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VA doctors freely handed out pain medications to veterans for years.
Then they stopped. The results have sometimes turned tragic.

http://www.startribune.com/cut-off-veterans-struggle-to-live-with-va-s-new-painkiller-policy/311225761/

Story by Mark Brunswick, Photographs by Brian Peterson Star Tribune

July 12, 2015 — 12:00PM

WORST-CASE: Iraq veterans Zach Williams and Ryan Trunzo overdosed after battling chronic pain and withdrawls from pain medication.

Zach Williams came home to Minnesota with two Purple Hearts for his military service in Iraq. He also carried other lasting war wounds.

Back pain made it hard for him to stand. A brain injury from the explosions he endured made his moods erratic.

Williams eased the chronic pain with the help of narcotics prescribed for years by the Minneapolis Veterans Medical Center. Then the VA made a stark and sudden shift: Instead of doling out pills to thousands of veterans like him — a policy facing mounting criticism — they began cutting dosages or canceling prescriptions, and, instead, began referring many vets to alternative therapies such as acupuncture and yoga.

At first, the change seemed to work: Worrisome signs of prescription drug addiction among a generation of vets appeared to ebb. But the well-intentioned change in prescription policy has come with a heavy cost. Vets cut off from their meds say they feel abandoned, left to endure crippling pain on their own, or to seek other sources of relief.

Or worse.

On Sept. 20, 2013, police were called to Williams’ Apple Valley home, donated to him by a veterans group grateful for his sacrifice. Williams, 35, lay dead in an upstairs bedroom. He had overdosed on a cocktail of pills obtained from a variety of doctors.

Authorities ruled his death an accident, officially “mixed drug toxicity.” Advocates for veterans and some treatment counselors angrily call it something else: the tragic result of the VA’s failure to provide support and services for vets in the wake of the national move away from prescription pain pills.

At the VA’s Medical Center in Minneapolis, for instance, there is one chiropractor on staff for the more than 90,000 patients it sees a year. 

“The VA has been doing an awful job on this issue,” said Dr. Andrew Kolodny, chief medical officer for Phoenix House, a drug and alcohol rehabilitation organization that runs more than 130 treatment programs in nine states, including programs for veterans.

Before alternative therapies can work, Kolodny said, the VA needs to better tend to the addicts it has created.

Video (2:05): Neva Howard talks about how pain changed her fiancé, Zach Williams.

Mark Vancleave

Hugh Quinn, a veterans advocate for Itasca County, is even more blunt: “The VA let them get wound up on all these drugs and now they cut them off completely,” he said. “These guys are coming into my office and they are a goddamn mess and the VA is just blowing them off.”

VA leaders strongly defend the work they’ve done to wean thousands of vets off highly addictive pain pills and to direct them toward other ways to treat their chronic pain.

“VA has been at the forefront in dealing with pain management, and we will continue to do so to better serve the needs of veterans,” Carolyn Clancy, the interim VA undersecretary for health, told the Senate Veterans’ Affairs Committee earlier this year.

In May, four members of Congress asked the U.S. Government Accountability Office why vets are having trouble accessing alternative treatments and why some vets are no longer getting the medications they need.

Generation of addicts

Almost 60 percent of veterans returning from the last decade of war list chronic pain as their most common medical problem.

The VA’s initial solution: a powerful but potentially addictive class of drugs known as opioids.

During an 11-year period ending in 2013, the number of prescriptions from the VA for pain meds like oxycodone and morphine surged 259 percent nationally.

At VA hospitals in Minneapolis, St. Cloud, and Fargo, prescriptions for morphine and oxycodone more than doubled for every 100 patients from 2001 to 2014.

Methadone prescriptions almost tripled, according to data obtained by the Star Tribune through the federal Freedom of Information Act.

Lawmakers and some veterans groups, concerned about overdoses, drug suicides and reports that medications were being sold on the street, pushed the VA to adopt more effective pain management protocols.

Cutting back at three VA hospitals

A 2012 DEA rule change led to a steep decline in prescriptions for addictive painkillers at VA hospitals and clinics, while the number of veterans seeking treatment for chronic pain has steadily increased since the start of the wars in Afghanistan and Iraq. The charts below show pain prescription data for the three regional VA hospitals in Minneapolis, St. Cloud and Fargo since 2001.

In 2009, the VA instituted new regulations that required clinicians to treat the root causes of pain, rather than just dispense more painkillers.

In the midst of the changes, another federal agency – the Drug Enforcement Administration – in 2012 imposed new rules on the pain prescriptions the VA is still providing.

The Minneapolis VA, which had one of the highest rates of high-dosage prescription pain medications, has embraced the new directive to reduce painkiller use among its patients.

It pioneered a program that emphasized education and alternative therapies like yoga, chiropractic treatment and acupuncture. You can see the link, for the best chiro around you.

In a three-year period from 2011 to 2014, it reduced the number of veterans on long-term high-dose opioids by 78 percent.

National VA leaders trumpeted Minneapolis’ success.

“I would be the last person to say we are now right where we want to be with our pain care in VA, but I will be the first person to say that we are well along in the process of getting there,” Dr. Robert Petzel, then the VA’s undersecretary for health, told Congress last year, using the Minneapolis program as an example.

In Minneapolis, Dr. Peter Marshall, head of the Minneapolis VA’s pain management staff, launched the Opioid Safety Initiative in 2011. In letters to primary care doctors, he and his team offered to help wean their high-dosage patients from their reliance on the most highly addictive painkillers.

By October 2014, the number of high-dosage prescriptions at the Minneapolis VA was down 90 percent.

Video (2:04): Dr. Peter Marshall explains the goals of the VA’s pain management strategy.Mark Vancleave

“We didn’t have any plan to cut anybody off,” Marshall said. “We were telling people, ‘It’s not safe for us to continue prescribing.’ ”

In their published findings, Marshall and his colleagues wrote that there were fewer complaints than expected.

“Patients mostly appreciated what we were doing,” said Marshall, who now directs pain management programs at the Minneapolis VA and the VA’s Upper Midwest region.

While the paper recommended further research into patient satisfaction, the study surveyed only providers and pharmacists.

‘I don’t have a life’

Although statistics aren’t available, deaths of vets linked to the VA’s pain policy are showing up in headlines around the country.

Last July, Navy veteran Kevin Keller drove himself to a drugstore parking lot next to a VA community clinic in Wytheville, Va., late at night, walked to the door of the clinic and shot himself in the head.

In recent years Keller had complained that VA doctors were reducing his pain medication. Keller had scribbled a note to a friend. In capital letters it read: “SORRY I BROKE INTO YOUR HOUSE AND TOOK YOUR GUN TO END THE PAIN! FU VA!!! CAN’T TAKE IT ANYMORE.”

In October 2013, Todd Roy, a 45-year-old Persian Gulf veteran, shot himself in the head with a shotgun in friend Charlie Bollman’s garage in Watkins, Minn. In 2008, the VA, citing alcohol and drug abuse, had cut off Roy’s Vicodin for pain in his arm and shoulder.

“If someone is taking narcotics and you cut him off cold turkey, there’s nothing good that’s going to come from that,” Bollman said.

Living with the VA’s new painkiller policy has been a tough adjustment for recent and older vets alike.

Army vet Dan Klutenkamper said he went to the VA in 2012 to seek help for chronic pain for a degenerative disc brought on by two tours in Iraq and one in Afghanistan. “They told me they weren’t giving anything out right now because of the mismanagement of the medications that they had done,” he said.

After several attempts, Klutenkamper said he gave up and began abusing alcohol. He’s sober now. Except for a prescription for anti-depressants, Klutenkamper says he avoids the VA.

For more than 40 years, Vietnam vet Peter Ingravallo has suffered back pain after being hit with shrapnel during an ambush. With a 100 percent disability rating, Ingravallo took 25 milligrams of oxycodone every four hours until the Minneapolis VA sent him a letter telling him it was reducing his medications by 70 percent. It also warned that he would lose his benefits if he got meds from somewhere else.

There was no dosage tapering and no offer of alternatives, he said.

“As far as my life, I don’t have a life,” said Ingravallo, who this year took out a private health insurance policy because of his frustrations with the VA. “I’m in constant pain.”

A LONG WAIT: After two tours in Iraq and one in Afghanistan, Army veteran Dan Klutenkamper (right) went to the VA to seek help for chronic pain. It took him a year to get his first appointment on his disability claim and 7 months to find out if it was service related.

CONSTANT PAIN: Vietnam vet Peter Ingravallo took 25 mg of oxycodone every four hours until his medication was cut by 70 percent.

New rules govern use

The Minneapolis VA’s chronic pain unit offers a weekly, hourlong “Pain Options Class” and has developed a landmark four-week inpatient treatment program.

But at times the VA also sends a harsher message.

Some veterans, many who had no history of addiction, got letters announcing they were being taken off their pain medications without offers of assistance or explanation.

“There wasn’t a lot of discussion with the veteran except for the provider saying, ‘We’re not going to be doing this anymore because it’s not good for you,’ ” said Joy Ilem, of Disabled American Veterans, one of the country’s largest veteran service groups.

Some vets have been warned that if they don’t take part in educational programs, they won’t get prescriptions. Failure to submit urine samples could result in expulsion from the program.

Vets also complain of being kicked out of programs for failing “pain contracts” they were ordered to sign. The contracts require the vets to agree to submit to urine screenings and to take one of several VA opioid safety classes or risk being denied their medications.

A VA directive acknowledges problems with pain contracts, called Opioid Pain Care Agreements (OPCAs), citing concerns about their use of “threatening language and their potential to undermine trust.”

The VA denies that veterans are “kicked out” of the Minneapolis VA or Minneapolis pain management services. But, it said, if a veteran’s pain medications are found to be causing harm or failing to help, they may be “appropriately reduced or discontinued.”

“Are you kicking people off opioids then or are you trying to do the right thing?” asked Marshall, the Minneapolis VA’s head of pain management.

The VA appears to have sent mixed messages about the contracts, including whether they even exist.

In a May 2014 letter to U.S. Sen. Al Franken, D-Minn., whose office had asked questions about local VA operations, Patrick Kelly, the director of the Minneapolis VA, wrote, “It is VA policy to have patients sign a pain agreement, sometimes termed a ‘pain contract,’ for patients who are receiving narcotic medications.”

But when the Star Tribune asked the Minneapolis VA to provide the numbers of vets who have signed its pain contract and how many have failed, a spokesman said, “There is no pain contract, so there can be no violation of a pain contract.”

Asked about the discrepancy, the VA said its policies changed five days after the letter to Franken’s office was sent.

From weaning to OD

FATHERLESS: Zach Williams’ fiancée, Neva Howard, with their baby girl, Katerina.

Zach Williams’ fiancée, Neva Howard, said he had initially embraced nearly every program the VA had to offer, taking classes to deal with PTSD and working closely with his doctor on his pain.

But one day when a nurse gave him his meds, there were fewer than there should have been. There were even fewer as time went on. Howard said a nurse told him that a decision had been made to wean him from the medications.

“He said, ‘I’m totally OK with weaning off. But you can’t just do it and not talk to me about it,’ ” she said. “After a couple times dealing with that kind of stuff, he just didn’t want anything else to do with them. There was no communication.”

The Minneapolis VA, which treated Williams, did not comment on his case, citing privacy laws.

Williams started seeing a private physician, and Howard said there appeared to be progress. But there were still days he couldn’t get out of bed. His diet consisted mostly of pizza and energy drinks.

He treated the injuries to his body and mind with prescriptions from several doctors. When he died, police found an assortment of drugs around the house: a sealed container of the stimulant Adderall, sealed prescriptions of the panic disorder drug Clonazepam and the painkiller oxycodone. On the kitchen table were two packages of the painkiller Fentanyl. A combination of Fentanyl and the panic disorder drug Venlafaxine had proved fatal.

A continuing problem

The VA still faces complaints that it hands out too many pain prescriptions. A VA hospital in Tomah, Wis., is the subject of continuing investigations by the VA inspector general and by state authorities after doctors prescribed so many narcotic painkillers that some veterans called the place “Candy Land.”

But U.S. Rep. Tim Walz, D-Minn., a member of the House Veterans Affairs Committee, said he is hearing more about the VA withholding pain medication. “These are powerful tools that provide relief they can’t get anywhere else,” Walz said. “If it’s appropriate to use an opioid, then let’s do so with a plan so that there is an endgame.”

In June, VA officials were called to Capitol Hill to address concerns that their aggressive pain management policies were going too far. Sen. Tammy Baldwin, D-Wis., introduced a bill requiring stronger guidelines for prescribing opioids. It would also require the VA to develop plans for researching and using alternative pain therapies.

“We have a long way to go to figure out what works best,” she said.

‘The pain was too great’

Ryan Trunzo’s descent from promising soldier to drug addict is detailed in more than 500 pages of medical files and Army reports. His family in Andover shared them in hopes that his story would illustrate the effect of the VA’s policies.

Trunzo, who was 19 when he joined the Army, served in Iraq from February to November 2008 and was injured when his convoy was hit by a roadside bomb.

He suffered several small fractures in his back and was given some painkillers.

There were other traumas: the death of a close friend, the shooting death of an Iraqi boy and an incident in which he said he was ordered to stand guard while a superior officer sexually assaulted an Iraqi woman.

A soldier’s descent into addiction

Back home in Andover, the St. Cloud VA prescribed drugs — 13 pages’ worth over time.

But, because of a history of addiction during his military service and the change in VA policy, for the pain Trunzo got tablets of nothing stronger than over-the-counter-strength ibuprofen.

MISSING SON: Paula Trunzo in her son Ryan’s bedroom, which remains as it was before he died. Ryan Trunzo was injured in Iraq and received pain medication at the St. Cloud VA. But with the change in VA policy, he received only ibuprofen, and eventually started using street drugs. His family found him, a syringe in each arm and one in his chest, when they returned to their Andover home on Father’s Day weekend last year.

“When Ryan came back home, he went to doctors to get pain medication and couldn’t get it,” said his mother, Paula Trunzo. “That’s when Ryan started using street drugs to stop the pain, to stop the memories.”

The last entry in his file documents a 35-minute VA clinic visit on June 6 last year. The notes started: “Veteran presents today reporting he is having a terrible time.”

A week later, on Father’s Day weekend, the family packed up for the cabin near Lake Vermilion. Ryan didn’t go. Driving back, Paula suspected something was wrong. She rushed into their home.

Ryan lay dead on his bed, a syringe in each arm and one in his chest. The cause of death was heroin toxicity. He was 26. His mother thinks he meant to take his own life. “The pain was too great,” she said.

A St. Cloud VA spokesman said it could not comment on Trunzo’s treatment, citing federal regulations, but added: “We were deeply saddened to learn of Ryan’s death, and understand the family’s grief.”

Paula Trunzo has a one-word answer when asked now how she feels about the VA.

“Disgust,” she said. “I feel like the VA took my son’s life.”

Staff writer Glenn Howatt contributed to the data analysis of this story.
Mark Brunswick • 612-673-4434

PART 2:
HIGH DEMAND, FEW OPTIONS

Veterans face strapped system as VA shifts to alternative therapies.

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VA kicks vets off pain meds in favor of alternatives like yoga and acupuncture, but it’s not keeping up with the desperate demand.

http://www.startribune.com/the-new-goal-at-the-va-treating-the-root-causes-of-veterans-pain/311225971/

VA kicks vets off pain meds in favor of alternatives like yoga and acupuncture, but it’s not keeping up with the desperate demand.
Story by Mark Brunswick, Photographs by Brian Peterson Star Tribune
July 12, 2015 — 12:00PM

The backroom of the James Ballentine VFW Post #246 in Minneapolis’ Uptown neighborhood looks more appropriate for meat raffles and ladies’ auxiliary meetings than for medical treatments.

But one night this spring, the post — just 7 miles from one of the country’s major Veterans Affairs medical centers — became the best refuge for veterans struggling to cope with the pain of injuries from their military service. Eight acupuncture chairs, four chiropractic chairs and three treatment beds were set up, awaiting vets who would soon be arriving.

Alternative therapy — from acupuncture to yoga — is a key part of the VA’s new effort to reduce vets’ dependence on highly addictive pain medication. The Minneapolis Veterans Medical Center is helping lead the effort, with a first-in-the-nation chronic pain program that emphasizes education and other alternatives to drugs.
PART 1: WOUND UP, CUT OFF
Iraq veterans Zach Williams and Ryan Trunzo overdosed after battling chronic pain and withdrawls from pain medication.

But the free services offered by the Minneapolis VFW post are not authorized by the VA. They are an outgrowth of the frustration and anguish many vets feel about being ordered into a program that can serve only a fraction of those in need. The Minneapolis VA’s inpatient pain program, for example, has managed to graduate only 33 vets in the year that it has been operating.

The VA says it’s adding more services. But as more vets find themselves cut off from prescription painkillers, the demands on the strapped VA system are bound to grow.
VideoVideo (2:39): Joseph Simenstad reflects on his struggle with pain. “I just want a day off from it.”
Mark Vancleave

“You don’t have a real comprehensive, coordinated project available to these vets,” said Dr. Gary Kaplan, a clinical associate professor at Georgetown University School of Medicine who recently attended a conference about the military’s pain management program. “It’s a tragedy.”

Shayne Johnson came to the “feed ’em & treat ’em” event at the VFW. The post, which provided free appetizers and a sit-down dinner, sponsored the event with Northwestern Health Sciences University in Bloomington, which provided free chiropractic evaluations, acupuncture and massage.

Johnson suffers chronic pain as a result of his service in Iraq as a Navy Seabee. He said the chiropractic care he gets from Northwestern and from a private provider he pays out of his pocket have turned out to be better than the alternatives offered at the Minneapolis VA.

At the VA he got one series of chiropractic treatments several years ago, but he said the appointments were difficult to schedule, often as much as three weeks out. He said the VA also kept pushing muscle relaxants, and he was concerned about getting dependent. He would return to the VA if programs were better. “I would go there all the time if I could get a chiropractic visit.”

Vets say they have waited up to two months for an appointment with the Minneapolis VA’s sole chiropractor.

Marine Corps veteran Robin Smith struggles with pain all the time. “You don’t sleep. You get a little rough and you don’t smile a lot.” Smith initially enrolled in the Minneapolis VA Pain clinic earlier this year, but was told he could only get acupuncture ten times a year, per VA policy. He now pays for it himself in Grand Rapids.
ROUGH: Marine Corps veteran Robin Smith struggles with pain all the time. “You don’t sleep. You get a little rough and you don’t smile a lot.” Smith initially enrolled in the Minneapolis VA Pain clinic earlier this year, but was told he could only get acupuncture ten times a year, per VA policy. He now pays for it himself in Grand Rapids.

Dominic Anspach of Minneapolis underwent an acupuncture treatment at a VFW event that was free but was not authorized by the VA.
SEEKING RELIEF: Dominic Anspach of Minneapolis underwent an acupuncture treatment at a VFW event that was free but was not authorized by the VA.

Christopher Cassirer, president of Northwestern, said he has offered to help the Minneapolis VA expand its chiropractic treatments, to no avail.

While the VA says it is embracing alternative therapies, critics, including members of Congress, say the VA appears to want to keep the services under its own roof, where it can monitor treatment and control costs.

The Minneapolis VA hired its first chiropractor in 2014 and was overwhelmed by the response, with more than 850 visits in less than five months. Because of the demand, 23 veterans have been allowed to make appointments with chiropractors outside the VA. The Minneapolis VA said it hopes to have its second chiropractor in place this summer.

Dr. Carolyn Clancy, then the interim VA undersecretary of health, told a congressional committee in June that the VA is conducting research to identify predictors for veterans who abuse opioids and which veterans might respond best to nonnarcotic treatments. “We have some research going on in that area and we have a lot more to learn,” she said.
Success stories

Few dispute that the VA had a painkiller problem. Prescriptions for narcotics such as oxycodone and methadone had tripled nationally in the 11 years before the VA realized it had created a crisis of drug dependency among veterans.

The new goal: Instead of doling out addictive drugs that mask chronic pain, identify and treat its root causes.

Late last year, the National Institutes of Health and the VA announced 13 research projects totaling about $21.7 million over five years to study nondrug approaches to pain.

Given the limited number of people able to enter the trials, it could take at least five years to get productive data, said Georgetown’s Kaplan.

After suffering years of chronic pain, John Szuch, an Air Force tail gunner in the first Gulf War, enrolled in the VA’s chronic pain rehabilitation program. After graduating in November, Szuch has a new lease on life and does tai chi at home a few times a week.
GRADUATE: After suffering years of chronic pain, John Szuch, an Air Force tail gunner in the first Gulf War, enrolled in the VA’s chronic pain rehabilitation program. After graduating in November, Szuch has a new lease on life and does tai chi at home a few times a week.

Air Force veteran John Szuch has no doubt about the value of these alternative approaches. “It literally changed my life,” he said.

Szuch was a tail gunner on B-52s, flying combat missions during the first Gulf War.

His service left him with a herniated disc and a severe stabbing pain in his thigh. Years of pain medications did not help.

He had tried meditation and sleep therapy. He was sedentary and anxious. His VA psychologist recommended he apply to the Minneapolis VA’s chronic pain rehabilitation program.

The four-week intensive residential program is the only pain program in Minnesota accredited by the Commission for the Accreditation of Rehabilitation Facilities.

Patients meet with practitioners from seven disciplines to develop a treatment plan that includes hourlong group sessions led by psychologists, occupational therapists, pharmacists and nurses.

Up and running for a little more than a year, it has graduated 33 vets, including Szuch.

“You have to be at the bottom of the barrel for the people offered this class,” he said. “People who go into this class, we’re in some bad places mentally. But you have to have the willingness to still want to get better.”
Yoga videos and needles

Other veterans in the Minneapolis pain programs complain of one-size-fits-all treatments and persistent problems with scheduling, particularly for younger veterans with jobs or schooling and veterans who live far from a VA clinic.

Brian Lewis was sexually assaulted aboard the USS Frank Cable in 2000 and was discharged a year later with chronic pain from internal injuries that left him with a 100 percent disability rating. Lewis said pain medications were dispensed freely when he was at the Baltimore VA.
How far is the VA Hospital?
The Minneapolis VA Health Care System is one of the ten largest VA medical centers in the country, serving more than 100,000 veterans in a six-state area of the Upper Midwest. The three major medical centers used by veterans in Minnesota are in Minneapolis, St. Cloud and Fargo.

When he moved to Minnesota to attend law school and sought treatment at the Minneapolis VA, he was told doctors weren’t comfortable with his level of medications because of the new drug policy.

At one point his pain pills were reduced to one Vicodin a day. The remaining pain is so intense that he says he often has to lie on the floor while he studies, and some days he has felt suicidal. The ordeal is testing his relationship with his fiancée and his best friend.

The VA has offered to sign him up for yoga classes, but Lewis is in law school in St. Paul when the class is offered at the clinic in Minneapolis.

He lost 70 pounds in four months and has been hospitalized twice at the VA for a stomach ailment and the pain.

“When there’s nothing that can be done about the physical pain, the psychological pain takes over,” Lewis said. “If I had one thing to say to my fiancée and my best friend it would be to say that I am sorry for what I’ve become.”

Persian Gulf War veteran Kurt Saylor has made the three-hour trip from Grand Rapids to the Minneapolis pain management clinic every month for chronic pain that extends from the middle of his arms to his hands and from the middle of his legs to his feet. He sleeps two to three hours a night.

“They gave me a video to watch, yoga, and said, ‘Do this every morning.’ How is that going to make me sleep? ” he said.

Robin Smith, who was in the Marines for 3 ½ years in Vietnam, has been in pain since a steel beam almost cut his right leg off during a typhoon.

He said acupuncture treatments have helped.

He initially enrolled in the Minneapolis VA pain program but said he was told the policy would allow him acupuncture only 10 times a year. He now pays for acupuncture himself through a civilian provider.

Without it, he is in pain all the time.

“People ask you what’s the level of your pain? Is it a 10? What is a 10 that never goes away? It’s still a 10,” he said.

In response to written questions, the Minneapolis VA said it’s clear the inpatient program, while optimal, might not work for veterans with work, family, school or other obligations. For those veterans, it said other care is available.
Refuge for veterans

Displeasure with the VA’s pain treatment has prompted some veterans to seek relief in renegade programs such as Eagle’s Healing Nest outside Sauk Centre, Minn.

Eagle’s Healing Nest is a somber and restful place. There are 23 white crosses planted on the main lawn of the 125-acre campus, a reminder of the estimated number of U.S. veterans and active-duty military personnel who kill themselves every day.

Many vets who come here have been bounced around by the VA. They suffer from substance abuse problems and many have been prescribed addictive narcotics by the VA for pain, only to find them recently restricted.

The center offers drug and alcohol counseling and therapy. Every week, a chiropractor comes to the campus and the sign-up sheet is always full.

Founded in 2012, Eagle’s Healing Nest often works with the local VA to help vets in crisis. But it is always at arm’s length, by design of founder and director Melony Butler, who relishes her role as a rogue operator in the massive VA machinery.

“Imagine being a combat vet with many achievements and now you are being told you are an addict; and you’re addicted based on the medication that those who are supposed to care for you gave you,” she said.
The Eagle’s Healing Nest in Sauk Centre was founded in 2012 to help vets in crisis and often bounced around by the VA. On their front lawn, you will see 23 white crosses, representing the estimated number of military personnel, both active duty and veterans who kill themselves every day in America.
23 EVERY DAY: The Eagle’s Healing Nest in Sauk Centre was founded in 2012 to help vets in crisis and often bounced around by the VA. On their front lawn, you will see 23 white crosses, representing the estimated number of military personnel, both active duty and veterans who kill themselves every day in America.

In the day room of one Eagle’s Nest cottage, Vietnam vet and long-term resident Joe Simenstad pulls up an X-ray of his spine from a computer. The image shows bones as a twisted and contorted road.

Surgery won’t solve his pain, he has been told. Chiropractic treatments at the VA have made it worse. Physical therapy and hanging on tables for inversion therapy have offered only brief relief. The same for acupuncture and massage.

He admits that he has abused drugs and alcohol in the past and has even relapsed while staying at Eagle’s Nest. But he said he went out seeking illegal drugs only when the VA cut off his pain meds.

In a controlled environment where staff dispense the medications to him, he said the medications offer the best relief. “The point is, there is life after addiction, and even addicts have pain,” he said.

U.S. Rep. Tim Walz, D-Minn., said there is a need to balance concerns about the amount of pain meds prescribed with the damage done by faulty weaning. Alternatives are being discussed, he said, including the assignment of a pain care management specialist to each veteran. “You’ve got to be offering these guys more than one yoga class a week,” he said.

After a hearing in April about pain prescription abuse at a Tomah, Wis., VA hospital, Walz, a member of the House Veterans Affairs Committee, sent a letter to the VA asking what he thought were straightforward questions, such as how many pain specialists it had hired, how long it takes for a vet to see a pain specialist and how many VA pain clinics actually exist.

Two months later, Clancy wrote back, apologizing for the delay. She said the VA had provided pain clinic services to 140,000 vets through the end of 2014, a 10 percent increase from 2013; that 105 VA hospitals now provide pain clinic services; and that the VA had added eight doctors to its pain clinics in 2014, bringing the total to 124.

Clancy’s letter was dated June 25. Two days earlier, the Senate had confirmed Clancy’s replacement.

Mark Brunswick • 612-673-4434
PART 1:
WOUND UP, CUT OFF
Iraq veterans Zach Williams and Ryan Trunzo overdosed after battling chronic pain and withdrawls from pain medication.

Filed under: General Problems | 3 Comments »

https://www.talktotrump.org/?

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An end to opioid overdoses, addiction?

http://www.dailyrecord.com/story/news/2017/01/29/end-opioid-overdoses-addiction/97003094/

How naive .. that there are no addicts out there with a degree in chemistry that could figure out how to circumvent the abuse deterrent process… post it on the web or “dark web” and their process as an abuse deterrent – IS TOAST !

A Morristown-based pharmaceutical company hopes a medical breakthrough it patented last month may break the lethal cycle of rising opioid addiction and overdoses, once and for all.

Alitair Pharmaceuticals, Inc., a clinical stage-pharmaceutical company typically focused on respiratory health, announced on Dec. 15 that it had obtained a U.S. patent covering its prescription-drug overdose-reduction technology, trademarked as ODR.

The ODR chemical compound is designed to modulate drug release and reduce the risk of prescription-drug overdose, regardless of how many tablets or capsules are ingested, bonding to the opioid on a molecular level and providing appropriate release of a drug at labeled doses, but limiting release at excessive doses.

“Can you imagine a world where people can take pain-killers without the risk of addiction or overdose?” Howard said. “This is the biggest idea I’ve had in my entire life.”

“This could have a major impact on our opioid-abuse problem, not only here in New Jersey but across the nation,” said Assemblyman Anthony M. Bucco, who recently met with Howard at his legislative office to discuss his discovery.

“Basically, we form a formulation with what are called ion exchange resins,” Howard said. “The way it works is when you swallow the tablet, only hydrochloric acid will make the (ODR) come off this formulation. We found a way, in layman’s explanation, to deplete the hydrochloric acid in your stomach, then no more drug will be released. We have demonstrated in laboratory studies that we can control the release. If you take one tablet, for example, of hydrocodone for pain, you get 100 percent of release. If you take two, you get about 70 percent release from those two tablets. If you take three, you get 50 percent release. Above that level, you will get no additional release from the tablets.”

Following the depletion of hydrochloric acid in the system, the body would need at least an hour or two to replace it, “by which time the drugs will have passed through your stomach,” Howard said.

ODR also would prevent opioid abuse in other forms, such as addicts who grind a pill into powder to snort or liquidity it to inject it for a stronger “rush.”

“You can’t smoke them, you can’t inject them, you can’t snort them up your nose,” he said. “You can’t grind a molecule. The only thing that causes release of the drug is hydrochloric acid. A chemist might be able to figure out a way to eliminate the active drug (in the opioid pill), but it would require a very high level of skill and knowledge. The average abuser probably wouldn’t be able to do that. They’d have to go to college for a coupe of years to take chemistry courses.”

The ODR-opioid combination also would help the elderly or other users who may confuse their dosages and take too much by mistake.

“You don’t have to do anything, you don’t have to know anything, it’s built into the system,” he said. “I always draw a parallel to the passive-safety systems in cars, like air bags, antilock brakes and stability-control systems.”

Howard says a typical drug costs about $300 million to develop, test and bring it to market, but that he sees a simpler, less-expensive path for ODR and hopes to have it approved within two to three years.

“Human testing will cost about $500,000 to $1 million, so it’s not big money compared to the average drug, because those are completely new compounds that have to go through all kinds of testing,” Howard said.

Ion exchange resins are already used in several approved products, and Alitair would combine it with approved drugs such as codeine, hydrocodone and oxycodone, so “it’s a much simpler path to market,” Howard said. “We’re just going to reformulate them.”

Alitair’s patent is specifically for an ionic exchange resin that binds to opioids.

He also hopes to get ODR into an existing FDA fast-track program for important drugs that might also help accelerate its path to the market.

Howard said from a business standpoint, he would like Alitair to ultimately develop a brand-name pain-killer that includes the ODR compound, but that he would make the formulation available to any manufacturer in the interest of public health.

“The goal is to develop a life-saving drug,” he said. “I want people to live.”

Howard’s background includes serving as the senior vice president of new products and business development for Chester-based Adams Respiratory Therapeutics, a subsidiary of Reckitt Benckiser, where he oversaw development of successful over-the-counter products such as Mucinex.

“This is not his first time in this arena,” Bucco said. “I plan on having a conversation with the governor about this. I served many years and was a founding member of Daytop New Jersey, and I’ve seen this epidemic first-hand. Anybody that has been involved in the substance-abuse treatment field would definitely be interested in  this.”

Christie has spent considerable time and effort in recent weeks centering the final year of his administration on battling addiction. Christie spokesman Brian Murray said he would forward information about Howard’s patent to the governor.

Staff Writer William Westhoven: 973-917-9242; wwesthoven@GannettNJ.com.

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A way to predict who’ll become a drug addict

http://www.cbsnews.com/news/a-way-to-predict-wholl-become-a-drug-addict/?

Most MEDICAL DIRECTORS – abt 75% – are just GP/FP with a few internists thrown in… In all likelihood, they no longer practice medicine and may have not have practiced much after graduating from school and getting their license.  Most are making medical decisions way outside of their skill sets and since their paycheck comes from the insurance company… one would suspect that their opinions are biased toward what would benefit the bottom line of the insurance company. This may be the primary reason that there are so many personal injury lawyers… trying to level the playing field for the injured person against the demands of the insurance company.  IMO, this article is basically a bunch of HOGWASH !

Allen, 25, works in a Trenton, New Jersey, auto body shop alongside a middle-aged man who’s straining to lift bumpers and fenders. Allen’s co-worker came back after a hip replacement because he feared that he would be fired. Allen knows this guy will turn to “street meds” to ease his pain.

Dr. Adam Seidner knows the same thing — from his sky-high view as global medical director at Travelers Insurance (TRV). Armed with “big data” on 1.5 million injuries and disabilities, Seidner believes he can predict who’s at risk of becoming an addict — and how best to treat them. That has led Travelers to develop a system to profile not actual painkiller addicts, but potential ones.

If Seidner is right, it could help address a problem that’s now a plague. Some 2 million Americans are hooked on highly potent prescription drugs like fentanyl, while another 500,000 are “in the clutches of heroin.” In recent years, more Americans have died annually from overdoses, 33,000 of them, than from car accidents — a list that includes celebrities such as Prince and Michael Jackson.

So what’s Seidner’s solution? First, get rid of the addiction fiction claiming that people choose to become junkies. “Perhaps 5 percent of addicts do it for the euphoria,” said Seidner, who spent years detoxing prisoners. “Most take opioids to relieve suffering from chronic pain.”

And that’s scary because it puts an estimated 50 million Americans who suffer from chronic pain in the cross-hairs of potential addiction. They come to doctors’ offices complaining of bad backs, repetitive stress, falls, strains and “soft tissue” injuries.

Ever since the 1980s, about nine times out of 10, doctors have traditionally prescribed the most effective remedy for pain: drugstore opioids. They range from the mild, like codeine, to the strong, such as OxyContin (oxycodone) and Percocet (a combination of acetaminophen and oxycodone).

Although opioids curb the pain, they don’t cure the patient. And they have a will of their own. Within a month, these drugs invade the patient’s mind, which then tells the body to “feel” pain, whether it’s real or not, and thus creates a dependency.

Patients then demand the opioid — in stronger and stronger doses — and if they can’t get it legally or through their medical plan, they may steal prescription pads, use drugs like Imodium that mimic some of opioids’ effects and ultimately move on to street sources, where a $10 bag of heroin is both cheaper and stronger than a $200 prescription.

After years of trying to “just say ‘no’” to an epidemic that kills 46 people a day in the U.S., the medical profession, along with federal and state governments, recognized the danger. “I will not willingly watch another 1,600 of our citizens die,” former presidential candidate and New Jersey Governor Chris Christie told his state legislature this year.

On Jan. 19, the mayor of Everett, Washington, also asked the city council to authorize a lawsuit against Purdue Pharma, the maker of OxyContin, alleging that it knew the painkiller was being diverted to the illicit market and didn’t do enough to stop it.

But stopping the deadly flow of painkillers is a difficult process. As one doctor in Princeton, New Jersey, who asked not to be identified, said: ”What do you do when a patient comes to you in pain?” Physicians still write more than 200 million opioid prescriptions a year.

The latest data from Maryland, Ohio and New England, where the opioid crisis is most intense, shows an increase in fatalities. Drug companies have promoted medications like fentanyl, a synthetic opioid that can be as much as 50 times more potent that heroin.

“It’s like pushing on one side of a balloon,” said Travelers’ Seidner. “It just bulges out the other.”

Travelers has a big dog in this fight. It’s the largest workers’ compensation insurer in a $45 billion business that helps companies manage medical benefits for employees injured on the job. It handles a quarter-million of these claims each year.

The longer an employee stays off the job and runs up medical bills, the more the insurer loses. The average claim now runs $40,000 over three years. But with caps on temporary disability now declared unconstitutional in some states, claims could last for decades.

That’s where Travelers’ addict-prediction model comes in, because the first step is to identify a potential addict. To do that, Seidner has assembled “statisticians and brainiacs” to predict which injuries will turn into chronic pain cases and push the patient down the “slippery slope” to opioid dependency.

Travelers developed a program called Early Severity Predictor, which looks at four areas:

• Pharmaceutical frequency. What drugs are the patients using and how much. Are they also popping pills on the side?
• Co-morbidity. Are they suffering from other conditions, like diabetes or osteoporosis? Do they smoke?
• Muscular health. Are they in good condition?
• Mental health. Are they angry with their employers? Do they fear going back to work and facing the same injury?

Other factors the model considers are sex, socioeconomic status, education and the nature of the injury: shoulder, knee or slipped disk.

A typical person with a chronic injury who might become dependent could be a middle-aged white male factory worker with a bad back.

Identifying the potential addict is only part of the problem. Getting rid of the chronic pain and the potential addiction is the other. 

Once such a patient is identified, Travelers can begin to harness resources. It starts by talking to the patient’s doctor. In many states, doctors are under no obligation to talk to the insurer, but nearly seven in 10 will. This is probably because the insurer covers treatments like physical therapy, sports medicine, stimulation devices, yoga, stretching and psychology.

“We embrace all modalities, but we don’t do traditional psychoanalysis,” said Seidner. “Instead, we use therapy that will change behavior.”

Seidner and his team have analyzed 20,000 cases of opioid addiction since 2015, identified 9,000 at-risk patients and worked with 2,500 of them. Since then, about 1,400 no longer demonstrate any significant use of opioids, and medical expenses have fallen by 50 percent. 

Much of that reduction has come from reduced use of opioids, which used to constitute 50 percent of all the prescription drugs that workers comp paid for, according to Travelers Vice President Rich Ives. Now it’s only 23 percent.

Vice President Loretta Worters of the Insurance Information Institute, which represents the industry, concurred that “Travelers Early Severity Predictor is certainly helping.”

Let’s be clear. Travelers will only help the companies that pay its premiums and the people employed by those companies. But its strategy, including how to predict drug addiction, provides a roadmap for governments, doctors or anyone with a chronic injury who wants to escape the curse of opioid dependency.

In some instances, it’s as easy as looking in a mirror. If you’re taking drugs for a bad back, consider stretching. If you hate your job, try to find another one before you’re reinjured. If you’re depressed, seek help. 

Opioids will only make things worse. And when you take an opioid of any kind, the addiction clock is ticking. If taken longer than a month, you may already be addicted and not even know it.

Finally, when you see a doctor for pain, ask whether another treatment beside opioids might work — before he or she pulls out the prescription pad.

“Probably 80 percent of the time it’s a bad idea to prescribe opioids,” Seidner said. “We need to address the pain, but how we do it is the important thing.”

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CDC Abruptly Canceled A Long-Planned Climate Summit Days Before Trump Became President

http://www.huffingtonpost.com/entry/cdc-climate-conference-trump_us_588658f4e4b096b4a233bae1

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Depression is as bad for your heart as high cholesterol

http://www.foxnews.com/health/2017/01/28/depression-is-as-bad-for-your-heart-as-high-cholesterol.html

It is common knowledge that anxiety and depression go hand in hand with chronic pain… “they say” that pain won’t kill anyone… but this study suggests that untreated pain could be a contributing factor to heart attacks

When you think of heart attacks, you might assume the most common causes are smoking, high cholesterol, or obesity. Mental health issues probably don’t spring to mind. But a new study suggests that depression poses just as great a risk to your heart health as those more familiar heart disease contributors.

In a new analysis, German researchers looked at health information from 3,428 European men, ages 45 to 74, who were followed for 10 years. And it turned out, dying from cardiovascular disease during the study period was as strongly associated with depression as it was with several of the classic “big five” heart disease risk factors: obesity, high cholesterol, diabetes, high blood pressure, and smoking.

Depression—which for this study, was determined by a checklist of mood symptoms, including anxiety and fatigue—accounted for about 15 percent of cardiovascular and coronary heart disease deaths, and high cholesterol and obesity for 8 to 21 percent. Diabetes posed less of a risk, accounting for 5 to 8 percent of heart-related deaths. This also helps in read more about intravascular ultrasound

Only two risk factors accounted for more cardiovascular deaths than depression: smoking (between 17 and 20 percent) and high blood pressure (between 30 and 34 percent). Writing in the journal Atherosclerosis, the authors conclude that “depressed mood and exhaustion holds a solid middle position within the concert of major cardiovascular risk factors.”

RELATED: 10 Signs You Could Be Depressed

Mental-health screenings should be standard in patients who have classic heart disease risk factors, they write, and depression should be addressed to hopefully prevent additional risk to the heart. Plus, they add, treating depression is likely to have noticeable, tangible benefits to patients—something that can’t be said for factors like high blood pressure or cholesterol.

Heidi May, PhD, a cardiovascular researcher at the Intermountain Medical Center Heart Institute in Salt Lake City, says that the new research is “very much in line with what’s currently being reported by other studies.” May was not involved in the analysis, but has also studied the link between depression and heart disease.

“There’s a growing recognition for the need to screen and treat depression, and that doing so can reduce the risk of negative cardiovascular outcomes,” she says. “This study adds to the research by looking at specific mood symptoms, so I think it’s a great addition to what we already know.”

May says that depression likely affects the heart in a variety of direct and indirect ways. “There are some physiological changes that take place in the body with depression, and there are also behavioral changes.” Depressed people are more likely to smoke, exercise less, and skip their prescribed medication, for example.

For the current study, the results for each variable were adjusted for all other risk factors—suggesting that depression is independently linked to heart disease, and is not just a contributor to unhealthy behaviors.

Previous research has also shown that this association is likely a two-way street: Just as depression can contribute to heart disease, suffering from a serious heart condition can also lead to depression. And in turn, depression can then impair recovery.

That’s why it’s important not only for people with cardiovascular risk factors to take care of their mental health, says May, but also for people with depression to take care of their hearts. “These conditions have a compounding effect,” she says, “and they should all be treated—whether you have one risk factor or five.”

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