The Syracuse Veterans Affairs hospital prescribed Heath Phillips (above) up to five medications, leaving him in “zombie-like” state. (Courtesy of Heath Phillips)
WASHINGTON — There are days when Navy veteran Brian Lewis is in too much pain to get out of bed.
Since he moved to the outskirts of Saint Paul, Minn. three months ago, he’s been trying to get a medication consultation at the local veterans hospital. Lewis, a former Navy petty officer third class, needs opioid painkillers for nerve damage he sustained during his service at Naval Base San Diego — but he’ll have to wait until the end of March due to a backlog of patients.
Getting out of bed, or at least out of his chair, used to be a problem for Navy veteran Heath Phillips too, but for a different reason. Doctors at the Veterans Affairs hospital in Syracuse prescribed the former seaman up to five different medications between 2009 and 2010, making him so intoxicated that his wife had to drive him to his own doctor appointments. His kids would make fun of him while he sat in his chair at home, drooling. “You’re a zombie,” they’d say.
Phillips hasn’t taken medication since then. He doesn’t trust the veterans’ facilities anymore.
The two cases, with vastly different approaches to drug prescription underscore an issue plaguing health care at Veterans Affairs hospitals – lack of uniformity in care.
“It goes back to the problem of VA hospitals being very independent and each one setting their own local policies in terms of what’s tolerated and what’s not,” Lewis said. “It varies from place to place, and there’s no real sense of regularity or continuity across the VA system.”
VA officials did not respond to repeated requests for comment.
Lack of Unity
Unclear drug management guidelines in the Department of Defense have led to inconsistent prescription practices in veterans’ hospitals across the nation, the department’s Inspector General Office reported in February. For veterans, the consequences range from increased drug abuse to disproportionate rates of accidental drug-related deaths, according to the journal Medical Care.
The National Institute on Drug Abuse reported that prescription drug abuse by service members doubled from 2002 to 2005, and almost tripled from 2005 to 2008. Veterans are especially susceptible to drug misuse because they often have mental health issues and physical injuries, requiring them to take several medications at once and to change prescriptions frequently, the DoD inspector general’s report said. A January 2012 report by the Army noted that prescription medications accounted for 72 percent of the Army’s 197 drug-related accidental deaths between fiscal 2009 and 2011.
The poor organization of pain treatment by the Veterans Health Administration leaves patients at twice the risk of fatal accidental medication poisoning as non-VHA patients, according to a 2011 study by the journal Medical Care.
Plus, the absence of drug take-back programs has limited the ability for veterans to dispose of their addictive medications.
Lawmakers on Capitol Hill have taken notice, holding hearings on prescription use among veterans. But the congressional criticism has spurred a knee-jerk reaction in veterans’ hospitals — causing them to reel back their prescriptions, leaving people like Lewis in limbo.
The inconsistency of regulations across hospitals has caught the attention of many veterans and advocacy group leaders, including Doug Walker of the Disabled Veterans National Foundation.
“The issues that [the VA has] range from hospital to hospital, they’re not really consistent issues,” Walker said. “Some hospitals will be strapped for personnel, some will be strapped for medical equipment.”
And with veterans of two recent wars returning home, things aren’t about to get easier, Walker said.
Brian Lewis sustained nerve damage serving in the Navy and is now unable to get pain medications to relieve his symptoms. (Courtesy of Brian Lewis)
A Deadly Cocktail
In October 2013, veterans and widows of veterans appeared before a congressional committee to highlight the problem of veteran overmedication.
Kimberly Green, a 21-year air force veteran, testified about the death of her husband, Ricky Green, a 23-year army veteran who retired in 2010 as a Sergeant First Class with injuries to his back, knees and ankles sustained while training to be a paratrooper.
Ricky died on Oct. 29, 2011, four days after VA doctors performed surgery on his lower back. The cause of death: mixed drug intoxication complicating recent spine surgery. He was 43.
Because of the chronic pain from his injuries, VA doctors had written Ricky a lengthy list of prescriptions, including Oxycodone, Hydrocodone, Valium, Ambien, Zoloft, Gabapentin and Tramadol.
“My husband … followed the orders of his VA doctors in taking these pain medications — and these pain medications led to his death,” Kimberly said.
At one point, Ricky was taking Oxycodone and diazepam — a combination that proved lethal, she said.
Ricky had sleep apnea, a condition that causes shallow, strained breathing in sleep. Sleep apnea requires special consideration when doctors are prescribing pain medications, according to VA/DOD Clinical Practice Guidelines. Ricky’s sleep apnea interacted fatally with the painkillers.
Officials insist that Veterans Affairs is taking action against disorganization in the system.
“Health Affairs is currently evaluating how best to meet the need for additional policy and safeguards” to enhance current policies, said Kevin Dwyer, spokesman for the Defense Health Agency.
The department maintains a prescription database that cross references veterans’ prescriptions with their medical history to determine risk for an adverse drug event. The system — which also screens against prescriptions obtained by service members when deployed — prevented more than 700,000 potentially life-threatening drug interactions between 2000 and 2013, Dwyer said.
The database is used to flag high-risk veterans and communicate warning to military treatment facilities. But the DOD has been reviewing cases where physicians have manually overridden warning flags, Dwyer said.
The DOD, however, has yet to fully implement its guidelines, Kimberly said. Doing so could have saved the lives of people like Ricky.
“I strongly believe that my husband was entitled to receive the quality of care that the VA, and DOD set forth in writing their own guidelines,” Kimberly said. “However, these guidelines have not been fully implemented and are not being followed — and our veterans are suffering the consequences.”
The progress of VA reform has been called into question, too. At an online seminar in 2012, Dr. Bob Kerns, a former national program director for pain management who works at a VA Hospital in Connecticut, said the Clinical Practice Guidelines have not been fully implemented since they were published in 2010.
“Ricky survived serving in combat zones in over 20 years of military service, but he could not survive the VA and his negligent treatment,” Kimberly said.
The DOD has participated in the Drug Enforcement Administration’s national drug take-back day since 2011 to help veterans dispose of unwanted or outdated prescriptions. But the department has not had the authority to create its own program, which means military hospitals cannot take back unwanted drugs. According to Dwyer, the DEA recently told the DOD that it would give DOD hospitals and clinics with on-site pharmacies “collector” status so they could manage their own drug take-back programs.
“A drug take-back program would indeed reinforce ongoing DOD activities in patient safety, suicide prevention and pain management,” Dwyer said.
Looking forward
Veterans and advocates say that more than anything, the issue of painkiller policy reform needs awareness, not money.
“More funding doesn’t always do it,” Walker said of the Disabled Veterans National Foundation.
Even outside of veteran care, pain treatment is a “hugely controversial” issue within the medical community, said Siegfried Othmer, chair of Homecoming for Veterans, a treatment research institute.
“There is not a unity of perspective on this. The mainstream of doctors think of pain doctors — people who really focus on pain conditions — as being medically reckless,” Othmer said.
Othmer develops pain treatment that teaches the brain to deal with pain so that veterans don’t have to rely on painkillers. Painkillers, he says, create dependency because their effects only last so long.
“It’s endless,” Othmer said. “There’s just no good end to that story.”
