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Study: VA not following protocols on dispensing narcotic painkillers

Lawrence Vass, 55, of Tampa says the three-week rehabilitation program he just completed at James A. Haley VA Medical Center has dramatically improved his daily life, once ruled by crippling pain.
Lawrence Vass, 55, of Tampa says the three-week rehabilitation program he just completed at James A. Haley VA Medical Center has dramatically improved his daily life, once ruled by crippling pain.
Published May 27, 2014

With VA hospitals already under scrutiny for forgoing care and falsifying records, a new report faults the U.S. Department of Veterans Affairs for mishandling narcotic painkillers.

VA medical centers routinely violated their own protocols while prescribing opioid drugs to about 450,000 veterans in 2012, the VA inspector general reported.

Doctors failed to conduct mandatory urine screenings. Patients refilled prescriptions early with impunity. Veterans combined narcotics and other powerful drugs — and six out of 10 patients on painkillers had mental problems or a history of abusing drugs.

Narcotic painkillers "can cause serious harm, including overdose and death,'' the report said. "Patient adherence with the proper use of opioids is crucial.''

Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing, said the report reflects a nationwide epidemic of narcotic use for chronic pain, but also a failure within the VA to enforce proper precautions.

"Vets are at high risk of chronic pain injuries suffered fighting overseas, and opioids are highly addictive,'' Kolodny said. "The overdose rate within the VA system is twice the national average.''

The inspector general report provided no statistics for individual hospitals, but patients in the Tampa Bay area may fare better than most.

The region that includes Florida, south Georgia, Puerto Rico and the Virgin Islands has the fifth-lowest narcotic painkiller usage in the VA's 21-region system, according to spokeswoman Susan Wentzell.

The C.W. Bill Young VA Medical Center in Pinellas County recently started a full-time chiropractic service to help patients manage pain without opioids. The James A. Haley VA Medical Center in Tampa runs the VA's only inpatient rehab program, which has weaned vets off narcotics for 26 years and trains VA outpatient employees around the country to do the same.

Opioid-based medicines — such as morphine, oxycodone and hydrocodone — were originally designed for acute pain from traumatic injury or surgery, said psychologist Jennifer Murphy, who runs Haley's rehab program.

Narcotics are not as useful for chronic pain, such as from a damaged spinal disc or severe arthritis, Murphy said, because patients in time build up tolerance, which can lead to higher doses and then addiction.

"The evidence is mixed, at best, to support chronic opioid therapy,'' she said.

Yet nationwide, and in the VA, treatment of chronic pain with narcotics "has risen dramatically in the last five to 10 years,'' Murphy said.

The VA has protocols for monitoring opioid treatment, but the inspector general report, released earlier this month, said those protocols were frequently ignored.

About half of VA patients suffer from chronic pain, the report said, often a product of job-related injury. About 15 percent of those patients were given narcotic painkillers in 2012, and 5 percent were "chronic users,'' meaning they took painkillers for longer than 90 days.

Among other report findings:

• VA protocol calls for a urine test before a narcotic is first prescribed, plus follow-up visits every two to four weeks. Only 6 percent of patients had both the test and follow-up.

• About 23 percent of veterans refilled their narcotics prescriptions at least seven days early, indicating overuse. About 14 percent refilled at least 11 days early.

• Random urine tests were recommended every one to six months, but only 38 percent of vets received the them.

• About 13 percent of the patients were current substance abusers. In such cases, VA protocols bar narcotics unless patients get substance abuse treatment at the same time. Only 31 percent did.

• About 7 percent of the vets on narcotic painkillers also received benzodiazepines — powerful drugs such as Valium and Xanax prescribed for anxiety, insomnia and other conditions that depress the central nervous system, making them a dangerous combination with opioids.

In its response to the report, the VA said it had already instituted reforms since 2012.

Almost 40,000 fewer vets now receive narcotic painkillers and 80,000 more are getting drug screenings, the agency said.

At Haley's inpatient rehabilitation program, about 150 veterans yearly spend three weeks going through withdrawal and learning to manage pain with physical therapy, relaxation, counseling and non-narcotic medicine.

Chronic pain disrupts people's lives physically, emotionally and socially, said Murphy, the director. Sometimes, just moving hurts so much that patients will avoid activity and jeopardize their relationships.

The program also teaches them to pace themselves and move safely. "Our goal is to improve function,'' Murphy said.

In follow-ups held three months, six months and a year after discharge, she said, only about 20 percent of patients have returned to narcotics.

Lawrence Vass, 55, of Tampa, who completed the program last week, crippled his back, legs and knees lifting steel as a combat engineer more than 30 years ago.

The pain worsened as he aged despite a regimen of narcotics and muscle relaxants. If he took his wife to a movie, Vass said, his limit was about 30 minutes before "I've got to be standing up and walking around."

By the time he entered Haley, he bent over as he walked.

"I got tired of living like that, Vass said. "Very secluded, very angry, very distant.''

Haley has given him a new start, he said.

"I'm not walking around with a grouchy face anymore. I went to the park yesterday. It was a beautiful day.''

Stephen Nohlgren can be reached at