A pharmacist at the Tomah Veterans Affairs Medical Center in Wisconsin said she was discouraged by higher-ups from performing drug tests on patients prescribed opiates, as is recommended by VA guidelines.
In a joint U.S. House and Senate committee hearing in Tomah on March 30, Noelle Johnson, a pharmacist who was fired from the facility and now is employed by VA as a pain management specialist in Des Moines, Iowa, said pharmacists were discouraged from testing patients for drug use for fear of what prescribing physicians might learn.
If the tests were negative, it might indicate that the patient was not taking the medication, raising questions as to whether they were "diverting" or selling their meds.
If the tests were strongly positive, it could suggest overuse or abuse and VA could be held liable "when something unfortunate happened," Johnson said she was told.
"I believe that this is the point of urine drug testing, to substantiate use and misuse of high-risk medications for the safety of veterans and the public," Johnson said. "What happened to the doctors' oath of "First Do No Harm?"
During three hours of testimony, House Veterans' Affairs and Senate Homeland Security and Government Affairs committee members heard from families of patients who died at the Tomah VA, former employees who said they warned VA officials about physicians suspected of overmedicating patients but were fired or reprimanded for doing so and VA administrators in charge of investigating wrongdoing at the hospital.
The facility came under fire earlier this year after reports surfaced that at least two providers prescribed more opiate pain medications than their peers and patients died from drug toxicity.
The VA Office of Inspector General launched an investigation in 2011 into the number of narcotics prescriptions distributed at the facility as well as drug trafficking, mismanagement and intimidation of pharmacists by hospital administrators and doctors.
But the OIG was not able to "substantiate the majority of the allegations" and closed the case in 2014 without publicly releasing the report, raising questions of a cover up or concerted effort to protect the providers in question, Dr. David Houlihan and nurse practicioner Deborah Frasher.
During the hearing, VA OIG John Daigh defended his decision not to release the report.
"The data we collected did not support the allegations that led us to Tomah, and knowing that our national report would highlight the many deficiencies in VA providers' compliance with these guidelines, I chose to administratively close this report," Daigh said.
A Center for Investigative Reporting investigation published in January found a 14-fold increase in the number of oxycodone pills prescribed at the Tomah VA Medical Center, from 50,000 in 2004 to 712,000 in 2012.
Veterans at the hospital told a reporter that distribution was so rampant, they nicknamed the place "Candy Land." Last Aug. 30, a 35-year-old Marine Corps veteran, Jason Simcakoski, died of an overdose while in the inpatient psychiatric ward and 32 other unanticipated deaths have occurred at the facility in the past few years.
Simcakoski died while under the care of Houlihan and another physician. He had checked himself in for anxiety and was scheduled for release that day, but having been put on a new medication, Suboxone, in addition to the 14 other medications he was taking — tranquilizers, an antipsychotic medication and tramadol — could not move, according to his father Marvin Simcakoski.
"I regret leaving my son in his room alone that morning only to get a call hours later that he had stopped breathing," Simcakoski said.
VA clinical practice guidelines for treating acute anxiety and post-traumatic stress note that opiates may be helpful in curbing acute pain resulting from a severe injury that may attribute to the development of PTSD.
To treat these ailments, however, other medications such as antidepressants are recommended, according to the VA guidelines.
Marvin and Heather Simcakoski said Jason did not have the condition for which opiates are usually prescribed — chronic pain.
But he was put on a powerful one — tramadol — just days before he died, they said during the hearing.
VA clinical practice guidelines call for performing a urine drug test before prescribing opioids and randomly testing throughout the prescription period.
But according to Daigh, just 10 percent of veterans at Tomah received the recommended drug testing.
An internal investigation is underway of Houlihan and Frasher, who were placed on administrative leave March 10.
Dr. Carolyn Clancy, acting undersecretary for health affairs, said once the investigations are concluded, VA will "act quickly, decisively, and productively," with veterans' care, health and safety leading any personnel decisions the department makes.
She added too, that a number of organizations — the OIG, Joint Commission, Drug Enforcement Agency and the Wisconsin Department of Safety and Professional Services — have reviewed or also are investigating the facility.
"The stories [families have] told have been noted by others and are a profound and invaluable gift to us. And we will use that to improve. ... Our commitment to you is that we will use this information to improve now and in the future," Clancy said.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.