The American Legion
STATEMENT FOR THE RECORD
OF THE AMERICAN LEGION
SUBCOMMITEE ON HEALTH
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES
“BETWEEN PERIL AND PROMISE: FACING THE DANGERS OF VA’S SKYROCKETING USE OF PRESCRIPTION PAINKILLERS TO TREAT VETERANS”
OCTOBER 10, 2013
A CBS News Story 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).
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 in September 2013.
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.
Symptom Clusters amongst OEF/OIF Veterans (Lew Study)
Secondly, OEF/OIF veterans with mental health diagnoses 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.
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.
…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.
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 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.
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 firstname.lastname@example.org.
 Primarily Posttraumatic Stress Disorder
 Resolution No. 150 Support for Pain Management Research, Treatment and Therapies at DOD, VA, and NIH