August 7, 2017
Joe Davidson | The Washington Post
WASHINGTON — The information about the veteran is scant, clinical in tone, yet disturbing.
"At the time of his death, the patient was a male in his forties with a past medical history significant for PTSD, chronic low back pain, obstructive sleep apnea, obesity, and depression," the Department of Veterans Affairs inspector general reported.
The veteran is identified as "Patient 1." He was "hospitalized twice for suicidal ideation and a reported suicide attempt." But only later, in a case of a buried lead, does the report say another attempt was successful - "suicide caused by toxic levels of sertraline, morphine, and gabapentin."
This veteran - one of 20 who kill themselves every day, a frightening figure - received medical care from the Department of Veterans Affairs (VA) and a non-VA doctor who prescribed opioids for his chronic pain.
While psychological factors were the reasons and drugs were the tools, the suicide was facilitated by a hole in a system designed to give vets the choice, in same cases, to obtain outside medical care at government expense. With Patient 1, "there is no evidence in the medical record that any of his VA providers were aware of the new opioid prescriptions," according to the inspector general.
That gap in coordination, added to differing clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside VA are not required to follow departmental guidelines.
Veterans receiving opioid prescriptions from private clinics "may be at greater risk for overdose and other harm because medication information is not being consistently shared," Inspector General Michael J. Missal said when the report was released last week. "That has to change. Health-care providers serving veterans should be following consistent guidelines for prescribing opioids and sharing information that ensures quality care for high-risk veterans."
His office recommended that VA:
"Require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing."
Ensure those providers have "a complete up-to-date list of medications and medical history."
Require community providers to review VA opioid guidelines.
Ensure that if community facilities don't meet VA opioid standards that "immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider."
VA agreed, at least in principle, with all the recommendations.
"With America facing a looming doctor shortage and demand for veterans health care outpacing VA's ability to provide it in-house, better coordination between VA and non-VA providers is absolutely essential," said VA press secretary Curt Cashour.
It's absolutely essential considering that about 142 Americans die daily from a drug overdose, "a death toll equal to September 11th every three weeks," said a report by the President's Commission on Combating Drug Addiction and the Opioid Crisis issued the day before Missal's. Declaring opioids "a prime contributor to our addiction and overdose crisis," the commission called on President Trump to declare a national emergency empowering the government to take "bold steps" against drug abuse.
In response to the report, VA Secretary David J. Shulkin issued a statement noting that "recent studies and stories have pointed to VA's success in its approach to pain management and responsible use of opioids with our Veteran patients."
Since launching the Opioid Safety Initiative in 2013, VA says, the number of its patients receiving opioids fell by 27 percent and the number on long-term opioid therapy dropped 33 percent. Shulkin said VA is widely sharing its eight best practices to balance pain management and opioid use under the acronym S.T.O.P. P.A.I.N.
Missing from that list is cannabis. It could be an ally in the fight against opioid abuse, as the nation's largest veterans' service organization recognizes, except for Uncle Sam's outdated and repressive view of marijuana. Citing data showing that states permitting medical marijuana have an opioid mortality rate almost 25 percent below that of other states, the American Legion has urged the government to acknowledge the potential medical value of cannabis and to reclassify it to expand research into its use for patients.
"We also want to point out that the increased focus on addiction is, in some cases, hurting veterans who suffer with chronic pain and have been on long-term narcotic-based pain relievers," said Louis J. Celli Jr., veterans' affairs and rehabilitation division director at the American Legion. "For some patients, lifelong pain management through prescription medications is all they have that allows them to function. For some, removing these medications can lead to depression, decreased ability to care for themselves, and, in some cases, suicide."
While supporting flexibility in care, veterans' groups are cautious about the department's Choice program, which funds private-sector health services for vets. On Tuesday, Congress approved $2.1 billion for Choice to help VA build Shulkin's vision for "an integrated system that allows veterans to receive the best health care possible."
But the integration isn't as good as it needs to be, which is a danger when care is fragmented among VA and private providers, said Garry Augustine, executive director of the Disabled American Veterans.
The outside providers might not know all they need to know about a patient or share their records with VA. Coordination is key, he said, but not always present.
"Under the current Choice program, it isn't as tight as it should be," Augustine added. "That should be addressed."
And soon - before another vet, like Patient 1, falls through the gap.