by Art Levine
Yet even though Secretary McDonald, a former CEO of Procter & Gamble in Cincinnati, was personally warned by the whistleblowers about hospital conditions in a letter about five months before the story broke, he did nothing. In fact, in January 2016, supervisor Hetrick and hospital chief Temeck were awarded $12,500 and $5,000 in bonuses, respectively, USA Today reported. A month later, while forcing out Hetrick and Temeck from their jobs after the publicity, McDonald and Dr. David Shulkin approved an initial OMI “inspection” that found no safety problems. That investigation didn’t bother to interview any of the public whistleblowers; it also ignored 581 separate “quality events”—including bone-contaminated instruments—affecting 16 percent of all the hospital’s surgeries, outlined in that fiscal 2015 report obtained by Scripps. Finally, McDonald and the new regional supervisor publicly vowed to protect whistleblowers who provided more information. But just two days after this offer was made to a surgical tech, Scott Landrum, who went public with his safety concerns for the first time at a televised community meeting in April 2016, he was threatened by the VA hospital with being fired. During Secretary McDonald’s reign, the VA evaded questions about this scandal that flourished on the watch of the new VA secretary, Shulkin, when he headed the VHA division.
Now that Shulkin is in charge, the department is defiantly standing by its earlier findings and responses: “The VA OMI and other reviews of sterile processing practices at the Cincinnati VA Medical Center affirmed that high quality, safe services were and continue to be provided to veterans. No personnel actions were taken as a result of these reviews,” a spokesperson said in a March 2017 statement. This brief, dismissive response to a locally reported scandal that received virtually no major national attention is perhaps the best sign yet that the VA remains fundamentally broken and unchanged.
So in the absence of a genuine crackdown, about two dozen current and former employees who went public as whistleblowers first joined together in June 2015 to form the informal reform alliance “VA Truth Tellers.” The group prods the agency to get serious about improving care and transforming its bureaucratic culture. “Until the VA starts terminating the bad actors, everything else is just fluff around the edges and accomplishes nothing,” Ryan Honl told USA Today.
The VA and its defenders have never really acknowledged these harsh realities, so it’s difficult to understand how, for instance, the VA’s latest suicide prevention plans announced in 2016 can truly succeed. These include providing meaningful same-day treatment access for veterans with urgent mental health needs at 1,000 different facilities. The Clay Hunt suicide prevention act does require a third-party assessment of the VA’s efforts by December 2018 and each year thereafter, with the evaluators selected by the agency itself. Unfortunately, there are several groups, such as the Joint Commission for hospitals, that have a reputation for rubber-stamping whatever facilities pay their way, so it’s unclear how the public will be able to prevent the agency from gaming or even evading the Clay Hunt Act.
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IN THE CONTEXT OF THE USUAL WASHINGTON RESPONSE TO A SCANDAL—the ritual sacrifice of a few top officials as scapegoats to appease a rabid media—the lack of even an ersatz response after Secretary Eric Shinseki was forced out in May 2014 has been staggering. In June 2015, over a year after dozens of needless deaths were exposed at the Tomah hospital, the national VA finally responded with vague proposals that included “listening sessions,” but took no effective actions that would prevent future Tomah administrative scandals.
Following the prescribing excesses, Tomah officials also said they were following tougher new DEA guidelines on opiate prescribing that, some veteran advocates say, are harming patients with legitimate pain issues. That’s because patients are now required to see their doctors in person once a month for refills—a near-impossible task amid the backlog and delays throughout the VA system. Equally troubling, the VA’s crackdown on opiate prescribing—a swing from one extreme to another—may be contributing to an increase in heroin and illegal opiate medication use among veterans, as well as suicides from pain-wracked veterans going through unmonitored withdrawal.
Veterans are twice as likely to die from accidental opioid overdoses as non-veterans, the VA reported in 2011. As chronicled in Sam Quinones’s book Dreamland, by the late 1990s, the VA joined with leading medical organizations and the drug industry in promoting the unproven notion that opiates were “virtually non-addictive” when used to treat chronic pain. As secret corporate records disclosed in litigation showed, the VA’s pain management team became a propaganda arm for the drug industry, fueled in part by a $200,000 grant from Purdue Pharma, the manufacturer of OxyContin whose executives pled guilty to “misbranding” the drug’s addictive dangers in 2007. The department’s pain experts released a “Pain as the 5th Vital Sign Toolkit” for clinicians in 2000, then joined with DOD in 2003 in issuing guidelines spreading the industry’s fraudulent message: “Repeated exposure to opioids … only rarely cause addiction.” Helping spread the gospel of opioids for chronic pain was psychiatrist Rollin Gallagher, who testified in 2002 against restricting OxyContin before the FDA and worked as a consultant for Purdue and other narcotic manufacturers before becoming the VA’s deputy national program manager for pain management, a position he still holds as of this writing. In response to questions from The Austin American-Statesman in 2012, he said, “I am not influenced by the pharmaceutical industry in my work,” noting that he hasn’t received drug industry funds since 2006 and claiming he advocates safer pain management.
The department started backing away from its freewheeling prescribing of opiates only a few years ago with new initiatives that led to approximately a 25 percent drop in opiate prescribing, although it doesn’t track veterans who have turned to heroin or illegal prescriptions as a result of the cutbacks. Meanwhile, the agency has promoted more holistic approaches to pain. But even with these assorted reform pronouncements, the number of veterans with opioid-use disorders increased 55 percent over five years by 2015—and there are still few signs that any clinicians or administrators associated with reckless care faced any strong sanctions. Ignoring these deadly failures and the Tomah scandal altogether, Shulkin, in an opinion piece he co-authored in JAMA Internal Medicine in March 2017, shamelessly painted the VA as a national role model: “The VA has been able to address opioid overuse and pain management in a comprehensive manner.” Yet back at Tomah, the doctors, administrators and nurses who played a role in the deaths of Jason Simcakoski and over thirty other veterans weren’t initially disciplined, and not even a single dollar was deducted from anybody’s paycheck. As Ryan Honl, the original Tomah whistleblower, observed in mid-2015 with undisguised bitterness in an email: “Houlihan is still on paid leave. No one disciplined. Not a single person whatsoever. Nothing.” (The doctor’s paid leave lasted until he was finally fired in November 2015, and, of course, he was back in business treating patients until recently.)
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THE VENOMOUS BUREAUCRATIC CULTURE ALSO REFLECTED THE VA’S LONGSTANDING failure to actually implement and monitor their sweeping mental health plans. That’s the inescapable conclusion drawn from the findings in recent years of even the agency’s own insipid Inspector General office; an under-reported federal court ruling in 2011 that condemned the VA’s “unchecked incompetence” in mental health care; and the daily tragedies and barriers to quality care that veterans endure. It was a commonly cited—and tragic—statistic that twenty-two military veterans take their own lives each day, based on the VA’s own analysis of the data. A more recent, comprehensive July 2016 VA report placed the suicide rate at twenty a day, with 7,400 veterans killing themselves a year—a rate that is an alarming 21 percent higher when compared to civilian adults. Meanwhile, every month nearly 1,000 veterans attempt to take their own lives. By some measures, that’s more than one attempt every half hour. Roughly two-thirds of veterans who commit suicide are over fifty, the VA has reported. But an updated analysis showed a 44 p
ercent increase in the suicide rate of male VA patients between ages eighteen and twenty-four in a recent three-year span.
One problem could be the VA’s troubled Veterans Crisis line. Reports mounted in 2015 about a hotline system that often placed distressed callers on hold or shifted them to voicemail. One suicidal thirty-year-old Illinois veteran, Thomas Young, called the VA crisis line in July 2015, but no one answered. Wracked with despair, he went to the nearest rail lines outside a suburban Chicago Metra stop and waited for a train to run him over. His body was found on July 23rd, leaving behind a wife and two daughters to mourn him. “The next day, the veteran’s phone rang—it was VA’s emergency line returning his call,” according to the revelations at a 2016 Senate hearing reported by the conservative Daily Caller. Military Times found that some hotline staffers are still answering as few as one call a day even after a new hotline director was forced out in June 2016 after only six months.
The VA promised to build a new satellite Veterans Crisis Line site in Atlanta by October 2016 to create “redundancy” and add two hundred more responders. The VA asserted in an April 2017 congressional hearing and statements to the press that the problem of busy suicide calls rolling over for waits as long as thirty minutes had basically been solved, with claimed rollover rates of under 1 percent. Members of Congress were skeptical, and hidden problems remain: Benjamin Krause, a critic of the VA, recently reported on his DisabledVeterans.org website that a disabled veteran, Rob Matthews, recounted being transferred to an overseas operator with a foreign accent, not an American, when he called the crisis line during a family emergency. “It made me feel like I was sold out, and I have a loss of hope due to the response I received,” Matthews said.
All such failures are emblematic of broader patterns of indifference and shoddy care in the VA system—yet it’s worth recalling that it’s still better than what most mentally ill civilians receive. As many as half of Iraq-Afghanistan war veterans suffering from PTSD and depression, along with other illnesses, get treatment from the VA, according to a RAND Corporation study and recent VA reports. But only a portion of them get “minimally adequate” mental health care, RAND found—and that was based on the VA’s own hyped statistics.
The end result of such neglect can be seen in both the rising numbers of suicides and accidental prescription drug deaths. Starting in 2012 and continuing through today, more active duty soldiers die from suicide than in battle. Roughly 4,400 service members and over 75,000 veterans killed themselves between January 2005 and the end of 2015, according to the latest available findings. On this front, however, the VA is essentially better than no treatment at all: since 2001 the rise in suicides of veterans who manage to access VA care rose just under 9 percent, while the suicide rate for those who don’t use VA services or receive no treatment at all increased by 39 percent.
Women veterans are especially vulnerable to deficiencies in a VA system that was created primarily for men, and commit suicide at an increasingly high rate. An important VA study released in 2015 found that although women veterans commit suicide at somewhat lower rates than male veterans, their suicide rates were six times the rates of women without service records—and nearly twelve times higher than civilians for female veterans ages eighteen to twenty-nine. That’s often because of the trauma resulting from the high rate of sexual assaults in the military.
It’s small comfort that the increased rate of suicides was far higher among female veterans who couldn’t bring themselves to access a VA controlled by a male-oriented military culture. A scathing 2014 report by Disabled American Veterans on the failure of the VA and other federal agencies to provide adequate services to post-9/11 female war veterans concluded: “Nearly 300,000 women veterans are put at risk by a system designed for and dominated by male veterans.”
In practice, what this all means is that the increasing numbers of women veterans will likely be exposed to much of the same neglect and roadblocks to receiving quality care that men have endured for years.
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EVEN AS SUICIDES GARNER MOST OF THE PUBLIC’S ATTENTION ON MILITARY mental health issues, the prescription drug deaths of veterans such as Eric Layne and other West Virginia veterans in 2008 were early warning signs of a related health-care disaster that has never been seriously addressed. Neither the Department of Defense nor the VA has conducted a full-scale inquiry into the numbers, scope and specific causes of accidental overdoses due to prescribed psychiatric drugs, although the opiate crisis has obviously drawn considerable attention. But independent inquiries by veterans’ advocates, a leading academic researcher and a few media outlets have uncovered disturbing trends in mental health prescribing. By some estimates, reform advocates charge, over four hundred active-duty soldiers and veterans died in their barracks or at home from antipsychotic-related sudden cardiac death by 2014. As one reformer, neurologist Dr. Fred Baughman, contends, until military leadership limits the availability of antipsychotics, antidepressants or prescription polypharmacy, such deaths will likely continue.
A few rigorous studies suggest that thousands of veterans have been killed by accidental prescription drug overdoses in the last decade. One of the few scholarly reports on accidental overdose deaths of veterans, by University of Michigan and VA researcher Amy Bohnert, used 2005 data to conclude in 2011 that 1,013 patients receiving VA services died through unintentional overdoses, mostly from prescription medications. Legal opioids, at nearly a third of the accidental overdose deaths, were the most common substances involved, while nonnarcotic psychiatric drugs and sedatives were involved in 22 percent of the deaths she studied. Strikingly, the risk of prescription drug deaths including opiates was highest among mentally ill veterans even without a “co-occurring” addiction diagnosis, her follow-up research showed.
Remarkably, in 2014 across the entire US population, nearly 50 percent more people—almost 16,000—died from psychiatric drug overdoses than from heroin. According to the CDC, the psych med fatalities were led by benzodiazepines and other sedatives, although nearly 19,000 people were killed by prescription opiates.
As of 2016, the VA hasn’t released more recent overdose data, but because veterans were already dying from drugs at twice the rate of civilians in 2005, the annual number of veterans’ deaths hasn’t climbed as much as the civilian plague, Bohnert told me. Even with the scant available information from the agency, it’s still reasonable to assume that the number of veterans dying from accidental overdoses annually is nearing 2,000, if not more. Just the striking 272 percent increase in the VA’s legal opioid prescribing between 2001 and 2012, according to data obtained by the Center for Investigative Reporting, should be a source of concern.
In some localities, the potentially deadly spike in prescribing was far worse. The Fayetteville Observer discovered that in the Fayetteville, North Carolina, area, the VA’s prescriptions for the opiate hydrocodone shot up 4,100 percent in 11 years by 2012, with nearly 48,000 patients on that drug alone. National trend data from the CDC is just as alarming: The number of accidental overdose deaths for all people at least doubled between 2005 and 2016 to over 59,000 a year, mostly due to prescription opiates and heroin. Heroin use has increased nearly 500 percent in a decade.
“Mental health providers need to assess and address the risk of death from accidental [prescription] overdose among patients with psychiatric disorders in addition to risk for suicide,” Bohnert, an assistant professor in Michigan University’s psychiatry department, recommended in The American Journal of Psychiatry in 2012.
Yet despite new drug safety initiatives, few in the VA are successfully implementing such preventive steps for psychiatric medications, or keeping a systematic public count of these tragedies. They represent far more than numbers on a spreadsheet to Heather Simcakoski and the other widows and families left behind.
Of course, prescription drugs, if poorly monitored, could on their own drive veterans to suicide. These potential dangers have been established since the 1990s when c
lass action and wrongful death lawsuits exposed that manufacturers hid those risks for some patients taking such fraudulently marketed drugs as Paxil and the discredited cure-all Neurontin.
All these controversies have played out amid the raging debate among medical experts over the risk of increased suicide and the medical value of antidepressants. Those suffering from depression may just have to look to their own experience with medications and weigh the conflicting advice and competing “meta-analysis” overviews, even with the knowledge that many of those authoritative conclusions are undermined by corrupted drug industry studies. The arguments for and against antidepressants, as marshaled in books by such authors as Dr. Peter Kramer and Irving Kirsch, shouldn’t deter those with depression from consulting with an empathetic psychiatrist who will take any concerns about side effects seriously. Ideally, people grappling with depression should decide in collaboration with their doctor whether such medication is the best course. While it does seem that the benefits of appropriately prescribed antidepressants outweigh the risks for adults with major depression (with up to 70 percent of patients experiencing a significant reduction in symptoms), there isn’t a consensus on whether those drugs are effective for mental illnesses such as anxiety, moderate chronic depression or major depression in children and adolescents.
The case for medicating the young with antidepressants took another blow in the fall of 2015, when The BMJ (formerly British Medical Journal) re-analyzed previously hidden data in GlaxoSmithKline’s notorious Study 329 on Paxil for adolescents with major depression. The BMJ researchers found that the drug was ineffective and that the study failed to disclose that youth on Paxil were as much as eleven times more likely to engage in seriously suicidal behavior than those on placebo.