By Sandra Basu
WASHINGTON — Lawmakers charged that the VA is not doing enough to ensure that medication use is properly managed among veterans — particularly those already struggling with mental health issues.
VA officials were questioned on prescription mismanagement and risk of veteran suicide during a hearing held by the House Committee on Veterans’ Affairs Oversight and Investigations Subcommittee.
“Currently, VA has approximately 10 different programs dealing with prescription medications and suicide prevention, but it does not appear that any of these programs interact with one another,” said House subcommittee chairman Rep. Mike Coffman (R-CO). “No one is talking to anyone else. How can we ensure that the veterans are getting the proper care, the proper follow-up and the proper advice if the right hand doesn’t know what the left hand is doing?”
“We know from multiple IG and GAO reports that VA has struggled to properly monitor opioids and the mental health of its patients,” added Rep. Ann McLane Kuster (R-NH). “I’m concerned that a potentially deadly mix of opioid use, mental health disorders and lack of oversight is contributing to our high rate of veteran suicide.”
The VA estimates that 50% to 60% of veteran patients experience chronic pain due to battlefield and other service-related injuries. VHA Interim Under Secretary Carolyn Clancy told lawmakers that her agency has “more work to do to reduce opioid use, meet the increasing demands for mental healthcare and prevent suicides.”
She described some of the actions taken to improve the situation. When it comes to medication management, a newer program VA is implementing is a “one-on-one” coaching program to help align individual prescribing practices with published medical evidence, Clancy explained. The Academic Detailing Initiative consists of “one-on-one coaching for every single clinician prescriber,” in the VA system by a specially trained clinical pharmacist.
“Based on the results of a three-year pilot, I believe Academic Detailing holds the promise of continued progress personalizing veterans’ pain management and assure medication safety,” she further explained in a written statement.
In her written statement, Clancy discussed a predictive model and clinical decision-support tool developed by VA to identify patients with opioid prescriptions who are at risk of suicide-related events and overdose. The tool is currently being pilot-tested.
Meanwhile, lawmakers expressed their concerns about medication management for veterans.
Rep. David Roe (R-TN) said he had heard of medications prescribed to troops in DoD being discontinued when the servicemembers transitioned to VA.
Clancy, however, said that was not the case, adding, “They continue on the drugs that they were getting in the service.”
Rep. Beto O’Rourke (D-TX) said he was concerned that, in the effort to reduce opioid prescribing, veterans might have their prescriptions cut off too abruptly and seek relief through street drugs.
“How many of those no longer receiving prescriptions are now using heroin or other street drugs?” he asked.
O’Rourke also said that veterans in his congressional district are having trouble getting an appointment with their provider to have their painkiller prescriptions renewed.
“At a minimum they are suffering, and in some cases I would connect that suffering to suicides that we see in El Paso,” he added, expressing a concern that veterans would go without appropriate medications or seek a dangerous alternative on the street.
During the hearing, Clancy promised O’Rourke that he had her “unwavering commitment” to address access issues in his district.
Also testifying was GAO Healthcare Director Randall Williamson. He spoke about findings from a November 2014 report showing that, out of a review of records of 30 veterans with major depressive disorder, 26 were not assessed at four to six weeks after initiation of antidepressant treatment, as required by clinical practice guidelines.
In response to a question from Coffman as to why this was not occurring, Clancy responded, “We will be looking to see whether that is a feature of the fact that we were having access problems and it was hard to get people back in, or whether we weren’t just on the ball.”
Congressmembers also questioned when improvements would be made to the Veterans Crisis Line so that veterans who call their local VA can directly connect to the hotline without having to hang up first and then call the hotline.
Clancy told lawmakers that change should be fully implemented by November or December; veterans then would be able to press a number on their phone and be directly transferred to the hotline when calling their local facility.
Roe said he didn’t understand why it would take so long to make a seemingly simple fix.
“How long does it take to change a phone number?” he asked.
Clancy said the VA wants to make sure that staffers taking the calls aren’t overstressed, pointing out that a suicide had occurred among that group.
“As you can imagine, that is a very, very stressful job,” she said. “So that is the reason that we are just testing it first in about 20 different facilities this summer, and then we will roll it out full steam this fall.”
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.