(7/17/2015) VA must strike better balance in managing veterans’ pain.

http://www.startribune.com/va-must-strike-better-balance-in-managing-veterans-pain/316371311/

The two-part Star Tribune series, which ran Sunday and Monday, documented a different though equally disturbing facet of pain medication mismanagement. The series’ findings suggest that the VA system swung too suddenly in the other direction after the national spotlight on overprescribing. Veterans with a legitimate need for powerful pain medications aren’t getting them or are facing unacceptable delays in getting refills. The VA also appears to have been ill-prepared to help veterans access alternative therapies — such as acupuncture — during pain medication tapering.

The series’ findings merit the same kind of scrutiny that overprescribing did. Veterans should not be imprisoned by pain because doctors are unwilling or unable to prescribe the medications they need…

http://www.startribune.com/cut-off-veterans-struggle-to-live-with-va-s-new-painkiller-policy/311225761/

Part 1

Williams eased the chronic pain with the help of narcotics prescribed for years by the Minneapolis Veterans Medical Center. Then the VA made a stark and sudden shift: Instead of doling out pills to thousands of veterans like him — a policy facing mounting criticism — they began cutting dosages or canceling prescriptions, and, instead, began referring many vets to alternative therapies such as acupuncture and yoga.

At first, the change seemed to work: Worrisome signs of prescription drug addiction among a generation of vets appeared to ebb. But the well-intentioned change in prescription policy has come with a heavy cost. Vets cut off from their meds say they feel abandoned, left to endure crippling pain on their own, or to seek other sources of relief.

Or worse.

On Sept. 20, 2013, police were called to Williams’ Apple Valley home, donated to him by a veterans group grateful for his sacrifice. Williams, 35, lay dead in an upstairs bedroom. He had overdosed on a cocktail of pills obtained from a variety of doctors.

Authorities ruled his death an accident, officially “mixed drug toxicity.” Advocates for veterans and some treatment counselors angrily call it something else: the tragic result of the VA’s failure to provide support and services for vets in the wake of the national move away from prescription pain pills.

At the VA’s Medical Center in Minneapolis, for instance, there is one chiropractor on staff for the more than 90,000 patients it sees a year…

Before alternative therapies can work, Kolodny said, the VA needs to better tend to the addicts it has created…

The Minneapolis VA, which had one of the highest rates of high-dosage prescription pain medications, has embraced the new directive to reduce painkiller use among its patients. It pioneered a program that emphasized education and alternative therapies like yoga, chiropractic treatment and acupuncture. In a three-year period from 2011 to 2014, it reduced the number of veterans on long-term high-dose opioids by 78 percent…

In their published findings, Marshall and his colleagues wrote that there were fewer complaints than expected. “Patients mostly appreciated what we were doing,” said Marshall, who now directs pain management programs at the Minneapolis VA and the VA’s Upper Midwest region. While the paper recommended further research into patient satisfaction, the study surveyed only providers and pharmacists…

Although statistics aren’t available, deaths of vets linked to the VA’s pain policy are showing up in headlines around the country.

Last July, Navy veteran Kevin Keller drove himself to a drugstore parking lot next to a VA community clinic in Wytheville, Va., late at night, walked to the door of the clinic and shot himself in the head.

In recent years Keller had complained that VA doctors were reducing his pain medication. Keller had scribbled a note to a friend. In capital letters it read: “SORRY I BROKE INTO YOUR HOUSE AND TOOK YOUR GUN TO END THE PAIN! FU VA!!! CAN’T TAKE IT ANYMORE.”

In October 2013, Todd Roy, a 45-year-old Persian Gulf veteran, shot himself in the head with a shotgun in friend Charlie Bollman’s garage in Watkins, Minn. In 2008, the VA, citing alcohol and drug abuse, had cut off Roy’s Vicodin for pain in his arm and shoulder…

For more than 40 years, Vietnam vet Peter Ingravallo has suffered back pain after being hit with shrapnel during an ambush. With a 100 percent disability rating, Ingravallo took 25 milligrams of oxycodone every four hours until the Minneapolis VA sent him a letter telling him it was reducing his medications by 70 percent. It also warned that he would lose his benefits if he got meds from somewhere else…

Some vets have been warned that if they don’t take part in educational programs, they won’t get prescriptions. Failure to submit urine samples could result in expulsion from the program.

Vets also complain of being kicked out of programs for failing “pain contracts” they were ordered to sign. The contracts require the vets to agree to submit to urine screenings and to take one of several VA opioid safety classes or risk being denied their medications…

Ryan Trunzo’s descent from promising soldier to drug addict is detailed in more than 500 pages of medical files and Army reports…  Trunzo, who was 19 when he joined the Army, served in Iraq from February to November 2008 and was injured when his convoy was hit by a roadside bomb. He suffered several small fractures in his back and was given some painkillers.

There were other traumas: the death of a close friend, the shooting death of an Iraqi boy and an incident in which he said he was ordered to stand guard while a superior officer sexually assaulted an Iraqi woman…

But, because of a history of addiction during his military service and the change in VA policy, for the pain Trunzo got tablets of nothing stronger than over-the-counter-strength ibuprofen…

http://www.startribune.com/the-new-goal-at-the-va-treating-the-root-causes-of-veterans-pain/311225971/

Part 2

The Minneapolis VA hired its first chiropractor in 2014 and was overwhelmed by the response, with more than 850 visits in less than five months. Because of the demand, 23 veterans have been allowed to make appointments with chiropractors outside the VA. The Minneapolis VA said it hopes to have its second chiropractor in place this summer.

Dr. Carolyn Clancy, then the interim VA undersecretary of health, told a congressional committee in June that the VA is conducting research to identify predictors for veterans who abuse opioids and which veterans might respond best to nonnarcotic treatments…

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