Pubdate: Fri, 27 Aug 2010
Source: Boston Globe (MA)
Copyright: 2010 Globe Newspaper Company
Contact: http://bostonglobe.com/news/opeds/letter.aspx?id=6340
Website: http://www.boston.com/globe/
Details: http://www.mapinc.org/media/52
Author: Joseph P. Kahn, Globe Staff

FOR ADDICTED VETERAN, REGULATION IS ENEMY

Government Balks at Covering Treatment for Painkiller Dependency

BRAINTREE - In the space of a few hours, on bomb-clearing patrol near 
Balad, Iraq, US Army Corporal Eric Small and his unit were rocked by 
three separate roadside explosions. He sustained serious injuries to 
his head, back, neck, and hip. Small's combat days were over.

It was the summer of 2008, and Small spent 10 months convalescing in 
military hospitals. He came home to Massachusetts with two lasting 
wartime souvenirs: a Purple Heart medal and a painkiller addiction.

But in a bitter irony for Small and his family, the same government 
that sent him to war balked for months before agreeing to pay for the 
treatment his doctors feel best addresses his drug addiction. Small's 
frustration is shared by some medical specialists who say it's 
shameful to deny him, and others like him, coverage for a condition 
he acquired doing his patriotic duty. The issue has been federal 
regulations that restrict coverage for treatment of drug addiction 
for military personnel.

"I never dreamed when I joined the military that I'd be put in this 
situation," Small, 29, said at his Braintree apartment, with his 
wife, Shannon, and baby daughter, Isabella, nearby. "I wasn't a drug 
addict. I didn't do drugs. Suddenly I'm going through withdrawals, 
wanting my body to stop being the way it is."

Percocet, the painkiller Small had been taking, is potent and can 
become highly addictive. Small no longer takes the drug, having been 
put on buprenorphine, a cutting-edge medication used to treat opiate 
dependency. Addiction specialists consider it the gold standard for 
treating drug dependencies like his, safer and more effective in many 
cases than older-generation drugs like methadone. Buprenorphine is 
also approved by the Federal Drug Administration for treatment of chronic pain.

Paying for buprenorphine, which costs $250 a week, has left the 
Smalls more than $3,500 in debt and scrambling to make ends meet.

Tricare, the military's health care provider, did recently agree to 
cover the cost of Small's buprenorphine, sold under the brand name 
Suboxone. But that approval did not come easily; it took months of 
negotiation between Small's physician and Tricare, which will not 
approve the drug for "maintenance therapy of opioid dependency," but 
will for detoxification and supervised drug withdrawal. In Small's 
case, Tricare is covering the drug for pain management as well.

To many addiction specialists, all that amounts to a distinction 
without a real difference - and a conundrum for doctors wanting to 
provide optimal care for patients like Small. (Small's physician 
declined to be interviewed.)

"There's no assurance that next month Corporal Small won't be denied 
coverage or any assurance the next person [who asks] won't be denied 
too," said Dr. Robert Newman of New York's Beth Israel Medical 
Center, a leading addiction specialist who has been advocating for a 
change in government policy. "We're talking about physicians paid by 
our government who decide their patients require a certain treatment, 
and yet an insurer can arbitrarily overrule them. I see no 
justification for this. None."

The American Medical Association, in its published policy on 
physician-prescribed drugs, offers "strong support" to doctors who 
lawfully use an FDA-approved drug "for an unlabeled indication when 
such use is based upon sound medical opinion" - in other words, 
prescribe a drug for pain control when the primary reason for taking 
it is to help the patient kick a drug habit.

The AMA also urges third-party payers such as Medicare to cover 
prescription drugs under such circumstances, deeming them "reasonable 
and necessary medical care."

Chris Hassan, CEO of Colonial Management Group, a California-based 
chain of addiction-treatment centers, said the US military and 
federal government have been slow to pay for new medications that 
treat drug addiction. "Medical treatment of addiction in the VA 
[Veterans Administration] system is not even standard-of-care, never 
mind cutting-edge," Hassan said. "We put people in harm's way, then 
create another problem for them by putting this stigma on them. It's 
like someone getting blown up by a land mine and then you deny him a 
wheelchair."

The roadblock to coverage in cases like this is a Department of 
Defense regulation. It stipulates that while insurance benefits may 
be extended for drugs that treat illness or injury, they "cannot be 
authorized to support or maintain an existing or potential drug abuse 
situation." Drug-maintenance programs swapping one addictive drug for 
another are not covered.

In April, Representative James McGovern of Massachusetts joined seven 
other members of Congress in petitioning Defense Secretary Robert 
Gates to amend Tricare benefits to cover methadone and buprenorphine. 
"Military families struggling with addiction need help," their letter 
concluded. In June, Defense Undersecretary Clifford Stanly assured 
the congressmen that Tricare is "pursuing changes" in its policy of 
disallowing coverage for opioid dependency.

Small is fortunate compared to many who have returned from Iraq and 
Afghanistan with lifelong disabilities. Beyond the brain injuries and 
shattered bodies are epidemic levels of post-traumatic stress 
disorder and suicide. In Small's unit alone, the 509th Combat 
Engineer Company, two soldiers took their own lives while in Iraq, 
according to Small.

This spring, retired Army General Barry McCaffrey warned that serious 
drug use among US military personnel in Afghanistan had doubled since 
2006, while the Drug Policy Alliance has estimated that nearly 
one-third of Afghanistan and Iraq vets show signs of post-traumatic 
stress disorder. That condition is "strongly associated with 
substance abuse and dependency," according to the National Institute 
on Drug Abuse. Moreover, as Newman and others note, drug dependency 
affects tens of thousands of veterans' dependents and survivors as well.

Small remains on active-duty status and will probably be discharged 
early next year, when he should become eligible for full VA benefits, 
including medication coverage. However, he's concerned that his 
treatment for drug dependency may give the Army an excuse to deny him 
some benefits, his Purple Heart notwithstanding. Until his discharge, 
meanwhile, he draws a $3,300 monthly salary and housing allowance.

Hoping to become an emergency medical technician, he harbors no ill 
will toward the Army, he said, and feels he received good medical 
care and counseling, for the most part. Yet he acknowledges he's not 
the same man who joined the military three years ago with the intent 
of someday becoming a police officer or firefighter.

Nine months in a Texas military hospital changed everything, said 
Small, who at one point was taking 20 different medications for pain, 
anxiety, depression, and insomnia. Shannon Small said her husband's 
pill consumption didn't seem to concern his Texas doctors.

"Maybe because so many other people there had their arms and faces 
blown off," she said. Because his injuries were less visible, if no 
less painful, she added: "they were kind of shrugging him off. Like, 
'Take more Percocet - it'll mask the pain. Then we'll deal with you later.' "

Small's problems weren't confined to his physical discomfort, the 
couple said. Plagued by anxiety attacks, he began refusing to get in 
a car unless he could drive himself. "I was mentally stuck," he said, 
reflecting on his long convalescence. He still will not ride with 
others driving, even his wife, and avoids crowded places.

By Small's last hospital stay, in Missouri, his addiction to Percocet 
had become painfully obvious. Last September he admitted his problem 
to his superior officers, who had him checked into a rehab clinic. 
Put on methadone during his seven-day stay, he suffered painful 
withdrawal symptoms, however, and went back on Percocet to ease his 
discomfort. A few weeks later another physician treating Small 
recommended Suboxone, which proved to be a positive, if expensive, step.

Only after Small's months of resubmitting insurance forms did Tricare 
consent to pay for his treatment, and even now he's been told he 
can't recoup what he spent on Suboxone out of pocket.

Speaking publicly about his situation "isn't to get money," Small 
said, while his daughter cooed in a playpen nearby. "It's for others 
in my situation. The rule needs to get changed. People need to know 
what's happening to the veterans who come home, that we're not over 
there shooting people - and getting shot at - for nothing." 
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MAP posted-by: Richard Lake