By Sandra Basu
WASHINGTON — In the wake of accusations that veterans are over-prescribed powerful painkillers, a House of Representatives subcommittee chairman called on VA to adopt more effective pain management protocols.
“The stakes are too high for VA to continue to get it wrong,” said Rep. Dan Benishek, MD, (R-MI), who chaired a subcommittee hearing titled “Between Peril and Promise: Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkillers to Treat Veterans.”
Benishek questioned VA for using what he says is a pain management treatment model “that makes primary care, rather than specialty care, the predominant treatment setting for veterans suffering from pain.” Benishek worked part-time at the Oscar G. Johnson VA Medical Center in Iron Mountain, MI, for 20 years.
The hearing came on the heels of a report by the Center for Investigative Reporting that VA prescriptions of hydrocodone, oxycodone, methadone and morphine increased by 270% in the past 12 years. The data for the report was obtained through the Freedom of Information Act.
“VA can and must change course and act now to reduce their reliance on the use of prescription painkillers,” Rep. Jeff Miller (R-FL), chairman of the House Committee on Veterans’ Affairs, said at the hearing.
Toll of Painkillers
Veterans and family members of deceased veterans testified at the subcommittee about the toll of overprescribing opioids at VA facilities.
Heather Renae McDonald told lawmakers that her husband, Scott Alan McDonald, was treated by the VA and was on up to 15 pills a day within the first six months of back pain and mental health treatment. In September of 2012, she said she found her husband dead on their couch after he had been prescribed Percocet.
McDonald maintained that her husbands’ liver was inflamed and that VA clinicians would have known that if they had done liver function testing, in light of the large number of medications he was taking.
“When I asked VA why more tests were not performed to make sure he was healthy enough, they responded that it was not routine to evaluate our soldiers’ pain medication distribution,” she told lawmakers.
Kimberly Stowe Green, meanwhile, told lawmakers that her husband, Ricky Green, died in 2011 “because of the prescription pain and sleeping medications that VA and its doctors prescribed for him.” Green said that the Arkansas State Crime Laboratory and the state medical examiner performed an autopsy and found the cause of death was “mixed drug intoxication.”
“The VA already has written guidelines for prescribing painkillers, but these are not being followed,” she told lawmakers.
Justin Minyard, who is medically retired from the Army, said that he had suffered from back pain and was prescribed painkillers by both DoD and VA healthcare providers. At his worst point, he said he was taking enough opioid pain medication to treat four terminally ill cancer patients.
After looking for other options to control his pain, he found a doctor at Fort Bragg who was conducting a clinical trial of spinal cord stimulation. That treatment has been successful for him, and he said he is now off opioids. He cautioned, however, that not all veterans and servicemembers have the resources and awareness to advocate for alternatives to opioids pain regimens.
“My wife had to advocate for me, not taking ‘no’ for an answer,” he said in his written statement.
In other testimony, two VA physicians testifying before the House subcommittee said they were pressured to prescribe painkillers to patients.
Pamela Gray, MD, told the subcommittee she was coerced into prescribing prescription painkillers at the Hampton, VA, VAMC, where she worked from 2008 to 2010 before being fired after she objected to those practices, according to her testimony.
“During my two-year period, I was coerced to writing drug [prescriptions] that I knew in my medical experience were wrong. When I would object, I was simply told to do it or else,” she said.
Gray further said that she would document in her medical notes in the electronic health record that she was being coerced by nonmedical employees to write prescriptions for opioids but that the notes were altered.
Gray also said she was named the head of pain management at her medical center on the first day of her job, despite havingno training for it.
“I was never asked if I wanted to assume this role. I was informed. I was [in] pain management with zero training,” she explained. “My concern with that is that it is not standard of care.”
Another clinician, Claudia J. Bahorik, DO, also told lawmakers of the predicament facing VA physicians when it comes to prescribing painkillers.
“It is not uncommon for a doctor to refuse to write a narcotics prescription only to have the [veteran] go to the administration,” she said. “What happens? The administrator calls another doc and tells 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 response, VHA Principal Deputy Undersecretary of Health Robert L. Jesse, MD, thanked the family members of the deceased veterans for sharing their stories at the hearing. He also told the subcommittee that VA is “strongly committed to ensuring veterans do have what they need to manage their pain, and that includes not just medications.”
“This is not an issue limited to veterans. Veterans are a population who are particularly challenged, but this is a national crisis,” Jesse pointed out.
When lawmakers asked Jesse about concerns that physicians were pressured to write prescriptions, he said that was “absolutely indefensible” and that, as physicians, they should “feel absolutely that they should refuse to do that.”
Also testifying was Steven Scott, MD, VHA chief of physical medicine and rehabilitation service. He discussed the pain-reduction strategies used at the James A. Haley Veterans’ Hospital and Clinics in Tampa, FL. The facility has both an inpatient and outpatient Chronic Pain Rehabilitation Program that uses a variety of strategies.It has been twice recognized as a Clinical Center of Excellence by the American Pain Society, according to Scott’s written testimony.
Still, lawmakers suggested that the system must be fixed. Rep. Julia Brownley (D-CA) said that while she has faith that there are pockets of excellence in the VA, the system “appears to be broken.”
“How do you respond to the comments that we have a system of quick-and-cheap over good-and-thorough and that the basic principles of medicine have been abandoned?,” she asked.
“I don’t believe that is the case systemwide,” Jesse responded.