.
Mr. Benishek. Thank you, Ms. Brownley. Dr. Wenstrup, you
have five minutes.
Mr. Wenstrup. Thank you, Mr. Chairman. My first question
is, are providers at the VA protected in some way or free in
some way from malpractice claims? Yes, doctor?
Dr. Gray. Interesting. In a way, yes. Because basically you
are suing the Federal government. I am glad you asked that, if
I can go a little bit further?
Mr. Wenstrup. Please.
Dr. Gray. All you need to practice at a VA is a state
license. So if you have a Florida license, you can come to
Virginia and work at the VA. I went to my state Board of
Medicine to ask for help in this matter. The State of Virginia,
as many of the states do, has an outstanding program where via
Internet you can find out in 30 seconds whether a patient has
gone to multiple providers for opioids, whether they are double
dipping inside the system and outside the system. The answer I
got from my administrators was we are the Federal government,
we do not have to.
Mr. Wenstrup. Yes, in Ohio we have a similar program so
that you can check what medications patients are getting
through multiple providers. And you know, I have contended in
my practice, which my last day in private practice was in
December, and I always contended when I was dealing with non-
providers or people outside of our office, determining what
patients should or should not get, I would speak to them and
say, ``Well, how does this patient come to see you then if you
are making this decision?'' And I usually would get what I
wanted in that context. Because I do believe that unless you
sit down with a patient, and you look them in the eye, and you
put your hands on them, you should not be making their medical
decisions. But that is another issue for another day.
Dr. Gray. That is a real doctor, sir.
Mr. Wenstrup. I am sorry?
Dr. Gray. That is a real doctor.
Mr. Wenstrup. Oh, well thank you, ma'am. But my question
really for all of you, what within the VA system would really
motivate any of the providers, or any administrator, to be
exceptional, and to be efficient? And to really provide a high
level of care? What is built into the system that motivates
that? Because for an independent practitioner in the private
sector, it is your reputation. It is a standard of care, it is
your state medical board. And I am wondering what in the VA
system provides that, or motivates one? If anything?
Dr. Gray. That is private practice. I was a physician in
private practice for 25 years before I went to the VA. And it
is your pride. What you would have to do within the VA system,
and again this is my two-year experience in one VA hospital,
but you would have to interrupt the current system of
reimbursement, let us say. Every one of my service chiefs, all
of my superiors received a bonus, a raise, and a promotion.
Mr. Wenstrup. On what matrix?
Dr. Gray. It----
Mr. Wenstrup. Going up?
Dr. Gray. Correct. The theme here is do it as cheaply as
possible, and this is my opinion, but do it as cheaply as
possible. You well know these opioids cost pennies, just
pennies. And I guess they think a human life is just pennies as
well.
I established a therapeutic swimming program at zero cost
to the VA because the facilities were in place. The van, the
driver, the pool, I had patients willing and eager to
participate. I got no response from my supervisors. It was
cheaper to just give them opioids.
Mr. Wenstrup. Dr. Scott?
Dr. Scott. Congressman, that is a very good question and I
could answer it both from a clinical side as well as a personal
side. It is providing good quality care and having good
outcomes. I find that is what drives my staff to be very
excellent, both in treating the war injured back, both treating
this chronic pain program. I could sit down with any of my team
and they have great pride in what they do, because the
patients, they see the change, they see the improvement, they
see the outcomes. And they are so overwhelming in this program
that they basically, they come to work loving the work. Not for
the VA but for the patients, to fulfill our VA mission, here to
serve those. And providing that high quality of care, and
getting that atmosphere where everyone is important, everyone
can contribute, everyone's suggestions are listened to and
acted on. That is what makes a good quality, that is what makes
the atmosphere a positive, that is what makes the outcome. It
is not money. It is basically those. That is what I found over
time. That is why this program has gone for 25 years, because
we have had people that constantly see these outcomes that are
so good. And it keeps driving them to continue to be better and
for the next patient. And I just want to share that with you.
And for myself, the same thing. What drives me is not what
they cannot do, what they can do. What drives me is just what
some of the people said, when they feel helpless, hopeless,
when they feel like basically pain is running their life, we
get them control of their life. We get them control of their
pain. And when they leave the program I give them a new
mission, to go out and serve our country again. And basically
it is a good feeling. And then when they do that and they come
back, it is priceless. It is why we are here. It is our
mission.
Mr. Wenstrup. I applaud you for promoting that type of
motivation. And for those that provide care under your
tutelage, that they are taking that approach. That is personal
pride and that is how I practice. But I do not think that
everyone has that luxury right now, or performs in that manner.
And I yield back.
Mr. Benishek. Mr. Bilirakis?
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
And I really appreciate you holding this hearing and allowing
me to sit on the panel.
Dr. Scott, I want to thank you for all the quality health
care you have provided over the years. I represent, as you
know, the Tampa Bay area so I am very familiar with Haley. And
you, sir, are a true patriot. So thank you very much. And I
appreciate your testimony as well.
I understand from the testimony that approximately 30 teams
from across the country have visited your facility to observe
the model system and learn how to enhance pain treatment
services at their facilities. Have these teams from VA, are the
teams from VA or from the private sector? Are you aware of any
programs similar to yours that have been established as a
result of these visits? And what more can be done to increase
the provision of programs like yours across the VA health
system?
Dr. Scott. We have had 30 of them. They come and spend
about two and a half days. And they spend it, first we have
groups, we have small groups. We teach them one on one. They
have multiple disciplines so we match them up with the
different disciplines, too. We show them the whole structure of
the program. We show the administrative aspect of the program.
We have a tremendous outcome based type program. In other
words, we do not measure pain with just a zero to ten level. We
also measure all the different aspects of how you function with
the pain. And so function is very important. So we have
basically, we developed our own scale there, you know, to
actually measure pain. Not just a number, but how you interact
with that pain, how you function with that pain. How you
function with your wife, with your child, as was mentioned.
That is just as important, too. And those things are all
measurable. And we can then measure them when they come, when
they go, when they leave, and we try to teach these teams that.
Our goal is for them to go back and hopefully set up that
tertiary interdisciplinary team that could take patients in the
more complex level and manage that, too.
And then we are available if they want to come back again.
If they want to communicate by phone, if they want to interact
too. So our goal is to really try to facilitate and help the VA
learn what we have learned for 25 years.
Mr. Bilirakis. Thank you. Thank you again for thinking
outside the box. Of the veterans patients that received care
through the chronic pain rehabilitation program last year, how
many resided outside of your facility's catchment area? If you
can answer that question?
Dr. Scott. Yeah, probably more than half come from outside.
We basically have a, in our mission stuff we have a hundred
mile radius. So if they are within a hundred miles, they come
in, we can screen them in. If they are beyond a hundred miles,
like I mentioned we have had them from Hawaii, we have them
everywhere in the country, we basically have to screen by
phone, by mail, by letter and that. And so we have different
mechanisms. But it usually about, if I admit four, I admit four
patients on a Monday, and discharge four. They are there three
weeks. We have 12 patients there all the time. And generally I
will have one from North Dakota, Nebraska, and maybe even up in
New England, and then one from local. So we see them from all
over. And that is one of the neat things, is the fact that they
all, when they come together, they all band together like a
bank of brothers and they support each other. And with that,
then they leave and they continue on those relationships. And
with those continued relationships they keep the compliance and
they keep adding to the program over time.
So I think about, Dr. Bilirakis, I think it, I should say
Congressman Bilirakis, it is about half and half, half local,
half distant.
Mr. Bilirakis. How are we raising public awareness, you
know, so the veterans across the country can be aware of this
great program?
Dr. Scott. Well we try different things. And we are doing
it, you know, we tried it through the professional channels
with education and with research. We tried it with website, we
actually had our own website for a while. We tried it with, on
the Internet, a system that we have in the VA. We are
constantly trying to get the word out as best we can about this
program.
We are not completely up to full capacity all the time. We
are at about 85 percent bed capacity. It takes an individual,
just so you know because we monitor this stuff real closely, it
takes us from the time of consult to time that comes in, less
than about 30 days. So, and so we want to make sure the access
is there and maintained. We want to make sure the beds are
occupied and we want to make sure we are available to help any
veteran in this country.
Mr. Bilirakis. Well thank you very much. Thank you very
much, Mr. Chairman, for allowing me to sit on the panel. I
appreciate it. Thank you all for your testimony.
Mr. Benishek. Dr. Harris?
Mr. Harris. Thank you very much. And I want to thank Dr.
Gray and Dr. Bahorik for being here because, you know, we do
hear that it is a problem when you complain against a physician
working in the VA system, complaining about what is going on.
Dr. Bahorik, you mentioned the Jackson facility. That is the
one that was written up in the New York Times, a couple of
prominent articles this year, right, about major problems with
prescribing of controlled dangerous substances? And in some
instances particularly involving, as I think you indicated you
were involved with, you know, advanced practice nurses who
prescribe and, you know, were not following DEA regulations?
That is the same, that is the facility, right? That Jackson
facility?
Dr. Bahorik. That is the same facility, yes, it is.
Mr. Harris. That is what I thought. And you also mentioned
there was a facility, I guess, I do not think it was that one,
it must have been another one, where one of the advanced
practice nurses actually was indicated to be the Chief of, the
Director of Pain Medicine, or the Pain Specialist in the
facility?
Dr. Bahorik. Yes. A nurse practitioner is a Director of
Pain Medicine. Well, she is actually the director. I think
there is a director on paper that is not there----
Mr. Harris. Okay.
Dr. Bahorik. --at the Wilmington VA Medical Center.
Mr. Harris. At Wilmington in Delaware?
Dr. Bahorik. Yes.
Mr. Harris. Okay. And what was, do you know what that
person's training is that would qualify that individual to be a
pain specialist?
Dr. Bahorik. No, I do not actually.
Mr. Harris. Okay.
Dr. Bahorik. But I can tell you it is not as much as a
physician.
Mr. Harris. Okay. And what is what is going to bring me up.
Because you know there is this problem that is brewing in the
VA about the nursing handbook that is going to say that all
APRNs are supposed to achieve, become licensed independent
practitioners. And that will basically certify that they can
have independent practice of physicians. But your two, your
recommendations, number ten and 12 are number ten, reverse the
trend to replace physicians with cheaper extended care
providers. Is that what you are talking about? A trend
somewhere to go to less expensive, because the VA does pay
midlevel providers less, less expensive midlevel providers?
Dr. Bahorik. Yes, that is exactly what the trend is. And I
feel that it is dangerous. I have been a number of places. I
have seen problems with misdiagnoses. One of the things that
really concerns me is these extended care providers were never
intended to function independently. However, the VA has taken
upon themselves to decide that they are equivalent in taking
care of patients the same as a physician.
Mr. Harris. So that change to the nursing handbook would be
of some concern? That would require----
Dr. Bahorik. Yes, exactly, it would be.
Mr. Harris. Okay, that is what I thought. And number 12,
recommendation 12 is return specialty care to the domain of
physician specialists. Now this is intriguing to me because as
you know advanced practice nurses claim specialty training
that, and I know because I am practicing one of those
specialties, that is far less training than a physician gets.
But according to the VA under the new nursing handbook my
understanding is if an advanced practice nurse claims specialty
training and is certified, usually by a nursing group in that
specialty, then they would have independent practice in the VA
to practice that specialty?
Dr. Bahorik. Yes, and that is what is happening. A lot of
times when you send a patient to a specialist, you will get,
most of the time you will get a report back from a physician
assistant or a nurse practitioner. And there may or may not be
any supervision by the specialist.
Mr. Harris. Okay. That is what I thought. Thank you very
much. And I yield back my time.
Mr. Benishek. Ms. Brownley has another questions she would
like to ask.
Ms. Brownley. I just wanted to ask Dr. Gray perhaps that
did you ever have an opportunity to refer one of your patients
to this facility in Tampa?
Dr. Gray. Thank you for asking that. I brought that model,
the Tampa model, back to Hampton and asked if we could
implement it. That was the result of the pain conference which
was held in Florida and it was for VISNs 1 through 11. I was
told we had no need of it, we had opioids. We certainly did not
need anything like that. And if you try and refer outside of
your VISN, the answer is no. So for us in Virginia we had
Richmond, McGuire, where we could refer patients. And just as
the gentleman referred to earlier, they can get an appointment.
It will be 12 months, 14 months, 16 months from the date that
you call for the appointment. And that is deemed adequate.
Ms. Brownley. Thank you.
Mr. Benishek. Let me ask, follow up that. Who told you
that, you could not refer, or could not bring that model back?
Dr. Gray. The Chief of Medicine, the Chief of Primary Care,
the Chief of Staff.
Mr. Benishek. Thank you. Well, I thank you all for being on
this panel. And for your testimony today. You all are excused
and we will welcome the third panel to the table. Thank you.
Dr. Gray. Thank you.
Mr. Benishek. Thank you.
Joining us on the third panel today from the Department of
VA is Dr. Robert Jesse, who is the Principal Deputy Under
Secretary for Health for the Veterans Health Administration.
And Dr. Jesse is accompanied by Dr. Robert Kerns, the National
Director for Pain Research for the Veterans Health
Administration. I would like to thank you both for being here
today. Unfortunately, you have the job to explain what the VA
is doing after we have had this testimony from the previous two
panels, so I wish you luck with that. Dr. Jesse, please proceed
with your testimony.
STATEMENT OF ROBERT L. JESSE, M.D., PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY ROBERT KERNS,
PH.D., NATIONAL DIRECTOR FOR PAIN RESEARCH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Jesse. Thank you, Chairman Benishek and Ranking Member
Brownley, and Members of the Committee.
Before I start into formal remarks I would just like to
address Mrs. McDonald and Mrs. Green. I am sorry, I cannot turn
around and still be on the microphone. But there are no words
that I can say to express how deeply I feel about both the
suffering your husbands were going through and the suffering
that you are going through now. But I would like to thank you
for coming forward and telling your story. And if there is any
way that we can honor their life, it is by keeping that story
out there and by ensuring, by your holding us to the fire that
we learn from it. Your comments about not letting this happen
to other people are very, are taken. And I do so much
appreciate your being here.
And likewise, to Mr. Renschler and Mr. Minyard, thank God
you are still with us. And whatever we can do to restore your
trust in the VA, please give us a chance.
So let me just start by extending those sympathies to all
our Nation's veterans who suffer from chronic pain and from the
many devastating ways in which that presents. The VA, let me be
very clear, that we are strongly committed to ensure that
veterans do have what they need to manage their pain. And that
includes not just medications but to truly get to the root
cause of this.
This is not an issue limited to veterans. Veterans are a
population who are particularly challenged. But this is a
national crisis. And in 2011 the Institute of Medicine
published ``Relieving Pain in America.'' This challenges tens
of millions of Americans and it takes an incredible toll on
morbidity, on mortality, on disability, and just has an
incredible impact on not just the people suffering pain but
their families and their communities.
The burden of pain amongst veterans is considerable. I
think it was mentioned up to 60 percent, certainly around 50
percent, of the returning veterans from this War are affected
to some extent by chronic pain. And they often require
intensive strategies, as you heard from Dr. Scott, for the
effective management of that pain. Sometimes that requires the
use of opioids. These are proven therapies, particularly in
severe pain, when other medications and modalities have not
proven to be fully effective.
To be very clear, we all know that there are risks to these
medications. There are risks to patients. As you heard from Dr.
Gray, there are risks to providers who at times provide these
medicines. And we all know that there are risks to the
communities as well. And VA is working broadly across all
segments with partners to try and ensure the effective use of
opioid therapy when indicated for patients with chronic pain.
The VA has been at the forefront of health systems in this
country in trying to deal with this issue. We began in 1998
with a national strategy for pain management. In 2000 the VA
recognized pain as the fifth vital sign. This I think was an
incredibly important statement requiring providers to routinely
screen and assess for pain as a vital indicator of health
status. A year or so later the joint commission came up with a
similar strategy.
The pain management directive, as you heard, was published
in 2009. And that described a series of policies and procedures
for the implementation of a step care model of pain that is the
single standard of pain in the VA.
VA has worked closely with DoD. In 2010 we published
evidence based guidelines, and we have continued that
relationship through a number of strategies, including the
health executive committee chartering a joint pain work group
the singular goal of which is to ensure that the pain treatment
strategies used in DoD are consistent with those used in VA so
as servicemembers traverse from active duty into primary care
there is not a disruption in their care, and you heard the
devastating consequences of when that happens here today.
We are improving education and training on safe opioid
therapy. This has an opioid safety initiative. This is actually
finally giving us the kind of data that gives us the insight to
see how these prescribing practices are occurring across the
country. And when we have that data available to clinicians we
can see significant successes in the reduction in the use of
chronic opioids. We also have public safety initiatives. As
there was discussion earlier, about participation in the state
prescription monitoring programs. It was not that VA was, we
did not have to do it, it was that we were not allowed to do
it. And in 2011 we asked Congress for legislation that would
permit us. In its wisdom, Congress granted that legislative
relief in 2012 and now VA is participating, or will be
participating in these state reporting boards. It is very
important for both the patient's safety as well as the safety
of communities.
We have expertise in this field. You have heard from Dr.
Scott. I am here with Dr. Kerns so I am not going to go through
all that right now. So I know that my time is up.
I do want to acknowledge, Mr. Chairman, that we are
committed to improving veterans' health and well being. We know
they have difficult problems. We know that they are suffering.
And we are doing our, we are doing absolutely our best to and
change a system from one that rewards an encounter and gives a
prescription, to one that is built on healing relationships.
This is crucial and vital to dealing with all of our patients
and we certainly thank the efforts of this Committee and the
Full Committee in meeting those goals. Thank you.
[The prepared statement of Robert L. Jesse appears in the
Appendix]
Mr. Benishek. Thanks, Dr. Jesse. I yield myself five
minutes to ask questions. I guess you had a standard answer,
five minute talk there. I wish you would have responded a
little bit to the testimony that we have had previously.
Because frankly, I feel bad for you because you have to come
here and defend the VA, and tell everyone how you are really
working hard to fix the problem. But what I would like to know
is what are you going to do about the situation where Dr. Gray
described, where she was told to do something and then she did
not do it, and then they changed the record? What is going to
happen with that? I mean, apparently nothing happened. Now so
are you going to take that and do something about it?
Dr. Jesse. No I, first of all I was not aware of that until
today. VA actually has----
Mr. Benishek. Do you think that is a good idea?
Dr. Jesse. No, it is absolutely not a good idea.
Mr. Benishek. If, yes. I will have to look into it. I do
not know the situation. I have only heard this from Dr. Gray
today.
Mr. Benishek. Right, right, right, and me, too.
Dr. Jesse. But as I said, for VA to change a record there
is actually a formal process that is required to do that. So--
--
Mr. Benishek. Do you think a physician note should be
changed? What are the circumstances that would allow an
administrator to change the note of a doctor?
Dr. Jesse. As far as I am aware there would be none unless
there are factual, untrue, unfactual issues in there. In fact--
--
Mr. Benishek. But doctor----
Dr. Jesse. --we do change notes all the time----
Mr. Benishek. --I appreciate your comments. But I would
like if you can maybe answer me this, could you please figure
out the policy for that? And maybe report back to me in maybe a
month or so?
Dr. Jesse. I absolutely will, sir.
Mr. Benishek. The circumstance? Because, you know, I just
do not think that that is very good policy. And I think Dr.
Gray is pretty disappointed about the way she was treated. And
I can see that the VA has to prove it, and all that. But----
Dr. Jesse. No, I----
Mr. Benishek. --I do not think that is sort of the behavior
that we want to foster in the VA. If you could, could you do
that for me----
Dr. Jesse. Absolutely.
Mr. Benishek. --maybe come back to the Committee in a month
with a report?
Dr. Jesse. Absolutely.
Mr. Benishek. Okay. Now let me go on from there. The policy
of having a pain specialist appointed at a VA hospital who has
no previous experience in pain treatment, do you think that is
a good policy to have? Now why was Dr. Gray appointed the pain
specialist when she had no previous experience in pain? She is
an internist and a rheumatologist. So she has some experience
there.
Dr. Jesse. Yeah.
Mr. Benishek. But why would somebody like that, or a nurse
practitioner, for example, be designated as the pain
specialist? Why would that happen?
Dr. Jesse. I cannot explain why it happened in Dr. Gray's
case but----
Mr. Benishek. Do you think that is a good policy?
Dr. Jesse. So I think there is----
Mr. Benishek. I know you are in a tough situation here
because you have to defend the VA. But you see, what I am
trying to get to is that these policies are indefensible. And
they should be changed. And you sitting there and saying, we
have got to do better, you know, that is all well and good. But
I would like to see some actual plans to make that happen.
Dr. Jesse. So there were, we have pain medicine
specialists. That is a specialty within medicine, it has
separate boards. And to confuse the terms of pain specialist,
pain points of contact, and pain medicine specialist, I think
we need to be clear about the language. A small facility, a
CBOC, is not going to have on staff a pain medicine
specialist----
Mr. Benishek. Well no, of course. But she apparently was
more than just the pain point of contact. She was the pain
specialist, according to what she said. She did not describe
herself as the pain point of contact. I am a general surgeon
and probably deal with a lot of pain. Maybe not as much chronic
pain as the average family practitioner. But I usually have a
system of where to refer. And so that one person is dealing
with the pain treatment. And it is not just narcotics, it is a
whole spectrum of care such as Dr. Scott mentioned.
Dr. Jesse. Well one of the key principles as the step care
plan, as is outlined in the directive, is actually knowing
where and when to refer. That is why that system was set up. So
people are not trying to manage things that are outside their
scope of capabilities.
Mr. Benishek. Well it sounds as if that Dr. Gray and the
other doctor were encouraged not to refer people, but
encouraged to use narcotics. Which, I do not know----
Dr. Jesse. Well that is indefensible. That is absolutely
indefensible. And as physicians they should feel absolutely
that they should refuse to do that.
Mr. Benishek. Well I am glad----
Dr. Jesse. I have, in my career in the VA I have never been
forced or asked----
Mr. Benishek. I am glad to hear you say that, Dr. Jesse,
frankly. So thank you for saying that. And I would then say to
all physicians who work in the VA to stick to your guns and
treat the patient as you think best, and please report this
kind of stuff to us here. I think I am out of time. Thank you
very much, doctor.
Dr. Jesse. May I follow----
Ms. Brownley. See if Ms. Brownley wants you----
Dr. Jesse. Well, I am sorry, but not on my time. Maybe on
someone else's.
Dr. Jesse. Okay.
Ms. Brownley. So Dr. Jesse, I just want to understand your
responsibility in the VA. Is your responsibility for quality of
care? Or is your responsibility to oversee and make sure the
system is working and you are really accountable? In today's
hearing we are talking about pain management, that you are
accountable for the VA and how they perform pain management?
Dr. Jesse. So I do not think that is an either/or question.
I think ultimately the accountability is that all veterans
receive absolutely the best possible care they can receive.
Ms. Brownley. Okay.
Dr. Jesse. And that includes the ability to compare that
care that they are receiving to some standard if there is one,
to certain expectations, and certainly to the expectations of
the patient.
Ms. Brownley. Well I think in today's hearing I leave
compelled that the system appears to be broken. I am going to
have faith that there are pockets of excellence and in Tampa it
looks like there is one certainly there, and there probably are
in other parts of the country. But you know, how do you respond
to the comments about we have a system of quick and cheap over
good and thorough, and the basic principles of medicine have
been abandoned? I mean----
Dr. Jesse. I would argue, and I am not one that would like
to argue with other witnesses, but I do not believe that that
is the case systemwide. The question by Dr. Wenstrup was asked,
you know, what would motivate somebody to work in the VA if it
is just quick and the simple? And the simple, or the very
complex answer, is that we are there because we want to take
good care of veterans. I am, I had a choice in 2000 between
going into private practice, actually going to work in industry
or working in the VA, and I chose to work in the VA. At that
time it was not an excellent system, but I wanted to make it
so. Today I think it is an excellent system. It is not
outstanding. It still has problems. But we are making it better
everyday. And the fundamental reason behind that is because the
veterans actually really appreciated what we did for them. And
a certain person by the name of Harold Jesse, who I was born on
a Navy base, I grew up with my father who was a career Naval
officer. I entrusted his care to the VA and I wanted to give
back. And people work in the VA for those kinds of reasons, not
because it is an easy come, easy go system.
Ms. Brownley. And I am not questioning your commitment to
that whatsoever.
Dr. Jesse. All right.
Ms. Brownley. I absolutely am not. But it is, you know, how
do we get your commitment permeated all the way down to each
and every one of our veterans so that they are treated in the
way that they need to be treated? And clearly walking away from
this hearing I think we all have to agree that there are areas
that we must look into, and there are areas that I think we
just have to put on our chart, get to the bottom of it, and
figure out ways in which we can improve upon it.
And I just, I wanted to also ask, Mrs. Green in your
testimony asked about what the VA does after a death of one of
our soldiers, a veteran.
Dr. Jesse. Mm-hmm.
Ms. Brownley. And the analysis that is done thereafter. And
so I wanted to follow up on that question to understand if that
is happening after every death? And are we collecting data to
determine the cause of death? And are we collecting it?
Dr. Jesse. So unexpected death is supposed to be studied.
This is how we learn. You know, as physicians----
Ms. Brownley. Well would it not in a pain management
situation, where there is not any----
Dr. Jesse. Yeah.
Ms. Brownley. --you know, you are not having heart problems
or any other things----
Dr. Jesse. But, yeah, those are----
Ms. Brownley. --would that more or less qualify under
unusual----
Dr. Jesse. Absolutely, because those are unexpected deaths,
as are the suicides. And one of the things where we really are
making change is historically we have asked did we do
everything that we should have? And often the answer is yes.
But the real question is, did we do everything that we could
have? And that requires a much deeper introspective view into
each one of these cases. And we are beginning to change the
culture that we really begin to get to that level of
understanding and depth. Because that is where we are really
going to be able to begin to change this equation.
Ms. Brownley. Well it is a cultural change.
Dr. Jesse. Yes.
Ms. Brownley. And cultural changes are hard, really, really
hard.
Dr. Jesse. Yes.
Ms. Brownley. But so, but are you collecting that data?
Dr. Jesse. So we have that data. We have in the past couple
of years actually been collecting the data in a way that it
becomes searchable so we can look at that. We also have the
National Center for Patient Safety that does the root causes
analysis. And they roll all of them up and look for
commonalities across the systems where issues arise. And this
is really key. Because often seeing it once does not really
raise a red flag. But when you can look across the system and
see it happening two, or three, or four times, then it does.
And then we really need to understand how the system is
allowing these things to happen. But it is only when people
look, it is only when people like Dr. Gray raise issues and can
do that in a way that they feel safe, and I apologize that that
seemed to be contentious in her instance. But the ability for
people to safely raise issues without being, getting into
trouble for it, is the foundation of a just culture. And the
only way that we are really going to change patient safety
outcomes and improve health care.
Ms. Brownley. Well I would certainly be interested to see
what the data is and what any conclusions, you know, may come
from it. Because I, I mean just anyway we can have that
conversation another time.
Dr. Jesse. And we would be happy to do so.
Ms. Brownley. Thank you for your testimony and I yield
back.
Mr. Benishek. I appreciate your comments there, Dr. Jesse.
And let me just say that I assume that Dr. Bahorik will not
face any negative professional repercussions----
Dr. Jesse. No.
Mr. Benishek. --in the department as a result of her
testimony here, is that correct?
Dr. Jesse. I would certainly hope not. And if she does, she
should let me know.
Mr. Benishek. All right, thank you. Mr. Wenstrup?
Mr. Wenstrup. Thank you, Mr. Chairman. You know, I want to
applaud so many caregivers in the VA system.
Dr. Jesse. Thank you.
Mr. Wenstrup. I know that in my private practice two of my
partners give a couple of days a week to operate at the VA and
they only have the interest of the patient in mind and that is
why they are serving at the VA. And I think that is reflective
of most at the VA. It is the system that I think we have to
deal with and have to address. And you know, the purpose of
these hearings is to hear the truth and to right wrongs. And
hopefully we will accomplish that with what we are doing here
today.
To Dr. Kerns, you know, we hear the testimony today about
the spinal cord stimulator, and I am sure you are very familiar
with that with what you do, I would imagine, is would that be
correct, sir?
Dr. Kerns. First of all, yes, let me echo the comments of
others. I really do not want to miss the opportunity to express
my sympathies to the people that were on the first panel in
particular, and actually to the trouble that the physicians on
the second panel have also experienced in the VA.
So yes, I am well aware of spinal cord stimulation. Just so
you know, I am a psychologist, not a physician, so I am not a
prescriber. But to the point about spinal cord stimulation, it
is an evidenced based therapy for certain, but not all chronic
pain, conditions, and only actually a small proportion likely
benefit. It is a capacity that we are growing in VA. It is my
understanding that as many as 40 of 152 core facilities
actually do spinal cord implants, spinal cord stimulations. And
a much larger proportion of facilities, certainly a majority,
have pain medicine specialists who have the capacity to manage
care for veterans who have received spinal cord stimulation
either in the VA or outside the VA.
Mr. Wenstrup. So of course your concern when you have the
testimony earlier where he goes to the physician and he says,
``I am not even familiar with the procedure,'' that is of
concern. So from where you sit do you feel that you have
everything you need to make providers aware of all the
modalities that are available? And that you have the providers
that can actually provide that type of care?
Mr. Kerns. So thank you for that question. I was also
privileged to serve, actually, not as a representative of the
VA, on the Institute of Medicine Committee that this Congress
chartered. This is a key problem in the United States and in
the VA. We (VA) are in fact a model of what we are trying to do
in terms of improving education and actually training of
providers in VA. So to one key example, I know there is
interest of this Subcommittee about the interface between VA
and Department of Defense. So there is a health executive
committee chartered work group. And from that has emerged a
very well funded joint incentive fund initiative that promotes
education and training and consistency of pain care across the
DoD/VA. I would also say there is a complementary initiative,
well funded, to bring auricular acupuncture that has been
developed in the battlefield in DoD into the VA and build that
capacity as well. So these education and training initiatives
are very important and timely as we work to address a national
problem that most everybody from medical schools, nursing
schools, other professional schools acknowledge is a failure to
provide this education in our professional training schools.
And I like the work that VA is doing in that regard.
Mr. Wenstrup. Thank you, and I yield back.
Mr. Benishek. Thank you, Dr. Wenstrup.
Mr. Harris. Thank you very much, and thank you Mr.
Chairman. You know, as a veteran I do know that and I
appreciate that the VA system is trying to do its best in
difficult environments, within budgetary constraints, within
personnel constrains, etcetera. But I want to ask specifically
since one of the issues that came up since the hearing is on
prescription narcotic overuse perhaps in the VA system, and you
know one of the findings that was at the Jackson investigation
back in earlier in this year, was this issue of, you know,
advanced practice nurses, supervision of advanced practice
nurses, whether it was adequate, there were all kinds of, and
you have read the report, you know what I am talking about
there.
And now, you know, one issue that has come up is this
nursing handbook issue. Where instead of the VA kind of
following along with Dr. Bahorik's recommendations are, which
actually, you know, an attempt to provide better treatment for
our veterans, including those in pain in the pain management
system, is, you know, one of her recommendations, reverse the
trend to replace physicians with cheaper extended care
providers. But the nursing handbook change which would
encourage all advanced practice nurses to become licensed
independent providers, for instance let us say you had an
advanced practice nurse who was named the pain specialist, or
medicine, whatever the title is at the VA. But that person felt
uncomfortable doing that, they felt uncomfortable in
independent practice. They actually thought that it was
appropriate to be collaborating or supervised by a specialist
physician. The nursing handbook says they have to go work
somewhere else. You either achieve independent practice, or you
go work somewhere else. This is strange. Because in an
environment like pain management, or in the environment on a
care team, like in my specialty, anesthesiology. You know, the
culture usually is that there is a culture of it is
multidisciplinary, it is collaborative, and with recognition
that there are a different level of providers with different
levels of expertise. It seems to be doing exactly the opposite
way with that thing.
So I am going to ask you, Dr. Jesse, do you feel given that
this is under serious consideration, I know that the Ranking
Member and chair have letters to you addressing concerns, and
the AMVETS, and other groups, do you feel that the training is
equivalent, or the ability to treat patients is equivalent, for
the APRNs achieving licensed independent practice, and medical
specialists?
Dr. Jesse. So----
Mr. Harris. --simple question. Do you roughly make----
Dr. Jesse. No, I do not equate them at all. But I want to
be clear about something. The nursing handbook was a draft. It
has not been approved. It is not----
Mr. Harris. Well I am, what I am getting to is, what is
your opinion on it since you are going to be one of the
decision makers, I understand?
Dr. Jesse. So the, I am a cardiologist. I do not believe
that a nurse practitioner, I have very good nurse practitioners
and PAs that work with us in cardiology, but we work as a team.
Mr. Harris. And you, but----
Dr. Jesse. Just as you work with----
Mr. Harris. Correct. But independent practice assumes not
working as a team, that is why it is called independent
practice. And in fact, under statute, in states that establish
independent practice, it specifically says, and I can quote
from the statutes, that they work without involvement,
requiring not physician involvement. That is what independent
practice means----
Dr. Jesse. Right.
Mr. Harris. --in state statutes.
Dr. Jesse. Right.
Mr. Harris. No physician involvement. In the pain
management program in the VA system, do you think that would be
an improvement?
Dr. Jesse. No, not necessarily.
Mr. Harris. Okay, not necessarily. But under what
circumstances would that be an improvement?
Dr. Jesse. So if we had a, if we had a VA facility that did
not have inpatient surgery, outpatient surgery, but there were
the need for some level of skills that a nurse anesthetist
could bring, that would be useful to veterans so that they
would not have to travel. Now in our system----
Mr. Harris. Dr. Jesse, I asked about pain management, not
anesthesia. I specifically asked about pain management.
Dr. Jesse. But in those situations, whatever the nurse
anesthetist could bring to that it would be useful to veterans.
But they would still be working within the construct of a team,
even if that team were conducted to one of the major medical
centers. So again, this is, this handbook that you have seen is
a very early draft. It is not agreed upon by the system. We
will not move anything forward until we have had robust
discussions with external stakeholders, including the
societies. I know ASA is very interested in this. I know that
the Family Practice folks are very interested, and AMA is very
interested. And I can tell you that this will not move forward
until we have had those discussions with all of the
stakeholders.
Mr. Harris. Sure, and I appreciate that. And specifically
with regard to pain management, you understand the complexity--
--
Dr. Jesse. Yes.
Mr. Harris. --of the DEA regulations----
Dr. Jesse. Oh, absolutely.
Mr. Harris. --and supervision requirement?
Dr. Jesse. Yes.
Mr. Harris. Because of course you do not have the ability
of preemption with DEA law. Thank you very much, Dr. Jesse. And
thank you very much for holding the hearing. And I want to
thank the Committee for allowing me to participate.
Mr. Benishek. Thanks, Dr. Harris. If there are no further
questions, I would excuse the third panel. Let me just say
this. I think Mrs. McDonald brought it up at the very
beginning, that this is not the end of it. Because there are
many things that we will have to address here. Dr. Jesse, I
look forward to working with you to answer some of the
questions that were raised here and develop an overall plan
within the VA to markedly improve the pain management system
there. And I look forward to your reports. And hopefully we can
just maybe get together for a couple of meetings outside the
hearing venue----
Dr. Jesse. We would very much like that, sir.
Mr. Benishek. --make progress in this area. I want to thank
again all the Members of the panels that have participated
here. And thank you so much. I ask unanimous consent that all
Members have five legislative days to revise and extend their
remarks and include extraneous material. Without objection, so
ordered. I would like to also thank our witnesses again for
joining us. The hearing is now adjourned.
[Whereupon, at 1:52 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Dan Benishek M.D.
Good morning and thank you all for being here today.
I welcome you all to today's hearing, ``Between Peril and Promise:
Facing the Dangers of VA's Skyrocketing Use of Prescription Painkillers
to Treat Veterans''
Today's subject is one of the most serious and significant we will
discuss all year. It is also one that is particularly poignant and
personal to me.
I spent twenty years serving our veterans as a doctor at the Oscar
G. Johnson VA Medical Center in Iron Mountain, Michigan.
In that capacity, I understand all too well what it means for a
veteran and a patient to be in pain.
Pain can be an unrelenting enemy - one that thwarts an individual's
ability to work and enjoy the activities they once loved, hinders their
relationships with their family and friends, and impacts their capacity
to be comfortable in their own home.
On a daily basis, my veteran patients would confide in me about the
pain they were in, the many ways in which they were hurting, and - more
than anything - their desperate desire to find relief.
Perhaps nowhere else is that more clear than in the heartbreaking
testimony we will hear shortly from two surviving spouses, Heather
McDonald and Kimberly Green.
Their husbands, Scott McDonald and Ricky Green, honorably served
our Nation in uniform and came home -as far too many of our returning
veterans do - hurting and in pain.
These men sought treatment from the Department charged with caring
for them - the VA - hoping to get the help they needed so they could
once again take full and successful ownerships of their own lives,
without pain as their constant companion.
Sadly, rather than getting the best care anywhere, Scott and Rickey
were prescribed a disturbing array of pain, psychiatric, and sleeping
medications without any clear consideration or special attention paid
to how these powerful drugs were interacting with each other or
affecting Scott and Rickey's physical and mental well-being.
The combined effects of these multiple medications ultimately took
their lives.
We will also hear from two veterans - Joshua Renschler and Justin
Minyard - who will give us a first-hand account of the struggles they
faced with VA's apparent overreliance on opioid-based medications for
pain management.
At one time, Joshua was prescribed thirteen different medications.
Despite his pleas that the medications weren't working, he was never
referred to a pain specialist.
Justin was prescribed enough opioid pain medications on a daily
basis to treat four terminally ill cancer patients. He eventually
sought care outside of VA to find an effective treatment to manage his
pain.
To say that I am disturbed by these accounts and by the multiple
reports we hear every day about the skyrocketing use of prescription
painkillers - particularly opioids - to treat veterans in pain would be
a major understatement.
VA's band aid approach to suppressing the symptoms of pain rather
than treating the root causes must stop.
VA maintains a pain management treatment model that makes primary
care, rather than specialty care, the predominant treatment setting for
veterans suffering from pain.
Yet - as I know from personal experience - the multifaceted nature
of chronic pain, particularly when multiple medications are being
prescribed, should not be managed by a primary care physician, but
rather by a qualified pain specialist who is trained to understand the
complexities of treating these conditions.
I want to be very clear that this hearing is not intended to vilify
the many hard working primary care providers working every day to care
for veterans in pain at VA medical facilities across the country. I
have been in their shoes and I know the challenges they face in
providing the high-quality care our veterans deserve.
Rather, our intent here today is to initiate better provider
practices and, most importantly, better care coordination for our
veterans and their loved ones so that no other family has to experience
the pain, the suffering, or the loss that our witnesses on the first
panel have already experienced.
It is critical for VA to take responsibility for its failures and
rise to the challenge to change and take immediate action to adopt
effective pain management policies, protocols, and practices.
We have already lost too many veterans on the home front to battles
with chronic pain.
The stakes are too high for VA to continue getting it wrong.
Prepared Statement of Hon. Julia Brownley
Good morning. I would like to thank everyone for attending today's
hearing.
Chronic pain is a debilitating condition that affects veterans at a
much higher rate than in the civilian population. According to the
Department of Veterans Affairs, in the newest cohort of veterans,
chronic pain is the most common medical problem reported in veterans
returning from the battlefield with estimates as high as 60 percent for
those who seek treatment at VA.
Modern warfare often leads to serious but survivable physical and
neurological injuries such as amputations, spinal cord injury,
traumatic brain injury, gunshot wounds, and more. Often times these
same veterans experience mental health issues as well such as post-
traumatic-stress disorder, anxiety, and depression. And while advances
in medical technology have saved the lives of many wounded soldiers,
many veterans of our Armed Forces are forced to live a life that is
dominated by acute and chronic pain. Providing safe, effective,
adequate pain management is a crucial component of improving veteran
health care.
The treatment of chronic severe pain often involves physicians
prescribing opioid analgesics, a highly addictive pain killer that if
not properly monitored can lead to death. Testimony from our first
panel highlights the dangers of opioid use and just how quickly
veterans get trapped in a rapid downward spiral of addiction and pain.
I know that VA has a National Pain Management Strategy, and I look
forward to hearing from Dr. Jesse regarding the ramping up ofp clinics
and services throughout the Veterans Health Administration. I am also
very interested in progress being made with the Department of Defense
on transitioning servicemembers and the management of medications
between the agencies.
Finally, VA recognizes that chronic and acute pain among our
veterans is a serious problem and in fact, is a priority. I applaud
them for taking the lead on this issue. But I am concerned that
comprehensive pain care is not consistently provided throughout the
VA's health care system.
I look forward to hearing from our witnesses today. Thank you, Mr.
Chairman, and I now yield back.
Prepared Statement of Hon. Jeff Miller, Chairman
Thank you Dr. Benishek for holding this critical hearing to examine
the Department of Veterans affairs (VA) skyrocketing use of
prescription painkillers to care for veterans with acute and chronic
pain.
Many of our servicemembers are returning home from the battlefield
with serious injuries and acute pain, and as they transition to veteran
status, the pain often lingers and leads to chronic pain.
For these veterans, the pain level, not the veteran, sets the
agenda for the day, sets the tone for their families, and keeps the
veteran from fully participating in the life he or she once had.
Yet, when these veterans reach out and entrust the VA to relieve
their pain, the treatment they often receive is the systemwide default
prescribing of prescription painkillers.
According to a CBS News report, based on VA data, over the past
eleven years the number of patients treated by the VA is up twenty nine
percent, while narcotic prescriptions written by VA doctors and nurse
practitioners are up two hundred and fifty nine percent.
The rapid rise in VA's use of prescription painkillers corresponds
with data that indicates VA patients are dying of narcotic overdoses at
twice the national average.
This is heart wrenching proof that VA's approach to pain management
is failing and in need of an immediate overhaul.
These powerful prescriptions are not a cure-all and must not be
doled out like a magic pill to fix chronic pain.
Veterans depend upon VA to uphold its mission of restoring the
health of those who have borne the burdens of battle.
But instead of helping them manage their battles with pain in a
healthy manner, VA has opted instead to use treatment that has the
power to destroy, rather than restore their lives.
VA can and must change course and act now to reduce their reliance
on the use of prescription painkillers.
We know there are pain care specialists who understand the
complexities of treating these conditions, and VA must make them
accessible to help veterans manage their pain without the disturbing
risks of the long term use of prescription painkillers.
VA providers should be required to adhere to evidence-based
prescription guidelines and be held accountable when those guidelines
are not followed.
The veteran patient and their loved ones must be listened to,
followed closely, and supported with a treatment plan that can best
help them regain happy, healthy lives.
Anything less is unacceptable.
Prepared Statement of Heather McDonald
Scott Alan McDonald 5/24/77 9/13/12
After graduating from Belpre HS in 1995, Scott Alan McDonald took
an oath to uphold the dignity and honor of the United States Army. For
15 years, he served honorably in the uniform of his country and was
proud to serve as a UH- 60 Blackhawk mechanic and Crew Chief for a
medivac unit.
Bosnia, Panama, Iraq, and Afghanistan were ust a few of the war
torn countries that he dedicated his life to making a difference in. In
his career he experienced heartache, unimaginable violence, death, and
the overall devastating effects of war. He saw many of his fellow
soldiers give their lives in the ultimate sacrifice to their country
and narrowly escaped with his own life in tact.
He loved his country and what the American Flag stands for. He was
a brother in arms to thousands of fellow soldiers and a truly
remarkable man that never met a stranger. Scott had larger than life
expectation for his daughters Yasmin and Reise. Because of his
commitment to family and Honor, on Jan. 9, 2011 I married him.
On 30 April 2011, Scott's career with the Army had come full circle
and he hung up his uniform for good. He began seeking treatment for
Back and shoulder pain at the Chalmers P Whylie Ambulatory Care Center
in Columbus, Ohio. Almost immediately he was placed on medication.
Starting with ibuprofin, gabapentin, and meloxicam. After only a few
visits he was refered to Mental Heath where he was then diagnosed with
Severe Post-Tramatic Stress Disorder, adding several anti-depression
and anxiety meds such as Zoloft and Valium. And this is were the roller
coaster of drugs come into play.
Everytime Scott came home from an apt. He would have different
meds. Progressivly over the year and half that he was recieving
treatment, the medications changed many times often adding new meds,
changing dosages and recommending that he takes the meds differently
then the printed dosaging. We researched the drugs online and saw that
there were many dangerous interaction involved with the medications he
was on, but being that Scott had been conditioned to follow orders, he
believed fully that his Dr.'s were doing all they could to help him.
With every apt. the medication changed the side effects changed, and
Scott himself was changing.
On 12 September 2012 Scott attended another oh his scheduled
appointments. This time they had added a powerful narcotic, Percocet.
This opiate drug was much different than the vicodine that he had
previously been taking. The directions on the bottle said to not exceed
3000 mg of acetaminophen. Scott followed the orders. At 0730 on the
13th, less than 24 hrs after he was prescibed the Percocet, I found
Scott on the couch. He was cold and unresponsive. I tried all I could
and EMS also arrived but it was far to late for Scott. At 35 years old,
this husband and father was gone! He left behind a wife, 2 daughters
and many friends and family members who loved him very much.
Now the question is why? Why was this mans life tragectly cut
short. It is well know how America's wounded warriors are being
victimized by the huge backlog in their VA claims. Forcing families to
wait months and in most cases Years to receive benefits that the
earned. Nonetheless the Department of Veterans Affairs states that they
are incredibly proud of the shrinking backlog, that it has begun
issuing bonus to the buraucrats who meet the Departments numerical
goals in case load reduction.
Keeping our men and woman doped up to keep them quiet and happy is
not treatment. It is cruelty and torture and in too many cases It's
manslaughter! For many American Service Members the VA is utilized as
free healthcare to those who earned it thru their dedication and
commitment to honor their country. In far too many cases , these
service members become lost in the system and simply become a number
and no longer viewed as productive members of society.
Tests that can save lives are not being performed. A simple `` I am
in pain'' is a good enough evaluation to prescribe painkillers. And a
patient claiming that a medication isn't working well enough , is
grounds to change the medication.
In the civilian sector is routine and often manditory to preform
blood tests on patients that are just starting treatment or have been
receiving treatment for a prolonged amount of time. I learned this thru
speaking to Medical professionals at various local treatment
facilities. This is how I learned about the LFT or liver function test
commonly refered to as the Liver Enzyme Test. Being that the liver is
responsible for a multitude of tasks including the metobolization on
medications like narcotics but filtering out the toxins that are left
behind it got me thinking, `` Did doctors do this test for Scotty''?
So, I asked them! And they responded, but not with what I had hoped
for.
`` Liver function tests are NOT routine in the treatment of out
veterans, and that my husbands healthcare was handled and well managed
``
I was not only sickened by their response, but that day, I decided
that no more shall die! Had they done the simple test, they would have
discovered that due to the overwhelming amount of medications that
Scott had been exposed to, his liver was inflammed and vurtually dying.
But instead, it was only discovered by the coroner. I have no doubt
that this test would have saved my husbands life, and Scott would be
here today to watch his kids grow up to be beautiful young woman.
I have no doubt that a large percentage of the veteran overdose
cases could have been prevented by this test. But instead they met a
similar demise. Father's are gone, never to walk their daughters down
the isle on her wedding day, or to throw a football with their sons.
Children left without a mother to embrace them, and simply kiss the boo
boo's..
There is nothing that I can say or do to bring Scott or the
countless others back. There is nothing I can say or do to take away
the pain we as family members have experienced. But there is so much
that you, as Leaders can do. The regulations that involve our veterans
need to be evauluated and changed. The irresponsible distribution of
narcotics to our heros needs to STOP!!
So I Heather Renae McDonald, the proud wife of an American Hero who
was taken too soon, stand here before you today to DEMAND that you take
better care of our veterans. I stand before you to speak as an advocate
for the countless widows, widowers, and children of those who lost a
fight they didn't sign a contract to fight. I will stand with the many,
and for those who have not found their voice to speak out, I vow to be
your voice.
Together, we can still save thousands of lives. So I beg you, as
the Leaders that have the ability and power to make these changes to do
so.
If we do not act quickly, I fear that many more lives will be lost
due to the malpractice and grotesk lack of proper care that the VA
hands out.
When they signed that contract, they gave their bodies to their
country, now you owe them their lives. These men and women deserve so
much better. They deserve to live because they were committed and
selflessly chose to wear the uniform of the UNITED STATES MILITARY .
Prepared Statement of Kimberly Stowe Green
Mr. Chairman (Dan Benishek), Ranking Minority Member (Julia
Brownley), and all Distinguished Members of the Subcommittee:
Introduction
My name is Kimberly Green. I am honored to have been invited to
speak to you today at this hearing entitled ``Between Peril and
Promise: Facing the Dangers of VA's Skyrocketing Use of Prescription
Painkillers to Treat Veterans.'' I am accompanied here today by my
attorney Brant Mittler who is also a medical doctor.
I respectfully request that my written statement be incorporated
into the official records of this hearing.
The VA determined Ricky He was at first determined to be 50%
disabled due to service related activities. And later the amount of
disability was increased to 80%. Rickey was injured in the army during
his training activities and from his paratrooper activities jumping out
of planes and from his military police work in securing combat areas.
The injuries to his back, knees and ankles caused him to have chronic
pain later in his life.
I served my country for 21 years in the United States Air Force. I
retired out of the military as a Master Sergeant. I am the widow of
Ricky Green. My husband served his country for 23 years in the United
States Army. He was a military policeman and paratrooper and he served
with distinction in Desert Storm I. He retired out of the military as a
Sergeant First Class.
I have no contracts or commercial ties to the VA or the federal
government.
The VA's Skyrocketing Use of Prescription Painkillers Caused the Death
of My Husband Ricky Green
My husband - Ricky Green - died as a result of the VA's
skyrocketing use of prescription painkillers. On behalf of my husband,
myself, and our two grieving sons, Andrew Evan Green, aged 21, and
Alexander Michael Green, age 16, I want to ask this committee to do all
that it can to prevent other veterans from dying in the same manner
that my husband died.
My husband died on October 29, 2011 at the age of 43 after lower
back surgery performed four days earlier on October 25, 2011. The
Arkansas State Crime Lab and its Medical Examiner performed an autopsy
and determined that the cause of death for my husband was Mixed Drug
Intoxication complicating recent lumbar spine surgery. My husband died
because of the prescription pain and sleeping medications that the VA
and its doctors prescribed for him and dispensed to him out of the VA
pharmacy.
I'm here to put names and faces on that sterile statistic of
``mixed drug intoxication complicating recent lumbar spinal surgery''.
The VA Already Has Written Guidelines for Prescribing Pain Killers but
These Are Not Being Followed
The Veteran's Health Administration's National Pain Management
Strategy, initiated November 12, 1998, established Pain Management as a
national priority.
You can go to the VHA website today - http://www.va.gov/
painmanagement - and see for yourself that the VA has written
guidelines for prescribing pain medications. The two primary ones are
(1) VHA Directive 2009-53 dated October 28, 2009 on Pain Management
(http://www.va.gov/painmanagement/docs/vha09paindirective.pdf); and (2)
the Veteran's Administration/Department of Defense Clinical Practice
Guideline Management of Opioid Therapy for Chronic Pain dated May, 2010
(http://www.healthquality.va.gov/COT--312--Full-er.pdf). These
guidelines include stepped care that involves primary care, secondary
consultation, and interdisciplinary care and special measures to
include testing, evaluating and monitoring to reduce the risks inherent
in the use of prescription painkillers - and one of the most notable
risks is accidental overdose. The problem is - these guidelines have
not been fully implemented and are not being followed - they were
repeatedly violated in my husband's case - and he had to pay with his
life for that fact.
VHA Directive 2009-53 states at page A-3 that ``[t]he potential for
fatal overdose either by accident or in a suicidal attempt in patients
suffering from multiple disorders or with polypharmacy must be
considered in prescribing opioids and other medications.'' The
potential for fatal overdose with these drugs was not adequately
considered by the VA and its doctors treating my husband.
The Clinical Practice Guidelines require physicians to closely
monitor and evaluate patients who are being prescribed prescription
pain killers for chronic pain and these guidelines specially warn these
physicians at page 24, and other places, about the dangers of drug-drug
interactions that can cause death. The VA and its doctors prescribed
and provided to my husband his medications - and the interactions among
these drugs killed my husband.
During the course of his treatment at the VA, the VA and its
doctors wrote my husband prescriptions, and VA pharmacies filled these
prescriptions, for his chronic back pain which was service connected,
for the following drugs: Oxycodone, Hydrocodone, Valium, Ambien,
Zoloft, Gabapentin, and Tramadol. My husband, Ricky Green, followed the
orders of his VA doctors in taking these pain medications - and these
pain medications led to his death. He was not suicidal in taking these
drugs - again he was just following his doctors' orders.
The Clinical Practice Guidelines contain a section that requires
physicians to take special care in prescribing pain medications for
patients such as my husband who had sleep apnea. Unfortunately, again,
no such special precautions were taken for my husband - and the
guidelines were simply ignored - such that the drugs interacted with
the sleep apnea to cause my husband to stop breathing and to die.
In my husband's case, the VA and its doctors, over-prescribed my
husband pain medications over a long period of time but after he had
back surgery on October 25, 2011 related to the injuries he had
incurred while on active duty he got a lethal drug cocktail that
included oxycodone, and diazepam which were reviewed by the VA and
filled by the VA pharmacy on October 26, 2011.
These two drugs - prescribed and provided by the VA and its doctors
and pharmacist in violation of the Clinical Practice Guideline -
together with the sleep apnea - are what produced according to the
Arkansas State Medical Examiner produced ``a significant stated of
analgesia sedation, and respiratory depression'' which led to my
husband's death. Ricky stopped breathing and died in his sleep on
October 29, 2011.
I want to be clear in my testimony to this committee - I strongly
believe that my husband was entitled to receive the quality of care
that the VA, and DoD, set forth in writing in their own guidelines.
However, these guidelines have not been fully implemented and are not
being followed - and our veterans are suffering the consequences.
You do not have to take my word for it that these guidelines have
not been implemented or followed. I was able to find on the internet
the contents of a Cyber Seminar dated October 2, 2012 - about one year
after my husband's death - entitled ``Overdose Among VA Patients
Receiving Opioid Therapy for Pain; Risk Factors and Prevention.''
(http://www.hsrd.research.va.gov/for--researchers/cyber--seminars). The
introducer and participant at that seminar - a Dr. Bob Kerns - is a
National Program Director for Pain Management and he is based at a VA
Hospital in Connecticut. Here is a quote from him at that seminar:
``... the VA/DoD Clinical Practice Guidelines. Its full implementation
across the VA really has not been actualized or realized yet. So for
those - there are a couple hundred people on the call that work
facilities. I am guessing that many of you work in facilities that
really have not thoroughly digested those guidelines and looked to
implement the recommendations of the guidelines at a facility level,
let alone at an individual level. And we should be doing that
first....''
How long must our veterans be made to wait until these guidelines
are fully implemented and begin saving the lives of our veterans?
If these guidelines would have been followed my husband would not
have been prescribed drugs that caused him to have a mixed drug
interaction and to stop breathing. If these guidelines would have been
followed my husband would have been closely examined, monitored, and he
would not have been provided the lethal cocktail of drugs that killed
him.
Our Veterans Who Honorably Served Their Country Deserve Better
Healthcare from the VA
I believe the VA and its doctors, rather than treating all of the
underlying causes of my husband's back pain, took the easier way out
and overmedicated him with prescription pain killers. I believe this is
happening far too much and I note that statistics have been compiled
that show in Fayetteville, Arkansas - where my husband was treated -
there is a high incidence of over-prescribing pain medications for
veterans.
Treatment of the underlying medical conditions, physical therapy,
counseling, monitoring, in-patient hospital stays - these are the kinds
of things I believe our veterans need and are entitled to - not just
the over-medication of prescription pain killers to mask their pain. In
my husband's case - he constantly asked the VA and its doctors to treat
the root cause of his health problems - and to reduce the opiate pain
medications he was being prescribed. The VA failed to do that in his
case.
In Honor of My Husband
I am proud of my husband. After serving his country for over twenty
years in the military he went back to school and earned his college
degree in criminal justice. He had plans to go to law school so that he
could be a voice for other veterans in their time of need. He was 43
years old when he died. He should have had a long life ahead of him.
Ricky survived serving in combat zones in his over twenty years of
military service, but he could not survive the VA and his negligent
treatment of him.
This lethal cocktail of drugs -which again included Oxycodone and
Diazepam among many other drugs - were prescribed by VA doctors and
dispensed at the VA pharmacy. I have sent pictures of the bottles of
the medicines my husband was taking to this subcommittee. These pill
bottles - clear evidence of the negligence of the VA and its doctors -
are now in safe keeping at the Sheriff's office in Fort Smith,
Arkansas.
My husband was a hero and a great husband and father. He stood up
for his country honorably when his country called for him. He trusted
VA doctors. He deserved much better treatment than what he received at
the VA. Now, because of what the VA has done to my husband, my husband
and I will not be able to grow old together. He will not be with me at
the college graduation ceremonies for our two sons. He will not be with
me at the wedding ceremonies for our two sons. He will never see and
come to know his grandchildren. The VA has taken the life of a great
man. And the VA has left his family - including his wife and two sons -
decimated and grief stricken.
I am here today to honor my husband's memory and to demand better
treatment for the men and women - like my husband and I - who have
honorably served our country in the military. The VA has written
guidelines in place for the safe use of prescription pain killers - and
the VA will have to follow these guidelines or more veterans will
needlessly lose their lives - just like my husband did.
I am proud to do my part and to stand up and fight on behalf of my
husband and not allow him or me to be a quiet victim of injustice. I
have heard excuses - the guidelines are not standards of care and some
veterans who die of overdoses were suicidal - these are excuses that
the VA is making because it has failed to take the action needed to
fully implement and follow the written guidelines that have already
been published.
Let me be clear: the VA knew that Ricky was not suicidal, the VA
knew that Ricky did not display drug seeking behavior. The VA knew
Ricky want to reduce the amount of pain medication he was taking.
I think in my case - and in many other similar cases - the VA
should admit what it has done wrong, make up for it, and most
importantly - stop this kind of thing from happening in the future.
To those who have been injured or killed in the past by the VA and
its doctors - these victims deserve just compensation.
More importantly - the VA and its doctors must avoid causing future
victims - by doing the right thing and implementing, training,
following, monitoring, and evaluating the VA and its doctors on the
written guidelines for prescription pain medications that are already
in place.
Prescription pain killers in high doses and over time are
dangerous. There are better ways of treating our veterans.
The VA, Humana, and Project HERO
Humana and the VA have teamed up on a project called Project HERO.
You can go to http://www.humana-veterans.com/about-hvhs/project-
hero.asp to learn about this program. This website provides that
``[t]he ultimate goal of Project HERO is to ensure that all health care
delivered by the VA, either through VA providers or community partners,
is of comparable quality and consistency for veterans.''
My husband was in the Project HERO program and it did him no good
at all.
My understanding is that this Committee has heard the testimony of
Brad Jones, Chief Operating Officer, Humana Healthcare Services, Inc.,
at a hearing on September 14, 2012. He claimed in his testimony that
``[W]ith the exception of veterans participating in Project HERO and
Project ARCH, veterans are left to navigate a confusing healthcare
system on their own and become lost to the VA. The VA has no mechanism
to track and monitor the care that Veterans receive in the community
and there is no guarantee that these Veterans do not lose the quality,
safety, and other protections that HERO and ARCH provide.''
Mr. Jones further testified that ``lack of care coordination
hinders the VA's ability to optimize its resources because there can be
duplicative and conflictive treatment regimen. This not only results in
wasted resources, but can also cause adverse medical outcomes.''
Mr. Jones contended that Humana and Project HERO provided a
``strong care coordination element.''
This did not happen in my husband's case. His care was not
coordinated. He was not provided the care he needed. He was not allowed
the in-patient hospital care that he needed. And his prescription drugs
were not coordinated and monitored to ensure safety.
No one at the VA or at Humana questioned why he got all of the
medication that were prescribed when he had a diagnosis of sleep apnea.
Again - it is a case of written guidelines and programs - that are
not implemented.
Questions That Deserve Answers from the Veteran's Administration and
Humana
It is my understanding that when unexpected deaths occur, the VA
does an analysis to find out why the death occurred. I want to know if
such an analysis was ever done in my husband's case. I want to know if
the VA has or will investigate the death of my husband and learn
something from his death. Has the VA considered why my husband was
forced out of the hospital one day after his back surgery instead of
being allowed to stay three to five days as we had been told? Has the
VA looked at the autopsy report so that it can see that the drugs it
gave my husband killed him? Does the VA consider all the drugs that my
husband Ricky Green was taking - with his diagnosis of sleep apnea - a
quality problem and health care that fell below the standard of care
and its own guideline? Does the VA understand that the interactions of
all the drugs that they provided my husband killed him - and that these
drug interactions are critical and must be taken into account before
prescription pain killers are so cavalierly prescribed? Has the VA
considered how dangerous it is to provide pain medications and sleeping
pills to someone with sleep apnea such as my husband? And have the VA
and Humana asked each other - who dropped the ball here - and why
Project HERO did nothing at all to protect my husband. I would like
this Committee to use its powers of investigation to uncover why Humana
and Project HERO did not protect my husband Ricky Green from the lethal
cocktail of drugs that killed him. Why can't the powerful computer
systems at both the VA and Humana that process the medical records of
our veterans be programmed to monitor the kinds of drug interactions
and dangerous conditions like sleep apnea to alert both doctors and
pharmacists when dangerous prescribing occurs like those that killed
Ricky?
I hope the VA - and if not the VA then this Committee - will ask
these questions, learn something, and save the lives of our veterans in
the future. That is the one way - the only way - that my husband will
not have died in vain.
Conclusion and Call for Action
I will NOT be silent about any of this. My husband doesn't have a
voice therefore I am his voice. I want to see that this over drugging
of our Veterans Stops AND that there IS accountability for these
physicians actions. Prescribing sleeping pills, valium, tramadol, oxy,
hydrocodone, to my husband was nothing but a death sentence. This is
happening more and more and this has to STOP!
I want to leave you on this committee with a simple request -
demand that the VA follow its own written guidelines, demand that the
VA put in place procedures that punish VA doctors and staff who do not
follow these written guidelines, and demand that the VA and its doctors
put a stop to this epidemic of the VA's skyrocketing use of
prescription painkillers to treat veterans.
Prepared Statement of Josh Renschler
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, I am honored to have the opportunity to speak to you
today regarding my experiences with Pain Management treatment from the
Department of Veterans Affairs. I proudly served in the United States
Army as an Infantryman for 5 1/2 years. I am now the director of men's
programming for a non-profit organization that assists service members,
veterans and their families; who are struggling due to deployment
related trauma. Based on my own experiences with the VA, and having
witnessed first-hand the experiences of other veterans whom I have
mentored; it is my belief that the VA has continually fallen short of
providing veteran-centered care; the VA has completely missed the mark
of meeting veteran's needs on an individual case by case basis as well
as employing best practices to care for common injuries/illnesses.
Pertaining to the VA's increasing use of opioids in pain management it
is my belief that current practices are reckless and irresponsible at
best. It is my intention to bring these issues into the light before
this committee so they may be addressed by the VA in order to affect
changes in policies and practices in order to improve care for all
Veterans.
I was medically retired from the Army due to severe injuries from a
mortar blast in Iraq and entered into the VA system in 2008. I was
assigned to the Deployment Health Team at American Lake VA Hospital in
Lakewood, WA and to the PolyTrauma Team from the Seattle VA Medical
Center. At the time, I was on approximately 8 medications which treated
me for sleep, migraines, pain, seizures and anxiety. It had taken Army
doctors 3 years to discover and balance an effective, safe medication
mix. My VA primary care doctor told me that several of those
medications were not on the VA formulary and that VA would not pay for
them. My primary care provider at American Lake began experimenting
with different medications on me, despite the urging of my wife due to
the failure of these medications in the past. The side effects caused
me so much difficulty that I began to backslide in my recovery. I was
soon on 13 medications (some to simply counter the effects of others);
and soon all my conditions worsened and I had a severe panic attack at
work. As a result, I lost my job, costing my family our home and
vehicle. As my back pain continued to worsen, my primary care provider
simply increased the dose of Percocet until it was no longer effective
even at the extreme dosing of 12-15 5mg tablets a day. Soon I was
issued methadone and eventually morphine tablets to take in between
dosing of Percocet. By mid-2009, these ridiculous dosages kept me from
working. Though the pain was wildly out of control, visits to my
primary care provider were- 3 months apart and at each appointment I
would beg for anything other than more meds. PolyTrauma finally granted
a referral to see a Physical Therapist at American Lake; I was very
excited to do something proactive. But the Physical Therapist simply
asked me questions about my pain as he sat at a computer, and did
nothing more than give me pages of instructions on stretching exercises
to try at home and follow up with him in two weeks. As I then required
the support of a cane just to walk, this left me feeling nearly
hopeless. A little over a month later, an appointment with Neurosurgery
finally led to an order for an MRI and EMG, which showed severe nerve
damage and disc deterioration, and eventually a referral to a private
Neurosurgeon. He was amazed that I was still walking and infuriated
with the VA for allowing this to go on so long, and scheduled an urgent
surgery 3 days later. By then (March 2010), due to the length of time
the problems went unresolved; the nerve damage had become permanent. I
still have no feeling in my left leg to this day.
From 2008-2011, I continued to take the ``cocktail'' of medications
prescribed through the VA. I had never heard of a pain clinic and was
never offered alternative therapies despite my pleading. (I did pay out
of pocket as I could for Chiropractic care and massage therapy for some
minor relief.) Over the course of these years, I was not once monitored
for effects on Liver or Kidneys despite the high occurrence of Liver
and Kidney issues with several of my medications. Finally, in early
2011 a new VA primary care doctor at the American Lake VA became very
concerned and ordered a blood test that revealed extremely elevated
Liver enzymes in dangerous levels. With a doubling of those levels over
the next two months, I was referred to a Hematologist, who conducted a
Liver biopsy. At this point my wife and I were very worried, so we
began to slowly stop taking all but my seizure medications within 2
weeks; as we awaited my biopsy. Life became very difficult, but I
didn't wish to die. The biopsy showed minor scarring of the Liver; the
problem was diagnosed as Non-Alcoholic Steatohepatitis. This led me to
get off all but one of my medications; a subsequent blood test showed a
drastic drop in my Liver enzymes to near safe levels (and they
continued to drop over the next 6 months until reaching ``high
normal'').
By mid 2011, the nerve pain I'd experienced before the surgery
began to come back, and the frustrating cycle all began over again with
the unhelpful, uncaring Physical Therapy, and being sent to
Occupational Therapy where I was given a ``wedge pillow'' to elevate my
legs at bedtime and a device to help me put my socks on. My primary
care doctor began treating my pain with oxycodone; I was now very
restricted on what I could take due to my Liver issues. I demanded to
see Neurosurgery and was given a referral to see the department head of
Neurosurgery at the Seattle VA hospital. She informed me of a non-
opiate medication called Lyrica that could drastically reduce my nerve
pain and that had very few side-effects, but it was a non-formulary
(expensive) medication. As she had anticipated, the pharmacy denied her
request for the drug. Despite her subsequently getting recommendations
from two other department heads in support of her resubmitted request,
the VA pharmacy again denied it. Unwilling to go down the road of
dangerous medications again, I spent $12,000 for a therapeutic hot tub,
$3,000 for a massage chair, and began seeing a chiropractor regularly.
This account has no happy ending. I am currently taking (6) 5mg
oxycodone tablets daily, and I find no relief from pain laying,
sitting, or standing and I have been begging and pleading with the VA
to help me to little avail. Late in 2012, I did have the opportunity to
try acupuncture through the VA; it was a 6-month wait for 6
appointments spread over 6 weeks. But as it was only available in
Seattle, the hour long car ride defeated the minimal relief it
provided. I still have not been offered a pain management clinic,
though what I really need is a ``hands-on'' physical therapist, or a
referral to a private hospital for another surgery.
Let me emphasize that I made this trip not to gain advantage for
myself, but because I hope my testimony will help lead to changes in
the way VA facilities handle pain-management. I hope that focusing on
cases like mine will end irresponsible practices like prescribing
medications that have potentially dangerous side effects with limited
to no oversight of those medications. I hope it will result in much
greater emphasis on pain-management and on improving overall quality of
life, to include use of alternative therapies. And I hope that combat
veterans experiencing chronic pain won't ever again be denied
potentially helpful drugs simply because of their cost. I thank you for
your time and for your careful oversight on this matter.
Prepared Statement of Justin Minyard
My name is Justin Minyard and I want to thank Chairman Benishek and
Ranking Member Brownley for the opportunity to appear before the
committee and address this vital subject.
I am a medically retired member of the U.S. Army. Before being
forced to retire from the Army due to my debilitating back pain, I was
a first responder at the Pentagon on 9/11 and a special operations
interrogator in Afghanistan and Iraq. But due to injuries sustained in
combat operations, I struggled with serious chronic pain and a
dependence on the opioid medication that was the only option provided
to me by the Armed Services healthcare system. Finally, after several
years searching, I found lasting pain relief through spinal cord
stimulation, or SCS. Today, I am proud to say that I have not taken a
single dose of opioid pain medication in the last two years. No veteran
should have to struggle for as long as I did - early access to
interventionalists in the VA is critical.
Being free from opioid dependence has allowed me to serve as the
founder of Operation Shifting Gears, a non-profit dedicated to serving
injured or disabled veterans and as spokesperson for
RaceAgainstPain.com, a community of chronic pain sufferers. I take it
upon myself to personally encourage veterans and others suffering from
chronic pain to explore options outside of opioid pain relief, such as
spinal cord stimulation.
I first developed chronic back pain when I was serving as a member
of the Presidential Escort, 3rd U.S. Infantry Old Guard, stationed at
Fort Meyer. On 9/11, my unit was one of the first responders at the
Pentagon. For the next 72 hours, we searched for survivors, working on
adrenaline to move huge pieces of rubble. As a result of those efforts,
I sustained a serious back injury - damaged discs and fractured
vertebrae.
My back pain drastically impacted my life from September 11th
onwards. I didn't seek treatment immediately, but instead took over-
the-counter painkillers and tried to simply work through the pain. I
volunteered to learn Arabic and become an interrogator. During my
deployment to Afghanistan, I experienced another incident where I fell
two stories out of the back of a helicopter, causing a disc to rupture
and fracturing my vertebrae. I returned home due to the pain and had my
first back surgery, a laminectomy, to replace one of the bulging discs
and repair the fracture.
Despite the fact that my daughter Mackenzie was only three weeks
old, it was 2007 and the army was in need of experienced interrogators
like me to serve in Iraq, so I volunteered to go. While there, the
weight of carrying a full 80-100 lb. combat load every day combined
with a vehicle rollover caused further damage to my back. I came home
and met with the army doctors, who told me that my spine was rapidly
deteriorating and I needed reconstructive back surgery.
The physician left the room and I turned to my wife, Amy, and said,
``What do you think we should do?'' I knew she wanted me to stay home;
I knew I should stay home. Mackenzie was only 5 months old at this
point and Amy was working full-time. But I thought about my unit that
was still in Iraq and the fact that I wanted to complete the mission we
were sent there to do. So when my doctor came back in the room and I
told him I was going to go against his advice and return to Iraq, he
said, ``If you insist on going back, this is really the only way you
are going to be able to make it through.'' He handed me a prescription
for opioids and I said, ``Okay, if that's what we need to do, that's
what we will do.'' I had the bottle in my hand and I was ready to go.
For the next 10 months in Iraq, I was able to do my job. My pain
was fluctuating somewhere on a daily basis between a four and a nine on
a 1-to-10 scale, but I was regularly taking about four to eight pills
of high-dose opioid pain medication at the time. It was a very rough
situation, but I was able mask that with the opioid pain medications.
That was a double-edged sword - the opioids allowed me to continue
combat operations, but they allowed me to continue damaging my back as
well. But because of the way opioid pain medication works with your
body, you build up a tolerance quickly and for me, in the middle of the
desert, I didn't have a lot of other options for pain relief. I sought
help from a Special Forces medic, who was able to call back to the
States and request spinal cord epidural kits to be shipped to the base.
So there I was, in an army tent in the middle of the desert, getting
epidurals in order to continue working in Iraq.
August 4th, 2008 was my breaking point. I came back to the team
house after an extremely challenging 3-day mission. I stepped out of my
Humvee and my right leg simply gave out. I couldn't take another step.
I learned later on that it was because of nerve damage that had
occurred due to the compression putting pressure on the main nerve
running through my right leg. It was terrifying - I arrived at the team
house at about 5:00 in the afternoon and by 6:15 p.m., I was on a
helicopter being medevac'd to Balad Air Force Base.
Coming back from Iraq, it quickly became evident that I had to be
in a wheelchair. Because of the damage to my back, I couldn't walk more
than 2 or 3 steps without some help. The first time I sat in the
wheelchair, I felt like a different person. I felt like I had lost
something.
My life when I returned back home was not my life. It was terrible.
I was in a great deal of pain. I was dealing with mental issues like
anxiety and depression.
I started an intense opioid pain medication regimen. The metaphor I
think best gives people an idea of what it is like is: once I started
on high-dose opioid pain pills; once that train left the station, it
was going 1,000 miles an hour and wasn't making any stops. My life
literally revolved around, ``When is my next pill?,'' ``When is my next
refill?'' and ``When does my dose get increased?'' If you wanted to
talk to me about my job performance, if you wanted to talk to me about
Friday night dinner plans, if you wanted to talk to me about plans for
Christmas, I just didn't care. Unless you were going to tell me that
you were going to give me a ride to the pharmacy or you were going to
tell me that it was time to take my next pain pill, I didn't care. In
fact, I would either ignore you or treat you very poorly.
At my worst point, I was taking enough opioid pain medication to
treat four terminally ill cancer patients. That was on a daily basis.
It had enormous physical and mental effects on me - people would often
look at me and my eyes would be rolled into the back of my head. When I
talked to people, I just wouldn't make any sense; it would all be
incoherent. If I wasn't babbling incoherently, I would be asleep or
simply drooling on myself.
I was on an insane amount of opioid pain medication. My dependency
happened so fast. It felt like I blinked and then I looked up and my
life revolved around getting my fix. I remember a point when I
realized, ``Okay this is starting to become a problem!'' But soon after
that, even that thought left my mind. My days drifted by like this:
wake up: pain pill; have lunch: pain pill; in the afternoon: pain pill;
and on and on. It was not a pleasant experience.
I am very ashamed about those years because I treated the people
that mattered most to me very poorly. There were years that I went
without telling my wife, who stayed by my side throughout the entire
process, ``Thank you for taking care of me.'' I was not the husband my
wife deserved and I was not the father my daughter deserved. That was
not the life I wanted. It was a very dark and difficult part of my
life.
I continued to use a wheelchair but I didn't want to accept the
diagnosis I had been given, which was that it was most likely going to
be part of my life for the rest of my days. But, I was offered no
choice by the medical services to address the cause of my injuries;
only means to mask the effects with ever increasing amounts of opioids.
I was finally forced to look on my own for options that were available
that could possibly repair the damage and help me start walking again.
That led me to my second back surgery at Duke University Hospital: a
highly invasive, extremely painful anterior/posterior inter-body fusion
in which surgeons inserted eight titanium rods that form a cage around
my spine to support all of the damage to my back.
In preparing for the surgery, Duke actually had to call in a
special pain management team to figure out how and what medication they
were going to use that would be strong enough to overcome my body's
tolerance to the high amounts of opioids I was already using. The pain
management team said, ``Surely we are reading this chart wrong. This
guy hasn't really been on this amount of opioid pain medication for
this long, has he?'' They had to go back and do a case study to figure
out what kind of anesthesia to prescribe.
That surgery was successful in that it allowed me to become more
active and rely on the wheelchair less, but I was still in pain. I was
still completely dependent on opioids and that was unacceptable to me.
I hated having to rely on something else to get through the day and I
knew my years of dependence on pain medication were negatively
impacting my family - and would likely lead to fatal medical side
effects.
The defining point for me, when I realized I could not go on living
a life dependent on opioid medication, was watching a home video of
myself on Christmas morning. In the video, you see my daughter approach
me while we were all together in the family room and ask me to help her
open a present. As she was handing it to me, I was trying to hold on to
it. And all of a sudden my neck muscles and head just kind of rolled
back. My eyes rolled back in my head. I started drooling on myself. I
don't think there could be much more of an impactful, defining moment
where you realize something is wrong, so I started trying to find
another solution.
Without help from the Government, it was a major challenge
navigating the maze of providers and bureaucracy before finally being
referred to an interventional pain specialist at Fort Bragg. My doctor,
who happened to be conducting a clinical trial of SCS therapy, took a
vested, personal interest in my case and I credit him with turning my
life around.
The VA didn't make it easy for me to connect with people like him.
My wife had to advocate for me, not taking ``No'' for an answer. But
the VA hospitals and TRICARE should be doing everything they can to
spread the word about his specialty: interventional pain management.
So the doctor said to me, ``Have you heard about spinal cord
stimulation (SCS)?'' And I said, ``Spinal cord what?'' He explained the
technology, made by Boston Scientific and others, to me. The
implantable device would block my brain from receiving a pain signal
and instead, mask that signal into a tingling feeling, as if a tuning
fork is going off inside your body. He said, ``It is a way for you to
manage your pain and not have your pain manage you.'' He even explained
that I would have the chance to test drive the device for one week
before moving forward with the permanent implant and see if it would
provide effective relief and that I was a good candidate for a clinical
trial with SCS that was just starting at Fort Bragg.
Having the ability to test drive SCS was the ultimate selling point
for me. Unlike my anterior/posterior inter-body fusion surgery, I could
actually try this device with a minimally invasive procedure. I find
that very rare in medical treatment.
So I immediately asked, ``When can you get me in for a trial?'' I
came in for a trial a few weeks later and in less than the time it
takes to get a cavity filled, I had the trial device implanted in a
simple, outpatient surgery.
During the trial period, they placed the two leads in the area of
my back where I needed the most pain relief. As soon as I woke up, they
used the computer to manipulate the system and set up my pain
management programs. The first time the stimulator was activated it
felt incredible. As cliche as it sounds, I thought to myself, ``This
device is going to be a life changer.'' I was getting more pain relief
from the one area the machine targeted in that moment than I had since
I started on opioids years ago.
After that, the team went through my new Precision System's four
different pain programs. At each point they asked, ``Can you feel here?
Can you feel here?'' And I would tell him, ``Can you move it left?''
and I felt it. It's not unpleasant - it's like an internal massage
moving across your back. With each keyboard click I heard, I could feel
the impulse moving through my body and hitting the target pain area.
Once it locks in to wherever your pain is, it's almost like magic. It's
unbelievable because it is pain relief right where you need it. Not
only does the SCS focus in on where you need it, but I was also given a
remote that allows me to turn up the power to get even more relief in
certain areas that are hurting on a given day. It is amazing to go for
so many years struggling with pain relief and, all of a sudden, I can
push a button and my pain can drop from a seven to a four.
I was floored. I wanted the permanent device implanted immediately.
I said, ``My test drive is done, I only need to go around the block
once! I'm good.''
But the bottom line is everyone has to do the trial. Mine was three
days, and when I went back in to remove the trial, I couldn't wait to
have the permanent version. I was counting down the minutes and calling
the doctor's office every day, saying, ``Let me know if someone
cancels. I'll drive up there. I'll sleep in the doctor's office,
because I know this spinal cord stimulator is going to be it for me.''
Three weeks later, I had the permanent spinal cord stimulator
implanted and that is where my life started to turn around. That was
the defining moment. I was able to get the remote for my permanent SCS
and start using it to manage my pain.
The relief I felt from SCS allowed me to start tapering down my
medications. My goal was to ultimately be free of all opioids. That
process took time and it was difficult, but it was completely worth it.
I am now at the point where I have not taken an opioid-based pain
pill in more than 2 years. I actually have a medical directive that
states that if I am taken to the hospital, I am not allowed to be
administered a narcotic without my consent. And if I am unconscious, my
wife has to give consent. I have this because I went through this
process and I don't need the medications, nor do I want them anymore.
Like I said before, once you start...once on that train... it is a
very, very, very fast and scary progression to the point where it is
out of control.
I just want to leave you with something. There are a lot of
soldiers in my situation. And not just soldiers, but a lot of people in
this country who were pushed onto the opioid pain train, and now
they're moving so fast and they can't get off of it. I consider myself
extremely lucky that I was able to push through the maze of providers
in TRICARE and find the doctor who knew the secret - at least for me.
But there are many soldiers who are not so lucky; soldiers who lack the
resources and awareness to advocate for alternatives to opioid pain
regimens and are left to the crushing reality of lifelong opioid
dependence or worse. A recent VA study spotlighted the horrific
epidemic of suicide amongst veterans, 22 per day.
Pain is a pervasive condition with the impacts and burdens reaching
far beyond the patient - to families, society, etc. According to NIH,
when including healthcare costs, lost income, and lost productivity,
pain costs almost $100 billion per year. We must increase awareness
about alternatives to opioid pain medication in the VA system. The VA
must work to create accessible regional centers equipped with access to
skilled interventional pain specialists. We must train more doctors in
these techniques and devote more resources to raising awareness. We
should also begin collecting data on long-term outcomes of
interventional therapies versus opioid therapy so we have the numbers
to show that the techniques that helped me will help other soldiers,
too.
The VA is a great place to start, because so many veterans come
home and struggle, just as I did. I continue to struggle with the VA in
getting timely appointments with a specialist to manage my SCS therapy,
but my hope is that in the future, policies will be in place to help
people like me manage their SCS therapy and to help prevent soldiers
and their families from the devastating effects of opioid dependence.
Thank you all, so much, for listening to my story.
Prepared Statement of Pamela J. Gray, M.D.
October 10, 2013
At the outset I would like to thank the members of this committee
on Veterans Affairs for offering me an opportunity to share my first
hand experiences as a physician at a Veterans Hospital located in
Hampton, Virginia.
I am presenting to you a letter I wrote to my State Senator in
March 2010. The thoughts and observations in the letter were recorded
with great clarity. I have included the names of individuals as in the
original letter. As the truth was documented originally, so I chose to
let it stand.
I beg of you to hear these words and act decisively to improve the
healthcare delivery system for our deserving veterans.
Thanking you in advance for your attention.
Respectfully submitted,
Pamela J. Gray, M.D.
Dear Senator Webb,
I am writing to you to report my experiences with the delivery of
medical care at the Hampton VAMC. My observations from April 2008 to
March 2010 note the level of care is not consistent with community
standards. As a physician working at the Hampton VA during that time
period, I witnessed an abuse of authority which is a potential danger
to public health and safety, specifically the overprescribing of
opioids providing opportunity for diversion into the Hampton Community.
As a result of reporting this information I have been terminated as of
March 26, 2010. I am seeking whistleblower protection. The first
contact via telephone to your office in Norfolk was December 2009. I am
also asking you to contact the Office of the Inspector General on my
behalf. I was initially contacted by Special Agent Molly Morgan on
February 1, 2010, however, I am asking for further investigation as I
feel my termination is reprisal for my concerns regarding prescribing
of Schedule II narcotics.
I have been employed as a physician at the VAMC since April 28,
2008. I was hired in the capacity of 30% Rheumatology, 70% Primary
Care. I have been informed by fellow physicians that in the six months
prior to my arrival in multiple Primary Care Staff meetings, I was
identified as a ``pain specialist.'' I have no specialized training as
a pain specialist nor did I ever identify myself as such. After my
arrival, I was informed I would manage difficult pain patients with
musculoskeletal diagnoses being treated with large doses of Schedule II
narcotics. As this is not a standard of care in the community, I sought
to give a more appropriate level of care. I encountered resistance on
the part of my service chiefs, clinic nurses, telecare nurses and
nursing supervisors. My concern at this point was the overprescribing
of opioids with the potential for diversion into the Hampton/Newport
News communities. It is well documented that 10-20% of opioid users
become addicted. The opportunity for diversion was of concern as this
had been documented at the V.A. in Beckley, West Virginia. This was
also well known by my service chiefs and the Chief of Staff as we had
discussed it in full. I received no support for my efforts. I was told
by the Chief of Medicine to ``think twice before refusing to write
narcotics in a time of economic downturn.''
I served on the Pain Committee upon appointment by the Director of
the VAMC, Ms. Mims. There are multiple instances when I have been
coerced or even ordered to write for Schedule II narcotics when it was
against my medical judgment. Ms. Mims called me directly out of a Pain
Committee meeting, ordering me to write opioids for a patient who had
no objective findings to support a musculoskeletal diagnosis requiring
such treatment. He was a thirty-eight (38) year old male with knee pain
with normal exam and x-rays. Non-medical personnel tried to influence
me to write for opioids, again for incorrect purposes. A patient care
advocate, Mr. Waylon Murphy, and an Administrative Assistant, Roger
Barkers, tried to persuade me to do so. This was documented in my
medical notes. I was ordered to alter my notes by Dr. Karin Soobert,
Chief of Primary Care. As I had documented factual truth, I refused. It
is illegal to alter notes in a medical record; an addendum may be added
but notes cannot be deleted. My note was deleted under the orders of
Dr. Soobert, who is also Chair of Medical Records. I continued to lobby
on behalf of the patients for a better level of care as well as
improved work environment for the physicians, physician's assistants
and nurse practitioners who also felt pressure to write Schedule II
narcotics against their better judgment. This was reported to Ruth
November, J.D, Office of Regional Counsel, McGuire VAMC, Richmond, VA
in April, 2009 (See email of same date).
Although pain management was not an area I wished to pursue, I
served on the Pain Committee, represented our Medical Center at a
National Pain Conference for VISN 1-11 and wrote the standard operating
procedure for VAMC that is now in current use. I did everything which
was asked of me by my two Service Chiefs and the Director. I brought
all information back from the National Pain Conference to Dr. Soobert,
Service Chief, and Dr. Arul, Chief of Staff. No change was implemented
in one year.
As an advocate for a patient who was sent out of the Hampton V.A.
Medical Center Emergency Room while he was having a CVA (cardiovascular
accident or stroke), I sought neurologic consultation for the patient
in July of 2009. The consult was refused three times. As a result of
trying to protect the community image of the VAMC and care for the
patient, I was threatened in writing that further such action ``may
result in disciplinary action to include removal'' by Dr. Soobert. I
have appealed her action and have been denied. The patient has filed
suit against the VAMC Hampton.
In trying to improve patient care, I have received death threats
from patients, coercion to practice poor medicine by non-medical
personnel, have been found guilty of an ethics violation committed by
another physician and now face a Professional Standards Board Review
without being allowed to review any documents to be used against me. My
service line chief who initiated the PSB denied knowing anything about
the Board meeting. I am informed by Ms. Ruby Sheperd in Human Resources
this originated directly as a result of Dr. Soobert's request. Dr.
Soobert denied knowledge of this and denied me access to my records for
review prior to the Board.
In the twenty-three (23) months of my employment: 1) I have been
forced to do work in which I have no professional training, 2) been
ordered by supervisors and the Director to write large amounts of
Schedule II narcotics in inappropriate medical circumstances, 3) have
had my medical records altered to hide factual documentation, 4) have
received sexual harassment by a male nurse, again, regarding opioids,
5) been reprimanded for advocating for a stroke victim's right to care
from the VAMC Hampton who, as a Marine veteran, was sent out of the
Hampton VAMC Emergency Room as he was having a stroke, resulting in
permanent brain injury, 6) been threatened to be reported to the
National Data Bank for a non-reportable Level I Peer Review and 7) been
subjected to situations involving entrapment by supervisors to ``not
stop writing for opioids in a time of economic downturn''/say
defamatory remarks about ethnicity/say defamatory remarks about the
Director, all of which I resisted as I found these actions
reprehensible. I now am being asked to cover another physician's clinic
in Hampton in the clinic where I received the death threats and had a
male nurse scream at me for refusal to overprescribe opioids to hide
the actions of a married doctor who has had a sexual relationship with
a married nurse. Both have had their jobs protected. I am asked to
participate in the cover up of a crime.
A Probationary Review Board to decide whether to terminate me was
called on February 4, 2010. As of today, March 24, 2010, I have never
been notified of its findings. One of the three physician members of
the Committee referred a patient to me for ongoing care on March 10,
2010. I received a letter from the Union attorney on March 8, 2010
stating he had no knowledge of the outcome of the Board. The February
23, 2010 minutes of the Virginia Beach VAMC clinic where I had seen
patients indicated I was to return to Virginia Beach April 2010. At
4:15, March 12, 2010 I received notification to come to Dr. Karin
Soobert's office at the conclusion of my work. When I did not appear by
4:30, I received a second call telling me ``not to forget to come to
Dr. Soobert's office.'' When I arrived at 4:45 p.m. I was informed I
was terminated. No cause was given. I was denied Union representation.
I was told to sign the document placed in front of me. I asked to
review it with a Union attorney. I was told to sign it ``right now''
and ``turn in your badge.'' As it was then after close of business, I
had no one to turn to for questions. In the termination note to follow,
I was given Kellie Franks as the Human Resources person to contact. I
called, leaving my cell phone number as a contact. I received no return
call for one week. When she called she wanted to know what my questions
were and she would call me back. Upon return call, I was given another
contact name and number. When Evelyn Stephenson was contacted she
informed me she did not know the answers to my questions (Cobra
coverage, retirement funds, continuing Union dues, etc.) and that I
should ``go to the liberry [sic] and look it up.'' I have no answers to
date. I was denied a written response.
Physicians in Primary Care at Hampton VAMC have three choices when
prescribing large amounts of opioids. They may resign (3 excellent
physicians did so in the past 12 months - Drs. Pagador, Hilland and
Wozniak), do as they are told, or be terminated. Dr. Jamal Al-Zhara was
terminated when he refused to alter records to hide emergency room
errors. Dr. Soobert fired him and then prevented him from working at
other VA Hospitals.
The Primary Care Physicians have no support from Administration
including at the Director level. Examples of excess opioids includes:
55 year old male received Morphine MS Contin 30 mg twice
daily, Tramadol 300 mg daily, Percocet 4 times daily, 1 Fentanyl patch
25 mg every 3 days for carpal tunnel since 2004, was not seen since
2004, had no labs checked since 2004, and had the opioids mailed to
him.
64 year old, 102 pound female hospitalized for morphine/
vodka overdose receiving 1800 tabs hydrocodone monthly concurrently
with morphine sulphate (MS Contin) 100 mg tabs, 360 tabs monthly, and
has received as many as 3,600 5 mg Oxycodone at monthly intervals
38 year old male, normal exam, normal x-rays ordered by
Director Mims to continue filling his Percocet. Had been receiving 360
tabs every month.
39 year old male, working full time as farmer in Suffolk,
VA receiving MS Contin, Duragesic patches, Percocet and Tramadol
simultaneously for neck pain. Evidence of receiving Percocet from an
outside, private primary physician and VAMC, never went to pain
management consult but meds continued.
50 year old male, diagnosed with ``low back pain'' 10
years ago, last x-ray in 2004, wants more than Tylenol #3 (codeine) 4
per day, Tramadol 4 per day. Refused labs and x-rays, wants pain meds
refilled.
55 year old male on morphine for ``low back pain'' 30 mg
tabs 3 times per day, 240 tabs monthly mailed and Oxycodone 40 mg
daily, 240 tabs monthly.
56 year old male wants Percocet for ``chronic generalized
pain.'' He wants 10 Percocet daily. I refuse. He reports me to
administration. I am ordered by Dr. Karin Soobert to write the
prescription. When I explain, she reports me for failure to follow
orders. Contacted by Mr. Roger Barkers, Administrative Assistant, to
write prescriptions.
52 year old male on morphine 300 mg CR, 2 tabs 3 times
daily for Lupus. He does not have Lupus. He reported me to Roger
Barkers who had Dr. Mowery see the patient and write the opioids.
Patient on 1080 mg of morphine daily, 4 Oxycodone 80 mg twice daily for
disease he does not have.
55 year old male demands morphine and Oxycodone because
``I want them and you have to give them to me.'' Abusive. Police
called. Another provider gives the meds the same day.
56 year old sleeps through appointment with me. I feel he
is over-medicated. He is diagnosed with rheumatoid arthritis with no
DMARD since 2000. On morphine 90 mg daily, Oxycodone 10 mg daily,
receiving 180 tabs morphine and 100 tabs Oxycodone monthly. I begin to
taper on October 8, 2008, wife calls for in for more meds within 1
week. I was reported.
52 year old on Fentanyl patches. No CBC (complete blood
count) since 2004, no LFT (liver function test) since 2007 and last
urine drug screen 2008. Patches are mailed to him monthly for mild
osteoarthritis. I alert Dr. Soobert this is not standard practice. I am
terminated the following day.
Tens of thousands of examples exist. I have repeatedly alerted Dr.
Karin Soobert, Chief of Primary care, Dr. Mary Kim Voss, Chief of
Medicine and Dr. Arul, Chief of Staff that, due to fear of
administrative reprisal, these are the rules, not the exception. The
doctors are afraid to refuse the patients' demands. The amounts of
Schedule II narcotics prescribed indicate diversion into the community
is occurring.
I have consistently seen more patient than the other physicians. I
am the only primary care physician to be over 100% booked in the
history of the Primary Care at the VAMC Hampton. I have received the
praise of my fellow physicians and nurses. It is my fondest desire to
return to my position as a physician at the VAMC. There are fine
physicians who wish to improve the level of care given to our veterans
if given the opportunity and administrative support. Please assist me
in bringing about the necessary changes to make this happen. I
understand fully the gravity of these accusations and factual
documentation exists for all.
Respectfully,
Pamela J. Gray, MD
Prepared Statement of Claudia J. Bahorik, D.O.
BACKGROUND INFORMATION
As a Board-Certified Family Physician for over twenty years and
having worked in the medical field wearing various hats for over forty
years, I feel more than qualified to enter an opinion on the current
state of affairs regarding the narcotic situation at the VA primary
care clinics. For the last 3= years I have been a traveling primary
care physician for the VA Interim Staffing Program. During this time, I
worked as a physician directly providing medical care to veterans at
thirteen different VA facilities. Additionally, I am a physician
acupuncturist, a licensed physical therapist, and more importantly, I
am a disabled veteran who also is a consumer of care at the VA.
SUMMARY
Although the VA can demonstrate they have guidelines and resources
for the prescription of narcotics, on the grassroots level the primary
care providers are struggling to stay afloat in a system flawed with
errors, lacking oversight at all levels, and burdened by policies and
politics that make it difficult to monitor and manage veterans with
pain. These veterans, through the VA's own emphasis on pain, come to
expect and demand narcotics, see pain control with narcotics as their
``right,'' and bristle at attempts to limit use of these potent,
addictive, and potentially lethal medications.
DISCUSSION:
The problem with narcotics is but the tip of the iceberg and the VA
the Titanic headed full speed ahead for catastrophe. To quote a fellow
physician, even a garbage dump looks good when you're flying at 50,000
feet.
Perhaps the narcotic fiasco run amuck will serve as the impetus to
revamp a system steeped in tradition and run by a good ole boys club
that protects its members even under legitimate fire. Take the recent
hearings in Pittsburgh and the Legionairre's problem. The VSN
(division) director Mr. Moreland was rewarded with a $63,000 bonus,
which his superior Dr.Petzel found no problem with authorizing. An
administrator from the Jackson, Mississippi VAMC when faced with
serious charges is allowed to step down from his position and continue
to see patients. Another administrator involved in Jackson narcotic
disaster was reportedly transferred to a similar position at an
unsuspecting VA in Tennessee. These are but a few recent examples of an
administrative ``shell game'' played by those at the helm of the VA
Health Care System.
Then there's the case of a physician assistant in Maine who was so
unreliable and had so many complaints from staff and veterans that in
an ordinary medical practice would have discharged him long ago. Around
February of this year the VSN decided to investigate and place the man
on paid administrative leave. He had been missing work on a regular
basis, absent during working hours and no one knew his whereabouts (it
was rumored that he was teaching an unauthorized course at a local
college over lunch and saw no problem making vets wait 1 = hours until
he returned), and veterans were regularly requesting they be
transferred to another provider.
This physician assistant would not obtain his own DEA license (drug
enforcement agency) to prescribe narcotics (he told me he refused to
pay for it, insisting the VA should pay for this license), instead,
asked the physician in the adjacent office to write narcotic
prescriptions on patients he had never met or examined (a violation of
DEA prescribing policies). Then it was discovered that the physician
assistant had been documenting that he had been doing extensive
physical examinations on many vets who later complained to staff (and
myself) that he never touched them (since most of the vets are also of
Medicare age, this constitutes Medicare fraud). As far as I could
ascertain, when I later covered his panel of vets, the only part of the
physical exam for which he reliably performed per the veteran's
admissions was the rectal exam.
As I worked with his former patient panel, it became obvious that
not only had he not examined patients, he had ignored their complaints,
in many cases had misdiagnosed veterans, and in some cases there was a
potentially life-threatening delay in diagnosis. He had month after
month seen to their narcotic prescriptions, yet never had examined the
body part(s) for which they had a pain complaint. I discovered that the
problems lists were incomplete or inaccurate, the medications lists
were often not updated or accurate, and his notes worthless and
unreliable.
As of about eight months later, this physician assistant was still
on administrative leave, still getting paid, and the investigating
committee could not make a determination as to his disposition. When a
system cannot dispose of their own dead wood, how can one expect that
system to effectively monitor and police itself?
This is but one example of failure to provide veterans with the
high quality of care the VA likes to list on their flyers. In
particular, the provision of veterans with narcotics in a rather
cavalier fashion appears to be a systemic problem. I have been in
thirteen VA facilities in the last 3 = years while employed as a
traveling physician with what initially was known as the VA Physician
Locums Program and now is the VA Interim Staffing Program. The program
in its hayday, employed ninety physicians who also traveled around to
other VA facilities throughout the country. How easy would it have been
to survey these grassroots physicians, asking about the narcotics
situation, particularly after many of us complained to our
administration. I requested that our comments and concerns be passed
along, but nothing was done. When our staff had telephone group
conferences (few and far between), the problems we were experiencing
with being expected to sign-off on narcotic prescriptions was brought
up during at least two conferences. Again, nothing was done.
Suggestions were made to alert the facilities to the need to
address our responsibilities as interim staffing and the facility
expectations regarding continuing to write for narcotics, particularly
when never having seen the veteran. We were all concerned that this
violated the DEA policies and was a potential threat to the veterans
and could result in DEA action against us. These comments never went
any further, were not passed along to VACO (VA Central Office) who in
their ignorance used us as a bunch of narcotic prostitutes.
This sounds rather far-fetched, but when the sparks hit the fan at
Jackson, and it came out that the nurse practitioners were illegally
writing narcotic prescriptions, VACO begged the VA locums staff to find
physicians to immediately fly to Jackson to help with the situation.
The only catch was that we were never informed that upon arrival we
were going to be the narcotic pushers, and not do primary care, but get
the drugs rolling.
The staff physicians had refused to write prescriptions for
narcotics on patients they had never seen and the ER docs felt the same
way. As one of the first two volunteers for this assignment, we were
met by the administrator who informed us that even with his
administrative duties he could manage reviewing thirty charts per day.
He instructed us to simply look the chart over, see if the vet was
``stable'', and knock out the narcotic prescriptions that his veterans
were clammering for since the nurse practitioners lost their ability to
write due to DEA action. He saw no reason to do a physical examination
and said we needed only a ``face to face'' visit to satisfy the DEA.
When I pointed out that not only could I not physically or ethically be
able to push through 30 vets on narcotics, but I needed sufficient time
and space to perform examinations.
I was stuck in a section at Jackson, not far from the airport type
screening at the front door (equipped with guards, metal detectors, and
an X-ray screening device), and assigned my own swash-buckling
narcotics police nurse, a male clerk, and had the angry vets lined-up
at my gates on a daily basis. I insisted on drug screens on every one
prior to my even seeing them, and when they came back positive for
illicit substances, or not positive for substances they should have
been on, they were cut-off.
It was obvious that the administration was not in favor of my
examining each vet, or reviewing each chart in a methodical fashion. My
request from day one for an examination table was met with questions as
to what purpose would I require an examination table for. To examine
the vet properly was the response, yet my request went unanswered for
one week until I threatened to climb back on the plane that very day if
I didn't get the exam table. I got my table.
What I discovered at Jackson, by reviewing charts from a vast
assortment of nurse practitioners, was typical of many of the VA
facilities in which I have worked. Jackson perhaps was the worse
example. I discovered that narcotic prescriptions were rubber-stamped
month after month, sometimes for two years on end, without a
reexamination of the body part(s) in pain. Sure, the veterans were seen
by the provider, but the pain was addressed by merely asking if the vet
had pain and to rate it using the infamous 1/10 rating scheme. This
violates not only the standards the VA itself has posted (that is, if
you can find these web-sites easily in the heat of battle), but the
dictates of the DEA and ethical practice standards. Nearly every
facility I have gone to for providing emergency coverage has the same
recurring problems. Notes that are incomplete, poorly typed, difficult
to read, and are rushed off to completion to satisfy time constraints
administrators place on providers, so that billing can be completed
immediately. No one seems to remember how to write a note, listing in
order of importance the problems in a logical, clearly documented
fashion. The art of note-writing had a purpose, that of assuring
continuity of care is possible and reflecting the thoughts and
impressions of the provider. If you compare the VA notes to those of
outside physicians, our notes are a shameful disgrace. And yes, it does
impact on the quality of care when I cannot pick up a chart and look at
the last note or two and figure out what the veterans problems are,
what the provider was thinking or planned. You would think this would
be one of the measures of quality. It is not.
It became obvious that no one was supervising the nurse
practitioners at Jackson, who essentially were practicing
independently. As I reviewed the charts, I discovered notes that were
incomplete regarding major health issues, conditions that were
misdiagnosed, problem lists that were not up-to-date, medicine lists
that were not current, tests were not being done, and in general, it
appeared that they had fallen into a pattern of habit regarding the
knee-jerk response to automatically refilling narcotic prescriptions.
Often there were no recent consultations to specialists, no updated
tests such as MRI's, and a lack of inquisitive investigation of pain
complaints. Many times positive urine tox screens were ignored as well
as drug screens that should have been negative. Drug screening was
infrequent and if performed, was announced or anticipated by the
routines of testing. There was no attention to the potential impact on
poly-pharmacy on the health of veterans.
The same problems noted at Jackson were also noted at other VA
facilities. Administrators expected that temporary or new providers
would jump right into the mix, continue what the prior providers had
started, and keep the veterans happy. After all, a happy vet is one
that doesn't write damning letters to his Congressman about how the VA
ignores his pain. These letters reportedly adversely affect that VSN's
(division's) money flow from above.
Many facilities now shuffle the narcotic renewals from provider to
provider when a position is left vacant, sometimes having
administrators temporarily cover the narcotic prescriptions until a
provider is replaced or returns. Again, these veterans are not seen in
an actual face to face encounter, their charts are superficially
scanned, and out pops a narcotic prescription ready to churn out of the
VA pill mill.
The same problems exist at other VA facilities regarding
documenting not only a veteran's pain complaints, but the medical
encounter itself. Providers notes often are pages and pages of cut and
paste, including a record of the exam using a repetitive template of
basic findings, but little in the way of a pain-directed physical exam.
Notes are shamefully difficult to read, have incomplete listings of
problems in the assessment section, and have sketchy plans outlined.
The providers often are forced for the sake of time to address scores
of pop-up ``reminders'' that have been triggered by the computer in
order to appear as if they are providing what some administrator has
identified as an indicator of quality care. These type of notes are
conducive to mistakes. Several times I have seen a diagnose drop-off
the radar because the medication expired for the problem and the
provider doesn't have the time to review the scores of notations
littering the path to discovery of all medical issues.
The one medication that never seems to be lost is the prescription
for narcotics. Unfortunately, substance abuse may be listed on the main
problem list, but it is often ignored when dealing with a pain
complaint. Another factor that is often ignored is the potential
interaction of multiple psychiatric medications prescribed. It is sort
of the `go ask Alice when she's ten feet tall' culture. There are pills
for everything, and pushing pills is one thing the VA is good at - so
good that the VA had been cited as being the biggest supplier of on-
street legal drugs in the United States, and the largest consumer of
narcotics in the world.
How did it get that way? It appears that about ten years ago the VA
decided that pain was the fifth vital sign (after temperature, pulse,
respiration and blood pressure). It became so ingrained that staff
members were chastised if they did not ask about pain, even if the
veteran had presented with no intention of discussing pain, they would
be flagged. Now, not only do they ask about pain, but they must ask if
you want something done about it that very day. It is no wonder medical
problems fail to get addressed or are missed.
Pain management has become a double edged sword for the medical
providers. You are damned if you don't prescribe narcotics and damned
when you do and someone has an adverse outcome. Both cases result in
complaints, and depending on how well placed the veteran is, those
complaints can generate considerable aggravation for administration.
Often I watched as a vet I had denied giving a prescription of
narcotics to, although I had documented in great detail the rationale,
as the vet would present to administration to have the non-clinical
administrators order another provider to write for the medication
(Jackson VAMC was quite good at this). The other scenario was the vets
would go to the VA emergency room, and often just to get them out
quickly, the prescription would be written.
Facilities encourage prescriptions of narcotics by denying
alternative forms of treatment such as chiropractic (most facilities do
not have a chiropractor or enough of them), massage, or acupuncture.
The VA's vocational rehabilitation department spent $8000 sending me to
a physician acupuncture course two years ago, and I have yet to find a
facility that will credential me so I can provide this service to vets.
They give the excuse of having no one to supervise me. It makes no
sense when acupuncture is less invasive than performing minor surgical
procedures, cutting someone with a scalpel, or poking holes in skin to
drain abscesses, all of which I am credentialed to do. The true issue
is that they don't want to open a can of worms, ie., be faced with
having the vets demanding more of the same service. It is infinitely
cheaper to dole out narcotics than it is to have veterans deal with
pain through alternative measures. That is the bottom line.
Furthermore, the pharmacy gestapo controls the formulary, which is
dictated in tern by the bonus a manager might receive if the costs are
kept down. For instance, if you want to provide the non-formulary drug
Lyrica for pain modulation, it typically is not approved by the
pharmacist that oversees physician drug prescribing. You are instructed
to use the older, less effective drug gabapentin first, document its
lack of effect, then try a concoction of other pharmaceuticals all with
central nervous system depressing effects first. If the veteran lives
through the experimentation with chemicals coming at him from all
directions and types of providers, maybe at some point they will relent
and allow you to provide the drug.
Another example is Voltaren gel, a topical anti-inflammatory drug
that can be rubbed into painful joints to control pain. It works and
unfortunately for the veterans, it's non-formulary. Many vets are on so
many drugs they should be putting omeprazole (Prilosec)in the water to
counter the effects on their stomachs. Non-steroidal anti-inflammatory
medications (NSAID's) are notorious for causing stomach ulcers,
gastrointestinal bleeds, and even heart problems, yet these are the
preferred first-line drugs that we are supposed to push - if one
doesn't work, try another and another. Just add the omeprazole, the H2
blocker (like Zantac), or Cytotec that causes uncontrollable sudden
bursts of diarrhea. Give them any number and combination of narcotics
and mental health drugs, but don't allow the vet to use a topical
substance, even on a trial basis, because it costs too much. Tell me,
what is the cost of hospitalization for a GI bleed? Or the cost to
society when a vet dies of a drug overdose?
No, the pharmacy is a dynasty, run by the new Ph.D.'s on the block,
the Pharm.D. The pharmacists control the formulary, which is kept a
secret and never, never published (the National formulary is published,
however, each VSN can decide on what drugs to include or not include),
since people might start to realize how few drugs and how old the drugs
are that the VA allows on the formulary (and this is somehow up-to-
date, high quality care?).
Not only do the pharmacists control the drugs, they now tell us how
to practice medicine. It appears the VA has condoned such practices -
pharmacists are cheaper than docs, maybe know the drugs' theoretical
advantages, and are loving the increased responsibility. Unfortunately,
the VA leaders pushed us to this slippery slope in the name of cost-
savings. When you think of it, why even have physicians when
pharmacists take over management of hypertension, hyperlipidemia,
diabetes in their ``clinics,'' - clinics in which they are given an
entire block of time to deal with a few targeted medical disorders.
Perhaps if the providers had such luxury there would be better control
of chronic diseases, including pain management.
To cite an example, recently I had two pharmacists tell me they
wouldn't authorize the use of Voltaren gel for a vet who had numerous
failures with other meds, stomach issues, and problems with narcotics.
They instructed me, the physician, that I should have the veteran lose
weight (as if that will happen magically overnight), exercise (which he
couldn't do much of due to his severe knee problem), refer him to
physical therapy (which would do nothing for severe degenerative
arthritis), and I should treat his ``gout'' because that might be
causing his aches and pains. Twice I wrote back that the vet does not
have gout (he had several joint aspirations proving this) and that an
increase in uric acid (hyperuricemia) does not equate necessarily to a
diagnosis of gout. Not only are the pharmacists telling us how to
practice medicine, they are now diagnosing veterans.
What about the returning heroes coming back from the sandboxes in
the Middle East? Often they are started on narcotics while deployed,
just to keep them in the field. They arrive at our doors on medications
for depression (who wouldn't be depressed with the ridiculous number of
back-to-back deployments), medications for anxiety such as Xanax, a
medication to prevent the nightmares of PTSD, one or two pills to make
them sleep (like zolpidem that makes then do things like sleep walking,
night driving while asleep, asleep eating, or making crazy purchases
on-line, none of which they remember upon waking), another anti-
depressant when the first one isn't quite performing the chemical
lobotomy, perhaps a drug for attention deficit (it's no wonder they
can't stay focused considering the drug soup bathing their brains), and
to round off the cocktail they have been prescribed a narcotic or maybe
even two for that ubiquitous pain complaint.
They present to facilities, young men typically, strung out on
prescription cocktails, mentally shattered, and desperate for help. The
VA dictates that, rightfully so, they need to be priority patients.
However, they haven't figured out how to assimilate another body into
the mix when they can't even accommodate the veterans currently on the
roles. So administration begins another ``shell game,'' moving patients
out of a provider's panel into the officially unassigned category. The
slot created on a panel allows them to put in the new OEF/OIF
(Operation Enduring Freedom and Operation Iraqi Freedome) veteran for
his initial appointment. Therefore, the providers panels are bulging,
current veterans cannot get timely appointments, and if someone is sick
and doesn't have the luxury of having an outside physician, they are
out of luck.
What happens when these hurting vets, soldiers with PTSD driving
their miseries, are told there are no appointments even though there is
a mandate (which they are aware of) directing facilities to get them in
within so many days? One poor hero, desperate to get his PTSD treated,
after too many rejections by the Wilminton VAMC, reportedly shot
himself in the parking lot of the facility.
Walk-ins are definitely not welcome, nor is the system even user
friendly if the providers do make room. Patients are expected to be
``squeezed-in'', which only serves to make the provider run late (bad,
a ding against the provider and the facility). Since time can't be
created, then the other veterans with appointments get short-changed in
their face-to-face, now hurried appointments.
It would be too logical to pre-schedule slots that are reserved for
sick visits. Even if that were done, the veterans cannot get through to
their assigned offices on the telephone. Yes, the telephone system that
links the VA facilities is archaic, inefficient, and contributes to the
large number of vets getting frustrated after repetitively calling a VA
answering service in Colorado (or some such place that might as well be
on the moon) and be asked to leave a message - a message that some busy
clinic clerk might get to some time that day. I have not found one VA
facility in nearly fours years of traveling as a gypsy doc for the VA
who has a direct phone number to their assigned clinic that their
patients can call in a normal fashion in order to be seen. So the
response the VA has to this is to insist walk-ins must be seen that
day. How this can be achieved is up to the staff who have no power to
alter schedules, block-out time slots, or do anything creative without
first going through levels of supervisors or one of the infamous, omni-
present and omnipotent, sacred VA committees.
Oh, the VA has a solution. The pressure now is not to bring the
vets in for a real appointment, providers are encouraged to try to do
telephone appointments - a scheduled phone call of 15 minutes to do the
same thing you would normally do in 30 minutes, sans the physical exam,
without eyes on the patient, with minimal prep time, and no scheduled
time to write notes. It's no wonder sloppy is the norm. The providers
end up staying later and later to catch-up, becoming more and more
dissatisfied, and it is not rocket science to recognize that the
providers mutate to the point of being pill-pushing automatons. VA
survival tactics 101 - an ideal setting conducive to narcotics being
passed merrily along with the rest of the mind-altering medications.
Is it going to get any better regarding the monitoring of
narcotics? Probably it will until all the heat dies down, the newpapers
get tired of the same story with a different twist, and the pressure
returns to keep costs low. There are problems inherent in the system
that impact on the way the narcotics are being prescribed. The
providers are saddled with stifling paperwork, regulations and rules
generated by persons who never treat patients, a computer system that
is cumbersome and not user friendly, and no ability to control
decisions that impact negatively on productivity.
Who ever heard of having a provider assigned to one exam room which
also functions as a medical office? When a provider wants to see the
next vet, he has to first change the paper of the exam table (maybe
even wipe it down first), and then walk down to hall to fetch the
patient. Five minutes wasted. The provider has to be a typist, a
transcriptionist, the person who enters each and every drug a veteran
receives from an outside physician in a labor-intensive fashion (it
would be too logical to have the screening nurse do this chore), the
one who enters each lab tests one by one (no clicking on panels for our
docs), the person who enters a detailed consult to specialists
(specialist who can decide to deny a consult based on how busy or
motivated they are), or perform the lengthy questionnaire prior to
entering an MRI (which a clerk could easily do).
The specialists also are the ones that are so pampered that they
can agree to a consult only if the provider enters the testing that the
specialist wants, that they will review, yet the provider has to take
time to enter tests as if they were the specialist's secretary. Then it
is up to the provider to make sure the vet attends the appointment. If
they don't make the appointment, it's still the provider's burden of
responsibility.
From the other side of the coin, as a disabled veteran I get
medical care from the Lebanon VAMC in Pennsylvania. Recently, I went to
see an ENT specialist for an ear infection causing hearing loss to the
point I couldn't hear with my stethyscope. The surgeon was rude,
refused to let me explain my problem in a succinct fashion, and instead
insisted that he first wanted to read my chart (perhaps he should have
done that before I entered the room for my 30 minute consult time slot
he insisted on having since I hadn't been seen in over a year by ENT).
After several minutes he rolled his chair over to the ENT (barber-like)
chair where I sat, spun the examination chair rapidly, reached up and
began to examine my right ear without having listened to what my new
complaint was. He inquired, ``So what is wrong with your right ear?'' I
explained that had he let me provide a history he might know I had a
recurring problem with both ears. The treatment as I already knew from
several such bouts, was to suction the residual debris from my ear
canals. As he rapidly and vigorously moved the suction device in my
ears he repetitively hurt me (he got too close to the ear drum). Every
time I would reflexively flinch and every time he would chastise me for
moving, regardless of the pain his less than gentle approach was
creating. The final insult was when he berated me for waiting so long
to come in (over a year), when in reality the problem have begun
abruptly over the prior week.
Prior to that episode, I went to a VA doc for a complaint of
feeling ill for a month, having symptoms of a kidney infection, and
being concerned about my health. This fill-in ex-Navy physician, sat
flipping through my thick paper chart (thick because the VA had all
sorts of records from the illnesses caused by Anthrax immunizations),
reached over and patted my hand, and asked, ``Did you ever think of
seeing a psychiatrist?''
A week later I was in the hospital with a mild stroke and a kidney
infection.
Another VA surgeon performed a colonoscopy on me, never explained
the procedure (doesn't matter than I am a physician), had me sign the
consent, and then never bothered to tell me after the procedure what he
did or didn't find. He just instructed the nurse to show me the photos
from the colonoscopy and tell me the results. He was much too important
as the Chief of Surgery to bother with mundane details.
Now if specialists treats me, a physician that way, how do they
treat the run of the mill veterans? I hear complaints like this all the
time about the insensitivity, the rushed consults, and the non-
professional behaviors of specialists on the VA payroll. Being the
sacred cows of the VA, they are untouchables.
Meanwhile, the provider is inundated with useless, repetitive
computer messages known as ``view alerts.'' No one seems to know how to
stop messages that tell us an appointment was made (we only need to
know if one wasn't made and why). Labs pop up as view alerts over and
over again, the same labs, multiple labs presented separately in
multiple view alerts, hundreds of view alerts. Then there are the
mandatory staff meetings, time wasted that could be addressed though
memos or e-mails. RN's aren't even allowed to enter unsigned orders to
assist providers in performing duties, or are not allowed to do tasks
within their scope of practice that could simplify the office
procedures (like entering the orders for the endless medication renewal
requests so that after reviewing the chart, the provider could more
quickly sign the orders) and free up the provider to see patients.
Some nurses refuse to help providers with phone calls. Some nurses,
like at Durham refused to do much to help the veterans. If I would ask
them to flush a veterans ears (a facility that actually allowed the
nurses to do this), they would answer that they needed to schedule an
appointment. It didn't matter that it was an elderly veteran who lived
a distance away. They were out of the office 12:00 sharp and out the
door at 4:30 come hell or high water, which the provider usually was
overcome by at the end of the day.
Don't expect that blood pressures listed in the charts are correct.
For a matter of convenience the VA purchased all these expensive
electronic BP machines that typically register higher than the true
resting BP. You will never find the BP entered for both arms as you
would in private practice, which is standard operating procedure for a
patient with hypertension. A difference in pressure could indicate a
blockage in one of the main arteries coming off the heart (this isn't
fantasy, I am a prime example of a subclavian blockage diagnosed only
because I insisted the BP be taken in both arms). The machines
automatically send the single BP to the electronic medical records, but
apparently they aren't set-up to manage two BP's. Therefore, if the
busy doctor wants a true reading he has to first scrounge around to
find a manual cuff, find one that actually works or has all the parts,
and then try to find a large cuff for the big arms. . . More wasted
time that physicians' could be using to think, to prevent disaster.
Yes, the VA physicians, nurse practitioners, and physician
assistants are expected to be the supermen and women of the VA, yet
have little input as to things that impact their day to day activities.
Yes, the providers are not properly screening veterans taking
narcotics, simply as a matter of sheer survival and keeping one's head
above water. Of course, it is their fault for putting up with the
system, not trying to change it, but be forewarned that those who do
speak up are likely to lose their jobs. People are rewarded for keeping
their opinions under the radar, their hands hog-tied, and their jaws
wired shut. Welcome to the world of the VA.
RECOMMENDATIONS REGARDING NARCOTIC PRESCRIPTION
1. Provide an intensive training course for prescribers of
narcotics that is done in-house, not on a video monitor that providers
can wander in and out of the training session ad lib (this was
witnessed at a recent Tele-training course held by Wilmington VAMC).
Provide written materials and references to all physicians, not merely
the ones who were able to attend the live training. The course should
be at the physician level, not watered down to include all personnel.
Separate training should be done for nurses and staff having roles that
intersect the provision of narcotics to veterans.
2. Educate the veterans on options for and benefits of pain control
with an emphasis on non-narcotic solutions.
a. For veterans currently on regular large doses of narcotics,
require mandatory attendance at educational seminars.
b. For veterans inappropriately prescribed or taking large amounts
of narcotics concurrently with or without other central nervous system
depressants, for veterans with a history of current or past substance
abuse, provide an in-patient residence program. This program should
promote healthy living concepts, introduce non-narcotic alternatives,
provide an independent medical examination (a second opinion) of their
pain complaints, and result in designing a comprehensive pain control
program with minimal narcotic usage.
c. Acknowledge alternative forms of care by making a dedicated
effort to provide such services.
1) Allow providers trained in alternative forms of care to deliver
these services (for instance, I am a licensed physician acupuncturist
and have not been allowed (in the last two years that I have been
licensed) by any VSN credentialing board to provide this service to
veterans in lieu of prescribing narcotics).
2) Pay for chiropractic services on a ``fee-basis'' program if a
chiropractor is not on staff. If not on staff, advertise and hire
enough necessary to deliver these services.
3) Allow the VA physical therapists (who now are required to have
Ph.D. degrees) to function as part of the pain management team and do
more than simply sending the veteran out the door with a list of home
exercises (Note: I also have been a licensed physical therapist for 40
years, with a Master's Degree as well!)
3. VA Pain Services should be directed by a full-time physician
with special training in Pain Management.
a. Physician Assistants (PA's) and Nurse Practitioners (NP's)
should not be the primary source of care in the Pain Management service
when a veteran is referred by other providers for evaluation of a
difficult pain management case.
b. Veterans managed by PA's and NP's should be evaluated on a
regular basis by the Pain Management physician
c. Veterans placed on significant doses of narcotics by the Pain
Service should not be allowed to transfer the prescription of these
narcotics to primary care providers simply because it is beneath the
dignity of the Pain Service to perform such mundane activities (this is
the role their extended care providers can address).
4. Physicians and extended care providers need to be responsible
for obtaining a complete pain history, performing a thorough
examination pertaining to each body part in pain, ordering appropriate
lab tests, studies (eg.,X-rays, MRI's, CT's) and consultations.
a. Adequate time needs to be dedicated to the investigation of the
pain complaint. This process is necessarily time-intensive and requires
an appointment not riddled with other issues or concerns. That is, the
session should not be part of a routine check-up for multiple medical
issues, during which time multiple medication prescriptions need to be
addressed and written, or when time is spent coordinating care with
multiple outside physicians (as is commonplace).
b. Measures need to be taken to assure that the persons prescribing
narcotics have proper training in physical assessment of
musculoskeletal conditions. Perhaps giving providers extra training
with the orthopedic service or on the pain service might be indicated.
c. Charts of veterans receiving narcotics should be randomly
reviewed by peers, or the pain service if requested, to determine
appropriateness of narcotic prescription.
d. Clinical Pharmacologists (Pharm D level) should also review
narcotic prescriptions for appropriateness, likelihood of drug
interactions (particularly in the presence of other mind-altering
drugs).
5. Dedicated monitoring should be required of all persons taking
narcotics (other than for a brief episode).
a. The urine drug (tox) screening process needs to be revised:
1) Veterans are familiar with criteria that military screening
entails (witnessed drug screens, emptying pockets, leaving personal
belongings out of the room)
2) Urine drugs screens needs to be both announced and unannounced,
regardless of suspicion for diversion or abuse.
3) The screening needs to be taken seriously by both the staff and
veteran. No excuses can be accepted when a request is made for
providing a specimen.
4) The specimen needs to be collected in a manner consistent with
accepted protocol, such as is used in pre-employment screening or post-
accident screening by industry. For example, the veteran shall not have
access to running water, the toilet water is dyed with a chemical
designed to foil surreptitious dippers, and specimen containers should
be specially designed for urine tox screening (such as to monitor pH
and temperature). The veteran must empty their pockets, leave
belongings outside the room, and preferably be monitored.
5) The issue of insufficient staffing must be addressed. This makes
another case for the prescription of narcotics to be managed by
providers at a facility equipped to properly monitor for drug misuse
and other substance abuse.
b. Unannounced pill counts need to be performed, even in veterans
not suspected of diversions or abuse, since no one can predict who will
be the guilty culprit.
c. Although signing of Pain Contracts is not proven to be much of a
deterrent, its use may serve to provide the veteran with the rules of
engagement and serve as a warning that certain behaviors will not be
tolerated.
d. The ``lost prescription'' story needs to be addressed up front.
Veterans need to know they are responsible for keeping their controlled
substances in a safe place.
e. The business of providing `bogus' police reports as evidence of
theft should be addressed initially upon signing the pain contract.
f. The practice of allowing veterans to ``slip-up'' and have a
dirty urine should not be tolerated. These veterans should immediately
be referred to Pain Management or a Suboxone program.
6. Safety issues need to be addressed regarding veterans who are
prescribed narcotics, particularly when in combination with other
centrally acting depressants or mind-altering drugs.
a. Veterans who are on other mind-altering drugs are at increased
risk of accidental overdose and unwanted side effects.
b. Psychiatry should be responsible for assessing the
appropriateness of all the mental health medications, particularly if
narcotics are being prescribed.
c. Veterans should be offered alternative treatments for mental
health disorders, including sleep problems and PTSD, such as intensive
counseling programs and holistic approaches (relaxation exercises,
melatonin, Herbals, acupuncture).
d. Pharm.D. pharmacists should also routinely earmark cases
involving potentially interacting or additive medications for review on
an on-going list.
e. A master list of each provider's narcotic patients should be
maintained and accessible to both provider and those engaged in
monitoring.
f. The state's narcotic data banks should be routinely accessed by
either the provider or preferably the Pharm. D. This practice should be
encouraged, since it is infrequently performed by busy providers who
are currently expected to be a revolving door for veteran health care.
By querying the data bank, veterans who doctor shop for narcotics can
easily be spotted. For instance, earlier this year I discovered a vet
that had been to 10 different providers who had written for narcotics
for this vet between January and June.
g. There should be a nationwide central clearing house to which
states be mandated to report all persons obtaining narcotic
prescriptions. This data bank should be accessible to anyone providing
an ongoing regimen of narcotics to an individual.
7. Safety issues need to be addressed regarding the persons who
prescribe, interact and provide services related to the prescriptions
of drugs.
a. Security at Community Based Outpatient Clinics (CBOC's) is non-
existent. Some CBOC's have a system to silently alert the staff to a
situation, but the keyboard must be accessible. Some CBOC's have silent
alarms under the provider's desks, that go to the central office's
police station. By the time local police are notified and arrive, the
situations has either resolved or had an adverse outcome.
b. Providers and staff are at increased risk of harm by disgruntled
veterans - veterans who have problems with anger management, PTSD,
anxiety, depression, and whose thought processes are chemically
challenged by a cocktail of prescribed and possibly unprescribed
substances. These veterans who have suffered unimaginable situations
during their service to our country often lack the coping mechanisms,
the internal restraints, or even the normal problem solving
capabilities a non-medicated, mentally together individual would
normally display.
c. Staff members have been assaulted, some killed, by veterans
angry with care, whose demands are not met, or have been refused
narcotic prescriptions.
1) In Jackson, Missippi about 10 years ago a physician was shot and
killed by a veteran who was denied pain medication.
2) Again in Jackson, two or three years ago a doctor had acid
thrown in her face because a veteran was dissatisfied.
3) In Maine, a veteran reportedly became angry recently with not
getting narcotics and ran his car into the side of their new CBOC
building.
4) Another veteran angry about not getting his narcotics presented
to the `mother ship' in Maine reportedly hunting for the administrator
to shoot. Instead, he was confronted by the police and a ``suicide by
cop'' incident occurred.
5) Not long ago in Delaware two psychiatrists were reportedly
attacked by a patient (it is rumored that both physicians have left the
system)
5) I was told by a Phoenix VAMC staff member at the VA Intermin
Staffing Program when I complained about concerns as to my safety while
at Jackson, that this is not uncommon and a provider had been shot at
the Phoenix VAMC.
6) The magnitude of the risk cannot be assessed since these
statistics, if kept, are not available to staff.
7) Staff are not allowed to carry or have access to any type of
protective device, such as a TASER or Mace. Instead, we are given silly
little learning modules instructing us how to speak, act, or move to
theoretically defuse volatile situations. One time I was forced to
suggest that the all-female staff might grab the fire extinguisher to
spray any violent perpetrator.
8) When potentially violent veterans or those who are known to have
a history of violence or aggressive behavior directed against staff are
identified, little effort on the part of administration is made to
ensure the safety of staff. A complaint must be made to the
``Disruptive Behavior Committee'' after the fact, who will then decide
on the final disposition of the complaint. The perception of the staff
who were threatened or attacked seems to be overshadowed by the
veterans ``rights'', of which there seem to be more of than the staff's
rights when it comes to safety.
9) Often the vet will simply be reassigned to another provider at
the facility, even though the vet will be coming into contact with the
disparaged staff members.
10) The most potentially violent vets are as a last resort required
to present for care at a VA hospital where a guard must be assigned to
the veteran. In a remote CBOC this is not an option.
11) Even the provider asking the staff to call the local Police to
stand-by during an encounter is met with administrative objections and
this action has to be approved by someone who has no medical
background, direct knowledge of the situation, and nothing to suffer if
a veteran loses control.
12) In summary, the staff's concerns about potentially violent
persons in the workplace needs to be honored with swift action designed
to lessen the risk to staff.
9. One life lost is too many on either side of the coin.
GENERAL RECOMMENDATIONS
1. Complete reorganization of the VA Health Care System,
eliminating the ``top heavy'' emphasis of the current organizational
scheme.
2. Elimination of bonuses paid to administrators at various levels
that provide incentive to provide the cheapest medical care, and NOT
provide the most effective strategies for medical services, including
pain management
3. Across the board ``retirement'' of administrators who have been
shuffled to other facilities in the face of controversy, as pawns in a
real life ``shell game'' that merely transposes problem administrators,
and whitewashes solutions to problems that threaten the health of
veterans.
4. Return the baton of health care administration to the realm of
those trained in medicine - the physicians, nurses, extended care
providers, and personnel in other medical specialties. Eliminate
policies that allow non-medical personnel, including those without
college education and no medical background, to oversee and implement
policies that directly impact medical professionals.
5. Identify, address, and eliminate the rules and regulations that
have restricted the ability of medical professionals to practice their
profession according to the highest (not the cheapest) standards,
including making medical decisions that impact upon the quality of
health care, within the scope of their medical licenses.
6. Upgrade the computer system used by the VA - the sacred tail
that wags the dog. Implement user-friendly touch screens on portable
lap-tops, making the providers more efficient and mobile. Field-test
programs and changes with users/providers who don't live in a world of
techno-gobblygook, instead of just adding layers of patches and
illogical, inefficient steps designed by IT (information technology)
geeks that do not consult or care to consult with the providers who are
slowed by laborious and unnecessary steps in documentation. The system
should be provider-driven for purposes of accurate, efficient note-
keeping to direct medical care with the least amount of burden, not
administrator-focused for the purposes of forcing provision of data to
be used for purposes that shed a positive light on the top dogs and
their potential bonuses.
7. Return the provision of medical care to the realm of physicians,
who by nature of their extensive education and training, are the ones
who not only know what constitutes quality care, but should be allowed
to see to it that this care is provided to our veterans. Do not mistake
the concept of quality medical care as being the cheapest care that can
be provided to the masses.
8. Analyze the VA sanctioned indicators of quality care and
determine if the measures used are merely ways to polish statistics to
make the upper echelon appear to be the shining knights of the VA
dynasty.
9. Allow extended care providers, nurse practitioners and physician
assistants, to practice according to their own practice acts. Do not
allow the VA to rewrite their job descriptions based on administrators'
perceived ability to provide equivalent primary care, which equates to
merely ``adequate'' health care (most of the time for non-complex
cases) at a cheaper cost. Allow the physicians to follow the more
medically complex cases, including oversight of all the pain management
cases, and allow the extended care providers to do the routine nuts and
bolts daily medical services. Currently the system is flip-flopped,
with the NP's and PA's having smaller panels of patients than the
physicians, who are expected to manage much larger panels, thus having
less time to contemplate or effectively manage their clients
complicated medical issues. Consequently, there is not even time to
supervise or consult of the cases handled by extended care providers
who largely function independently at the VA. Basically, the simpler
cases should be handled by extended care providers and the more complex
ones managed by physicians who should be given more time with these
difficult cases.
10. Reverse the trend to replace physicians with cheaper extended
care providers. Realign the team units to be directed by a physician
who oversees that team's nurses and extended care providers along with
ancillary staff. Currently the physicians are powerless due to the
dictates of the administrative burdens. Implement methods to simplify
and expedite day to day practices which historically have to pass
through several layers of administration who jockey for control.
11. Recognize that the heart and soul of the medical team is
composed of the providers of medical care. The current PACT approach
(Patient Aligned Care Team) is based on a belief that the patient sits
atop the health care team pyramid, when, in fact, the veterans are
partners with the providers of medical care. The back to basics
approach is based on the notion that the health care team is there to
provide the best and most efficient care to the veteran, but the
veteran does not have ownership of that team. The concept promulgated
by the VA known as ``Pain as the 5th Vital Sign'' and that pain must be
addressed regardless of other medical issues, is evidence of how
terribly wrong a well-meaning system can become when care is driven by
administrative demands and unreasonable expectations.
12. Return specialty care to the domain of physician specialists.
Currently, many nurse practitioners and physician assistants perform
specialty consults without physician intervention. The extended
caregivers do not have equivalent training, their specialty training
being largely on-the-job training. If there are not enough specialists,
such as dermatologists and ENT physicians, contract the services out to
medical experts and don't rely on cheap substitutes.
13. Address the problem with the National VA Formulary being so
restrictive, loaded with cheap generics and limited drug choices in
various categories. Currently each VSN's pharmacy decides which drugs
they will supply, which is based on cost-saving practices that allow
chiefs to obtain monetary rewards for limiting costs. Pharmacists are
the persons currently making decisions about medical necessity of non-
formulary medications, often basing their decisions on studies that
they are instructed to quote to justify their sometimes inappropriate
denials or decisions. Return physicians to the front-line of drug-
prescribing. Make the facilities publish the medication lists on-line
so the providers of medical care will know what drugs are available per
category and veterans will know the limitations of the formulary.
Currently, it is impossible to get the VSN pharmacy to print a list of
drugs they authorize as ``formulary'' - their rationale being the list
changes daily, which in this day and age of computers is a particularly
feeble excuse. This practice really equates to a veiled attempt by
cost-cutters to maintain a wall of secrecy and whose practices are
designed to exert control over providers.
14. Emphasize non-medicinal oriented approach to health care
instead of focusing on which little pill can relieve a problem, and
address what the veteran can do to help himself.
a. Do group visits for problems such as weight loss or chronic
medical problems requiring education such as diabetes, hypertension,
and hyperlipidemia - the `Big Three' problems making up the nemesis of
the VA.
b. Introduce alternative medicine approaches to be realistic
options to facilities, such as acupuncture, chiropractic, massage, Tai
Chi, and other such ``mindfulness'' oriented care.
c. Allow physical therapists to return to hands-on activities, not
being forced by time constraints to be mere machine jockeys or mere
distributors of exercises to do at home.
d. Allow physicians who are trained or to be trained in acupuncture
and to utilize it according to the principles of established practice
within their daily practices.
15. Address Poly-Pharmacy as a real problem with potentially real-
life serious consequences. Realize the current system of ``medicine
reconciliation,'' no matter how well-intentioned, just isn't working.
People are over-medicated because medication is cheaper than
alternatives, less labor-intensive than a provider explaining rationale
and alternatives (which are currently limited), and reinforced by the
revolving door mentality (get them in and out as quickly as possible).
Acknowledge that by farming out much care to inaccessible specialists
(often due to limitation of training and experience by extended care
providers), there is no one who truly is ``Captain of the Ship'' - the
role primary care physicians were designed to fulfill. Medications are
added to already long lists of medications willy-nilly, with computer-
generated reminders of ``poly-pharmacy'' and warnings of potentially
serious interactions often being ignored.
16. Identify true measures of quality care instead of relying on
surrogates that are designed to make an administrator's fiscal bottom
line look good and perhaps contribute to his bonus. For instance, the
current system rewards a provider based on whether they complete the
computer-generated ``Reminders'' on-time or if they do the billing
correctly and promptly, or do the endless and repetitive computer
education modules on time (assigned by some well-intentioned
administrator at the top who is far-removed from patient care). This
says nothing about quality. Ignoring the fact that the veterans
complaints have not been completely addressed, or all the interacting
medical conditions were not taken into consideration, or that the
physicians'documentations of encounters are worse than a beginning
medical student's. These are examples of practices destined to result
in harm to a veteran in the form of mistakes, misdiagnoses, delay of
care, and adverse reactions, any of which could be life-threatening.
17. Return to Basics, providing all aspects of primary care at
offices and eliminating unnecessary consultations of specialists and
stopping the practice of making veterans travel distances for care
within the boundaries of primary care.
A. Allow offices to perform simple point of care testing:
1. Ability to perform finger stick blood sugars (a test which is
readily done in the home by patients but is not allowed in offices due
to lack of common sense by the administrators and lack of guidelines
defining these simple office procedures).
2. Ability to perform finger stick INR's in the office to
facilitate in-office management of anticoagulation
3. Ability to do simple hemoccult testing (stool for Blood) in the
office (CLIA waved testing) by nurses and providers without being
subjected to onerous & ridiculous regulations that defy common sense.
4. Ability to use specially designed urine tox screen containers
when obtaining specimens (for example, Monitor pH and temperature of
urine)
B. Allow physicians, NP's and PA's to practice according to their
training:
1. Provide necessary supplies for performing simple procedures,
such as performing biopsies of suspicious skin lesions, minor
laceration repair so that veterans do not have to wait unnecessarily
long times for appointments with specialists and have to travel
unnecessarily for procedures that can be office-based.
2. Train and accommodate providers who desire to do Joint
injections, trigger point injections, or other simple procedures
3. Permit physicians who are trained in alternative medicine
techniques to practice their skills (such as herbal therapy,
acupuncture, manipulation). Develop an environment of support for
providers who chose to use non-pharmacological approaches as part of
their practices. Provide additional funding for training in alternative
medicine.
C. Allow nurses to perform simple procedures they are trained to do
without being hog-tied by regulations.
For example:
1. Perform screening and removal of cerumen (ear wax) from veterans
to eliminate referral to specialists and not make the veteran wait for
care or have to travel long distances to the VA hospitals.
2. Allow nurses to follow a predetermined policy for monitoring INR
test results to facilitate anti-coagulation (which many elderly vets
are on).
3. Allow nurses to remove sutures so vets do not have to
unnecessarily travel long distances to specialists
4. Allow RN's to function as valuable team members, and provide
medical technologists for drawing blood and obtaining and recording
vital signs.
Do not put LPN's in medical technologist positions or fail to
recognize their training prepares them to do more than most facilities
are allowing (the problem is that there appears to be an emphasis on
hiring more highly paid RN's and not using less expensive LPN's who can
do most of what an out-patient office requires of nurses). Encourage
the RN's to do more patient-oriented services, such as patient
education.
18. Encourage providers to attend outside the VA medical education
courses to learn the most up-to-date practices:
a. Provide ample education funds sufficient to attend at least one
extensive medical review course per year (currently the VA only pays
$1000 per provider per year, which is a fraction of what non-VA
providers are offered and does not cover the cost of a decent course).
b. Take the funding from the reported lavish junkets the
administrators have sent themselves on in recent years and subsidize
education, which will ultimately benefit veterans.
19. Eliminate waste at all levels. For example:
a. VSN administrator being paid a $63,000 bonus for quality care
when the facility had a Legionnaire's outbreak.
b. The Department of Veterans Affairs purchased pictures to spend
leftover fiscal year dollars for $562,000 (per the Washington Post)when
the veterans themselves would gladly have contributed veteran-made
artwork for free (Washington Post).
c. One facility purchased about 8 large flat-screen new televisions
that were hung in the cafeteria which were not used as TV's but to
flash a display of photos scanned repetitively, which supposedly were
designed to calm the staff.
d. Eliminate blocking out an hour each week for an entire staff
meeting, which takes providers away from patient care, and
inefficiently transmitting information that could be passed-on by e-
mail memos.
e. Eliminate indiscriminate purchase of expensive tele-health
monitoring equipment which appears to be a priority over basic
essentials such as decent suture removal kits, cerumen removal
supplies, glucometers, point of care INR testing devices, minor
surgical equipment, and liquid nitrogen.
f. One facility purchased off-brand wall mounted otoscopes for
their new office (which likely were deemed more cost-effective by a
bean-counter), but failed to realize that the standard otoscope tips
don't fit the cheap knock-offs. To use them, the provider has to
perform an exercise in finger dexterity, which slows the examination
process.
g. One New Jersey new CBOC facility was supposed to have a
temperature-controlled room to store medications (which was never set-
up as planned). Consequently, when temperatures soared in the office
above the safe level, several thousand dollars' worth of medications
had to be destroyed. When the nurse manager returned these to the
pharmacy, a non-clinical administrative worker (with no medical
training) berated the nurse for doing her job and attempting to prevent
veterans from being given compromised medications.
h. Employees from multiple facilities complain about the
inefficient and wasteful system for obtaining ID badges. This usually
amounts to each employee making multiple trips to the VSN headquarters
(aka the `mother ship') information technology (IT) department when
getting an ID badge. These appointments are tightly controlled by the
IT staff, who make appointments for their convenience and not
necessarily the convenience or needs of employees.
Furthermore, often the system is ``down'', or if working, it can
take hours of waiting to print one ID card. This process occurs after
the employee is again finger printed (if it has been more than 3-6
months since the last badge was issued) - another time-consuming and
expensive proposition). Several employees report driving 4-5 hours one-
way from their CBOC (Community Based Out-Patient Clinic) only to be
told they must return again and again-some as often as 5 times to
obtain the sacred ``PIV'' ID badge. This badge designed is to travel
with the employee from facility to facility, yet the various IT
departments inappropriately inactivate the badges. This can become a
costly process. For example, for each of the 70 doctors and extended
care providers now in the VA Interim Staffing locums department, that
means with each of 3-4 assignments per year there is a good likelihood
that this process of wasted work days and IT employee hours will be
repeated over and over again at a cost not even factored in to the
scheme of things. No one is counting lost productivity, the cost of
travel back and forth, and how this contributes to waste and
interruption of care.
Curiously, this inept system has found me going to five different
IT departments, making several trips at each facility resulting in a
significant amount of time away from treating veterans.
This also means that five times I've been fingerprinted and my
fingerprints run through the FBI system (or whoever checks our status).
At what cost is this?
Does anyone do anything? Does anyone care?
i. Another gross waste is the time and money spent by each VA
facility's credentialing department. Of the now seventy physicians
(previously ninety) who are part of the VA traveling physician corps
(now called VA Interim Staffing), each physician has to be ``re-
credentialed'' for each VA assignment. If each physician does three
assignments per year that is 210 times per year references have to be
contacted, 210 times per year the National Practitioner Data Bank is
queried (not an insignificant cost for each query), and 210 times a
huge number of staff have to track down the same information (all
physicians and extended care providers) are initially credentialed upon
hire).
The simple solution is for the VA Central Office (VACO) to issue a
mandate that physicians or other `providers' employed by the VA can be
credentialed on a temporary basis at a facility that has an emergency
need for staffing based on credentials from the parent facility. This
loss of money had been going on during the over four years of this
program's existence in spite of numerous complaints by providers.
20. Make it easier to remove employees who are consistently not
performing according to job standards.
a. Do not allow the practice of moving administrators around the VA
system, relocating them in a secret ``shell game'' to other VSN's
(divisions)when performance has come into question.
b. Do not allow investigations to drag on through committee inertia
or inability to take a stand on cases of abuse, or fraud.
One noteworthy case in New England involved a physician assistant
accused of fraudulent medical records, poor work ethic, failure
physically examine patients, and failure to monitor narcotics (some of
the reported charges). At last report, the investigation was now into
at least the 8th month, while the provider received full pay while on
administrative leave (and reportedly also working in an ER at a local
hospital outside the VA).
21. The VA is experiencing shortages of provider, which is at the
core of the problems surrounding the VA, yet a program that was helping
short-staffed facilities is in serious jeopardy.
a. The VA has its own corps of traveling physicians (some PA's),
initially a great idea for getting temporary emergency medical coverage
for VA facilities that needed providers to help deliver medical care to
veterans who would otherwise go untreated.
b. Now due to micromanaging by the upper echelon and an emphasis on
cost containment, the number of providers dropped from 90 to about 70,
the focus is on cost-cutting, and the program now hires only part-time
people who do not get benefits.
c. The VA Intermin Staffing Program now charges facilities, so
there was a dramatic drop in the number of facilities requesting a VA
locums provider (from well over a hundred facilities to about twenty).
d. So what happens to the vets because facilities do not have it
budgeted to supply providers when short-staffed? They don't get care,
or they are shuffled to another on-staff provider who already doesn't
have the time to manage his/her panel. This contributes to the problem
with failure to adequately manage pain medications.
e. What does the VACO offer as a solution to our program? Of
course, hire another supervisor, an expensive Director of the VA
Intermin Staffing Program. Great credentials, but did he ever do locums
work? The program can't afford to keep trained, readily available
physicians on their payroll, but they can add another layer of
administration. A s I mentioned previously, the system is far too top
heavy and bogged down with committees that govern committees, and rules
that sustain committees.
God Save Our Veterans! Apparently, no one else can.
Prepared Statement of Dr. Steven G. Scott, M.D.
Good morning, Chairman Benishek, Ranking Member Brownley and
Members of the Committee. Thank you for the opportunity to participate
in this oversight hearing and to discuss specifically the Department of
Veterans Affairs' (VA) James A. Haley Veterans' Hospital's Chronic Pain
Rehabilitation Program (CPRP) that treats Veterans experiencing acute
and chronic pain.
For many individuals, chronic pain is much more than a lingering
medical problem. It is instead a pervasive, unrelenting, and serious
condition that affects every area of an individual's life including
their mental health, physical health, family life, vocation,
friendships, and even sleep. For these individuals, chronic pain is an
unending daily battle where pain assumes command. Even the most
rudimentary daily decisions - whether to go shopping; attend a medical
appointment; see a friend - are based not on the individual's
preferences, but instead on their level of pain. We call this
constellation of pain related problems a ``Chronic Pain Syndrome'' or
CPS. Estimates are that more than 25 percent of adults with chronic
pain also have symptoms of CPS, and while pain may have been the cause
of these problems, there is evidence that once established, these
related problems linger even if the underlying pain is substantially
reduced.
Unfortunately, many individuals with CPS attempt to fight these
problems using increasing amounts of opioid analgesics. But, these
efforts are rarely successful. Due to the complexity of CPS, no single
treatment approach is the answer. A multi-disciplinary and multi-
modality approach is almost always necessary.
CHRONIC PAIN REHABILITIATION PROGRAM OVERVIEW
The James A. Haley Veterans' Hospital and Clinics in Tampa, Florida
have both an inpatient and outpatient Chronic Pain Rehabilitation
Program (CPRP). The Haley Veterans' Hospital has the only VA inpatient
CPRP. The CPRP was designed to specifically treat Veterans and active
duty military personnel with chronic pain syndrome (CPS). The CPRP is
an evidence-based, intensive, interdisciplinary, 19-day inpatient
chronic pain treatment program that targets not only pain intensity,
but also all of the accompanying symptoms of CPS. The core philosophy
of the CPRP recognizes the complex interactions between
pathophysiological, emotional, social, perceptual, cultural, and
situational components of chronic pain.
The CPRP teaches pain self-management practices where participants
assume responsibility for their daily functioning and learn to actively
manage their pain. For most participants this includes increasing their
level of independent functioning, increasing activity levels, reducing
the emotional distress associated with chronic pain, eliminating
reliance on opioid analgesics and/or muscle relaxants, reducing pain
intensity, improving marital, familial and social relationships,
increasing vocational and recreational opportunities, and improving
overall quality of life.
One of the unique aspects of the program is that all participants
taking opioid analgesics at admission are tapered off these medications
during the course of treatment. This practice began in 1988 when CPRP
was established, and continues today. We do this because opioids
essentially have no positive effects for this group of patients.
Eliminating opioids for this group of individuals does not increase
their pain nor increase their daily impairment. In fact, we have found
that eliminating opioid reliance has virtually no effect on treatment
outcomes. Individuals who discontinue these medications during
treatment improve, as much or more than those who were not using opioid
analgesics at admission \1\.
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\1\ Murphy J, Clark M, Banou E,. Opioid Cessation and
Multidimensional Outcomes After Interdisciplinary Chronic Pain
Treatment. Clin J Pain 2013;29:109-117.
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CPRP TREATMENT COMPONENTS
The CPRP uses a variety of strategies to enhance self-management
skills, increase activity, and reduce pain. These include daily goal-
directed programs of individualized exercises, walking, pool therapy,
occupational therapy, relaxation training, medical management,
recreational therapy, and educational classes. Much of the skill
enhancement and self-management training is provided by pain
psychologists who serve as rehabilitation coaches and use individual
cognitive and behavioral therapy techniques to reduce emotional
distress, encourage self-reliance, enhance pain management skills and
promote healthy lifestyles. Family members are involved in treatment
when available and prior to discharge participants develop a plan of
continued rehabilitation that can be implemented at home.
The typical participant in the CPRP is a male or female Veteran in
their late 40s who has been fighting pain constantly for the last 15
years on average. They have tried virtually every known treatment,
ranging from surgery to multiple medications or injections, and out of
desperation may have become victims of a variety of pseudo treatments
promising total pain relief at substantial individual cost. They are
depressed, irritable, anxious and often angry with the medical
establishment that they feel has failed them. Marital and family
problems abound, separation or divorce is common, and friendships have
dissolved. Typically they are unemployed or disabled and face a variety
of financial challenges or crises. Many may misuse prescribed
medications, alcohol, or other substances to try to cope. Although this
cycle began with a single distinct pain, they now experience multiple
pain problems many of which can develop or intensify due to their
sedentary lifestyle and prolonged stress.
These same individuals, when offered hope, compassionate treatment,
and the camaraderie of others in similar circumstances typically
demonstrate remarkable improvements and resiliency during this 19-day
inpatient program. When we used standardized measures to asses these
changes, we see the following outcomes: reductions in pain severity,
improvements in mood and sleep; increased strength, flexibility, and
endurance; enhanced engagement with life and families; significant
weight loss; and, increased confidence in their abilities to manage
their lives despite elimination of opioid analgesics and other
potentially harmful medications. \2\ What we find after this treatment
are individuals who are now laughing instead of frowning, seeking out
contact with others instead of avoiding, and who are proud about their
accomplishments. It is not rare to observe individuals who entered the
program reliant on wheelchairs, walk out the door unaided at discharge.
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\2\ Murphy J, et al (2013).
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CPRP RECOGNITION
In the CPRP's 25 years of existence, the program and its staff have
received numerous accolades and awards. The CPRP has been recognized as
a two-time Clinical Center of Excellence by the American Pain Society.
The CPRP is one of only two programs that has twice won this
prestigious award, the other being a program at Stanford University.
The program has also received the prestigious Secretary of Veterans
Affairs Olin E. Teague Award for clinical excellence and been
accredited six times by the Commission on Accreditation of
Rehabilitation Facilities (CARF). CPRP leaders have been actively
involved in promoting system-wide enhancements in VA pain care,
particularly for Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn Veterans suffering from chronic pain in combination
with other significant physical and emotional co-morbidities. As the
most specialized chronic inpatient pain treatment option in the VA
health care system, the program accepts referrals from all 50 states,
Puerto Rico and the US Virgin Islands.
In 2009, the CPRP was selected to serve as the VA's national
training site for interdisciplinary pain programs. Thirty teams from
across the country have visited the James A. Haley Veterans' Hospital
to observe the model system and learn how to enhance pain treatment
services at their facilities. The training program has focused on
helping these teams develop tertiary level, CARF-accredited pain
programs in order to help meet the 2009 Veterans Health Administration
Pain Management Directive 2009-053 mandating an interdisciplinary CARF
option in each Veterans Integrated Support Network. The positive
effects of these trainings are manifest by the increase from 2 CARF-
accredited programs in 2009, both in the same VISN, to 8 CARF
accredited programs in the VHA in 2013; 14 other VHA facilities are
presently applying for CARF accreditation for a developed program or in
the process of developing a CPRP with the intention of applying for
CARF accreditation.
Conclusion
Mr. Chairman, VA is committed to providing the high quality of care
that our Veterans have earned and deserve. I appreciate the opportunity
to appear before you today to discuss the James A. Haley Veterans'
Hospital's Chronic Pain Rehabilitation Program, and I am grateful for
your support and encouragement in identifying and resolving challenges
as we find new ways to care for Veterans. I am prepared to respond to
any questions you may have.
Prepared Statement of Dr. Robert L. Jesse, M.D.
Good morning, Chairman Benishek, Ranking Member Brownley and
Members of the Committee. Thank you for the opportunity to participate
in this oversight hearing and to discuss the Department of Veterans
Affairs' (VA) pain management programs and the use of medications,
particularly opioids, to treat Veterans experiencing acute and chronic
pain. I am accompanied today by Dr. Robert Kerns, VA National Director
for Pain Research, Veterans Health Administration.
The issues related to pain and pain management are by no means
exclusive to VA. As described in the 2011 Institute of Medicine (IOM)
report, ``Relieving Pain in America: A Blueprint for Transforming
Prevention, Care, Education, and Research'' \1\, pain is a public
health challenge that affects millions of Americans and is rising in
prevalence. Pain contributes to national rates of morbidity, mortality,
and disability and there are costs of pain both on the toll it takes on
people's lives and economically. The IOM estimated that chronic pain
alone affects 100 million United States citizens and that the cost of
pain in the United States is at least $560-635 billion each year, which
is the combined cost of lost productivity and the incremental cost of
healthcare.
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\1\ Institute of Medicine. 2011. Relieving Pain in America: A
Blueprint for Transforming Pain Prevention, Care, Education and
Research. Washington, D.C.: The National Academies Press.
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Studies show more than 50 percent of all Veterans enrolled and
receiving care at VHA are affected by chronic pain, which is a much
higher rate than in the general adult population. That makes pain
management a very important clinical issue for VA. My testimony today
will focus on how VA is providing comprehensive and patient-centered
pain management services to improve the health of Veterans. The
statement will highlight VA's current pain management strategies, the
prevalence and use of opioid therapy to manage chronic pain in high
risk veterans, the challenges of prescription drug diversion \2\ and
abuse among Veterans, and the actions VA is taking to improve the
management of chronic pain, including the safe use of opioid
analgesics, and the use of best practices across the VA health care
system.
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\2\ Diversion is the use of prescription drugs for recreational
purposes.
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Prescription Drug Diversion and Abuse Challenges
Opioid analgesics may help many patients manage their severe pain
when other medications and modalities are ineffective or are only
partially effective. However, there may be risks to both individual
patients as well as to the surrounding community when these agents are
not prescribed or used appropriately. VA has embarked on a two pronged
approach to addressing the challenge of prescription drug diversion and
abuse among Veteran patients.
One approach is to improve the education and training in pain
management and safe opioid prescribing for clinicians and the
interdisciplinary teams that provide pain management care for Veterans.
A complementary approach involves improving risk management through two
systems initiatives. The first system initiative, the Opioid Safety
Initiative, employs the tremendous advantages of VHA's electronic
health record. This system-wide initiative identifies patients with one
or a combination of risk factors, for example, high doses of opioids
and opioids combined with sedatives to identify providers whose
prescribing practices are misaligned with medical evidence/strong
practices and to provide counseling, education and support for them to
improve their care of Veterans with pain.
The second system-wide risk management approach to support the
Veterans' and public's safety is promulgation of new regulations that
enable VHA to participate in state Prescription Drug Monitoring
Programs (PDMP). These programs, featuring appropriate health privacy
protections, allow for the interaction between VA and state databases,
so that providers in either can view electronic information about
opioid prescriptions and be able to identify potentially vulnerable at-
risk individuals. PDMPs can provide information to VA on prescribing
and dispensing of controlled substances to Veterans outside the VA
health care system. Participation in PDMPs will enable providers to
identify patients who have received non-VA prescriptions for controlled
substances, which in turn offers greater opportunity to discuss the
effectiveness of these non-VA prescriptions in treating their pain or
symptoms. More importantly, information that can be gathered through
these programs will help both VA and private providers to prevent harm
to patients that could occur if the provider was unaware that a
controlled substance medication had been prescribed elsewhere already.
Current VA Pain Management Strategies
Chronic Pain in Veterans
The burden of pain on the Veteran population is considerable. We
know that Veterans have much higher rates of chronic pain than the
general population. \3\ Chronic pain is the most common medical problem
in Veterans returning from the last decade of conflict (almost 60
percent). \4\ Many of these Veterans have survived serious, even
extreme, injuries often associated with road-side bombs and other blast
injuries. These events can cause damage to multiple bodily sites
including amputations and spinal cord injuries. These Veterans also
survived severe psychological trauma associated with exposure to the
horrors of war on the battlefield. Many Veterans require a combination
of strategies for the effective management of pain, including treatment
with opioid analgesics, which are known to be effective for at least
partially relieving pain caused by many different medical conditions
and injuries. In 2010, VA and the Department of Defense (DoD) published
evidence-based Clinical Practice Guidelines for the use of chronic
opioid therapy in chronic pain. The guidelines reserve the use of
chronic opioids for patients with moderate to severe pain who have not
responded to, or responded only partially to, clinically indicated,
evidence-based pain management strategies of lower risk, and who also
may benefit from a trial of opioids to improve pain control in the
service of improving function and quality of life.
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\3\ Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L.
(2006). Pain among veterans of Operations Enduring Freedom and Iraqi
Freedom. Pain Medicine, 7, 339-343.
\4\ Veterans Health Administration (2013). Analysis of VA health
care utilization among Operation Enduring Freedom (OEF), Operation
Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. Washington,
DC: Department of Veterans Affairs.
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We also know that the long-term use of opioids is associated with
significant risks, particularly in vulnerable individuals, such as
Veterans with Post-Traumatic Stress Disorder (PTSD), depression,
Traumatic Brain Injury (TBI) and family stress - all common in Veterans
returning from the battlefield, and in Veterans with addiction
disorders. Chronic pain in Veterans is often accompanied by co-morbid
mental health conditions (up to 50 percent in some cohorts) caused by
the psychological trauma of war, as well as neurological disorders,
such as TBI caused by blast and concussion injuries. In fact, one study
documented that more that 40 percent of Veterans admitted to a
polytrauma unit in VHA suffered all three conditions together - chronic
pain, PTSD, and post-concussive syndrome. \5\
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\5\ Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., &
Cifu, D.X. (2009). Prevalence of chronic pain, posttraumatic stress
disorder, and post-concussive syndrome in OEF/OIF veterans: The
polytrauma clinical triad. Journal of Rehabilitation Research and
Development, 46, 697-702.
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In addition to these newly injured Veterans suffering from chronic
pain conditions and neuropsychological conditions, VA cares for
millions of Veterans from earlier conflicts, who along with chronic
pain and psychological conditions resulting from their earlier war
injuries, are now developing the many diseases of aging, such as
cancer, neuropathies, spinal disease, and arthritis, which cause
chronic, often terrible pain. All these Veterans also deserve
appropriate pain care, including, when indicated, the safe use of
opioid analgesics.
VA cares for a Veteran population that suffers much higher rates of
chronic pain than the civilian population, and also experiences much
higher rates of co-morbidities (PTSD, depression, TBI) and
socioeconomic dynamics (family stress, disability, joblessness) that
contribute to the complexity and challenges of pain management with
opioids. \6\ Because more Veterans have the kind of severe and
disabling pain conditions that require stronger treatments such as
opioids, more of them have risks for overdose due to depression, PTSD
and addiction.
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\6\ See citations 3 and 4.
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In recognition of the seriousness of the impact of chronic pain on
our Veterans' health and quality of life, VHA was among one of the
first health systems in the country to establish a strong policy on
chronic pain management and to implement a system-wide approach to
addressing the risks of opioid analgesia. Our approach is outlined
below.
VA National Pain Management Strategy and VHA Pain Management Directive
As part of the VA's National Pain Management Strategy, \7\ VHA Pain
Management Directive 2009-053 \8\ was published in October 2009 to
provide uniform guidelines and procedures for providing pain management
care. These include standards for pain assessment and treatment,
including use of opioid therapy when appropriate, for evaluation of
outcomes and quality of pain management, and for clinician competence
and expertise in pain management. Since publication of the Pain
Management Directive, a dissemination and implementation plan has been
enacted that supports the following:
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\7\ The overall objective of the national strategy is to develop a
comprehensive, multicultural, integrated, system-wide approach pain
management that reduces pain and suffering and improves quality of life
for Veterans experiencing acute and chronic pain associated with a wide
range of injuries and illnesses, including terminal illness.
\8\ www.va.gov/vhapublications/viewpublication.asp?pub--id=2781
Comprehensive staffing and training plans for providers
and staff;
Comprehensive patient/family education plans to empower
Veterans in pain management;
Development of new tools and resources to support the
pain management strategy, and
Enhanced efforts to strengthen communication between VA's
Central Office (VACO) and leadership from facilities \9\ and Veterans
Integrated Service Networks (VISNs).
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\9\ The term ``facilities'' or ``facility'' refers to VA's 151
medical centers, hospitals, or healthcare systems.
Following the guidance of the VHA National Pain Management
Strategy, and in compliance with generally accepted pain management
standards of care, the Directive provides policy and procedures for the
improvement of pain management through implementation of the Stepped
Care Model for Pain Management (SCM-PM), the single standard of pain
care for VHA, central to ensuring Veterans receive appropriate pain
management services. The Directive also requires tracking opioid use
and implementing strong practices in risk management to improve
Veterans' safety.
Consistent with this model, a key objective is to expand capacity
for specialty pain care services. Present data demonstrates an increase
in this capacity over the past year, continuing this yearly trend since
data were first analyzed in fiscal year (FY) 2005. Specifically, we
know that:
All VISNs are providing dedicated Pain Clinic services
with dedicated Pain Clinics in about 95 percent of facilities.
Through the third quarter of FY 2013, VHA provided Pain
Clinic services to 104,388 unique Veterans (including both inpatient
and outpatient pain clinic services). Compared to the same time period
in FY 2012, this represents a 3.6 percent increase in the number of
Veterans served in these specialty clinics.
Total Pain Clinic encounters increased to 316,204 through
the third quarter of FY 2013; up 2.6 percent over this same time period
in FY 2012.
Of the 95 percent of facilities with Pain Clinic
Services, 84 percent have dedicated physician staff through the second
quarter of FY 2013 (includes all physician specialty areas delivering
Pain Clinic services by both VHA and In-House Contract Physician
staff).
Through the second quarter of FY 2013, 59 percent of
facilities have physicians who specialize in Pain Medicine, and 44
percent of physician-delivered services VHA wide are provided by those
who specialize in Pain Medicine. In the same period, 95 percent of Pain
Clinic services were provided by VHA physicians, 3 percent by contract,
and 2 percent by in-house fee physicians.
Physician pain specialist staffing has increased slightly
from 113 full-time equivalent employees in FY 2012 to 115 through the
second quarter of FY 2013.
The current supply of physicians providing specialty Pain
Clinic services per 100,000 unique patients, is 1.93, with an average
of 2.22 support staff per physician (including administrative staff,
advanced-practice providers, and other clinical staff).
Oversight and Accountability
Several key responsibilities are articulated in the Pain Management
Directive. The Directive establishes a National Pain Management Program
Office (NPMPO) in VACO that has the responsibility for policy
development, coordination, oversight, and monitoring of VHA's National
Pain Management Strategy. The Directive further authorizes the
establishment of a multidisciplinary VHA National Pain Management
Strategy Coordinating Committee that supports the Program Office in
achieving its strategic goals and objectives. The Committee is
comprised of 15 members to include: anesthesiology, employee education,
geriatrics and extended care, mental health, neurology, nursing, pain
management, patient education, pharmacy benefits management, primary
care/internal medicine, quality performance, rehabilitation medicine,
research, and women Veterans' health.
The Directive requires VISN Directors to ensure that all facilities
establish and implement current pain management policies consistent
with this Directive. VISN and facility pain management points of
contact serve key roles as links between the NPMPO and VHA health care
facilities. Facility directors are responsible for ensuring that
accepted standards of pain care are met. The facilities establish
multidisciplinary pain management committees to provide oversight,
coordination, and monitoring of pain management activities and
processes to facilitate the implementation of VA's Pain Management
Strategy.
The NPMPO maintains records of VISN and facility compliance, along
with other key organizational requirements contained in the Directive.
All VISNs and facilities have appointed National Pain Office pain
management points of contact, established multidisciplinary committees,
and implemented pain management policies as required by the Directive.
Stepped Care Model for Pain Management
As mentioned earlier, SCM-PM is the single standard of pain care
for VHA to ensure Veterans receive appropriate pain management
services. Specifically, SCM-PM provides for assessment and management
of pain conditions in the primary care setting. This is supported by
timely access to secondary consultation from pain medicine, behavioral
health, physical medicine and rehabilitation, specialty consultation,
and care by coordination with palliative care, tertiary care, advanced
diagnostic and medical management, and rehabilitation services for
complex cases involving co-morbidities such as mental health disorders
and TBI.
In FY 2012, VHA made several important investments in implementing
the SCM-PM. Major transformational initiatives support the objectives
of building capacity for enhanced pain management in the primary care
setting, including education of Veterans and caregivers in self-
management, as well as promoting equitable and timely access to
specialty pain care services.
There are other important efforts contributing to the
implementation of SCM-PM in VHA facilities. Current initiatives focus
on empowering Veterans in their pain management, and expanding capacity
for Veterans to receive evidence-based psychological services as a
component of a comprehensive and integrated plan for pain management.
For example, during FY 2012, the VHA National Telemental Health Center
expanded its capacity to deliver face-to-face, psychological services
to Veterans remotely via high-speed videoconferencing links. This
initiative not only emphasizes the delivery of cognitive behavior
therapy for Veterans with chronic pain, but also promotes pain self-
management, leading to reductions in pain and improvements in physical
functioning and emotional well being.
Additionally, a Primary Care and Pain Management Task Force is
developing a comprehensive strategic and tactical plan for promoting
full implementation of the SCM-PM in the Primary Care setting, and it
continues to work on several products in support of this effort. For
instance, the Task Force is continuing to expand its network of
facility- level Primary Care Pain Management points of contact (Pain
Champions) who meet monthly, via teleconference, to identity and share
strong practices that have led to improved pain care in primary care
settings.
VA's pain management initiatives are designed to optimize timely
sharing of new policies and guidance related to pain management
standards of care. Of particular importance are VHA's continuing
efforts to promote safe and effective use of opioid therapy for pain
management, particularly those initiatives designed to mitigate risk
for prescription pain medication misuse, abuse, addiction, and
diversion.
Created in 2011, VA's Specialty Care Access Network-Extension of
Community Healthcare Outcome (SCAN-ECHO) initiative allows pain
specialists to train primary care providers in community based
outpatient clinics (CBOCs) closer to Veterans' homes, particularly in
rural and underserved geographic areas. Benefits of this program
include reduced travel costs, improved quality of care, and increased
provider and Veteran satisfaction. Multiple modules are available on
VA's on-line Talent Management System (TMS), based on VA/DoD pain
guidelines and approved for continuing education credits for
physicians, nurses, pharmacists, and psychologists, thereby ensuring a
standardized level of knowledge across pain care delivery. This
initiative supports the implementation and evaluation of seven pain
SCAN-ECHO regional training hubs. Each hub, designed to provide support
for up to twenty Patient-Aligned Care Teams (PACT), is staffed by
experts in pain management, and linked by real-time videoconferencing
to PACT teams away from the medical center.
VHA has also implemented the Consult Management initiative, which
uses E-Consults and phone consults, to change how specialty care
services are delivered throughout VHA. E-Consult provides clinical
support from provider to provider. E-Consult is an alternative to face-
to-face visits, and is expected to improve access, communication, and
coordination of care. Through a formal consult request, a provider
requests a specialist to address a clinical problem or to answer a
clinical question for a specific patient. Using information provided in
the consult request and/or review of the patient's electronic health
record (EHR), the consultant provides a documented response that
addresses the request without a face-to-face visit. This method of
consultation supports patient-centric care, reduces the burden of
travel for the Veteran, and reduces overall travel and non-VA costs.
A particularly exciting initiative in its pilot phase of
development is the pain management application for smart phones that
will be used by Veterans and their care partners to develop pain self-
management skills. This tool, called VA Pain Coach, will eventually
interface with VHA's EHR, with appropriate privacy protections in a
secure mobile application environment, allowing Veteran-reported
information about pain, functioning, and other key elements to be
securely stored and accessible to clinicians. VA Pain Coach, which is
part of a suite of VA applications called ``Clinic in Hand'', is in the
third month of a one-year pilot test with 1150 Operation Enduring
Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their
caregivers. In the future, a complementary initiative will build a
clinician-facing application that will enhance the capacity of
clinicians and Veterans to share in monitoring, decision making,
treatment planning, and reassessment of pain management interventions.
VHA continues to work to strengthen its ability to meet the pain
management needs of Veterans with complex chronic pain conditions with
co-morbidities. Of particular importance are continued efforts to
promote access to integrated care services for Veterans experiencing
chronic pain and symptoms of PTSD, mild TBI, sleep disorders, and other
common co-morbid conditions. In partnership with VHA's Mental Health
Services, the ongoing Evidence-Based Psychotherapy initiative has been
expanded to include an initiative on cognitive behavior therapy for
chronic pain.
VHA's NPMPO also partners with Primary Care Services in support of
its Post-Deployment Integrative Care Initiative. This field-based
initiative, developed in 2008, supports integrated care clinical
platforms for providing post-deployment services in VAMCs nationally.
An example of this initiative is the PACT-based collaborative for post-
deployment pain care. This initiative focuses on PACT and pain
specialists in interdisciplinary collaborative care based on the Step
Care Model of pain management. An additional monthly community of
practice discussion, as well as a monthly call for a network of PACT
Primary Care Pain Champions, were recently added focusing specifically
on pain care in PACT settings to further the implementation of good
pain care and rational opioid use.
VHA's capacity to provide Veterans with equitable access to
specialty care services is strengthened by integrating other services
important for pain management. For example, a partnership with
Rehabilitation Services plans to build capacity for rehabilitation
medicine services, including chiropractic services. Recently, the NPMPO
contributed to a national educational conference, focusing on
rehabilitation services, to promote models of integrated care that
emphasize the role of rehabilitation specialists for pain management.
Further, the NPMPO continues to partner with Women Health Services
to develop a strategic plan that will strengthen the capacity for women
Veteran centered pain management services. In April 2012, VHA sponsored
a Women's Health National audio conference on pain management for Women
Veterans.
The NPMPO also partners with Pharmacy Benefits Management Services
(PBM) and others in development of a comprehensive approach to promote
the safe and effective use of long-term opioid therapy for Veterans. Of
particular note was the promulgation of regulations permitting VA to
participate with a growing number of states that have state
Prescription Drug Monitoring Programs (PDMP). Thus, following state
laws, VA providers can query PDMP databases about prescriptions from
providers outside the VA, and can respond to queries from outside the
VA about Veterans receiving controlled medications from the VA, leading
to better communications with Veterans and all their caregivers about
safe practices. The NPMPO also collaborates with PBM on the Opioid
Safety Initiative which involves providing facility feedback on
provider prescribing and facility utilization of opioids. This program
was piloted in 4 VISNs and was implemented system-wide in August and
September 2013.
VHA Pain Management Centers
The Under Secretary for Health chartered an Interdisciplinary Pain
Management Center Work Group to provide guidance and oversight for
VHA's efforts to develop VISN level tertiary care Pain Management
Centers. These Centers have the capacity for providing advanced pain
medicine diagnostics, surgical and interventional procedures,
subspecialty pain care, and intensive, integrated chronic pain
rehabilitation for Veterans with complex, co-morbid, or treatment
refractory conditions. There are currently nine Commission for the
Accreditation of Healthcare Facilities, or CARF, accredited pain
rehabilitation centers in VHA. This includes one Center at the James
Haley Veterans Hospital in Tampa, which is one of only two
multidisciplinary pain management centers to be twice recognized by the
American Pain Society as a Clinical Center of Excellence. The other is
a program at Stanford University.
Finally, the DoD-VA Health Executive Council (HEC) Pain Management
Work Group (PMWG) was chartered to develop a model system of
integrated, timely, continuous, and expert pain management for
Servicemembers and Veterans. The Work Group participates in VA/DoD
Joint Strategic Planning (JSP) process to develop and implement the
strategies and performance measures, as outlined in the JSP guidance,
and shares responsibility in fostering increased communication
regarding functional area between Departments. The Group also
identifies and assesses further opportunities for the coordination and
sharing of health related services and resource between the
Departments. A key development is the HEC PMWG's sponsoring of two
Joint Incentive Fund projects to improve Veterans' and Servicemembers'
access to competent pain care in the SCM-PM: the Joint Pain and
Education Project (JPEP), and the ``Tiered Acupuncture Training Across
Clinical Settings'' (ATACS) projects. The latter project, ATACS,
represents VHA's initiative to make evidence-based complementary and
alternative medicine therapies widely available to our Veterans
throughout VHA. A VHA and DoD network of medical acupuncturists are
being identified and trained in Battlefield (auricular) Acupuncture by
regional training conferences organized jointly by VHA and DoD. The
goal of the project is for them to return to their facilities and VISNs
with the skills to train local providers in Battlefield Acupuncture,
which has been used successfully in DoD front-line clinics around the
world. This initiative will provide Veterans with a wider array of pain
management choices when they present with chronic pain.
Prevalence and Use of Opioid Therapy for the Management of Chronic Pain
in Veterans
To monitor the use of opioids by patients in the VA health care
system, VA tracks multi-drug therapy for pain in patients receiving
chronic or long-acting opioid therapy for safety and effectiveness.
This includes tracking of use of guideline recommended medications for
chronic pain (i.e., certain anticonvulsants, tricyclic antidepressants
(TCA), and serotonin and norepinephrine reuptake inhibitors (SNRI)
which have been shown to be effective for treatment of some chronic
pain conditions), and tracking of concurrent prescribing of opioids and
certain sedative medications (e.g., benzodiazepines and barbiturates)
which can contribute to oversedation and overdose risk when taken with
opioids and the other medications for pain listed above.
The prevalence of Veterans using opioids has been measured for
Veterans using VHA health care services. For FY 2012, of the 5,779,668
patients seen in VA, 433,136 (7.5 percent) received prescriptions for
more than 90 days supply of short acting opioid medications and 92,297
(1.6 percent) received at least one prescription for a long-acting
opioid medication in the year. Thus, since chronic pain is the most
common condition in all Veterans enrolled in VHA, more than 50 percent,
a relatively small percentage of those Veterans are receiving opioid
therapy, consistent with the DoD-VA Clinical Practice Guidelines which
limit their use to patients with moderate to severe persistent pain
that has not responded to other safer alternatives that are clinically
appropriate. Of these 525,433 patients that received chronic or long-
acting opioid therapy, 79,025 (15 percent) were also prescribed a TCA,
90,066 (17 percent) were also prescribed an SNRI, and 178,361 (34
percent) were also prescribed an anticonvulsant some time in FY 2012.
The co-prescription of TCAs and/or SNRIs with opioids is first line
therapy for the more severe cases of pain related to nerve damage from
disease (e.g., diabetes, cancer) or from injuries (e.g., battlefield
blast and projectile injuries with or without limb amputation and
spinal cord injury). The numbers above suggest that clinical teams are
using medically indicated combinations of medications that are
specifically needed for these more severe conditions, which themselves
are often co-morbid with musculoskeletal pain such as injuries to
joints, spine and muscles. Of note, these prescriptions may or may not
have overlapped with the opioid prescription during the year.
In FY 2012, 193,644 (37 percent) of the patients prescribed chronic
or long-acting opioid therapy received an overlapping prescription for
a sedative medication. Notably, 272,719 (52 percent) of patients on
chronic or long-acting opioid therapy also received non-medication-
based rehabilitative treatments as part of their treatment plan (e.g.,
physical therapy (32 percent), chiropractic care (1 percent), programs
to encourage physical activity (9 percent) or occupational therapy (17
percent), and 241,465 (46 percent) also received behavioral or
psychosocial treatment for chronic pain or co-morbid mental health
conditions.
These data, showing the use of non-medication treatments, suggest
that Veterans are benefitting from VHA's efforts to create access to
additional pain treatment modalities besides medication. This is
consistent with VA's commitment to transform pain care to a
biopsychosocial model \10\ that addresses all the factors that by
research are demonstrated to affect Veterans' success in chronic pain
treatment. Pursuant to this aim, a multi-modality, team-based, stepped
care model, per VHA Directive 2009-053, is being implemented widely
throughout VHA, and in coordination with DoD.
---------------------------------------------------------------------------
\10\ The Biopsychosocial Model takes the position that the causes
and outcomes of many illnesses often involve the interaction of
physical and pathophysiologic factors, psychological traits and states,
and social-environmental factors. Effective treatment planning accounts
for the salience of these factors in the precipitation and perpetuation
of illness and illness-related disability.
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Improving Chronic Pain Management and Use of Best Practices in VHA
The strategies outlined earlier regarding VHA Pain Management
Directive were developed and are being implemented to improve pain
management outcomes for our patients. To achieve successful
transformation of pain care in VHA several strategic goals must be met.
Health Care Provider Education and Training
First, as recognized by the IOM in its extensive 2011 review,
``Pain in America'' and the American Medical Association in its 2010
Report on Pain Medicine \11\, and as articulated in VHA's Pain
Management Directive in 2009-053, a formal commitment to pain
management education and training for students and trainees in all
clinical disciplines is required. For example, VHA, which provides
training for a large proportion of medical students and residents, has
the opportunity to establish a system-wide requirement for education
and training of physicians in pain management, as recommended in the
Directive.
---------------------------------------------------------------------------
\11\ Lippe PM, Brock C, David JJ, Crossno R, Gitlow S. The First
National Pain Medicine Summit - Final Summary Report. Pain Med
2010;11(10):1447-68.
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The Joint Pain and Education Project, JPEP, mentioned earlier, has
proposed training faculty in all VA training sites to pursue the
implementation of such a curriculum, so that new generations of
providers and other clinicians will themselves become the new teachers
of good pain care. JPEP will target all levels of learner: the Veteran
and his/her family and caregiver; the public; clinicians from all
disciplines; specific providers and clinicians in practicing at each
level of the SCM-PM: primary care, pain medicine specialty care, and
other specialty care. VA is providing national leadership in developing
interdisciplinary and discipline-specific competencies for pain
management, in developing a system-wide approach to trainings, and in
providing leadership roles in national projects to improve pain
education and training.
Outcomes and Best Practices
In summary, there is growing evidence of the successful
implementation of a Stepped Care Model for Pain Management in VHA.
Importantly, Veterans receiving long term opioid therapy for management
of chronic pain are increasingly likely to be receiving this therapy in
the context of multidisciplinary and multimodal care that often
incorporates physical and occupational therapy and mental health
services. All VISNs provide specialty pain clinic services, and the
number of Veterans who receive these services has grown steadily for
the past five years. Nine facilities now provide CARF accredited pain
rehabilitation services, a rapid increase in the availability of these
higher specialized pain rehabilitation services for our most complex
Veterans with debilitating chronic pain and comorbid mental health
disorders.
VA learns from VISN and VA medical centers that are early adopters
of implementing evidence based guidelines and best practices. The
Minneapolis VAMC has had great success after their VISN leadership and
Medical Center leadership organized multi-disciplinary team with pain
providers, clinical pharmacist, psychologist, psychiatry, patient
advocates and toxicologists. Interdisciplinary approaches were
identified to address patients on the higher doses of opioid
medications. The PACTs were encouraged to offer trials of non-opioid
care and increase access to behavioral pain management resources as
alternatives. Patients were assessed frequently to evaluate the trials
of lower doses of medication and success of non-opioid alternative
care. After implementing best practices, this medical center saw over a
fifty percent decrease in the need to prescribe opioids for chronic
pain management, in higher doses. The facilities' practices were shared
nationally through educational teleconferences. VA applauds the work by
this medical center and others like it to progress toward a standard of
care for safer opioid prescribing
VA is working aggressively to promote the safe and effective use of
long-term opioid therapy for Veterans with chronic pain for whom this
important therapy is indicated. VA's Opioid Safety Initiative holds
considerable promise for mitigating risk for harms among Veterans
receiving this therapy, for promoting provider competence in safe
prescribing of opioids, and in promoting Veteran-centered, evidence-
based, and coordinated multidisciplinary pain care for Veterans with
chronic pain. Early evidence of success in reducing overall opioid
prescribing and average dose per day of opioid therapy is encouraging.
VA also has the opportunity to measure the impact of new policies
and programs systematically and in a way that enhances the outcomes of
interdisciplinary pain care for Veterans. VA's Office of Research and
Development Pain Portfolio for FY 2013 consisted of 82 projects
relevant to the treatment, diagnosis, and mechanisms underlying painful
conditions experienced by Veterans, totaling approximately $16.4
million (an increase of $4.5 million from 2012).
VA recently funded a new research project that identifies a cohort
of all Veterans in care in VHA with diagnosed painful musculoskeletal
disorders. This database provides an important opportunity to examine
pain care in VHA, including multidisciplinary pain care consistent with
the SCM-PM, costs of care, and outcomes. VA is currently exploring the
development of a prospective electronic system for supplementing this
system by collection of Veteran reported outcomes. VA Pain Coach
already described may provide an initial secure platform for this
important initiative. Another opportunity is to partner with our DoD
and National Institutes of Health colleagues to develop a registry of
Veterans with painful conditions that can link with a similar system,
called PASTOR Patient Reported Outcomes Measurement Information System
(PROMIS), being developed in DoD military treatment facilities.
In addition to interagency collaborations mentioned earlier, VHA
pain experts serve on the Interagency Pain Research Coordinating
Committee (IPRCC). The IPRCC was tasked by the Undersecretary for
Health at the Department of Health and Human Services to create a
comprehensive population health-level strategy for pain prevention,
treatment, management, and research.
Finally, on February 25, 2013, VHA submitted a notice in the
Federal Register (FR Doc. 2013-04248) outlining a Pain Public Private
Collaboration for the development of novel therapies to treat painful
conditions. The goal is to partner VHA investigators with industry
sponsors to develop or test new therapies for chronic pain
Conclusion
Mr. Chairman, we know our work to improve pain management programs
and the use of medications will never be truly finished. However, we
are confident that we are building more accessible, safe and effective
programs and opportunities that will be responsive to the needs of our
Veterans. We appreciate your support and encouragement in identifying
and resolving challenges as we find new ways to care for Veterans. VA
is committed to providing the high quality of care that our Veterans
have earned and deserve, and we appreciate the opportunity to appear
before you today. My colleagues and I are prepared to respond to any
questions you may have.
Statements For The Record
THE AMERICAN LEGION
A CBS News Story \1\ on September 19, 2013 reported that Army SPC
Scott McDonald, a veteran of five tours of duty in Iraq, was found dead
by his wife on his couch at home due to the nine different painkillers
and psychiatric pills prescribed by the Department of Veterans Affairs
(VA).
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\1\ http://www.cbsnews.com/8301-18563--162-57603767/veterans-dying-
from-overmedication/
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A second veteran, Army SPC Jeffery Waggoner, who was being treated
by the Roseburg VA Medical Center for severe Post Traumatic Stress
Disorder (PTSD), was prescribed ``with a battery of drugs so generous
that in the weeks leading up to the patient's overdose in a Sleep Inn
Motel, his medical records show, he only woke up only to take his
medicine, which was a cocktail of 19 different medications,'' according
to a Center for Investigative Reporting article \2\ in September 2013.
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\2\ http://www.va.gov/oig/pubs/VAOIG-12-01872-258.pdf
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The overprescribing of pain medications is a tragic and dire
situation many veterans face, which leads to further health problems
and quality of life issues such as substance abuse disorders,
depression, and in SPC McDonald's and Waggoner's cases, their lives.
The American Legion appreciates the committee for their concern in
holding this hearing and utilizing their oversight authority to work to
improve the lives of America's veterans that depend on VA for their
healthcare and treatment of pain symptoms. With proper care and
medication management, even severely disabled veterans can still lead
meaningful and productive lives. However, unless close scrutiny and
care is exercised, even small problems with medications can spiral into
much larger issues. All concerned parties must also be open minded, and
consider other, alternative therapies to medication when considering
long term care not only for pain management, but for other conditions
including psychological disorders. By working together, the veterans of
America, the service organizations such as The American Legion that
serve them, as well as the concerned members of this committee and
within the VA, a means to deal with the problem of pain management and
mental health management that accounts for many factors to determine
the best strategy for each, individual veteran can be developed.
Challenge of Prescription Drug Diversion and Abuse Among Veteran
Patients
The American Legion believes that the misuse or abuse of
prescription drugs amongst veteran patients is not necessarily due to
veterans' drug seeking and drug diversion behaviors but on several
health care delivery system failures such as:
Fragmentation within and between health care systems
during service members' time of transition and as a veteran with
multiple systems of care;
Inability to distinguish between traumatic brain injury,
post-traumatic stress disorder and pain symptoms and overprescribing of
pain medications to mental health patients
Improvements needed in the management, oversight and
clinical directives for VA providers' prescribing of opiates
Fragmentation Within and Between Different Health Care Systems
During Veterans Transition from the Military and as a Veteran
Compounding the concern of medication management leaving the
military, veterans can be seen in multiple systems of care such as the
DOD's Military Health Care System, TRICARE, Medicare, Medicaid or in
the private sector where different providers within of or external
systems can concurrently prescribe or overprescribe pain medications.
The only real check against conflicting prescriptions is the self-
reporting of the veterans, which may be muddled by the very
prescription drugs they need to manage their pain or symptoms.
While the State Drug Monitoring Program aims to reduce the number
of controlled substances that are prescribed to individuals across
multiple systems of care throughout the state, this database relies on
providers to ensure medication reconciliation and information
technology systems can provide this data to the state in real time.
Currently, VA lacks a national information technology system and way to
view all dispensing of medications to veterans through their VA Medical
Centers, Community Based Outpatient Clinics and Consolidated Mail Out
Pharmacy. In 2003, the VA submitted a pharmacy reengineering project to
improve visibility over every inpatient and outpatient prescription
dispensed which would enable providers in different VA hospitals and
clinics to monitor risk for overprescribing of medications. However,
the authorization and funding for this project was never approved,
authorized or funded by VA's Office of Information Technology due to
other competing IT projects.
Inability to Distinguish between Traumatic Brain Injury, Post
Traumatic Stress Disorder and Pain Symptoms and Overprescribing of Pain
Medications to Mental Health Patients
Three studies address the growing concern of pain management of
veterans and improvements needed. First, in 2009, Dr. Henry L. Lew
authored a research study titled ``Prevalence of chronic pain,
posttraumatic stress disorder, and persistent post-concussive symptoms
in OIF/OEF veterans'' in the Journal of Rehabilitation Research and
Development. In the study, he found that within a sample of 340
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
veterans, 42.1 percent were diagnosed with multiple co-morbidities
associated with the diagnosis of mild TBI, sleep disorders, substance
abuse, psychiatric illness, visual disorders and cognitive disorders
(see exhibit below). This inability of providers to know what
constellation of symptoms and diagnoses makes treatment for these post
deployment health care conditions more difficult.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Secondly, OEF/OIF veterans with mental health diagnoses \3\ were
found to be significantly more likely to receive prescriptions for
oxycodone, hydrocodone and other opioids than those with symptoms of
pain and no mental health issue, according to a VA study released in
March 2012 \4\.
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\3\ Primarily Posttraumatic Stress Disorder
\4\ https://jama.jamanetwork.com/
issue.aspx?journalid=67&issueid=22492
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Dr. Karen Seal and colleagues at the San Francisco Veterans Affairs
Medical Center's study, ``Association of Mental Health Disorders with
Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq
and Afghanistan'' published these findings in the Journal of the
American Medical Association. The study sample consisted of 141,029
Iraq and Afghanistan veterans who were diagnosed with pain from 2005-
2010 and found 15,676 (11 percent) of veterans with PTSD were
prescribed opioids within the year for at least 20 consecutive days
compared to 6.45 percent of veterans not diagnosed with any mental
health disorder.
The study further commented on barriers to receiving mental health
and the need for primary care clinicians to be trained in the co-
morbidity of symptoms between PTSD and substance use disorder as well
as the risk of prescribing both sedative and opioids and alternative
therapies should be considered.
Third, Dr. Charles Hoge and Dr. Carl Castro's study, ``Mild
Traumatic Brain Injury in U.S. Soldiers Returning From Iraq'' found
that ``evidence-based treatments for persistent post-concussive
symptoms are lacking, results of diagnostic procedures for mild TBI or
deployment related cognitive effects are inconclusive and management
focuses largely on alleviating symptoms and reinforces the need for a
multidisciplinary approach centered in primary care. Further the study
recommended the establishing of deployment health clinics to address
the multiple physiological and physical symptoms and collaborative care
approaches in primary care settings to improve intervention strategies.
Improvements needed in the management, oversight and clinical
directives for VA providers' prescribing of opioid prescriptions
The VA Office of Inspector General (OIG) Office of Healthcare
Inspections released a report on August 21, 2012 from an inspection of
the VA Maine Healthcare System's Calais Community Based Outpatient
Clinic on the prescribing of opioids for chronic pain. The OIG found
that ``providers did not adequately assess patients who were prescribed
opioids for chronic pain; facility managers asked providers to write
opioid prescriptions for patients whom the providers had not assessed
and patients often obtained prescriptions from multiple providers due
to staffing constraints.''
The most disconcerting finding pointed out by the OIG was that
``current VHA regulations do not require a provider to see a patient
before writing an opioid prescription''.
What The American Legion is Doing
TBI and PTSD Committee
The American Legion commissioned a TBI and PTSD Ad Hoc Committee in
2010 ``to investigate the existing science and procedures and
alternative methods for treating TBI and PTSD.'' During the three year
study, the committee held six meetings and met with leading authorities
in DOD, VA and personally interviewed veterans. One of the major
reasons for formation of the committee was the overprescribing of
medications and no new alternative therapies were being developed.
The committee examined the overlap of symptoms between TBI, PTSD
and pain symptoms which could lead to misdiagnoses and treatment for
the wrong medical condition. The committee found that ``the primary
treatment across the agencies and branches of services (active, reserve
and guard) is pain management and medication to treat the symptoms;
there is every indication that the pharmacology approach is not the
answer. Additionally, there is a need for DOD and VA to research TBI
and PTSD research and treatments currently being used in the private
sector, such as Hyperbaric Oxygen Therapy, Virtual Reality Therapy,
other Complimentary and Alternative Medicines, instead of
pharmacological treatments.''
One service member that was interviewed by the TBI and PTSD
Committee said that he was at the Warrior Transition Unit in Ft.
Carson, Colorado and taking 18 different prescriptions for treatment of
pain and other mental health symptoms. The service member was accepted
into the National Intrepid Center of Excellence in Bethesda, MD and
upon arrival the center said he would be taking half of the number of
prescriptions. When he left the NICOE three weeks later, he was only
taking nine prescriptions but when he went back to the WTU in Ft.
Carson, they put him back on his original 18 medications.
Any progress made at the Center of Excellence is being undercut by
the inability of multiple programs serving the veteran health care
needs to get on the same page.
American Legion Resolution and Position on Pain Management
The American Legion adopted a resolution \5\ to require federal
funding for pain management research, treatment and therapies at the
Department of Defense, Department of Veterans Affairs and at the
National Institutes of Health be significantly increased and that the
Congress and the President's administration re-double their efforts to
ensure that an effective pain management program be uniformly
established and implemented. The resolution also called on DOD and VA
to increase their investment in pain management clinical research by
improving and accelerating clinical trials at military and VA treatment
facilities and affiliated university medical centers and research
programs.
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\5\ Resolution No. 150 Support for Pain Management Research,
Treatment and Therapies at DOD, VA, and NIH
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Veteran Testimonials
The American Legion reached out to our 2,600 accredited service
officers and members regarding concerns they faced with pain management
and medication management in VA. The following testimonials are real
life anecdotes representing what we are hearing from American Legion
members and veterans through our extensive network of service officers:
Veteran #1 - Many pain meds do not work for me for
whatever reason plus I'm a large person who lived with a lot of back
pain for over 30 years before I allowed them to operate on my back---
the surgery was very successful although I am still in some pain (but
not near as much as I used to be). Anyway I was given oxycodene [sic]
and a normal dose doesn't scratch the surface so I no longer take them
because if I take a larger than normal dose I run the risk of bad
reactions-once I was very paranoid for a couple of hours, another time
I was flat stoned, and I don't remember too much about the third time
but I know I was very light headed and uncomfortable for a couple of
hours; so I flushed the rest of the prescription and do not take
anything.
Veteran #2 - For a client with a long term prescribed
therapy/treatment we have noted that doctors are now reducing the
amounts provided and providing limited alternatives. Now, this may just
again be a perception by the veteran but the veteran involved may be
convinced he/she cannot accomplish daily living without the extended
use of heavy/controlled meds. This becomes an explosive situation for a
veteran utilizing/abusing/or addicted to the meds. In a case just
recently the doctor advised the vet he would no longer get his 90 day
supply of pain medications. This vet is combat wounded and suffers from
severe PTSD. The immediate reaction was for the vet to almost become
suicidal as he felt his conditions would no longer be adequately
treated. He was told he would have to contact pain management and work
on an alternative method for his chronic pain condition. Was this what
he was actually told? We are unsure and find ourselves as advocates
having to research the facts while we attempt to keep the vet calmed.
We understand the intention is to begin limiting the use of heavier
medications and we support this contention as we see a number of vets
being ``numbed'' to handle the real or perceived pain. There are also
two sides to every story but we are advocates and not medical
professionals.
Veteran #3 - My main concern is in reference to what
seems the VA's treating of the symptoms rather than the cause of the
symptoms. Many of my veterans have complained that the VA isn't
interested in finding and treating their problems and their solution is
to dispense another pill instead of actual treatment. Another complaint
is that clinicians seem to be reluctant to provide alternative
treatments or therapies and don't give serious consideration or pursue
using them. Most of these veterans aver that they are over medicated
and are not receiving good proactive healthcare by their providers.
Actions Needed to Improve the Management of Chronic Pain and the
Utilization of Best Practices Across the VA Health Care System
The American Legion urges Congress, DOD and VA to take the
following steps to strengthen programs and initiatives to reduce the
administering and prescribing of pain medication to service members and
veterans.
Pain management research, treatment and therapies at the
Department of Defense, Department of Veterans Affairs and at the
National Institutes of Health be significantly increased and that the
Congress and the Administration re-double their efforts to ensure that
an effective pain management program be uniformly established and
implemented.
DOD and VA increase their investment in pain management
clinical research by improving and accelerating clinical trials at
military and VA treatment facilities and affiliated university medical
centers and research programs
The VA should carefully consider and look at new pain management
and medication tracking requirements such as:
Development of a more integrated care approach within
primary care to address pain and the constellation of post deployment
health illnesses and injuries to include pain specialists and
pharmacists within VA's Primary Care Aligned Team model.
VA should prioritize funding and development of Pharmacy
Reengineering Program to coordinate all VA medications with a system
that can track all medications between VA Medical Centers, Community
Based Outpatient Clinics and Consolidated Mail Out Pharmacy to ensure
opiates or other controlled substances are not overprescribed.
VA should develop national procedures and directives to
ensure that providers see veteran patients prior to prescribing
opioids.
VA should conduct a system-wide training of all providers
and clinicians on reduction of pain medications and improved
coordination, monitoring and oversight including parameters of numbers
of medications and patients at risk that are taking several different
medications.
VA should develop national procedures and directives on
the administration of pain medications to veterans specifically with
mental health illness and develop training for primary care clinicians
on treating pain symptoms concurrently.
Studying medication, as well as alternative treatments, is an
important task to ensuring the system for providing health care for
veterans remains the best resource for their health needs. As this
issue continues to develop, The American Legion looks forward to
working with the Committee, as well as DOD and VA, to find solutions.
For additional information regarding this testimony, please contact Mr.
Ian de Planque at The American Legion's Legislative Division, (202)
861-2700 or [email protected].
IRAQ & AFGHANISTAN VETERANS OF AMERICA
Statement of Jacqueline A. Maffucci, Ph.D., Research Director \1\
Chairman Benishek, Ranking Member Brownley, and Distinguished
Members of the Subcommittee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA), I
would like to extend our gratitude for being given the opportunity to
share with you our views and recommendations regarding pain management
practices, an important issue that affects the lives of thousands of
service members and veterans.
IAVA is the nation's first and largest nonprofit, nonpartisan
organization for veterans of the wars in Iraq and Afghanistan and their
supporters. Founded in 2004, our mission is critically important but
simple - to improve the lives of Iraq and Afghanistan veterans and
their families. With a steadily growing base of nearly 270,000 members
and supporters, we strive to help create a society that honors and
supports veterans of all generations.
In partnership with other military and veteran service
organizations, IAVA has worked tirelessly to see that veterans' and
service members' health concerns are comprehensively addressed by the
Department of Veterans Affairs (VA) and the Department of Defense
(DoD). IAVA understands the necessity of integrated, effective, world-
class healthcare for service members and veterans, and we will continue
to advocate for the development of increased awareness, recognition and
treatment of service-connected health concerns, chronic pain and pain
management included.
According to a 2011 Institute of Medicine report, chronic pain
affects approximately 100 million American adults. Nationally, the
number of individuals diagnosed with chronic pain and the number of
powerful narcotics prescribed to treat pain have increased in the last
decade. Concurrently, prescription drug abuse is on the rise \2\. The
CDC has called prescription drug abuse an epidemic in the U.S, and the
White House has developed a National Drug Control Strategy to address
the issue \3\. This is a national issue, and one from which our service
members and veterans are not immune.
A recent report from the Center for Investigative Reporting found
that over the last 12 years, there has been a 270 percent increase in
Veterans Health Administration (VHA) prescriptions for four powerful
opiates \4\. Given the last 12 years of conflict and the intense
physical demands on our troops, it is no surprise that over half of the
OEF/OIF veterans seeking VA medical care report chronic pain, nor is it
a surprise that the majority of veterans seeking primary care treatment
from the VA report pain as a major concern \5\.
Reports presented by the VHA on pain management illustrate the
scope of pain and pain management practices within the VA and the
unique potential causes of pain among veterans \5\. For Iraq and
Afghanistan veterans, improved body armor and medical advancements has
allowed for higher survival rates, but increased amputations and other
lifelong impacts of nerve and skeletal damage, coupled with
musculoskeletal concerns from the weight of wearing heavy body armor,
highlight a need for successful pain management strategies for veterans
of these conflicts. In 2012, the second most common reason for
outpatient clinical visits and the fourth most common reason for
hospitalization among active duty service members was musculoskeletal
concerns \6\. With time and age, these injuries will most likely worsen
\6\. This highlights the importance of comprehensive, integrated pain
management protocols in military and veteran medical care.
Pain management is challenging in that pain manifests itself
differently from patient to patient. Further, assessing pain and
devising a management strategy can be very difficult, particularly
given that this is a relatively new area of focus in the clinical
research field. Related to this, the primary care physicians who see
the bulk of patients with chronic pain have repeatedly reported that
they feel underprepared to treat these patients due to a lack of
training. In a 2013 study specific to VHA, this trend was echoed by the
VHA providers who were surveyed as well \7\.
These same providers reported that barriers within VHA kept them
from feeling prepared to treat chronic pain. These included formulary
barriers, inability to access state prescription monitoring programs
(which would allow them to see if patients have previously been
prescribed controlled medications like opioids), and barriers to
consulting with experts outside of the VA.
Chronic pain is also particularly prevalent in polytrauma cases,
which are among the most complex medical cases to address. Pain often
presents in consort with other conditions, such as depression, anxiety,
PTSD, or TBI. Providers can be challenged to treat pain that is
comorbid with other conditions because of the difficulty of managing
multiple conditions. Some of these conditions may also limit the drugs
available to the patient, making treatment options limited.
These issues constitute major challenges to pain management.
Certainly part of a treatment program for chronic pain may include
strong anti-pain medication, including opioids; but a schedule of
treatment should not be limited to pharmaceutical remedies and should
integrate a host of other proven therapies. This is why a stepped case
management system can be very helpful. In this type of system, a
primary care physician has the support of an integrated, multi-
disciplinary team of providers to design and implement a comprehensive
pain management plan for the patient.
The VA and DoD have been relatively proactive in how they approach
management of chronic pain. Since 2000, VHA has instructed its
providers to treat pain as the fifth vital sign \8\. Much like heart
rate and blood pressure, inquiring about and documenting complaints of
pain has been integrated into the physical exam. VA has also put more
resources into research to understand pain assessment and treatment.
And they have partnered with DoD to publish clinical practice
guidelines and to restructure pain management protocols, recognizing
that the responsibility for care often falls on the primary care
physician while specialty support in the form of multidisciplinary pain
management clinics may be relied upon as well.
Given the challenging nature of understanding pain, how it
manifests, and how to best treat it, these have all been laudable
initiatives on the part of VA and DoD. But the challenge remains to
uniformly and effectively translate all of these efforts into practice.
Too often we hear the stories of veterans who are prescribed what seems
like an assortment of anti-psychotic drugs and/or opioids with very
little oversight or follow-up. On the flip side, there are also stories
of veterans with enormous pain and doctors who won't consider their
requests for stronger medication to manage the pain.
One IAVA family member has expressed tragic exasperation with
respect to the VA's current opioid drug usage practices. Her husband,
who was prescribed nine different medications to address a range of
health issues related to pain, anxiety, and depression, tragically
passed away from what was labeled an accidental overdose by the
coroner. Since then, his widow has been fighting to include
overmedication by the VA on his death certificate. The VA's response in
this case has been to blame the widow, saying simply that she was
trained to be a caregiver. But while she was indeed trained to provide
care and assistance for her husband, that training did not include
medication management.
In a similar case highlighted last month by CBS, a veteran with
five tours of duty in Iraq and Afghanistan received a treatment plan
from the VA with a total of eight prescriptions. When he was prescribed
a ninth drug by the VA, he took the medicine as instructed. The next
morning he was found by his wife; his death was classified as an
accidental death due to overmedication.
It is not our job to second-guess the judgment of the doctors
treating these patients, but it is our job to question the system that
is providing overall care to our veterans and tracking this care. It is
unacceptable to hear repeated stories like these, but they should drive
us to look at the system as a whole and how it can be fundamentally
improved.
In part, some of the challenges may be in the inherent differences
between the VA and DoD systems of care, whether it be in their
available formularies, uniformity of record keeping, use of medical
terminology, or the interoperability, or lack thereof, of the medical
record systems. Care for our service member and veteran population
should involve one integrated approach and a successful pain management
program requires a seamless transition between VA and DoD providers.
But beyond that, once a veteran is received into the VHA system,
it's not just about putting out policies, clinical practice guidelines,
and funding research. At the end of the day, the success will be seen
in how those products are implemented into practice and how they are
continually assessed for effectiveness. The key will be in education,
integration, and assessment.
We can advance our knowledge of pain and pain management all we
want, but it won't do our veterans any good if VA cannot efficiently
and effectively integrate these findings into their management
practices and have a plan in place to continually improve upon accepted
practice with evidence-based findings.
Mr. Chairman, we again appreciate the opportunity to offer our
views on this important topic and we look forward to continuing to work
with each of you, your staff, and this subcommittee to improve the
lives, health, and livelihoods of veterans and their families.
Thank you for your time and attention.
1 Dr. Jacqueline Maffucci, IAVA's Research Director, holds a Ph.D.
in neuroscience from the University of Texas at Austin. She previously
worked with Army staff and senior leaders to develop, implement, and
monitor research programs and opportunities to address the health and
wellness needs of service members.
2 Institute of Medicine. (2011, June). Relieving pain in America a
blueprint for transforming prevention, care, education, and research
[PDF]. Washington, D.C. Retrieved from http://www.iom.edu//media/Files/
Report%20Files/2011/Relieving-Pain-in-America-ABlueprint-for-
Transforming-Prevention-Care-Education Research/
Pain%20Research%202011%20Report%20Brief.pdf
3 Vital signs: overdoes of prescription opioid pain relievers-
United States, 1999-2008. (2011, November 4). Center for Disease
Control and Prevention Mobidity and Mortality Weekly Report 60(43). 11-
16. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6043a4.htm?s--cid=mm6043a4--w
4 Glantz, A. (2013, September 28). VA's opiate overload feeds
veterans' addictions, overdose death. Center for investigative
reporting. Retrieved from http://cironline.org/node/5261
5 Management of opioid therapy for chronic pain. (2010, May). VA/
DOD Clinical Practice Guideline. Retrieved from http://
www.healthquality.va.gov/Chronic--Opioid--Therapy--COT.asp
6 Hospitalizations among members of the active component, U.S.
armed forces, 2012. (2013, April). Medical Surveillance Monthly Report
20(4), 11-23. Retrieved from http://www.afhsc.mil/viewMSMR?file=2013/
v20--n04.pdf
7 Kerns, R. (2013, February). ``Psychological Treatment of Chronic
Pain'' [Webinar]. VA Pain Management, Spotlight on Pain Management.
Retrieved from www.va.gov
8 Department of Veterans Affairs, Office of Public Affairs. (2011,
February). VA initiates pain management program [Press Release].
Retrieved from http://www.va.gov/opa/pressrel/pressrelease.cfm?id=244
NATIONAL ASSOCIATION FOR ALCOHOLISM AND DRUG ABUSE COUNSELORS
Pain Management Programs and the Use of Opioids to Treat Veterans
Current evidenced-based practice is supported through research and
application showing that medication assisted treatment can be an
effective means of treating individuals with opioid addiction.
NAADAC, the Association for Addiction Professionals, does not
discount the significant positive medical uses use of opioids to treat
pain; however, NAADAC remains deeply concerned by the trend that has
rendered opioids as the first choice for pain management by doctors.
Behavioral therapeutic intervention, used in conjunction with
medication assisted treatment, is far more effective in managing pain,
as well as treating addiction, in terms of increasing the prospects for
long-term recovery.
Given the inherent risk of dependence precipitated by opioids,
NAADAC fully recommends that all non-opioid treatment options be
explored before opioids are prescribed. In other words, NAADAC more
strongly urges and supports the use of other clinical techniques and
therapeutic interventions before the use of opioid administration for
pain management.
Many veterans have been exposed to the use of use of prescription
medication while serving in Afghanistan and Iraq and other service
related involvement. In fact, it has been estimated that between 20 -
25 percent of troops stationed in these war zones have received
prescriptions for sleep, anxiety, and depression, among some of the
more prevalent issues being addressed. There is concern that the
treatment community is creating a pill culture because of the large
numbers of prescriptions being issued by the Departments of Defense and
Veterans Affairs. This uptick in prescribed medication will continue to
cause a higher likelihood of diversion incidences.
NAADAC would endorse and support a recommendation that all
prescribers of pain and psychotropic medications be required to receive
education and training in addictive disorders. This increased knowledge
of the addiction process and evidenced-based therapeutic interventions,
in addition to medication assisted treatment, would go a long way
towards stemming the ever-increasing tide of overprescribing opioids
before considering other options in pain management treatment.
``NAADAC's Mission is to lead, unify, and empower addiction focused
professionals to achieve excellence through education, advocacy,
knowledge, standards of practice, ethics, professional development and
research.'' - NAADAC Mission Statement
NAADAC, the Association for Addiction Professionals, is the largest
membership organization serving addiction counselors, educators and
other addiction-focused health care professionals, who specialize in
addiction prevention, treatment, research and education. With more than
9,000 members and over fifty affiliates, NAADAC's members work to
create healthier individuals, families and communities through
prevention, intervention, treatment, continuing care and recovery
support. NAADAC promotes excellence in care by promoting the highest
quality and most up-to-date, science-based services to our addiction
professionals and the clients, families and communities they serve.
NAADAC does this by providing education, clinical training and
certification. In the last eight years NAADAC has credentialed more
than 15,000 counselors, playing an important role in sustaining quality
health care services and protecting the well-being of the public.
WOUNDED WARRIOR PROJECT
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee:
Thank you for inviting Wounded Warrior Project to offer a
perspective on VA treatment of veterans experiencing acute and chronic
pain, and for convening a hearing on this very important subject.
Working with this generation of wounded, injured and ill veterans,
we at Wounded Warrior Project (WWP) see daily the devastating impact of
pain resulting from polytrauma and in-theater injury. In WWP's
surveying nearly 27 thousand wounded warriors this year, 63% of survey
respondents had been hospitalized as a result of their wounds or
injuries, \1\ with some 68% having suffered blast injuries and 17%
bullet or shrapnel wounds. \2\ Most of these warriors live with pain.
In fact, two-thirds of the nearly 14 thousand respondents said they had
moderate, severe, or very severe bodily pain. \3\ Some 80% said their
pain interferes with work; among them, 30% said pain interfered with
work ``extremely'' or ``quite a bit.'' \4\
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\1\ Franklin, et al.,2013 Wounded Warrior Project Survey Report, 16
(July 23, 2013).
\2\ Id., 22.
\3\ Id., 42.
\4\ Id., 42.
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Pain is the most frequent reason patients seek medical care in the
United States. \5\ In general, studies of VA patients show that the
pain veterans experience is significantly worse than that of the
general public and is thought to be associated with greater exposure to
trauma and psychological stress. \6\
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\5\ Office of the Army Surgeon General, Pain Management Task Force
Final Report, ``Providing a Standardized DoD and VHA Vision and
Approach to Pain Management to Optimize the Care for Warriors and their
Families,'' E-1 (May 2010) . http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
\6\ Id., 1.
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Our troops' post-9/11 combat experience is adding new chapters to
medicine's understanding of pain and pain-management. As is well
understood, large numbers of combatants have survived polytraumatic
injuries in Iraq and Afghanistan because of remarkable advances in
modern military medicine and transport. But these warriors are at high
risk of developing unremitting pain. Early study indicates that the
prevalence of pain in soldiers with polytrauma is as high as 96%, and
that high percentages of those suffering polytrauma experience pain-
related impairment in physical and emotional function. \7\ (As we are
learning, polytrauma pain is inherently complex, as multiple pathways
may be affected, to include acute pain associated with surgery,
centralized pain associated with spinal cord injury, headache due to
traumatic brain injury, neuropathic pain due to nerve injury, and
phantom pain associated with amputation. \8\ Post-traumatic stress
disorder and traumatic brain injury, the largely invisible ``signature
wounds'' of the war, not only have the effect of increasing warriors'
pain but of complicating treatment. As we heard from one VA
psychologist at a tertiary VA medical center in the Midwest, ``[Pain
issues are] a MAJOR problem that seriously and negatively impact mental
health care, and make my job a lot harder.''
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\7\ War on Pain: New Strategies in Pain Management for Military
Personnel and Veterans. (June 2011). Federal Practitioner. (28,2). Pg.
8.
\8\ Id, 8.
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While treating pain is one of medicine's oldest challenges, ``pain
medicine'' is a relatively new and evolving medical specialty. \9\ The
Veterans Health Administration has certainly played an important role
in attempting to develop a systematized approach to managing pain,
beginning in 1998 with the formulation of a national pain strategy. VHA
promoted the concept of ``Pain as the 5th Vital Sign'' in order to
provide consistency in pain-assessments throughout the health care
system. The initiative recognized the complexity of chronic pain
management, especially for patients whose pain was compounded by PTSD,
combat injuries, and substance use, and recognized further that such
management was often beyond the expertise of a single practitioner.
---------------------------------------------------------------------------
\9\ Office of the Army Surgeon General, Pain Management Task Force
Final Report, ``Providing a Standardized DoD and VHA Vision and
Approach to Pain Management to Optimize the Care for Warriors and their
Families,'' E-1 (May 2010) , http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
---------------------------------------------------------------------------
Taking account of an earlier Inspector General finding that the
extent of VA's implementation of its national pain strategy had varied
and that more work had been needed, \10\ Congress in 2008 directed VA
to develop and implement a comprehensive policy on the management of
pain experienced by VA patients. \11\ In apparent response to the law,
VHA in October 2009 published a directive on pain-management to provide
policy and implementation procedures for improving pain management and
to comply with generally accepted pain management standards of care.
This directive reiterated that pain management is a ``national
priority,'' a priority first articulated in the initial 1998 national
pain strategy. The 2009 directive not only established a ``stepped
care'' continuum model - beginning with primary care and advancing to
timely access to interdisciplinary specialty consultation and
collaboration, and finally to tertiary, interdisciplinary care
requiring advanced diagnostics and CARF-accredited pain rehabilitation
programs. Among its objectives, the national strategy is to create
system-wide care standards for pain-management; establish skills in
pain management; ensure performance of timely, regular and consistent
pain-assessments in all VHA settings; and provide for an
interdisciplinary, multi-mode approach to pain management that
emphasizes optimal pain control, improved function, and quality of
life. VISN directors are responsible for ensuring that all facilities
establish and implement pain management policies consistent with the
directive, and facility directors are responsible for meeting the
objectives of the strategy, for fully implementing the stepped model of
care, and for meeting the strategy's standards of pain care. \12\ (In
addition to this framework, VHA and DoD counterparts developed clinical
practice guidelines for management of opioid therapy for chronic pain.
The guidelines, first published in 2003, were intended to improve pain
management, quality of life and quality of care. The guidelines were
updated in May 2010 to reflect evidence-based practice. \13\)
---------------------------------------------------------------------------
\10\ Report on the Veterans' Health Care Policy Enhancements Act of
2008, H. Rep. 110-786 (July 29, 2008), accessed at http://
thomas.loc.gov/cgi-bin/cpquery/T?&report=hr786&dbname=110&
\11\ Section 501, Veterans'Mental Health and Other Care
Improvements Act of 2008, Public Law 110-387 (October 10, 2008)
\12\ Department of Veterans Affairs, VHA Directive 2009-053
(October 28, 2009).
\13\ Department of Veterans Affairs and Department of Defense,
Clinical Practice Guidelines: Management of Opioid Therapy for Chronic
Pain (May 2010).
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Viewed as a statement of policy and an implementation directive,
the National Strategy directive is praiseworthy. But the measure of
such an initiative is the reality on the ground - more specifically,
what is the experience of veterans who live with often-chronic pain?
Over the past week, we have engaged key WWP field staff from around
the country to understand the VA pain-management experience of warriors
with whom they work on a daily basis. The accounts they provided us
reflect their engagement with warriors at dozens of VA medical
facilities across the country. We have also interviewed a number of
warriors (among them WWP staff) who have struggled with chronic pain to
understand their experience directly, following up on a pain-management
roundtable we convened two years ago. Several themes emerged.
Notwithstanding a strategic objective of systemwide standards of care,
the picture is one of variability of experience - from medical center
to medical center, and even from warrior to warrior. Despite a policy
directive that addresses implementation-procedure and establishes
levels of responsibility, VHA does not appear to be proactively working
to enforce its pain-management policies. And while VHA does have
valuable resources with which to support implementation of pain-
management strategies, inadequate training of clinicians and staff play
a role in their not being used.
A starting point in managing a patient's pain is surely a full,
competent pain assessment, and the national strategy directive
identifies the performance of appropriate timely pain assessments
consistently across the continuum as a core objective. Primary care is
identified as a first step in that continuum, and when ``a competent
primary care provider workforce (including behavioral care)'' cannot
manage a pain condition, timely access to specialty consultation (step
two) is required. The experience of our warriors suggests, however,
that the fundamental objectives associated with these first steps are
often not met. Specifically, our on-the-ground staff shared the
following observations:
Rather than being provided a full pain assessment, the
common primary care experience is that a brief examination is provided
and the remainder of the appointment is devoted to inputting (or
updating) medication prescriptions. Staff report that ``Medications are
given with no treatment plan or direction other than `take the
medications.'''
A senior benefits specialist on our team told us that
``when I review medical records for veterans and see that they are on
extensive pain medication I always ask if they have been referred to
pain management for an assessment. The answer is usually `no.'''
A full pain assessment would include a review of a
patient's electronic medical records (to include records of earlier
treatment at other VA facilities) to better understand their pain care
needs. That information is also vital to ensure that medications and
techniques will be efficacious for a given veteran and that previously-
failed approaches will not be re-instituted, as well as to avoid
prescribing medications that may exacerbate underlying psychological or
neurological conditions. Notwithstanding the importance of such review,
patients frequently find that clinicians do not use VISTA to pull
remote data and/or other pertinent and often critical prior medical
records. (It was observed, in that regard, that ``VA has a `Cadillac e-
record system,'' but many clinicians and staff ``don't know how to
drive it,'' reflecting deficiencies in training and adherence to
standards.)
Primary Care Managers routinely fail to present veterans
with pain-relief options that are available and recommended for those
presenting with chronic pain.
The reality is that primary care is generally a hurried
experience that does not allow time for questions, for development of a
treatment plan, or for discussion of the appropriate time-frame for any
particular pain treatment before consideration of trying something new.
The primary care provider will send out requests for
additional treatment, but those requests are not necessarily followed
up. Specifically, warriors experience a lack of follow-through within
the VA Medical Centers for setting up requested medical appointments
and/or routine care follow up appointments. Compounding this
frustration, the patient has no way to reach the provider, doctor or
nurse without physically having an appointment.
Reliance on and monitoring of the use of opiate medication is, of
course, an area of particular concern, and requires delicate case-by-
case consideration. Understanding how variable care can be from
facility to facility, we do not suggest that our teammates'
observations necessarily describe consistent systemwide practice. At
the same time, the observations of WWP staff from around the country
strongly suggest that the following scenarios they have described are
not at all uncommon:
Narcotic medications are provided regularly with no
treatment plan. These medications are provided on six-month intervals
without follow up, and can be filled using the online system or over
the telephonic system. These are shipped directly to the warrior's
home.
Illustrative of that experience, a benefits-specialist on
our staff described having gone to a VA medical center to have a
prescription for Tylenol 3 filled. He stated that the medication had
worked in managing pain associated with his collapsed discs in his
upper back and herniated discs in his lower spine. He reported that ``I
went to the pharmacy and was waiting for an hour. When I asked what was
the hold-up, I was told they had to get the prescription from the
locked cabinet where they kept the opiates. I was told that Tylenol 3
is not on the formulary and they had substituted oxycontin. Bottom
line: I asked for a `hand grenade,' they gave me an `A-Bomb.'''
If, on the other hand, warriors ask for narcotic
medications they are most often not given them.
Describing his own experiences as well as those of other warriors
with whom he has worked at a number of VA medical facilities across the
country, one of our staff offered the following perspective:
``From my own experiences and of those relayed to me by my fellow
wounded warriors, VA facilities vary wildly in how they approach pain
management. Overlooking potential complications with their referrals
seems to be a common mistake and often the assessments are not
comprehensive. VA pain-management practices for warriors with
polytrauma have been incredibly inconsistent, generally unsuited for a
full recovery, and have not taken into account the warrior's other
issues (such as PTSD). The system seems to operate completely on `easy
fixes' by overprescribing. I know several warriors who have become
addicted to opiates as a result of mismanaged treatment plans and even
turning to street drugs. One Marine I served with who was injured in
2005 has overdosed on prescribed medications, turned to heroin because
of his addictions, and to this day relies on a VA referred methadone
clinic. I have never heard of non-pharmaceutical options being offered
directly, only of them being brought up by the warriors themselves to
their physician. Despite resources for alternative treatments, I have
not known the VA to directly point the warrior to them.''
VHA's national pain management strategy reflects the important
understanding that quality of life is a standard outcome measure of
treatment effectiveness, including the treatment of pain. Consistent
with that view, we applaud the emphasis the national strategy directive
places on individualized plans of care - even as we convey our
disappointment that the evidence we have compiled calls into question
how much progress VA has made in instituting such individualized pain-
care plans. As noted in the directive, however, one important element
in such plans are non-pharmacologic interventions. In asking our field
staff, however, how widely complementary therapies are available, we
were advised, with two exceptions (one of whom had himself been
prescribed acupuncture and massage therapy for severe back pain) that
none was aware of any instance in which complementary therapies such as
acupuncture or yoga had been offered.
While we see abundant evidence that there remain wide gaps in
realizing the first two steps of the national strategy's stepped-care
model, its third step - providing tertiary, interdisciplinary care may
be even more distant. To the best of our knowledge, the Chronic Pain
Rehabilitation Program at James A. Haley Veterans Medical Center
(Tampa, FL) is the only VA program that currently meets the pain center
criteria and is CARF-accredited. With chronic pain so widespread a
concern among veterans, and particularly among our wounded warriors, it
is difficult to understand so limited a deployment of tertiary
resources.
Accounts of the experiences of warriors with whom we work
underscore that much more progress must be made:
Toby Snell, a Marine from Washington state, sustained severe
injuries from a car bomb in Iraq in 2006 and shared his story with WWP:
Toby was originally prescribed Vicodin by the Navy, which did not
work for pain. Upon leaving the Marines, the VA again prescribed
Vicodin despite his objections. He was referred to the Pain Management
Clinic in the late 2007-early 2008 timeframe. He was told many times
the pain was ``in his head'' but was ultimately prescribed 120mg
extended release morphine/day. Medication still did not address his
pain.
He was not allowed to see Ortho Surgery per his Primary Care doctor
and the Pain Management doctors because he was told there was nothing
they could do. He was, however, sent to the University of Washington
School of Medicine for a second opinion in 2008, but the doctor there
was not authorized to perform any diagnostic testing. As a result, she
was unable to assist.
The VA then recommended a combination of morphine and fentanyl, but
Toby refused because he was already very ``out of it'' due to the
morphine and it wasn't working. He didn't want to add new meds.
In 2009, Toby self-reduced to 90mg/day with the help of
Acupuncture. His Polytrauma doc had been trying to get fee-basis
acupuncture for some time but had been denied until the VA hired their
own provider.
In the Fall of 2011, the Wounded Warrior Regiment recommended Toby
go to Operation Mend at UCLA. Toby finally made it to UCLA in March of
2013 after significant delays from the VA in providing Toby's medical
records. Doctors there diagnosed him with significant damage in his
sacroiliac joint and were able to conduct a 20 minute procedure to
resolve the issue.
Ultimately, Toby wanted to get off of the morphine. A VA nurse told
him that the only thing she could recommend was a ``prison-like'' detox
facility intended for substance abusers.
Toby approached his VA Primary Care doctor who wanted to help, but
clearly stated that he did not have experience in this field. The
doctor recommended a slow/gradual approach but offered no additional
specific guidance. As much as this doctor seemed to want to help, he
was just not equipped to assist.
Over a 6 week period, Toby self-reduced from 90mg/day to 0mg/day.
In the last few days/weeks, he was sick to his stomach and ultimately
had to take other meds to control his nausea. At no point did the VA
proactively assist in this process.
Ideally, Toby would have wanted them to treat the root cause of the
pain rather than just trying to medicate. Additionally, at the time of
the detox, he would have much preferred to be admitted to an
``appropriate'' in-patient facility that could have helped to monitor
the weaning process as well as its effects on his other injuries (TBI,
PTSD).
Each case is, of course, unique. But the profound frustration Toby
described mirrors that of other veterans, for whom their battles with
pain parallel their battles with seemingly rigid barriers encountered
at some VA facilities.
A warrior in Houston, Brandon Price, for example, coping with back
pain from an IED blast and knee pain from a gunshot wound, reported
waiting over 3 years to get into a pain management program at the
Houston VA. He was told he was `too young' to be experiencing chronic
pain and denied consults with the program until he worked with the
Medical Center's patient advocate. He finally got into the program in
Spring of 2013, but was told because of his delay in getting
appropriate pain management care, he would have to go back to primary
care to treat the severe muscle tension that was impairing their
ability to treat his back pain. He will not be seen again in the
program until January of next year. In the meantime, his primary care
team try to help all they can and he appreciates their work, however
they do not have the resources and expertise to treat his severe pain.
In addition, they are not allowed to prescribe any narcotic pain
medication, so even if it would be appropriate for treating his pain,
he would have to wait to be seen again by the pain management program
for such a prescription.
Our warriors' experiences and the observations of our teammates
across the country do raise serious questions. What steps, for example,
have been taken to address systems issues that may impede realization
of pain-management policy goals? \14\ The gap between policy and
practice, however, raises even broader questions. What, for example,
does it mean for the Veterans Health Administration to describe pain
management as a ``national priority?'' Given that declaration of
``national priority,'' the recognition that the practice of pain-
management in this country has been widely variable, \15\ and VA's
important role in the education and training of a large percentage of
our physician workforce, is there not a high burden on senior VHA
leadership to ensure that the letter and spirit of its pain-management
policy is actually implemented across the system? Does the term
``priority'' actually hold meaning, in an operational sense? Indeed,
one might even ask whether the Veterans Health Administration has
characterized so many subjects as ``priorities'' that it has become
difficult to make any issue a real priority!
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\14\ The Report of (VA) Consensus Conference: Practice
Recommendations for Treatment of Veterans with Comorbid TBI, Pain and
PTSD (January 20, 2010) cited the need to support clinicians who
provide interdisciplinary care, noting that ``there is no consistent
workload credit given to clinicians who take the time to manage or
review cases with other providers'' and the need for such credit to
promote coordinated, collaborative care. The report also cited the
importance of encouraging and offering incentives to providers to
follow clinical practice guidelines regarding the use of non-formulary
medications, noting the need for a ``'by-pass' around the sometimes
complex non-formulary approval process'' and the lack of a standardized
protocol for such review and approvals. See Report at http://
www.ptsd.va.gov/professional/pages/handouts-pdf/TBI--PTSD--Pain--
Practice--Recommend.pdf.
\15\ Office of the Army Surgeon General, Pain Management Task Force
Final Report, ``Providing a Standardized DoD and VHA Vision and
Approach to Pain Management to Optimize the Care for Warriors and their
Families,'' E-1 (May 2010) , http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
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We pose these questions as an organization that works with and
advocates for those whose sacrifices are immeasurable and to whom this
country owes a profound debt that must include provision of timely,
effective care for and rehabilitation of service-incurred wounds,
injuries and illnesses. We do not suggest that managing chronic pain in
warriors who, for example, have suffered polytrauma is easy or
necessarily susceptible of resolution in a primary care clinic. Nor -
to cite another critical challenge VHA has identified as a priority--is
it necessarily easy to provide timely, effective mental health care to
warriors who struggle with PTSD and often co-occurring behavioral
health issues. But these surely must be real priorities - obligations
that must be met ahead of others and met fully--for a health care
system dedicated to the care of veterans.
These concerns lead us to urge this committee to continue to press
VHA to make much more progress in the area of pain-management, but also
to re-establish what the term ``priority'' means for the Veterans
Health Administration, and to exercise whatever tools are needed to
realize those highest priorities. They begin, in our view, with wounded
warriors and their optimal timely care and rehabilitation. To fail to
meet that obligation is, in our view, to fail all veterans.
VIETNAM VETERANS OF AMERICA
Chairman Benishek, Ranking Member Brownley, and Distinguished
Members of the House Veterans' Affairs Subcommittee on Health, on
behalf of President John Rowan, our Board of Directors, and our
membership, Vietnam Veterans of America (VVA) thanks you for the
opportunity to present our statement for the record re: the Department
of Veterans Affairs (VA) pain management programs and the use of
medications, particularly opioids to treat veterans experiencing acute
and chronic pain.
Our veterans, returning from two protracted wars, deserve the very
best. Most agree that includes access to jobs, education, affordable
housing, quality health care, and equal opportunity employment
opportunities. After defending our freedom overseas, our soldiers,
sailors, airmen and Marines are clearly facing a crisis at home. We
need to ensure that those who have taken care of us abroad are taken
care of once they transition back to civilian life.
One area that is often overlooked is the proper diagnosis and
treatment for veterans suffering from chronic pain. While millions of
Americans suffer from chronic pain, many are veterans who brought the
unfortunate souvenir back from war. Despite the media attention given
to post-traumatic stress disorder (PTSD), the number one malady
suffered by America's active duty military personnel is
musculoskeletal. Given the number of physical injuries often
experienced by troops, it is not surprising that chronic pain is a
frequent problem among returning military personnel from Operation
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). Common sources
of chronic pain for these troops are in the head (traumatic-brain
injury or TBI) or post-concussion syndrome, legs (fractures,
amputations), burns, shoulders, back, and knees. Other physical
injuries include spinal-cord and eye injuries, as well as auditory
trauma.
According to a May 2011 study by the American Pain Society, about
nine in 10 Iraq and Afghanistan veterans who registered for care with
the Department of Veterans Affairs are experiencing pain. More than
half of these veterans have significant pain, the study asserted. In
raw numbers, of the 291,205 who enrolled for VA health care between
October 2003 and December 2008, 141,029 received a diagnosis of a
painful condition not caused by cancer.
It's no secret that the best way to treat chronic, severe pain is
by keeping it under control all the time, and for severe pain, the
World Health Organization recommends strong opioids such as
hydrocodone, as well as other such medications called adjuvant
therapies, as needed for the particular kind of pain. In fact, a paper
published in the March 7, 2012 Journal of the American Medical
Association described the pattern of opioid prescription for returning
OIF/OEF vets. Of the 291,205 who enrolled for VA health care between
October 2003 and December 2008, 141, 029 received a diagnosis of a
painful condition not caused by cancer; and of that number, 15,676
received a prescription of an opioid drug that lasted at least 20 days.
And now in October 2013 we learn that the death rate from overdoses
of such drugs at VA hospitals is twice the national average while the
data also show the VA continues to prescribe increasing amounts of
narcotic painkillers to many patients. Prescriptions for four opiates--
hydrocodone, oxycodone, methadone and morphine--have surged by 270
percent in the past 12 years, according to data from the Center for
Investigative Reporting (CIR) obtained through the Freedom of
Information Act. CIR's analysis exposed the full scope of that
increase, which far outpaced the growth in VA patients and varied
dramatically across the nation among VA hospitals.
And chronic pain is not limited to America's newest generation of
military personnel. It is also a significant malady among our older
veterans, especially Vietnam veterans suffering from PTSD, hepatitis C,
and those exposed to the herbicide Agent Orange. Given these
morbidities, it may not be surprising to see a higher frequency of
prescription opioids for these vets. Other common chronic pain
complaints often include headache, low back pain, cancer pain,
arthritis pain, neurogenic pain (pain resulting from damage to the
peripheral nerves or to the central nervous system itself), psychogenic
pain (pain not due to past disease or injury or any visible sign of
damage inside or outside the nervous system). Frequently these veterans
have two or more co-existing chronic pain conditions, including chronic
fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel
disease, interstitial cystitis, temporo-mandibular joint dysfunction,
and vulvodynia. In addition, research suggests these chronic pain
patients complain of cognitive impairment, such as forgetfulness,
difficulty with attention, difficulty completing tasks, impaired
memory, mental flexibility, verbal ability, speed of response in a
cognitive task, and speed in executing structured tasks.
We can help veterans, both young and older, by ensuring they have
access to improved treatments and medications to better manage their
chronic pain. The fact is every person experiences pain differently and
responds to treatments in different ways. Whether the pain stems from
head trauma, spinal-cord and eye injuries or an amputation, there must
be a variety of options available to treat the unique symptoms our
veterans are experiencing. But the rise in prescription drug abuse
threatens to stifle these options for fear of the further spread of
abuse and misuse. We must not let that happen.
Make no mistake, prescription drug abuse is a major concern within
the veteran community and VVA supports proactive measures to educate
veterans of this threat and to encourage responsible prescribing to
ensure these medicines stays out of the hands of those who abuse and
misuse the drugs. But we cannot allow for the abuse dynamic to restrict
veterans' access to the highest quality medications and treatments
needed to relieve their pain.
Prescription medicines are not the only solution for every veteran.
But for those who need them, they are critical. Together we can ensure
our warriors can live long and productive lives, even if they have to
manage pain. Access to quality health care and new options for
treatment will protect the next generation of Americans coming back
from war from experiencing the same challenges of past generations.
Whether a veteran has been wounded in combat, has experienced a
non-battle injury, or is currently working through a recovery, chronic
physical pain has the potential to play a significant role in their
rehabilitation and reintegration process. In fact, managing the
psychological and emotional effects of chronic pain can be just as
challenging as the pain itself. Let us not stand in the way of our
heroes fulfilling their dreams.
Vietnam Veterans of America
Funding Statement
October 10, 2013
The national organization Vietnam Veterans of America (VVA) is a
non-profit veterans' membership organization registered as a 501(c)
(19) with the Internal Revenue Service. VVA is also appropriately
registered with the Secretary of the Senate and the Clerk of the House
of Representatives in compliance with the Lobbying Disclosure Act of
1995.
VVA is not currently in receipt of any federal grant or contract,
other than the routine allocation of office space and associated
resources in VA Regional Offices for outreach and direct services
through its Veterans Benefits Program (Service Representatives). This
is also true of the previous two fiscal years.
For further information, contact: Executive Director of Policy and
Government Affairs, Vietnam Veterans of America. (301) 585-4000,
extension 127
AMERICAN PSYCHIATRIC ASSOCIATION
On behalf of the American Psychiatric Association (APA), the
medical specialty society representing over 35,000 psychiatric
physicians and their patients nationwide, I welcome the opportunity to
submit a statement for the record regarding the October 10th House
Veterans Affairs' Subcommittee on Health hearing, ``Between Peril and
Promise: Facing the Dangers of VA's Skyrocketing Use of Prescription
Painkiller's to Treat Veterans.''
The APA has for several years stressed the need for funding and
workforce strength to support comprehensive mental health and substance
use disorder treatment in the Veterans' Health Administration (VHA).
The October 10th hearing highlighted a few issues which the APA has
long advocated: improved prescription drug management programs (PDMPs)
at the VHA as well as interoperability with state-run PDMPs, training
of medical personnel on options for medically assisting substance use
recovery, and the urgent need for non-opioid medications to treat
chronic pain.
The focus of our statement is the veteran and returning military
population, but issues such as medication diversion (taking a relative
or friends' medication), medication seeking (doctor-shopping), improper
prescribing, inadequate informatics on prescription utilization, and
the need for better pain management as well as utilizing medical
options to assist with substance use disorders are prevalent for the
United States population as a whole.
In 2008, Congress directed the VHA to develop and implement a
comprehensive policy on the management of pain experienced by VHA
patients. Many VHA facilities are making significant progress on
implementing the VA's mandate to improve pain management. In addition
to this policy framework, VHA and Department of Defense (DoD)
counterparts developed clinical practice guidelines for management of
opioid therapy for chronic pain. The guidelines, first published in
2003, were intended to improve pain management, quality of life and
quality of care. The guidelines were updated in May 2010 to reflect
evidence-based practice. However, challenges still exist to fully
implement evidence-based, comprehensive pain management as well as
opioid addiction treatment.
Prescription Drug Management Plans (PDMPs)
Prescription Drug Management Plans help to identify and prevent
potential misuse of prescription drugs, and assist in avoiding negative
health outcomes for VA patients, including emergency treatment and
accidental overdose. Thirty-eight states have PDMPs. Within the VHA
itself, there is uneven utilization by providers of the VA's own health
records program to verify prescription data for patients.
The APA has expressed concern that barriers to quality patient care
as well as a patient safety are the limitations in VHA's ability to
monitor prescriptions written for veterans outside of the VHA system.
Prescription data coordination can assist VHA physicians in identifying
veterans who need intervention and treatment for substance use
disorders as well as prevent intentional overdosing by alerting
physicians to multiple prescriptions. The APA is encouraged by the
Interim Final Rule on the VHA's prescription drug monitoring program
effective on February 11, 2013, (VA-2013-VHA-0005-0001), which codified
the VA's PDMP. The APA looks forward to the VHA's PDMP system's
interoperability with state-run PDMPs. We note, however, that there are
no national standards for state PDMP information sharing and
interoperability between states is a hurdle to overcome.
Therefore, the APA respectfully requests that the VA enhance its
collaboration with the Department of Justice, Department of Health and
Human Services and state Attorneys General to expedite interoperability
of the VA PDMP with state PDMP programs using the prescription
monitoring information exchange (PMIX) computer architecture.
Recruitment and Retention of Psychiatrists
VHA Deputy Undersecretary Robert Petzel, M.D., stated in January
2013 before the House Veterans' Affairs Committee that the major
workforce barrier to mental health and substance use treatment was the
VHA's difficulty in hiring and retaining psychiatric physicians.
Congressional testimony given by current and former psychiatric
physicians in the VHA highlights non-competitive pay, uneven training,
and long hiring processes as key barriers to developing and maintaining
a robust psychiatric workforce.
The APA strongly encourages the VHA to further adjust the pay
tables for psychiatric physicians to more accurately reflect the acuity
of VHA need as well as to redress the imbalance that occurs when newly
hired psychiatrists have compensation packages that are not aligned
with the compensation of career VHA psychiatrists with years of
experience and training. Such redress may improve the retention issues
at VHA.
Recruitment of psychiatrists as specialty physicians remains an
issue at the VHA. According to USAjobs.gov on September 17, there were
142 federal job vacancies for psychiatrists listed, of which 138 were
for the VHA; 128 positions were for permanent hires. Of the 128 vacant
full-time positions, only 33 (25%) were even eligible for medical
school loan repayment under the VHA's Education Debt Reduction Programs
(EDRP) program. Even if a VHA physician position is eligible for loan
repayment, eligibility does not confer actual loan repayment. Under the
EDRP program, a psychiatrist must apply for medical school loan
forgiveness within six months of his or her hire date. VHA's HR
departments are all too often unaware of this six-month stipulation,
rendering some psychiatrists ineligible.
The APA is developing a recruitment and retention workforce
proposal for psychiatrists at the VHA that would establish a medical
school loan forgiveness program similar to that provided by the U.S.
Army. The proposal would be a time limited opportunity to increase the
number of psychiatrists in the VHA and would also require a VHA study
on its impact. We look forward to working with Congress to enact this
and related proposals to increase the supply of psychiatrists providing
care to our nation's veterans.
Training the VHA Workforce: pain management and addiction treatment
Two issues overarch the VHA's nationwide ability to meet its
Congressional mandate to provide comprehensive pain management services
to our nation's veterans: evidence-based prescribing and pain
management techniques for all veterans and enhanced availability of
opioid-dependence treatment for those struggling with addiction.
The utilization of pain medication without benchmark pain
assessments and accompanying treatment plan is inconsistent with good
medical practice. Of particular concern is the prescription of multiple
pain medications to veterans with multiple medical issues. Data suggest
that some veterans with Post Traumatic Stress Disorder (PTSD)
experience pain at a more intense level than their counterparts without
PTSD. Veterans are subject to unique risk factors involving the misuse
of prescribed controlled substances (Karen H. Seal et al.,
``Association of Mental Health Disorders With Prescription Opioids and
High-Risk Opioid Use in US Veterans of Iraq and Afghanistan,'' 307 JAMA
940 (2012)). Many veterans being treated for opioid dependence also
have co-occurring diagnosis such as depression or anxiety. Treatment of
these co-occurring illnesses only underscores the need for more
psychiatrists in the VHA.
Academic detailing or enhanced pharmacologic training provided by
physicians to VHA medical personnel regarding evidence-based for
treatment of pain and opioid dependence is necessary throughout the
VHA. Certain Veterans Integrated Service Networks (VISNs), such as VISN
20, 21 and 6 have implemented short, in-service training programs to
change providers' practices in prescribing pain medication,
particularly for those patients with co-occurring PTSD and depression.
All too often, veterans (and other Americans) take prescription
pain medication for orthopedic or nerve injuries and become addicted to
or dependent on opioid medications used for pain. For opioid-addiction
treatment options, the APA strongly encourages the utilization of and
more trained physicians, particularly by psychiatrists who are
specially trained, in the use Suboxone and Buprenorphine in opioid-
dependence treatment. These medications act as `opioid antagonists' and
can assist in the supervised withdrawal from opioids. The APA is a
partner organization in two clinical mentoring and education
initiatives funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA): Physicians' Clinical Support System-
Buprenorphine (PCSS-B) and the Prescribers' Clinical Support System-
Opioid Therapies (PCSS-O). Through the SAMHSA-funded grant, the APA has
produced a series of webinars focused on the use of opioid therapies
for treatment of opioid dependence and on the safe use of opioids in
the treatment of chronic pain. The free webinars are available for
psychiatrists, physicians of other specialties, other prescribers,
residents, and other interested clinicians. Webinar recordings are
available on this site. www.pcssb.org/educational-and-training-
resources/special-topics and include:
The Use of Buprenorphine to Treat Co-occurring Pain and
Opioid Dependence in a Primary Care Setting
Learning the Evidence Behind Alternative/Complementary
Chronic Pain Management - Emphasis on Chronic Low Back Pain
Patterns of Opioid Use, Misuse, and Abuse in the
Military, VA, and US Population
Enhancing Access to PDMPs Through Health Information
Technology
Identifying and Intervening With Problematic Medication
Use Behaviors
Assessing and Screening for Addiction in Chronic Pain
Patients
Psychological Management and Pharmacotherapy of Patients
with Chronic Pain and Depression, Schizophrenia, and Post Traumatic
Stress Disorder (PTSD)
Research on New Pain Medications
Federal agencies are currently involved in the development of new
pain medications and methods to treat pain. The National Institute of
Drug Abuse (NIDA) has been at the forefront of biomedical exploration.
NIDA has, through an established testing program involving contract and
grant mechanisms, developed several opiates pharmacotherapies that have
been approved for use (Buprenorphine, Buprenorphine/Naloxone). Through
interaction with leading substance abuse experts in academia, the
pharmaceutical industry, and the Food and Drug Administration, NIDA has
developed standardized outcome measures and success criteria for
clinical pharmacotherapy trials, established clinical algorithms and
standards for the conduct of exploratory clinical concept studies;
human drug interaction studies; and Phase I, II, and III safety and
efficacy studies. The Department of Defense, Veterans' Administration
and the National Science Foundation are other major federal agencies
investigating new pain medications and treatment.
The APA has vigorously supported enhanced federal research to
encourage the development of a new class of pain medications that would
not have the same potentially addictive effects as long term use of
opioids. Sustained, robust federal investment must be a national
priority in order to make significant progress on inventing novel
medications and developing new mechanisms - biological or chemical - to
control pain. NIDA's Clinical Trials Networks are currently testing on
a few molecules of interest.
Pain management, addiction detection and effective treatment are
significant priorities for our nation's veterans. These objectives
require the better coordination of opioid and benzodiazepine
prescribing inside and outside the VHA. We strongly support robust
research and more training throughout VHA medical personnel of the uses
of medications such Suboxone and Buprenorphine to assist in the
treatment of addiction, along with the development of new non-opioid
medications to treat pain. Above all, we believe that access to a well-
trained workforce grounded in the highest quality care and respect for
veterans and their families is of paramount importance. We stand ready
to assist you in achieving these goals.
The APA appreciates the opportunity afforded by Chairman Benishek
and Representative Brownley to provide this statement on behalf of its
members. Should you have any questions or need further information,
please do not hesitate to contact my staff, Lizbet Boroughs, at (703)
907-7800 or [email protected].
Sincerely,
Saul Levin, M.D., M.P.A.
CEO and Medical Director
American Psychiatric Association
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