[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




BETWEEN PERIL AND PROMISE: FACING THE DANGERS OF VA'S SKYROCKETING USE 
             OF PRESCRIPTION PAINKILLERS TO TREAT VETERANS

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       THURSDAY, OCTOBER 10, 2013

                               __________

                           Serial No. 113-39

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

                       Jon Towers, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVE P. ROE, Tennessee               JULIA BROWNLEY, California, 
JEFF DENHAM, California              Ranking Minority Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana             RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               GLORIA NEGRETE MCLEOD, California
VACANCY                              ANN M. KUSTER, New Hampshire

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.














                            C O N T E N T S

                               __________

                            October 10, 2013

                                                                   Page

Between Peril And Promise: Facing The Dangers Of VA's 
  Skyrocketing Use Of Prescription Painkillers To Treat Veterans.     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
    Prepared Statement of Hon. Benishek..........................    51
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on 
  Health.........................................................     3
    Prepared Statement of Hon. Brownley..........................    52
Hon. Jeff Miller, Chairman, Committee on Veterans Affairs, U.S. 
  House of Representatives.......................................     4
    Prepared Statement of Hon. Miller............................    52

                               WITNESSES

Heather McDonald, Spouse of Scott McDonald, SPC (deceased).......     5
    Prepared Statement of Ms. McDonald...........................    53
Kimberly Stowe Green, Spouse of Ricky Green MSGT (Ret) (deceased)     6
    Prepared Statement of Ms. Green..............................    54
Joshua Renschler, Sgt. (Ret).....................................     8
    Prepared Statement of Mr. Renschler..........................    58
Justin Minyard, LSgt. (Ret)......................................    10
    Prepared Statement of Mr. Minyard............................    60
Pamela J. Gray, M.D..............................................    26
    Prepared Statement of Ms. Gray...............................    63
Claudia J. Bahorik, D.O..........................................    29
Prepared Statement of Ms. Bahorik................................    66
Steven G. Scott, M.D., Chief of Physical Medicine and 
  Rehabilitation Service, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    30
Prepared Statement of Mr, Scott..................................    80
Robert L. Jesse, M.D., Principal Deputy Under Secretary for 
  Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    41
Prepared Statement of Mr. Jesse..................................    82
    Accompanied by:

      Robert Kerns, Ph.D., National Director for Pain Research, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs; Kathleen M. Chard, Ph.D., Director, 
          Cognitive Processing Therapy Implementation, Director, 
          Trauma Recovery Center, Cincinnati VA Medical Center, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs

                       STATEMENTS FOR THE RECORD

The American Legion..............................................    90
Iraq and Afghanistan Veterans of America.........................    94
National Association for Alcoholism and Drug Abuse Counselors....    97
Wounded Warrior Project..........................................    97
Vietnam Veterans of America......................................   102
American Psychiatric Association.................................   104
 
BETWEEN PERIL AND PROMISE: FACING THE DANGERS OF VA'S SKYROCKETING USE 
             OF PRESCRIPTION PAINKILLERS TO TREAT VETERANS

                       Thursday, October 10, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:59 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek, Huelskamp, Wenstrup, 
Brownley, Ruiz, Negrete McLeod, Kuster.
    Also present: Representatives Miller, Bilirakis, Harris.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. Good morning. Thank you for being here today. 
The Subcommittee will come to order.
    Before we begin, I want to ask unanimous consent for our 
colleague from Maryland, Dr. Andy Harris, to sit at the dais 
and participate in today's hearing. Without objection, so 
ordered.
    And I am happy to see we have Mr. Miller here this morning, 
the Chairman of the Full Committee. Thank you for being here, 
Mr. Chairman.
    With that, I would like to welcome you all to today's 
hearing, ``Between Peril and Promise: Facing the Dangers of 
VA's Skyrocketing Use of Prescription Painkillers to Treat 
Veterans.''
    Today's subject is one of the most serious and significant 
we will discuss all year, and it is one that is particularly 
poignant and personal to me. I have spent 20 years serving our 
veterans as a physician at the Oscar D. Johnson VA Medical 
Center in Iron Mountain, Michigan. And in that capacity, I 
understand all too well what it means for a veteran and a 
patient to be in pain.
    Pain can be an unrelenting enemy, one that thwarts an 
individual's ability to work and enjoy the activities they once 
loved, hinders their relationship with their family and 
friends, and impacts their capacity to be comfortable in their 
own home. On a daily basis, my veteran patients would confide 
in me about the pain they were in, and many ways in which they 
were hurting, and more than anything else their desperate 
desire to find relief.
    Perhaps no where else is that more clear than in the 
heartbreaking testimony that we will hear shortly from two 
surviving spouses, Heather McDonald and Kimberly Green. Their 
husbands, Scott McDonald and Ricky Green, honorably served our 
Nation in uniform and came home, as far too many of our 
returning veterans have, hurting and in pain. These men sought 
treatment from the department charged with caring for them, the 
VA, hoping to get the help they needed so they could once again 
take full and successful ownership of their lives without pain 
as their constant companion. Sadly, rather than getting the 
best care anywhere, Scott and Ricky were prescribed a 
disturbing array of pain, psychiatric, and sleeping medications 
without any clear consideration or special attention paid to 
how these powerful drugs were interacting with each other or 
affecting Scott and Ricky's physical and mental well being. The 
combined effects of these multiple medications ultimately took 
their lives.
    We also will hear from two veterans, Joshua Renschler and 
Justin Minyard, who will give us a firsthand account of the 
struggles they faced with VA's apparent over-reliance on 
opiate-based medications for pain management. At one time, 
Joshua was prescribed 13 different medications. Despite his 
pleas that the medications were not working, he was never 
referred to a pain specialist. Justin was prescribed enough 
opiate pain medications on a daily basis to treat four 
terminally ill cancer patients. He eventually sought care 
outside of VA to find an effective treatment to manage his 
pain.
    To say that I am disturbed by these accounts and by the 
multiple reports we hear everyday about the skyrocketing use of 
prescription painkillers, particularly opiates, to treat 
veterans in pain would be a major understatement. VA's band-aid 
approach to suppressing the symptoms of pain rather than 
treating their root cause must stop. VA maintains a pain 
management treatment model that makes primary care rather than 
specialty care the predominant treatment setting for veterans 
suffering from pain. Yet as I know from personal experience, 
the multifaceted nature of chronic pain, particularly when 
multiple medications are being prescribed, should not be 
managed by a primary care physician, but rather by a qualified 
pain specialist who is trained to understand the complexities 
of treating these conditions.
    I want to be very clear that this hearing is not intended 
to vilify the many hardworking primary care providers working 
everyday to care for patients in pain at VA facilities across 
the Nation. I have been in their shoes. I know the challenges 
they face in providing the high quality care our veterans 
deserve. Rather, our intent here today, is to initiate better 
provider practices and most importantly better care 
coordination for our veterans and their loved ones so that no 
other family has to experience the pain, the suffering, or the 
loss that our witnesses on the first panel have already 
experienced.
    It is critical for VA to take responsibility for its 
failures and rise to the challenge to change and take immediate 
action to adopt effective pain management policies, protocols, 
and practices.
    We have already lost too many veterans on the homefront to 
battles with chronic pain. The stakes are too high for VA to 
continue to get it wrong.
    This is a really important matter to me. In my own personal 
practice, I realized that I just do not know everything there 
is to know about pain. And that we always, always send people 
with chronic pain to a specialist. To not do that is just 
inconceivable to me.
    I will now yield to our Ranking Member, Julia Brownley, for 
any opening statement she may have.

    [The prepared statement of Hon. Dan Benishek appears in the 
Appendix]

            OPENING STATEMENT OF HON. JULIA BROWNLEY

    Ms. Brownley. Thank you, Mr. Chair. And good morning. I 
would like to thank everyone who is in attendance today for 
being here.
    Chronic pain is a debilitating condition that affects 
veterans at a much higher rate than the civilian population. 
According to the Department of Veterans Affairs, in the newest 
cohort of veterans, chronic pain is the most common medical 
problem reported in veterans returning from the battlefield 
with estimates as high as 60 percent of those who seek 
treatment in the VA.
    Modern warfare often leads to serious but survivable 
physical and neurological injuries, such as amputations, spinal 
cord injury, traumatic brain injury, gunshot wounds, and many 
more. Oftentimes, these same veterans experience mental health 
issues as well, such as Post-Traumatic Stress Disorder and 
depression. And while advances in medical technology have saved 
the lives of many wounded soldiers, many veterans of our armed 
forces are forced to live a life that is dominated by acute and 
chronic pain.
    Providing safe, effective, adequate pain management is a 
crucial component of improving veterans health care. The 
treatment of chronic severe pain often involves physicians 
prescribing highly addictive painkillers, that if not properly 
monitored can lead to death. Testimony from our first panel 
highlights the dangers of prescription drugs and just how 
quickly veterans get trapped in a rapid downward spiral of 
addiction and pain.
    I know that VA has a national pain management strategy, and 
I look forward to hearing from Dr. Jesse regarding the ramping 
up of pain clinics and services throughout the Veterans Health 
Administration. I am also very interested in progress being 
made with the Department of Defense on transitioning 
servicemembers and the management of medications between the 
agencies.
    Finally, VA recognizes that chronic and acute pain among 
our veterans is a serious problem and in fact is a priority. I 
applaud them for taking the lead on this issue. But I am 
concerned that comprehensive pain care is not consistently 
provided throughout the VA's health care system.
    I look forward to hearing from our witnesses. I thank you 
again for being here. It is important for this panel, and 
Members, and the public to hear your stories. Thank you, Mr. 
Chairman, and I now yield back.

    [The prepared statement of Hon. Julia Brownley appears in 
the Appendix]

    Mr. Benishek. Thank you, Ms. Brownley. I would like to 
yield to Chairman of the Full Committee, Mr. Miller from 
Florida.

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you, Dr. Benishek and Ms. Brownley both 
for having this very important hearing. And as you have already 
said, many of our servicemembers are returning home with 
serious injuries from the battlefield and very acute pain. And 
as they transition to veterans status, the pain often lingers 
and leads to chronic illness.
    For these veterans, it is the pain level, not the veteran 
that sets the agenda for the day. It sets the tone for their 
families. And it keeps the veteran in many cases from fully 
participating in their daily lives and activities that they may 
have once had.
    Yet when these veterans reach out and entrust the VA to 
relieve their pain, the treatment they often receive is the 
systemwide default of prescribing prescription painkillers. CBS 
News has recently reported that based on VA data, over the past 
11 years, the number of patients treated by the VA is up 29 
percent, while the narcotic prescriptions written by VA doctors 
and nurse practitioners are up 259 percent.
    Look, veterans depend upon VA to uphold its mission of 
restoring the health of those who have borne battle. But 
instead of helping them manage their battles with pain, VA has 
opted instead to use a treatment that has the power to destroy 
rather than to restore their lives.
    VA can and must change course and act now to reduce their 
reliance on the use of prescription drugs. The veterans and 
their loved ones must be listened to, must be followed up with 
closely, and supported with a treatment that can best help them 
regain happy and healthy lives. Anything less is unacceptable. 
And I yield back.

    [The prepared statement of Hon. Jeff Miller appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Chairman. I would like to now 
formally welcome our first panel to the witness table. As I 
mentioned earlier, joining us is Heather McDonald from South 
Vienna, Ohio; and Kimberly Stowe Green from Fort Smith, 
Arkansas. Mrs. Green is a veteran of the United States Air 
Force. Thank you, ma'am, for your service. And thank you both 
for being here to deliver what I know is going to be very 
difficult testimony for you.
    Mrs. McDonald and Mrs. Green are joined by Joshua Renschler 
from Olympia, Washington; and Justin Minyard and Orlando 
Florida. Mr. Renschler and Mr. Minyard are both veterans of the 
United States Army and both continue to serve today as 
advocates for their fellow veterans. Thank you both for your 
service and for all the hard work that you continue to do.
    We appreciate you all being here with us today to tell your 
stories. Mrs. McDonald, please proceed with your testimony. We 
like to keep it around five minutes so that everyone has an 
opportunity to be heard.

 STATEMENTS OF HEATHER MCDONALD, SPOUSE OF SCOTT MCDONALD, SPC 
 (DECEASED); KIMBERLY STOWE GREEN, SPOUSE OF RICKY GREEN, MSGT 
   (RET)(DECEASED); JOSHUA RENSCHLER, SGT. (RET); AND JUSTIN 
                      MINYARD, 1SGT. (RET)

                 STATEMENT OF HEATHER MCDONALD

    Mrs. McDonald. First and foremost, I want to thank you all 
for inviting us here today to speak. This is a cause that I 
know that we are incredibly passionate about.
    After graduating from Belpre High School in 1995, Scott 
Alan McDonald took an oath to uphold the dignity and the honor 
of the United States Army. For 15 years, he served honorably in 
the uniform of his country and was proud to serve as a UH-60 
Black Hawk mechanic and crew chief for a medevac unit. Bosnia, 
Panama, Iraq, and Afghanistan are only a few of the war torn 
countries he dedicated his life to changing. In his career, he 
experienced heartache, unimaginable violence, death, and the 
overall devastating effects of war. He saw many of his fellow 
soldiers give the ultimate sacrifice, narrowly escaping many 
times himself. He loved his country and what the American Flag 
stands for. He was a brother in arms to thousands of fellow 
soldiers, and a truly remarkable man that never met a stranger. 
Scott had larger than life expectations for his children and 
because of his commitment and honor in January of 2011 we 
married.
    On April 30, 2011, Scott's career with the Army came full 
circle and he hung his uniform up for good. He began seeking 
the treatment from the VA for back pain and mental illness. The 
Chalmers P. Wylie Ambulatory Care Center in Columbus, Ohio 
immediately starting prescribing medications. Beginning with 
Ibuprofen, Neurontin, and Meloxicam, and graduating to Vicodin, 
Klonopin, Celexa, Zoloft, Valium, and Percocet. This is where 
the roller coaster began.
    My husband was taking up to 15 pills a day within the first 
six months of treatment. Every time Scott came home from an 
appointment, he had different medications, different dosages, 
different directions on how to take them. And progressively 
over the course of a year and a half of starting his treatment, 
the medications had changed so many times by adding and 
changing that Scott began changing. We researched many of the 
drugs that he was prescribed online and saw the dangerous 
interactions that they cause. Yet my husband was conditioned to 
follow orders. And he did so.
    On September 12, 2012, Scott attended another of his 
scheduled appointments. This is when they added Percocet. This 
was a much different medication than he was used to taking, and 
which they prescribed him not to exceed 500 milligrams of 
Acetaminophen. Again, my husband followed orders.
    Approximately 01:00 hours on the 13th of September, I 
arrived home from my job. I found Scott disoriented and very 
lethargic. I woke him and asked him if he was okay. He told me 
he was fine and that he just took what the doctors told him to 
take. At approximately 07:30 I found my husband cold and 
unresponsive. At 35 years old this father of two was gone.
    I ask myself why everyday. And when I asked the VA why more 
tests were not performed to make sure he was healthy enough, 
they responded by saying, it is not routine to evaluate our 
soldiers' pain medication distribution. A simple, ``I am in 
pain,'' constitutes a narcotic and, ``This is not working,'' 
constitutes their change of medication.
    I was sickened and disturbed by their response, and I 
decided at that point, no one else should die. I have no doubt 
that if the proper tests were being performed on our men and 
women, I would not be here today because my husband would be. I 
have no doubt that thousands of the soldiers that have fallen 
since coming home from War would be here today.
    As the silent soldiers and the spouses of our military 
members, we almost expect the possibility they will not come 
home from War. But we cannot accept that they fight for their 
country, and after the battle is over, they come home and die 
in front of their children and their loved ones and this has 
got to stop.
    When our men and women signed that contract they gave their 
bodies to their country. And I ask now, as the people that have 
the power and the ability to make these changes happen, to 
force regulations to change on behalf of all of the veterans 
out there that have died. And for their families, I beg you to 
reopen this issue and reevaluate the distribution of narcotics 
to our men and women when they come home. Because you do not 
only take the lives of these men and women, but you tarnish the 
lives of their families forever. They selflessly chose to wear 
the uniform the United States military, and when they come 
home, they should not be treated as numbers, nor should they be 
labeled as if they are no longer a productive or useful part of 
society. Thank you.

    [The prepared statement of Heather McDonald appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mrs. McDonald. I truly 
appreciate you being here and testifying. Mrs. Green, would you 
please begin?

               STATEMENT OF KIMBERLY STOWE GREEN

    Mrs. Green. Chairman Benishek, Ranking Minority Member 
Brownley, and all the distinguished Members of the 
Subcommittee, my name is Kimberly Green and I am honored to 
have been invited to speak to you today at this hearing. I am 
accompanied here today by my attorney Brad Miller, who is also 
a medical doctor. I respectfully request that my written 
statement be incorporated into the official records of this 
hearing.
    I live in Fort Smith Arkansas. I served my country for 21 
years in the United States Air Force serving both on active 
duty and reserve status. I retired as a Master Sergeant from 
the Arkansas Air National Guard. I am the widow of Ricky Green.
    My husband served his country for 23 years, serving both on 
active duty status and in the Reserves. He was a military 
policeman and a paratrooper and he served with distinction in 
Desert Storm. He retired as a Sergeant First Class.
    My husband Ricky Green died as a result of the VA's 
skyrocketing use of prescription painkillers. On behalf of my 
husband, myself, and our two grieving sons, I want to ask this 
Committee to do all that it can to prevent other veterans from 
dying in the same manner that my husband died.
    My husband died on October 29, 2011 at the age of 43, four 
days after lower back surgery. The Arkansas State Crime Lab and 
its medical examiner performed an autopsy and determined that 
the cause of death was mixed drug intoxication, complicating 
recent lumbar spine surgery. My husband died because of the 
prescription pain and sleeping medications that the VA and his 
doctors prescribed for him and dispensed to him out of the VA 
pharmacy.
    In treating Ricky's service-connected back pain, the VA 
doctors wrote prescriptions for the following drugs: Oxycodone, 
Hydrocodone, and the generic versions of Valium, Zoloft, 
Ambien, Gabapentin, and Tramapol, among others. Ricky trusted 
the VA doctors and followed their orders.
    The VA already has written guidelines for prescribing 
painkillers but these are not being followed. The clinical 
practice guidelines which have been in place since May of 2012 
require physicians to closely monitor and evaluate patients who 
are being prescribed prescription painkillers for chronic pain 
and warn physicians about the dangers of drug interactions that 
can cause death. The guidelines also warn physicians to take 
special care in prescribing pain medications for patients such 
as my husband who had sleep apnea.
    Unfortunately again, no such special precautions were taken 
for Ricky, who got a legal drug cocktail that included 
Oxycodone and Diazepam, which were reviewed by the VA and 
filled by the VA pharmacy on October 26, 2011.
    I strongly believe that my husband was entitled to receive 
the quality of care that the VA and Department of Defense set 
forth in their guidelines. However, last year the VA's national 
program director for pain management admitted that VA has not 
fully implemented the guidelines.
    I know that statistics show in Fayetteville, Arkansas where 
my husband was treated there is a high incidence of over-
prescribing pain medications for veterans. In my husband's 
case, he asked the VA to reduce the opiate pain medications he 
was taking, but the VA did not listen.
    I am proud of my husband. After serving his country for 
over 20 years in the military he went back to school and earned 
his college degree in criminal justice. Ricky survived serving 
in combat zones in his over 20 years of military service, but 
he could not survive the VA and its negligent treatment of him.
    I have heard excuses. The guidelines are not standards of 
care, and some veterans who have died of overdoses were 
suicidal. These are excuses that the VA is making because it 
has failed to take the action needed to fully implement and 
follow its own written guidelines that have already been 
published. Let me be clear, the VA knew that Ricky was not 
suicidal. The VA knew that Ricky did not display drug seeking 
behavior. The VA knew that he wanted to reduce the amount of 
pain medication he was taking. It is all documented in Ricky's 
medical records.
    Humana and the VA have teamed up on a program called 
Project Hero. Last year, this Committee heard the testimony of 
Brad Jones, Chief Operating Officer of Humana Healthcare 
Services. Mr. Jones contended that Humana and Project Hero 
provided a strong care coordination element. This did not 
happen in my husband's case. No one at the VA or Humana 
monitored his drugs to ensure safety, nor questioned why he got 
all of the medications when he had a diagnosis of sleep apnea.
    I would like this Committee to use its powers of 
investigation to uncover why Humana and Project Hero did not 
protect my husband Ricky from the lethal cocktail of drugs that 
killed him. Why cannot the powerful computer systems at both 
the VA and Humana that process the medical records of our 
veterans be programmed to monitor the kind of drug interactions 
and dangerous conditions like sleep apnea to alert both doctors 
and pharmacists when dangerous prescribing occurs, like that 
that killed Ricky?
    It is my understanding that when unexpected death occurs, 
the VA does an analysis to find out why the death occurred. I 
want to know if such an analysis was ever done in my husband's 
case, and whether or not the VA will investigate my husband's 
death so that other veterans will not suffer the same fate?
    I hope the VA, and if not the VA, then this Committee, will 
ask these questions, learn something to save the lives of our 
veterans in the future. This is the one way, the only way, that 
my husband will not have died in vain.
    I will not be silent about any of this. My husband does not 
have a voice, therefore I am his voice. I want to see that this 
overdrugging of our veterans stops and that there is 
accountability for these physicians' actions. I respectfully 
request that this Committee demand that the VA follow its own 
written guidelines, demand that the VA put in place procedures 
that punish VA doctors and staff who do not follow the written 
guidelines and demand that the VA and its doctors put a stop to 
this epidemic of the VA's skyrocketing use of prescription 
painkillers to treat veterans. Thank you.

    [The prepared statement of Kimberly Stowe Green appears in 
the Appendix]

    Mr. Benishek. Thank you so much, Mrs. Green. I really 
appreciate your being here. Mr. Renschler, could you proceed?

                 STATEMENT OF JOSHUA RENSCHLER

    Mr. Renschler. Chairman Benishek, Ranking Member Brownley, 
and Members of the Subcommittee, I am honored for the 
opportunity to speak to you today about my own experiences with 
the VA's pain management system, or lack thereof.
    Not only am I retired from the United States Army in which 
I proudly served as an infantryman for five and a half years, 
but as stated earlier I currently walk alongside of other 
veterans struggling to navigate the difficult systems in trying 
to find a new normal life.
    After I was medically retired from injuries sustained from 
a mortar blast in 2004, I left the Army in 2007 and entered 
immediately into the care of the VA in 2008. I was on eight 
different medications from the Department of Defense that took 
three years for Army doctors to balance a safe mix with limited 
side effects to allow me to have an opportunity to try to 
function. I entered into work at the only thing I knew how to 
do as an infantryman, I started working corrections.
    With the VA care, my first practitioner informed me that 
many of the medications I was on were not on the VA's formulary 
and they had to find a new mix. They began experimenting on me. 
Despite the urging of my wife telling them that many of the 
medications they wanted to try again already failed through 
DoD, they did it anyway. Within 12 months of VA care, I was on 
13 medications, many of which were to counter the effects of 
other medications, and I began to backslide in my recovery. It 
ended with me having a severe panic attack for the first time 
in my life while at work, resulting in the loss of my job, 
resulting in my family losing our house and our vehicle, and 
being virtually homeless, if it was not for our family stepping 
up and taking care of us.
    It 2009, I began to suffer from debilitating back pain as a 
result of my injuries. The VA's answer to that was to add 
narcotics into the mix of my medications that I was on at the 
time. I was on Percocet, and what happened was, as I took that, 
the more I took it, the less it worked because my body became 
tolerant to it.
    I continued to ask my VA doctors to find a proactive 
solution for the back pain rather than more medications, and 
the answer was an increase in the dosage to a level of 12 to 15 
five-milligram tablets a day. When that was no longer 
effective, I finally saw a neurosurgeon who sent me to a 
physical therapist. I was excited for a proactive solution. 
However, when I received that care, it entailed me sitting in a 
chair while the physical therapist asked me questions about the 
pain and printed off a package of papers that included 
instructions on stretches to do at home on my own, and asked me 
to follow up in two weeks. That made me feel hopeless and 
infuriated.
    When I began advocating strongly for my care at that point, 
my dosages maintained at the levels that they were, but they 
were augmented by other medications such as Morphine and 
Methadone. I began to not function well at all. I had children 
at the house and things were not going well at home. Finally, I 
was able to get an EMG and an MRI, which determined that I had 
severe nerve damage and resulted eventually in a fee service 
referral to a private hospital. When I went to that private 
neurosurgeon he asked me how long I had experienced the 
symptoms, and I had told him it had been over a year since it 
was that bad, and he was infuriated at the VA for allowing it 
to take place that long. He scheduled an urgent surgery that 
took place three days later and the result of the delay in my 
care meant that I have permanent nerve damage. I still have no 
feeling in my left leg to this day.
    I continued to take this cocktail of medications that the 
VA prescribed me less the narcotics following the surgery. And 
there was no oversight. It took me three months to get an 
appointment with a primary care doctor that usually changed who 
the person was that I saw every three months when I got in 
there.
    Finally I had a new prescriber in 2011, three years after I 
entered the system, who said many of these drugs are harmful to 
kidney and liver, let us get some blood work. The blood work 
determined that I had elevated liver enzymes to lethal levels. 
I immediately saw a hematologist who performed a biopsy and 
determined I had scarring of the liver and diagnosed me with 
non-alcoholic steatohepatitis. This prompted my wife and I to 
remove myself from all of my medications, save the seizure 
medications and as needed migraines.
    This makes life very difficult. But within six months my 
liver enzymes had returned to a high normal level. And I would 
rather be pill free and in pain than to die.
    I continued to have struggles. In 2011, the back pain 
returned and I began pleading again for my own care and I was 
denied everywhere I went. I went back through the hoops of 
physical therapy, occupational therapy, who, by the way offered 
me a device to help me put my socks on in the morning. I was 
denied any other care that I was asked for. I turned to 
spending $15,000 out of my own money to buy a therapeutic hot 
tub and a massage chair just hoping to find a way of managing 
my pain. I lived next door to a very nice lady who was a 
massage therapist who worked on me for free. These were the 
only ways I could manage my pain without the drugs.
    There is no happy ending to this account, I apologize. I am 
currently taking narcotics again. I am prescribed levels that 
allow me to take six five-millimeter Oxycodone a day. I cannot 
take Percocet because of my liver.
    Let me emphasize I did not make this trip here today to 
gain an advantage for myself. But I have walked alongside of 
countless veterans and I know this to be true: it is a hopeless 
situation when you are encountered with this type of 
debilitating pain. The VA is very quick to drop statistics on 
22 soldiers a day ending their lives. But they do not really 
look internally and realize that the hopelessness that comes at 
the very end for a veteran is when he reaches a level of 
debilitating pain that puts him into a hopeless situation at 
home. Being 30 years old and having to rely on a cane and a 
wheelchair and not being able to hold my child without physical 
pain is a hopeless situation. And when I cry out to the VA, my 
only source of medical care, to help me with this situation and 
I am hit with a brick wall and a bottle of pills that does not 
end the hopelessness, and in fact it makes it a more hopeless 
situation and results in the loss of life of countless of our 
veterans.
    I thank you for your time and your oversight on this 
matter, and I urge the VA to start looking internally for a 
solution to this epidemic.

    [The prepared statement of Joshua Renschler appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Renschler, for your 
testimony. I truly appreciate your comments. Mr. Minyard, 
please begin.

                  STATEMENT OF JUSTIN MINYARD

    Mr. Minyard. My name is Justin Minyard and I would like to 
thank you for the opportunity to appear before the Committee 
and address this vital subject.
    I am a medically retired member of the United States Army. 
Before retiring due to a series of spinal injuries, I was a 
first responder at the Pentagon on 9/11, and a special 
operations interrogator. I struggled with years of dependence 
on the opioid therapy, that was my only option made available 
to me for my chronic debilitating back pain. Finally after 
years of searching, I found lasting pain relief through spinal 
cord stimulation, or SCS. Today, I am proud to say that I am 
not taking a single dose of opioid pain pills in the last two 
years. No veteran should have to struggle for as long as I did. 
Early access to interventions in the VA is critical.
    I first developed chronic back pain when I was serving as a 
member of the Presidential Escort Third U.S. Infantry Old Guard 
stationed at Fort Myer. On 9/11, my unit was one of the first 
responders at the Pentagon. For the next 72 hours we searched 
for survivors, working on adrenaline to move huge pieces of 
rubble. As a result of these efforts, I sustained a serious 
back injury, damaged discs and ruptured vertebrae.
    My back pain drastically impacted my life from September 
11th onwards. In 2004 and 2007, I was deployed in the Middle 
East and reinjured my back during subsequent combat operations. 
When home on R&R, Army doctors told me my spine was rapidly 
deteriorating and I needed reconstructive back surgery. Despite 
knowing I should have the surgery, I wanted to complete the 
mission with my unit. My doctor responded, ``If you insist on 
going, this is the only way that you will be able to make it 
through.'' Then he handed me a bottle of prescription opioid 
pain pills.
    My pain fluctuated daily somewhere between a four and a 
nine on a one to ten pain scale. But I was able to mask that 
due to the high dose of pain pills. It was a very double edged 
sword. The pills allowed me to keep working, but they also 
allowed me to do further damage to my back.
    August 4, 2008 was my breaking point. I came back to our 
team hour in Iraq after an extremely challenging three-day 
mission. I stepped out of my HUMVEE and my right leg simply 
gave out. I could not take another step and it was terrifying. 
I was subsequently Medevac'd on a helicopter to Balad Air Force 
Base.
    Returning home, my life was not my life. I was in a great 
deal of pain, confined to a wheelchair, and struggling with 
severe PTSD. I also started an intense opioid pain medication 
management regimen. My life revolved around when is my next 
pill? When is my next dosage increase? And when can I get my 
next refill? At my worst point, I was taking enough pills daily 
to treat four terminally ill cancer patients.
    I had enormous physical and mental effects on me. I was so 
high on the opioids that my eyes would often roll in the back 
of my head and if I was not babbling incoherently, I was 
drooling on myself.
    My wife stayed by my side throughout the entire process, 
but for years I went without even telling her thank you for 
taking care of me. I was not the husband my wife deserved and I 
was not the father my daughter deserved, and it was a very dark 
and difficult part of my life, one of which I am extremely 
ashamed and regret today.
    With no options offered by the medical services and after 
seeing a video of myself passed out with my daughter in my lap, 
I started to look for treatment on my own. I had a spinal 
fusion procedure that helped me regain some mobility, but did 
nothing to lessen my pain or dependence on opioid medication.
    It was a major challenge navigating the bureaucracy of the 
VA and DoD health care systems. My wife had to advocate for me, 
never taking no for an answer. Finally we found an 
interventional pain specialist at Fort Bragg conducting a trial 
study of SCS therapy. I credit both with turning my life 
around. My specialist explained how an implantable device could 
stop my brain from receiving pain signals. After a test drive, 
I had the permanent device implanted in less time than it takes 
to have a cavity filled. When the device was turned on, I was 
floored. With each adjustment to the device, I could feel the 
impulse moving through my body and hitting my targeted pain 
areas. All of a sudden, to push a button and have my pain drop 
significantly was life changing.
    The relief that I felt from SCS allowed me to start 
tapering my medications. That process took time and was 
extremely difficult, but it was worth it. I am now at the point 
where I have not taken an opioid-based pain pill in more than 
two years.
    The bottom line is that I consider myself extremely lucky 
that I was able to push through the maze of providers and find 
a doctor knowledgeable about SCS. The majority of soldiers are 
not so lucky. Soldiers who lack the resources and awareness to 
advocate for alternatives to opioids are left with the crushing 
reality of lifelong opioid dependence, or worse. A recent VA 
study spotlighted the horrific epidemic of suicide among 
veterans, 22 per day. We must increase awareness about 
alternatives to opioid medication in the VA system. The VA must 
work to create access to interventional pain specialist 
knowledgeable in state of the art pain management treatment. We 
must train more doctors in these techniques and devote more 
resources to raising awareness.
    We should also be collecting data on long term outcomes of 
interventional therapies versus opioid therapies so we have the 
numbers to show that the techniques that helped me will help 
other soldiers as well. The VA is a great place to start 
because so many veterans come home and struggle just as I did.
    I continue to struggle with the VA in getting timely 
appointments with the specialist to manage my SCS therapy. But 
my hope is that in the future, policies will be in place to 
help people like me manage their SCS therapy, and to help 
shield soldiers and their families from the devastating effects 
of opioid dependance.
    Thank you very much for your time and for listening to my 
story.

    [The prepared statement of Justin Minyard appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Minyard. We truly appreciate 
your comments.
    I yield myself five minutes for questions. Thank you all 
once again. I guess I have a question, let me just start with 
Mrs. McDonald. Did your husband see the same person every time 
he went to the VA?
    Mrs. McDonald. No, sir.
    Mr. Benishek. So was that person their regular primary care 
physician that they saw?
    Mrs. McDonald. Both his pain management and his mental 
health management prescription bottles had the same doctor's 
name on them. But it was a rarity that he either saw them, it 
was a rarity that he saw the same doctor twice. Many times he 
came home from appointments frustrated because he, especially 
in mental health, had to basically relive the last 15 years and 
five deployments over, and over, and over again. And he never 
felt like that was ever going to be treatment for his PTSD. You 
know, like I said, almost immediately after seeking treatment, 
he was diagnosed with severe PTSD. In July of 2011, just months 
before he died, he was awarded 80 percent disability after 
never having an MRI, x-rays, nothing to prove where this pain 
came from.
    Mr. Benishek. Mrs. Green, let me ask you the same question. 
Did your husband see the same person over and over again?
    Mrs. Green. My husband had an assigned neurologist, a VA 
doctor, and then he also had a civilian doctor. So he had two 
neurologists. But he had other doctors that he did see at the 
Fort Smith VA Clinic. And he would see different health 
practitioners. So it could be a number of, a different number--
--
    Mr. Benishek. Were you ever involved in asking the 
physician, did you ever go with him to his appointments and ask 
about all these medications?
    Mrs. Green. I had, yes sir, I had attempted to go with him. 
They would not let me back with him into the room. Now I did 
see his----
    Mr. Benishek. They would not let you go with him to see the 
doctor? Is that what you are saying?
    Mrs. Green. No sir, they would not. Now I did see his 
doctor with him when he was, he had a spinal fusion in May of 
2011, and I did see the doctor with him, and then the back 
surgery, I saw the doctor with him for the back surgery.
    Mr. Benishek. So you never did, neither one of your 
husbands actually saw a pain specialist about----
    Mrs. Green. No sir, my husband had never been referred to a 
pain specialist.
    Mrs. McDonald. I had, actually, just prior to my husband's 
death, when he went for his appointment on the 12th, I 
suggested to him that he talk to his doctor and allow me to 
talk to them. Because I feared that the amount of medication 
that he was on was what was preventing us from conceiving. 
Because he had completely deteriorated, not just as a person, 
but his health was going downhill. My husband was in stage two 
liver failure, which was only discovered by the coroner.
    Mr. Benishek. Unbelievable. Mr. Renschler, is that your 
experience as well? Did you see the same person?
    Mr. Renschler. No sir, I did not see a pain specialist. And 
primary care, often as the deployment health team was 
attempting to shift focus, the primary care provider would 
often change from one appointment to the next.
    Mr. Benishek. Mr. Minyard?
    Mr. Minyard. Sir just prior----
    Mr. Benishek. I just want to know if you, did you see a 
regular, I mean, did you end up going, was this within the VA 
system, this pain----
    Mr. Minyard. My chronic pain treatment both was in with the 
DoD and the VA. I can tell you that before I was referred to an 
interventionalist pain specialist, I was already at the point 
where I was daily taking 240 milligrams of Oxycontin, 60 
milligrams of Oxycodone, and 40 milligrams of Valium a day 
prescribed by my general practitioner, the same doctor that 
prescribed medicine if I have a cold or the strep throat. And 
that also alternated between sometimes she decided to go with a 
100 microgram Fentanyl patch, again which is typically used for 
patients that are not long for this world. So it was a long 
time----
    Mr. Benishek. Did it seem, did any of you have the 
experience where the physician, or maybe you were not aware, 
that they were looking to get you to someone that could manage 
this better than they could and they just could not get the 
appointment? Or they just decided that they were going to do 
the management? Was there any, do any of you remember any----
    Mr. Minyard. In my situation, sir, my primary care provider 
made it clear to me that she was my primary care provider and 
it was her responsibility to manage my medication.
    Mr. Benishek. All right.
    Mr. Minyard. If that can answer your question.
    Mr. Benishek. All right. I think I am out of time now. I 
will yield to Ms. Brownley for five minutes in questions.
    Ms. Brownley. Thank you, Mr. Chair. And thank you all for 
being here, and thank you for your service to our country. And 
I think we all owe you, each and every one of you, a deep 
apology for not responding to your needs the way you have 
defended our country. And Mrs. McDonald and Mrs. Green, I 
include you in thanking you for your service to our country and 
being married to your spouse and supporting him through this 
process. That you, too, need to be thanked for your service. So 
thank you all. I think this is obviously a very, very important 
topic, and hearing your individual stories, I think is 
important for the American people to hear.
    I wanted to ask a question, my first question anyway, and 
this question is more directed to Mr. Minyard and Mr. 
Renschler. And I was wondering about your experiences and maybe 
experiences from other wounded warriors that you may, more 
regarding the continuity of treatment from the Army to the VA, 
and perhaps from one VA facility to another VA facility?
    Mr. Renschler. I will answer that to the best of my 
knowledge. Again, I have walked alongside of countless veterans 
over the last several years in a volunteer capacity and walked 
them through, attempted to navigate the VA health care system 
to get the best care possible. In my experience, it takes quite 
often a door kicker mentality to get veterans the care that 
they need. We, I have hand walked them to a physician's door, 
to a social worker's door, to a mental health practitioner's 
door and said, ``This person needs help today.'' And that is 
the way we have been able to make things happen in people's 
lives.
    To answer as quick as possible, no. There is not good 
continuity of care from one facility to another. There is not 
good continuity of care from DoD to VA. You know, as I spoke on 
my specific experience leaving DoD and entering VA care, my 
medications were not only the VA formulary. So they completely 
changed my medication regime, put me on more harmful 
medications, which ended up causing me a backslide in my 
recovery which took the Army three years to establish.
    As far as, there is a veteran that I work with currently 
that has left Portland VA facility in Oregon and moved into 
Washington State. And upon entering Washington State American 
Lake VA Hospital, he was told that his medications are not able 
to be purchased through the American Lake VA Hospital because 
they do not have the budget for the non-formulary medication 
that the other facility had. And this was, again, a medication 
that took six years to figure out the best thing for him. And 
they are not going to purchase it anymore, which is causing him 
a backslide in his pain management as well. So the short answer 
is no, there is not good continuity of care.
    Ms. Brownley. Thank you. And I think I said Mr. Green, I 
apologize. I meant Mr. Minyard, if you had any additional 
comments in terms of continuity of treatment?
    Mr. Minyard. Ma'am, with all due respect, I would not, in 
my opinion and through my experience, I would not place the 
word continuity anywhere in a sentence that contains the other 
nouns DoD and VA. To give you a quick answer. The systems to 
me----
    Ms. Brownley. Yeah. I hear you.
    Mr. Minyard. --do not work.
    Ms. Brownley. Thank you.
    Mr. Minyard. Yes, ma'am.
    Ms. Brownley. And then really to anyone who would like to 
respond, you know, can you talk a little bit to, about to what 
extent and with the VA facilities, has there been any kind of 
sort of comprehensive interdisciplinary approach to your 
situation or to others that you might, we talk about a primary 
provider, therapist, others who are working as a team?
    Mrs. McDonald. I guess I can say one thing about that. 
After my husband's death I did contact the VA almost 
immediately. I was, the VA itself told me that I needed to 
immediately start the process to claim my husband's death 
pension to help my family. What doing that immediately does, I 
do not know. I took 11 months to start receiving any 
retroactive pay from my husband's pension. I lost my home. I 
lost my car. When I asked them during the filing of the claim, 
the VA asked me whether I felt my husband's death was service-
connected or not. First, that is not my decision. Every pill he 
put in his mouth was due to an ailment or injury he received 
either in theory due to his service for his country, so yes, 
that makes it service-connected. Why it took nine months for 
them to make a decision and a rating on that? No, I was simply 
told, ``I am sorry, Mrs. McDonald, this is the process. It 
takes time.'' There is a huge backlog. I feel like the VA right 
now is proud of themselves because they are saying the backlog 
is going down. The amount of claims are lessening. Well, of 
course they are. Because they are dying. They are not receiving 
treatment anymore because they are not here to receive it.
    You know, when I asked the VA, you know, why? Why was his 
health care not well managed? And the response they gave me was 
that there was nothing else that they could have done, and that 
his health care was well managed and properly maintained. No.
    Ms. Brownley. Thank you very much. And I yield back.
    Mr. Benishek. Mr. Huelskamp?
    Mr. Huelskamp. Thank you, Mr. Chairman. I would like to 
also apologize, as my colleague has done, for what has occurred 
here. I have a couple of follow up questions. The Chairman was 
asking, I think in terms of continuity of care. And I was also 
struck by the denial of Mrs. McDonald's for the ability to walk 
in with your husband and participation in those appointments. 
Is that what I understood correctly? That you requested and the 
VA would say no, you cannot come back and visit with----
    Mrs. McDonald. Many times I would go to the appointments 
with my husband in the very beginning of his treatment. I 
wanted to, first of all he was in denial that he even had PTSD, 
like most soldiers and veterans I think battle with that. 
Probably more than the pain itself is the denial behind the 
fact that they may actually have a mental health issue 
underlying a lot of the war that they have experienced. Once I 
was able to get him convinced that he needed, it actually took 
the help of another veteran to convince him he needed help. I 
did go for the first several months and I had to wait in the 
waiting room. I was told that due to privacy issues, I was not 
allowed to be there with my husband. Now in the civilian 
sector, doctors normally will allow a spouse to go back there 
just because, especially prescribing medication, once they have 
received that medication, they might not remember the orders 
that the doctor gave them afterwards of taking the medication. 
It was frustrating. I finally stopped going.
    Mr. Huelskamp. Did your husband request that you come in 
there, and they denied that? I am just curious what the VA 
policy is.
    Mrs. McDonald. On the September 12th appointment, the day 
before he died, he requested that I be allowed to go with him 
to his, he was finally being scheduled to see a pain specialist 
at the Ohio State University Neurological Surgery Center for 
his back pain. A consultation, and they were going to allow me 
to be there. That would have been September 24, 2012, but Scott 
was deceased by the 13th.
    Mr. Huelskamp. Okay. Mrs. Green, was it a similar 
experience?
    Mrs. Green. Somewhat. I was denied the right to go in with 
my husband, and he did want me in there. But they refused 
because of privacy issues.
    Mr. Huelskamp. Mr. Chairman, it sounds, I look forward to 
hearing what VA has to say.
    Mrs. Green. This is going on, mm-hmm.
    Mr. Huelskamp. Because you want to be in there, the patient 
would like to see you in there, and the VA, do you think it was 
a preference of the physician or the provider? Or do you think 
that was just their policy?
    Mrs. Green. Sir, I cannot answer, I cannot speak, I do not 
know.
    Mr. Huelskamp. All right, thank you. How big were these 
clinics in terms of how many providers were there? Were these 
pretty massive clinics, or were they small where you were 
receiving care?
    Mrs. Green. The clinic at the VA in Fort Smith is not a 
huge facility. But they do, we do have a lot of returning 
servicemen and women, and it is utilized frequently from the 
Guard, a lot of transitioning soldiers. So, but it is not a 
very big facility.
    Mr. Huelskamp. Mm-hmm. And Mrs. McDonald, when you were 
concerned on PTSD, what was the, how would they have handled 
that? You have to go see someone separately? Or you could bring 
it up to the primary care physician if your husband was 
willing? And do you know how they would have handled that?
    Mrs. McDonald. I do not know how they would have handled 
it. You know, my primary concern of telling him, look, flat 
out, ``I am going with you,'' my husband never accused me of 
having the ability to keep my mouth shut. I was going with him, 
regardless of what they said, because I had watched his 
medications fluctuate in such a way, especially for his PTSD, 
my husband was no longer Scott McDonald. I did not know who the 
man was that I was married to.
    Mr. Huelskamp. Thank you.
    Mrs. McDonald. He would become angry and violent. And in 
the months prior to his death, we had finally thought we had 
found a remedy, that he was back to himself. He was back to 
being a father and a husband. But he had been labeled 80 
percent disabled.
    Mr. Huelskamp. Okay.
    Mrs. McDonald. Or he jokingly would say he did not mind 
being a soccer dad.
    Mr. Huelskamp. All right.
    Mrs. McDonald. But I could see that he was broken.
    Mr. Huelskamp. Okay. All right. Thank you. I yield back, 
Mr. Chairman.
    Mr. Benishek. Thank you, Mr. Huelskamp. I call upon Dr. 
Ruiz.
    Mr. Ruiz. Thank you, Mr. Chairman. Thank you for your 
service. Thank you for all those days that you went wondering, 
and thank you for finding hope in your struggle to make sure 
that other people do not get treated like you did.
    I am an emergency medicine doctor and I treat patients who 
come in when they are at their last wits, when they just cannot 
take it any more. When that pain is unbearable, they cannot see 
their doctor, or it is just relentless. Can you tell me about 
the experiences, have you, did you ever have those moments 
where you sought care for acute pain, acute on that chronic 
pain, at a different facility in the emergency department that 
was not affiliated with the VA?
    Mrs. McDonald. As far as with my husband?
    Mr. Ruiz. Yes.
    Mrs. McDonald. No, because we quite frankly could not 
afford it. We utilized the VA because it is free health care 
for the first five years after separation from the military.
    Mr. Ruiz. Okay.
    Mrs. McDonald. And it is what we could afford.
    Mr. Ruiz. How about the others?
    Mr. Renschler. The same answer. We honestly cannot afford 
for that to happen. We, it took us a long time to recover from 
the financial hardships of losing my job. And once my benefits 
started, I could not afford to seek treatment elsewhere. We had 
to put together, as I said, a pain management regime that 
worked for us. We paid out of pocket for a while for 
chiropractic care and we found somebody through church who 
would work on me chiropractically for free, and our neighbor is 
a massage therapist. And we found things that worked for us 
just to get by. But you know, it would be really cool if the VA 
would take care of some of that too.
    Mrs. Green. My husband always said that when he enlisted 
into the military the VA had promised him his free, or his 
health care. And when he was VA service-connected, he said he 
trusted the VA and that he was going to use the VA. And so his 
facilities that he utilized was the VA.
    Mr. Ruiz. My understanding is that the VA will not cover 
acute emergencies outside of the VA in what they cover? Is that 
true or not true?
    Mrs. Green. I cannot answer that.
    Mr. Ruiz. Okay. My question also is referring to all those 
times that you mentioned that there was a doctor that would add 
a new medicine, or that would change the dose, and that there 
was no continuity of care, like it is not the same doctor. 
Sometimes that may occur outside of a VA system or not, or 
inside. I know in this case, it did occur on the inside. And 
sometimes that does occur on the outside. What was it like to 
get information from the VA to those doctors in terms of 
knowing what the medications they were on, and what is the 
dose, and what is the regimen that was prescribed? Because 
sometimes when you do not have that information, they see you 
for the very first time, and there is no continuity, there is 
no history. They just look at a list of maybe what you have 
been on before, and so they will prescribe you, just to handle 
that specific situation. How is the ability to acquire records 
or call your physician from the VA?
    Mr. Minyard. Sir, I can try to answer that. I think it 
would be easier if everybody in this room, we all worked 
together to try to raise the Titanic, than try to get my 
medical records from the VA to a civilian hospital. And to have 
a doctor from the VA call my civilian provider, that would be 
unheard of, sir. In my experience, it is extremely difficult to 
get. It is kind of a chain link process. It is extremely 
difficult for me to get my DoD records into the VA. If that 
happens in piecemeal, once they do get to the VA, and I do need 
to go see a civilian provider, I have yet to receive documents 
that I asked for 12 months ago. And I volunteered to come to 
the VA where the records are kept, take time from work, and 
photocopy them myself. And we are at 12 months and counting, 
sir. It is extremely difficult.
    Mrs. McDonald. I think for me, I was only able to obtain, 
and we are still in the process of obtaining my husband's full 
medical docket after the estate hearing, in which I was 
appointed the executor. I think the bigger question is, is why 
is there not more continuity between the doctors at the same 
VA? Why is my husband being prescribed the same medication and 
two weeks later sees another doctor who says, ``do not take 
that,'' but then the same medications show up in our mailbox? 
My husband was just receiving pills left and right, that it 
seemed like with every months that passed the plastic bowl, 
mixing bowl that we kept all his meds in, had to become bigger. 
Because they just become so abundant. And nobody ever said, 
``stop taking this one, switch to this one.'' It was, ``this 
does not come in that milligram, okay, so-and-so has you on,'' 
nobody was going through his records and saying, ``this doctor 
already gave you this, so I am not going to go and do this.'' 
So I think there needs to be a lot more communication amongst 
the doctors who work in the exact same area, in the exact same 
field, and treat the exact same patient.
    Mr. Ruiz. I absolutely agree with you, and I think that is 
the primary question here is, what kind of safety mechanisms 
are in place to ensure that a prescription cannot be prescribed 
until they have a consultation with the appropriate pain 
specialist, which we know that they have, you have a lack of, 
in the VA, and the pharmacy, to start to have a different 
ability to look at the interactions between drugs.
    There is a big push now, I know in the hospital that I work 
in at Eisenhower Medical Center, where every patient, the 
nurses, and the doctors have to get together and they have to 
look at the interactions and identify those interactions for 
every single drug that they take. I think these are approaches 
and policies that the VA may have, like you mentioned there are 
clinical guidelines. But it is the implementation, and what are 
the quality control measures that also look, not only at the 
actual science of those interactions but the patient/doctor 
relationship.
    Not allowing the next of kin, the spouse, to be seen with 
the patient for privacy reasons, is one of the biggest hog 
washes I have ever heard. And the other thing is to make sure 
that we look at pain in a holistic manner. To look at the 
complexity of pain not only on the science, but also the 
effects of the interactions with family, their ability to 
function, their mental health, like you mentioned, and the 
perception of who they are as a human being. And I think that 
these are questions that we will be asking the VA and we will 
be looking thoroughly into.
    So I thank you for giving voice to the voiceless. Although 
they are not voiceless, their voice lives in you. And I know 
that. Because I feel like your spouses are here, and I feel 
like all of your friends that are doing that are here with you. 
So thank you very much.
    Mr. Benishek. Thank you, doctor. Now we will have five 
minutes from Dr. Wenstrup.
    Mr. Wenstrup. Thank you, Mr. Chairman. And I, like the 
others, applaud you for being here, and to have the courage to 
be here and to take up this new mission in life. Basically, the 
things that I was going to bring up my colleague, Dr. Ruiz, 
really pretty much covered. And as a caregiver, and as one that 
has given care in the DoD, I am an Army Reservist, I understand 
that side of it, and the complexities there with it. And it 
bothers me when we hear what we just heard, because this could 
not go on, I do not think very well in the civilian side, the 
things that are taking place.
    And so my question to sort of piggyback on Dr. Ruiz is, 
when you went to the doctor, you or your spouse, did they ever 
take the time to review the current medicines while prescribing 
something new that you are aware of?
    Mrs. Green. My husband went to the VA doctor in September, 
a month before his death, to request that his medications be 
reviewed. And how the VA, how the health care provider reviewed 
it was to tell him that he should continue taking all of his 
medications. And wrote that in the medical summary. And it is 
clear in the medical summary of his medical records. And he 
followed the orders of the doctor.
    Mr. Wenstrup. Is that similar for all of you? I would 
imagine that----
    Mr. Renschler. I think she paints a pretty good picture of 
what it feels like and the transition I had to take for myself 
in learning how to advocate, and I learned it pretty good from 
my wife. She is about 5'5'' but she is a pistol. When we would 
go into the hospital and the doctors would say, ``you are going 
to take this pill,'' I would be like, ``yes, sir, it is going 
to help me.'' As far as reviewing the medications, every visit, 
they would print off at the nurse's station a current list of 
medications. Not necessarily to go over them or to ask how they 
are doing, but I am sure that this comes down to a policy 
issue, this is how they are executing the policy to review 
those medications. At each visit, the doctor prints off a 
current list of medications and hands it to me as we are 
walking out the door.
    You know, I think a big issue that I would like to raise as 
we are talking about this specifically is the oversight. You 
know, many of these medications have harmful side effects. And 
the problem that arises, I am sure in the civilian community, 
that primary care providers change and they move. But this 
happens really frequently at our VA facilities. It happens, 
they go from team to team. And when you are put on a new 
medication with harmful side effects and there is no oversight 
to say, ``hey, how is this doing for you?'' three days later, 
that is a dangerous practice.
    Mr. Wenstrup. That goes to my next question. When you were 
receiving your medications, was there ever a consultation with 
a pharmacist to discuss the medications that you are on?
    Mr. Renschler. That is another practice, at least at our 
facility, is that when you pick up your medications, if it is a 
new or renewal, we have to sit in front of the pharmacist who 
looks it up, and at our facility they say, ``this is the 
medication that you are getting and these are some of the known 
side effects.'' And they print, for me, they have printed off a 
fact sheet for the medications and then prescribe them to me. 
So.
    Mr. Wenstrup. Were you ever offered a consultation with 
pain management specialists?
    Mr. Renschler. No.
    Mr. Wenstrup. Mr. Minyard?
    Mr. Minyard. Sir, I took it upon myself to try to track 
down the pain specialist in our VA. Nobody could tell me what 
office he was in. So I literally walked the three or four 
floors of the VA, office to office, asking who the pain 
specialist was.
    Once I got there, I quickly realized it was an exercise in 
futility. Because his answers for my condition and my injuries 
were either go back on long term opioid-based treatment 
regimen, or he could do lumbar epidural shots. I mentioned that 
I had a spinal cord stimulator already implanted and it helped 
me, it was instrumental in stopping a dose of opioids that 
would have killed me very shortly. And he, this is, now to put 
this in perspective, this is the interventionalist pain 
specialist in charge of one of the largest VAs in Florida. The 
guy that we all are supposed to go to for pain management. He 
had never heard of a spinal cord stimulator. That blows my 
mind. That to me is beyond unacceptable. And for me, as a 
patient to have to pull out a brochure and say, ``This is what 
it does, doctor.'' And I did it very tactfully and very 
respectfully. But for me, I am an Army guy. And I am having to 
talk to a medical professional and explain a device that is 
used to treat pain, the field in which he has gone above and 
beyond to become educated in? And the most absurd part of it 
is, I was thrown out of the office.
    The reception I got from him was, again, you are an Army 
guy, I am the pain specialist, how are you going to teach me 
anything? Here is your brochure. Thank you very much. Have a 
nice day. That was my situation. Which is absurd, sir, in my 
opinion.
    Mr. Wenstrup. I agree. Well my time is expired. I want to 
thank you all very much. I appreciate it.
    Mr. Benishek. Thank you, doctor. Ms. Kuster?
    Ms. Kuster. Thank you very much, and thank you Mr. Chairman 
for holding this hearing. And to our colleagues, particularly 
our doctor colleagues, I want to say that we are fortunate to 
have their expertise on this panel.
    I just want to say in addition to thanking you all for your 
courage to come forward today, and please know that you are 
giving voice to your spouses. And for you all, for your 
service, thank you, and for coming forward. I have been married 
for 27 years to a man who lives with chronic pain, not from 
military purposes, but I very much understand the story that 
all four of you have told, and it is something that I have 
lived with everyday and the psychological impact and the 
physical impact.
    But I want to focus on, Mr. Minyard, your experience with 
this spinal cord stimulator. And just for me to understand as a 
new Member of Congress, how that type of answer to your prayers 
could be made available to more people in the VA system? And I 
know it is complicated managing pain. For my husband, he has 
tried every treatment that you have described and many that you 
have not. He now is getting hip replacement surgery, where 
people had talked about major back surgery. And in fact, this 
is one of the first times that I have seen him pain free. So I 
think it is complex in terms of the connections. But how to get 
from this opportunity that you had for more people across the 
spectrum, to have these types of cutting edge therapies that 
could make a tremendous difference in people's lives, do you 
have any suggestions for that?
    Mr. Minyard. Yes, ma'am. And I am very grateful for the 
question, and I will try to answer it as best as I can as a 
patient with the device that it works. I am obviously not an 
industry expert or anything like that, or a policy maker.
    Ms. Kuster. Sure, mm-hmm.
    Mr. Minyard. But the biggest stumbling block to getting 
this medical innovation, technology like this, that I have seen 
and when I deal with other veterans and other people that are 
dependent and addicted, as I was, to Oxycontin, is, or opioid 
pain medication, is that providers, as well as patients have to 
be educated. That is, for me, if I ran the world, that is where 
I would start. Because if you do not know about it, you cannot 
teach somebody about it. So if more doctors were made aware and 
learned about the technology, and it does not just have to be 
what I have, but it is medical innovation. Looking for a 
better, more effective way to treat veterans and other chronic 
pain sufferers, not just veterans. So it is, in my opinion, 
again ma'am, it is not being satisfied with the status quo of 
we have been doing opioid pain medication for long term chronic 
pain treatment. It seems to be going okay, so let us stick with 
that. Why not strive to do something better?
    And the ramifications of long term opioid-based pain 
medication, if you look at the, I spoke about this yesterday, a 
lot of times you hear the argument there is a cost benefit 
ratio. Pain pills are, I am assuming, much cheaper than 
technology like this. But cost benefit analysis is, that is not 
really realistic when you are looking at, if you want to do 
cost benefit analysis, we can do that. Let us go ahead and put, 
what cost are you going to put on my marriage? My ability to 
now know my daughter, who I did not know for three years 
because I was stoned and I was deployed? What value is there 
for me to be excited to read a book with my daughter at story 
time, at bedtime? What value do you place on me being happy and 
excited about my ten-year anniversary on Saturday? I, I did not 
think there was any way I could make it to ten years. If I was 
my wife, I would have divorced me 20 times ago.
    But the point is, it has to, in my opinion, it has to start 
with education and the desire to look beyond the standard and 
the status quo. It seems to me every other, car industries for 
example, they do not settle for this year's model, is the best 
we are going to do, and we are good with it. They constantly 
strive to look for new innovations, better ways to sell their 
product. Why do we not do the same thing with patients? Look 
for more effective ways for them to live well, have a family, 
be a productive member of society, and manage their pain as 
opposed to their pain managing them, ma'am?
    Ms. Kuster. Thank you very much. My time is up. But in the 
civilian side there is a process, and I am sure Dr. Wenstrup is 
familiar with the quality assurance, and it is something that 
we could look into of trying to get to a place where these 
situations did not happen. So thank you so much for coming here 
today and sharing with us.
    Mr. Benishek. Thank you. Mr. Bilirakis?
    Mr. Bilirakis. Thank you, doctor. I appreciate it very 
much. And I want to thank you all for your service. I 
appreciate it. Thank you for your willingness to testify as 
well.
    Mr. Minyard, I have one question. I understand that at one 
point you went to VA with a list of private sector providers in 
your area who were able to see you and could provide the 
treatment you needed, and were told by the VA that you could 
not access care in the community and would instead need to 
travel to another VA facility hours away. Is this true? And 
again, it would take months for you to get the next available 
appointment, which I think is unacceptable. Please describe 
that experience for us. And why did the VA tell you that you 
could not be seen in the community? I think this is a very 
important question. So please, if you will, thanks.
    Mr. Minyard. Yes, sir. Part of the technology I have and 
the pain therapy I have is treated by spinal cord stimulation. 
The Orlando VA, as I said earlier, the pain doctor there was 
not even aware of this treatment. And I went on Google Maps, 
looked up 60 providers within a ten-mile radius of the Orlando 
VA, civilian providers, that could give me the support I needed 
to maintain the device I use to manage my pain without opioids.
    I went to the highest, I went, I started at the bottom and 
went up the chain of command at the Orlando VA, and then asked 
for the appeal to be sent up to Gainesville, saying why can I 
not, why with bonuses being paid to VA CEOs for outstanding 
performance when people are dying in the hospitals, why with 
big, you know, conventions being thrown that cost millions of 
dollars, why cannot somebody pay for me just to go down the 
street and get my device fixed? And they said no. It costs too 
much. We have a doctor in Gainesville, I live in Orlando, that 
deals with this type of thing.
    So I said okay, can we get an appointment? And this was 
last May. They said, okay, we will put you on the list.
    Mr. Bilirakis. So you have a doctor at the VA in 
Gainesville, that is affiliated----
    Mr. Minyard. In Gainesville.
    Mr. Bilirakis. Okay.
    Mr. Minyard. I will see that doctor in June of 2014.
    Mr. Bilirakis. June----
    Mr. Minyard. I made that appointment in May of 2013. So I 
am eagerly looking forward to it next year, sir.
    Mr. Bilirakis. So in other words there are several, you 
said close to 60 providers, private sector providers in the 
area that could see you almost immediately?
    Mr. Minyard. Last count. And on top of that, sir, I know 
our time is getting short, but due to multiple TBI injuries, 
you know, one too many times being blown up, I have seizure 
disorder. The result of that is I have fairly frequent 
seizures, typically three to four every five months. So my 
license gets revoked every six months I have a seizure. So that 
was another case I brought up with the VA, saying you would 
rather me try to arrange a ride from Orlando to Gainesville, at 
the same time I have a full-time job which I was subsequently 
fired from because the VA kept canceling my appointments and 
that is another story. But knowing I did not have a drivers 
license, they still insisted that I was not allowed to go five 
miles from my home to a civilian doctor. Instead, I would wait 
until an appointment was available. And then, they actually 
called me and their words were, ``We need you to arrange some 
transportation. Do you not have a wife?'' My wife is a VP for a 
Fortune 500 company. She is taking care of me, my daughter, and 
progressed in her career unbelievably. So yes sir, I do have a 
wife. But I am not asking her to take time off to drive me to 
Gainesville when you can send me five minutes away. And that 
was that situation you are referring to, sir. If it did not 
happen to me, I would have trouble believing it, sir.
    Mr. Bilirakis. All right, thank you. Anyone else want to 
comment on that on the panel? But also I would like if you do 
not mind, I would like to talk to you further after the 
hearing?
    Mr. Minyard. Yes, sir. It would be my pleasure.
    Mr. Bilirakis. Okay. Please. Please. Anyone else want to 
comment on this particular issue?
    Mrs. Green. My husband was referred for a sleep apnea test 
and there is a sleep facility in Fort Smith. And he, the 
referral was for Missouri. We had to take him to Missouri for 
his sleep apnea test. Not once, but twice, when there is a 
sleep facility in Fort Smith, Arkansas. Twice.
    Mr. Bilirakis. Thank you very much. I yield back the 
balance of my time. Thank you.
    Mr. Benishek. Dr. Harris?
    Mr. Harris. Thank you very much. I want to thank the Chair 
and the Ranking Member and other Members of the Committee to 
let me sit in on this. As you know, I am an anesthesiologist. 
So pain management, although not my subspecialty, is certainly 
related. And I have a couple, just a couple of very brief 
questions. Sergeant Renschler, let me ask you a question about 
the denial by the formulary of Lyrica. Which I find 
fascinating, because you know, Federal employees can get 
Lyrica. I mean, you can go on all kinds of health coverage to 
get Lyrica. But my question is very specific. My understanding 
is about your testimony the Chief of Neurosurgery said you 
should get Lyrica. And then it was denied by the pharmacy, by 
someone in the, did someone examine you from the pharmacy? Sit 
down, take a history, go over the indications, possible 
indications? Or was this just a paper denial as far as you 
know?
    Mr. Renschler. Sir, it is a disgusting situation and it 
went down like this. I went up to visit the Chief of 
Neurosurgery in the Seattle Medical Center. She came up with 
this medication option, said it might be a really great thing 
to improve my quality of life and reduce my dependence on 
opiate-based medications which is something that was a big goal 
for me. And it had very few side effects and it certainly was 
not damaging to the liver, so it was a great thing for me and 
my wife. When she put in, she did tell me it was non-formulary 
and it might be a battle to get it, but she was pretty 
confident that her rank would allow us to get this. It was 
denied. And she called me on the phone and told me it was 
denied but she was gathering the signatures from two other 
department heads to resubmit a request back to the pharmacy 
because when they responded to her they told her, ``he should 
try things such as Lidocaine ointment and Gabapentin.'' And----
    Mr. Harris. And again, just, because I think you have 
answered the question. It was recommended by someone who never 
met you----
    Mr. Renschler. Never met me, never evaluated me.
    Mr. Harris. --did not know the specifics?
    Mr. Renschler. And did not know the specifics.
    Mr. Harris. And my belief is, as I am sure you share, this 
was because Lyrica actually costs more than other medications, 
right? So this is a cost saving measure. It is just 
fascinating, that is fascinating to me. And just very briefly, 
Sergeant Minyard, let me just ask you because, you know, part 
of your testimony was pretty, as you have found out pain 
management can get pretty specific, require a lot, we require a 
high level of training.
    Mr. Minyard. Yes.
    Mr. Harris. Because you could not find someone in the VA 
system who actually, nearby who could do what you had, which as 
you found out is pretty standard in the outside world.
    Mr. Minyard. Yes.
    Mr. Harris. I mean, six or seven years ago, when I was 
giving anesthesia for people like you who were getting spinal 
cord stimulators implanted. When you were in overseas, though, 
were you getting epidural steroid injections in a tent in Iraq? 
I mean, I am an OB anesthesiologist. I have given thousands of 
epidurals to patients in labor. I would never dream of doing 
epidural steroids on a pain patient because you actually need 
some special training to do it properly. But is that what you 
were getting? Were you getting epidural steroid injections?
    Mr. Minyard. Yes, sir. I----
    Mr. Harris. I mean, and again----
    Mr. Minyard. I do not want to sound----
    Mr. Harris. --this is a VA hearing. It is not on DoD, 
obviously.
    Mr. Minyard. Yes, sir.
    Mr. Harris. The DoD was responsible for delivering that. 
But I think the appreciation is, is that perhaps even 
systemwide, not even just the VA, maybe in the DoD, I mean 
there may be no appreciation for how very, for how the 
treatment of pain has changed over time. Multimodality. I mean, 
epidural steroids may well have been indicated in your case. 
But doing it in a tent in Iraq? I mean this----
    Mr. Minyard. Not even a tent, sir.
    Mr. Harris. Oh, I am being generous----
    Mr. Minyard. Yes, sir.
    Mr. Harris. --this was a tent.
    Mr. Minyard. I mean, what would happen, sir----
    Mr. Harris. But you know what I mean? I am sure you did not 
have an interventional pain management specialist doing that 
intervention?
    Mr. Minyard. Sir, the docs that performed those, what would 
happen is, we would have, I would have my team's trucks rolled 
up outside the team house ready to go. As soon as all pre-
combat checks were done, I went around the corner to a small 
enclosed area, three walls enclosed, and the RN that was 
attached to our trauma team would give me my epidural. And we 
would wait a few minutes to make sure everything was good, and 
then I would put on my combat kit, and roll on that mission. 
And I had eight of those.
    Mr. Harris. I am going to apologize for the way the U.S. 
government handled that. Thank you very much, Mr. Chairman.
    Mr. Benishek. Thank you, doctor. Well it was particularly 
frustrating to me to hear your many stories, one after another. 
But the challenges that you have addressed here seem to be 
remarkably similar for each of you. I hope that the 
administration officials that are here listened as closely as I 
did to the testimony. And if there are no further questions, 
the first panel is now excused. Thank you all so very much.
    Now I will welcome the second panel to the witness table. 
Joining us on the second panel is Dr. Pamela Gray. Dr. Gray is 
a former provider at the Hampton VA Medical Center. Also in our 
second panel is Dr. Claudia Bahorik. Dr. Bahorik is a provider 
with VA's interim staffing program. In that capacity, she has 
worked at 13 different VA medical facilities across the 
country. She is also a disabled veteran, so thank you ma'am for 
your service. We are also joined by Dr. Steven Scott, the Chief 
of Physical Medicine and Rehab Services at the James A. Haley 
Veterans Hospital in Tampa, Florida. Thank you all for being 
here and for your hard work on behalf of our servicemembers and 
veterans.
    We will begin with Dr. Gray. Dr. Gray, please proceed with 
your testimony.

 STATEMENTS OF PAMELA J. GRAY, M.D.; CLAUDIA J. BAHORIK, D.O.; 
   AND STEVEN G. SCOTT, M.D., CHIEF OF PHYSICAL MEDICINE AND 
 REHABILITATION SERVICE, VETERANS HEALTH ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

                STATEMENT OF DR. PAMELA J. GRAY

    Dr. Gray. Thank you. At the outset, I would like to thank 
the Members of this Committee on Veterans' Affairs for offering 
me this opportunity. I am grateful for your time. I must also 
tell you that I am most honored to be in the presence of the 
four individuals who occupied these seats ahead of us. I would 
beg of this Committee to hear their stories and realize that 
they represent tens of thousands of similar stories. Tens of 
thousands.
    I have included for your review today, a letter that I 
wrote to my State Senator. I do not mean at all for you to be 
bored by the trivial details of that letter. I use it as a 
jumping off point for you to hear the physician's side of what 
it was like, at least at one VA center in Hampton, Virginia, 
between 2008 and 2010 when I tried to work through the system 
and failed. As a result of trying to work through the system, 
and realizing the gravity of these complaints and the validity 
of my concerns, I offered myself up as a sacrificial lamb.
    When you are employed as a physician, you are prohibited at 
a VA medical center from speaking out to the general public. 
You are to work through chain of command. I did so, and it fell 
on deaf ears. I went to my State Senator, knowing that the 
inevitable outcome would be to be terminated, which was indeed 
the case. But it was only through doing that, that my story was 
discovered. And I would like you to understand how I am here 
today.
    I went through appropriate chain of command, went to 
service chiefs, chief of staff, director of the center, 
represented my VA as a VISN 1 through 11 conference on pain, I 
went through all the appropriate channels and failed. I am here 
because of the investigative reporting of a CBS News producer. 
And for that I am grateful.
    I would pray of this Committee, no I would beg, I would beg 
of you to offer constructive intervention. Your flowery words 
of praise, thanks, condolence are heartfelt, I am quite sure. 
And they are eloquent. But if true change and action does not 
come out of this Committee, all here have failed.
    With that in mind, I am going to just some highlights of my 
letter to my Senator. Not for details, and yes, there are names 
in that letter. And I chose to let them stay. I see no point in 
mentioning them in this testimony but they are in the written 
form. I do that because I spoke the truth then, and I speak the 
truth now.
    I am a physician with 30 years experience. I am an 
internist and a rheumatologist. I closed my private practice 
and went to the VA in 2008. I never misrepresented myself. I am 
an internist, and a rheumatologist, and I was, had a dual 
appointment with internal medicine 30 percent, and primary care 
70 percent. In the first hour of my first day, I was informed 
that I was head of pain management. In my ten years of post-
graduate training, I had no pain management training. It is an 
entity unto itself. And it is a subspecialty that has 
subspecialty training. I was never asked if I was willing to 
assume this role, I was informed. So to those observations and 
questions that came before, I was pain management with zero 
training.
    My concern about that was, it is not standard of care. If 
you are going to portray yourself as an obstetrician, you 
should have OB/GYN training. A surgeon should have surgical 
training. That is common sense. The VA in Hampton obviously did 
not realize that.
    I tried to do what was asked of me. I thought it would be 
reasonable. They had no pain management, no rheumatologist. And 
so I decided to try and work through the system. I went through 
service chiefs, clinic nurses, telecare nurses, supervisors, 
when I found abberances in the way of treatment, 
musculoskeletal pain syndromes. I pointed out that ten to 20 
percent of opioid users become addicted, we were creating 
addicts. All of this fell on deaf ears. The Chairman of the 
Department of Internal Medicine gave me this response to my 
query as why we were writing so many prescriptions for opioids, 
``think twice before refusing to write these narcotics. It is a 
time of economic downturn.'' I do not know if that was a threat 
of the loss of my job, or if it alluded to the possible 
diversion of narcotics. I do not know.
    During my two-year period, I was coerced to writing drugs 
that I knew in my medical experience were wrong. When I would 
object, I was simply told to do it or else. The physicians are 
given three choices. One is acquiesce and keep your job. Two is 
quit; and three physicians quit during my two years there, one 
within 30 days of being hired due to objection to writing these 
massive amounts of opioids. I chose to work within the system, 
which led to termination, the third choice.
    I documented in my notes, in 30 years of practice, I know 
how to write a note, I know how to be complete, I included the 
facts. I was being coerced by non-medical employees, non-M.D.s, 
to write for large amounts of opioids. When that was discovered 
in my medical note, which was an electronic medical record, I 
was ordered to delete the note or alter the note. I had 
reported the truth and I refused. The Chief of the Department 
of Primary Care altered my note, buried the note which 
documented the truth. And I had the proof, I had the original 
note, and then the subsequent note that was entered into the 
chart. And I reported that to the Office of Regional Counsel at 
McGuire in Richmond, Virginia. Nothing came of it. Again, I was 
trying to work through the system which was what was 
appropriate.
    Upon representing my VA at the National Pain Conference, 
which was in 2009, I brought all of that information back to 
both Service Chiefs, the Chief of Staff, the Director. And in 
the two years after that timeframe, nothing was implemented, 
absolutely nothing.
    I became an advocate for several of the patients. There are 
patients who are smart enough to know about spinal stimulators, 
about alternate treatments. And as a result of trying to be a 
patient advocate, I was threatened with further action may 
result in disciplinary action to include removal. So again, the 
system failed me. I received death threats from patients. I was 
called before a probationary review board, not told of the 
charges against me, not allowed to review my records. And my 
Chief denied knowing anything about this review board when she 
herself had called for it.
    So during my two years, I was forced to do work for which I 
had no professional training. I was ordered by supervisors to 
write large amounts of Schedule 2 narcotics for inappropriate 
medical circumstances. I had my medical records altered to hide 
factual documentation. I received sexual harassment by a male 
nurse, who would come to my office during lunch hour and 
threaten me if I did not write for the opioids. And when I 
reported it, I was asked if there were any other witnesses. 
Since there were no witnesses but the two of us during lunch 
hour, ergo it did not happen.
    I was reprimanded for standing up for the rights of a 
patient. I was threatened to be reported to the National Data 
Bank, which is a mechanism for egregious complaints against 
physicians. And you have to reach a certain level of severity 
to be reported, and I did not. But they gave me that threat. 
And I was subjected to situations of entrapment, trying to get 
me to admit to things that were not true in an effort to build 
the case against me.
    I underwent that board. I was never apprised of the 
findings. I was called to my boss' office and terminated.
    I can see that I am over time. But I would like to beg, if 
I may offer the 11 patients that are at the end of this letter. 
And I will go through them quickly. The bottom line in all of 
them are they are on massive amounts of medication. You do not 
have to know anything about medicine, you do not have to know 
the difference between Morphine and Tramadol and Percocet, all 
you have to do is hear the quantities.
    There was a 55-year old man, the first patient I saw in 
this musculoskeletal clinic, who had carpal tunnel. I bet you 
everyone here has had carpal tunnel symptoms. If you flex your 
hand for too long, these fingers will go a little numb. It is 
fixable with surgery. This gentleman has the surgery. He had 
none of the findings of chronic entrapment of the nerve. He had 
Morphine, Fentanyl patch, Tramadol, Percocet, he had been 
getting it since 2004, he had not been seen since 2004. He had 
had no labs checked since 2004. He had the opioids mailed to 
him. He did not even have to come in.
    You had two veterans tell you about liver dysfunction as a 
result of these drugs. You must check the labs. There is not a 
civilian pain management, musculoskeletal clinic, 
rheumatologist, primary care, anything that would do this to a 
patient.
    I can go through them all. I am over my time. This is 
representative.

    [The prepared statement of Pamela J. Gray appears in the 
Appendix]

    Mr. Benishek. I truly appreciate your testimony, Dr. Gray. 
But time is a precious thing here in Congress----
    Dr. Gray. I understand.
    Mr. Benishek. --and I just want to make sure that everyone 
has the opportunity to testify. We will certainly include the 
statement, your written statement in the record.
    Dr. Gray. Thank you.
    Mr. Benishek. I appreciate your efforts here. Dr. Bahorik?

                STATEMENT OF CLAUDIA J. BAHORIK

    Dr. Bahorik. I am here because no one else will speak out. 
My colleagues are afraid for their jobs. I am here as a 
physician who is concerned about the health and welfare of our 
vets. I also happen to be a physician acupuncturist, and a 
licensed physical therapist. I am here, too, because as he 
said, I am a disabled vet.
    We have been asked to discuss the problem of narcotic 
prescriptions within the VA. I am here to tell you that the 
system is broken, that it is a set up for catastrophe, at least 
on the part of the veterans who get caught up in the pain game.
    As a traveling physician, I have worked in 13 VA facilities 
from Guam to Maine, including the notorious VA in Jackson, 
Mississippi. Jackson serves as a perfect example of a system 
gone haywire. This was a system so cavalier that this VA 
facility did not think the Drug Enforcement Agency rules 
applied to it. So when they, DEA, stopped all the nurse 
practitioners from writing narcotics, the VA traveling docs 
were asked to help and I volunteered. I arrived to discover 
that I had been assigned the job of writing narcotic 
prescriptions for the vets that needed their monthly renewals. 
The first thing the head administrator told us was that we only 
had to review the charts, make sure they were stable, and write 
the prescriptions. He said he could do 30 charts a day while he 
was still playing top dog.
    He did not understand why I objected, why I insisted I 
needed time to take a history, to examine the vets, and to 
review the chart. This is the same administrator that thought 
his own staff should write narcotic prescriptions on patients 
they never saw. He also paid medical residents at night to 
review charts on patients sight unseen so the pill mill could 
churn out more narcotics.
    So they stuck me in a tiny exam room with no exam table, so 
I could not examine the vets. They gave me a nurse and we set 
out to screen the vets. What I found was a disgrace. I 
discovered that veterans' narcotic prescriptions were being 
renewed month after month, months on end, sometimes for one to 
two years without an examination of the body part that was in 
pain. They had been seen for routine medical problems, but the 
pain evaluation amounted to merely asking them to rate the pain 
on a scale of one to ten.
    This was not just a few of the nurse practitioners whose 
patients I saw, it was the rule rather than the exception. 
Often, there were no x-rays, no recent MRIs, no tests, no 
specialist consultations for the pain problem. Just more and 
more narcotics on top of other medications.
    There was no true attempt to screen for misuse or drug 
diversion. I found that urine tox screens were infrequently 
done and often they were positive for substances like cocaine 
and pot, or negative when they should have been positive. Many 
of the vets were misdiagnosed. Some had potentially serious 
conditions. Pain contracts were not being completed. When urine 
drug screening was done, no one even checked to see if the 
specimen was body temperature, or if the specimen was even from 
the veteran. No one was bothering to call the state databanks 
to see how many providers in the state were giving the people 
narcotics. I am here to tell you that this is not just a 
problem at Jackson, it is endemic throughout the VA where quick 
and cheap is rewarded over good and thorough.
    Furthermore, it is uncommon for a doctor to refuse to write 
a narcotic prescription, only to have the vet go to the 
administration. What happens? The administrators call another 
doc and tell them to write the prescription. Or the vet will go 
to the emergency room to get their narcotics. Worse yet, 
doctors are being verbally abused, attacked, or injured when 
veterans who are on dangerous concoctions of mind altering 
substances are cut off. In Jackson, a doctor was shot and 
killed. Another had acid thrown in her face. In Delaware, two 
mental health workers were attacked. A vet who was denied 
narcotics ran his truck into the VA clinic in Lincoln, Maine. 
Another vet in Maine attempted to enter the VA with a gun to 
shoot the administrator. He became a case of suicide by cop.
    Why is this happening? Unfortunately, we have given the 
veterans the impression that for whatever problem they have, we 
have a pill to help it. One or two pills for depression, one 
for anxiety, one or two for sleep, one for PTSD, then add a few 
more pills for problems like hypertension or diabetes, asthma, 
then add one or two or three prescriptions for narcotics. What 
happens if the vet adds some over the counter medications, or 
if he drinks alcohol? We have a prescription for chemical 
lobotomy, a veteran who is at risk for fatal interactions. 
Someone whose brain is bathed in a chemical soup.
    The VA will show you guidelines and resources available to 
providers showing how much they are doing. These are the same 
administrators that create regulations, mandates, requirements 
that are so mind boggling that physicians are no longer captain 
of their ships. Basic principles of medicine are abandoned. 
Primary care providers are struggling to stay afloat in a 
system bogged down with mismanagement, bonuses that reward 
cheap care, not true quality care, and policies that make it 
nearly impossible to adequately and safely monitor the health 
care given to the brave men and women who served our country. 
Thank you.

    [The prepared statement of Claudia J. Bahorik appears in 
the Appendix]

    Mr. Benishek. Thank you for your testimony. Dr. Scott, 
would you please begin?

                  STATEMENT OF STEVEN G. SCOTT

    Dr. Scott. I just want to begin by expressing my sincere 
sympathy to Mrs. McDonald and Mrs. Green who were here. And to 
you and your families, I just want to express that before I 
begin my testimony.
    Good morning Chairman Benishek, Ranking Member Brownley, 
and Members of the Committee, thank you for the opportunity to 
participate in this oversight hearing and to discuss 
specifically the Department of Veterans, James A. Haley 
Veterans Hospital Chronic Pain Rehabilitation Program in Tampa, 
Florida that treats veterans experiencing acute and chronic 
pain. VA's chronic pain rehabilitation program was established 
in 1988. Our involvement in this program over the last 25 
years, is a demonstration of our commitment to addressing pain 
management. We, recognizing that chronic pain can be very 
disabling and these veterans need our help.
    Chronic pain is pain that does not resolve within three to 
six months. When chronic pain causes significant psychosocial 
dysfunction, then it is called chronic pain syndrome. Chronic 
pain syndrome is defined as chronic pain with significant 
psychosocial dysfunction. While pain may be the cause of these 
psychosocial problems, there is evidence that once established, 
these related problems linger even if the underlying pain is 
substantially reduced.
    Unfortunately, many individuals with chronic pain syndrome 
attempt to fight these problems using increasing amounts of 
opioid analgesics. But these efforts are rarely successful. Due 
to the complexity of the syndrome, no single treatment approach 
is the answer. A multidisciplinary and multimodality approach 
is almost always necessary.
    Tampa VA has both an inpatient and an outpatient chronic 
rehabilitation program, and has the only VA chronic pain 
program. The program is specifically designed to treat veterans 
and active duty military personnel with chronic pain. The 
program is evidence based, intensive, interdisciplinary, 19-day 
inpatient chronic pain treatment program that targets not only 
the pain intensity but also all the symptoms of chronic pain 
syndrome. The core philosophy of this program recognizes the 
complex interactions between the pathological, physiological, 
emotional, social, perceptual, cultural, situational components 
of chronic pain. Approximately half the patients submitted to 
this program are taking opioids and approximately half are not.
    The program teaches pain self-management principles, where 
the participants assume responsibility for their daily 
functioning and learn to actually manage their pain. For most 
participants, this includes increasing their level of 
independent functioning; increasing their activity levels; 
reducing their emotional distress associated with chronic pain; 
eliminating their reliance on opioid analgesics or muscle 
relaxers; reducing pain intensity; improving marital, family, 
and social relationships, improving vocational and recreational 
opportunities; and improving their overall quality of life.
    A unique aspect of this program is that all participants 
who take an opioid analgesic at admission are tapered off these 
medications during the course of the treatment. We have found 
that patients taken off these opioids, experience similar 
improvements to patients who are not taking opioids in all 
areas of treatment outcomes over time, including pain severity; 
activities of daily living; mobility; and all other 
psychosocial problems.
    In its 25 years of existence, the program and its staff 
have received numerous awards. The program has been recognized 
as a two-time Clinical Center of Excellence by the American 
Pain Society. It has also received the prestigious Secretary of 
Veterans Affairs Olin Teague Award for Clinical Excellence, and 
has been accredited six times by the Commission of 
Accreditation of Rehabilitation Facilities, or CARF. Their 
programs leaders have been actively involve in promoting 
systemwide enhancement of VA pain care. As the most specialized 
chronic inpatient pain treatment option in the VA health care 
system, the program has already accepted and treated referrals 
from all 50 states, Puerto Rico, and the United States Virgin 
Islands, and military installations from around the world.
    In 2009, the Chronic Pain Program was selected to serve as 
VA's trading site for interdisciplinary pain programs. To date 
we have hosted 30 teams from across the country to observe the 
Tampa VA model system, and learn how to enhance pain treatment 
services at their facilities. The training program helps meet 
the 2009 VHA Pain Management Directive, mandating an 
interdisciplinary CARF accredited pain programs in each of the 
VISNs' integrated supported network. The positive effects of 
these training are seen in the increase from two CARF-
accredited programs in 2009 to eight CARF-accredited programs 
in 2013, and it is anticipated that an additional 14 VA chronic 
pain programs will achieve CARF accreditation.
    Mr. Chairman, VA is committed to providing a high quality 
of care that our veterans have earned and deserve. I appreciate 
the opportunity to appear before you today to discuss the Tampa 
VA chronic pain rehabilitation program, and I am grateful for 
your support in identifying and resolving challenges as we find 
new ways to care for veterans. I am prepared to respond to your 
questions that you may have.

    [The prepared statement of Steven G. Scott appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Dr. Scott. I am going to 
yield myself five minutes to ask some questions. Dr. Gray, it 
is my understanding that each VA medical center is supposed to 
have a pain specialist. So I guess the pain specialist at your 
VA medical center was you, then, right? I mean, you were the 
one that was called the pain specialist even though you had no 
experience, is that correct?
    Dr. Gray. Correct.
    Mr. Benishek. And now was it you that testified that your 
records were changed?
    Dr. Gray. Correct.
    Mr. Benishek. You know, that is very much a fear that I 
have about the electronic medical records. Because I know 
myself at the VA, I experienced that as well. You know, I had a 
path report that said it was benign, and then the patient, that 
is why I sent the patient home for six weeks. And then when 
they came back, the same path report had mysteriously changed 
and become malignant. And yet, I had no evidence that there was 
a path report six weeks ago that said benign. So, you know, it 
makes you look bad. And this situation, where you are saying 
how the medical record is changed, was there any evidence in 
the medical record, that it had been changed without your 
consent?
    Dr. Gray. Absolutely. Not that it was changed without my 
consent. Because I had been ordered by my superior to alter my 
notes, and I had documented the truth, I refused. I took it 
upon myself to print my note.
    Mr. Benishek. Good idea.
    Dr. Gray. The electronic medical records cannot be entered 
into other than the treating physician or someone who has a 
pass level, and it could be a medical records person. My Chair, 
who ordered me to change my record, was Chief of Medical 
Records. She deleted the entire segment that she had ordered me 
to change. So the note started with my verbage, ended with my 
verbage, was signed with my signature. There was no record, and 
then reprinted, entered into the record as such. I printed that 
one, too.
    Mr. Benishek. So you have a record of the----
    Dr. Gray. Yes, sir.
    Mr. Benishek. --pre and the post?
    Dr. Gray. Yes, sir.
    Mr. Benishek. Well I wish I would have copied that path 
report. To tell you the truth, this is a real scary thing for 
me because of the fact that, here we have got government 
controlled health care, where administrators are going to be 
changing the physician's notes to make themselves look good is 
a pretty scary situation in my estimation.
    Dr. Bahorik, you relate a very similar story about being 
told how to treat patients by people that are not physicians, 
is that correct?
    Dr. Bahorik. Yes, it certainly is. Administrators that are 
not physicians are often in positions to supervise us and tell 
us what to do. Not only that, she was talking about pain 
specialists. For instance, at Wilmington in Delaware, the pain 
specialist is not a physician, it is a nurse practitioner who 
tells us what to do. And the other problem with a pain 
specialist is, if the person does get sent to a pain specialist 
they, once they start them on narcotics, they actually dump 
them back on primary care and expect us to continue the 
prescriptions. They just want to do their procedures and 
injections, and they do not want to bother with the mundane 
work of, or the day to day monitoring people on narcotics.
    Mr. Benishek. Dr. Scott, let me ask you this question. It 
sounds as if you have a pretty dynamic pain specialty service 
there in the VA at Tampa. Do you have any experience with the 
way they manage pain elsewhere in the VA? I mean, it seems to 
me like you should be an example to the VA, as how pain 
management should occur. But it does not seem from the 
testimony we have had today that that is actually happening.
    Dr. Scott. We are trying to, because we set up this, we are 
trying to get other centers to come and educate them at our 
center, sort of team to team like interactions. And we have had 
30 of them that have actually come. This program is real unique 
because I actually have seen individuals, I have been in this 
program long enough, you know, it is 25 years so you can 
imagine, I have been 23 years at this program, that I have 
actually seen veterans from D-Day, you know, that have had 
chronic pain. I have seen veterans that have had chronic pain 
from Korea from frostbite and that. I have seen veterans from 
Vietnam. I have seen veterans from Gulf War I. I have seen 
complex veterans that have polytrauma, chronic pain from this 
War. And in some of those invisible type wounds where they, you 
know, we have seen those too. And they have all been successful 
in this. And they have all done well. And we have a program 
that, when you do this CARF stuff, it is an outcome based. So 
we are constantly, everyday, everybody in the team is trying to 
improve. Improve the process, improve the program.
    And over 25 years this thing has been polished off and is 
really a fine, I guess you would say, program that you could 
really try to model after. And that is what we are attempting 
to do, to educate more people out in the VA or elsewhere, by 
coming. We also try to do some research. We also try to do 
educational. We just do our best as we can. And but it has 
definitely a 25-year track records of excellent outcomes.
    Mr. Benishek. Thank you, Dr. Scott. I am out of time. Ms. 
Brownley?
    Ms. Brownley. Thank you, Mr. Chair. And thank you to all of 
you for your testimony.
    Dr. Gray, I wanted to ask you if you have any evidence at 
all that the story that you have told by trying to work through 
the system and do the right thing, if at the end of the day do 
you know if there was any kind of investigation by the VA to 
determine both sides of the story in your situation?
    Dr. Gray. No, ma'am. If I tell you the grounds for my 
dismissal were that I did not say good morning to a nurse. 
There was no addressing my issues. The Office of Inspector 
General, when I asked for a copy of the report as a result of 
my queries about physicians being bullied into overwriting 
opioids, they found that the waiting times for physical therapy 
were not excessive. That had never been my complaint. That had 
nothing to do with prescribing opioids.
    So no, to my knowledge the issues were covered up, not 
addressed. And the entrapment issues that I alluded to were 
these trivial, trivial things that were used against me. They 
did not want to address the facts.
    Ms. Brownley. What happens in the VA when we know a patient 
is now an addict to their drug? I have heard over and over 
again today it is just different cocktails, more drugs. Is 
there a point in which that stops and ceases?
    Dr. Gray. No. No, ma'am.
    Ms. Brownley. Dr. Bahorik, you said in your opening 
comments you had background in both acupuncture and physical 
therapy?
    Dr. Bahorik. Yes, I am glad you brought that up. I have 
been an acupuncturist for a little over two years. And every 
facility I have gone to I have asked to be credentialed to do 
acupuncture, particularly for pain patients. And I have been 
denied. Not because I do not have credentials. I am licensed as 
a physician acupuncturist. Just because they do not want to 
open up a can of worms because patients are going to find out 
that the service is valuable, and then they would have to pay 
for someone. Same thing with chiropractors. They do not have 
enough chiropractors. They do not do alternative things like 
massage, or anything to that respect. Mr. Renschler mentioned 
that when he went to physical therapy they did nothing. Well as 
a physical therapist and after having been to 13 facilities I 
can tell you that that is the absolute truth. Not only do they 
not do anything, patients cannot get in.
    Ms. Brown. Thank you. Dr. Scott, do you use acupuncture at 
all or massage therapy in any of your----
    Dr. Scott. Yes, we credential people in acupuncture, and we 
also use massage, and we also use, have a chiropractor. We also 
have alternative things. And I also submitted some new research 
on CAM stuff, too, so we believe in that, too. And we believe 
it. We use it as part of our overall holistic approach to pain 
management. And I think that it is part of that whole, looking 
at this thing in more of a total thing than just a separate 
thing. So we do all of those things. And if the physical 
therapy, if we cannot, we use a lot of, if there is sometimes, 
if it is closer to home we use non-VA care. I mean, we 
basically use what is best for the patient. The----
    Ms. Brownley. You had mentioned about the training that you 
do. Do you train across the country in acupuncture so that 
others are licensed? Or massage therapy? Or----
    Dr. Scott. We currently at the present time do not have a 
manual or I guess you would say a training program in those 
areas. We do have residency education, you know, and residency 
programs like neurology and physical medicine rehab that we 
train individuals or we can send them to places that get that 
training, too. But we do not have train the trainers, if that 
is what you mean, at our place.
    Ms. Brownley. And is the training, it sounds to me the way 
you have described it, the training is voluntary. That if 
people want to come and get trained, they come to your center. 
But you are not sort of overseeing centers across the country 
saying, trying to look at where they need to be trained, if 
people are up to speed in where they need to be?
    Dr. Scott. Right. The 2009 pain directive says that every 
VISN should have what they call a tertiary and 
interdisciplinary team for pain. And we are trying to offer our 
25 years of experience to facilitate that in the VISN area. But 
I do not have a, I am just a local pain director. I do not have 
any kind of a say on who comes and when they come. Except they 
are always invited.
    Ms. Brownley. Thank you. I have run out of time. I yield 
back.
    Mr. Benishek. Thank you, Ms. Brownley. Dr. Wenstrup, you 
have five minutes.
    Mr. Wenstrup. Thank you, Mr. Chairman. My first question 
is, are providers at the VA protected in some way or free in 
some way from malpractice claims? Yes, doctor?
    Dr. Gray. Interesting. In a way, yes. Because basically you 
are suing the Federal government. I am glad you asked that, if 
I can go a little bit further?
    Mr. Wenstrup. Please.
    Dr. Gray. All you need to practice at a VA is a state 
license. So if you have a Florida license, you can come to 
Virginia and work at the VA. I went to my state Board of 
Medicine to ask for help in this matter. The State of Virginia, 
as many of the states do, has an outstanding program where via 
Internet you can find out in 30 seconds whether a patient has 
gone to multiple providers for opioids, whether they are double 
dipping inside the system and outside the system. The answer I 
got from my administrators was we are the Federal government, 
we do not have to.
    Mr. Wenstrup. Yes, in Ohio we have a similar program so 
that you can check what medications patients are getting 
through multiple providers. And you know, I have contended in 
my practice, which my last day in private practice was in 
December, and I always contended when I was dealing with non-
providers or people outside of our office, determining what 
patients should or should not get, I would speak to them and 
say, ``Well, how does this patient come to see you then if you 
are making this decision?'' And I usually would get what I 
wanted in that context. Because I do believe that unless you 
sit down with a patient, and you look them in the eye, and you 
put your hands on them, you should not be making their medical 
decisions. But that is another issue for another day.
    Dr. Gray. That is a real doctor, sir.
    Mr. Wenstrup. I am sorry?
    Dr. Gray. That is a real doctor.
    Mr. Wenstrup. Oh, well thank you, ma'am. But my question 
really for all of you, what within the VA system would really 
motivate any of the providers, or any administrator, to be 
exceptional, and to be efficient? And to really provide a high 
level of care? What is built into the system that motivates 
that? Because for an independent practitioner in the private 
sector, it is your reputation. It is a standard of care, it is 
your state medical board. And I am wondering what in the VA 
system provides that, or motivates one? If anything?
    Dr. Gray. That is private practice. I was a physician in 
private practice for 25 years before I went to the VA. And it 
is your pride. What you would have to do within the VA system, 
and again this is my two-year experience in one VA hospital, 
but you would have to interrupt the current system of 
reimbursement, let us say. Every one of my service chiefs, all 
of my superiors received a bonus, a raise, and a promotion.
    Mr. Wenstrup. On what matrix?
    Dr. Gray. It----
    Mr. Wenstrup. Going up?
    Dr. Gray. Correct. The theme here is do it as cheaply as 
possible, and this is my opinion, but do it as cheaply as 
possible. You well know these opioids cost pennies, just 
pennies. And I guess they think a human life is just pennies as 
well.
    I established a therapeutic swimming program at zero cost 
to the VA because the facilities were in place. The van, the 
driver, the pool, I had patients willing and eager to 
participate. I got no response from my supervisors. It was 
cheaper to just give them opioids.
    Mr. Wenstrup. Dr. Scott?
    Dr. Scott. Congressman, that is a very good question and I 
could answer it both from a clinical side as well as a personal 
side. It is providing good quality care and having good 
outcomes. I find that is what drives my staff to be very 
excellent, both in treating the war injured back, both treating 
this chronic pain program. I could sit down with any of my team 
and they have great pride in what they do, because the 
patients, they see the change, they see the improvement, they 
see the outcomes. And they are so overwhelming in this program 
that they basically, they come to work loving the work. Not for 
the VA but for the patients, to fulfill our VA mission, here to 
serve those. And providing that high quality of care, and 
getting that atmosphere where everyone is important, everyone 
can contribute, everyone's suggestions are listened to and 
acted on. That is what makes a good quality, that is what makes 
the atmosphere a positive, that is what makes the outcome. It 
is not money. It is basically those. That is what I found over 
time. That is why this program has gone for 25 years, because 
we have had people that constantly see these outcomes that are 
so good. And it keeps driving them to continue to be better and 
for the next patient. And I just want to share that with you.
    And for myself, the same thing. What drives me is not what 
they cannot do, what they can do. What drives me is just what 
some of the people said, when they feel helpless, hopeless, 
when they feel like basically pain is running their life, we 
get them control of their life. We get them control of their 
pain. And when they leave the program I give them a new 
mission, to go out and serve our country again. And basically 
it is a good feeling. And then when they do that and they come 
back, it is priceless. It is why we are here. It is our 
mission.
    Mr. Wenstrup. I applaud you for promoting that type of 
motivation. And for those that provide care under your 
tutelage, that they are taking that approach. That is personal 
pride and that is how I practice. But I do not think that 
everyone has that luxury right now, or performs in that manner. 
And I yield back.
    Mr. Benishek. Mr. Bilirakis?
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it. 
And I really appreciate you holding this hearing and allowing 
me to sit on the panel.
    Dr. Scott, I want to thank you for all the quality health 
care you have provided over the years. I represent, as you 
know, the Tampa Bay area so I am very familiar with Haley. And 
you, sir, are a true patriot. So thank you very much. And I 
appreciate your testimony as well.
    I understand from the testimony that approximately 30 teams 
from across the country have visited your facility to observe 
the model system and learn how to enhance pain treatment 
services at their facilities. Have these teams from VA, are the 
teams from VA or from the private sector? Are you aware of any 
programs similar to yours that have been established as a 
result of these visits? And what more can be done to increase 
the provision of programs like yours across the VA health 
system?
    Dr. Scott. We have had 30 of them. They come and spend 
about two and a half days. And they spend it, first we have 
groups, we have small groups. We teach them one on one. They 
have multiple disciplines so we match them up with the 
different disciplines, too. We show them the whole structure of 
the program. We show the administrative aspect of the program. 
We have a tremendous outcome based type program. In other 
words, we do not measure pain with just a zero to ten level. We 
also measure all the different aspects of how you function with 
the pain. And so function is very important. So we have 
basically, we developed our own scale there, you know, to 
actually measure pain. Not just a number, but how you interact 
with that pain, how you function with that pain. How you 
function with your wife, with your child, as was mentioned. 
That is just as important, too. And those things are all 
measurable. And we can then measure them when they come, when 
they go, when they leave, and we try to teach these teams that. 
Our goal is for them to go back and hopefully set up that 
tertiary interdisciplinary team that could take patients in the 
more complex level and manage that, too.
    And then we are available if they want to come back again. 
If they want to communicate by phone, if they want to interact 
too. So our goal is to really try to facilitate and help the VA 
learn what we have learned for 25 years.
    Mr. Bilirakis. Thank you. Thank you again for thinking 
outside the box. Of the veterans patients that received care 
through the chronic pain rehabilitation program last year, how 
many resided outside of your facility's catchment area? If you 
can answer that question?
    Dr. Scott. Yeah, probably more than half come from outside. 
We basically have a, in our mission stuff we have a hundred 
mile radius. So if they are within a hundred miles, they come 
in, we can screen them in. If they are beyond a hundred miles, 
like I mentioned we have had them from Hawaii, we have them 
everywhere in the country, we basically have to screen by 
phone, by mail, by letter and that. And so we have different 
mechanisms. But it usually about, if I admit four, I admit four 
patients on a Monday, and discharge four. They are there three 
weeks. We have 12 patients there all the time. And generally I 
will have one from North Dakota, Nebraska, and maybe even up in 
New England, and then one from local. So we see them from all 
over. And that is one of the neat things, is the fact that they 
all, when they come together, they all band together like a 
bank of brothers and they support each other. And with that, 
then they leave and they continue on those relationships. And 
with those continued relationships they keep the compliance and 
they keep adding to the program over time.
    So I think about, Dr. Bilirakis, I think it, I should say 
Congressman Bilirakis, it is about half and half, half local, 
half distant.
    Mr. Bilirakis. How are we raising public awareness, you 
know, so the veterans across the country can be aware of this 
great program?
    Dr. Scott. Well we try different things. And we are doing 
it, you know, we tried it through the professional channels 
with education and with research. We tried it with website, we 
actually had our own website for a while. We tried it with, on 
the Internet, a system that we have in the VA. We are 
constantly trying to get the word out as best we can about this 
program.
    We are not completely up to full capacity all the time. We 
are at about 85 percent bed capacity. It takes an individual, 
just so you know because we monitor this stuff real closely, it 
takes us from the time of consult to time that comes in, less 
than about 30 days. So, and so we want to make sure the access 
is there and maintained. We want to make sure the beds are 
occupied and we want to make sure we are available to help any 
veteran in this country.
    Mr. Bilirakis. Well thank you very much. Thank you very 
much, Mr. Chairman, for allowing me to sit on the panel. I 
appreciate it. Thank you all for your testimony.
    Mr. Benishek. Dr. Harris?
    Mr. Harris. Thank you very much. And I want to thank Dr. 
Gray and Dr. Bahorik for being here because, you know, we do 
hear that it is a problem when you complain against a physician 
working in the VA system, complaining about what is going on. 
Dr. Bahorik, you mentioned the Jackson facility. That is the 
one that was written up in the New York Times, a couple of 
prominent articles this year, right, about major problems with 
prescribing of controlled dangerous substances? And in some 
instances particularly involving, as I think you indicated you 
were involved with, you know, advanced practice nurses who 
prescribe and, you know, were not following DEA regulations? 
That is the same, that is the facility, right? That Jackson 
facility?
    Dr. Bahorik. That is the same facility, yes, it is.
    Mr. Harris. That is what I thought. And you also mentioned 
there was a facility, I guess, I do not think it was that one, 
it must have been another one, where one of the advanced 
practice nurses actually was indicated to be the Chief of, the 
Director of Pain Medicine, or the Pain Specialist in the 
facility?
    Dr. Bahorik. Yes. A nurse practitioner is a Director of 
Pain Medicine. Well, she is actually the director. I think 
there is a director on paper that is not there----
    Mr. Harris. Okay.
    Dr. Bahorik. --at the Wilmington VA Medical Center.
    Mr. Harris. At Wilmington in Delaware?
    Dr. Bahorik. Yes.
    Mr. Harris. Okay. And what was, do you know what that 
person's training is that would qualify that individual to be a 
pain specialist?
    Dr. Bahorik. No, I do not actually.
    Mr. Harris. Okay.
    Dr. Bahorik. But I can tell you it is not as much as a 
physician.
    Mr. Harris. Okay. And what is what is going to bring me up. 
Because you know there is this problem that is brewing in the 
VA about the nursing handbook that is going to say that all 
APRNs are supposed to achieve, become licensed independent 
practitioners. And that will basically certify that they can 
have independent practice of physicians. But your two, your 
recommendations, number ten and 12 are number ten, reverse the 
trend to replace physicians with cheaper extended care 
providers. Is that what you are talking about? A trend 
somewhere to go to less expensive, because the VA does pay 
midlevel providers less, less expensive midlevel providers?
    Dr. Bahorik. Yes, that is exactly what the trend is. And I 
feel that it is dangerous. I have been a number of places. I 
have seen problems with misdiagnoses. One of the things that 
really concerns me is these extended care providers were never 
intended to function independently. However, the VA has taken 
upon themselves to decide that they are equivalent in taking 
care of patients the same as a physician.
    Mr. Harris. So that change to the nursing handbook would be 
of some concern? That would require----
    Dr. Bahorik. Yes, exactly, it would be.
    Mr. Harris. Okay, that is what I thought. And number 12, 
recommendation 12 is return specialty care to the domain of 
physician specialists. Now this is intriguing to me because as 
you know advanced practice nurses claim specialty training 
that, and I know because I am practicing one of those 
specialties, that is far less training than a physician gets. 
But according to the VA under the new nursing handbook my 
understanding is if an advanced practice nurse claims specialty 
training and is certified, usually by a nursing group in that 
specialty, then they would have independent practice in the VA 
to practice that specialty?
    Dr. Bahorik. Yes, and that is what is happening. A lot of 
times when you send a patient to a specialist, you will get, 
most of the time you will get a report back from a physician 
assistant or a nurse practitioner. And there may or may not be 
any supervision by the specialist.
    Mr. Harris. Okay. That is what I thought. Thank you very 
much. And I yield back my time.
    Mr. Benishek. Ms. Brownley has another questions she would 
like to ask.
    Ms. Brownley. I just wanted to ask Dr. Gray perhaps that 
did you ever have an opportunity to refer one of your patients 
to this facility in Tampa?
    Dr. Gray. Thank you for asking that. I brought that model, 
the Tampa model, back to Hampton and asked if we could 
implement it. That was the result of the pain conference which 
was held in Florida and it was for VISNs 1 through 11. I was 
told we had no need of it, we had opioids. We certainly did not 
need anything like that. And if you try and refer outside of 
your VISN, the answer is no. So for us in Virginia we had 
Richmond, McGuire, where we could refer patients. And just as 
the gentleman referred to earlier, they can get an appointment. 
It will be 12 months, 14 months, 16 months from the date that 
you call for the appointment. And that is deemed adequate.
    Ms. Brownley. Thank you.
    Mr. Benishek. Let me ask, follow up that. Who told you 
that, you could not refer, or could not bring that model back?
    Dr. Gray. The Chief of Medicine, the Chief of Primary Care, 
the Chief of Staff.
    Mr. Benishek. Thank you. Well, I thank you all for being on 
this panel. And for your testimony today. You all are excused 
and we will welcome the third panel to the table. Thank you.
    Dr. Gray. Thank you.
    Mr. Benishek. Thank you.
    Joining us on the third panel today from the Department of 
VA is Dr. Robert Jesse, who is the Principal Deputy Under 
Secretary for Health for the Veterans Health Administration. 
And Dr. Jesse is accompanied by Dr. Robert Kerns, the National 
Director for Pain Research for the Veterans Health 
Administration. I would like to thank you both for being here 
today. Unfortunately, you have the job to explain what the VA 
is doing after we have had this testimony from the previous two 
panels, so I wish you luck with that. Dr. Jesse, please proceed 
with your testimony.

  STATEMENT OF ROBERT L. JESSE, M.D., PRINCIPAL DEPUTY UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY ROBERT KERNS, 
  PH.D., NATIONAL DIRECTOR FOR PAIN RESEARCH, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Jesse. Thank you, Chairman Benishek and Ranking Member 
Brownley, and Members of the Committee.
    Before I start into formal remarks I would just like to 
address Mrs. McDonald and Mrs. Green. I am sorry, I cannot turn 
around and still be on the microphone. But there are no words 
that I can say to express how deeply I feel about both the 
suffering your husbands were going through and the suffering 
that you are going through now. But I would like to thank you 
for coming forward and telling your story. And if there is any 
way that we can honor their life, it is by keeping that story 
out there and by ensuring, by your holding us to the fire that 
we learn from it. Your comments about not letting this happen 
to other people are very, are taken. And I do so much 
appreciate your being here.
    And likewise, to Mr. Renschler and Mr. Minyard, thank God 
you are still with us. And whatever we can do to restore your 
trust in the VA, please give us a chance.
    So let me just start by extending those sympathies to all 
our Nation's veterans who suffer from chronic pain and from the 
many devastating ways in which that presents. The VA, let me be 
very clear, that we are strongly committed to ensure that 
veterans do have what they need to manage their pain. And that 
includes not just medications but to truly get to the root 
cause of this.
    This is not an issue limited to veterans. Veterans are a 
population who are particularly challenged. But this is a 
national crisis. And in 2011 the Institute of Medicine 
published ``Relieving Pain in America.'' This challenges tens 
of millions of Americans and it takes an incredible toll on 
morbidity, on mortality, on disability, and just has an 
incredible impact on not just the people suffering pain but 
their families and their communities.
    The burden of pain amongst veterans is considerable. I 
think it was mentioned up to 60 percent, certainly around 50 
percent, of the returning veterans from this War are affected 
to some extent by chronic pain. And they often require 
intensive strategies, as you heard from Dr. Scott, for the 
effective management of that pain. Sometimes that requires the 
use of opioids. These are proven therapies, particularly in 
severe pain, when other medications and modalities have not 
proven to be fully effective.
    To be very clear, we all know that there are risks to these 
medications. There are risks to patients. As you heard from Dr. 
Gray, there are risks to providers who at times provide these 
medicines. And we all know that there are risks to the 
communities as well. And VA is working broadly across all 
segments with partners to try and ensure the effective use of 
opioid therapy when indicated for patients with chronic pain.
    The VA has been at the forefront of health systems in this 
country in trying to deal with this issue. We began in 1998 
with a national strategy for pain management. In 2000 the VA 
recognized pain as the fifth vital sign. This I think was an 
incredibly important statement requiring providers to routinely 
screen and assess for pain as a vital indicator of health 
status. A year or so later the joint commission came up with a 
similar strategy.
    The pain management directive, as you heard, was published 
in 2009. And that described a series of policies and procedures 
for the implementation of a step care model of pain that is the 
single standard of pain in the VA.
    VA has worked closely with DoD. In 2010 we published 
evidence based guidelines, and we have continued that 
relationship through a number of strategies, including the 
health executive committee chartering a joint pain work group 
the singular goal of which is to ensure that the pain treatment 
strategies used in DoD are consistent with those used in VA so 
as servicemembers traverse from active duty into primary care 
there is not a disruption in their care, and you heard the 
devastating consequences of when that happens here today.
    We are improving education and training on safe opioid 
therapy. This has an opioid safety initiative. This is actually 
finally giving us the kind of data that gives us the insight to 
see how these prescribing practices are occurring across the 
country. And when we have that data available to clinicians we 
can see significant successes in the reduction in the use of 
chronic opioids. We also have public safety initiatives. As 
there was discussion earlier, about participation in the state 
prescription monitoring programs. It was not that VA was, we 
did not have to do it, it was that we were not allowed to do 
it. And in 2011 we asked Congress for legislation that would 
permit us. In its wisdom, Congress granted that legislative 
relief in 2012 and now VA is participating, or will be 
participating in these state reporting boards. It is very 
important for both the patient's safety as well as the safety 
of communities.
    We have expertise in this field. You have heard from Dr. 
Scott. I am here with Dr. Kerns so I am not going to go through 
all that right now. So I know that my time is up.
    I do want to acknowledge, Mr. Chairman, that we are 
committed to improving veterans' health and well being. We know 
they have difficult problems. We know that they are suffering. 
And we are doing our, we are doing absolutely our best to and 
change a system from one that rewards an encounter and gives a 
prescription, to one that is built on healing relationships. 
This is crucial and vital to dealing with all of our patients 
and we certainly thank the efforts of this Committee and the 
Full Committee in meeting those goals. Thank you.

    [The prepared statement of Robert L. Jesse appears in the 
Appendix]

    Mr. Benishek. Thanks, Dr. Jesse. I yield myself five 
minutes to ask questions. I guess you had a standard answer, 
five minute talk there. I wish you would have responded a 
little bit to the testimony that we have had previously. 
Because frankly, I feel bad for you because you have to come 
here and defend the VA, and tell everyone how you are really 
working hard to fix the problem. But what I would like to know 
is what are you going to do about the situation where Dr. Gray 
described, where she was told to do something and then she did 
not do it, and then they changed the record? What is going to 
happen with that? I mean, apparently nothing happened. Now so 
are you going to take that and do something about it?
    Dr. Jesse. No I, first of all I was not aware of that until 
today. VA actually has----
    Mr. Benishek. Do you think that is a good idea?
    Dr. Jesse. No, it is absolutely not a good idea.
    Mr. Benishek. If, yes. I will have to look into it. I do 
not know the situation. I have only heard this from Dr. Gray 
today.
    Mr. Benishek. Right, right, right, and me, too.
    Dr. Jesse. But as I said, for VA to change a record there 
is actually a formal process that is required to do that. So--
--
    Mr. Benishek. Do you think a physician note should be 
changed? What are the circumstances that would allow an 
administrator to change the note of a doctor?
    Dr. Jesse. As far as I am aware there would be none unless 
there are factual, untrue, unfactual issues in there. In fact--
--
    Mr. Benishek. But doctor----
    Dr. Jesse. --we do change notes all the time----
    Mr. Benishek. --I appreciate your comments. But I would 
like if you can maybe answer me this, could you please figure 
out the policy for that? And maybe report back to me in maybe a 
month or so?
    Dr. Jesse. I absolutely will, sir.
    Mr. Benishek. The circumstance? Because, you know, I just 
do not think that that is very good policy. And I think Dr. 
Gray is pretty disappointed about the way she was treated. And 
I can see that the VA has to prove it, and all that. But----
    Dr. Jesse. No, I----
    Mr. Benishek. --I do not think that is sort of the behavior 
that we want to foster in the VA. If you could, could you do 
that for me----
    Dr. Jesse. Absolutely.
    Mr. Benishek. --maybe come back to the Committee in a month 
with a report?
    Dr. Jesse. Absolutely.
    Mr. Benishek. Okay. Now let me go on from there. The policy 
of having a pain specialist appointed at a VA hospital who has 
no previous experience in pain treatment, do you think that is 
a good policy to have? Now why was Dr. Gray appointed the pain 
specialist when she had no previous experience in pain? She is 
an internist and a rheumatologist. So she has some experience 
there.
    Dr. Jesse. Yeah.
    Mr. Benishek. But why would somebody like that, or a nurse 
practitioner, for example, be designated as the pain 
specialist? Why would that happen?
    Dr. Jesse. I cannot explain why it happened in Dr. Gray's 
case but----
    Mr. Benishek. Do you think that is a good policy?
    Dr. Jesse. So I think there is----
    Mr. Benishek. I know you are in a tough situation here 
because you have to defend the VA. But you see, what I am 
trying to get to is that these policies are indefensible. And 
they should be changed. And you sitting there and saying, we 
have got to do better, you know, that is all well and good. But 
I would like to see some actual plans to make that happen.
    Dr. Jesse. So there were, we have pain medicine 
specialists. That is a specialty within medicine, it has 
separate boards. And to confuse the terms of pain specialist, 
pain points of contact, and pain medicine specialist, I think 
we need to be clear about the language. A small facility, a 
CBOC, is not going to have on staff a pain medicine 
specialist----
    Mr. Benishek. Well no, of course. But she apparently was 
more than just the pain point of contact. She was the pain 
specialist, according to what she said. She did not describe 
herself as the pain point of contact. I am a general surgeon 
and probably deal with a lot of pain. Maybe not as much chronic 
pain as the average family practitioner. But I usually have a 
system of where to refer. And so that one person is dealing 
with the pain treatment. And it is not just narcotics, it is a 
whole spectrum of care such as Dr. Scott mentioned.
    Dr. Jesse. Well one of the key principles as the step care 
plan, as is outlined in the directive, is actually knowing 
where and when to refer. That is why that system was set up. So 
people are not trying to manage things that are outside their 
scope of capabilities.
    Mr. Benishek. Well it sounds as if that Dr. Gray and the 
other doctor were encouraged not to refer people, but 
encouraged to use narcotics. Which, I do not know----
    Dr. Jesse. Well that is indefensible. That is absolutely 
indefensible. And as physicians they should feel absolutely 
that they should refuse to do that.
    Mr. Benishek. Well I am glad----
    Dr. Jesse. I have, in my career in the VA I have never been 
forced or asked----
    Mr. Benishek. I am glad to hear you say that, Dr. Jesse, 
frankly. So thank you for saying that. And I would then say to 
all physicians who work in the VA to stick to your guns and 
treat the patient as you think best, and please report this 
kind of stuff to us here. I think I am out of time. Thank you 
very much, doctor.
    Dr. Jesse. May I follow----
    Ms. Brownley. See if Ms. Brownley wants you----
    Dr. Jesse. Well, I am sorry, but not on my time. Maybe on 
someone else's.
    Dr. Jesse. Okay.
    Ms. Brownley. So Dr. Jesse, I just want to understand your 
responsibility in the VA. Is your responsibility for quality of 
care? Or is your responsibility to oversee and make sure the 
system is working and you are really accountable? In today's 
hearing we are talking about pain management, that you are 
accountable for the VA and how they perform pain management?
    Dr. Jesse. So I do not think that is an either/or question. 
I think ultimately the accountability is that all veterans 
receive absolutely the best possible care they can receive.
    Ms. Brownley. Okay.
    Dr. Jesse. And that includes the ability to compare that 
care that they are receiving to some standard if there is one, 
to certain expectations, and certainly to the expectations of 
the patient.
    Ms. Brownley. Well I think in today's hearing I leave 
compelled that the system appears to be broken. I am going to 
have faith that there are pockets of excellence and in Tampa it 
looks like there is one certainly there, and there probably are 
in other parts of the country. But you know, how do you respond 
to the comments about we have a system of quick and cheap over 
good and thorough, and the basic principles of medicine have 
been abandoned? I mean----
    Dr. Jesse. I would argue, and I am not one that would like 
to argue with other witnesses, but I do not believe that that 
is the case systemwide. The question by Dr. Wenstrup was asked, 
you know, what would motivate somebody to work in the VA if it 
is just quick and the simple? And the simple, or the very 
complex answer, is that we are there because we want to take 
good care of veterans. I am, I had a choice in 2000 between 
going into private practice, actually going to work in industry 
or working in the VA, and I chose to work in the VA. At that 
time it was not an excellent system, but I wanted to make it 
so. Today I think it is an excellent system. It is not 
outstanding. It still has problems. But we are making it better 
everyday. And the fundamental reason behind that is because the 
veterans actually really appreciated what we did for them. And 
a certain person by the name of Harold Jesse, who I was born on 
a Navy base, I grew up with my father who was a career Naval 
officer. I entrusted his care to the VA and I wanted to give 
back. And people work in the VA for those kinds of reasons, not 
because it is an easy come, easy go system.
    Ms. Brownley. And I am not questioning your commitment to 
that whatsoever.
    Dr. Jesse. All right.
    Ms. Brownley. I absolutely am not. But it is, you know, how 
do we get your commitment permeated all the way down to each 
and every one of our veterans so that they are treated in the 
way that they need to be treated? And clearly walking away from 
this hearing I think we all have to agree that there are areas 
that we must look into, and there are areas that I think we 
just have to put on our chart, get to the bottom of it, and 
figure out ways in which we can improve upon it.
    And I just, I wanted to also ask, Mrs. Green in your 
testimony asked about what the VA does after a death of one of 
our soldiers, a veteran.
    Dr. Jesse. Mm-hmm.
    Ms. Brownley. And the analysis that is done thereafter. And 
so I wanted to follow up on that question to understand if that 
is happening after every death? And are we collecting data to 
determine the cause of death? And are we collecting it?
    Dr. Jesse. So unexpected death is supposed to be studied. 
This is how we learn. You know, as physicians----
    Ms. Brownley. Well would it not in a pain management 
situation, where there is not any----
    Dr. Jesse. Yeah.
    Ms. Brownley. --you know, you are not having heart problems 
or any other things----
    Dr. Jesse. But, yeah, those are----
    Ms. Brownley. --would that more or less qualify under 
unusual----
    Dr. Jesse. Absolutely, because those are unexpected deaths, 
as are the suicides. And one of the things where we really are 
making change is historically we have asked did we do 
everything that we should have? And often the answer is yes. 
But the real question is, did we do everything that we could 
have? And that requires a much deeper introspective view into 
each one of these cases. And we are beginning to change the 
culture that we really begin to get to that level of 
understanding and depth. Because that is where we are really 
going to be able to begin to change this equation.
    Ms. Brownley. Well it is a cultural change.
    Dr. Jesse. Yes.
    Ms. Brownley. And cultural changes are hard, really, really 
hard.
    Dr. Jesse. Yes.
    Ms. Brownley. But so, but are you collecting that data?
    Dr. Jesse. So we have that data. We have in the past couple 
of years actually been collecting the data in a way that it 
becomes searchable so we can look at that. We also have the 
National Center for Patient Safety that does the root causes 
analysis. And they roll all of them up and look for 
commonalities across the systems where issues arise. And this 
is really key. Because often seeing it once does not really 
raise a red flag. But when you can look across the system and 
see it happening two, or three, or four times, then it does. 
And then we really need to understand how the system is 
allowing these things to happen. But it is only when people 
look, it is only when people like Dr. Gray raise issues and can 
do that in a way that they feel safe, and I apologize that that 
seemed to be contentious in her instance. But the ability for 
people to safely raise issues without being, getting into 
trouble for it, is the foundation of a just culture. And the 
only way that we are really going to change patient safety 
outcomes and improve health care.
    Ms. Brownley. Well I would certainly be interested to see 
what the data is and what any conclusions, you know, may come 
from it. Because I, I mean just anyway we can have that 
conversation another time.
    Dr. Jesse. And we would be happy to do so.
    Ms. Brownley. Thank you for your testimony and I yield 
back.
    Mr. Benishek. I appreciate your comments there, Dr. Jesse. 
And let me just say that I assume that Dr. Bahorik will not 
face any negative professional repercussions----
    Dr. Jesse. No.
    Mr. Benishek. --in the department as a result of her 
testimony here, is that correct?
    Dr. Jesse. I would certainly hope not. And if she does, she 
should let me know.
    Mr. Benishek. All right, thank you. Mr. Wenstrup?
    Mr. Wenstrup. Thank you, Mr. Chairman. You know, I want to 
applaud so many caregivers in the VA system.
    Dr. Jesse. Thank you.
    Mr. Wenstrup. I know that in my private practice two of my 
partners give a couple of days a week to operate at the VA and 
they only have the interest of the patient in mind and that is 
why they are serving at the VA. And I think that is reflective 
of most at the VA. It is the system that I think we have to 
deal with and have to address. And you know, the purpose of 
these hearings is to hear the truth and to right wrongs. And 
hopefully we will accomplish that with what we are doing here 
today.
    To Dr. Kerns, you know, we hear the testimony today about 
the spinal cord stimulator, and I am sure you are very familiar 
with that with what you do, I would imagine, is would that be 
correct, sir?
    Dr. Kerns. First of all, yes, let me echo the comments of 
others. I really do not want to miss the opportunity to express 
my sympathies to the people that were on the first panel in 
particular, and actually to the trouble that the physicians on 
the second panel have also experienced in the VA.
    So yes, I am well aware of spinal cord stimulation. Just so 
you know, I am a psychologist, not a physician, so I am not a 
prescriber. But to the point about spinal cord stimulation, it 
is an evidenced based therapy for certain, but not all chronic 
pain, conditions, and only actually a small proportion likely 
benefit. It is a capacity that we are growing in VA. It is my 
understanding that as many as 40 of 152 core facilities 
actually do spinal cord implants, spinal cord stimulations. And 
a much larger proportion of facilities, certainly a majority, 
have pain medicine specialists who have the capacity to manage 
care for veterans who have received spinal cord stimulation 
either in the VA or outside the VA.
    Mr. Wenstrup. So of course your concern when you have the 
testimony earlier where he goes to the physician and he says, 
``I am not even familiar with the procedure,'' that is of 
concern. So from where you sit do you feel that you have 
everything you need to make providers aware of all the 
modalities that are available? And that you have the providers 
that can actually provide that type of care?
    Mr. Kerns. So thank you for that question. I was also 
privileged to serve, actually, not as a representative of the 
VA, on the Institute of Medicine Committee that this Congress 
chartered. This is a key problem in the United States and in 
the VA. We (VA) are in fact a model of what we are trying to do 
in terms of improving education and actually training of 
providers in VA. So to one key example, I know there is 
interest of this Subcommittee about the interface between VA 
and Department of Defense. So there is a health executive 
committee chartered work group. And from that has emerged a 
very well funded joint incentive fund initiative that promotes 
education and training and consistency of pain care across the 
DoD/VA. I would also say there is a complementary initiative, 
well funded, to bring auricular acupuncture that has been 
developed in the battlefield in DoD into the VA and build that 
capacity as well. So these education and training initiatives 
are very important and timely as we work to address a national 
problem that most everybody from medical schools, nursing 
schools, other professional schools acknowledge is a failure to 
provide this education in our professional training schools. 
And I like the work that VA is doing in that regard.
    Mr. Wenstrup. Thank you, and I yield back.
    Mr. Benishek. Thank you, Dr. Wenstrup.
    Mr. Harris. Thank you very much, and thank you Mr. 
Chairman. You know, as a veteran I do know that and I 
appreciate that the VA system is trying to do its best in 
difficult environments, within budgetary constraints, within 
personnel constrains, etcetera. But I want to ask specifically 
since one of the issues that came up since the hearing is on 
prescription narcotic overuse perhaps in the VA system, and you 
know one of the findings that was at the Jackson investigation 
back in earlier in this year, was this issue of, you know, 
advanced practice nurses, supervision of advanced practice 
nurses, whether it was adequate, there were all kinds of, and 
you have read the report, you know what I am talking about 
there.
    And now, you know, one issue that has come up is this 
nursing handbook issue. Where instead of the VA kind of 
following along with Dr. Bahorik's recommendations are, which 
actually, you know, an attempt to provide better treatment for 
our veterans, including those in pain in the pain management 
system, is, you know, one of her recommendations, reverse the 
trend to replace physicians with cheaper extended care 
providers. But the nursing handbook change which would 
encourage all advanced practice nurses to become licensed 
independent providers, for instance let us say you had an 
advanced practice nurse who was named the pain specialist, or 
medicine, whatever the title is at the VA. But that person felt 
uncomfortable doing that, they felt uncomfortable in 
independent practice. They actually thought that it was 
appropriate to be collaborating or supervised by a specialist 
physician. The nursing handbook says they have to go work 
somewhere else. You either achieve independent practice, or you 
go work somewhere else. This is strange. Because in an 
environment like pain management, or in the environment on a 
care team, like in my specialty, anesthesiology. You know, the 
culture usually is that there is a culture of it is 
multidisciplinary, it is collaborative, and with recognition 
that there are a different level of providers with different 
levels of expertise. It seems to be doing exactly the opposite 
way with that thing.
    So I am going to ask you, Dr. Jesse, do you feel given that 
this is under serious consideration, I know that the Ranking 
Member and chair have letters to you addressing concerns, and 
the AMVETS, and other groups, do you feel that the training is 
equivalent, or the ability to treat patients is equivalent, for 
the APRNs achieving licensed independent practice, and medical 
specialists?
    Dr. Jesse. So----
    Mr. Harris. --simple question. Do you roughly make----
    Dr. Jesse. No, I do not equate them at all. But I want to 
be clear about something. The nursing handbook was a draft. It 
has not been approved. It is not----
    Mr. Harris. Well I am, what I am getting to is, what is 
your opinion on it since you are going to be one of the 
decision makers, I understand?
    Dr. Jesse. So the, I am a cardiologist. I do not believe 
that a nurse practitioner, I have very good nurse practitioners 
and PAs that work with us in cardiology, but we work as a team.
    Mr. Harris. And you, but----
    Dr. Jesse. Just as you work with----
    Mr. Harris. Correct. But independent practice assumes not 
working as a team, that is why it is called independent 
practice. And in fact, under statute, in states that establish 
independent practice, it specifically says, and I can quote 
from the statutes, that they work without involvement, 
requiring not physician involvement. That is what independent 
practice means----
    Dr. Jesse. Right.
    Mr. Harris. --in state statutes.
    Dr. Jesse. Right.
    Mr. Harris. No physician involvement. In the pain 
management program in the VA system, do you think that would be 
an improvement?
    Dr. Jesse. No, not necessarily.
    Mr. Harris. Okay, not necessarily. But under what 
circumstances would that be an improvement?
    Dr. Jesse. So if we had a, if we had a VA facility that did 
not have inpatient surgery, outpatient surgery, but there were 
the need for some level of skills that a nurse anesthetist 
could bring, that would be useful to veterans so that they 
would not have to travel. Now in our system----
    Mr. Harris. Dr. Jesse, I asked about pain management, not 
anesthesia. I specifically asked about pain management.
    Dr. Jesse. But in those situations, whatever the nurse 
anesthetist could bring to that it would be useful to veterans. 
But they would still be working within the construct of a team, 
even if that team were conducted to one of the major medical 
centers. So again, this is, this handbook that you have seen is 
a very early draft. It is not agreed upon by the system. We 
will not move anything forward until we have had robust 
discussions with external stakeholders, including the 
societies. I know ASA is very interested in this. I know that 
the Family Practice folks are very interested, and AMA is very 
interested. And I can tell you that this will not move forward 
until we have had those discussions with all of the 
stakeholders.
    Mr. Harris. Sure, and I appreciate that. And specifically 
with regard to pain management, you understand the complexity--
--
    Dr. Jesse. Yes.
    Mr. Harris. --of the DEA regulations----
    Dr. Jesse. Oh, absolutely.
    Mr. Harris. --and supervision requirement?
    Dr. Jesse. Yes.
    Mr. Harris. Because of course you do not have the ability 
of preemption with DEA law. Thank you very much, Dr. Jesse. And 
thank you very much for holding the hearing. And I want to 
thank the Committee for allowing me to participate.
    Mr. Benishek. Thanks, Dr. Harris. If there are no further 
questions, I would excuse the third panel. Let me just say 
this. I think Mrs. McDonald brought it up at the very 
beginning, that this is not the end of it. Because there are 
many things that we will have to address here. Dr. Jesse, I 
look forward to working with you to answer some of the 
questions that were raised here and develop an overall plan 
within the VA to markedly improve the pain management system 
there. And I look forward to your reports. And hopefully we can 
just maybe get together for a couple of meetings outside the 
hearing venue----
    Dr. Jesse. We would very much like that, sir.
    Mr. Benishek. --make progress in this area. I want to thank 
again all the Members of the panels that have participated 
here. And thank you so much. I ask unanimous consent that all 
Members have five legislative days to revise and extend their 
remarks and include extraneous material. Without objection, so 
ordered. I would like to also thank our witnesses again for 
joining us. The hearing is now adjourned.

    [Whereupon, at 1:52 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

              Prepared Statement of Hon. Dan Benishek M.D.
    Good morning and thank you all for being here today.
    I welcome you all to today's hearing, ``Between Peril and Promise: 
Facing the Dangers of VA's Skyrocketing Use of Prescription Painkillers 
to Treat Veterans''
    Today's subject is one of the most serious and significant we will 
discuss all year. It is also one that is particularly poignant and 
personal to me.
    I spent twenty years serving our veterans as a doctor at the Oscar 
G. Johnson VA Medical Center in Iron Mountain, Michigan.
    In that capacity, I understand all too well what it means for a 
veteran and a patient to be in pain.
    Pain can be an unrelenting enemy - one that thwarts an individual's 
ability to work and enjoy the activities they once loved, hinders their 
relationships with their family and friends, and impacts their capacity 
to be comfortable in their own home.
    On a daily basis, my veteran patients would confide in me about the 
pain they were in, the many ways in which they were hurting, and - more 
than anything - their desperate desire to find relief.
    Perhaps nowhere else is that more clear than in the heartbreaking 
testimony we will hear shortly from two surviving spouses, Heather 
McDonald and Kimberly Green.
    Their husbands, Scott McDonald and Ricky Green, honorably served 
our Nation in uniform and came home -as far too many of our returning 
veterans do - hurting and in pain.
    These men sought treatment from the Department charged with caring 
for them - the VA - hoping to get the help they needed so they could 
once again take full and successful ownerships of their own lives, 
without pain as their constant companion.
    Sadly, rather than getting the best care anywhere, Scott and Rickey 
were prescribed a disturbing array of pain, psychiatric, and sleeping 
medications without any clear consideration or special attention paid 
to how these powerful drugs were interacting with each other or 
affecting Scott and Rickey's physical and mental well-being.
    The combined effects of these multiple medications ultimately took 
their lives.
    We will also hear from two veterans - Joshua Renschler and Justin 
Minyard - who will give us a first-hand account of the struggles they 
faced with VA's apparent overreliance on opioid-based medications for 
pain management.
    At one time, Joshua was prescribed thirteen different medications. 
Despite his pleas that the medications weren't working, he was never 
referred to a pain specialist.
    Justin was prescribed enough opioid pain medications on a daily 
basis to treat four terminally ill cancer patients. He eventually 
sought care outside of VA to find an effective treatment to manage his 
pain.
    To say that I am disturbed by these accounts and by the multiple 
reports we hear every day about the skyrocketing use of prescription 
painkillers - particularly opioids - to treat veterans in pain would be 
a major understatement.
    VA's band aid approach to suppressing the symptoms of pain rather 
than treating the root causes must stop.
    VA maintains a pain management treatment model that makes primary 
care, rather than specialty care, the predominant treatment setting for 
veterans suffering from pain.
    Yet - as I know from personal experience - the multifaceted nature 
of chronic pain, particularly when multiple medications are being 
prescribed, should not be managed by a primary care physician, but 
rather by a qualified pain specialist who is trained to understand the 
complexities of treating these conditions.
    I want to be very clear that this hearing is not intended to vilify 
the many hard working primary care providers working every day to care 
for veterans in pain at VA medical facilities across the country. I 
have been in their shoes and I know the challenges they face in 
providing the high-quality care our veterans deserve.
    Rather, our intent here today is to initiate better provider 
practices and, most importantly, better care coordination for our 
veterans and their loved ones so that no other family has to experience 
the pain, the suffering, or the loss that our witnesses on the first 
panel have already experienced.
    It is critical for VA to take responsibility for its failures and 
rise to the challenge to change and take immediate action to adopt 
effective pain management policies, protocols, and practices.
    We have already lost too many veterans on the home front to battles 
with chronic pain.
    The stakes are too high for VA to continue getting it wrong.

                                 
               Prepared Statement of Hon. Julia Brownley
    Good morning. I would like to thank everyone for attending today's 
hearing.
    Chronic pain is a debilitating condition that affects veterans at a 
much higher rate than in the civilian population. According to the 
Department of Veterans Affairs, in the newest cohort of veterans, 
chronic pain is the most common medical problem reported in veterans 
returning from the battlefield with estimates as high as 60 percent for 
those who seek treatment at VA.
    Modern warfare often leads to serious but survivable physical and 
neurological injuries such as amputations, spinal cord injury, 
traumatic brain injury, gunshot wounds, and more. Often times these 
same veterans experience mental health issues as well such as post-
traumatic-stress disorder, anxiety, and depression. And while advances 
in medical technology have saved the lives of many wounded soldiers, 
many veterans of our Armed Forces are forced to live a life that is 
dominated by acute and chronic pain. Providing safe, effective, 
adequate pain management is a crucial component of improving veteran 
health care.
    The treatment of chronic severe pain often involves physicians 
prescribing opioid analgesics, a highly addictive pain killer that if 
not properly monitored can lead to death. Testimony from our first 
panel highlights the dangers of opioid use and just how quickly 
veterans get trapped in a rapid downward spiral of addiction and pain.
    I know that VA has a National Pain Management Strategy, and I look 
forward to hearing from Dr. Jesse regarding the ramping up ofp clinics 
and services throughout the Veterans Health Administration. I am also 
very interested in progress being made with the Department of Defense 
on transitioning servicemembers and the management of medications 
between the agencies.
    Finally, VA recognizes that chronic and acute pain among our 
veterans is a serious problem and in fact, is a priority. I applaud 
them for taking the lead on this issue. But I am concerned that 
comprehensive pain care is not consistently provided throughout the 
VA's health care system.
    I look forward to hearing from our witnesses today. Thank you, Mr. 
Chairman, and I now yield back.

                                 
            Prepared Statement of Hon. Jeff Miller, Chairman
    Thank you Dr. Benishek for holding this critical hearing to examine 
the Department of Veterans affairs (VA) skyrocketing use of 
prescription painkillers to care for veterans with acute and chronic 
pain.
    Many of our servicemembers are returning home from the battlefield 
with serious injuries and acute pain, and as they transition to veteran 
status, the pain often lingers and leads to chronic pain.
    For these veterans, the pain level, not the veteran, sets the 
agenda for the day, sets the tone for their families, and keeps the 
veteran from fully participating in the life he or she once had.
    Yet, when these veterans reach out and entrust the VA to relieve 
their pain, the treatment they often receive is the systemwide default 
prescribing of prescription painkillers.
    According to a CBS News report, based on VA data, over the past 
eleven years the number of patients treated by the VA is up twenty nine 
percent, while narcotic prescriptions written by VA doctors and nurse 
practitioners are up two hundred and fifty nine percent.
    The rapid rise in VA's use of prescription painkillers corresponds 
with data that indicates VA patients are dying of narcotic overdoses at 
twice the national average.
    This is heart wrenching proof that VA's approach to pain management 
is failing and in need of an immediate overhaul.
    These powerful prescriptions are not a cure-all and must not be 
doled out like a magic pill to fix chronic pain.
    Veterans depend upon VA to uphold its mission of restoring the 
health of those who have borne the burdens of battle.
    But instead of helping them manage their battles with pain in a 
healthy manner, VA has opted instead to use treatment that has the 
power to destroy, rather than restore their lives.
    VA can and must change course and act now to reduce their reliance 
on the use of prescription painkillers.
    We know there are pain care specialists who understand the 
complexities of treating these conditions, and VA must make them 
accessible to help veterans manage their pain without the disturbing 
risks of the long term use of prescription painkillers.
    VA providers should be required to adhere to evidence-based 
prescription guidelines and be held accountable when those guidelines 
are not followed.
    The veteran patient and their loved ones must be listened to, 
followed closely, and supported with a treatment plan that can best 
help them regain happy, healthy lives.
    Anything less is unacceptable.

                                 
                 Prepared Statement of Heather McDonald
Scott Alan McDonald 5/24/77  9/13/12
    After graduating from Belpre HS in 1995, Scott Alan McDonald took 
an oath to uphold the dignity and honor of the United States Army. For 
15 years, he served honorably in the uniform of his country and was 
proud to serve as a UH- 60 Blackhawk mechanic and Crew Chief for a 
medivac unit.
    Bosnia, Panama, Iraq, and Afghanistan were ust a few of the war 
torn countries that he dedicated his life to making a difference in. In 
his career he experienced heartache, unimaginable violence, death, and 
the overall devastating effects of war. He saw many of his fellow 
soldiers give their lives in the ultimate sacrifice to their country 
and narrowly escaped with his own life in tact.
    He loved his country and what the American Flag stands for. He was 
a brother in arms to thousands of fellow soldiers and a truly 
remarkable man that never met a stranger. Scott had larger than life 
expectation for his daughters Yasmin and Reise. Because of his 
commitment to family and Honor, on Jan. 9, 2011 I married him.
    On 30 April 2011, Scott's career with the Army had come full circle 
and he hung up his uniform for good. He began seeking treatment for 
Back and shoulder pain at the Chalmers P Whylie Ambulatory Care Center 
in Columbus, Ohio. Almost immediately he was placed on medication. 
Starting with ibuprofin, gabapentin, and meloxicam. After only a few 
visits he was refered to Mental Heath where he was then diagnosed with 
Severe Post-Tramatic Stress Disorder, adding several anti-depression 
and anxiety meds such as Zoloft and Valium. And this is were the roller 
coaster of drugs come into play.
    Everytime Scott came home from an apt. He would have different 
meds. Progressivly over the year and half that he was recieving 
treatment, the medications changed many times often adding new meds, 
changing dosages and recommending that he takes the meds differently 
then the printed dosaging. We researched the drugs online and saw that 
there were many dangerous interaction involved with the medications he 
was on, but being that Scott had been conditioned to follow orders, he 
believed fully that his Dr.'s were doing all they could to help him. 
With every apt. the medication changed the side effects changed, and 
Scott himself was changing.
    On 12 September 2012 Scott attended another oh his scheduled 
appointments. This time they had added a powerful narcotic, Percocet. 
This opiate drug was much different than the vicodine that he had 
previously been taking. The directions on the bottle said to not exceed 
3000 mg of acetaminophen. Scott followed the orders. At 0730 on the 
13th, less than 24 hrs after he was prescibed the Percocet, I found 
Scott on the couch. He was cold and unresponsive. I tried all I could 
and EMS also arrived but it was far to late for Scott. At 35 years old, 
this husband and father was gone! He left behind a wife, 2 daughters 
and many friends and family members who loved him very much.
    Now the question is why? Why was this mans life tragectly cut 
short. It is well know how America's wounded warriors are being 
victimized by the huge backlog in their VA claims. Forcing families to 
wait months and in most cases Years to receive benefits that the 
earned. Nonetheless the Department of Veterans Affairs states that they 
are incredibly proud of the shrinking backlog, that it has begun 
issuing bonus to the buraucrats who meet the Departments numerical 
goals in case load reduction.
    Keeping our men and woman doped up to keep them quiet and happy is 
not treatment. It is cruelty and torture and in too many cases It's 
manslaughter! For many American Service Members the VA is utilized as 
free healthcare to those who earned it thru their dedication and 
commitment to honor their country. In far too many cases , these 
service members become lost in the system and simply become a number 
and no longer viewed as productive members of society.
    Tests that can save lives are not being performed. A simple `` I am 
in pain'' is a good enough evaluation to prescribe painkillers. And a 
patient claiming that a medication isn't working well enough , is 
grounds to change the medication.
    In the civilian sector is routine and often manditory to preform 
blood tests on patients that are just starting treatment or have been 
receiving treatment for a prolonged amount of time. I learned this thru 
speaking to Medical professionals at various local treatment 
facilities. This is how I learned about the LFT or liver function test 
commonly refered to as the Liver Enzyme Test. Being that the liver is 
responsible for a multitude of tasks including the metobolization on 
medications like narcotics but filtering out the toxins that are left 
behind it got me thinking, `` Did doctors do this test for Scotty''?
    So, I asked them! And they responded, but not with what I had hoped 
for.
    `` Liver function tests are NOT routine in the treatment of out 
veterans, and that my husbands healthcare was handled and well managed 
``
    I was not only sickened by their response, but that day, I decided 
that no more shall die! Had they done the simple test, they would have 
discovered that due to the overwhelming amount of medications that 
Scott had been exposed to, his liver was inflammed and vurtually dying. 
But instead, it was only discovered by the coroner. I have no doubt 
that this test would have saved my husbands life, and Scott would be 
here today to watch his kids grow up to be beautiful young woman.
    I have no doubt that a large percentage of the veteran overdose 
cases could have been prevented by this test. But instead they met a 
similar demise. Father's are gone, never to walk their daughters down 
the isle on her wedding day, or to throw a football with their sons. 
Children left without a mother to embrace them, and simply kiss the boo 
boo's..
    There is nothing that I can say or do to bring Scott or the 
countless others back. There is nothing I can say or do to take away 
the pain we as family members have experienced. But there is so much 
that you, as Leaders can do. The regulations that involve our veterans 
need to be evauluated and changed. The irresponsible distribution of 
narcotics to our heros needs to STOP!!
    So I Heather Renae McDonald, the proud wife of an American Hero who 
was taken too soon, stand here before you today to DEMAND that you take 
better care of our veterans. I stand before you to speak as an advocate 
for the countless widows, widowers, and children of those who lost a 
fight they didn't sign a contract to fight. I will stand with the many, 
and for those who have not found their voice to speak out, I vow to be 
your voice.
    Together, we can still save thousands of lives. So I beg you, as 
the Leaders that have the ability and power to make these changes to do 
so.
    If we do not act quickly, I fear that many more lives will be lost 
due to the malpractice and grotesk lack of proper care that the VA 
hands out.
    When they signed that contract, they gave their bodies to their 
country, now you owe them their lives. These men and women deserve so 
much better. They deserve to live because they were committed and 
selflessly chose to wear the uniform of the UNITED STATES MILITARY .

                                 
               Prepared Statement of Kimberly Stowe Green
    Mr. Chairman (Dan Benishek), Ranking Minority Member (Julia 
Brownley), and all Distinguished Members of the Subcommittee:
Introduction
    My name is Kimberly Green. I am honored to have been invited to 
speak to you today at this hearing entitled ``Between Peril and 
Promise: Facing the Dangers of VA's Skyrocketing Use of Prescription 
Painkillers to Treat Veterans.'' I am accompanied here today by my 
attorney Brant Mittler who is also a medical doctor.
    I respectfully request that my written statement be incorporated 
into the official records of this hearing.
    The VA determined Ricky He was at first determined to be 50% 
disabled due to service related activities. And later the amount of 
disability was increased to 80%. Rickey was injured in the army during 
his training activities and from his paratrooper activities jumping out 
of planes and from his military police work in securing combat areas. 
The injuries to his back, knees and ankles caused him to have chronic 
pain later in his life.
    I served my country for 21 years in the United States Air Force. I 
retired out of the military as a Master Sergeant. I am the widow of 
Ricky Green. My husband served his country for 23 years in the United 
States Army. He was a military policeman and paratrooper and he served 
with distinction in Desert Storm I. He retired out of the military as a 
Sergeant First Class.
    I have no contracts or commercial ties to the VA or the federal 
government.
The VA's Skyrocketing Use of Prescription Painkillers Caused the Death 
        of My Husband Ricky Green
    My husband - Ricky Green - died as a result of the VA's 
skyrocketing use of prescription painkillers. On behalf of my husband, 
myself, and our two grieving sons, Andrew Evan Green, aged 21, and 
Alexander Michael Green, age 16, I want to ask this committee to do all 
that it can to prevent other veterans from dying in the same manner 
that my husband died.
    My husband died on October 29, 2011 at the age of 43 after lower 
back surgery performed four days earlier on October 25, 2011. The 
Arkansas State Crime Lab and its Medical Examiner performed an autopsy 
and determined that the cause of death for my husband was Mixed Drug 
Intoxication complicating recent lumbar spine surgery. My husband died 
because of the prescription pain and sleeping medications that the VA 
and its doctors prescribed for him and dispensed to him out of the VA 
pharmacy.
    I'm here to put names and faces on that sterile statistic of 
``mixed drug intoxication complicating recent lumbar spinal surgery''.
The VA Already Has Written Guidelines for Prescribing Pain Killers but 
        These Are Not Being Followed
    The Veteran's Health Administration's National Pain Management 
Strategy, initiated November 12, 1998, established Pain Management as a 
national priority.
    You can go to the VHA website today - http://www.va.gov/
painmanagement - and see for yourself that the VA has written 
guidelines for prescribing pain medications. The two primary ones are 
(1) VHA Directive 2009-53 dated October 28, 2009 on Pain Management 
(http://www.va.gov/painmanagement/docs/vha09paindirective.pdf); and (2) 
the Veteran's Administration/Department of Defense Clinical Practice 
Guideline Management of Opioid Therapy for Chronic Pain dated May, 2010 
(http://www.healthquality.va.gov/COT--312--Full-er.pdf). These 
guidelines include stepped care that involves primary care, secondary 
consultation, and interdisciplinary care and special measures to 
include testing, evaluating and monitoring to reduce the risks inherent 
in the use of prescription painkillers - and one of the most notable 
risks is accidental overdose. The problem is - these guidelines have 
not been fully implemented and are not being followed - they were 
repeatedly violated in my husband's case - and he had to pay with his 
life for that fact.
    VHA Directive 2009-53 states at page A-3 that ``[t]he potential for 
fatal overdose either by accident or in a suicidal attempt in patients 
suffering from multiple disorders or with polypharmacy must be 
considered in prescribing opioids and other medications.'' The 
potential for fatal overdose with these drugs was not adequately 
considered by the VA and its doctors treating my husband.
    The Clinical Practice Guidelines require physicians to closely 
monitor and evaluate patients who are being prescribed prescription 
pain killers for chronic pain and these guidelines specially warn these 
physicians at page 24, and other places, about the dangers of drug-drug 
interactions that can cause death. The VA and its doctors prescribed 
and provided to my husband his medications - and the interactions among 
these drugs killed my husband.
    During the course of his treatment at the VA, the VA and its 
doctors wrote my husband prescriptions, and VA pharmacies filled these 
prescriptions, for his chronic back pain which was service connected, 
for the following drugs: Oxycodone, Hydrocodone, Valium, Ambien, 
Zoloft, Gabapentin, and Tramadol. My husband, Ricky Green, followed the 
orders of his VA doctors in taking these pain medications - and these 
pain medications led to his death. He was not suicidal in taking these 
drugs - again he was just following his doctors' orders.
    The Clinical Practice Guidelines contain a section that requires 
physicians to take special care in prescribing pain medications for 
patients such as my husband who had sleep apnea. Unfortunately, again, 
no such special precautions were taken for my husband - and the 
guidelines were simply ignored - such that the drugs interacted with 
the sleep apnea to cause my husband to stop breathing and to die.
    In my husband's case, the VA and its doctors, over-prescribed my 
husband pain medications over a long period of time but after he had 
back surgery on October 25, 2011 related to the injuries he had 
incurred while on active duty he got a lethal drug cocktail that 
included oxycodone, and diazepam which were reviewed by the VA and 
filled by the VA pharmacy on October 26, 2011.
    These two drugs - prescribed and provided by the VA and its doctors 
and pharmacist in violation of the Clinical Practice Guideline - 
together with the sleep apnea - are what produced according to the 
Arkansas State Medical Examiner produced ``a significant stated of 
analgesia sedation, and respiratory depression'' which led to my 
husband's death. Ricky stopped breathing and died in his sleep on 
October 29, 2011.
    I want to be clear in my testimony to this committee - I strongly 
believe that my husband was entitled to receive the quality of care 
that the VA, and DoD, set forth in writing in their own guidelines. 
However, these guidelines have not been fully implemented and are not 
being followed - and our veterans are suffering the consequences.
    You do not have to take my word for it that these guidelines have 
not been implemented or followed. I was able to find on the internet 
the contents of a Cyber Seminar dated October 2, 2012 - about one year 
after my husband's death - entitled ``Overdose Among VA Patients 
Receiving Opioid Therapy for Pain; Risk Factors and Prevention.'' 
(http://www.hsrd.research.va.gov/for--researchers/cyber--seminars). The 
introducer and participant at that seminar - a Dr. Bob Kerns - is a 
National Program Director for Pain Management and he is based at a VA 
Hospital in Connecticut. Here is a quote from him at that seminar: 
``... the VA/DoD Clinical Practice Guidelines. Its full implementation 
across the VA really has not been actualized or realized yet. So for 
those - there are a couple hundred people on the call that work 
facilities. I am guessing that many of you work in facilities that 
really have not thoroughly digested those guidelines and looked to 
implement the recommendations of the guidelines at a facility level, 
let alone at an individual level. And we should be doing that 
first....''
    How long must our veterans be made to wait until these guidelines 
are fully implemented and begin saving the lives of our veterans?
    If these guidelines would have been followed my husband would not 
have been prescribed drugs that caused him to have a mixed drug 
interaction and to stop breathing. If these guidelines would have been 
followed my husband would have been closely examined, monitored, and he 
would not have been provided the lethal cocktail of drugs that killed 
him.
Our Veterans Who Honorably Served Their Country Deserve Better 
        Healthcare from the VA
    I believe the VA and its doctors, rather than treating all of the 
underlying causes of my husband's back pain, took the easier way out 
and overmedicated him with prescription pain killers. I believe this is 
happening far too much and I note that statistics have been compiled 
that show in Fayetteville, Arkansas - where my husband was treated - 
there is a high incidence of over-prescribing pain medications for 
veterans.
    Treatment of the underlying medical conditions, physical therapy, 
counseling, monitoring, in-patient hospital stays - these are the kinds 
of things I believe our veterans need and are entitled to - not just 
the over-medication of prescription pain killers to mask their pain. In 
my husband's case - he constantly asked the VA and its doctors to treat 
the root cause of his health problems - and to reduce the opiate pain 
medications he was being prescribed. The VA failed to do that in his 
case.
In Honor of My Husband
    I am proud of my husband. After serving his country for over twenty 
years in the military he went back to school and earned his college 
degree in criminal justice. He had plans to go to law school so that he 
could be a voice for other veterans in their time of need. He was 43 
years old when he died. He should have had a long life ahead of him. 
Ricky survived serving in combat zones in his over twenty years of 
military service, but he could not survive the VA and his negligent 
treatment of him.
    This lethal cocktail of drugs -which again included Oxycodone and 
Diazepam among many other drugs - were prescribed by VA doctors and 
dispensed at the VA pharmacy. I have sent pictures of the bottles of 
the medicines my husband was taking to this subcommittee. These pill 
bottles - clear evidence of the negligence of the VA and its doctors - 
are now in safe keeping at the Sheriff's office in Fort Smith, 
Arkansas.
    My husband was a hero and a great husband and father. He stood up 
for his country honorably when his country called for him. He trusted 
VA doctors. He deserved much better treatment than what he received at 
the VA. Now, because of what the VA has done to my husband, my husband 
and I will not be able to grow old together. He will not be with me at 
the college graduation ceremonies for our two sons. He will not be with 
me at the wedding ceremonies for our two sons. He will never see and 
come to know his grandchildren. The VA has taken the life of a great 
man. And the VA has left his family - including his wife and two sons - 
decimated and grief stricken.
    I am here today to honor my husband's memory and to demand better 
treatment for the men and women - like my husband and I - who have 
honorably served our country in the military. The VA has written 
guidelines in place for the safe use of prescription pain killers - and 
the VA will have to follow these guidelines or more veterans will 
needlessly lose their lives - just like my husband did.
    I am proud to do my part and to stand up and fight on behalf of my 
husband and not allow him or me to be a quiet victim of injustice. I 
have heard excuses - the guidelines are not standards of care and some 
veterans who die of overdoses were suicidal - these are excuses that 
the VA is making because it has failed to take the action needed to 
fully implement and follow the written guidelines that have already 
been published.
    Let me be clear: the VA knew that Ricky was not suicidal, the VA 
knew that Ricky did not display drug seeking behavior. The VA knew 
Ricky want to reduce the amount of pain medication he was taking.
    I think in my case - and in many other similar cases - the VA 
should admit what it has done wrong, make up for it, and most 
importantly - stop this kind of thing from happening in the future.
    To those who have been injured or killed in the past by the VA and 
its doctors - these victims deserve just compensation.
    More importantly - the VA and its doctors must avoid causing future 
victims - by doing the right thing and implementing, training, 
following, monitoring, and evaluating the VA and its doctors on the 
written guidelines for prescription pain medications that are already 
in place.
    Prescription pain killers in high doses and over time are 
dangerous. There are better ways of treating our veterans.
The VA, Humana, and Project HERO
    Humana and the VA have teamed up on a project called Project HERO. 
You can go to http://www.humana-veterans.com/about-hvhs/project-
hero.asp to learn about this program. This website provides that 
``[t]he ultimate goal of Project HERO is to ensure that all health care 
delivered by the VA, either through VA providers or community partners, 
is of comparable quality and consistency for veterans.''
    My husband was in the Project HERO program and it did him no good 
at all.
    My understanding is that this Committee has heard the testimony of 
Brad Jones, Chief Operating Officer, Humana Healthcare Services, Inc., 
at a hearing on September 14, 2012. He claimed in his testimony that 
``[W]ith the exception of veterans participating in Project HERO and 
Project ARCH, veterans are left to navigate a confusing healthcare 
system on their own and become lost to the VA. The VA has no mechanism 
to track and monitor the care that Veterans receive in the community 
and there is no guarantee that these Veterans do not lose the quality, 
safety, and other protections that HERO and ARCH provide.''
    Mr. Jones further testified that ``lack of care coordination 
hinders the VA's ability to optimize its resources because there can be 
duplicative and conflictive treatment regimen. This not only results in 
wasted resources, but can also cause adverse medical outcomes.''
    Mr. Jones contended that Humana and Project HERO provided a 
``strong care coordination element.''
    This did not happen in my husband's case. His care was not 
coordinated. He was not provided the care he needed. He was not allowed 
the in-patient hospital care that he needed. And his prescription drugs 
were not coordinated and monitored to ensure safety.
    No one at the VA or at Humana questioned why he got all of the 
medication that were prescribed when he had a diagnosis of sleep apnea.
    Again - it is a case of written guidelines and programs - that are 
not implemented.
Questions That Deserve Answers from the Veteran's Administration and 
        Humana
    It is my understanding that when unexpected deaths occur, the VA 
does an analysis to find out why the death occurred. I want to know if 
such an analysis was ever done in my husband's case. I want to know if 
the VA has or will investigate the death of my husband and learn 
something from his death. Has the VA considered why my husband was 
forced out of the hospital one day after his back surgery instead of 
being allowed to stay three to five days as we had been told? Has the 
VA looked at the autopsy report so that it can see that the drugs it 
gave my husband killed him? Does the VA consider all the drugs that my 
husband Ricky Green was taking - with his diagnosis of sleep apnea - a 
quality problem and health care that fell below the standard of care 
and its own guideline? Does the VA understand that the interactions of 
all the drugs that they provided my husband killed him - and that these 
drug interactions are critical and must be taken into account before 
prescription pain killers are so cavalierly prescribed? Has the VA 
considered how dangerous it is to provide pain medications and sleeping 
pills to someone with sleep apnea such as my husband? And have the VA 
and Humana asked each other - who dropped the ball here - and why 
Project HERO did nothing at all to protect my husband. I would like 
this Committee to use its powers of investigation to uncover why Humana 
and Project HERO did not protect my husband Ricky Green from the lethal 
cocktail of drugs that killed him. Why can't the powerful computer 
systems at both the VA and Humana that process the medical records of 
our veterans be programmed to monitor the kinds of drug interactions 
and dangerous conditions like sleep apnea to alert both doctors and 
pharmacists when dangerous prescribing occurs like those that killed 
Ricky?
    I hope the VA - and if not the VA then this Committee - will ask 
these questions, learn something, and save the lives of our veterans in 
the future. That is the one way - the only way - that my husband will 
not have died in vain.
Conclusion and Call for Action
    I will NOT be silent about any of this. My husband doesn't have a 
voice therefore I am his voice. I want to see that this over drugging 
of our Veterans Stops AND that there IS accountability for these 
physicians actions. Prescribing sleeping pills, valium, tramadol, oxy, 
hydrocodone, to my husband was nothing but a death sentence. This is 
happening more and more and this has to STOP!
    I want to leave you on this committee with a simple request - 
demand that the VA follow its own written guidelines, demand that the 
VA put in place procedures that punish VA doctors and staff who do not 
follow these written guidelines, and demand that the VA and its doctors 
put a stop to this epidemic of the VA's skyrocketing use of 
prescription painkillers to treat veterans.

                                 
                  Prepared Statement of Josh Renschler
    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, I am honored to have the opportunity to speak to you 
today regarding my experiences with Pain Management treatment from the 
Department of Veterans Affairs. I proudly served in the United States 
Army as an Infantryman for 5 1/2 years. I am now the director of men's 
programming for a non-profit organization that assists service members, 
veterans and their families; who are struggling due to deployment 
related trauma. Based on my own experiences with the VA, and having 
witnessed first-hand the experiences of other veterans whom I have 
mentored; it is my belief that the VA has continually fallen short of 
providing veteran-centered care; the VA has completely missed the mark 
of meeting veteran's needs on an individual case by case basis as well 
as employing best practices to care for common injuries/illnesses. 
Pertaining to the VA's increasing use of opioids in pain management it 
is my belief that current practices are reckless and irresponsible at 
best. It is my intention to bring these issues into the light before 
this committee so they may be addressed by the VA in order to affect 
changes in policies and practices in order to improve care for all 
Veterans.
    I was medically retired from the Army due to severe injuries from a 
mortar blast in Iraq and entered into the VA system in 2008. I was 
assigned to the Deployment Health Team at American Lake VA Hospital in 
Lakewood, WA and to the PolyTrauma Team from the Seattle VA Medical 
Center. At the time, I was on approximately 8 medications which treated 
me for sleep, migraines, pain, seizures and anxiety. It had taken Army 
doctors 3 years to discover and balance an effective, safe medication 
mix. My VA primary care doctor told me that several of those 
medications were not on the VA formulary and that VA would not pay for 
them. My primary care provider at American Lake began experimenting 
with different medications on me, despite the urging of my wife due to 
the failure of these medications in the past. The side effects caused 
me so much difficulty that I began to backslide in my recovery. I was 
soon on 13 medications (some to simply counter the effects of others); 
and soon all my conditions worsened and I had a severe panic attack at 
work. As a result, I lost my job, costing my family our home and 
vehicle. As my back pain continued to worsen, my primary care provider 
simply increased the dose of Percocet until it was no longer effective 
even at the extreme dosing of 12-15 5mg tablets a day. Soon I was 
issued methadone and eventually morphine tablets to take in between 
dosing of Percocet. By mid-2009, these ridiculous dosages kept me from 
working. Though the pain was wildly out of control, visits to my 
primary care provider were- 3 months apart and at each appointment I 
would beg for anything other than more meds. PolyTrauma finally granted 
a referral to see a Physical Therapist at American Lake; I was very 
excited to do something proactive. But the Physical Therapist simply 
asked me questions about my pain as he sat at a computer, and did 
nothing more than give me pages of instructions on stretching exercises 
to try at home and follow up with him in two weeks. As I then required 
the support of a cane just to walk, this left me feeling nearly 
hopeless. A little over a month later, an appointment with Neurosurgery 
finally led to an order for an MRI and EMG, which showed severe nerve 
damage and disc deterioration, and eventually a referral to a private 
Neurosurgeon. He was amazed that I was still walking and infuriated 
with the VA for allowing this to go on so long, and scheduled an urgent 
surgery 3 days later. By then (March 2010), due to the length of time 
the problems went unresolved; the nerve damage had become permanent. I 
still have no feeling in my left leg to this day.
    From 2008-2011, I continued to take the ``cocktail'' of medications 
prescribed through the VA. I had never heard of a pain clinic and was 
never offered alternative therapies despite my pleading. (I did pay out 
of pocket as I could for Chiropractic care and massage therapy for some 
minor relief.) Over the course of these years, I was not once monitored 
for effects on Liver or Kidneys despite the high occurrence of Liver 
and Kidney issues with several of my medications. Finally, in early 
2011 a new VA primary care doctor at the American Lake VA became very 
concerned and ordered a blood test that revealed extremely elevated 
Liver enzymes in dangerous levels. With a doubling of those levels over 
the next two months, I was referred to a Hematologist, who conducted a 
Liver biopsy. At this point my wife and I were very worried, so we 
began to slowly stop taking all but my seizure medications within 2 
weeks; as we awaited my biopsy. Life became very difficult, but I 
didn't wish to die. The biopsy showed minor scarring of the Liver; the 
problem was diagnosed as Non-Alcoholic Steatohepatitis. This led me to 
get off all but one of my medications; a subsequent blood test showed a 
drastic drop in my Liver enzymes to near safe levels (and they 
continued to drop over the next 6 months until reaching ``high 
normal'').
    By mid 2011, the nerve pain I'd experienced before the surgery 
began to come back, and the frustrating cycle all began over again with 
the unhelpful, uncaring Physical Therapy, and being sent to 
Occupational Therapy where I was given a ``wedge pillow'' to elevate my 
legs at bedtime and a device to help me put my socks on. My primary 
care doctor began treating my pain with oxycodone; I was now very 
restricted on what I could take due to my Liver issues. I demanded to 
see Neurosurgery and was given a referral to see the department head of 
Neurosurgery at the Seattle VA hospital. She informed me of a non-
opiate medication called Lyrica that could drastically reduce my nerve 
pain and that had very few side-effects, but it was a non-formulary 
(expensive) medication. As she had anticipated, the pharmacy denied her 
request for the drug. Despite her subsequently getting recommendations 
from two other department heads in support of her resubmitted request, 
the VA pharmacy again denied it. Unwilling to go down the road of 
dangerous medications again, I spent $12,000 for a therapeutic hot tub, 
$3,000 for a massage chair, and began seeing a chiropractor regularly. 
This account has no happy ending. I am currently taking (6) 5mg 
oxycodone tablets daily, and I find no relief from pain laying, 
sitting, or standing and I have been begging and pleading with the VA 
to help me to little avail. Late in 2012, I did have the opportunity to 
try acupuncture through the VA; it was a 6-month wait for 6 
appointments spread over 6 weeks. But as it was only available in 
Seattle, the hour long car ride defeated the minimal relief it 
provided. I still have not been offered a pain management clinic, 
though what I really need is a ``hands-on'' physical therapist, or a 
referral to a private hospital for another surgery.
    Let me emphasize that I made this trip not to gain advantage for 
myself, but because I hope my testimony will help lead to changes in 
the way VA facilities handle pain-management. I hope that focusing on 
cases like mine will end irresponsible practices like prescribing 
medications that have potentially dangerous side effects with limited 
to no oversight of those medications. I hope it will result in much 
greater emphasis on pain-management and on improving overall quality of 
life, to include use of alternative therapies. And I hope that combat 
veterans experiencing chronic pain won't ever again be denied 
potentially helpful drugs simply because of their cost. I thank you for 
your time and for your careful oversight on this matter.

                                 
                  Prepared Statement of Justin Minyard
    My name is Justin Minyard and I want to thank Chairman Benishek and 
Ranking Member Brownley for the opportunity to appear before the 
committee and address this vital subject.
    I am a medically retired member of the U.S. Army. Before being 
forced to retire from the Army due to my debilitating back pain, I was 
a first responder at the Pentagon on 9/11 and a special operations 
interrogator in Afghanistan and Iraq. But due to injuries sustained in 
combat operations, I struggled with serious chronic pain and a 
dependence on the opioid medication that was the only option provided 
to me by the Armed Services healthcare system. Finally, after several 
years searching, I found lasting pain relief through spinal cord 
stimulation, or SCS. Today, I am proud to say that I have not taken a 
single dose of opioid pain medication in the last two years. No veteran 
should have to struggle for as long as I did - early access to 
interventionalists in the VA is critical.
    Being free from opioid dependence has allowed me to serve as the 
founder of Operation Shifting Gears, a non-profit dedicated to serving 
injured or disabled veterans and as spokesperson for 
RaceAgainstPain.com, a community of chronic pain sufferers. I take it 
upon myself to personally encourage veterans and others suffering from 
chronic pain to explore options outside of opioid pain relief, such as 
spinal cord stimulation.
    I first developed chronic back pain when I was serving as a member 
of the Presidential Escort, 3rd U.S. Infantry Old Guard, stationed at 
Fort Meyer. On 9/11, my unit was one of the first responders at the 
Pentagon. For the next 72 hours, we searched for survivors, working on 
adrenaline to move huge pieces of rubble. As a result of those efforts, 
I sustained a serious back injury - damaged discs and fractured 
vertebrae.
    My back pain drastically impacted my life from September 11th 
onwards. I didn't seek treatment immediately, but instead took over-
the-counter painkillers and tried to simply work through the pain. I 
volunteered to learn Arabic and become an interrogator. During my 
deployment to Afghanistan, I experienced another incident where I fell 
two stories out of the back of a helicopter, causing a disc to rupture 
and fracturing my vertebrae. I returned home due to the pain and had my 
first back surgery, a laminectomy, to replace one of the bulging discs 
and repair the fracture.
    Despite the fact that my daughter Mackenzie was only three weeks 
old, it was 2007 and the army was in need of experienced interrogators 
like me to serve in Iraq, so I volunteered to go. While there, the 
weight of carrying a full 80-100 lb. combat load every day combined 
with a vehicle rollover caused further damage to my back. I came home 
and met with the army doctors, who told me that my spine was rapidly 
deteriorating and I needed reconstructive back surgery.
    The physician left the room and I turned to my wife, Amy, and said, 
``What do you think we should do?'' I knew she wanted me to stay home; 
I knew I should stay home. Mackenzie was only 5 months old at this 
point and Amy was working full-time. But I thought about my unit that 
was still in Iraq and the fact that I wanted to complete the mission we 
were sent there to do. So when my doctor came back in the room and I 
told him I was going to go against his advice and return to Iraq, he 
said, ``If you insist on going back, this is really the only way you 
are going to be able to make it through.'' He handed me a prescription 
for opioids and I said, ``Okay, if that's what we need to do, that's 
what we will do.'' I had the bottle in my hand and I was ready to go.
    For the next 10 months in Iraq, I was able to do my job. My pain 
was fluctuating somewhere on a daily basis between a four and a nine on 
a 1-to-10 scale, but I was regularly taking about four to eight pills 
of high-dose opioid pain medication at the time. It was a very rough 
situation, but I was able mask that with the opioid pain medications. 
That was a double-edged sword - the opioids allowed me to continue 
combat operations, but they allowed me to continue damaging my back as 
well. But because of the way opioid pain medication works with your 
body, you build up a tolerance quickly and for me, in the middle of the 
desert, I didn't have a lot of other options for pain relief. I sought 
help from a Special Forces medic, who was able to call back to the 
States and request spinal cord epidural kits to be shipped to the base. 
So there I was, in an army tent in the middle of the desert, getting 
epidurals in order to continue working in Iraq.
    August 4th, 2008 was my breaking point. I came back to the team 
house after an extremely challenging 3-day mission. I stepped out of my 
Humvee and my right leg simply gave out. I couldn't take another step. 
I learned later on that it was because of nerve damage that had 
occurred due to the compression putting pressure on the main nerve 
running through my right leg. It was terrifying - I arrived at the team 
house at about 5:00 in the afternoon and by 6:15 p.m., I was on a 
helicopter being medevac'd to Balad Air Force Base.
    Coming back from Iraq, it quickly became evident that I had to be 
in a wheelchair. Because of the damage to my back, I couldn't walk more 
than 2 or 3 steps without some help. The first time I sat in the 
wheelchair, I felt like a different person. I felt like I had lost 
something.
    My life when I returned back home was not my life. It was terrible. 
I was in a great deal of pain. I was dealing with mental issues like 
anxiety and depression.
    I started an intense opioid pain medication regimen. The metaphor I 
think best gives people an idea of what it is like is: once I started 
on high-dose opioid pain pills; once that train left the station, it 
was going 1,000 miles an hour and wasn't making any stops. My life 
literally revolved around, ``When is my next pill?,'' ``When is my next 
refill?'' and ``When does my dose get increased?'' If you wanted to 
talk to me about my job performance, if you wanted to talk to me about 
Friday night dinner plans, if you wanted to talk to me about plans for 
Christmas, I just didn't care. Unless you were going to tell me that 
you were going to give me a ride to the pharmacy or you were going to 
tell me that it was time to take my next pain pill, I didn't care. In 
fact, I would either ignore you or treat you very poorly.
    At my worst point, I was taking enough opioid pain medication to 
treat four terminally ill cancer patients. That was on a daily basis. 
It had enormous physical and mental effects on me - people would often 
look at me and my eyes would be rolled into the back of my head. When I 
talked to people, I just wouldn't make any sense; it would all be 
incoherent. If I wasn't babbling incoherently, I would be asleep or 
simply drooling on myself.
    I was on an insane amount of opioid pain medication. My dependency 
happened so fast. It felt like I blinked and then I looked up and my 
life revolved around getting my fix. I remember a point when I 
realized, ``Okay this is starting to become a problem!'' But soon after 
that, even that thought left my mind. My days drifted by like this: 
wake up: pain pill; have lunch: pain pill; in the afternoon: pain pill; 
and on and on. It was not a pleasant experience.
    I am very ashamed about those years because I treated the people 
that mattered most to me very poorly. There were years that I went 
without telling my wife, who stayed by my side throughout the entire 
process, ``Thank you for taking care of me.'' I was not the husband my 
wife deserved and I was not the father my daughter deserved. That was 
not the life I wanted. It was a very dark and difficult part of my 
life.
    I continued to use a wheelchair but I didn't want to accept the 
diagnosis I had been given, which was that it was most likely going to 
be part of my life for the rest of my days. But, I was offered no 
choice by the medical services to address the cause of my injuries; 
only means to mask the effects with ever increasing amounts of opioids. 
I was finally forced to look on my own for options that were available 
that could possibly repair the damage and help me start walking again. 
That led me to my second back surgery at Duke University Hospital: a 
highly invasive, extremely painful anterior/posterior inter-body fusion 
in which surgeons inserted eight titanium rods that form a cage around 
my spine to support all of the damage to my back.
    In preparing for the surgery, Duke actually had to call in a 
special pain management team to figure out how and what medication they 
were going to use that would be strong enough to overcome my body's 
tolerance to the high amounts of opioids I was already using. The pain 
management team said, ``Surely we are reading this chart wrong. This 
guy hasn't really been on this amount of opioid pain medication for 
this long, has he?'' They had to go back and do a case study to figure 
out what kind of anesthesia to prescribe.
    That surgery was successful in that it allowed me to become more 
active and rely on the wheelchair less, but I was still in pain. I was 
still completely dependent on opioids and that was unacceptable to me. 
I hated having to rely on something else to get through the day and I 
knew my years of dependence on pain medication were negatively 
impacting my family - and would likely lead to fatal medical side 
effects.
    The defining point for me, when I realized I could not go on living 
a life dependent on opioid medication, was watching a home video of 
myself on Christmas morning. In the video, you see my daughter approach 
me while we were all together in the family room and ask me to help her 
open a present. As she was handing it to me, I was trying to hold on to 
it. And all of a sudden my neck muscles and head just kind of rolled 
back. My eyes rolled back in my head. I started drooling on myself. I 
don't think there could be much more of an impactful, defining moment 
where you realize something is wrong, so I started trying to find 
another solution.
    Without help from the Government, it was a major challenge 
navigating the maze of providers and bureaucracy before finally being 
referred to an interventional pain specialist at Fort Bragg. My doctor, 
who happened to be conducting a clinical trial of SCS therapy, took a 
vested, personal interest in my case and I credit him with turning my 
life around.
    The VA didn't make it easy for me to connect with people like him. 
My wife had to advocate for me, not taking ``No'' for an answer. But 
the VA hospitals and TRICARE should be doing everything they can to 
spread the word about his specialty: interventional pain management.
    So the doctor said to me, ``Have you heard about spinal cord 
stimulation (SCS)?'' And I said, ``Spinal cord what?'' He explained the 
technology, made by Boston Scientific and others, to me. The 
implantable device would block my brain from receiving a pain signal 
and instead, mask that signal into a tingling feeling, as if a tuning 
fork is going off inside your body. He said, ``It is a way for you to 
manage your pain and not have your pain manage you.'' He even explained 
that I would have the chance to test drive the device for one week 
before moving forward with the permanent implant and see if it would 
provide effective relief and that I was a good candidate for a clinical 
trial with SCS that was just starting at Fort Bragg.
    Having the ability to test drive SCS was the ultimate selling point 
for me. Unlike my anterior/posterior inter-body fusion surgery, I could 
actually try this device with a minimally invasive procedure. I find 
that very rare in medical treatment.
    So I immediately asked, ``When can you get me in for a trial?'' I 
came in for a trial a few weeks later and in less than the time it 
takes to get a cavity filled, I had the trial device implanted in a 
simple, outpatient surgery.
    During the trial period, they placed the two leads in the area of 
my back where I needed the most pain relief. As soon as I woke up, they 
used the computer to manipulate the system and set up my pain 
management programs. The first time the stimulator was activated it 
felt incredible. As cliche as it sounds, I thought to myself, ``This 
device is going to be a life changer.'' I was getting more pain relief 
from the one area the machine targeted in that moment than I had since 
I started on opioids years ago.
    After that, the team went through my new Precision System's four 
different pain programs. At each point they asked, ``Can you feel here? 
Can you feel here?'' And I would tell him, ``Can you move it left?'' 
and I felt it. It's not unpleasant - it's like an internal massage 
moving across your back. With each keyboard click I heard, I could feel 
the impulse moving through my body and hitting the target pain area. 
Once it locks in to wherever your pain is, it's almost like magic. It's 
unbelievable because it is pain relief right where you need it. Not 
only does the SCS focus in on where you need it, but I was also given a 
remote that allows me to turn up the power to get even more relief in 
certain areas that are hurting on a given day. It is amazing to go for 
so many years struggling with pain relief and, all of a sudden, I can 
push a button and my pain can drop from a seven to a four.
    I was floored. I wanted the permanent device implanted immediately. 
I said, ``My test drive is done, I only need to go around the block 
once! I'm good.''
    But the bottom line is everyone has to do the trial. Mine was three 
days, and when I went back in to remove the trial, I couldn't wait to 
have the permanent version. I was counting down the minutes and calling 
the doctor's office every day, saying, ``Let me know if someone 
cancels. I'll drive up there. I'll sleep in the doctor's office, 
because I know this spinal cord stimulator is going to be it for me.''
    Three weeks later, I had the permanent spinal cord stimulator 
implanted and that is where my life started to turn around. That was 
the defining moment. I was able to get the remote for my permanent SCS 
and start using it to manage my pain.
    The relief I felt from SCS allowed me to start tapering down my 
medications. My goal was to ultimately be free of all opioids. That 
process took time and it was difficult, but it was completely worth it.
    I am now at the point where I have not taken an opioid-based pain 
pill in more than 2 years. I actually have a medical directive that 
states that if I am taken to the hospital, I am not allowed to be 
administered a narcotic without my consent. And if I am unconscious, my 
wife has to give consent. I have this because I went through this 
process and I don't need the medications, nor do I want them anymore. 
Like I said before, once you start...once on that train... it is a 
very, very, very fast and scary progression to the point where it is 
out of control.
    I just want to leave you with something. There are a lot of 
soldiers in my situation. And not just soldiers, but a lot of people in 
this country who were pushed onto the opioid pain train, and now 
they're moving so fast and they can't get off of it. I consider myself 
extremely lucky that I was able to push through the maze of providers 
in TRICARE and find the doctor who knew the secret - at least for me. 
But there are many soldiers who are not so lucky; soldiers who lack the 
resources and awareness to advocate for alternatives to opioid pain 
regimens and are left to the crushing reality of lifelong opioid 
dependence or worse. A recent VA study spotlighted the horrific 
epidemic of suicide amongst veterans, 22 per day.
    Pain is a pervasive condition with the impacts and burdens reaching 
far beyond the patient - to families, society, etc. According to NIH, 
when including healthcare costs, lost income, and lost productivity, 
pain costs almost $100 billion per year. We must increase awareness 
about alternatives to opioid pain medication in the VA system. The VA 
must work to create accessible regional centers equipped with access to 
skilled interventional pain specialists. We must train more doctors in 
these techniques and devote more resources to raising awareness. We 
should also begin collecting data on long-term outcomes of 
interventional therapies versus opioid therapy so we have the numbers 
to show that the techniques that helped me will help other soldiers, 
too.
    The VA is a great place to start, because so many veterans come 
home and struggle, just as I did. I continue to struggle with the VA in 
getting timely appointments with a specialist to manage my SCS therapy, 
but my hope is that in the future, policies will be in place to help 
people like me manage their SCS therapy and to help prevent soldiers 
and their families from the devastating effects of opioid dependence. 
Thank you all, so much, for listening to my story.

                                 
               Prepared Statement of Pamela J. Gray, M.D.
    October 10, 2013

    At the outset I would like to thank the members of this committee 
on Veterans Affairs for offering me an opportunity to share my first 
hand experiences as a physician at a Veterans Hospital located in 
Hampton, Virginia.
    I am presenting to you a letter I wrote to my State Senator in 
March 2010. The thoughts and observations in the letter were recorded 
with great clarity. I have included the names of individuals as in the 
original letter. As the truth was documented originally, so I chose to 
let it stand.
    I beg of you to hear these words and act decisively to improve the 
healthcare delivery system for our deserving veterans.
    Thanking you in advance for your attention.

    Respectfully submitted,

    Pamela J. Gray, M.D.

    Dear Senator Webb,
    I am writing to you to report my experiences with the delivery of 
medical care at the Hampton VAMC. My observations from April 2008 to 
March 2010 note the level of care is not consistent with community 
standards. As a physician working at the Hampton VA during that time 
period, I witnessed an abuse of authority which is a potential danger 
to public health and safety, specifically the overprescribing of 
opioids providing opportunity for diversion into the Hampton Community. 
As a result of reporting this information I have been terminated as of 
March 26, 2010. I am seeking whistleblower protection. The first 
contact via telephone to your office in Norfolk was December 2009. I am 
also asking you to contact the Office of the Inspector General on my 
behalf. I was initially contacted by Special Agent Molly Morgan on 
February 1, 2010, however, I am asking for further investigation as I 
feel my termination is reprisal for my concerns regarding prescribing 
of Schedule II narcotics.
    I have been employed as a physician at the VAMC since April 28, 
2008. I was hired in the capacity of 30% Rheumatology, 70% Primary 
Care. I have been informed by fellow physicians that in the six months 
prior to my arrival in multiple Primary Care Staff meetings, I was 
identified as a ``pain specialist.'' I have no specialized training as 
a pain specialist nor did I ever identify myself as such. After my 
arrival, I was informed I would manage difficult pain patients with 
musculoskeletal diagnoses being treated with large doses of Schedule II 
narcotics. As this is not a standard of care in the community, I sought 
to give a more appropriate level of care. I encountered resistance on 
the part of my service chiefs, clinic nurses, telecare nurses and 
nursing supervisors. My concern at this point was the overprescribing 
of opioids with the potential for diversion into the Hampton/Newport 
News communities. It is well documented that 10-20% of opioid users 
become addicted. The opportunity for diversion was of concern as this 
had been documented at the V.A. in Beckley, West Virginia. This was 
also well known by my service chiefs and the Chief of Staff as we had 
discussed it in full. I received no support for my efforts. I was told 
by the Chief of Medicine to ``think twice before refusing to write 
narcotics in a time of economic downturn.''
    I served on the Pain Committee upon appointment by the Director of 
the VAMC, Ms. Mims. There are multiple instances when I have been 
coerced or even ordered to write for Schedule II narcotics when it was 
against my medical judgment. Ms. Mims called me directly out of a Pain 
Committee meeting, ordering me to write opioids for a patient who had 
no objective findings to support a musculoskeletal diagnosis requiring 
such treatment. He was a thirty-eight (38) year old male with knee pain 
with normal exam and x-rays. Non-medical personnel tried to influence 
me to write for opioids, again for incorrect purposes. A patient care 
advocate, Mr. Waylon Murphy, and an Administrative Assistant, Roger 
Barkers, tried to persuade me to do so. This was documented in my 
medical notes. I was ordered to alter my notes by Dr. Karin Soobert, 
Chief of Primary Care. As I had documented factual truth, I refused. It 
is illegal to alter notes in a medical record; an addendum may be added 
but notes cannot be deleted. My note was deleted under the orders of 
Dr. Soobert, who is also Chair of Medical Records. I continued to lobby 
on behalf of the patients for a better level of care as well as 
improved work environment for the physicians, physician's assistants 
and nurse practitioners who also felt pressure to write Schedule II 
narcotics against their better judgment. This was reported to Ruth 
November, J.D, Office of Regional Counsel, McGuire VAMC, Richmond, VA 
in April, 2009 (See email of same date).
    Although pain management was not an area I wished to pursue, I 
served on the Pain Committee, represented our Medical Center at a 
National Pain Conference for VISN 1-11 and wrote the standard operating 
procedure for VAMC that is now in current use. I did everything which 
was asked of me by my two Service Chiefs and the Director. I brought 
all information back from the National Pain Conference to Dr. Soobert, 
Service Chief, and Dr. Arul, Chief of Staff. No change was implemented 
in one year.
    As an advocate for a patient who was sent out of the Hampton V.A. 
Medical Center Emergency Room while he was having a CVA (cardiovascular 
accident or stroke), I sought neurologic consultation for the patient 
in July of 2009. The consult was refused three times. As a result of 
trying to protect the community image of the VAMC and care for the 
patient, I was threatened in writing that further such action ``may 
result in disciplinary action to include removal'' by Dr. Soobert. I 
have appealed her action and have been denied. The patient has filed 
suit against the VAMC Hampton.
    In trying to improve patient care, I have received death threats 
from patients, coercion to practice poor medicine by non-medical 
personnel, have been found guilty of an ethics violation committed by 
another physician and now face a Professional Standards Board Review 
without being allowed to review any documents to be used against me. My 
service line chief who initiated the PSB denied knowing anything about 
the Board meeting. I am informed by Ms. Ruby Sheperd in Human Resources 
this originated directly as a result of Dr. Soobert's request. Dr. 
Soobert denied knowledge of this and denied me access to my records for 
review prior to the Board.
    In the twenty-three (23) months of my employment: 1) I have been 
forced to do work in which I have no professional training, 2) been 
ordered by supervisors and the Director to write large amounts of 
Schedule II narcotics in inappropriate medical circumstances, 3) have 
had my medical records altered to hide factual documentation, 4) have 
received sexual harassment by a male nurse, again, regarding opioids, 
5) been reprimanded for advocating for a stroke victim's right to care 
from the VAMC Hampton who, as a Marine veteran, was sent out of the 
Hampton VAMC Emergency Room as he was having a stroke, resulting in 
permanent brain injury, 6) been threatened to be reported to the 
National Data Bank for a non-reportable Level I Peer Review and 7) been 
subjected to situations involving entrapment by supervisors to ``not 
stop writing for opioids in a time of economic downturn''/say 
defamatory remarks about ethnicity/say defamatory remarks about the 
Director, all of which I resisted as I found these actions 
reprehensible. I now am being asked to cover another physician's clinic 
in Hampton in the clinic where I received the death threats and had a 
male nurse scream at me for refusal to overprescribe opioids to hide 
the actions of a married doctor who has had a sexual relationship with 
a married nurse. Both have had their jobs protected. I am asked to 
participate in the cover up of a crime.
    A Probationary Review Board to decide whether to terminate me was 
called on February 4, 2010. As of today, March 24, 2010, I have never 
been notified of its findings. One of the three physician members of 
the Committee referred a patient to me for ongoing care on March 10, 
2010. I received a letter from the Union attorney on March 8, 2010 
stating he had no knowledge of the outcome of the Board. The February 
23, 2010 minutes of the Virginia Beach VAMC clinic where I had seen 
patients indicated I was to return to Virginia Beach April 2010. At 
4:15, March 12, 2010 I received notification to come to Dr. Karin 
Soobert's office at the conclusion of my work. When I did not appear by 
4:30, I received a second call telling me ``not to forget to come to 
Dr. Soobert's office.'' When I arrived at 4:45 p.m. I was informed I 
was terminated. No cause was given. I was denied Union representation. 
I was told to sign the document placed in front of me. I asked to 
review it with a Union attorney. I was told to sign it ``right now'' 
and ``turn in your badge.'' As it was then after close of business, I 
had no one to turn to for questions. In the termination note to follow, 
I was given Kellie Franks as the Human Resources person to contact. I 
called, leaving my cell phone number as a contact. I received no return 
call for one week. When she called she wanted to know what my questions 
were and she would call me back. Upon return call, I was given another 
contact name and number. When Evelyn Stephenson was contacted she 
informed me she did not know the answers to my questions (Cobra 
coverage, retirement funds, continuing Union dues, etc.) and that I 
should ``go to the liberry [sic] and look it up.'' I have no answers to 
date. I was denied a written response.
    Physicians in Primary Care at Hampton VAMC have three choices when 
prescribing large amounts of opioids. They may resign (3 excellent 
physicians did so in the past 12 months - Drs. Pagador, Hilland and 
Wozniak), do as they are told, or be terminated. Dr. Jamal Al-Zhara was 
terminated when he refused to alter records to hide emergency room 
errors. Dr. Soobert fired him and then prevented him from working at 
other VA Hospitals.
    The Primary Care Physicians have no support from Administration 
including at the Director level. Examples of excess opioids includes:

      55 year old male received Morphine MS Contin 30 mg twice 
daily, Tramadol 300 mg daily, Percocet 4 times daily, 1 Fentanyl patch 
25 mg every 3 days for carpal tunnel since 2004, was not seen since 
2004, had no labs checked since 2004, and had the opioids mailed to 
him.
      64 year old, 102 pound female hospitalized for morphine/
vodka overdose receiving 1800 tabs hydrocodone monthly concurrently 
with morphine sulphate (MS Contin) 100 mg tabs, 360 tabs monthly, and 
has received as many as 3,600 5 mg Oxycodone at monthly intervals
      38 year old male, normal exam, normal x-rays ordered by 
Director Mims to continue filling his Percocet. Had been receiving 360 
tabs every month.
      39 year old male, working full time as farmer in Suffolk, 
VA receiving MS Contin, Duragesic patches, Percocet and Tramadol 
simultaneously for neck pain. Evidence of receiving Percocet from an 
outside, private primary physician and VAMC, never went to pain 
management consult but meds continued.
      50 year old male, diagnosed with ``low back pain'' 10 
years ago, last x-ray in 2004, wants more than Tylenol #3 (codeine) 4 
per day, Tramadol 4 per day. Refused labs and x-rays, wants pain meds 
refilled.
      55 year old male on morphine for ``low back pain'' 30 mg 
tabs 3 times per day, 240 tabs monthly mailed and Oxycodone 40 mg 
daily, 240 tabs monthly.
      56 year old male wants Percocet for ``chronic generalized 
pain.'' He wants 10 Percocet daily. I refuse. He reports me to 
administration. I am ordered by Dr. Karin Soobert to write the 
prescription. When I explain, she reports me for failure to follow 
orders. Contacted by Mr. Roger Barkers, Administrative Assistant, to 
write prescriptions.
      52 year old male on morphine 300 mg CR, 2 tabs 3 times 
daily for Lupus. He does not have Lupus. He reported me to Roger 
Barkers who had Dr. Mowery see the patient and write the opioids. 
Patient on 1080 mg of morphine daily, 4 Oxycodone 80 mg twice daily for 
disease he does not have.
      55 year old male demands morphine and Oxycodone because 
``I want them and you have to give them to me.'' Abusive. Police 
called. Another provider gives the meds the same day.
      56 year old sleeps through appointment with me. I feel he 
is over-medicated. He is diagnosed with rheumatoid arthritis with no 
DMARD since 2000. On morphine 90 mg daily, Oxycodone 10 mg daily, 
receiving 180 tabs morphine and 100 tabs Oxycodone monthly. I begin to 
taper on October 8, 2008, wife calls for in for more meds within 1 
week. I was reported.
      52 year old on Fentanyl patches. No CBC (complete blood 
count) since 2004, no LFT (liver function test) since 2007 and last 
urine drug screen 2008. Patches are mailed to him monthly for mild 
osteoarthritis. I alert Dr. Soobert this is not standard practice. I am 
terminated the following day.

    Tens of thousands of examples exist. I have repeatedly alerted Dr. 
Karin Soobert, Chief of Primary care, Dr. Mary Kim Voss, Chief of 
Medicine and Dr. Arul, Chief of Staff that, due to fear of 
administrative reprisal, these are the rules, not the exception. The 
doctors are afraid to refuse the patients' demands. The amounts of 
Schedule II narcotics prescribed indicate diversion into the community 
is occurring.
    I have consistently seen more patient than the other physicians. I 
am the only primary care physician to be over 100% booked in the 
history of the Primary Care at the VAMC Hampton. I have received the 
praise of my fellow physicians and nurses. It is my fondest desire to 
return to my position as a physician at the VAMC. There are fine 
physicians who wish to improve the level of care given to our veterans 
if given the opportunity and administrative support. Please assist me 
in bringing about the necessary changes to make this happen. I 
understand fully the gravity of these accusations and factual 
documentation exists for all.

    Respectfully,

    Pamela J. Gray, MD

                                 
             Prepared Statement of Claudia J. Bahorik, D.O.
BACKGROUND INFORMATION
    As a Board-Certified Family Physician for over twenty years and 
having worked in the medical field wearing various hats for over forty 
years, I feel more than qualified to enter an opinion on the current 
state of affairs regarding the narcotic situation at the VA primary 
care clinics. For the last 3= years I have been a traveling primary 
care physician for the VA Interim Staffing Program. During this time, I 
worked as a physician directly providing medical care to veterans at 
thirteen different VA facilities. Additionally, I am a physician 
acupuncturist, a licensed physical therapist, and more importantly, I 
am a disabled veteran who also is a consumer of care at the VA.
SUMMARY
    Although the VA can demonstrate they have guidelines and resources 
for the prescription of narcotics, on the grassroots level the primary 
care providers are struggling to stay afloat in a system flawed with 
errors, lacking oversight at all levels, and burdened by policies and 
politics that make it difficult to monitor and manage veterans with 
pain. These veterans, through the VA's own emphasis on pain, come to 
expect and demand narcotics, see pain control with narcotics as their 
``right,'' and bristle at attempts to limit use of these potent, 
addictive, and potentially lethal medications.
DISCUSSION:
    The problem with narcotics is but the tip of the iceberg and the VA 
the Titanic headed full speed ahead for catastrophe. To quote a fellow 
physician, even a garbage dump looks good when you're flying at 50,000 
feet.
    Perhaps the narcotic fiasco run amuck will serve as the impetus to 
revamp a system steeped in tradition and run by a good ole boys club 
that protects its members even under legitimate fire. Take the recent 
hearings in Pittsburgh and the Legionairre's problem. The VSN 
(division) director Mr. Moreland was rewarded with a $63,000 bonus, 
which his superior Dr.Petzel found no problem with authorizing. An 
administrator from the Jackson, Mississippi VAMC when faced with 
serious charges is allowed to step down from his position and continue 
to see patients. Another administrator involved in Jackson narcotic 
disaster was reportedly transferred to a similar position at an 
unsuspecting VA in Tennessee. These are but a few recent examples of an 
administrative ``shell game'' played by those at the helm of the VA 
Health Care System.
    Then there's the case of a physician assistant in Maine who was so 
unreliable and had so many complaints from staff and veterans that in 
an ordinary medical practice would have discharged him long ago. Around 
February of this year the VSN decided to investigate and place the man 
on paid administrative leave. He had been missing work on a regular 
basis, absent during working hours and no one knew his whereabouts (it 
was rumored that he was teaching an unauthorized course at a local 
college over lunch and saw no problem making vets wait 1 = hours until 
he returned), and veterans were regularly requesting they be 
transferred to another provider.
    This physician assistant would not obtain his own DEA license (drug 
enforcement agency) to prescribe narcotics (he told me he refused to 
pay for it, insisting the VA should pay for this license), instead, 
asked the physician in the adjacent office to write narcotic 
prescriptions on patients he had never met or examined (a violation of 
DEA prescribing policies). Then it was discovered that the physician 
assistant had been documenting that he had been doing extensive 
physical examinations on many vets who later complained to staff (and 
myself) that he never touched them (since most of the vets are also of 
Medicare age, this constitutes Medicare fraud). As far as I could 
ascertain, when I later covered his panel of vets, the only part of the 
physical exam for which he reliably performed per the veteran's 
admissions was the rectal exam.
    As I worked with his former patient panel, it became obvious that 
not only had he not examined patients, he had ignored their complaints, 
in many cases had misdiagnosed veterans, and in some cases there was a 
potentially life-threatening delay in diagnosis. He had month after 
month seen to their narcotic prescriptions, yet never had examined the 
body part(s) for which they had a pain complaint. I discovered that the 
problems lists were incomplete or inaccurate, the medications lists 
were often not updated or accurate, and his notes worthless and 
unreliable.
    As of about eight months later, this physician assistant was still 
on administrative leave, still getting paid, and the investigating 
committee could not make a determination as to his disposition. When a 
system cannot dispose of their own dead wood, how can one expect that 
system to effectively monitor and police itself?
    This is but one example of failure to provide veterans with the 
high quality of care the VA likes to list on their flyers. In 
particular, the provision of veterans with narcotics in a rather 
cavalier fashion appears to be a systemic problem. I have been in 
thirteen VA facilities in the last 3 = years while employed as a 
traveling physician with what initially was known as the VA Physician 
Locums Program and now is the VA Interim Staffing Program. The program 
in its hayday, employed ninety physicians who also traveled around to 
other VA facilities throughout the country. How easy would it have been 
to survey these grassroots physicians, asking about the narcotics 
situation, particularly after many of us complained to our 
administration. I requested that our comments and concerns be passed 
along, but nothing was done. When our staff had telephone group 
conferences (few and far between), the problems we were experiencing 
with being expected to sign-off on narcotic prescriptions was brought 
up during at least two conferences. Again, nothing was done.
    Suggestions were made to alert the facilities to the need to 
address our responsibilities as interim staffing and the facility 
expectations regarding continuing to write for narcotics, particularly 
when never having seen the veteran. We were all concerned that this 
violated the DEA policies and was a potential threat to the veterans 
and could result in DEA action against us. These comments never went 
any further, were not passed along to VACO (VA Central Office) who in 
their ignorance used us as a bunch of narcotic prostitutes.
    This sounds rather far-fetched, but when the sparks hit the fan at 
Jackson, and it came out that the nurse practitioners were illegally 
writing narcotic prescriptions, VACO begged the VA locums staff to find 
physicians to immediately fly to Jackson to help with the situation. 
The only catch was that we were never informed that upon arrival we 
were going to be the narcotic pushers, and not do primary care, but get 
the drugs rolling.
    The staff physicians had refused to write prescriptions for 
narcotics on patients they had never seen and the ER docs felt the same 
way. As one of the first two volunteers for this assignment, we were 
met by the administrator who informed us that even with his 
administrative duties he could manage reviewing thirty charts per day. 
He instructed us to simply look the chart over, see if the vet was 
``stable'', and knock out the narcotic prescriptions that his veterans 
were clammering for since the nurse practitioners lost their ability to 
write due to DEA action. He saw no reason to do a physical examination 
and said we needed only a ``face to face'' visit to satisfy the DEA. 
When I pointed out that not only could I not physically or ethically be 
able to push through 30 vets on narcotics, but I needed sufficient time 
and space to perform examinations.
    I was stuck in a section at Jackson, not far from the airport type 
screening at the front door (equipped with guards, metal detectors, and 
an X-ray screening device), and assigned my own swash-buckling 
narcotics police nurse, a male clerk, and had the angry vets lined-up 
at my gates on a daily basis. I insisted on drug screens on every one 
prior to my even seeing them, and when they came back positive for 
illicit substances, or not positive for substances they should have 
been on, they were cut-off.
    It was obvious that the administration was not in favor of my 
examining each vet, or reviewing each chart in a methodical fashion. My 
request from day one for an examination table was met with questions as 
to what purpose would I require an examination table for. To examine 
the vet properly was the response, yet my request went unanswered for 
one week until I threatened to climb back on the plane that very day if 
I didn't get the exam table. I got my table.
    What I discovered at Jackson, by reviewing charts from a vast 
assortment of nurse practitioners, was typical of many of the VA 
facilities in which I have worked. Jackson perhaps was the worse 
example. I discovered that narcotic prescriptions were rubber-stamped 
month after month, sometimes for two years on end, without a 
reexamination of the body part(s) in pain. Sure, the veterans were seen 
by the provider, but the pain was addressed by merely asking if the vet 
had pain and to rate it using the infamous 1/10 rating scheme. This 
violates not only the standards the VA itself has posted (that is, if 
you can find these web-sites easily in the heat of battle), but the 
dictates of the DEA and ethical practice standards. Nearly every 
facility I have gone to for providing emergency coverage has the same 
recurring problems. Notes that are incomplete, poorly typed, difficult 
to read, and are rushed off to completion to satisfy time constraints 
administrators place on providers, so that billing can be completed 
immediately. No one seems to remember how to write a note, listing in 
order of importance the problems in a logical, clearly documented 
fashion. The art of note-writing had a purpose, that of assuring 
continuity of care is possible and reflecting the thoughts and 
impressions of the provider. If you compare the VA notes to those of 
outside physicians, our notes are a shameful disgrace. And yes, it does 
impact on the quality of care when I cannot pick up a chart and look at 
the last note or two and figure out what the veterans problems are, 
what the provider was thinking or planned. You would think this would 
be one of the measures of quality. It is not.
    It became obvious that no one was supervising the nurse 
practitioners at Jackson, who essentially were practicing 
independently. As I reviewed the charts, I discovered notes that were 
incomplete regarding major health issues, conditions that were 
misdiagnosed, problem lists that were not up-to-date, medicine lists 
that were not current, tests were not being done, and in general, it 
appeared that they had fallen into a pattern of habit regarding the 
knee-jerk response to automatically refilling narcotic prescriptions. 
Often there were no recent consultations to specialists, no updated 
tests such as MRI's, and a lack of inquisitive investigation of pain 
complaints. Many times positive urine tox screens were ignored as well 
as drug screens that should have been negative. Drug screening was 
infrequent and if performed, was announced or anticipated by the 
routines of testing. There was no attention to the potential impact on 
poly-pharmacy on the health of veterans.
    The same problems noted at Jackson were also noted at other VA 
facilities. Administrators expected that temporary or new providers 
would jump right into the mix, continue what the prior providers had 
started, and keep the veterans happy. After all, a happy vet is one 
that doesn't write damning letters to his Congressman about how the VA 
ignores his pain. These letters reportedly adversely affect that VSN's 
(division's) money flow from above.
    Many facilities now shuffle the narcotic renewals from provider to 
provider when a position is left vacant, sometimes having 
administrators temporarily cover the narcotic prescriptions until a 
provider is replaced or returns. Again, these veterans are not seen in 
an actual face to face encounter, their charts are superficially 
scanned, and out pops a narcotic prescription ready to churn out of the 
VA pill mill.
    The same problems exist at other VA facilities regarding 
documenting not only a veteran's pain complaints, but the medical 
encounter itself. Providers notes often are pages and pages of cut and 
paste, including a record of the exam using a repetitive template of 
basic findings, but little in the way of a pain-directed physical exam.
    Notes are shamefully difficult to read, have incomplete listings of 
problems in the assessment section, and have sketchy plans outlined. 
The providers often are forced for the sake of time to address scores 
of pop-up ``reminders'' that have been triggered by the computer in 
order to appear as if they are providing what some administrator has 
identified as an indicator of quality care. These type of notes are 
conducive to mistakes. Several times I have seen a diagnose drop-off 
the radar because the medication expired for the problem and the 
provider doesn't have the time to review the scores of notations 
littering the path to discovery of all medical issues.
    The one medication that never seems to be lost is the prescription 
for narcotics. Unfortunately, substance abuse may be listed on the main 
problem list, but it is often ignored when dealing with a pain 
complaint. Another factor that is often ignored is the potential 
interaction of multiple psychiatric medications prescribed. It is sort 
of the `go ask Alice when she's ten feet tall' culture. There are pills 
for everything, and pushing pills is one thing the VA is good at - so 
good that the VA had been cited as being the biggest supplier of on-
street legal drugs in the United States, and the largest consumer of 
narcotics in the world.
    How did it get that way? It appears that about ten years ago the VA 
decided that pain was the fifth vital sign (after temperature, pulse, 
respiration and blood pressure). It became so ingrained that staff 
members were chastised if they did not ask about pain, even if the 
veteran had presented with no intention of discussing pain, they would 
be flagged. Now, not only do they ask about pain, but they must ask if 
you want something done about it that very day. It is no wonder medical 
problems fail to get addressed or are missed.
    Pain management has become a double edged sword for the medical 
providers. You are damned if you don't prescribe narcotics and damned 
when you do and someone has an adverse outcome. Both cases result in 
complaints, and depending on how well placed the veteran is, those 
complaints can generate considerable aggravation for administration. 
Often I watched as a vet I had denied giving a prescription of 
narcotics to, although I had documented in great detail the rationale, 
as the vet would present to administration to have the non-clinical 
administrators order another provider to write for the medication 
(Jackson VAMC was quite good at this). The other scenario was the vets 
would go to the VA emergency room, and often just to get them out 
quickly, the prescription would be written.
    Facilities encourage prescriptions of narcotics by denying 
alternative forms of treatment such as chiropractic (most facilities do 
not have a chiropractor or enough of them), massage, or acupuncture. 
The VA's vocational rehabilitation department spent $8000 sending me to 
a physician acupuncture course two years ago, and I have yet to find a 
facility that will credential me so I can provide this service to vets. 
They give the excuse of having no one to supervise me. It makes no 
sense when acupuncture is less invasive than performing minor surgical 
procedures, cutting someone with a scalpel, or poking holes in skin to 
drain abscesses, all of which I am credentialed to do. The true issue 
is that they don't want to open a can of worms, ie., be faced with 
having the vets demanding more of the same service. It is infinitely 
cheaper to dole out narcotics than it is to have veterans deal with 
pain through alternative measures. That is the bottom line.
    Furthermore, the pharmacy gestapo controls the formulary, which is 
dictated in tern by the bonus a manager might receive if the costs are 
kept down. For instance, if you want to provide the non-formulary drug 
Lyrica for pain modulation, it typically is not approved by the 
pharmacist that oversees physician drug prescribing. You are instructed 
to use the older, less effective drug gabapentin first, document its 
lack of effect, then try a concoction of other pharmaceuticals all with 
central nervous system depressing effects first. If the veteran lives 
through the experimentation with chemicals coming at him from all 
directions and types of providers, maybe at some point they will relent 
and allow you to provide the drug.
    Another example is Voltaren gel, a topical anti-inflammatory drug 
that can be rubbed into painful joints to control pain. It works and 
unfortunately for the veterans, it's non-formulary. Many vets are on so 
many drugs they should be putting omeprazole (Prilosec)in the water to 
counter the effects on their stomachs. Non-steroidal anti-inflammatory 
medications (NSAID's) are notorious for causing stomach ulcers, 
gastrointestinal bleeds, and even heart problems, yet these are the 
preferred first-line drugs that we are supposed to push - if one 
doesn't work, try another and another. Just add the omeprazole, the H2 
blocker (like Zantac), or Cytotec that causes uncontrollable sudden 
bursts of diarrhea. Give them any number and combination of narcotics 
and mental health drugs, but don't allow the vet to use a topical 
substance, even on a trial basis, because it costs too much. Tell me, 
what is the cost of hospitalization for a GI bleed? Or the cost to 
society when a vet dies of a drug overdose?
    No, the pharmacy is a dynasty, run by the new Ph.D.'s on the block, 
the Pharm.D. The pharmacists control the formulary, which is kept a 
secret and never, never published (the National formulary is published, 
however, each VSN can decide on what drugs to include or not include), 
since people might start to realize how few drugs and how old the drugs 
are that the VA allows on the formulary (and this is somehow up-to-
date, high quality care?).
    Not only do the pharmacists control the drugs, they now tell us how 
to practice medicine. It appears the VA has condoned such practices - 
pharmacists are cheaper than docs, maybe know the drugs' theoretical 
advantages, and are loving the increased responsibility. Unfortunately, 
the VA leaders pushed us to this slippery slope in the name of cost-
savings. When you think of it, why even have physicians when 
pharmacists take over management of hypertension, hyperlipidemia, 
diabetes in their ``clinics,'' - clinics in which they are given an 
entire block of time to deal with a few targeted medical disorders. 
Perhaps if the providers had such luxury there would be better control 
of chronic diseases, including pain management.
    To cite an example, recently I had two pharmacists tell me they 
wouldn't authorize the use of Voltaren gel for a vet who had numerous 
failures with other meds, stomach issues, and problems with narcotics. 
They instructed me, the physician, that I should have the veteran lose 
weight (as if that will happen magically overnight), exercise (which he 
couldn't do much of due to his severe knee problem), refer him to 
physical therapy (which would do nothing for severe degenerative 
arthritis), and I should treat his ``gout'' because that might be 
causing his aches and pains. Twice I wrote back that the vet does not 
have gout (he had several joint aspirations proving this) and that an 
increase in uric acid (hyperuricemia) does not equate necessarily to a 
diagnosis of gout. Not only are the pharmacists telling us how to 
practice medicine, they are now diagnosing veterans.
    What about the returning heroes coming back from the sandboxes in 
the Middle East? Often they are started on narcotics while deployed, 
just to keep them in the field. They arrive at our doors on medications 
for depression (who wouldn't be depressed with the ridiculous number of 
back-to-back deployments), medications for anxiety such as Xanax, a 
medication to prevent the nightmares of PTSD, one or two pills to make 
them sleep (like zolpidem that makes then do things like sleep walking, 
night driving while asleep, asleep eating, or making crazy purchases 
on-line, none of which they remember upon waking), another anti-
depressant when the first one isn't quite performing the chemical 
lobotomy, perhaps a drug for attention deficit (it's no wonder they 
can't stay focused considering the drug soup bathing their brains), and 
to round off the cocktail they have been prescribed a narcotic or maybe 
even two for that ubiquitous pain complaint.
    They present to facilities, young men typically, strung out on 
prescription cocktails, mentally shattered, and desperate for help. The 
VA dictates that, rightfully so, they need to be priority patients. 
However, they haven't figured out how to assimilate another body into 
the mix when they can't even accommodate the veterans currently on the 
roles. So administration begins another ``shell game,'' moving patients 
out of a provider's panel into the officially unassigned category. The 
slot created on a panel allows them to put in the new OEF/OIF 
(Operation Enduring Freedom and Operation Iraqi Freedome) veteran for 
his initial appointment. Therefore, the providers panels are bulging, 
current veterans cannot get timely appointments, and if someone is sick 
and doesn't have the luxury of having an outside physician, they are 
out of luck.
    What happens when these hurting vets, soldiers with PTSD driving 
their miseries, are told there are no appointments even though there is 
a mandate (which they are aware of) directing facilities to get them in 
within so many days? One poor hero, desperate to get his PTSD treated, 
after too many rejections by the Wilminton VAMC, reportedly shot 
himself in the parking lot of the facility.
    Walk-ins are definitely not welcome, nor is the system even user 
friendly if the providers do make room. Patients are expected to be 
``squeezed-in'', which only serves to make the provider run late (bad, 
a ding against the provider and the facility). Since time can't be 
created, then the other veterans with appointments get short-changed in 
their face-to-face, now hurried appointments.
    It would be too logical to pre-schedule slots that are reserved for 
sick visits. Even if that were done, the veterans cannot get through to 
their assigned offices on the telephone. Yes, the telephone system that 
links the VA facilities is archaic, inefficient, and contributes to the 
large number of vets getting frustrated after repetitively calling a VA 
answering service in Colorado (or some such place that might as well be 
on the moon) and be asked to leave a message - a message that some busy 
clinic clerk might get to some time that day. I have not found one VA 
facility in nearly fours years of traveling as a gypsy doc for the VA 
who has a direct phone number to their assigned clinic that their 
patients can call in a normal fashion in order to be seen. So the 
response the VA has to this is to insist walk-ins must be seen that 
day. How this can be achieved is up to the staff who have no power to 
alter schedules, block-out time slots, or do anything creative without 
first going through levels of supervisors or one of the infamous, omni-
present and omnipotent, sacred VA committees.
    Oh, the VA has a solution. The pressure now is not to bring the 
vets in for a real appointment, providers are encouraged to try to do 
telephone appointments - a scheduled phone call of 15 minutes to do the 
same thing you would normally do in 30 minutes, sans the physical exam, 
without eyes on the patient, with minimal prep time, and no scheduled 
time to write notes. It's no wonder sloppy is the norm. The providers 
end up staying later and later to catch-up, becoming more and more 
dissatisfied, and it is not rocket science to recognize that the 
providers mutate to the point of being pill-pushing automatons. VA 
survival tactics 101 - an ideal setting conducive to narcotics being 
passed merrily along with the rest of the mind-altering medications.
    Is it going to get any better regarding the monitoring of 
narcotics? Probably it will until all the heat dies down, the newpapers 
get tired of the same story with a different twist, and the pressure 
returns to keep costs low. There are problems inherent in the system 
that impact on the way the narcotics are being prescribed. The 
providers are saddled with stifling paperwork, regulations and rules 
generated by persons who never treat patients, a computer system that 
is cumbersome and not user friendly, and no ability to control 
decisions that impact negatively on productivity.
    Who ever heard of having a provider assigned to one exam room which 
also functions as a medical office? When a provider wants to see the 
next vet, he has to first change the paper of the exam table (maybe 
even wipe it down first), and then walk down to hall to fetch the 
patient. Five minutes wasted. The provider has to be a typist, a 
transcriptionist, the person who enters each and every drug a veteran 
receives from an outside physician in a labor-intensive fashion (it 
would be too logical to have the screening nurse do this chore), the 
one who enters each lab tests one by one (no clicking on panels for our 
docs), the person who enters a detailed consult to specialists 
(specialist who can decide to deny a consult based on how busy or 
motivated they are), or perform the lengthy questionnaire prior to 
entering an MRI (which a clerk could easily do).
    The specialists also are the ones that are so pampered that they 
can agree to a consult only if the provider enters the testing that the 
specialist wants, that they will review, yet the provider has to take 
time to enter tests as if they were the specialist's secretary. Then it 
is up to the provider to make sure the vet attends the appointment. If 
they don't make the appointment, it's still the provider's burden of 
responsibility.
    From the other side of the coin, as a disabled veteran I get 
medical care from the Lebanon VAMC in Pennsylvania. Recently, I went to 
see an ENT specialist for an ear infection causing hearing loss to the 
point I couldn't hear with my stethyscope. The surgeon was rude, 
refused to let me explain my problem in a succinct fashion, and instead 
insisted that he first wanted to read my chart (perhaps he should have 
done that before I entered the room for my 30 minute consult time slot 
he insisted on having since I hadn't been seen in over a year by ENT). 
After several minutes he rolled his chair over to the ENT (barber-like) 
chair where I sat, spun the examination chair rapidly, reached up and 
began to examine my right ear without having listened to what my new 
complaint was. He inquired, ``So what is wrong with your right ear?'' I 
explained that had he let me provide a history he might know I had a 
recurring problem with both ears. The treatment as I already knew from 
several such bouts, was to suction the residual debris from my ear 
canals. As he rapidly and vigorously moved the suction device in my 
ears he repetitively hurt me (he got too close to the ear drum). Every 
time I would reflexively flinch and every time he would chastise me for 
moving, regardless of the pain his less than gentle approach was 
creating. The final insult was when he berated me for waiting so long 
to come in (over a year), when in reality the problem have begun 
abruptly over the prior week.
    Prior to that episode, I went to a VA doc for a complaint of 
feeling ill for a month, having symptoms of a kidney infection, and 
being concerned about my health. This fill-in ex-Navy physician, sat 
flipping through my thick paper chart (thick because the VA had all 
sorts of records from the illnesses caused by Anthrax immunizations), 
reached over and patted my hand, and asked, ``Did you ever think of 
seeing a psychiatrist?''
    A week later I was in the hospital with a mild stroke and a kidney 
infection.
    Another VA surgeon performed a colonoscopy on me, never explained 
the procedure (doesn't matter than I am a physician), had me sign the 
consent, and then never bothered to tell me after the procedure what he 
did or didn't find. He just instructed the nurse to show me the photos 
from the colonoscopy and tell me the results. He was much too important 
as the Chief of Surgery to bother with mundane details.
    Now if specialists treats me, a physician that way, how do they 
treat the run of the mill veterans? I hear complaints like this all the 
time about the insensitivity, the rushed consults, and the non-
professional behaviors of specialists on the VA payroll. Being the 
sacred cows of the VA, they are untouchables.
    Meanwhile, the provider is inundated with useless, repetitive 
computer messages known as ``view alerts.'' No one seems to know how to 
stop messages that tell us an appointment was made (we only need to 
know if one wasn't made and why). Labs pop up as view alerts over and 
over again, the same labs, multiple labs presented separately in 
multiple view alerts, hundreds of view alerts. Then there are the 
mandatory staff meetings, time wasted that could be addressed though 
memos or e-mails. RN's aren't even allowed to enter unsigned orders to 
assist providers in performing duties, or are not allowed to do tasks 
within their scope of practice that could simplify the office 
procedures (like entering the orders for the endless medication renewal 
requests so that after reviewing the chart, the provider could more 
quickly sign the orders) and free up the provider to see patients.
    Some nurses refuse to help providers with phone calls. Some nurses, 
like at Durham refused to do much to help the veterans. If I would ask 
them to flush a veterans ears (a facility that actually allowed the 
nurses to do this), they would answer that they needed to schedule an 
appointment. It didn't matter that it was an elderly veteran who lived 
a distance away. They were out of the office 12:00 sharp and out the 
door at 4:30 come hell or high water, which the provider usually was 
overcome by at the end of the day.
    Don't expect that blood pressures listed in the charts are correct. 
For a matter of convenience the VA purchased all these expensive 
electronic BP machines that typically register higher than the true 
resting BP. You will never find the BP entered for both arms as you 
would in private practice, which is standard operating procedure for a 
patient with hypertension. A difference in pressure could indicate a 
blockage in one of the main arteries coming off the heart (this isn't 
fantasy, I am a prime example of a subclavian blockage diagnosed only 
because I insisted the BP be taken in both arms). The machines 
automatically send the single BP to the electronic medical records, but 
apparently they aren't set-up to manage two BP's. Therefore, if the 
busy doctor wants a true reading he has to first scrounge around to 
find a manual cuff, find one that actually works or has all the parts, 
and then try to find a large cuff for the big arms. . . More wasted 
time that physicians' could be using to think, to prevent disaster.
    Yes, the VA physicians, nurse practitioners, and physician 
assistants are expected to be the supermen and women of the VA, yet 
have little input as to things that impact their day to day activities. 
Yes, the providers are not properly screening veterans taking 
narcotics, simply as a matter of sheer survival and keeping one's head 
above water. Of course, it is their fault for putting up with the 
system, not trying to change it, but be forewarned that those who do 
speak up are likely to lose their jobs. People are rewarded for keeping 
their opinions under the radar, their hands hog-tied, and their jaws 
wired shut. Welcome to the world of the VA.
            RECOMMENDATIONS REGARDING NARCOTIC PRESCRIPTION
    1. Provide an intensive training course for prescribers of 
narcotics that is done in-house, not on a video monitor that providers 
can wander in and out of the training session ad lib (this was 
witnessed at a recent Tele-training course held by Wilmington VAMC). 
Provide written materials and references to all physicians, not merely 
the ones who were able to attend the live training. The course should 
be at the physician level, not watered down to include all personnel. 
Separate training should be done for nurses and staff having roles that 
intersect the provision of narcotics to veterans.
    2. Educate the veterans on options for and benefits of pain control 
with an emphasis on non-narcotic solutions.

    a. For veterans currently on regular large doses of narcotics, 
require mandatory attendance at educational seminars.

    b. For veterans inappropriately prescribed or taking large amounts 
of narcotics concurrently with or without other central nervous system 
depressants, for veterans with a history of current or past substance 
abuse, provide an in-patient residence program. This program should 
promote healthy living concepts, introduce non-narcotic alternatives, 
provide an independent medical examination (a second opinion) of their 
pain complaints, and result in designing a comprehensive pain control 
program with minimal narcotic usage.

    c. Acknowledge alternative forms of care by making a dedicated 
effort to provide such services.

    1) Allow providers trained in alternative forms of care to deliver 
these services (for instance, I am a licensed physician acupuncturist 
and have not been allowed (in the last two years that I have been 
licensed) by any VSN credentialing board to provide this service to 
veterans in lieu of prescribing narcotics).

    2) Pay for chiropractic services on a ``fee-basis'' program if a 
chiropractor is not on staff. If not on staff, advertise and hire 
enough necessary to deliver these services.

    3) Allow the VA physical therapists (who now are required to have 
Ph.D. degrees) to function as part of the pain management team and do 
more than simply sending the veteran out the door with a list of home 
exercises (Note: I also have been a licensed physical therapist for 40 
years, with a Master's Degree as well!)

    3. VA Pain Services should be directed by a full-time physician 
with special training in Pain Management.

    a. Physician Assistants (PA's) and Nurse Practitioners (NP's) 
should not be the primary source of care in the Pain Management service 
when a veteran is referred by other providers for evaluation of a 
difficult pain management case.

    b. Veterans managed by PA's and NP's should be evaluated on a 
regular basis by the Pain Management physician

    c. Veterans placed on significant doses of narcotics by the Pain 
Service should not be allowed to transfer the prescription of these 
narcotics to primary care providers simply because it is beneath the 
dignity of the Pain Service to perform such mundane activities (this is 
the role their extended care providers can address).

    4. Physicians and extended care providers need to be responsible 
for obtaining a complete pain history, performing a thorough 
examination pertaining to each body part in pain, ordering appropriate 
lab tests, studies (eg.,X-rays, MRI's, CT's) and consultations.

    a. Adequate time needs to be dedicated to the investigation of the 
pain complaint. This process is necessarily time-intensive and requires 
an appointment not riddled with other issues or concerns. That is, the 
session should not be part of a routine check-up for multiple medical 
issues, during which time multiple medication prescriptions need to be 
addressed and written, or when time is spent coordinating care with 
multiple outside physicians (as is commonplace).

    b. Measures need to be taken to assure that the persons prescribing 
narcotics have proper training in physical assessment of 
musculoskeletal conditions. Perhaps giving providers extra training 
with the orthopedic service or on the pain service might be indicated.

    c. Charts of veterans receiving narcotics should be randomly 
reviewed by peers, or the pain service if requested, to determine 
appropriateness of narcotic prescription.

    d. Clinical Pharmacologists (Pharm D level) should also review 
narcotic prescriptions for appropriateness, likelihood of drug 
interactions (particularly in the presence of other mind-altering 
drugs).

    5. Dedicated monitoring should be required of all persons taking 
narcotics (other than for a brief episode).

    a. The urine drug (tox) screening process needs to be revised:

    1) Veterans are familiar with criteria that military screening 
entails (witnessed drug screens, emptying pockets, leaving personal 
belongings out of the room)

    2) Urine drugs screens needs to be both announced and unannounced, 
regardless of suspicion for diversion or abuse.

    3) The screening needs to be taken seriously by both the staff and 
veteran. No excuses can be accepted when a request is made for 
providing a specimen.

    4) The specimen needs to be collected in a manner consistent with 
accepted protocol, such as is used in pre-employment screening or post-
accident screening by industry. For example, the veteran shall not have 
access to running water, the toilet water is dyed with a chemical 
designed to foil surreptitious dippers, and specimen containers should 
be specially designed for urine tox screening (such as to monitor pH 
and temperature). The veteran must empty their pockets, leave 
belongings outside the room, and preferably be monitored.

    5) The issue of insufficient staffing must be addressed. This makes 
another case for the prescription of narcotics to be managed by 
providers at a facility equipped to properly monitor for drug misuse 
and other substance abuse.

    b. Unannounced pill counts need to be performed, even in veterans 
not suspected of diversions or abuse, since no one can predict who will 
be the guilty culprit.

    c. Although signing of Pain Contracts is not proven to be much of a 
deterrent, its use may serve to provide the veteran with the rules of 
engagement and serve as a warning that certain behaviors will not be 
tolerated.

    d. The ``lost prescription'' story needs to be addressed up front. 
Veterans need to know they are responsible for keeping their controlled 
substances in a safe place.

    e. The business of providing `bogus' police reports as evidence of 
theft should be addressed initially upon signing the pain contract.

    f. The practice of allowing veterans to ``slip-up'' and have a 
dirty urine should not be tolerated. These veterans should immediately 
be referred to Pain Management or a Suboxone program.

    6. Safety issues need to be addressed regarding veterans who are 
prescribed narcotics, particularly when in combination with other 
centrally acting depressants or mind-altering drugs.

    a. Veterans who are on other mind-altering drugs are at increased 
risk of accidental overdose and unwanted side effects.

    b. Psychiatry should be responsible for assessing the 
appropriateness of all the mental health medications, particularly if 
narcotics are being prescribed.

    c. Veterans should be offered alternative treatments for mental 
health disorders, including sleep problems and PTSD, such as intensive 
counseling programs and holistic approaches (relaxation exercises, 
melatonin, Herbals, acupuncture).

    d. Pharm.D. pharmacists should also routinely earmark cases 
involving potentially interacting or additive medications for review on 
an on-going list.

    e. A master list of each provider's narcotic patients should be 
maintained and accessible to both provider and those engaged in 
monitoring.

    f. The state's narcotic data banks should be routinely accessed by 
either the provider or preferably the Pharm. D. This practice should be 
encouraged, since it is infrequently performed by busy providers who 
are currently expected to be a revolving door for veteran health care. 
By querying the data bank, veterans who doctor shop for narcotics can 
easily be spotted. For instance, earlier this year I discovered a vet 
that had been to 10 different providers who had written for narcotics 
for this vet between January and June.

    g. There should be a nationwide central clearing house to which 
states be mandated to report all persons obtaining narcotic 
prescriptions. This data bank should be accessible to anyone providing 
an ongoing regimen of narcotics to an individual.

    7. Safety issues need to be addressed regarding the persons who 
prescribe, interact and provide services related to the prescriptions 
of drugs.

    a. Security at Community Based Outpatient Clinics (CBOC's) is non-
existent. Some CBOC's have a system to silently alert the staff to a 
situation, but the keyboard must be accessible. Some CBOC's have silent 
alarms under the provider's desks, that go to the central office's 
police station. By the time local police are notified and arrive, the 
situations has either resolved or had an adverse outcome.

    b. Providers and staff are at increased risk of harm by disgruntled 
veterans - veterans who have problems with anger management, PTSD, 
anxiety, depression, and whose thought processes are chemically 
challenged by a cocktail of prescribed and possibly unprescribed 
substances. These veterans who have suffered unimaginable situations 
during their service to our country often lack the coping mechanisms, 
the internal restraints, or even the normal problem solving 
capabilities a non-medicated, mentally together individual would 
normally display.

    c. Staff members have been assaulted, some killed, by veterans 
angry with care, whose demands are not met, or have been refused 
narcotic prescriptions.

    1) In Jackson, Missippi about 10 years ago a physician was shot and 
killed by a veteran who was denied pain medication.

    2) Again in Jackson, two or three years ago a doctor had acid 
thrown in her face because a veteran was dissatisfied.

    3) In Maine, a veteran reportedly became angry recently with not 
getting narcotics and ran his car into the side of their new CBOC 
building.

    4) Another veteran angry about not getting his narcotics presented 
to the `mother ship' in Maine reportedly hunting for the administrator 
to shoot. Instead, he was confronted by the police and a ``suicide by 
cop'' incident occurred.

    5) Not long ago in Delaware two psychiatrists were reportedly 
attacked by a patient (it is rumored that both physicians have left the 
system)

    5) I was told by a Phoenix VAMC staff member at the VA Intermin 
Staffing Program when I complained about concerns as to my safety while 
at Jackson, that this is not uncommon and a provider had been shot at 
the Phoenix VAMC.

    6) The magnitude of the risk cannot be assessed since these 
statistics, if kept, are not available to staff.

    7) Staff are not allowed to carry or have access to any type of 
protective device, such as a TASER or Mace. Instead, we are given silly 
little learning modules instructing us how to speak, act, or move to 
theoretically defuse volatile situations. One time I was forced to 
suggest that the all-female staff might grab the fire extinguisher to 
spray any violent perpetrator.

    8) When potentially violent veterans or those who are known to have 
a history of violence or aggressive behavior directed against staff are 
identified, little effort on the part of administration is made to 
ensure the safety of staff. A complaint must be made to the 
``Disruptive Behavior Committee'' after the fact, who will then decide 
on the final disposition of the complaint. The perception of the staff 
who were threatened or attacked seems to be overshadowed by the 
veterans ``rights'', of which there seem to be more of than the staff's 
rights when it comes to safety.

    9) Often the vet will simply be reassigned to another provider at 
the facility, even though the vet will be coming into contact with the 
disparaged staff members.

    10) The most potentially violent vets are as a last resort required 
to present for care at a VA hospital where a guard must be assigned to 
the veteran. In a remote CBOC this is not an option.

    11) Even the provider asking the staff to call the local Police to 
stand-by during an encounter is met with administrative objections and 
this action has to be approved by someone who has no medical 
background, direct knowledge of the situation, and nothing to suffer if 
a veteran loses control.

    12) In summary, the staff's concerns about potentially violent 
persons in the workplace needs to be honored with swift action designed 
to lessen the risk to staff.

    9. One life lost is too many on either side of the coin.
                        GENERAL RECOMMENDATIONS
    1. Complete reorganization of the VA Health Care System, 
eliminating the ``top heavy'' emphasis of the current organizational 
scheme.

    2. Elimination of bonuses paid to administrators at various levels 
that provide incentive to provide the cheapest medical care, and NOT 
provide the most effective strategies for medical services, including 
pain management

    3. Across the board ``retirement'' of administrators who have been 
shuffled to other facilities in the face of controversy, as pawns in a 
real life ``shell game'' that merely transposes problem administrators, 
and whitewashes solutions to problems that threaten the health of 
veterans.

    4. Return the baton of health care administration to the realm of 
those trained in medicine - the physicians, nurses, extended care 
providers, and personnel in other medical specialties. Eliminate 
policies that allow non-medical personnel, including those without 
college education and no medical background, to oversee and implement 
policies that directly impact medical professionals.

    5. Identify, address, and eliminate the rules and regulations that 
have restricted the ability of medical professionals to practice their 
profession according to the highest (not the cheapest) standards, 
including making medical decisions that impact upon the quality of 
health care, within the scope of their medical licenses.

    6. Upgrade the computer system used by the VA - the sacred tail 
that wags the dog. Implement user-friendly touch screens on portable 
lap-tops, making the providers more efficient and mobile. Field-test 
programs and changes with users/providers who don't live in a world of 
techno-gobblygook, instead of just adding layers of patches and 
illogical, inefficient steps designed by IT (information technology) 
geeks that do not consult or care to consult with the providers who are 
slowed by laborious and unnecessary steps in documentation. The system 
should be provider-driven for purposes of accurate, efficient note-
keeping to direct medical care with the least amount of burden, not 
administrator-focused for the purposes of forcing provision of data to 
be used for purposes that shed a positive light on the top dogs and 
their potential bonuses.

    7. Return the provision of medical care to the realm of physicians, 
who by nature of their extensive education and training, are the ones 
who not only know what constitutes quality care, but should be allowed 
to see to it that this care is provided to our veterans. Do not mistake 
the concept of quality medical care as being the cheapest care that can 
be provided to the masses.

    8. Analyze the VA sanctioned indicators of quality care and 
determine if the measures used are merely ways to polish statistics to 
make the upper echelon appear to be the shining knights of the VA 
dynasty.

    9. Allow extended care providers, nurse practitioners and physician 
assistants, to practice according to their own practice acts. Do not 
allow the VA to rewrite their job descriptions based on administrators' 
perceived ability to provide equivalent primary care, which equates to 
merely ``adequate'' health care (most of the time for non-complex 
cases) at a cheaper cost. Allow the physicians to follow the more 
medically complex cases, including oversight of all the pain management 
cases, and allow the extended care providers to do the routine nuts and 
bolts daily medical services. Currently the system is flip-flopped, 
with the NP's and PA's having smaller panels of patients than the 
physicians, who are expected to manage much larger panels, thus having 
less time to contemplate or effectively manage their clients 
complicated medical issues. Consequently, there is not even time to 
supervise or consult of the cases handled by extended care providers 
who largely function independently at the VA. Basically, the simpler 
cases should be handled by extended care providers and the more complex 
ones managed by physicians who should be given more time with these 
difficult cases.

    10. Reverse the trend to replace physicians with cheaper extended 
care providers. Realign the team units to be directed by a physician 
who oversees that team's nurses and extended care providers along with 
ancillary staff. Currently the physicians are powerless due to the 
dictates of the administrative burdens. Implement methods to simplify 
and expedite day to day practices which historically have to pass 
through several layers of administration who jockey for control.

    11. Recognize that the heart and soul of the medical team is 
composed of the providers of medical care. The current PACT approach 
(Patient Aligned Care Team) is based on a belief that the patient sits 
atop the health care team pyramid, when, in fact, the veterans are 
partners with the providers of medical care. The back to basics 
approach is based on the notion that the health care team is there to 
provide the best and most efficient care to the veteran, but the 
veteran does not have ownership of that team. The concept promulgated 
by the VA known as ``Pain as the 5th Vital Sign'' and that pain must be 
addressed regardless of other medical issues, is evidence of how 
terribly wrong a well-meaning system can become when care is driven by 
administrative demands and unreasonable expectations.

    12. Return specialty care to the domain of physician specialists. 
Currently, many nurse practitioners and physician assistants perform 
specialty consults without physician intervention. The extended 
caregivers do not have equivalent training, their specialty training 
being largely on-the-job training. If there are not enough specialists, 
such as dermatologists and ENT physicians, contract the services out to 
medical experts and don't rely on cheap substitutes.

    13. Address the problem with the National VA Formulary being so 
restrictive, loaded with cheap generics and limited drug choices in 
various categories. Currently each VSN's pharmacy decides which drugs 
they will supply, which is based on cost-saving practices that allow 
chiefs to obtain monetary rewards for limiting costs. Pharmacists are 
the persons currently making decisions about medical necessity of non-
formulary medications, often basing their decisions on studies that 
they are instructed to quote to justify their sometimes inappropriate 
denials or decisions. Return physicians to the front-line of drug-
prescribing. Make the facilities publish the medication lists on-line 
so the providers of medical care will know what drugs are available per 
category and veterans will know the limitations of the formulary. 
Currently, it is impossible to get the VSN pharmacy to print a list of 
drugs they authorize as ``formulary'' - their rationale being the list 
changes daily, which in this day and age of computers is a particularly 
feeble excuse. This practice really equates to a veiled attempt by 
cost-cutters to maintain a wall of secrecy and whose practices are 
designed to exert control over providers.

    14. Emphasize non-medicinal oriented approach to health care 
instead of focusing on which little pill can relieve a problem, and 
address what the veteran can do to help himself.

    a. Do group visits for problems such as weight loss or chronic 
medical problems requiring education such as diabetes, hypertension, 
and hyperlipidemia - the `Big Three' problems making up the nemesis of 
the VA.

    b. Introduce alternative medicine approaches to be realistic 
options to facilities, such as acupuncture, chiropractic, massage, Tai 
Chi, and other such ``mindfulness'' oriented care.

    c. Allow physical therapists to return to hands-on activities, not 
being forced by time constraints to be mere machine jockeys or mere 
distributors of exercises to do at home.

    d. Allow physicians who are trained or to be trained in acupuncture 
and to utilize it according to the principles of established practice 
within their daily practices.

    15. Address Poly-Pharmacy as a real problem with potentially real-
life serious consequences. Realize the current system of ``medicine 
reconciliation,'' no matter how well-intentioned, just isn't working. 
People are over-medicated because medication is cheaper than 
alternatives, less labor-intensive than a provider explaining rationale 
and alternatives (which are currently limited), and reinforced by the 
revolving door mentality (get them in and out as quickly as possible). 
Acknowledge that by farming out much care to inaccessible specialists 
(often due to limitation of training and experience by extended care 
providers), there is no one who truly is ``Captain of the Ship'' - the 
role primary care physicians were designed to fulfill. Medications are 
added to already long lists of medications willy-nilly, with computer-
generated reminders of ``poly-pharmacy'' and warnings of potentially 
serious interactions often being ignored.

    16. Identify true measures of quality care instead of relying on 
surrogates that are designed to make an administrator's fiscal bottom 
line look good and perhaps contribute to his bonus. For instance, the 
current system rewards a provider based on whether they complete the 
computer-generated ``Reminders'' on-time or if they do the billing 
correctly and promptly, or do the endless and repetitive computer 
education modules on time (assigned by some well-intentioned 
administrator at the top who is far-removed from patient care). This 
says nothing about quality. Ignoring the fact that the veterans 
complaints have not been completely addressed, or all the interacting 
medical conditions were not taken into consideration, or that the 
physicians'documentations of encounters are worse than a beginning 
medical student's. These are examples of practices destined to result 
in harm to a veteran in the form of mistakes, misdiagnoses, delay of 
care, and adverse reactions, any of which could be life-threatening.

    17. Return to Basics, providing all aspects of primary care at 
offices and eliminating unnecessary consultations of specialists and 
stopping the practice of making veterans travel distances for care 
within the boundaries of primary care.

    A. Allow offices to perform simple point of care testing:

    1. Ability to perform finger stick blood sugars (a test which is 
readily done in the home by patients but is not allowed in offices due 
to lack of common sense by the administrators and lack of guidelines 
defining these simple office procedures).

    2. Ability to perform finger stick INR's in the office to 
facilitate in-office management of anticoagulation

    3. Ability to do simple hemoccult testing (stool for Blood) in the 
office (CLIA waved testing) by nurses and providers without being 
subjected to onerous & ridiculous regulations that defy common sense.

    4. Ability to use specially designed urine tox screen containers 
when obtaining specimens (for example, Monitor pH and temperature of 
urine)

    B. Allow physicians, NP's and PA's to practice according to their 
training:

    1. Provide necessary supplies for performing simple procedures, 
such as performing biopsies of suspicious skin lesions, minor 
laceration repair so that veterans do not have to wait unnecessarily 
long times for appointments with specialists and have to travel 
unnecessarily for procedures that can be office-based.

    2. Train and accommodate providers who desire to do Joint 
injections, trigger point injections, or other simple procedures

    3. Permit physicians who are trained in alternative medicine 
techniques to practice their skills (such as herbal therapy, 
acupuncture, manipulation). Develop an environment of support for 
providers who chose to use non-pharmacological approaches as part of 
their practices. Provide additional funding for training in alternative 
medicine.

    C. Allow nurses to perform simple procedures they are trained to do 
without being hog-tied by regulations.

    For example:

    1. Perform screening and removal of cerumen (ear wax) from veterans 
to eliminate referral to specialists and not make the veteran wait for 
care or have to travel long distances to the VA hospitals.

    2. Allow nurses to follow a predetermined policy for monitoring INR 
test results to facilitate anti-coagulation (which many elderly vets 
are on).

    3. Allow nurses to remove sutures so vets do not have to 
unnecessarily travel long distances to specialists

    4. Allow RN's to function as valuable team members, and provide 
medical technologists for drawing blood and obtaining and recording 
vital signs.

    Do not put LPN's in medical technologist positions or fail to 
recognize their training prepares them to do more than most facilities 
are allowing (the problem is that there appears to be an emphasis on 
hiring more highly paid RN's and not using less expensive LPN's who can 
do most of what an out-patient office requires of nurses). Encourage 
the RN's to do more patient-oriented services, such as patient 
education.

    18. Encourage providers to attend outside the VA medical education 
courses to learn the most up-to-date practices:

    a. Provide ample education funds sufficient to attend at least one 
extensive medical review course per year (currently the VA only pays 
$1000 per provider per year, which is a fraction of what non-VA 
providers are offered and does not cover the cost of a decent course).

    b. Take the funding from the reported lavish junkets the 
administrators have sent themselves on in recent years and subsidize 
education, which will ultimately benefit veterans.

    19. Eliminate waste at all levels. For example:

    a. VSN administrator being paid a $63,000 bonus for quality care 
when the facility had a Legionnaire's outbreak.

    b. The Department of Veterans Affairs purchased pictures to spend 
leftover fiscal year dollars for $562,000 (per the Washington Post)when 
the veterans themselves would gladly have contributed veteran-made 
artwork for free (Washington Post).

    c. One facility purchased about 8 large flat-screen new televisions 
that were hung in the cafeteria which were not used as TV's but to 
flash a display of photos scanned repetitively, which supposedly were 
designed to calm the staff.

    d. Eliminate blocking out an hour each week for an entire staff 
meeting, which takes providers away from patient care, and 
inefficiently transmitting information that could be passed-on by e-
mail memos.

    e. Eliminate indiscriminate purchase of expensive tele-health 
monitoring equipment which appears to be a priority over basic 
essentials such as decent suture removal kits, cerumen removal 
supplies, glucometers, point of care INR testing devices, minor 
surgical equipment, and liquid nitrogen.

    f. One facility purchased off-brand wall mounted otoscopes for 
their new office (which likely were deemed more cost-effective by a 
bean-counter), but failed to realize that the standard otoscope tips 
don't fit the cheap knock-offs. To use them, the provider has to 
perform an exercise in finger dexterity, which slows the examination 
process.

    g. One New Jersey new CBOC facility was supposed to have a 
temperature-controlled room to store medications (which was never set-
up as planned). Consequently, when temperatures soared in the office 
above the safe level, several thousand dollars' worth of medications 
had to be destroyed. When the nurse manager returned these to the 
pharmacy, a non-clinical administrative worker (with no medical 
training) berated the nurse for doing her job and attempting to prevent 
veterans from being given compromised medications.

    h. Employees from multiple facilities complain about the 
inefficient and wasteful system for obtaining ID badges. This usually 
amounts to each employee making multiple trips to the VSN headquarters 
(aka the `mother ship') information technology (IT) department when 
getting an ID badge. These appointments are tightly controlled by the 
IT staff, who make appointments for their convenience and not 
necessarily the convenience or needs of employees.

    Furthermore, often the system is ``down'', or if working, it can 
take hours of waiting to print one ID card. This process occurs after 
the employee is again finger printed (if it has been more than 3-6 
months since the last badge was issued) - another time-consuming and 
expensive proposition). Several employees report driving 4-5 hours one-
way from their CBOC (Community Based Out-Patient Clinic) only to be 
told they must return again and again-some as often as 5 times to 
obtain the sacred ``PIV'' ID badge. This badge designed is to travel 
with the employee from facility to facility, yet the various IT 
departments inappropriately inactivate the badges. This can become a 
costly process. For example, for each of the 70 doctors and extended 
care providers now in the VA Interim Staffing locums department, that 
means with each of 3-4 assignments per year there is a good likelihood 
that this process of wasted work days and IT employee hours will be 
repeated over and over again at a cost not even factored in to the 
scheme of things. No one is counting lost productivity, the cost of 
travel back and forth, and how this contributes to waste and 
interruption of care.

    Curiously, this inept system has found me going to five different 
IT departments, making several trips at each facility resulting in a 
significant amount of time away from treating veterans.

    This also means that five times I've been fingerprinted and my 
fingerprints run through the FBI system (or whoever checks our status). 
At what cost is this?

    Does anyone do anything? Does anyone care?

    i. Another gross waste is the time and money spent by each VA 
facility's credentialing department. Of the now seventy physicians 
(previously ninety) who are part of the VA traveling physician corps 
(now called VA Interim Staffing), each physician has to be ``re-
credentialed'' for each VA assignment. If each physician does three 
assignments per year that is 210 times per year references have to be 
contacted, 210 times per year the National Practitioner Data Bank is 
queried (not an insignificant cost for each query), and 210 times a 
huge number of staff have to track down the same information (all 
physicians and extended care providers) are initially credentialed upon 
hire).

    The simple solution is for the VA Central Office (VACO) to issue a 
mandate that physicians or other `providers' employed by the VA can be 
credentialed on a temporary basis at a facility that has an emergency 
need for staffing based on credentials from the parent facility. This 
loss of money had been going on during the over four years of this 
program's existence in spite of numerous complaints by providers.

    20. Make it easier to remove employees who are consistently not 
performing according to job standards.

    a. Do not allow the practice of moving administrators around the VA 
system, relocating them in a secret ``shell game'' to other VSN's 
(divisions)when performance has come into question.

    b. Do not allow investigations to drag on through committee inertia 
or inability to take a stand on cases of abuse, or fraud.

    One noteworthy case in New England involved a physician assistant 
accused of fraudulent medical records, poor work ethic, failure 
physically examine patients, and failure to monitor narcotics (some of 
the reported charges). At last report, the investigation was now into 
at least the 8th month, while the provider received full pay while on 
administrative leave (and reportedly also working in an ER at a local 
hospital outside the VA).

    21. The VA is experiencing shortages of provider, which is at the 
core of the problems surrounding the VA, yet a program that was helping 
short-staffed facilities is in serious jeopardy.

    a. The VA has its own corps of traveling physicians (some PA's), 
initially a great idea for getting temporary emergency medical coverage 
for VA facilities that needed providers to help deliver medical care to 
veterans who would otherwise go untreated.

    b. Now due to micromanaging by the upper echelon and an emphasis on 
cost containment, the number of providers dropped from 90 to about 70, 
the focus is on cost-cutting, and the program now hires only part-time 
people who do not get benefits.

    c. The VA Intermin Staffing Program now charges facilities, so 
there was a dramatic drop in the number of facilities requesting a VA 
locums provider (from well over a hundred facilities to about twenty).

    d. So what happens to the vets because facilities do not have it 
budgeted to supply providers when short-staffed? They don't get care, 
or they are shuffled to another on-staff provider who already doesn't 
have the time to manage his/her panel. This contributes to the problem 
with failure to adequately manage pain medications.

    e. What does the VACO offer as a solution to our program? Of 
course, hire another supervisor, an expensive Director of the VA 
Intermin Staffing Program. Great credentials, but did he ever do locums 
work? The program can't afford to keep trained, readily available 
physicians on their payroll, but they can add another layer of 
administration. A s I mentioned previously, the system is far too top 
heavy and bogged down with committees that govern committees, and rules 
that sustain committees.
God Save Our Veterans! Apparently, no one else can.

                                 
            Prepared Statement of Dr. Steven G. Scott, M.D.
    Good morning, Chairman Benishek, Ranking Member Brownley and 
Members of the Committee. Thank you for the opportunity to participate 
in this oversight hearing and to discuss specifically the Department of 
Veterans Affairs' (VA) James A. Haley Veterans' Hospital's Chronic Pain 
Rehabilitation Program (CPRP) that treats Veterans experiencing acute 
and chronic pain.
    For many individuals, chronic pain is much more than a lingering 
medical problem. It is instead a pervasive, unrelenting, and serious 
condition that affects every area of an individual's life including 
their mental health, physical health, family life, vocation, 
friendships, and even sleep. For these individuals, chronic pain is an 
unending daily battle where pain assumes command. Even the most 
rudimentary daily decisions - whether to go shopping; attend a medical 
appointment; see a friend - are based not on the individual's 
preferences, but instead on their level of pain. We call this 
constellation of pain related problems a ``Chronic Pain Syndrome'' or 
CPS. Estimates are that more than 25 percent of adults with chronic 
pain also have symptoms of CPS, and while pain may have been the cause 
of these problems, there is evidence that once established, these 
related problems linger even if the underlying pain is substantially 
reduced.
    Unfortunately, many individuals with CPS attempt to fight these 
problems using increasing amounts of opioid analgesics. But, these 
efforts are rarely successful. Due to the complexity of CPS, no single 
treatment approach is the answer. A multi-disciplinary and multi-
modality approach is almost always necessary.
CHRONIC PAIN REHABILITIATION PROGRAM OVERVIEW
    The James A. Haley Veterans' Hospital and Clinics in Tampa, Florida 
have both an inpatient and outpatient Chronic Pain Rehabilitation 
Program (CPRP). The Haley Veterans' Hospital has the only VA inpatient 
CPRP. The CPRP was designed to specifically treat Veterans and active 
duty military personnel with chronic pain syndrome (CPS). The CPRP is 
an evidence-based, intensive, interdisciplinary, 19-day inpatient 
chronic pain treatment program that targets not only pain intensity, 
but also all of the accompanying symptoms of CPS. The core philosophy 
of the CPRP recognizes the complex interactions between 
pathophysiological, emotional, social, perceptual, cultural, and 
situational components of chronic pain.
    The CPRP teaches pain self-management practices where participants 
assume responsibility for their daily functioning and learn to actively 
manage their pain. For most participants this includes increasing their 
level of independent functioning, increasing activity levels, reducing 
the emotional distress associated with chronic pain, eliminating 
reliance on opioid analgesics and/or muscle relaxants, reducing pain 
intensity, improving marital, familial and social relationships, 
increasing vocational and recreational opportunities, and improving 
overall quality of life.
    One of the unique aspects of the program is that all participants 
taking opioid analgesics at admission are tapered off these medications 
during the course of treatment. This practice began in 1988 when CPRP 
was established, and continues today. We do this because opioids 
essentially have no positive effects for this group of patients. 
Eliminating opioids for this group of individuals does not increase 
their pain nor increase their daily impairment. In fact, we have found 
that eliminating opioid reliance has virtually no effect on treatment 
outcomes. Individuals who discontinue these medications during 
treatment improve, as much or more than those who were not using opioid 
analgesics at admission \1\.
---------------------------------------------------------------------------
    \1\ Murphy J, Clark M, Banou E,. Opioid Cessation and 
Multidimensional Outcomes After Interdisciplinary Chronic Pain 
Treatment. Clin J Pain 2013;29:109-117.
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CPRP TREATMENT COMPONENTS
    The CPRP uses a variety of strategies to enhance self-management 
skills, increase activity, and reduce pain. These include daily goal-
directed programs of individualized exercises, walking, pool therapy, 
occupational therapy, relaxation training, medical management, 
recreational therapy, and educational classes. Much of the skill 
enhancement and self-management training is provided by pain 
psychologists who serve as rehabilitation coaches and use individual 
cognitive and behavioral therapy techniques to reduce emotional 
distress, encourage self-reliance, enhance pain management skills and 
promote healthy lifestyles. Family members are involved in treatment 
when available and prior to discharge participants develop a plan of 
continued rehabilitation that can be implemented at home.
    The typical participant in the CPRP is a male or female Veteran in 
their late 40s who has been fighting pain constantly for the last 15 
years on average. They have tried virtually every known treatment, 
ranging from surgery to multiple medications or injections, and out of 
desperation may have become victims of a variety of pseudo treatments 
promising total pain relief at substantial individual cost. They are 
depressed, irritable, anxious and often angry with the medical 
establishment that they feel has failed them. Marital and family 
problems abound, separation or divorce is common, and friendships have 
dissolved. Typically they are unemployed or disabled and face a variety 
of financial challenges or crises. Many may misuse prescribed 
medications, alcohol, or other substances to try to cope. Although this 
cycle began with a single distinct pain, they now experience multiple 
pain problems many of which can develop or intensify due to their 
sedentary lifestyle and prolonged stress.
    These same individuals, when offered hope, compassionate treatment, 
and the camaraderie of others in similar circumstances typically 
demonstrate remarkable improvements and resiliency during this 19-day 
inpatient program. When we used standardized measures to asses these 
changes, we see the following outcomes: reductions in pain severity, 
improvements in mood and sleep; increased strength, flexibility, and 
endurance; enhanced engagement with life and families; significant 
weight loss; and, increased confidence in their abilities to manage 
their lives despite elimination of opioid analgesics and other 
potentially harmful medications. \2\ What we find after this treatment 
are individuals who are now laughing instead of frowning, seeking out 
contact with others instead of avoiding, and who are proud about their 
accomplishments. It is not rare to observe individuals who entered the 
program reliant on wheelchairs, walk out the door unaided at discharge.
---------------------------------------------------------------------------
    \2\ Murphy J, et al (2013).
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CPRP RECOGNITION
    In the CPRP's 25 years of existence, the program and its staff have 
received numerous accolades and awards. The CPRP has been recognized as 
a two-time Clinical Center of Excellence by the American Pain Society. 
The CPRP is one of only two programs that has twice won this 
prestigious award, the other being a program at Stanford University. 
The program has also received the prestigious Secretary of Veterans 
Affairs Olin E. Teague Award for clinical excellence and been 
accredited six times by the Commission on Accreditation of 
Rehabilitation Facilities (CARF). CPRP leaders have been actively 
involved in promoting system-wide enhancements in VA pain care, 
particularly for Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn Veterans suffering from chronic pain in combination 
with other significant physical and emotional co-morbidities. As the 
most specialized chronic inpatient pain treatment option in the VA 
health care system, the program accepts referrals from all 50 states, 
Puerto Rico and the US Virgin Islands.
    In 2009, the CPRP was selected to serve as the VA's national 
training site for interdisciplinary pain programs. Thirty teams from 
across the country have visited the James A. Haley Veterans' Hospital 
to observe the model system and learn how to enhance pain treatment 
services at their facilities. The training program has focused on 
helping these teams develop tertiary level, CARF-accredited pain 
programs in order to help meet the 2009 Veterans Health Administration 
Pain Management Directive 2009-053 mandating an interdisciplinary CARF 
option in each Veterans Integrated Support Network. The positive 
effects of these trainings are manifest by the increase from 2 CARF-
accredited programs in 2009, both in the same VISN, to 8 CARF 
accredited programs in the VHA in 2013; 14 other VHA facilities are 
presently applying for CARF accreditation for a developed program or in 
the process of developing a CPRP with the intention of applying for 
CARF accreditation.
Conclusion
    Mr. Chairman, VA is committed to providing the high quality of care 
that our Veterans have earned and deserve. I appreciate the opportunity 
to appear before you today to discuss the James A. Haley Veterans' 
Hospital's Chronic Pain Rehabilitation Program, and I am grateful for 
your support and encouragement in identifying and resolving challenges 
as we find new ways to care for Veterans. I am prepared to respond to 
any questions you may have.

                                 
            Prepared Statement of Dr. Robert L. Jesse, M.D.
    Good morning, Chairman Benishek, Ranking Member Brownley and 
Members of the Committee. Thank you for the opportunity to participate 
in this oversight hearing and to discuss the Department of Veterans 
Affairs' (VA) pain management programs and the use of medications, 
particularly opioids, to treat Veterans experiencing acute and chronic 
pain. I am accompanied today by Dr. Robert Kerns, VA National Director 
for Pain Research, Veterans Health Administration.
    The issues related to pain and pain management are by no means 
exclusive to VA. As described in the 2011 Institute of Medicine (IOM) 
report, ``Relieving Pain in America: A Blueprint for Transforming 
Prevention, Care, Education, and Research'' \1\, pain is a public 
health challenge that affects millions of Americans and is rising in 
prevalence. Pain contributes to national rates of morbidity, mortality, 
and disability and there are costs of pain both on the toll it takes on 
people's lives and economically. The IOM estimated that chronic pain 
alone affects 100 million United States citizens and that the cost of 
pain in the United States is at least $560-635 billion each year, which 
is the combined cost of lost productivity and the incremental cost of 
healthcare.
---------------------------------------------------------------------------
    \1\ Institute of Medicine. 2011. Relieving Pain in America: A 
Blueprint for Transforming Pain Prevention, Care, Education and 
Research. Washington, D.C.: The National Academies Press.
---------------------------------------------------------------------------
    Studies show more than 50 percent of all Veterans enrolled and 
receiving care at VHA are affected by chronic pain, which is a much 
higher rate than in the general adult population. That makes pain 
management a very important clinical issue for VA. My testimony today 
will focus on how VA is providing comprehensive and patient-centered 
pain management services to improve the health of Veterans. The 
statement will highlight VA's current pain management strategies, the 
prevalence and use of opioid therapy to manage chronic pain in high 
risk veterans, the challenges of prescription drug diversion \2\ and 
abuse among Veterans, and the actions VA is taking to improve the 
management of chronic pain, including the safe use of opioid 
analgesics, and the use of best practices across the VA health care 
system.
---------------------------------------------------------------------------
    \2\ Diversion is the use of prescription drugs for recreational 
purposes.
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Prescription Drug Diversion and Abuse Challenges
    Opioid analgesics may help many patients manage their severe pain 
when other medications and modalities are ineffective or are only 
partially effective. However, there may be risks to both individual 
patients as well as to the surrounding community when these agents are 
not prescribed or used appropriately. VA has embarked on a two pronged 
approach to addressing the challenge of prescription drug diversion and 
abuse among Veteran patients.
    One approach is to improve the education and training in pain 
management and safe opioid prescribing for clinicians and the 
interdisciplinary teams that provide pain management care for Veterans. 
A complementary approach involves improving risk management through two 
systems initiatives. The first system initiative, the Opioid Safety 
Initiative, employs the tremendous advantages of VHA's electronic 
health record. This system-wide initiative identifies patients with one 
or a combination of risk factors, for example, high doses of opioids 
and opioids combined with sedatives to identify providers whose 
prescribing practices are misaligned with medical evidence/strong 
practices and to provide counseling, education and support for them to 
improve their care of Veterans with pain.
    The second system-wide risk management approach to support the 
Veterans' and public's safety is promulgation of new regulations that 
enable VHA to participate in state Prescription Drug Monitoring 
Programs (PDMP). These programs, featuring appropriate health privacy 
protections, allow for the interaction between VA and state databases, 
so that providers in either can view electronic information about 
opioid prescriptions and be able to identify potentially vulnerable at-
risk individuals. PDMPs can provide information to VA on prescribing 
and dispensing of controlled substances to Veterans outside the VA 
health care system. Participation in PDMPs will enable providers to 
identify patients who have received non-VA prescriptions for controlled 
substances, which in turn offers greater opportunity to discuss the 
effectiveness of these non-VA prescriptions in treating their pain or 
symptoms. More importantly, information that can be gathered through 
these programs will help both VA and private providers to prevent harm 
to patients that could occur if the provider was unaware that a 
controlled substance medication had been prescribed elsewhere already.
Current VA Pain Management Strategies
Chronic Pain in Veterans
    The burden of pain on the Veteran population is considerable. We 
know that Veterans have much higher rates of chronic pain than the 
general population. \3\ Chronic pain is the most common medical problem 
in Veterans returning from the last decade of conflict (almost 60 
percent). \4\ Many of these Veterans have survived serious, even 
extreme, injuries often associated with road-side bombs and other blast 
injuries. These events can cause damage to multiple bodily sites 
including amputations and spinal cord injuries. These Veterans also 
survived severe psychological trauma associated with exposure to the 
horrors of war on the battlefield. Many Veterans require a combination 
of strategies for the effective management of pain, including treatment 
with opioid analgesics, which are known to be effective for at least 
partially relieving pain caused by many different medical conditions 
and injuries. In 2010, VA and the Department of Defense (DoD) published 
evidence-based Clinical Practice Guidelines for the use of chronic 
opioid therapy in chronic pain. The guidelines reserve the use of 
chronic opioids for patients with moderate to severe pain who have not 
responded to, or responded only partially to, clinically indicated, 
evidence-based pain management strategies of lower risk, and who also 
may benefit from a trial of opioids to improve pain control in the 
service of improving function and quality of life.
---------------------------------------------------------------------------
    \3\ Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L. 
(2006). Pain among veterans of Operations Enduring Freedom and Iraqi 
Freedom. Pain Medicine, 7, 339-343.
    \4\ Veterans Health Administration (2013). Analysis of VA health 
care utilization among Operation Enduring Freedom (OEF), Operation 
Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. Washington, 
DC: Department of Veterans Affairs.
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    We also know that the long-term use of opioids is associated with 
significant risks, particularly in vulnerable individuals, such as 
Veterans with Post-Traumatic Stress Disorder (PTSD), depression, 
Traumatic Brain Injury (TBI) and family stress - all common in Veterans 
returning from the battlefield, and in Veterans with addiction 
disorders. Chronic pain in Veterans is often accompanied by co-morbid 
mental health conditions (up to 50 percent in some cohorts) caused by 
the psychological trauma of war, as well as neurological disorders, 
such as TBI caused by blast and concussion injuries. In fact, one study 
documented that more that 40 percent of Veterans admitted to a 
polytrauma unit in VHA suffered all three conditions together - chronic 
pain, PTSD, and post-concussive syndrome. \5\
---------------------------------------------------------------------------
    \5\ Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., & 
Cifu, D.X. (2009). Prevalence of chronic pain, posttraumatic stress 
disorder, and post-concussive syndrome in OEF/OIF veterans: The 
polytrauma clinical triad. Journal of Rehabilitation Research and 
Development, 46, 697-702.
---------------------------------------------------------------------------
    In addition to these newly injured Veterans suffering from chronic 
pain conditions and neuropsychological conditions, VA cares for 
millions of Veterans from earlier conflicts, who along with chronic 
pain and psychological conditions resulting from their earlier war 
injuries, are now developing the many diseases of aging, such as 
cancer, neuropathies, spinal disease, and arthritis, which cause 
chronic, often terrible pain. All these Veterans also deserve 
appropriate pain care, including, when indicated, the safe use of 
opioid analgesics.
    VA cares for a Veteran population that suffers much higher rates of 
chronic pain than the civilian population, and also experiences much 
higher rates of co-morbidities (PTSD, depression, TBI) and 
socioeconomic dynamics (family stress, disability, joblessness) that 
contribute to the complexity and challenges of pain management with 
opioids. \6\ Because more Veterans have the kind of severe and 
disabling pain conditions that require stronger treatments such as 
opioids, more of them have risks for overdose due to depression, PTSD 
and addiction.
---------------------------------------------------------------------------
    \6\ See citations 3 and 4.
---------------------------------------------------------------------------
    In recognition of the seriousness of the impact of chronic pain on 
our Veterans' health and quality of life, VHA was among one of the 
first health systems in the country to establish a strong policy on 
chronic pain management and to implement a system-wide approach to 
addressing the risks of opioid analgesia. Our approach is outlined 
below.
VA National Pain Management Strategy and VHA Pain Management Directive
    As part of the VA's National Pain Management Strategy, \7\ VHA Pain 
Management Directive 2009-053 \8\ was published in October 2009 to 
provide uniform guidelines and procedures for providing pain management 
care. These include standards for pain assessment and treatment, 
including use of opioid therapy when appropriate, for evaluation of 
outcomes and quality of pain management, and for clinician competence 
and expertise in pain management. Since publication of the Pain 
Management Directive, a dissemination and implementation plan has been 
enacted that supports the following:
---------------------------------------------------------------------------
    \7\ The overall objective of the national strategy is to develop a 
comprehensive, multicultural, integrated, system-wide approach pain 
management that reduces pain and suffering and improves quality of life 
for Veterans experiencing acute and chronic pain associated with a wide 
range of injuries and illnesses, including terminal illness.
    \8\ www.va.gov/vhapublications/viewpublication.asp?pub--id=2781

      Comprehensive staffing and training plans for providers 
and staff;
      Comprehensive patient/family education plans to empower 
Veterans in pain management;
      Development of new tools and resources to support the 
pain management strategy, and
      Enhanced efforts to strengthen communication between VA's 
Central Office (VACO) and leadership from facilities \9\ and Veterans 
Integrated Service Networks (VISNs).
---------------------------------------------------------------------------
    \9\ The term ``facilities'' or ``facility'' refers to VA's 151 
medical centers, hospitals, or healthcare systems.

    Following the guidance of the VHA National Pain Management 
Strategy, and in compliance with generally accepted pain management 
standards of care, the Directive provides policy and procedures for the 
improvement of pain management through implementation of the Stepped 
Care Model for Pain Management (SCM-PM), the single standard of pain 
care for VHA, central to ensuring Veterans receive appropriate pain 
management services. The Directive also requires tracking opioid use 
and implementing strong practices in risk management to improve 
Veterans' safety.
    Consistent with this model, a key objective is to expand capacity 
for specialty pain care services. Present data demonstrates an increase 
in this capacity over the past year, continuing this yearly trend since 
data were first analyzed in fiscal year (FY) 2005. Specifically, we 
know that:

      All VISNs are providing dedicated Pain Clinic services 
with dedicated Pain Clinics in about 95 percent of facilities.
      Through the third quarter of FY 2013, VHA provided Pain 
Clinic services to 104,388 unique Veterans (including both inpatient 
and outpatient pain clinic services). Compared to the same time period 
in FY 2012, this represents a 3.6 percent increase in the number of 
Veterans served in these specialty clinics.
      Total Pain Clinic encounters increased to 316,204 through 
the third quarter of FY 2013; up 2.6 percent over this same time period 
in FY 2012.
      Of the 95 percent of facilities with Pain Clinic 
Services, 84 percent have dedicated physician staff through the second 
quarter of FY 2013 (includes all physician specialty areas delivering 
Pain Clinic services by both VHA and In-House Contract Physician 
staff).
      Through the second quarter of FY 2013, 59 percent of 
facilities have physicians who specialize in Pain Medicine, and 44 
percent of physician-delivered services VHA wide are provided by those 
who specialize in Pain Medicine. In the same period, 95 percent of Pain 
Clinic services were provided by VHA physicians, 3 percent by contract, 
and 2 percent by in-house fee physicians.
      Physician pain specialist staffing has increased slightly 
from 113 full-time equivalent employees in FY 2012 to 115 through the 
second quarter of FY 2013.
      The current supply of physicians providing specialty Pain 
Clinic services per 100,000 unique patients, is 1.93, with an average 
of 2.22 support staff per physician (including administrative staff, 
advanced-practice providers, and other clinical staff).
Oversight and Accountability
    Several key responsibilities are articulated in the Pain Management 
Directive. The Directive establishes a National Pain Management Program 
Office (NPMPO) in VACO that has the responsibility for policy 
development, coordination, oversight, and monitoring of VHA's National 
Pain Management Strategy. The Directive further authorizes the 
establishment of a multidisciplinary VHA National Pain Management 
Strategy Coordinating Committee that supports the Program Office in 
achieving its strategic goals and objectives. The Committee is 
comprised of 15 members to include: anesthesiology, employee education, 
geriatrics and extended care, mental health, neurology, nursing, pain 
management, patient education, pharmacy benefits management, primary 
care/internal medicine, quality performance, rehabilitation medicine, 
research, and women Veterans' health.
    The Directive requires VISN Directors to ensure that all facilities 
establish and implement current pain management policies consistent 
with this Directive. VISN and facility pain management points of 
contact serve key roles as links between the NPMPO and VHA health care 
facilities. Facility directors are responsible for ensuring that 
accepted standards of pain care are met. The facilities establish 
multidisciplinary pain management committees to provide oversight, 
coordination, and monitoring of pain management activities and 
processes to facilitate the implementation of VA's Pain Management 
Strategy.
    The NPMPO maintains records of VISN and facility compliance, along 
with other key organizational requirements contained in the Directive. 
All VISNs and facilities have appointed National Pain Office pain 
management points of contact, established multidisciplinary committees, 
and implemented pain management policies as required by the Directive.
Stepped Care Model for Pain Management
    As mentioned earlier, SCM-PM is the single standard of pain care 
for VHA to ensure Veterans receive appropriate pain management 
services. Specifically, SCM-PM provides for assessment and management 
of pain conditions in the primary care setting. This is supported by 
timely access to secondary consultation from pain medicine, behavioral 
health, physical medicine and rehabilitation, specialty consultation, 
and care by coordination with palliative care, tertiary care, advanced 
diagnostic and medical management, and rehabilitation services for 
complex cases involving co-morbidities such as mental health disorders 
and TBI.
    In FY 2012, VHA made several important investments in implementing 
the SCM-PM. Major transformational initiatives support the objectives 
of building capacity for enhanced pain management in the primary care 
setting, including education of Veterans and caregivers in self-
management, as well as promoting equitable and timely access to 
specialty pain care services.
    There are other important efforts contributing to the 
implementation of SCM-PM in VHA facilities. Current initiatives focus 
on empowering Veterans in their pain management, and expanding capacity 
for Veterans to receive evidence-based psychological services as a 
component of a comprehensive and integrated plan for pain management. 
For example, during FY 2012, the VHA National Telemental Health Center 
expanded its capacity to deliver face-to-face, psychological services 
to Veterans remotely via high-speed videoconferencing links. This 
initiative not only emphasizes the delivery of cognitive behavior 
therapy for Veterans with chronic pain, but also promotes pain self-
management, leading to reductions in pain and improvements in physical 
functioning and emotional well being.
    Additionally, a Primary Care and Pain Management Task Force is 
developing a comprehensive strategic and tactical plan for promoting 
full implementation of the SCM-PM in the Primary Care setting, and it 
continues to work on several products in support of this effort. For 
instance, the Task Force is continuing to expand its network of 
facility- level Primary Care Pain Management points of contact (Pain 
Champions) who meet monthly, via teleconference, to identity and share 
strong practices that have led to improved pain care in primary care 
settings.
    VA's pain management initiatives are designed to optimize timely 
sharing of new policies and guidance related to pain management 
standards of care. Of particular importance are VHA's continuing 
efforts to promote safe and effective use of opioid therapy for pain 
management, particularly those initiatives designed to mitigate risk 
for prescription pain medication misuse, abuse, addiction, and 
diversion.
    Created in 2011, VA's Specialty Care Access Network-Extension of 
Community Healthcare Outcome (SCAN-ECHO) initiative allows pain 
specialists to train primary care providers in community based 
outpatient clinics (CBOCs) closer to Veterans' homes, particularly in 
rural and underserved geographic areas. Benefits of this program 
include reduced travel costs, improved quality of care, and increased 
provider and Veteran satisfaction. Multiple modules are available on 
VA's on-line Talent Management System (TMS), based on VA/DoD pain 
guidelines and approved for continuing education credits for 
physicians, nurses, pharmacists, and psychologists, thereby ensuring a 
standardized level of knowledge across pain care delivery. This 
initiative supports the implementation and evaluation of seven pain 
SCAN-ECHO regional training hubs. Each hub, designed to provide support 
for up to twenty Patient-Aligned Care Teams (PACT), is staffed by 
experts in pain management, and linked by real-time videoconferencing 
to PACT teams away from the medical center.
    VHA has also implemented the Consult Management initiative, which 
uses E-Consults and phone consults, to change how specialty care 
services are delivered throughout VHA. E-Consult provides clinical 
support from provider to provider. E-Consult is an alternative to face-
to-face visits, and is expected to improve access, communication, and 
coordination of care. Through a formal consult request, a provider 
requests a specialist to address a clinical problem or to answer a 
clinical question for a specific patient. Using information provided in 
the consult request and/or review of the patient's electronic health 
record (EHR), the consultant provides a documented response that 
addresses the request without a face-to-face visit. This method of 
consultation supports patient-centric care, reduces the burden of 
travel for the Veteran, and reduces overall travel and non-VA costs.
    A particularly exciting initiative in its pilot phase of 
development is the pain management application for smart phones that 
will be used by Veterans and their care partners to develop pain self-
management skills. This tool, called VA Pain Coach, will eventually 
interface with VHA's EHR, with appropriate privacy protections in a 
secure mobile application environment, allowing Veteran-reported 
information about pain, functioning, and other key elements to be 
securely stored and accessible to clinicians. VA Pain Coach, which is 
part of a suite of VA applications called ``Clinic in Hand'', is in the 
third month of a one-year pilot test with 1150 Operation Enduring 
Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their 
caregivers. In the future, a complementary initiative will build a 
clinician-facing application that will enhance the capacity of 
clinicians and Veterans to share in monitoring, decision making, 
treatment planning, and reassessment of pain management interventions.
    VHA continues to work to strengthen its ability to meet the pain 
management needs of Veterans with complex chronic pain conditions with 
co-morbidities. Of particular importance are continued efforts to 
promote access to integrated care services for Veterans experiencing 
chronic pain and symptoms of PTSD, mild TBI, sleep disorders, and other 
common co-morbid conditions. In partnership with VHA's Mental Health 
Services, the ongoing Evidence-Based Psychotherapy initiative has been 
expanded to include an initiative on cognitive behavior therapy for 
chronic pain.
    VHA's NPMPO also partners with Primary Care Services in support of 
its Post-Deployment Integrative Care Initiative. This field-based 
initiative, developed in 2008, supports integrated care clinical 
platforms for providing post-deployment services in VAMCs nationally. 
An example of this initiative is the PACT-based collaborative for post-
deployment pain care. This initiative focuses on PACT and pain 
specialists in interdisciplinary collaborative care based on the Step 
Care Model of pain management. An additional monthly community of 
practice discussion, as well as a monthly call for a network of PACT 
Primary Care Pain Champions, were recently added focusing specifically 
on pain care in PACT settings to further the implementation of good 
pain care and rational opioid use.
    VHA's capacity to provide Veterans with equitable access to 
specialty care services is strengthened by integrating other services 
important for pain management. For example, a partnership with 
Rehabilitation Services plans to build capacity for rehabilitation 
medicine services, including chiropractic services. Recently, the NPMPO 
contributed to a national educational conference, focusing on 
rehabilitation services, to promote models of integrated care that 
emphasize the role of rehabilitation specialists for pain management.
    Further, the NPMPO continues to partner with Women Health Services 
to develop a strategic plan that will strengthen the capacity for women 
Veteran centered pain management services. In April 2012, VHA sponsored 
a Women's Health National audio conference on pain management for Women 
Veterans.
    The NPMPO also partners with Pharmacy Benefits Management Services 
(PBM) and others in development of a comprehensive approach to promote 
the safe and effective use of long-term opioid therapy for Veterans. Of 
particular note was the promulgation of regulations permitting VA to 
participate with a growing number of states that have state 
Prescription Drug Monitoring Programs (PDMP). Thus, following state 
laws, VA providers can query PDMP databases about prescriptions from 
providers outside the VA, and can respond to queries from outside the 
VA about Veterans receiving controlled medications from the VA, leading 
to better communications with Veterans and all their caregivers about 
safe practices. The NPMPO also collaborates with PBM on the Opioid 
Safety Initiative which involves providing facility feedback on 
provider prescribing and facility utilization of opioids. This program 
was piloted in 4 VISNs and was implemented system-wide in August and 
September 2013.
VHA Pain Management Centers
    The Under Secretary for Health chartered an Interdisciplinary Pain 
Management Center Work Group to provide guidance and oversight for 
VHA's efforts to develop VISN level tertiary care Pain Management 
Centers. These Centers have the capacity for providing advanced pain 
medicine diagnostics, surgical and interventional procedures, 
subspecialty pain care, and intensive, integrated chronic pain 
rehabilitation for Veterans with complex, co-morbid, or treatment 
refractory conditions. There are currently nine Commission for the 
Accreditation of Healthcare Facilities, or CARF, accredited pain 
rehabilitation centers in VHA. This includes one Center at the James 
Haley Veterans Hospital in Tampa, which is one of only two 
multidisciplinary pain management centers to be twice recognized by the 
American Pain Society as a Clinical Center of Excellence. The other is 
a program at Stanford University.
    Finally, the DoD-VA Health Executive Council (HEC) Pain Management 
Work Group (PMWG) was chartered to develop a model system of 
integrated, timely, continuous, and expert pain management for 
Servicemembers and Veterans. The Work Group participates in VA/DoD 
Joint Strategic Planning (JSP) process to develop and implement the 
strategies and performance measures, as outlined in the JSP guidance, 
and shares responsibility in fostering increased communication 
regarding functional area between Departments. The Group also 
identifies and assesses further opportunities for the coordination and 
sharing of health related services and resource between the 
Departments. A key development is the HEC PMWG's sponsoring of two 
Joint Incentive Fund projects to improve Veterans' and Servicemembers' 
access to competent pain care in the SCM-PM: the Joint Pain and 
Education Project (JPEP), and the ``Tiered Acupuncture Training Across 
Clinical Settings'' (ATACS) projects. The latter project, ATACS, 
represents VHA's initiative to make evidence-based complementary and 
alternative medicine therapies widely available to our Veterans 
throughout VHA. A VHA and DoD network of medical acupuncturists are 
being identified and trained in Battlefield (auricular) Acupuncture by 
regional training conferences organized jointly by VHA and DoD. The 
goal of the project is for them to return to their facilities and VISNs 
with the skills to train local providers in Battlefield Acupuncture, 
which has been used successfully in DoD front-line clinics around the 
world. This initiative will provide Veterans with a wider array of pain 
management choices when they present with chronic pain.
Prevalence and Use of Opioid Therapy for the Management of Chronic Pain 
        in Veterans
    To monitor the use of opioids by patients in the VA health care 
system, VA tracks multi-drug therapy for pain in patients receiving 
chronic or long-acting opioid therapy for safety and effectiveness. 
This includes tracking of use of guideline recommended medications for 
chronic pain (i.e., certain anticonvulsants, tricyclic antidepressants 
(TCA), and serotonin and norepinephrine reuptake inhibitors (SNRI) 
which have been shown to be effective for treatment of some chronic 
pain conditions), and tracking of concurrent prescribing of opioids and 
certain sedative medications (e.g., benzodiazepines and barbiturates) 
which can contribute to oversedation and overdose risk when taken with 
opioids and the other medications for pain listed above.
    The prevalence of Veterans using opioids has been measured for 
Veterans using VHA health care services. For FY 2012, of the 5,779,668 
patients seen in VA, 433,136 (7.5 percent) received prescriptions for 
more than 90 days supply of short acting opioid medications and 92,297 
(1.6 percent) received at least one prescription for a long-acting 
opioid medication in the year. Thus, since chronic pain is the most 
common condition in all Veterans enrolled in VHA, more than 50 percent, 
a relatively small percentage of those Veterans are receiving opioid 
therapy, consistent with the DoD-VA Clinical Practice Guidelines which 
limit their use to patients with moderate to severe persistent pain 
that has not responded to other safer alternatives that are clinically 
appropriate. Of these 525,433 patients that received chronic or long-
acting opioid therapy, 79,025 (15 percent) were also prescribed a TCA, 
90,066 (17 percent) were also prescribed an SNRI, and 178,361 (34 
percent) were also prescribed an anticonvulsant some time in FY 2012.
    The co-prescription of TCAs and/or SNRIs with opioids is first line 
therapy for the more severe cases of pain related to nerve damage from 
disease (e.g., diabetes, cancer) or from injuries (e.g., battlefield 
blast and projectile injuries with or without limb amputation and 
spinal cord injury). The numbers above suggest that clinical teams are 
using medically indicated combinations of medications that are 
specifically needed for these more severe conditions, which themselves 
are often co-morbid with musculoskeletal pain such as injuries to 
joints, spine and muscles. Of note, these prescriptions may or may not 
have overlapped with the opioid prescription during the year.
    In FY 2012, 193,644 (37 percent) of the patients prescribed chronic 
or long-acting opioid therapy received an overlapping prescription for 
a sedative medication. Notably, 272,719 (52 percent) of patients on 
chronic or long-acting opioid therapy also received non-medication-
based rehabilitative treatments as part of their treatment plan (e.g., 
physical therapy (32 percent), chiropractic care (1 percent), programs 
to encourage physical activity (9 percent) or occupational therapy (17 
percent), and 241,465 (46 percent) also received behavioral or 
psychosocial treatment for chronic pain or co-morbid mental health 
conditions.
    These data, showing the use of non-medication treatments, suggest 
that Veterans are benefitting from VHA's efforts to create access to 
additional pain treatment modalities besides medication. This is 
consistent with VA's commitment to transform pain care to a 
biopsychosocial model \10\ that addresses all the factors that by 
research are demonstrated to affect Veterans' success in chronic pain 
treatment. Pursuant to this aim, a multi-modality, team-based, stepped 
care model, per VHA Directive 2009-053, is being implemented widely 
throughout VHA, and in coordination with DoD.
---------------------------------------------------------------------------
    \10\ The Biopsychosocial Model takes the position that the causes 
and outcomes of many illnesses often involve the interaction of 
physical and pathophysiologic factors, psychological traits and states, 
and social-environmental factors. Effective treatment planning accounts 
for the salience of these factors in the precipitation and perpetuation 
of illness and illness-related disability.
---------------------------------------------------------------------------
Improving Chronic Pain Management and Use of Best Practices in VHA
    The strategies outlined earlier regarding VHA Pain Management 
Directive were developed and are being implemented to improve pain 
management outcomes for our patients. To achieve successful 
transformation of pain care in VHA several strategic goals must be met.
Health Care Provider Education and Training
    First, as recognized by the IOM in its extensive 2011 review, 
``Pain in America'' and the American Medical Association in its 2010 
Report on Pain Medicine \11\, and as articulated in VHA's Pain 
Management Directive in 2009-053, a formal commitment to pain 
management education and training for students and trainees in all 
clinical disciplines is required. For example, VHA, which provides 
training for a large proportion of medical students and residents, has 
the opportunity to establish a system-wide requirement for education 
and training of physicians in pain management, as recommended in the 
Directive.
---------------------------------------------------------------------------
    \11\ Lippe PM, Brock C, David JJ, Crossno R, Gitlow S. The First 
National Pain Medicine Summit - Final Summary Report. Pain Med 
2010;11(10):1447-68.
---------------------------------------------------------------------------
    The Joint Pain and Education Project, JPEP, mentioned earlier, has 
proposed training faculty in all VA training sites to pursue the 
implementation of such a curriculum, so that new generations of 
providers and other clinicians will themselves become the new teachers 
of good pain care. JPEP will target all levels of learner: the Veteran 
and his/her family and caregiver; the public; clinicians from all 
disciplines; specific providers and clinicians in practicing at each 
level of the SCM-PM: primary care, pain medicine specialty care, and 
other specialty care. VA is providing national leadership in developing 
interdisciplinary and discipline-specific competencies for pain 
management, in developing a system-wide approach to trainings, and in 
providing leadership roles in national projects to improve pain 
education and training.
Outcomes and Best Practices
    In summary, there is growing evidence of the successful 
implementation of a Stepped Care Model for Pain Management in VHA. 
Importantly, Veterans receiving long term opioid therapy for management 
of chronic pain are increasingly likely to be receiving this therapy in 
the context of multidisciplinary and multimodal care that often 
incorporates physical and occupational therapy and mental health 
services. All VISNs provide specialty pain clinic services, and the 
number of Veterans who receive these services has grown steadily for 
the past five years. Nine facilities now provide CARF accredited pain 
rehabilitation services, a rapid increase in the availability of these 
higher specialized pain rehabilitation services for our most complex 
Veterans with debilitating chronic pain and comorbid mental health 
disorders.
    VA learns from VISN and VA medical centers that are early adopters 
of implementing evidence based guidelines and best practices. The 
Minneapolis VAMC has had great success after their VISN leadership and 
Medical Center leadership organized multi-disciplinary team with pain 
providers, clinical pharmacist, psychologist, psychiatry, patient 
advocates and toxicologists. Interdisciplinary approaches were 
identified to address patients on the higher doses of opioid 
medications. The PACTs were encouraged to offer trials of non-opioid 
care and increase access to behavioral pain management resources as 
alternatives. Patients were assessed frequently to evaluate the trials 
of lower doses of medication and success of non-opioid alternative 
care. After implementing best practices, this medical center saw over a 
fifty percent decrease in the need to prescribe opioids for chronic 
pain management, in higher doses. The facilities' practices were shared 
nationally through educational teleconferences. VA applauds the work by 
this medical center and others like it to progress toward a standard of 
care for safer opioid prescribing
    VA is working aggressively to promote the safe and effective use of 
long-term opioid therapy for Veterans with chronic pain for whom this 
important therapy is indicated. VA's Opioid Safety Initiative holds 
considerable promise for mitigating risk for harms among Veterans 
receiving this therapy, for promoting provider competence in safe 
prescribing of opioids, and in promoting Veteran-centered, evidence-
based, and coordinated multidisciplinary pain care for Veterans with 
chronic pain. Early evidence of success in reducing overall opioid 
prescribing and average dose per day of opioid therapy is encouraging.
    VA also has the opportunity to measure the impact of new policies 
and programs systematically and in a way that enhances the outcomes of 
interdisciplinary pain care for Veterans. VA's Office of Research and 
Development Pain Portfolio for FY 2013 consisted of 82 projects 
relevant to the treatment, diagnosis, and mechanisms underlying painful 
conditions experienced by Veterans, totaling approximately $16.4 
million (an increase of $4.5 million from 2012).
    VA recently funded a new research project that identifies a cohort 
of all Veterans in care in VHA with diagnosed painful musculoskeletal 
disorders. This database provides an important opportunity to examine 
pain care in VHA, including multidisciplinary pain care consistent with 
the SCM-PM, costs of care, and outcomes. VA is currently exploring the 
development of a prospective electronic system for supplementing this 
system by collection of Veteran reported outcomes. VA Pain Coach 
already described may provide an initial secure platform for this 
important initiative. Another opportunity is to partner with our DoD 
and National Institutes of Health colleagues to develop a registry of 
Veterans with painful conditions that can link with a similar system, 
called PASTOR Patient Reported Outcomes Measurement Information System 
(PROMIS), being developed in DoD military treatment facilities.
    In addition to interagency collaborations mentioned earlier, VHA 
pain experts serve on the Interagency Pain Research Coordinating 
Committee (IPRCC). The IPRCC was tasked by the Undersecretary for 
Health at the Department of Health and Human Services to create a 
comprehensive population health-level strategy for pain prevention, 
treatment, management, and research.
    Finally, on February 25, 2013, VHA submitted a notice in the 
Federal Register (FR Doc. 2013-04248) outlining a Pain Public Private 
Collaboration for the development of novel therapies to treat painful 
conditions. The goal is to partner VHA investigators with industry 
sponsors to develop or test new therapies for chronic pain
Conclusion
    Mr. Chairman, we know our work to improve pain management programs 
and the use of medications will never be truly finished. However, we 
are confident that we are building more accessible, safe and effective 
programs and opportunities that will be responsive to the needs of our 
Veterans. We appreciate your support and encouragement in identifying 
and resolving challenges as we find new ways to care for Veterans. VA 
is committed to providing the high quality of care that our Veterans 
have earned and deserve, and we appreciate the opportunity to appear 
before you today. My colleagues and I are prepared to respond to any 
questions you may have.

                                 
                       Statements For The Record
                          THE AMERICAN LEGION
    A CBS News Story \1\ 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).
---------------------------------------------------------------------------
    \1\ http://www.cbsnews.com/8301-18563--162-57603767/veterans-dying-
from-overmedication/
---------------------------------------------------------------------------
    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 \2\ in September 2013.
---------------------------------------------------------------------------
    \2\ http://www.va.gov/oig/pubs/VAOIG-12-01872-258.pdf
---------------------------------------------------------------------------
    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.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Secondly, OEF/OIF veterans with mental health diagnoses \3\ 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 \4\.
---------------------------------------------------------------------------
    \3\ Primarily Posttraumatic Stress Disorder
    \4\ https://jama.jamanetwork.com/
issue.aspx?journalid=67&issueid=22492
---------------------------------------------------------------------------
    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.
    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 \5\ 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.
---------------------------------------------------------------------------
    \5\ Resolution No. 150 Support for Pain Management Research, 
Treatment and Therapies at DOD, VA, and NIH
---------------------------------------------------------------------------
Veteran Testimonials
    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 [email protected].

                                 
                 IRAQ & AFGHANISTAN VETERANS OF AMERICA
    Statement of Jacqueline A. Maffucci, Ph.D., Research Director \1\

    Chairman Benishek, Ranking Member Brownley, and Distinguished 
Members of the Subcommittee:
    On behalf of Iraq and Afghanistan Veterans of America (IAVA), I 
would like to extend our gratitude for being given the opportunity to 
share with you our views and recommendations regarding pain management 
practices, an important issue that affects the lives of thousands of 
service members and veterans.
    IAVA is the nation's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan and their 
supporters. Founded in 2004, our mission is critically important but 
simple - to improve the lives of Iraq and Afghanistan veterans and 
their families. With a steadily growing base of nearly 270,000 members 
and supporters, we strive to help create a society that honors and 
supports veterans of all generations.
    In partnership with other military and veteran service 
organizations, IAVA has worked tirelessly to see that veterans' and 
service members' health concerns are comprehensively addressed by the 
Department of Veterans Affairs (VA) and the Department of Defense 
(DoD). IAVA understands the necessity of integrated, effective, world-
class healthcare for service members and veterans, and we will continue 
to advocate for the development of increased awareness, recognition and 
treatment of service-connected health concerns, chronic pain and pain 
management included.
    According to a 2011 Institute of Medicine report, chronic pain 
affects approximately 100 million American adults. Nationally, the 
number of individuals diagnosed with chronic pain and the number of 
powerful narcotics prescribed to treat pain have increased in the last 
decade. Concurrently, prescription drug abuse is on the rise \2\. The 
CDC has called prescription drug abuse an epidemic in the U.S, and the 
White House has developed a National Drug Control Strategy to address 
the issue \3\. This is a national issue, and one from which our service 
members and veterans are not immune.
    A recent report from the Center for Investigative Reporting found 
that over the last 12 years, there has been a 270 percent increase in 
Veterans Health Administration (VHA) prescriptions for four powerful 
opiates \4\. Given the last 12 years of conflict and the intense 
physical demands on our troops, it is no surprise that over half of the 
OEF/OIF veterans seeking VA medical care report chronic pain, nor is it 
a surprise that the majority of veterans seeking primary care treatment 
from the VA report pain as a major concern \5\.
    Reports presented by the VHA on pain management illustrate the 
scope of pain and pain management practices within the VA and the 
unique potential causes of pain among veterans \5\. For Iraq and 
Afghanistan veterans, improved body armor and medical advancements has 
allowed for higher survival rates, but increased amputations and other 
lifelong impacts of nerve and skeletal damage, coupled with 
musculoskeletal concerns from the weight of wearing heavy body armor, 
highlight a need for successful pain management strategies for veterans 
of these conflicts. In 2012, the second most common reason for 
outpatient clinical visits and the fourth most common reason for 
hospitalization among active duty service members was musculoskeletal 
concerns \6\. With time and age, these injuries will most likely worsen 
\6\. This highlights the importance of comprehensive, integrated pain 
management protocols in military and veteran medical care.
    Pain management is challenging in that pain manifests itself 
differently from patient to patient. Further, assessing pain and 
devising a management strategy can be very difficult, particularly 
given that this is a relatively new area of focus in the clinical 
research field. Related to this, the primary care physicians who see 
the bulk of patients with chronic pain have repeatedly reported that 
they feel underprepared to treat these patients due to a lack of 
training. In a 2013 study specific to VHA, this trend was echoed by the 
VHA providers who were surveyed as well \7\.
    These same providers reported that barriers within VHA kept them 
from feeling prepared to treat chronic pain. These included formulary 
barriers, inability to access state prescription monitoring programs 
(which would allow them to see if patients have previously been 
prescribed controlled medications like opioids), and barriers to 
consulting with experts outside of the VA.
    Chronic pain is also particularly prevalent in polytrauma cases, 
which are among the most complex medical cases to address. Pain often 
presents in consort with other conditions, such as depression, anxiety, 
PTSD, or TBI. Providers can be challenged to treat pain that is 
comorbid with other conditions because of the difficulty of managing 
multiple conditions. Some of these conditions may also limit the drugs 
available to the patient, making treatment options limited.
    These issues constitute major challenges to pain management. 
Certainly part of a treatment program for chronic pain may include 
strong anti-pain medication, including opioids; but a schedule of 
treatment should not be limited to pharmaceutical remedies and should 
integrate a host of other proven therapies. This is why a stepped case 
management system can be very helpful. In this type of system, a 
primary care physician has the support of an integrated, multi-
disciplinary team of providers to design and implement a comprehensive 
pain management plan for the patient.
    The VA and DoD have been relatively proactive in how they approach 
management of chronic pain. Since 2000, VHA has instructed its 
providers to treat pain as the fifth vital sign \8\. Much like heart 
rate and blood pressure, inquiring about and documenting complaints of 
pain has been integrated into the physical exam. VA has also put more 
resources into research to understand pain assessment and treatment. 
And they have partnered with DoD to publish clinical practice 
guidelines and to restructure pain management protocols, recognizing 
that the responsibility for care often falls on the primary care 
physician while specialty support in the form of multidisciplinary pain 
management clinics may be relied upon as well.
    Given the challenging nature of understanding pain, how it 
manifests, and how to best treat it, these have all been laudable 
initiatives on the part of VA and DoD. But the challenge remains to 
uniformly and effectively translate all of these efforts into practice. 
Too often we hear the stories of veterans who are prescribed what seems 
like an assortment of anti-psychotic drugs and/or opioids with very 
little oversight or follow-up. On the flip side, there are also stories 
of veterans with enormous pain and doctors who won't consider their 
requests for stronger medication to manage the pain.
    One IAVA family member has expressed tragic exasperation with 
respect to the VA's current opioid drug usage practices. Her husband, 
who was prescribed nine different medications to address a range of 
health issues related to pain, anxiety, and depression, tragically 
passed away from what was labeled an accidental overdose by the 
coroner. Since then, his widow has been fighting to include 
overmedication by the VA on his death certificate. The VA's response in 
this case has been to blame the widow, saying simply that she was 
trained to be a caregiver. But while she was indeed trained to provide 
care and assistance for her husband, that training did not include 
medication management.
    In a similar case highlighted last month by CBS, a veteran with 
five tours of duty in Iraq and Afghanistan received a treatment plan 
from the VA with a total of eight prescriptions. When he was prescribed 
a ninth drug by the VA, he took the medicine as instructed. The next 
morning he was found by his wife; his death was classified as an 
accidental death due to overmedication.
    It is not our job to second-guess the judgment of the doctors 
treating these patients, but it is our job to question the system that 
is providing overall care to our veterans and tracking this care. It is 
unacceptable to hear repeated stories like these, but they should drive 
us to look at the system as a whole and how it can be fundamentally 
improved.
    In part, some of the challenges may be in the inherent differences 
between the VA and DoD systems of care, whether it be in their 
available formularies, uniformity of record keeping, use of medical 
terminology, or the interoperability, or lack thereof, of the medical 
record systems. Care for our service member and veteran population 
should involve one integrated approach and a successful pain management 
program requires a seamless transition between VA and DoD providers.
    But beyond that, once a veteran is received into the VHA system, 
it's not just about putting out policies, clinical practice guidelines, 
and funding research. At the end of the day, the success will be seen 
in how those products are implemented into practice and how they are 
continually assessed for effectiveness. The key will be in education, 
integration, and assessment.
    We can advance our knowledge of pain and pain management all we 
want, but it won't do our veterans any good if VA cannot efficiently 
and effectively integrate these findings into their management 
practices and have a plan in place to continually improve upon accepted 
practice with evidence-based findings.
    Mr. Chairman, we again appreciate the opportunity to offer our 
views on this important topic and we look forward to continuing to work 
with each of you, your staff, and this subcommittee to improve the 
lives, health, and livelihoods of veterans and their families.
    Thank you for your time and attention.

    1 Dr. Jacqueline Maffucci, IAVA's Research Director, holds a Ph.D. 
in neuroscience from the University of Texas at Austin. She previously 
worked with Army staff and senior leaders to develop, implement, and 
monitor research programs and opportunities to address the health and 
wellness needs of service members.

    2 Institute of Medicine. (2011, June). Relieving pain in America a 
blueprint for transforming prevention, care, education, and research 
[PDF]. Washington, D.C. Retrieved from http://www.iom.edu//media/Files/
Report%20Files/2011/Relieving-Pain-in-America-ABlueprint-for-
Transforming-Prevention-Care-Education Research/
Pain%20Research%202011%20Report%20Brief.pdf

    3 Vital signs: overdoes of prescription opioid pain relievers-
United States, 1999-2008. (2011, November 4). Center for Disease 
Control and Prevention Mobidity and Mortality Weekly Report 60(43). 11-
16. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6043a4.htm?s--cid=mm6043a4--w

    4 Glantz, A. (2013, September 28). VA's opiate overload feeds 
veterans' addictions, overdose death. Center for investigative 
reporting. Retrieved from http://cironline.org/node/5261

    5 Management of opioid therapy for chronic pain. (2010, May). VA/
DOD Clinical Practice Guideline. Retrieved from http://
www.healthquality.va.gov/Chronic--Opioid--Therapy--COT.asp

    6 Hospitalizations among members of the active component, U.S. 
armed forces, 2012. (2013, April). Medical Surveillance Monthly Report 
20(4), 11-23. Retrieved from http://www.afhsc.mil/viewMSMR?file=2013/
v20--n04.pdf

    7 Kerns, R. (2013, February). ``Psychological Treatment of Chronic 
Pain'' [Webinar]. VA Pain Management, Spotlight on Pain Management. 
Retrieved from www.va.gov

    8 Department of Veterans Affairs, Office of Public Affairs. (2011, 
February). VA initiates pain management program [Press Release]. 
Retrieved from http://www.va.gov/opa/pressrel/pressrelease.cfm?id=244

                                 
     NATIONAL ASSOCIATION FOR ALCOHOLISM AND DRUG ABUSE COUNSELORS
   Pain Management Programs and the Use of Opioids to Treat Veterans
    Current evidenced-based practice is supported through research and 
application showing that medication assisted treatment can be an 
effective means of treating individuals with opioid addiction.
    NAADAC, the Association for Addiction Professionals, does not 
discount the significant positive medical uses use of opioids to treat 
pain; however, NAADAC remains deeply concerned by the trend that has 
rendered opioids as the first choice for pain management by doctors. 
Behavioral therapeutic intervention, used in conjunction with 
medication assisted treatment, is far more effective in managing pain, 
as well as treating addiction, in terms of increasing the prospects for 
long-term recovery.
    Given the inherent risk of dependence precipitated by opioids, 
NAADAC fully recommends that all non-opioid treatment options be 
explored before opioids are prescribed. In other words, NAADAC more 
strongly urges and supports the use of other clinical techniques and 
therapeutic interventions before the use of opioid administration for 
pain management.
    Many veterans have been exposed to the use of use of prescription 
medication while serving in Afghanistan and Iraq and other service 
related involvement. In fact, it has been estimated that between 20 - 
25 percent of troops stationed in these war zones have received 
prescriptions for sleep, anxiety, and depression, among some of the 
more prevalent issues being addressed. There is concern that the 
treatment community is creating a pill culture because of the large 
numbers of prescriptions being issued by the Departments of Defense and 
Veterans Affairs. This uptick in prescribed medication will continue to 
cause a higher likelihood of diversion incidences.
    NAADAC would endorse and support a recommendation that all 
prescribers of pain and psychotropic medications be required to receive 
education and training in addictive disorders. This increased knowledge 
of the addiction process and evidenced-based therapeutic interventions, 
in addition to medication assisted treatment, would go a long way 
towards stemming the ever-increasing tide of overprescribing opioids 
before considering other options in pain management treatment.

    ``NAADAC's Mission is to lead, unify, and empower addiction focused 
professionals to achieve excellence through education, advocacy, 
knowledge, standards of practice, ethics, professional development and 
research.'' - NAADAC Mission Statement

    NAADAC, the Association for Addiction Professionals, is the largest 
membership organization serving addiction counselors, educators and 
other addiction-focused health care professionals, who specialize in 
addiction prevention, treatment, research and education. With more than 
9,000 members and over fifty affiliates, NAADAC's members work to 
create healthier individuals, families and communities through 
prevention, intervention, treatment, continuing care and recovery 
support. NAADAC promotes excellence in care by promoting the highest 
quality and most up-to-date, science-based services to our addiction 
professionals and the clients, families and communities they serve. 
NAADAC does this by providing education, clinical training and 
certification. In the last eight years NAADAC has credentialed more 
than 15,000 counselors, playing an important role in sustaining quality 
health care services and protecting the well-being of the public.

                                 
                        WOUNDED WARRIOR PROJECT
    Chairman Benishek, Ranking Member Brownley, and Members of the 
Subcommittee:
    Thank you for inviting Wounded Warrior Project to offer a 
perspective on VA treatment of veterans experiencing acute and chronic 
pain, and for convening a hearing on this very important subject.
    Working with this generation of wounded, injured and ill veterans, 
we at Wounded Warrior Project (WWP) see daily the devastating impact of 
pain resulting from polytrauma and in-theater injury. In WWP's 
surveying nearly 27 thousand wounded warriors this year, 63% of survey 
respondents had been hospitalized as a result of their wounds or 
injuries, \1\ with some 68% having suffered blast injuries and 17% 
bullet or shrapnel wounds. \2\ Most of these warriors live with pain. 
In fact, two-thirds of the nearly 14 thousand respondents said they had 
moderate, severe, or very severe bodily pain. \3\ Some 80% said their 
pain interferes with work; among them, 30% said pain interfered with 
work ``extremely'' or ``quite a bit.'' \4\
---------------------------------------------------------------------------
    \1\ Franklin, et al.,2013 Wounded Warrior Project Survey Report, 16 
(July 23, 2013).
    \2\ Id., 22.
    \3\ Id., 42.
    \4\ Id., 42.
---------------------------------------------------------------------------
    Pain is the most frequent reason patients seek medical care in the 
United States. \5\ In general, studies of VA patients show that the 
pain veterans experience is significantly worse than that of the 
general public and is thought to be associated with greater exposure to 
trauma and psychological stress. \6\
---------------------------------------------------------------------------
    \5\ Office of the Army Surgeon General, Pain Management Task Force 
Final Report, ``Providing a Standardized DoD and VHA Vision and 
Approach to Pain Management to Optimize the Care for Warriors and their 
Families,'' E-1 (May 2010) . http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
    \6\ Id., 1.
---------------------------------------------------------------------------
    Our troops' post-9/11 combat experience is adding new chapters to 
medicine's understanding of pain and pain-management. As is well 
understood, large numbers of combatants have survived polytraumatic 
injuries in Iraq and Afghanistan because of remarkable advances in 
modern military medicine and transport. But these warriors are at high 
risk of developing unremitting pain. Early study indicates that the 
prevalence of pain in soldiers with polytrauma is as high as 96%, and 
that high percentages of those suffering polytrauma experience pain-
related impairment in physical and emotional function. \7\ (As we are 
learning, polytrauma pain is inherently complex, as multiple pathways 
may be affected, to include acute pain associated with surgery, 
centralized pain associated with spinal cord injury, headache due to 
traumatic brain injury, neuropathic pain due to nerve injury, and 
phantom pain associated with amputation. \8\ Post-traumatic stress 
disorder and traumatic brain injury, the largely invisible ``signature 
wounds'' of the war, not only have the effect of increasing warriors' 
pain but of complicating treatment. As we heard from one VA 
psychologist at a tertiary VA medical center in the Midwest, ``[Pain 
issues are] a MAJOR problem that seriously and negatively impact mental 
health care, and make my job a lot harder.''
---------------------------------------------------------------------------
    \7\ War on Pain: New Strategies in Pain Management for Military 
Personnel and Veterans. (June 2011). Federal Practitioner. (28,2). Pg. 
8.
    \8\ Id, 8.
---------------------------------------------------------------------------
    While treating pain is one of medicine's oldest challenges, ``pain 
medicine'' is a relatively new and evolving medical specialty. \9\ The 
Veterans Health Administration has certainly played an important role 
in attempting to develop a systematized approach to managing pain, 
beginning in 1998 with the formulation of a national pain strategy. VHA 
promoted the concept of ``Pain as the 5th Vital Sign'' in order to 
provide consistency in pain-assessments throughout the health care 
system. The initiative recognized the complexity of chronic pain 
management, especially for patients whose pain was compounded by PTSD, 
combat injuries, and substance use, and recognized further that such 
management was often beyond the expertise of a single practitioner.
---------------------------------------------------------------------------
    \9\ Office of the Army Surgeon General, Pain Management Task Force 
Final Report, ``Providing a Standardized DoD and VHA Vision and 
Approach to Pain Management to Optimize the Care for Warriors and their 
Families,'' E-1 (May 2010) , http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
---------------------------------------------------------------------------
    Taking account of an earlier Inspector General finding that the 
extent of VA's implementation of its national pain strategy had varied 
and that more work had been needed, \10\ Congress in 2008 directed VA 
to develop and implement a comprehensive policy on the management of 
pain experienced by VA patients. \11\ In apparent response to the law, 
VHA in October 2009 published a directive on pain-management to provide 
policy and implementation procedures for improving pain management and 
to comply with generally accepted pain management standards of care. 
This directive reiterated that pain management is a ``national 
priority,'' a priority first articulated in the initial 1998 national 
pain strategy. The 2009 directive not only established a ``stepped 
care'' continuum model - beginning with primary care and advancing to 
timely access to interdisciplinary specialty consultation and 
collaboration, and finally to tertiary, interdisciplinary care 
requiring advanced diagnostics and CARF-accredited pain rehabilitation 
programs. Among its objectives, the national strategy is to create 
system-wide care standards for pain-management; establish skills in 
pain management; ensure performance of timely, regular and consistent 
pain-assessments in all VHA settings; and provide for an 
interdisciplinary, multi-mode approach to pain management that 
emphasizes optimal pain control, improved function, and quality of 
life. VISN directors are responsible for ensuring that all facilities 
establish and implement pain management policies consistent with the 
directive, and facility directors are responsible for meeting the 
objectives of the strategy, for fully implementing the stepped model of 
care, and for meeting the strategy's standards of pain care. \12\ (In 
addition to this framework, VHA and DoD counterparts developed clinical 
practice guidelines for management of opioid therapy for chronic pain. 
The guidelines, first published in 2003, were intended to improve pain 
management, quality of life and quality of care. The guidelines were 
updated in May 2010 to reflect evidence-based practice. \13\)
---------------------------------------------------------------------------
    \10\ Report on the Veterans' Health Care Policy Enhancements Act of 
2008, H. Rep. 110-786 (July 29, 2008), accessed at http://
thomas.loc.gov/cgi-bin/cpquery/T?&report=hr786&dbname=110&
    \11\ Section 501, Veterans'Mental Health and Other Care 
Improvements Act of 2008, Public Law 110-387 (October 10, 2008)
    \12\ Department of Veterans Affairs, VHA Directive 2009-053 
(October 28, 2009).
    \13\ Department of Veterans Affairs and Department of Defense, 
Clinical Practice Guidelines: Management of Opioid Therapy for Chronic 
Pain (May 2010).
---------------------------------------------------------------------------
    Viewed as a statement of policy and an implementation directive, 
the National Strategy directive is praiseworthy. But the measure of 
such an initiative is the reality on the ground - more specifically, 
what is the experience of veterans who live with often-chronic pain?
    Over the past week, we have engaged key WWP field staff from around 
the country to understand the VA pain-management experience of warriors 
with whom they work on a daily basis. The accounts they provided us 
reflect their engagement with warriors at dozens of VA medical 
facilities across the country. We have also interviewed a number of 
warriors (among them WWP staff) who have struggled with chronic pain to 
understand their experience directly, following up on a pain-management 
roundtable we convened two years ago. Several themes emerged. 
Notwithstanding a strategic objective of systemwide standards of care, 
the picture is one of variability of experience - from medical center 
to medical center, and even from warrior to warrior. Despite a policy 
directive that addresses implementation-procedure and establishes 
levels of responsibility, VHA does not appear to be proactively working 
to enforce its pain-management policies. And while VHA does have 
valuable resources with which to support implementation of pain-
management strategies, inadequate training of clinicians and staff play 
a role in their not being used.
    A starting point in managing a patient's pain is surely a full, 
competent pain assessment, and the national strategy directive 
identifies the performance of appropriate timely pain assessments 
consistently across the continuum as a core objective. Primary care is 
identified as a first step in that continuum, and when ``a competent 
primary care provider workforce (including behavioral care)'' cannot 
manage a pain condition, timely access to specialty consultation (step 
two) is required. The experience of our warriors suggests, however, 
that the fundamental objectives associated with these first steps are 
often not met. Specifically, our on-the-ground staff shared the 
following observations:

      Rather than being provided a full pain assessment, the 
common primary care experience is that a brief examination is provided 
and the remainder of the appointment is devoted to inputting (or 
updating) medication prescriptions. Staff report that ``Medications are 
given with no treatment plan or direction other than `take the 
medications.'''
      A senior benefits specialist on our team told us that 
``when I review medical records for veterans and see that they are on 
extensive pain medication I always ask if they have been referred to 
pain management for an assessment. The answer is usually `no.'''
      A full pain assessment would include a review of a 
patient's electronic medical records (to include records of earlier 
treatment at other VA facilities) to better understand their pain care 
needs. That information is also vital to ensure that medications and 
techniques will be efficacious for a given veteran and that previously-
failed approaches will not be re-instituted, as well as to avoid 
prescribing medications that may exacerbate underlying psychological or 
neurological conditions. Notwithstanding the importance of such review, 
patients frequently find that clinicians do not use VISTA to pull 
remote data and/or other pertinent and often critical prior medical 
records. (It was observed, in that regard, that ``VA has a `Cadillac e-
record system,'' but many clinicians and staff ``don't know how to 
drive it,'' reflecting deficiencies in training and adherence to 
standards.)
      Primary Care Managers routinely fail to present veterans 
with pain-relief options that are available and recommended for those 
presenting with chronic pain.
      The reality is that primary care is generally a hurried 
experience that does not allow time for questions, for development of a 
treatment plan, or for discussion of the appropriate time-frame for any 
particular pain treatment before consideration of trying something new.
      The primary care provider will send out requests for 
additional treatment, but those requests are not necessarily followed 
up. Specifically, warriors experience a lack of follow-through within 
the VA Medical Centers for setting up requested medical appointments 
and/or routine care follow up appointments. Compounding this 
frustration, the patient has no way to reach the provider, doctor or 
nurse without physically having an appointment.

    Reliance on and monitoring of the use of opiate medication is, of 
course, an area of particular concern, and requires delicate case-by-
case consideration. Understanding how variable care can be from 
facility to facility, we do not suggest that our teammates' 
observations necessarily describe consistent systemwide practice. At 
the same time, the observations of WWP staff from around the country 
strongly suggest that the following scenarios they have described are 
not at all uncommon:

      Narcotic medications are provided regularly with no 
treatment plan. These medications are provided on six-month intervals 
without follow up, and can be filled using the online system or over 
the telephonic system. These are shipped directly to the warrior's 
home.
      Illustrative of that experience, a benefits-specialist on 
our staff described having gone to a VA medical center to have a 
prescription for Tylenol 3 filled. He stated that the medication had 
worked in managing pain associated with his collapsed discs in his 
upper back and herniated discs in his lower spine. He reported that ``I 
went to the pharmacy and was waiting for an hour. When I asked what was 
the hold-up, I was told they had to get the prescription from the 
locked cabinet where they kept the opiates. I was told that Tylenol 3 
is not on the formulary and they had substituted oxycontin. Bottom 
line: I asked for a `hand grenade,' they gave me an `A-Bomb.'''
      If, on the other hand, warriors ask for narcotic 
medications they are most often not given them.

    Describing his own experiences as well as those of other warriors 
with whom he has worked at a number of VA medical facilities across the 
country, one of our staff offered the following perspective:

    ``From my own experiences and of those relayed to me by my fellow 
wounded warriors, VA facilities vary wildly in how they approach pain 
management. Overlooking potential complications with their referrals 
seems to be a common mistake and often the assessments are not 
comprehensive. VA pain-management practices for warriors with 
polytrauma have been incredibly inconsistent, generally unsuited for a 
full recovery, and have not taken into account the warrior's other 
issues (such as PTSD). The system seems to operate completely on `easy 
fixes' by overprescribing. I know several warriors who have become 
addicted to opiates as a result of mismanaged treatment plans and even 
turning to street drugs. One Marine I served with who was injured in 
2005 has overdosed on prescribed medications, turned to heroin because 
of his addictions, and to this day relies on a VA referred methadone 
clinic. I have never heard of non-pharmaceutical options being offered 
directly, only of them being brought up by the warriors themselves to 
their physician. Despite resources for alternative treatments, I have 
not known the VA to directly point the warrior to them.''

    VHA's national pain management strategy reflects the important 
understanding that quality of life is a standard outcome measure of 
treatment effectiveness, including the treatment of pain. Consistent 
with that view, we applaud the emphasis the national strategy directive 
places on individualized plans of care - even as we convey our 
disappointment that the evidence we have compiled calls into question 
how much progress VA has made in instituting such individualized pain-
care plans. As noted in the directive, however, one important element 
in such plans are non-pharmacologic interventions. In asking our field 
staff, however, how widely complementary therapies are available, we 
were advised, with two exceptions (one of whom had himself been 
prescribed acupuncture and massage therapy for severe back pain) that 
none was aware of any instance in which complementary therapies such as 
acupuncture or yoga had been offered.
    While we see abundant evidence that there remain wide gaps in 
realizing the first two steps of the national strategy's stepped-care 
model, its third step - providing tertiary, interdisciplinary care may 
be even more distant. To the best of our knowledge, the Chronic Pain 
Rehabilitation Program at James A. Haley Veterans Medical Center 
(Tampa, FL) is the only VA program that currently meets the pain center 
criteria and is CARF-accredited. With chronic pain so widespread a 
concern among veterans, and particularly among our wounded warriors, it 
is difficult to understand so limited a deployment of tertiary 
resources.
    Accounts of the experiences of warriors with whom we work 
underscore that much more progress must be made:
    Toby Snell, a Marine from Washington state, sustained severe 
injuries from a car bomb in Iraq in 2006 and shared his story with WWP:

    Toby was originally prescribed Vicodin by the Navy, which did not 
work for pain. Upon leaving the Marines, the VA again prescribed 
Vicodin despite his objections. He was referred to the Pain Management 
Clinic in the late 2007-early 2008 timeframe. He was told many times 
the pain was ``in his head'' but was ultimately prescribed 120mg 
extended release morphine/day. Medication still did not address his 
pain.
    He was not allowed to see Ortho Surgery per his Primary Care doctor 
and the Pain Management doctors because he was told there was nothing 
they could do. He was, however, sent to the University of Washington 
School of Medicine for a second opinion in 2008, but the doctor there 
was not authorized to perform any diagnostic testing. As a result, she 
was unable to assist.
    The VA then recommended a combination of morphine and fentanyl, but 
Toby refused because he was already very ``out of it'' due to the 
morphine and it wasn't working. He didn't want to add new meds.
    In 2009, Toby self-reduced to 90mg/day with the help of 
Acupuncture. His Polytrauma doc had been trying to get fee-basis 
acupuncture for some time but had been denied until the VA hired their 
own provider.
    In the Fall of 2011, the Wounded Warrior Regiment recommended Toby 
go to Operation Mend at UCLA. Toby finally made it to UCLA in March of 
2013 after significant delays from the VA in providing Toby's medical 
records. Doctors there diagnosed him with significant damage in his 
sacroiliac joint and were able to conduct a 20 minute procedure to 
resolve the issue.
    Ultimately, Toby wanted to get off of the morphine. A VA nurse told 
him that the only thing she could recommend was a ``prison-like'' detox 
facility intended for substance abusers.
    Toby approached his VA Primary Care doctor who wanted to help, but 
clearly stated that he did not have experience in this field. The 
doctor recommended a slow/gradual approach but offered no additional 
specific guidance. As much as this doctor seemed to want to help, he 
was just not equipped to assist.
    Over a 6 week period, Toby self-reduced from 90mg/day to 0mg/day. 
In the last few days/weeks, he was sick to his stomach and ultimately 
had to take other meds to control his nausea. At no point did the VA 
proactively assist in this process.
    Ideally, Toby would have wanted them to treat the root cause of the 
pain rather than just trying to medicate. Additionally, at the time of 
the detox, he would have much preferred to be admitted to an 
``appropriate'' in-patient facility that could have helped to monitor 
the weaning process as well as its effects on his other injuries (TBI, 
PTSD).

    Each case is, of course, unique. But the profound frustration Toby 
described mirrors that of other veterans, for whom their battles with 
pain parallel their battles with seemingly rigid barriers encountered 
at some VA facilities.

    A warrior in Houston, Brandon Price, for example, coping with back 
pain from an IED blast and knee pain from a gunshot wound, reported 
waiting over 3 years to get into a pain management program at the 
Houston VA. He was told he was `too young' to be experiencing chronic 
pain and denied consults with the program until he worked with the 
Medical Center's patient advocate. He finally got into the program in 
Spring of 2013, but was told because of his delay in getting 
appropriate pain management care, he would have to go back to primary 
care to treat the severe muscle tension that was impairing their 
ability to treat his back pain. He will not be seen again in the 
program until January of next year. In the meantime, his primary care 
team try to help all they can and he appreciates their work, however 
they do not have the resources and expertise to treat his severe pain. 
In addition, they are not allowed to prescribe any narcotic pain 
medication, so even if it would be appropriate for treating his pain, 
he would have to wait to be seen again by the pain management program 
for such a prescription.

    Our warriors' experiences and the observations of our teammates 
across the country do raise serious questions. What steps, for example, 
have been taken to address systems issues that may impede realization 
of pain-management policy goals? \14\ The gap between policy and 
practice, however, raises even broader questions. What, for example, 
does it mean for the Veterans Health Administration to describe pain 
management as a ``national priority?'' Given that declaration of 
``national priority,'' the recognition that the practice of pain-
management in this country has been widely variable, \15\ and VA's 
important role in the education and training of a large percentage of 
our physician workforce, is there not a high burden on senior VHA 
leadership to ensure that the letter and spirit of its pain-management 
policy is actually implemented across the system? Does the term 
``priority'' actually hold meaning, in an operational sense? Indeed, 
one might even ask whether the Veterans Health Administration has 
characterized so many subjects as ``priorities'' that it has become 
difficult to make any issue a real priority!
---------------------------------------------------------------------------
    \14\ The Report of (VA) Consensus Conference: Practice 
Recommendations for Treatment of Veterans with Comorbid TBI, Pain and 
PTSD (January 20, 2010) cited the need to support clinicians who 
provide interdisciplinary care, noting that ``there is no consistent 
workload credit given to clinicians who take the time to manage or 
review cases with other providers'' and the need for such credit to 
promote coordinated, collaborative care. The report also cited the 
importance of encouraging and offering incentives to providers to 
follow clinical practice guidelines regarding the use of non-formulary 
medications, noting the need for a ``'by-pass' around the sometimes 
complex non-formulary approval process'' and the lack of a standardized 
protocol for such review and approvals. See Report at http://
www.ptsd.va.gov/professional/pages/handouts-pdf/TBI--PTSD--Pain--
Practice--Recommend.pdf.
    \15\ Office of the Army Surgeon General, Pain Management Task Force 
Final Report, ``Providing a Standardized DoD and VHA Vision and 
Approach to Pain Management to Optimize the Care for Warriors and their 
Families,'' E-1 (May 2010) , http://www.dvcipm.org/files/reports/pain-
task-force-final-report-may-2010.pdf/view. Accessed October 1, 2013.
---------------------------------------------------------------------------
    We pose these questions as an organization that works with and 
advocates for those whose sacrifices are immeasurable and to whom this 
country owes a profound debt that must include provision of timely, 
effective care for and rehabilitation of service-incurred wounds, 
injuries and illnesses. We do not suggest that managing chronic pain in 
warriors who, for example, have suffered polytrauma is easy or 
necessarily susceptible of resolution in a primary care clinic. Nor - 
to cite another critical challenge VHA has identified as a priority--is 
it necessarily easy to provide timely, effective mental health care to 
warriors who struggle with PTSD and often co-occurring behavioral 
health issues. But these surely must be real priorities - obligations 
that must be met ahead of others and met fully--for a health care 
system dedicated to the care of veterans.
    These concerns lead us to urge this committee to continue to press 
VHA to make much more progress in the area of pain-management, but also 
to re-establish what the term ``priority'' means for the Veterans 
Health Administration, and to exercise whatever tools are needed to 
realize those highest priorities. They begin, in our view, with wounded 
warriors and their optimal timely care and rehabilitation. To fail to 
meet that obligation is, in our view, to fail all veterans.

                                 
                      VIETNAM VETERANS OF AMERICA
    Chairman Benishek, Ranking Member Brownley, and Distinguished 
Members of the House Veterans' Affairs Subcommittee on Health, on 
behalf of President John Rowan, our Board of Directors, and our 
membership, Vietnam Veterans of America (VVA) thanks you for the 
opportunity to present our statement for the record re: the Department 
of Veterans Affairs (VA) pain management programs and the use of 
medications, particularly opioids to treat veterans experiencing acute 
and chronic pain.
    Our veterans, returning from two protracted wars, deserve the very 
best. Most agree that includes access to jobs, education, affordable 
housing, quality health care, and equal opportunity employment 
opportunities. After defending our freedom overseas, our soldiers, 
sailors, airmen and Marines are clearly facing a crisis at home. We 
need to ensure that those who have taken care of us abroad are taken 
care of once they transition back to civilian life.
    One area that is often overlooked is the proper diagnosis and 
treatment for veterans suffering from chronic pain. While millions of 
Americans suffer from chronic pain, many are veterans who brought the 
unfortunate souvenir back from war. Despite the media attention given 
to post-traumatic stress disorder (PTSD), the number one malady 
suffered by America's active duty military personnel is 
musculoskeletal. Given the number of physical injuries often 
experienced by troops, it is not surprising that chronic pain is a 
frequent problem among returning military personnel from Operation 
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). Common sources 
of chronic pain for these troops are in the head (traumatic-brain 
injury or TBI) or post-concussion syndrome, legs (fractures, 
amputations), burns, shoulders, back, and knees. Other physical 
injuries include spinal-cord and eye injuries, as well as auditory 
trauma.
    According to a May 2011 study by the American Pain Society, about 
nine in 10 Iraq and Afghanistan veterans who registered for care with 
the Department of Veterans Affairs are experiencing pain. More than 
half of these veterans have significant pain, the study asserted. In 
raw numbers, of the 291,205 who enrolled for VA health care between 
October 2003 and December 2008, 141,029 received a diagnosis of a 
painful condition not caused by cancer.
    It's no secret that the best way to treat chronic, severe pain is 
by keeping it under control all the time, and for severe pain, the 
World Health Organization recommends strong opioids such as 
hydrocodone, as well as other such medications called adjuvant 
therapies, as needed for the particular kind of pain. In fact, a paper 
published in the March 7, 2012 Journal of the American Medical 
Association described the pattern of opioid prescription for returning 
OIF/OEF vets. Of the 291,205 who enrolled for VA health care between 
October 2003 and December 2008, 141, 029 received a diagnosis of a 
painful condition not caused by cancer; and of that number, 15,676 
received a prescription of an opioid drug that lasted at least 20 days.
    And now in October 2013 we learn that the death rate from overdoses 
of such drugs at VA hospitals is twice the national average while the 
data also show the VA continues to prescribe increasing amounts of 
narcotic painkillers to many patients. Prescriptions for four opiates--
hydrocodone, oxycodone, methadone and morphine--have surged by 270 
percent in the past 12 years, according to data from the Center for 
Investigative Reporting (CIR) obtained through the Freedom of 
Information Act. CIR's analysis exposed the full scope of that 
increase, which far outpaced the growth in VA patients and varied 
dramatically across the nation among VA hospitals.
    And chronic pain is not limited to America's newest generation of 
military personnel. It is also a significant malady among our older 
veterans, especially Vietnam veterans suffering from PTSD, hepatitis C, 
and those exposed to the herbicide Agent Orange. Given these 
morbidities, it may not be surprising to see a higher frequency of 
prescription opioids for these vets. Other common chronic pain 
complaints often include headache, low back pain, cancer pain, 
arthritis pain, neurogenic pain (pain resulting from damage to the 
peripheral nerves or to the central nervous system itself), psychogenic 
pain (pain not due to past disease or injury or any visible sign of 
damage inside or outside the nervous system). Frequently these veterans 
have two or more co-existing chronic pain conditions, including chronic 
fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel 
disease, interstitial cystitis, temporo-mandibular joint dysfunction, 
and vulvodynia. In addition, research suggests these chronic pain 
patients complain of cognitive impairment, such as forgetfulness, 
difficulty with attention, difficulty completing tasks, impaired 
memory, mental flexibility, verbal ability, speed of response in a 
cognitive task, and speed in executing structured tasks.
    We can help veterans, both young and older, by ensuring they have 
access to improved treatments and medications to better manage their 
chronic pain. The fact is every person experiences pain differently and 
responds to treatments in different ways. Whether the pain stems from 
head trauma, spinal-cord and eye injuries or an amputation, there must 
be a variety of options available to treat the unique symptoms our 
veterans are experiencing. But the rise in prescription drug abuse 
threatens to stifle these options for fear of the further spread of 
abuse and misuse. We must not let that happen.
    Make no mistake, prescription drug abuse is a major concern within 
the veteran community and VVA supports proactive measures to educate 
veterans of this threat and to encourage responsible prescribing to 
ensure these medicines stays out of the hands of those who abuse and 
misuse the drugs. But we cannot allow for the abuse dynamic to restrict 
veterans' access to the highest quality medications and treatments 
needed to relieve their pain.
    Prescription medicines are not the only solution for every veteran. 
But for those who need them, they are critical. Together we can ensure 
our warriors can live long and productive lives, even if they have to 
manage pain. Access to quality health care and new options for 
treatment will protect the next generation of Americans coming back 
from war from experiencing the same challenges of past generations.
    Whether a veteran has been wounded in combat, has experienced a 
non-battle injury, or is currently working through a recovery, chronic 
physical pain has the potential to play a significant role in their 
rehabilitation and reintegration process. In fact, managing the 
psychological and emotional effects of chronic pain can be just as 
challenging as the pain itself. Let us not stand in the way of our 
heroes fulfilling their dreams.
                      Vietnam Veterans of America
                           Funding Statement
                            October 10, 2013
    The national organization Vietnam Veterans of America (VVA) is a 
non-profit veterans' membership organization registered as a 501(c) 
(19) with the Internal Revenue Service. VVA is also appropriately 
registered with the Secretary of the Senate and the Clerk of the House 
of Representatives in compliance with the Lobbying Disclosure Act of 
1995.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives). This 
is also true of the previous two fiscal years.
    For further information, contact: Executive Director of Policy and 
Government Affairs, Vietnam Veterans of America. (301) 585-4000, 
extension 127

                                 
                    AMERICAN PSYCHIATRIC ASSOCIATION
    On behalf of the American Psychiatric Association (APA), the 
medical specialty society representing over 35,000 psychiatric 
physicians and their patients nationwide, I welcome the opportunity to 
submit a statement for the record regarding the October 10th House 
Veterans Affairs' Subcommittee on Health hearing, ``Between Peril and 
Promise: Facing the Dangers of VA's Skyrocketing Use of Prescription 
Painkiller's to Treat Veterans.''
    The APA has for several years stressed the need for funding and 
workforce strength to support comprehensive mental health and substance 
use disorder treatment in the Veterans' Health Administration (VHA). 
The October 10th hearing highlighted a few issues which the APA has 
long advocated: improved prescription drug management programs (PDMPs) 
at the VHA as well as interoperability with state-run PDMPs, training 
of medical personnel on options for medically assisting substance use 
recovery, and the urgent need for non-opioid medications to treat 
chronic pain.
    The focus of our statement is the veteran and returning military 
population, but issues such as medication diversion (taking a relative 
or friends' medication), medication seeking (doctor-shopping), improper 
prescribing, inadequate informatics on prescription utilization, and 
the need for better pain management as well as utilizing medical 
options to assist with substance use disorders are prevalent for the 
United States population as a whole.
    In 2008, Congress directed the VHA to develop and implement a 
comprehensive policy on the management of pain experienced by VHA 
patients. Many VHA facilities are making significant progress on 
implementing the VA's mandate to improve pain management. In addition 
to this policy framework, VHA and Department of Defense (DoD) 
counterparts developed clinical practice guidelines for management of 
opioid therapy for chronic pain. The guidelines, first published in 
2003, were intended to improve pain management, quality of life and 
quality of care. The guidelines were updated in May 2010 to reflect 
evidence-based practice. However, challenges still exist to fully 
implement evidence-based, comprehensive pain management as well as 
opioid addiction treatment.
Prescription Drug Management Plans (PDMPs)
    Prescription Drug Management Plans help to identify and prevent 
potential misuse of prescription drugs, and assist in avoiding negative 
health outcomes for VA patients, including emergency treatment and 
accidental overdose. Thirty-eight states have PDMPs. Within the VHA 
itself, there is uneven utilization by providers of the VA's own health 
records program to verify prescription data for patients.
    The APA has expressed concern that barriers to quality patient care 
as well as a patient safety are the limitations in VHA's ability to 
monitor prescriptions written for veterans outside of the VHA system. 
Prescription data coordination can assist VHA physicians in identifying 
veterans who need intervention and treatment for substance use 
disorders as well as prevent intentional overdosing by alerting 
physicians to multiple prescriptions. The APA is encouraged by the 
Interim Final Rule on the VHA's prescription drug monitoring program 
effective on February 11, 2013, (VA-2013-VHA-0005-0001), which codified 
the VA's PDMP. The APA looks forward to the VHA's PDMP system's 
interoperability with state-run PDMPs. We note, however, that there are 
no national standards for state PDMP information sharing and 
interoperability between states is a hurdle to overcome.
    Therefore, the APA respectfully requests that the VA enhance its 
collaboration with the Department of Justice, Department of Health and 
Human Services and state Attorneys General to expedite interoperability 
of the VA PDMP with state PDMP programs using the prescription 
monitoring information exchange (PMIX) computer architecture.
Recruitment and Retention of Psychiatrists
    VHA Deputy Undersecretary Robert Petzel, M.D., stated in January 
2013 before the House Veterans' Affairs Committee that the major 
workforce barrier to mental health and substance use treatment was the 
VHA's difficulty in hiring and retaining psychiatric physicians. 
Congressional testimony given by current and former psychiatric 
physicians in the VHA highlights non-competitive pay, uneven training, 
and long hiring processes as key barriers to developing and maintaining 
a robust psychiatric workforce.
    The APA strongly encourages the VHA to further adjust the pay 
tables for psychiatric physicians to more accurately reflect the acuity 
of VHA need as well as to redress the imbalance that occurs when newly 
hired psychiatrists have compensation packages that are not aligned 
with the compensation of career VHA psychiatrists with years of 
experience and training. Such redress may improve the retention issues 
at VHA.
    Recruitment of psychiatrists as specialty physicians remains an 
issue at the VHA. According to USAjobs.gov on September 17, there were 
142 federal job vacancies for psychiatrists listed, of which 138 were 
for the VHA; 128 positions were for permanent hires. Of the 128 vacant 
full-time positions, only 33 (25%) were even eligible for medical 
school loan repayment under the VHA's Education Debt Reduction Programs 
(EDRP) program. Even if a VHA physician position is eligible for loan 
repayment, eligibility does not confer actual loan repayment. Under the 
EDRP program, a psychiatrist must apply for medical school loan 
forgiveness within six months of his or her hire date. VHA's HR 
departments are all too often unaware of this six-month stipulation, 
rendering some psychiatrists ineligible.
    The APA is developing a recruitment and retention workforce 
proposal for psychiatrists at the VHA that would establish a medical 
school loan forgiveness program similar to that provided by the U.S. 
Army. The proposal would be a time limited opportunity to increase the 
number of psychiatrists in the VHA and would also require a VHA study 
on its impact. We look forward to working with Congress to enact this 
and related proposals to increase the supply of psychiatrists providing 
care to our nation's veterans.
Training the VHA Workforce: pain management and addiction treatment
    Two issues overarch the VHA's nationwide ability to meet its 
Congressional mandate to provide comprehensive pain management services 
to our nation's veterans: evidence-based prescribing and pain 
management techniques for all veterans and enhanced availability of 
opioid-dependence treatment for those struggling with addiction.
    The utilization of pain medication without benchmark pain 
assessments and accompanying treatment plan is inconsistent with good 
medical practice. Of particular concern is the prescription of multiple 
pain medications to veterans with multiple medical issues. Data suggest 
that some veterans with Post Traumatic Stress Disorder (PTSD) 
experience pain at a more intense level than their counterparts without 
PTSD. Veterans are subject to unique risk factors involving the misuse 
of prescribed controlled substances (Karen H. Seal et al., 
``Association of Mental Health Disorders With Prescription Opioids and 
High-Risk Opioid Use in US Veterans of Iraq and Afghanistan,'' 307 JAMA 
940 (2012)). Many veterans being treated for opioid dependence also 
have co-occurring diagnosis such as depression or anxiety. Treatment of 
these co-occurring illnesses only underscores the need for more 
psychiatrists in the VHA.
    Academic detailing or enhanced pharmacologic training provided by 
physicians to VHA medical personnel regarding evidence-based for 
treatment of pain and opioid dependence is necessary throughout the 
VHA. Certain Veterans Integrated Service Networks (VISNs), such as VISN 
20, 21 and 6 have implemented short, in-service training programs to 
change providers' practices in prescribing pain medication, 
particularly for those patients with co-occurring PTSD and depression.
    All too often, veterans (and other Americans) take prescription 
pain medication for orthopedic or nerve injuries and become addicted to 
or dependent on opioid medications used for pain. For opioid-addiction 
treatment options, the APA strongly encourages the utilization of and 
more trained physicians, particularly by psychiatrists who are 
specially trained, in the use Suboxone and Buprenorphine in opioid-
dependence treatment. These medications act as `opioid antagonists' and 
can assist in the supervised withdrawal from opioids. The APA is a 
partner organization in two clinical mentoring and education 
initiatives funded by the Substance Abuse and Mental Health Services 
Administration (SAMHSA): Physicians' Clinical Support System-
Buprenorphine (PCSS-B) and the Prescribers' Clinical Support System- 
Opioid Therapies (PCSS-O). Through the SAMHSA-funded grant, the APA has 
produced a series of webinars focused on the use of opioid therapies 
for treatment of opioid dependence and on the safe use of opioids in 
the treatment of chronic pain. The free webinars are available for 
psychiatrists, physicians of other specialties, other prescribers, 
residents, and other interested clinicians. Webinar recordings are 
available on this site. www.pcssb.org/educational-and-training-
resources/special-topics and include:

      The Use of Buprenorphine to Treat Co-occurring Pain and 
Opioid Dependence in a Primary Care Setting
      Learning the Evidence Behind Alternative/Complementary 
Chronic Pain Management - Emphasis on Chronic Low Back Pain
      Patterns of Opioid Use, Misuse, and Abuse in the 
Military, VA, and US Population
      Enhancing Access to PDMPs Through Health Information 
Technology
      Identifying and Intervening With Problematic Medication 
Use Behaviors
      Assessing and Screening for Addiction in Chronic Pain 
Patients
      Psychological Management and Pharmacotherapy of Patients 
with Chronic Pain and Depression, Schizophrenia, and Post Traumatic 
Stress Disorder (PTSD)

Research on New Pain Medications
    Federal agencies are currently involved in the development of new 
pain medications and methods to treat pain. The National Institute of 
Drug Abuse (NIDA) has been at the forefront of biomedical exploration. 
NIDA has, through an established testing program involving contract and 
grant mechanisms, developed several opiates pharmacotherapies that have 
been approved for use (Buprenorphine, Buprenorphine/Naloxone). Through 
interaction with leading substance abuse experts in academia, the 
pharmaceutical industry, and the Food and Drug Administration, NIDA has 
developed standardized outcome measures and success criteria for 
clinical pharmacotherapy trials, established clinical algorithms and 
standards for the conduct of exploratory clinical concept studies; 
human drug interaction studies; and Phase I, II, and III safety and 
efficacy studies. The Department of Defense, Veterans' Administration 
and the National Science Foundation are other major federal agencies 
investigating new pain medications and treatment.
    The APA has vigorously supported enhanced federal research to 
encourage the development of a new class of pain medications that would 
not have the same potentially addictive effects as long term use of 
opioids. Sustained, robust federal investment must be a national 
priority in order to make significant progress on inventing novel 
medications and developing new mechanisms - biological or chemical - to 
control pain. NIDA's Clinical Trials Networks are currently testing on 
a few molecules of interest.
    Pain management, addiction detection and effective treatment are 
significant priorities for our nation's veterans. These objectives 
require the better coordination of opioid and benzodiazepine 
prescribing inside and outside the VHA. We strongly support robust 
research and more training throughout VHA medical personnel of the uses 
of medications such Suboxone and Buprenorphine to assist in the 
treatment of addiction, along with the development of new non-opioid 
medications to treat pain. Above all, we believe that access to a well-
trained workforce grounded in the highest quality care and respect for 
veterans and their families is of paramount importance. We stand ready 
to assist you in achieving these goals.
    The APA appreciates the opportunity afforded by Chairman Benishek 
and Representative Brownley to provide this statement on behalf of its 
members. Should you have any questions or need further information, 
please do not hesitate to contact my staff, Lizbet Boroughs, at (703) 
907-7800 or [email protected].

    Sincerely,

    Saul Levin, M.D., M.P.A.
    CEO and Medical Director
    American Psychiatric Association

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