DEPARTMENT OF VETERANS AFFAIRS
VA Great Lakes Health Care System
500 E. Veterans Street
Tomah, WI 54660

 

May 1, 2014

The Honorable Tammy Baldwin
Member, United States Senate
Suite 1920

633 W. Wisconsin Avenue
Milwaukee, WI 53203

Dear Senator-Baldwin:

Thank you for allowing us the opportunity to respond to the concerns outlined in
your letter, dated April 7, 2014, on behalf of an anonymous constituent concerning
his allegations about general prescribing patterns at Tomah Veterans Affairs Medical
Center (VAMC). Your letter was forwarded to Dr. David Skripka, the Associate Chief
of Staff for Mental Health, virho assisted in reviewing and investigating these allegations. 
I offer the following in response:

Your constituent?s first allegations stated ?a large percentage of Veterans being
treated for substance abuse are for substances Including opiates, benzodiazepines,
and stimulants which were originally prescribed by VA providers'; and "these same
Veterans continue to be prescribed these substances of abuse While an aetive
treatment?. Dr Skripka and other staff performed chart reviews of every patient enrolled
in Tomah 5 residential treatment program for substance abuse In calendar year
2014. (January 1 to April 8 of 2014) Of the 65 patients enrolled this year, 14 patients
were being treated for abuse or addiction to opiates, benzodiazepines, and/or
stimulants in any form. Four of those 14 Veterans were being treated with opioid
replacement therapies such as buprenorphine or methadone that are recommended for
opioid use disorders; buprenorphine and methadone were not included In the ?ndings-
that follow . -

Of those 14 patients, only one began the abuse/addiction of a drug class after a VA
provider prescribed a medicine from that class. That same patient was also the only
one of the 14 patients who was currently prescribed a medication from a drug class that
was part of their addiction treatment.

The Veteran cited above is a Veteran over the age of 60 with multiple complex
medical problems including arthritis, kidney failure, and liver transplant. His primary
addiction was to alcohol, but he had also reported overusing both prescribed and
nonprescribed opiate pain medications at the time of a hospitalization. His hospital

 

team and outpatient primary care provider collaborated and decided the most
appropriate option was- to continue treating his pain using a modified regimen that still 
included opiates. with additional monitoring That new pain medication regimen was 
then continued during hie'residential substance abuse treatment

Some background may be' In order before addressing the other allegations. The
Departments of Veterans Affairs and Defense have published clinical practice
guidelines for the management of Post Traumatic Stress Disorder (PTSD), most
recently in 2010. Although the published studies in this area are very limited,
those guidelines do recommend that benzodiazepines be considered relatively
contraindicated for treatment of PTSD. The following statement is taken from the
cover of the clinical guidelines for PTSD noted above:

The Department of Veterans Affairs (VA) and the Department of Defense 
guidelines are based on the best information available at the time of publication.
They are-designed to provideinformation and assist in decision-making. They
are not intended to define a standard of care and should not be construed as
one. Also, they should not be interpreted as?prescribing an exclusive course of
management. Variations in practice will inevitably and appropriately occur when
providers take into account the needs of individual patients, available resources,
and limitations that are unique to an institution or type of practice. Every

- healthcare professional who' Is making Use of. these guidelines is responsible for
evaluating the appropriateness of applying them in any particular clinical
_s?ua?on.

There continues to be some professional debate and controversy relating to

benzodiazepines in PTSD, both in terms of general guidelines? and _in how those_

guidelines are applied to individual cases. However, .the for IndIvIdual
treatment decisions ultimately lies with the attending physician or? other ?provider;
responsible for a Veteran' 3 care. Their decisions should be informed by" t_he_ 
circumstances, needs, and preferences of that IndIVIdual patient. and all the
informational tools available at the time . ..

Your constituent alleges that prescribing benzodiazepines for Veterans with PTSD is

a standard practice, and that employees are pressured by management to prescribe
substances, apparently benzodiazepines, not compatible with national guidelines 
Dr Skripka indicates that he has directed the mid level providers that he supervises in
the residential substance abuse program to follow. certain general principles' In their
prescribing. These include avoiding changes In pre-exiSting medication regimens when
Veterans enter the program, unless those changes are coordinated with and approved
by the outpatient providers who will be resuming clinical responsibility when the Veteran
is discharged after 30 or 60 days. This direction has been given to avoid a scenario
where there is an abrupt change in medication that might be reversed when they return
to their primary outpatient provider. Medical providers across Tomah VAMC have also
been directed to speak with patients directly before making changes to medications.

 

Dr. Skripka otherwise strongly?denies any institutional'or management directlon to= 
medical providers indicating they are to initiate or otherwise prescribe benzodiazepines

to Veterans as a whole, or to Veterans with PTSD as a Whole. He requests that your -

constituent communicate any specific examples to me directly

Your constituent alleged that there are a "high? number of instances in which
controlled substances are prescribed prior to alternatives being trialed. Dr. Skripka-
indicated dif?culty responding with specific data to such a broad statement, as this 
includes many types of treatments prescribed for many different conditions by many
types of providers. He indicates that there are some conditions for which an initial trial
of a substance is appropriate, and also agrees that he has seen cases where
he believes appropriate alternative measures that could have been appropriate were not
tried ?rst. :He believes some of the data tools described below may be helpful, and

otherwise encourages your constituent to communicate specific examples that are

concerning through the VA channels available.

Dr. Skripka did want to acknowledge the overall importance of this issue, and the
areas where Tomah VAMC is focusing our improvement efforts. Aggregate measures
gathered by the VA at the national level have shown that Veterans at Tomah VAMC
with PTSD receive a benzodiazepine or sleeping medication more often than the mean
for other VA Medical Centers. However, those measures did not offer the ability to
analyze or. drill down further, or-to distinguish the-reason that benzodiazepines are 
prescribed. A recent Vetems Health Administration (VHA) 

initiative has been underway in recent months, and promises to offer tools for all VA

Medical Centers to review and "drill down? data relating to prescribing patterns, and to
compare themselves to- other medical centers. Tomah VAMC participated in this
initiative earlier this year and worked with a Veterans Integrated Service NetWork
(VISN) 12 VA Great Lakes Healthcare System pilot project to offer additional 
of benzodiazepine prescriptions This- -tool can enable theTomah VAMC to obtain-
including benzodiazepines, correlated with certain diagnosesThis tool also permits us-
to institute targeted education or monitoring as indicated. Tomah VAMC will be 
reporting efforts in this area to the VA Office of Mental Health Operations.

The opioid Safety Initiative (OSI) is another VHA initiative, intended to identify 
patients wiho are taking long?term opioids in a dose that is considered to be in excess.
of the north. The TornahVAMC Pain- Management Committee is. charged "with

implementing the 08! by evaluating thetpatient?s use of opioidsand providing

recommendations for their ongoing use or discontinuance. The'Pain Committee is a

multidisciplinary committee made up of two physicians, two clinical pharmacists, a nurse 

practitioner, a clinical nurse specialist, and a A comprehensive medical
record review is conducted by the committee and recommendations are made in-person
to the prescribing provider. This committee is reviewing two to three cases per week
and started in February 2014.

 

In the future, I would encourage your constituent to report their concerns

directly so that we may address specific examples and give us the chance to work 

their Issues at the lowest pOSSIble level first - 

Thank you again for this opportunity to address your constituent? 3 concerns with
treatment at the Tomah VAMC. If you have additional questions, please contact David
Skripka M. D. Associate Chief of Staff for Mental Health at (608) 372? 1631.

Sincerely.

arioV DeSanctis FACHE
Medical Center Director