W. Va. official cites area health issues in VA prescriptions
The Charleston (W. Va.) Daily Mail
BECKLEY, W.Va. — Administrators at the Beckley Veterans Affairs Medical Center know their hospital prescribes powerful painkillers at some of the highest rates in the nation.
But it's not necessarily a sign the hospital is over-prescribing the medication -- or of rampant abuse of the system -- and the hospital has taken steps to address the problem in recent years, officials recently told the Daily Mail.
"We were concerned when we saw it, but we have put things in place to make sure we are providing pain medications to the veterans that need it," Director Karin McGraw said. "And for the ones that we detect that they either don't need it or they may be abusing it, we stop it."
McGraw spoke in reference to data included in a recent investigation from the Center for Investigative Reporting -- a national nonprofit journalism organization. The center found from 2001 to 2012, the per-patient prescription rate for four pain medications was the second highest of any center in the nation.
The Huntington VA placed fourth on the list.
The center looked at prescriptions for hydrocodone, oxycodone, methadone and morphine. Oxycodone and hydrocodone are found in the medications OxyContin and Vicodin, respectively.
It also found prescription rates are rising faster than the number of patients using the facilities at a national level.
The report was old information to McGraw and Dr. John Berryman, the center's chief of staff. Reports provided as early as the late 2000s by the national VA informed the center of its high per-patient prescription rates, McGraw said.
Both pointed to the aging Vietnam veterans and younger veterans with injuries "never seen before" leading to more prescriptions. McGraw also said a national initiative, known as "pain as the 5th vital sign," called on VAs to more aggressively attack pain.
Both issues face all VAs, McGraw and Berryman said.
Southern West Virginia is notorious for obesity, diabetes, smoking and lack of physical activity, all of which are reported at a local and national level. Those kinds of health problems are only amplified when a patient also happens to be a veteran, Berryman said.
"(People in the area) tend to be, in my experience and just in my opinion, more used to smoking at an early age, paying less attention to normal health measures than what we try to advocate," Berryman said.
"Their health is, generally speaking, at a lower level in terms of maintenance than patients their age in other areas or states. So they may need more narcotic use to alleviate painful symptoms," he said.
He said that's a big reason why prescription rates at the Beckley VA are so different from those at the Martinsburg VA.
Martinsburg served more than double the number of patients than Beckley but prescribed about half the number of painkillers, according to the report. The overall health of the population in Martinsburg and surrounding areas is "non-comparable," Berryman said.
Most veterans served at Beckley served in Vietnam, McGraw said. For VAs close to military installations, the number of younger veterans is significantly higher, she said.
Younger veterans have options -- weight training, physical therapy -- that might preclude them from needing painkillers, she said.
Poor health is not unique to southern West Virginia. Many VA medical centers, like Beckley, do not directly neighbor a military installation.
There is fraudulent painkiller use at Beckley, Chief of Pharmacy Brenda Rappold said. But Rappold, McGraw and Berryman are confident policies and changes implemented in recent years will help keep it to a minimum.
Addressing 'rescue medications'
After reviewing national data, the Beckley VA started to make changes in 2009.
The administration hired a pain management specialist. The VA revamped its contract with patients who have long-term narcotic prescriptions in 2009, calling for patients to abide by stricter standards.
Each step helps more adequately address patient pain levels while making it easier to spot those trying to scam the system, Berryman said. But each has its potential problems.
The pain management specialist works with providers to determine the right level of pain medication for a patient, Rappold said. The hospital tries to find the right level of long-term pain medication that provides constant treatment.
Ideally, that's morphine.
Since 2009, Beckley has tried to use morphine for all long-term narcotics-based pain treatment. But that might have led to a spike in the number of prescriptions for hydrocodone or oxycodone.
"We are converting to a long-acting morphine because it is not as easy to divert the use of that, either by giving it to friends or wives or whatever or by selling them," Berryman said.
It takes a long time to find the right dosage for each patient, he said. In the meantime, a provider might need to prescribe a "rescue medication" like hydrocodone or oxycodone. It bridges the gap between morphine use until providers can figure out the correct amount of morphine that particular patient needs, Rappold said.
Depending on how long it takes to find the correct morphine dosage, it could require several short-term prescriptions for the "rescue medications," Berryman said.
The Center for Investigative Reporting's data show since 2009, the per-patient prescription rate of morphine has gone up. The same rate for hydrocodone went down from 2011 to 2012, but it's still seven times higher than it was in 2002, according to the report.
The VA tries to promote healthy lifestyles and avoid prescription painkillers as often as possible. Therapy, localized injections or other non-opiate pain medications are considered before more powerful prescriptions, Rappold and Berryman said.
As shown by the report, many patients are deemed in need of the powerful painkillers. Many patients don't think they've been treated until they're prescribed medication, Rappold argued.
"If you go to your doctor and they don't give you a prescription for pain or whatever you happen to have, you feel like you've actually not been treated appropriately ... You didn't get anything for your money that you paid to go see the doctor," she said.
There's no way to completely eliminate abuse, Berryman and Rappold said, but other policies help track and address problems.
By signing the contract, patients submit to spontaneous pill counts or blood tests. If pill totals or test results don't mesh with prescription schedules, it could be a sign of a problem, Berryman said.
If they believe a patient is addicted or selling the drugs, they gradually reduce the medication until the person no longer receives it. Berryman didn't specify how long it takes to "taper" a patient off the drugs.
Once the person is no longer receiving the medication, hospital policy says the person can't receive the same prescription for 6 months, Berryman said.
There is an active suboxone clinic at the VA center, Berryman said. Suboxone is a medication used to wean addicts off powerful prescription drugs. Although it can also be abused, it's proven a successful means for stopping dependency on other drugs for many people.
The VA also routinely refers patients to local treatment centers, Berryman said.
The VA's policies aren't foolproof. Patients know how to avoid positive tests, and tests are only administered after someone is suspected of misuse, Berryman said. The six-month policy is also discretionary.
Patients aren't allowed to get prescriptions for powerful painkillers from the VA and other providers at the same time, but it does happen.
Rappold guessed at least once or twice a month, prescription providers face a problem with a patient and powerful painkillers. Pharmacists, doctors and others at the hospital can typically see signs of people abusing or misusing their medications, Berryman said.
"I wish there was a magic formula that we could use to separate the people who need them from those who don't. And if we could do that without offending or without crossing legal lines, we would do that in a heartbeat," Berryman said.
"We believe people first, we wait to be disproven. When we see evidence of disproving that presumption, then we act on it, period. No matter who it is."