Vets twice as likely to overdose fatally — what the Dayton VA is doing about it
By KATIE WEDELL | Dayton (Ohio) Daily News | Published: October 7, 2018
DAYTON, Ohio (Tribune News Service) — One of Ohio’s largest drug rehabilitation facilities sits on the west side of Dayton but many local residents — including those who could qualify for free care there — are unaware of its existence.
With 99 residential beds, an outpatient clinic and programs to help recovering addicts find housing and employment, the Dayton Veterans Affairs Hospital has developed the kind of comprehensive addiction treatment program other agencies serving the general population strive to duplicate.
The Miami Valley is home to more than 83,400 veterans from all branches of the military, which equals about 10 percent of the total local population.
Historically, military personnel have been more likely to be prescribed prescription pain medication than the general population and more likely to abuse opioids, according to VA studies. Some reports have shown veterans are twice as likely to die from accidental opioid overdoses as nonveterans.
The VA is aware of those issues and has developed new prescribing and prevention practices, as well as a wrap-around system of care for those who have become addicted to drugs or alcohol.
The Dayton Daily News’ Path Forward initiative looks for solutions to how the region can shed its national reputation as ground zero for overdoses and can recover from the addiction crisis. We examined the VA’s programs to see if outside organizations can emulate its best practices. Some barriers exist, however, including restrictions on what services Medicaid will cover.
“It’s really, really changed me,” Marine Corps veteran Mason Brubaker said of the VA’s inpatient treatment program, which he just completed for alcohol addiction. “I’m not typically one that will spill my life story to anybody, but the way that they can communicate and talk to you and make you feel comfortable, it’s unbelievable.”
The Dayton VA wants to reach more veterans like Brubaker, many of whom might not know about their addiction services or that they may qualify for help.
“I thought the VA was for someone who had lost a leg in battle,” said Ted Froats, who is the public affairs officer for the Dayton VA and also a veteran. “Folks don’t realize that it really is for a wide array of things.”
Crisis crosses the fence line
The VA campus — 334 acres of federal property that houses a hospital, numerous outpatient clinics and medical offices, a nursing home, residential housing and the Dayton National Cemetery — hasn’t been immune to the opioid crisis raging outside its fence line.
In 2017, VA campus police conducted 67 drug-related investigations, up from 28 the year before. Twelve people overdosed on the VA grounds last year, including two deaths. Campus police carry the overdose-reversing drug naloxone, also known as Narcan, like many local police and fire departments.
A recent Inspector General report cleared the Dayton VA’s Mental Health Residential Rehabilitation Program of blame in one of those deaths. A veteran with a history of opioid-use disorder was found unconscious in a locked bathroom stall on the campus in early 2017.
The VA police department is utilizing all of the resources on campus to resolve drug cases when they arise. When a defendant appears in a local veterans’ court, a social worker and a representative from the Goodwill Easter Seals job placement program are there to support them.
“It’s not about writing a veteran a ticket or putting them in jail, it’s about getting a veteran the services they need,” VA Police Chief Earl Burkhart said. “Officers on the outside don’t have all of the resources that are available (at the VA) to get the people what they need.”
Continuum of care
One of those unique resources is the veterans’ health benefit that covers services not paid for by Medicaid or private insurance. The national VA budget calls for $382 million to be spent on opioid treatment for veterans in 2019, an increase of $15 million from 2018.
Many veterans whose conditions are service-related can qualify for free care at the VA, while some will be required to pay co-payments or other costs, based on their years of service, levels of income and disabilities.
In fiscal year 2018, the Dayton VA identified 1,236 patients with opioid-use disorder and treated 521 with medically assisted treatment and 371 with residential and outpatient treatment. The VA wasn’t able to provide any data to compare patients’ success rates with other VA facilities or nonveteran programs.
The VA system allows for many different types of services to be covered under one benefit plan — including prescriptions, medical care, addiction treatment, counseling, and programs for homeless and jobless vets.
Medicaid or private insurance often will pay for a certain amount of inpatient or outpatient substance-abuse disorder treatment, but usually doesn’t cover other services like a stay in a sober-living home, ongoing counseling, transportation or job training.
“Once we get people stabilized with treatment, then what?” said Helen Jones-Kelley, executive director of Montgomery County Alcohol Drug Addiction and Mental Health Services.
The county would like to be able to give people more access to things like peer support and employment training, Jones-Kelley said. ADAMHS hopes to use money coming from the 21st Century Cures Act to cover those other services so that all those recovering from addiction have the same kind of wrap-around support that’s available at the VA.
Currently, ADAMHS administers state, federal and local dollars to dozens of different agencies that provide various treatment services, Jones-Kelley said. But it wants to create more of a seamless, one-stop-shop system.
“I really think that’s what we’re building,” she said. “We’re trying to build a regional response so that we can create this continuum of care.”
Montgomery County’s Community Overdose Action Team (COAT) model has been praised by the White House for bringing together more than 100 different agencies to work collaboratively on attacking the opioid crisis, and the VA has a member on that team.
One obstacle to providing more comprehensive services on the size and scale of the VA has been Medicaid rules. Current law prohibits using Medicaid dollars to pay for treatment at residential mental-health or substance-abuse facilities with more than 16 beds.
But U.S. Sens. Rob Portman, R-Ohio, and Sherrod Brown, D-Ohio, secured a provision in the recently passed House-Senate opioid package that would lift that limit.
The rule dubbed the Institutions for Mental Disease exclusion has been in place since the creation of Medicaid in 1965. It was intended to ensure that states, rather than the federal government, continued to bear responsibility for paying for inpatient psychiatric services.
“The IMD exclusion has posed a significant obstacle to Medicaid patients with substance use disorder accessing the full continuum of care,” said American Society of Addiction Medicine President Kelly Clark in a Sept. 18 news release announcing the legislation.
The bill would lift the cap for five years.
Another provision in the opioids package would take existing grant programs at the U.S. Department of Labor and the U.S. Department of Health and Human Services and would create a six-year pilot project to combine job training and addiction-recovery services.
‘Thankful that I found this place’
A common thread in the stories of many veterans seeking help for addiction at the VA is that it wasn’t the first place they turned. Brubaker is from London, Ohio, and said he never thought of the Dayton VA as a resource available to him.
“I knew that I had a problem and I was trying to address it, but I just simply didn’t know how to,” he said.
It took prodding from several friends to get him to check out the VA’s services and to learn that he could do inpatient treatment there. Now that he’s been sober more than two months, he’s getting help with finding a job and an apartment and setting up ongoing support so he can continue to go to meetings.
“I’m just so thankful that I found this place and had this opportunity,” he said. “Where I’m from, those resources just simply aren’t there.”
Froats encouraged anyone who knows a veteran with substance abuse or other mental health issues to call 937-262-2159 because that person might be eligible for benefits.
Moving away from opioids
When a 2011 VA Health Systems study showed veterans were more likely than nonveterans to be prescribed opioids, the VA launched an opioid-reduction initiative in 2012. Since then, 99 percent of VA facilities nationwide have decreased their prescribing rates, according to a 2018 VA report.
The VA said doctors work to taper the dosages of patients who were on opioids as well as provide alternatives like nonopiate pain medication, medical massage, acupuncture, hypnosis, epidural steroids and nerve replacement.
“We live in a society where the idea is everybody should be pain-free, and that is an unrealistic expectation,” said Dr. Thomas Hardy, medical director at the Dayton VA Medical Center.
The Dayton facility has reduced the number of local veterans using opioids daily from about 3,500 during fiscal year 2017 to 2,000 in fiscal year 2018, he said.
Some veterans are unhappy their pain medication has been cut back, Hardy said, and it’s an ongoing education process.
John Langley, an Army veteran who’s a patient at the Dayton VA’s Springfield Community Based Outpatient Clinic, said his oxycodone prescription for back pain recently was cut in half.
“There’s days that I’m in such pain that I don’t know what I’m going to do,” said Langley, 78.
Langley served in South Korea in the early 1960s and has multiple back conditions that he said began with injuries during his service. He now uses a wheelchair and had to retire from his job at the post office due to disability.
At one point, he was prescribed 240 milligrams of opioid pain medication per day. It made him sleepy, he said, and he would bring extra pills back to the doctor.
“I told them I didn’t need that much medication,” he said. His dose was dropped to 120 milligrams per day, which he said worked for him.
But on his last visit to the doctor, he said his dosage was cut in half again to 60 milligrams per day. The doctor told him it was because they were working to prevent overdoses, Langley said.
“I wake up at 2 o’clock in the morning, suffering from pain,” he said. “I don’t think they’re doing some of the veterans justice.”
People have offered to buy pills from Langley before and he believes cutting doses will only lead to veterans’ seeking out drugs illegally.
“How many of those veterans that aren’t getting what they need are out buying it from the streets?” he said.
In health-care settings across the nation, providers are moving away from managing pain with opioid prescriptions, Froats said.
“Opiates are not as beneficial for pain as the health care community once believed,” he said. “In addition, up to 40 percent of those on opioids develop an addiction.”
The Dayton VA has reduced its opioid prescription rate by 44 percent since 2012, Froats said.
“To accomplish this reduction, we have slowly tapered opioid dosages while also offering more effective evidence-based alternatives for pain treatment,” he said.
VA guidelines call for a tapering of opioid dosage by 10 percent per month and Froats said guidelines were followed in Langley’s case. After the Dayton Daily News asked about Langley’s treatment, the VA assigned a patient advocate to reach out to him about his concerns, Froats said.
Any veteran prescribed a regimen that equals at least 100 milligrams of morphine equivalent per day is considered at high risk for overdose by the VA and is given naloxone to take home, plus training on how to administer it, along with their family members. In the past fiscal year, the Dayton VA administered more than 600 such kits.
“We have testimonials of people whose lives have been saved,” Hardy said.