The VA’s Pain Care Cluster

The VA’s Pain Care Cluster

(Editor’s Note: Darisse Smith is a retired U.S. Army helicopter pilot who recently wrote a column on National Pain Report about her struggle with chronic pain, addiction and going cold turkey off opiates.)

The Veterans Affairs’ healthcare scandal was big news for a few weeks this summer. People who have never utilized the VA were shocked and outraged that veterans died while waiting for appointments at VA hospitals.

But anyone who has relied on the VA system was already numb to the routine incompetence they witnessed. The main problem is that the VA as a whole is too big to make any systemic changes that are needed.

Who could do a better job treating patients? The civilian healthcare system. Haven’t vets earned the opportunity to choose their own doctors? We should at least get the same medical treatment as the insured civilian population.

Capt. Darisse Smith

Capt. Darisse Smith at Lake Dukan, Iraq

As a person with intractable lower back pain caused by my service as an Army helicopter pilot in Iraq, for a long time I was afraid of using the VA. But, I finally decided to give it a try.

For full disclosure, I had a terrible overall experience with military medicine while in the Army. In fact, the treatment was so negligent, I suffered from permanent nerve damage that created searing pain in my left leg. Without a spinal cord stimulator, I would have committed suicide.

I still had an open mind though, and after an initial wonderful experience getting enrolled and quickly seen by a VA primary care doctor, I was encouraged.

Eventually I was sent to a VA pain management clinic, where I was hopeful they would make some adjustments to my stimulator and help me wean off the fentanyl I had been on for 2 years.

My first visit to the clinic was stupefying. The resident looked directly at her computer screen while briskly asking questions. “What kind of pain are you having?” she said. “What have you been on?”

She didn’t intend to listen to my answers. She gave me no physical exam. And she prescribed morphine instead of fentanyl, cutting my equivalent dosage by 80%. I told her that morphine made me sleepy. Still looking at her computer, she said dismissively, “All opiates are the same.”

She left to consult the head doctor about her supposed treatment plan. He came in and said, “The VA has a directive about how high a dosage of opiates Iraq and Afghanistan veterans with post traumatic stress disorder can be on.”

There were no follow up questions about how I was feeling. Just a ridiculous lowering of my dosage and a “sucks to be you.” I wasn’t asked to sign a pain patient contract or given any guidance on the clinic’s rules and methodology.

What do they expect me to do when they lower my dosage that much? I have been in this game a long time. I won’t suffer because a doctor doesn’t care or doesn’t consult with me when making a treatment plan. So I doctor shopped outside the VA.

Naturally, they caught me on my next visit. The head doctor marched into the room and angrily asked, “Why did you do this?”

“I want you to look at my chart,” I told him. “You lowered my dosage without any supporting treatment and then never returned any of my calls.”

He interrupted and said: “There is no excuse for this.”

A couple of months later, they sent me a form to sign — wanting me to admit that I was a drug abuser. If they thought I was a drug abuser, where was the offer for substance abuse treatment?

Certainly, this is not an uncommon occurrence with civilian doctors. But the VA has a policy about how much veterans with PTSD can be prescribed, and that dosage is very low.

I have seen how unsuccessful these edicts from above usually worked out in the Army. If they were going to stick to this blanket decision, where was the support for the veterans? What do they think happens to a veteran when they’ve been on a stable dose one day — and the next are thrown into horrible pain and withdrawal?

veterans affairsWhat happens is they go somewhere else for help, like I did. Essentially, the VA’s decision about opiates is just moving the overdose and substance abuse statistics off their liability radar.

Let’s look at the real numbers concerning veterans and prescription drug abuse. According to the VA, there are 21 million veterans in the United States. The number utilizing the VA healthcare system ranges from 650,000 to 1 million.

My first impression is that the VA really doesn’t know how many opiate prescriptions they are doling out. According to an independent study conducted by Human Rights Watch, one million veterans are receiving opiates for chronic pain. There is a very high percentage of comorbidity in veterans with chronic pain and PTSD. The most reliable percentage that I could find was that 66% were diagnosed with both chronic pain and PTSD.

Of course, considering what combat veterans especially have gone through, PTSD and chronic pain would be a natural human response to war: 1) Commit violent acts against other human beings? Check. 2) Be afraid every day for a year? Check. 3) Have multiple people try to kill you? Check. 4) Beat your body up every day during your military career? Check.

The next logical and unfortunate link to chronic pain, PTSD and the prescribing of opiates is the rising numbers of veterans who are committing suicide or experiencing accidental overdoses. Overuse and/or addiction to opiates is also often linked to mental health issues.

The nature of PTSD is that the afflicted usually don’t aggressively seek treatment. In fact, in military culture it is still quite shameful to seek mental health treatment. About half of veterans with PTSD do not seek treatment.

The VA doesn’t actually track the effectiveness of their PTSD treatment, another failure. An independent study by the RAND Corporation found that of the 50% who do seek treatment, only half of that number get minimally effective PTSD treatment.

In my limited experience, I found it much easier not to get treatment. After getting a referral, a social worker called to evaluate me and talk about the available services. First of all, when I think of a social worker, I think of someone who is going to take away my baby. Even though I need help, I don’t want to be openly acknowledged as someone who needs it. It is an inane military mentality, but it is still relevant.

Do the people who work in the VA get a cleansing lobotomy when they enter those bureaucratic corridors? I tried to call the guy back, but he was hard to locate in the system. That was enough for me to avoid treatment altogether. No one followed up with me. I guess I just fell into a Siberian sinkhole

The VA spends $3 billion annually on PTSD care. But since they haven’t decided to track the outcome of their treatment, no one knows if the money is spent effectively. Spending $3 billion sure does look good and there are other statistics that might make the VA look good too. But the individual’s well being is not considered or tracked.

Instead, out of touch VA administrators make decisions like reducing one’s opiate dosage without really having any evidence to warrant this decision. Consider if I had listened to the doctor, and tried his low dosage. I would have suffered through withdrawal, and become very sad and depressed, with no where to go. I wouldn’t go to the pain doctor at the VA because he wouldn’t call me back and he had chastised me at my last appointment.

Darisse Smith

Darisse Smith

The PTSD referral eventually ran out and I dropped out of the VA system, frustrated. The VA never asked why. In fact, I’m not sure they’ve noticed that I’ve missed all of my other appointments.

Instead, I’ll go out into the civilian world where the VA will lose track of me forever.

I gave up having children in my 20’s, my ability to thrive in a crowd of people, and four lower back vertebrae in service of my country.

Don’t keep telling me that I deserve better without offering it. Give me affordable healthcare insurance, the veterans’ edition, and let me choose my own doctors in the real world.

 

Authored by: Darisse Smith

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MSA

They did this to me as well!!! I found out later they decided to blame it on a drug test that I supposedly failed. I have been prescribed Roxicodone and Oxycontin. My test came up with none of that but it did come up with morphine. BUT, the urine is tested twice and the other one had the test results as EXACTLY what I take. Three doctors admitted this error yet I have been trying to have the mistake fixed in my medical records and still cannot get it fixed. I am a VA employee so this is extremely troublesome. I pay for my own healthcare, exactly what they want me to do. I have called so many people and Patient Advocates ignore me and it even went to the Chief of Staff and Director who all never got back to me.

Has anyone heard if Marinol has had any drug overdoses? Of course, I heard this from a medicinal marijuana dispensary here in CA, so I don’t trust the source too much. Frankly, I would rather choose how I take Marijuana if I do choose whether I smoke it, vape it or eat it. I find I have most control either vaping or smoking. Mostly, I find that I am usually trying to hide sad feelings rather than the physical pain. Since I am plagued with that addiction thing, I only use it when I’m in absolute physical agony, fortunately not too often.

BL

Steve M, I am aware that Marinol/dronabinol will show up as positive. But, if your dr gave you a rx for Marinol/dronabinol and the blood levels for it are correct on a drug test, there shouldn’t be any problems. If the amounts are higher, then that would be a problem.

Steve M

BL

Yes, most pain management offices will discharge you because it’s federally illegal and they worry about the DEA. However, a prescription for Marinol/dronabinol (CIII) will make you test positive for THC (both screening test and GC/MS) , so you have an excuse for the positive test.

Many PMs make you choose cannabis OR opioids.

BL

Rick Rosio, I have a question. In many states where medical marijuana is legal, if your dr does a drug screen and you test positive for marijuana, you are dismissed from Pain Management. Do you know how this is addressed, if at all, in Washington state ?

If you live in a compassionate state that has passed a medical cannabis law, then Veterans who are suffering from injuries and PTSD, TBI, CTE can treat the symptoms with the least amount of toxic prescription medications and use cannabis under medical direction to help reduce opiate levels and heal from their injuries. http://www.veteransforcompassionatecare.org/clarecenter.asp

Thanks for your response! While I was actively getting healthcare through the VA here in Loma Linda, every doctor I had was a Resident, a doctor but still in training. That is fine if they have good supervision, though yes, I do think vets deserve better. What got me riled up is how a Resident might come up with a treatment plan by evaluating me and asking me questions, yet be overruled by a supervising doctor who neither read my chart nor talked to me. This was near the end of my so-called “journey” with the VA.

BL

Darisse, Thank You For Your Service. The city I live in has a VA Hospital and a large military installation close by. We also have a Medical School here. At different phases in their training, students from the medical school see patients at VA. This has been going on as far back as I can remember. I have never understood why VA would allow someone who was still in training to go to VA and present themselves as Physicians to Veterans.

Maybe if some Americans began to not go in the Service due to concerns over medical treatment for them and their family members and tell the politicians in Washington why, things might change. But, I doubt it.