Pubdate: Thu, 19 Feb 2015
Source: Washington Post (DC)
Copyright: 2015 The Washington Post Company
Contact: http://mapinc.org/url/mUgeOPdZ
Website: http://www.washingtonpost.com/
Details: http://www.mapinc.org/media/491
Author: Emily Wax- Thibodeaux

VETERANS GRAPPLE WITH RESTRICTIONS ON NARCOTICS

Amid VA Backlog, New Rules Leave Chronically Injured Patients in Pain

New federal rules that make it harder to get narcotic painkillers are 
taking an unexpected toll on thousands of veterans who depend on 
these prescription drugs to treat a wide variety of ailments, such as 
missing limbs and posttraumatic stress.

The restrictions, adopted last summer by the Drug Enforcement 
Administration to curb a national epidemic of opioid abuse, are for 
the first time, in effect, forcing veterans to return to the doctor 
every month to renew their medication, although many were already 
struggling to get appointments at overburdened VA health facilities. 
And even if patients can get appointments, the new rules pose an 
additional hardship for many who live a good distance from the health centers.

Although the tighter regulation applies to everyone on opioid 
painkillers, it's hitting veterans especially hard because so many 
are being treated for horrific injuries sustained during the long 
wars in Iraq and Afghanistan and have become dependent on the 
Department of Veterans Affairs' beleaguered health-care system for 
medical care.

The rules come at a time of turmoil for VA. The agency's widespread 
problem with patient backlogs burst into view last year with 
revelations that employees had covered up how long veterans had to 
wait for care, even for such pressing matters as cancer and suicide prevention.

In dramatically curtailing access to the highly addictive 
painkillers, the government is trying to roll back what the Centers 
for Disease Control and Prevention has termed "the worst drug 
addiction epidemic in the country's history, killing more people than 
heroin and crack cocaine." The rules apply to "hydrocodone 
combination products," such as Vicodin.

More than half a million veterans are now on prescription opioids, 
according to VA.

Pain experts at VA say that in hindsight they have been 
overmedicating veterans, and doctors at the Pentagon and VA now say 
that the use of the painkillers contributes to family strife, 
homelessness and even suicide among veterans. A study by the American 
Public Health Association in 2011 also showed that the overdose rate 
among VA patients is nearly double the national average.

But some veterans say they have come to depend on these painkillers 
to function and now, unable to get a timely renewal of the 
prescription, are suffering withdrawal symptoms that feel like a 
panic attack and the flu at the same time.

Craig Schroeder was injured in a makeshift-bomb explosion while 
serving as a Marine corporal in the "Triangle of Death," a region 
south of Baghdad. He suffers from traumatic brain injury, which has 
affected his hearing, memory and movement, and from pain related to a 
broken foot and ankle and a herniated disc in his back. He has been 
on a steady regimen of opioids.

But after the DEA regulations were put in place, he was unable to get 
an appointment to see his doctor for nearly five months, he said. He 
stayed in bed at his home in North Carolina much of that time.

"It was a nightmare. I was just in unbearable, terrible pain," he 
said. "I couldn't even go to the ER because those doctors won't write 
those scripts."

His wife, Stephanie Schroeder, said getting him a VA appointment 
turned into a part-time job and her "main mission in life." While 
part of the problem was a shortage of doctors, she said she also 
noticed that VA had become hostile toward patients who asked for painkillers.

"Suddenly, the VA treats people on pain meds like the new lepers," 
she said. "It feels like they told us for years to take these drugs, 
didn't offer us any other ideas, and now we're suddenly demonized, 
second-class citizens."

Officials at Disabled American Veterans, a veterans service 
organization, said VA needs to be more compassionate and help 
veterans through the changes.

"We're hearing from veterans with lifelong disabilities, who never 
had a problem with addiction issues. They have been on these drugs 
for decades, and then all of a sudden it was boom, a total change in 
attitudes," said Joy Ilem, the group's deputy national legislative director.

Gavin West, a clinical operations chief at VA, said there has been a 
systematic effort since autumn to contact veterans to explain the new 
rules, broader concerns about opioid use and alternative options for 
treatment. At the same time, he said, the agency is working to ensure 
that veterans get the access to medical care that's required.

"The DEA did a good thing here for opioid safety," he said. But he 
added, "How do you balance the sensitivity of patients and the new 
rules when all of a sudden a veteran, who's been treated with this 
medication for 15 years or 20 years, has everything change?"

To help patients adjust to the changes, Rollin Gallagher, VA's 
national director for pain management, said staff members are meeting 
personally with veterans. "There is the real anxiety of being in pain 
and losing control of that pain. We are aware of the fact that we 
need to pay attention to this," he said.

The agency recently set up a Choice Card program for veterans, which 
would allow those facing long wait lists or who live more than 40 
miles away from a VA hospital to use private clinic visits. Veterans 
say the initiative is complicated and confusing. VA officials 
acknowledged this month that veterans have been using this program at 
a lower rate than anticipated.

DEA officials declined to comment on the specific challenges that the 
new rules pose for veterans. Barbara L. Carreno, a DEA spokeswoman, 
said in a statement that everyone, including "practitioners employed 
by the U.S. Veterans Administration," have to follow the new 
regulations. The officials said the rules are a response to multiple 
medical studies that have showed that the opioid overdose rate is 
higher in the United States than anywhere else.

DEA officials offer some flexibility, allowing doctors to write 
prescriptions for up to 90 days by post-dating them. But many VA 
doctors will not do that because of concerns over fraud or fatal 
overdoses; doctors are telling patients they need to come back every 
month, medical staff say.

Half of all returning troops suffer chronic pain, according to a 
study in the June issue of the Journal of the American Medical 
Association. So a new generation of pain doctors is pushing for 
alternative ways to help veterans cope with chronic pain. Some 
alternatives are acupuncture, bright light therapy and medical 
marijuana. As part of a $21.7 million initiative with the National 
Institutes of Health, VA is looking for therapies that could 
substitute for opioids.

"Our hospitals are doing some really exciting things to combat 
chronic pain and take care of our veterans. There are VA hospitals 
that are using alpha-stimulation devices to treat pain and 
depression," VA Secretary Robert McDonald said. "That's only going to 
continue and keep getting better. And we are getting there."

In the meantime, however, veterans say they continue to bear the 
burden of the new restrictions on narcotic painkillers.

A retired staff Army sergeant who served in Iraq, who spoke on the 
condition of anonymity for medical privacy reasons, said he can't 
drive because of shrapnel in his femur and pelvis. He takes the bus 
nearly two hours for "a one-minute consult" to get his medications. 
He has been taking them for more than nine years and has never had an 
addiction problem, he said.

Mike Davis, a retired Army corporal, said he shattered his left arm 
from the elbow to the fingertips when he fell off of a Pershing 
missile during maneuvers in Germany in 1979. Over the years, he has 
had six surgeries.

After the last one, in 2003, he was prescribed opioids and said he 
has been on them since. Davis, who now works as a social worker in 
Illinois, said he feels lucky to have found a combination of 
painkillers that works for him.

"It's just insulting to the veteran to assume they are abusing these 
drugs," said his wife, Linda Davis, who works as his personal patient 
advocate. "I'm fully aware that people doctor-shop, some docs 
overprescribe. But I think they need to realize that there's a real 
difference between addiction and dependence."

But Andrew Kolodny, president of Physicians for Responsible Opioid 
Prescribing, called the new DEA rules "the single most important 
change that could happen. The best way to treat any disease, whether 
it's Ebola or opioid addiction, is to stop creating more people with 
the disease."

At the same time, he said, VA needs to do far more to help veterans 
through the rocky transition.

"Unfortunately, veterans are the victims here," Kolodny said. "The VA 
created this mess by aggressively jumping onto pills as the solution. 
But it's not something you can just abruptly stop."
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MAP posted-by: Jay Bergstrom