Congress to VA: More Oversight Needed for Vets in Pain

A subcommittee to the House Committee on Veteran Affairs questioned the Department of Veteran’s Affairs about the unrelenting tide of soldier suicides and mismanagement of opioid prescriptions at a hearing on Wednesday. Some representatives suggested the two crises might be intertwined.

“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,” said ranking member Ann McLane Kuster (D-N.H.).

In her opening statement, she cited the Centers for Disease Control and Prevention’s description of opioid abuse as “the worst drug addiction epidemic in the country’s history.” Yet, half a million veterans are taking the potent medications to manage serious pain problems, she said.

You can use statistics like this, that half a million veterans are taking opioids, but that doesn’t even begin to identify the problem.  In fact, when you break down these statistics, it may very well show that chronic pain is being under-treated and mistreated, with weak medications and drugs like mood stabilizers. Everyone can keep blaming opiates for addiction and suicides, but as long as the blame is being misplaced, nothing will get better.  And how come nobody addresses the high rates of alcohol abuse in this patient population?

Have there been cases where opioids were the only cause of an overdose or suicide?  If so, I haven’t read about it.  But I have read about veterans who have committed suicide because their pain medications were reduced or taken away — to be replaced with nothing.

A recent report from the Government Accountability Office questioned the VA’s efforts both to address veterans’ mental health problems and to properly oversee prescriptions. The report noted that the VA doesn’t have an accurate count of the number of veterans with depression because of “inappropriate coding.”

-VA data may “understate prevalence of major depressive disorder” in veterans treated at VA centers
-VA centers neglected to use standard assessment tools within 4 to 6 weeks of beginning antidepressants, VA’s own clinical practice guidelines (CPGs)
-VA reports of clinical and demographic data related to veterans’ suicides were flawed

With regard to opioid abuse, the Department of Veterans Affairs said it is helping to combat overuse of prescription drugs. Since the implementation of an opioid abuse prevention program 2 years ago, 100,000 fewer patients have been receiving opioids and another 34,000 fewer patients were given opioids and benzodiazepines together — because of known drug interactions. Another 75,000 patients were asked to take urine tests to ensure that veterans are using the drugs and not “diverting” or selling them.

You take away the drugs that work, and you don’t expect the suicide rates to increase?  Why? And how many drug test results were inaccurate?  How many veterans were abandoned because of this?

In trying to rein in one problem the VA may have created another. Rep. Beto O’Rourke (D-Texas) said that because of new policies aimed at reducing prescription abuse, some veterans’ prescriptions were cut off without notice and without the kind of tapering that patients taking such powerfully addictive drugs require.

You can correctly taper patients off these drugs, but then what kind of treatments can successfully replace them?  Surgery or acupuncture?  They’re not addressing the complete picture of treating chronic pain and are only concerned about addiction.

Other veterans, who must visit their doctors monthly in order to refill their prescriptions — another safety provision — aren’t able to get appointments, he said…  “So they go without or they go with something that they shouldn’t have that perhaps they buy on the street,” O’Rourke said. “At minimum they’re suffering, and in some cases I would connect that suffering to the suicides that we see in El Paso,” he added.

Lack of access to mental health care exacerbates this problem, said O’Rourke, who noted a 24% vacancy rate in mental health providers at veteran centers in El Paso, where mental health services for veterans are ranked 157 out of 158.

Tim Walz ( D-Minn.) reminded the VA that some of the questions plaguing the agency were answered by the Military Pain Care Act of 2008, which he helped author. Walz asked Carolyn Clancy, MD, interim undersecretary for Health at the Department of Veterans Affairs, why a bill designed 7 years ago to target the same issues in pain managment was never fully implemented. The bill expired 8 months ago. Three months ago, Walz sent a letter and still hasn’t received a response. “This might not have been the fix, but why didn’t we do it?… Why hasn’t it been done?”

Congress doesn’t follow up on implementation or the letters they write, and then allows a bill to expire — so where does the blame fall?

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