THANK YOU FOR YOUR SER­VICE

The VA killed thou­sands of vets and fu­eled the na­tional opi­oid cri­sis by reck­lessly throw­ing pills at a prob­lem

Newsweek - - PERISCOPE - by ART LEVINE illustration by FOREAL

LATE ONE SUM­MER NIGHT IN 2014, KEVIN KELLER BROKE INTO HIS BEST FRIEND’S HOME. Keller was a U.S. Navy vet wracked with con­stant pain, and be­cause his right arm had been crip­pled by a stroke, he had to use his left hand to scrawl a note of apol­ogy to his buddy: “Marty, Sorry I broke into your house and took your gun to end the pain! FU VA!!! Can’t take it any­more.” He then drove to his nearby Vet­er­ans Af­fairs out­pa­tient clinic in Wytheville, Vir­ginia, and pounded on the locked doors of the med­i­cal of­fice, prob­a­bly out of frus­tra­tion or as a fi­nal protest, since the fa­cil­ity had been closed for hours. Keller then put the bar­rel of his friend’s 9 mm pis­tol to his head and shot him­self.

Griev­ing friends told The Roanoke Times that Keller couldn’t han­dle how the VA was wean­ing him off painkillers. His doc­tors had told him cut­ting back would ex­tend his life, but Marty Austin, whose gun Keller stole that night, told the pa­per, “He did not want a longer life if he was go­ing to be mis­er­able and couldn’t do any­thing be­cause of the pain.”

Sui­cides like Keller’s and the wide­spread de­spair be­hind them are yet an­other tragic el­e­ment of a na­tional opi­oid cri­sis blamed for most of the 64,000 fa­tal drug over­doses a year. Opi­oids, mostly il­le­gally ob­tained coun­ter­feit pills and heroin, now ac­count for 63 per­cent of all drug deaths in the U.S., with fa­tal­i­ties climb­ing at an astounding rate of nearly 20 per­cent a year. In fact, the es­ti­mated num­ber of drug deaths in 2016 topped the to­tal num­ber of sol­diers killed in the Iraq and Viet­nam wars. There’s a grim irony in that statis­tic, be­cause the Depart­ment of Vet­er­ans Af­fairs has played a lit­tle-dis­cussed role in fu­el­ing the opi­oid epi­demic that is killing civil­ians and vet­er­ans alike. In 2011, vet­er­ans were twice as likely to die from ac­ci­den­tal opi­oid over­doses as non-vet­er­ans. One rea­son, as an ex­haus­tive Newsweek in­ves­ti­ga­tion—based on this re­porter’s book,

Men­tal Health, Inc.— found, is that for over a decade, the VA reck­lessly over­pre­scribed opi­ates and psy­chi­atric med­i­ca­tions. Since mid-2012, though, it has swung dan­ger­ously in the other di­rec­tion, or­der­ing a dras­tic cut­back of opi­oids for chronic pain pa­tients, but it is bungling that pro­gram and again putting vet­er­ans at risk. (It has also left un­touched one of the riski­est classes of med­i­ca­tions, an­tipsy­chotics— pre­scribed over­whelm­ingly for uses that aren’t ap­proved by the Food and Drug Ad­min­is­tra­tion (FDA), such as with post-trau­matic stress dis­or­der.)

A key role in spread­ing opi­ate use was played by Pur­due Pharma, the Oxy­con­tin man­u­fac­turer con­victed of hid­ing the drug’s ad­dic­tive prop­er­ties. It gave $200,000 to the VA pain man­age­ment team that es­sen­tially turned the VA into its pro­pa­ganda arm, ac­cord­ing to se­cret cor­po­rate doc­u­ments ob­tained by Newsweek. The team helped de­velop the ini­tial VA– Depart­ment of De­fense guide­lines that con­cluded opi­ates “rarely” cause ad­dic­tion. A 2001 bud­get plan out­lin­ing Pur­due’s mar­ket­ing schemes hailed “ad­di­tional cor­po­rate ini­tia­tives and part­ner­ing ef­forts [that] were very suc­cess­ful with the Vet­er­ans Ad­min­is­tra­tion” and other ma­jor health or­ga­ni­za­tions in pro­mot­ing the phony cam­paign, “Pain: The 5th Vi­tal Sign.”

To­day, the num­ber of pa­tients af­fected by the VA’S swing­ing opi­ate pen­du­lum is stag­ger­ing: 60 per­cent of vet­er­ans who fought in the Mid­dle East and 50 per­cent of older vet­er­ans have chronic pain. Since 2012, though, there has been a 56 per­cent drop to a mere 53,000 chronic pain VA pa­tients re­ceiv­ing opi­oids—lead­ing to swift, man­dated cut­offs re­gard­less of pa­tient well-be­ing and with vir­tu­ally no ev­i­dence that it’s a safe ap­proach. For a taste of the kind of in­dif­fer­ent care vets with chronic pain are get­ting, con­sider Marine vet­eran Robert Rose. He is now mostly con­fined to a wheel­chair, suf­fer­ing from se­vere spine, neck and knee in­juries from his mil­i­tary ser­vice—but un­til he was cut off from opi­oid pain med­i­ca­tions last year (de­spite not abus­ing them), he didn’t need a wheel­chair and was able to play with his grand­kids and build finely crafted wood­works. The pri­mary care

I am go­ing CRAZY be­cause of the pain and burn­ing up with anger at the VA.”

doc­tor at the Moun­tain Home, Ten­nessee, VA Med­i­cal Cen­ter told a hob­bled, di­a­betic Rose and his wife dur­ing an of­fice visit in May, “You should con­tinue smok­ing, as it will help you with the stress and frus­tra­tions you are deal­ing with now. And you should con­tinue to drink Moun­tain Dew, as the sugar mol­e­cules will at­tach to the pain re­cep­tors and block the pain you are ex­pe­ri­enc­ing with­out pain med­i­ca­tions.”

Rose is ig­nor­ing that ad­vice and rag­ing against how he and other vet­er­ans are be­ing treated—and mis­treated: “I am go­ing crazy be­cause of the pain and burn­ing up with anger at the VA, the [Cen­ters for Dis­ease Con­trol and Preven­tion] and [the Drug En­force­ment Ad­min­is­tra­tion (DEA)] for what they’re do­ing to so many Amer­i­cans and vet­er­ans.”

‘Don’t Fix the Problems’ in a cer­e­mony in the east room of the white

House in late June, Pres­i­dent Don­ald Trump signed a law mak­ing it eas­ier for the Depart­ment of Vet­er­ans Af­fairs to re­move bad em­ploy­ees and pro­tect whistle­blow­ers. He was joined by his new Vet­er­ans Af­fairs sec­re­tary, Dr. David Shulkin, and Sergeant Michael Ver­ado, who lost his left arm and leg to an im­pro­vised ex­plo­sive de­vice in Afghanistan in 2010, but had to wait 57 days for a prop­erly fit­ted pros­thetic and over three years for the VA to cor­rectly equip his home with ac­ces­si­bil­ity equip­ment—mak­ing him a liv­ing sym­bol of the agency’s wait-time scan­dals.

“In just a short time, we’ve al­ready achieved trans­for­ma­tive change at the Va—and be­lieve me, we’re just get­ting started,” the pres­i­dent de­clared. “For many years, the govern­ment failed to keep its prom­ise to our vet­er­ans. Vet­er­ans were put on se­cret wait­lists, given the wrong med­i­ca­tion, given the bad treat­ments and ig­nored in mo­ments of cri­sis for them. Many vet­er­ans died wait­ing for a sim­ple doc­tor’s ap­point­ment. Yet some of the em­ploy­ees in­volved in those scan­dals re­mained on the pay­rolls…. To­day, we are fi­nally chang­ing those laws to help make sure that the scan­dal of what we suf­fered so re­cently never, ever hap­pens again—and that our vet­er­ans can get the care they so richly de­serve.”

To some VA crit­ics, Trump’s se­lec­tion of Shulkin to head the agency makes it un­likely that sig­nif­i­cant changes will be made. “For vet­er­ans who voted for Don­ald Trump, this is go­ing to feel like a bait and switch,” says Ben­jamin Krause, founder of Dis­abled­vet­er­ans.org. “Keep­ing Shulkin will keep a host of flunkies and crim­i­nals who should have been part of the whole ‘drain the swamp’ prom­ise.”

The fetid VA swamp has been spread­ing for years un­der the last three VA sec­re­taries, in­clud­ing Shulkin. It’s an in­sti­tu­tion long no­to­ri­ous for vi­cious re­tal­i­a­tion against whistle­blow­ers and a pen­chant for false­hoods, ob­fus­ca­tion and de­lay, as well as ram­pant cover-ups of un­safe and some­times deadly con­di­tions—or even fraud—by the VA’S watch­dog agen­cies. This is all kept from view by what some long­time em­ploy­ees call “the code”— the in­sti­tu­tional si­lence and pro­tec­tion of­fered wrong­do­ers. Liken­ing it to the mob’s “omertà,” one high-rank­ing VA ad­min­is­tra­tor, who in­sisted on anonymity, tells Newsweek, “You don’t break ‘the code,’ or your ca­reer is over…. It’s a fear­ful en­vi­ron­ment.”

“The code,” that VA of­fi­cial says, “is de­signed to do this: don’t fix the problems.”

Shulkin’s me­dia of­fice de­clined re­peated re­quests for an in­ter­view with the VA sec­re­tary by this re­porter to dis­cuss the ram­pant problems at the

They are es­sen­tially pre­scrib­ing HEROIN pills.”

VA, but he has made some progress in clean­ing up the depart­ment—while demon­strat­ing a shrewd feel for pub­lic re­la­tions. The Bos­ton Globe re­ported in mid-july that the highly rated (by the VA) Manch­ester, New Hampshire, VA hospi­tal had to close an op­er­at­ing room be­cause ex­ter­mi­na­tors couldn’t get rid of flies, and thou­sands of pa­tients couldn’t make ap­point­ments for vi­tal, some­times life-sav­ing, treat­ments be­cause of a break­down in sched­ul­ing spe­cial­ized care out­side the VA. Whistle­blow­ers had been com­plain­ing about this for years, to no avail, but a few hours af­ter the Globe story broke, Shulkin re­moved the two top ad­min­is­tra­tors.

But even this re­sponse was more sym­bolic than sub­stan­tive. Many other shock­ing abuses have been ig­nored by Shulkin and his pre­de­ces­sors. In 2016, 34 whistle­blow­ers turned to the Scripps News Wash­ing­ton Bu­reau and its Cincin­nati TV af­fil­i­ate, WCPO, to re­port such problems as sur­geons al­legedly be­ing pres­sured to use blood- and bone-splat­tered in­stru­ments as “ster­il­ized” by the Cincin­nati VA hospi­tal’s then–act­ing chief of staff, Dr. Bar­bara Te­meck. Those com­plaints were backed by hun­dreds of dan­ger­ous in­ci­dents chron­i­cled in in­ter­nal doc­u­ments given to Scripps. (Te­meck has de­nied the al­le­ga­tions, although she was de­moted af­ter Scripps re­ported that she im­prop­erly pre­scribed opi­ates to the wife of her re­gional su­per­vi­sor.) The VA’S in­ves­ti­ga­tors didn’t in­ter­view any of the whistle­blow­ers quoted in the press and con­cluded that there were no safety problems at that VA Med­i­cal Cen­ter, a po­si­tion Shulkin’s VA still holds.

All told, nearly 2,000 VA whistle­blow­ers were forced in fis­cal year 2016 alone to ap­peal to an in­de­pen­dent fed­eral agency, the Of­fice of Spe­cial Coun­sel (OSC), to protest re­tal­i­a­tion while re­port­ing fraud or un­safe con­di­tions—more than the next four prob­lem­atic fed­eral de­part­ments com­bined. As The

Bos­ton Globe re­ported in Septem­ber, th­ese em­ployee com­plaints in­cluded nurs­ing home res­i­dents at the Bedford, Mas­sachusetts, Vet­er­ans Af­fairs Med­i­cal Cen­ter al­legedly be­ing starved of food for hours or left to lie naked in bed amid the squalor of soiled sheets.

Shulkin has es­tab­lished a new of­fice given a man­date to pro­tect whistle­blow­ers, but that hasn’t yet halted the re­tal­i­a­tion. “I don’t know of a sin­gle in­stance when a VA em­ployee has been held ac­count­able for ha­rass­ing whistle­blow­ers,” says Krause.

This turf-pro­tect­ing has per­haps been most ap­par­ent in the VA’S be­lated re­sponse to the na­tional opi­ate cri­sis it helped usher in. The VA doesn’t even keep an ac­cu­rate count of how many vet­er­ans have died of le­gal or il­le­gal drug over­doses, even though it of­fi­cially launched an Opi­oid Safety Ini­tia­tive in 2013 that has brought the VA’S opi­ate pre­scrib­ing down 30 per­cent. Nor does it reg­u­larly mon­i­tor opi­ate use by its pa­tients who seek le­gal or il­le­gal drugs out­side the VA.

The VA over­med­i­ca­tion epi­demic, which wasn’t on the re­form pri­or­i­ties list Shulkin re­leased in May, has be­come es­pe­cially ur­gent be­cause of its ap­par­ent link to the 20 sui­cides a day of vet­er­ans in the U.S.

Even those ear­lier VA fig­ures may be a gross un­der­state­ment. When the VA re­leased in Septem­ber state-by-state data, it showed, for ex­am­ple, that Ari­zona had a sui­cide rate as high as 53.6 per 100,000 across all age groups, nearly 40 per­cent higher than what the VA was re­port­ing na­tion­ally. Th­ese trou­bling sui­cide rates—at least dou­ble the civil­ian rate—haven’t been stemmed by all the VA’S sui­cide-preven­tion ef­forts (in­clud­ing the slowly im­prov­ing cri­sis line, 1-800-723-8255). For Ari­zona vet­er­ans between 18 and 34, the sui­cide rate was an as­ton­ish­ing 76.8 per 100,000, twice as high as the na­tional rate for all vet­er­ans. The av­er­age

sui­cide rates were es­pe­cially high in some ru­ral ar­eas across the coun­try, the new VA re­port said.

Even if the VA has done rel­a­tively lit­tle to re­form pre­scrib­ing, it’s be­com­ing more ev­i­dent that med­i­ca­tions play some role in all th­ese tragedies. For in­stance, a 2016 study by re­searchers at the South Texas Vet­er­ans Health­care Sys­tem found a nearly 400 per­cent in­crease in over­doses and sui­ci­dal be­hav­ior by Iraq and Afghanistan war vet­er­ans given too many psy­chotropic and opi­ate med­i­ca­tions, a prac­tice known as “polyphar­macy”—re­ceiv­ing five or more drugs af­fect­ing the cen­tral ner­vous sys­tem. An­other re­cent study of vet­er­ans’ sui­cides between 2004 and 2009 found that the sui­cide rate was twice as high for those pa­tients re­ceiv­ing the high­est doses of opi­oids com­pared to low doses, although no causal link was es­tab­lished for the meds.

This drug free-for-all has got­ten so bad that Re­pub­li­can Se­na­tor John Mc­cain of Ari­zona rein­tro­duced a bill called the Vet­er­ans Over­med­i­ca­tion Preven­tion Act. It de­mands that the VA com­mis­sion an in­de­pen­dent study to an­a­lyze all the sui­cides and ac­ci­den­tal over­doses of vet­er­ans who have died in the last five years, and item­ize all med­i­ca­tions they re­ceived. Mc­cain said in May that the ul­ti­mate goal is to “en­sure doc­tors de­velop safe and ef­fec­tive treat­ment plans for their vet­eran pa­tients.” Given the re­al­ity of to­day’s VA and its past fail­ures, that wor­thy goal seems un­likely to be achieved any­time soon.

The VA hasn’t fully ac­knowl­edged its role in the alarm­ing opi­ate ad­dic­tion rates among vet­er­ans. A 2012 JAMA (for­merly the Jour­nal of the Amer­i­can

Med­i­cal As­so­ci­a­tion) study showed that vet­er­ans with men­tal health dis­or­ders and PTSD were three times more likely to re­ceive opi­oids for pain di­ag­noses than other vet­er­ans. “They are es­sen­tially pre­scrib­ing heroin pills; the ef­fects of th­ese opi­ates are in­dis­tin­guish­able from heroin, and the VA jumped on this cam­paign to en­cour­age highly ad­dic­tive pre­scrib­ing,” says Dr. An­drew Kolodny, co-di­rec­tor of Bran­deis Univer­sity’s Opi­oid Pol­icy Re­search Col­lab­o­ra­tive. In Hunt­ing­ton, West Vir­ginia, a city so gripped by ad­dic­tion that 28 peo­ple over­dosed from heroin in a four-hour pe­riod last year, the lo­cal VA pre­scribes take-home opi­ates to roughly 18 per­cent of its pa­tients—a rate that’s about 230 per­cent higher than the na­tional av­er­age for all adult male pa­tients. When told about this fig­ure, Kolodny said, af­ter a shocked pause, “Wow! That’s very prob­lem­atic.” He then added, “Th­ese are ia­tro­genic—med­i­cally caused—addictions by the VA. The chick­ens are com­ing home to roost.”

In West Vir­ginia and most other states, the VA wors­ened the na­tion’s opi­oid cri­sis by es­sen­tially ig­nor­ing it—the VA didn’t even start re­port­ing all pa­tients get­ting opi­ates to state data­bases un­til the end of 2015, a de­lay that al­lowed those pa­tients to do more doc­tor-shop­ping and drug-deal­ing to and with civil­ians. VA phar­ma­cies were fi­nally com­pelled to share pre­scrib­ing records by a fed­eral opi­oid abuse law passed in July 2016, but by the end of last year, 18 state VA pro­grams still weren’t re­port­ing.

In May 2016, the board chair­man of the Amer­i­can Academy of Fam­ily Physi­cians wrote a let­ter to Shulkin, then head of the VA’S health agency, the Vet­er­ans Health Ad­min­is­tra­tion, plead­ing for the depart­ment to im­pose manda­tory opi­ate re­port­ing on all VA pro­grams. Speak­ing more than a year later, the AAFP’S pres­i­dent, Dr. John Meigs, tells News

week his or­ga­ni­za­tion has still not heard back from Shulkin or any­one else at the VA. “Pre­scrip­tion drug– mon­i­tor­ing pro­grams are among the im­por­tant ve­hi­cles for pre­vent­ing pa­tients from abus­ing opi­oid med­i­ca­tions and, as such, are a cor­ner­stone of the Amer­i­can Academy of Fam­ily Physi­cians’ ad­vo­cacy on deal­ing with this epi­demic,” he de­clares.

The dis­as­ter is likely to worsen un­der the Trump ad­min­is­tra­tion be­cause of its as­saults on Med­i­caid and Oba­macare; this af­fects vet­er­ans as well, since fewer than half of the na­tion’s 22 mil­lion vet­er­ans re­ceive their care from the VA. (In late Au­gust, the ad­min­is­tra­tion left no doubt it wanted to de­stroy the Oba­macare mar­ket­places by an­nounc­ing it would cut by 90 per­cent the ad­ver­tis­ing needed to pro­mote en­roll­ment and slash funds by 40 per­cent for help­ful “nav­i­ga­tors” to help peo­ple sign up for the pro­gram.) Nearly as trou­bling, the loom­ing de­nial of care is ag­gra­vated by the sui­cides, over­doses and il­le­gal use of opi­oids that are all com­pounded by dra­co­nian new fed­eral pain med­i­ca­tion re­stric­tions on chronic pain pa­tients. So when New Jer­sey Gover­nor Chris Christie’s fed­eral opi­oid com­mis­sion re­leased its ini­tial re­port at the end of July call­ing for swift fed­eral ac­tion, his home state news­pa­per, the Ne­wark Star-ledger, pointed to the ”ele­phant in the room.… The ob­vi­ous fact that Don­ald Trump’s team is striv­ing as hard as it can to gut Med­i­caid and make it even more dif­fi­cult to get

Th­ese are med­i­cally caused ADDICTIONS by the VA. The chick­ens are com­ing home to roost.”

treat­ment.” (Trump re­ferred to the opi­oid cri­sis as a “na­tional emer­gency” on Au­gust 10, but the fed­eral govern­ment hasn’t yet taken the steps needed to in­voke emer­gency pow­ers that could al­low for more spend­ing or loosen bu­reau­cratic re­stric­tions on pro­vid­ing med­i­ca­tion-as­sisted ad­dic­tion treat­ment, such as Subox­one, which cuts over­dose fa­tal­i­ties.)

‘What if He Were Your Son?’

in 2013, af­ter the cen­ter for in­ves­tiga­tive re­port­ing (CIR) ex­posed sky­rock­et­ing rates of opi­ate pre­scrib­ing by the VA, some of its physi­cians told a House vet­er­ans sub­com­mit­tee they were pres­sured to pre­scribe the ad­dic­tive painkillers—even to pa­tients they hadn’t ex­am­ined. Dr. Pamela Gray, a pri­mary care physi­cian fired from the Hamp­ton, Vir­ginia, VA hospi­tal, said, “There are mul­ti­ple in­stances when I have been co­erced or even or­dered to write for Sched­ule 2 nar­cotics when it was against my med­i­cal judg­ment.” VA of­fi­cials deny there were any sys­temic problems in their pre­scrib­ing prac­tices, yet in May 2014, the VA in­spec­tor gen­eral found that clin­i­cians were ig­nor­ing guide­lines for safe take-home opi­ate pre­scrib­ing, with one out of 10 chronic pain opi­oid users also re­ceiv­ing ben­zo­di­azepines in the course of a year—and 92 per­cent got them at the same time. This is a fla­grantly dan­ger­ous mix­ture that the fed­eral govern­ment flagged as a lethal com­bi­na­tion—while the FDA has re­cently added new warn­ings that it could cause “res­pi­ra­tory de­pres­sion, coma and death.”

And that’s what hap­pened to Marine Corps vet­eran Ja­son Sim­cakoski, who was tak­ing 16 dif­fer­ent Va-pre­scribed opi­ates, ben­zo­di­azepines, an an­tipsy­chotic and other se­dat­ing drugs be­fore he died. By the time he checked him­self into the Tomah, Wis­con­sin, VA’S in­pa­tient psy­chi­atric unit in the sum­mer of 2014 for help with anx­i­ety and a pill ad­dic­tion, VA lead­er­ship had known for years that there were deadly over­pre­scrib­ing problems there. But they didn’t be­gin to ad­dress the cri­sis un­til the CIR broke this story in Jan­uary 2015: “Opi­ates handed out like candy to ‘doped-up’ vet­er­ans at Wis­con­sin VA,” lead­ing to the deaths of over 30 vet­er­ans. The story laid out how opi­ate pre­scrib­ing had quin­tu­pled since Dr. Michael Houli­han—nick­named by vets “the Candy Man”—be­came chief of staff in 2005, while the num­ber of pa­tients served dropped. Na­tion­wide, opi­ate pre­scrib­ing in­creased 270 per­cent across the VA sys­tem since 9/11, CIR dis­cov­ered, while the pa­tient load had in­creased less than 40 per­cent by 2013. The lat­est guide­lines at the time for sen­si­ble opi­ate pre­scrib­ing were rou­tinely ig­nored at Tomah and many other VA fa­cil­i­ties, and Houli­han’s reck­less pre­scrib­ing was ex­ac­er­bated by his pen­chant for ter­ror­iz­ing any clin­i­cian and staffer who op­posed him. This was es­pe­cially no­table in his fir­ing of a psy­chol­o­gist who had ob­jected to the ex­ces­sive dop­ing of pa­tients, then faced re­lent­less ha­rass­ment from his su­per­vi­sor—and later killed him­self af­ter he lost his job.

Noelle John­son, a Vet­er­ans Af­fairs phar­ma­cist fired from Tomah af­ter she re­fused to fill high­dosage opi­ate pre­scrip­tions, notes that the VA’S ar­chaic soft­ware didn’t flag any dosage or in­ter­ac­tion warn­ings for the 1,080 mor­phine pills in 30 days she was pres­sured to pre­scribe a pa­tient with “psy­cho­log­i­cal pain.” She says, “My bosses tried to strong-arm phar­ma­cists.” She adds that she got the same kind of pres­sure at her new post with the Des Moines, Iowa, VA.

Although it was ob­vi­ous that Ja­son Sim­cakoski was an addict, the VA kept ship­ping him bag­fuls of opi­ates and ben­zos and an­tipsy­chotics, and he was also dosed with the stim­u­lants Ad­der­all and Ri­talin, which wors­ened his mood, be­hav­ior and in­som­nia. His doc­tors pre­scribed those for a ques­tion­able di­ag­no­sis of at­ten­tion deficit hy­per­ac­tiv­ity dis­or­der, just one of at least a dozen or so di­ag­noses slapped on him over the years, along with bipo­lar per­son­al­ity dis­or­der and PTSD.

“With all th­ese med­i­ca­tions, he went down­hill real fast,” says Ja­son’s fa­ther, Marvin Sim­cakoski. His weight bal­looned from 180 to 250 pounds, and he was too ashamed to go into a res­tau­rant on those rare days he went into town—he’d only or­der food from drive-thru win­dows. Near the end, he couldn’t even bend down to tie his shoes.

When Ja­son died in Au­gust 2014 of what the lo­cal med­i­cal ex­am­iner called “mixed drug tox­i­c­ity,” he had just been obey­ing his doc­tors’ or­ders: He was al­ready tak­ing 14 dif­fer­ent med­i­ca­tions, in­clud­ing high-risk opi­ates, ben­zo­di­azepine tran­quil­iz­ers and the se­dat­ing an­tipsy­chotic Sero­quel. Yet just two days be­fore his death, Ja­son was also given Subox­one, an opi­ate typ­i­cally used to re­duce de­pen­dence on other nar­cotics. This was soon fol­lowed by a pow­er­ful mi­graine med­i­ca­tion, Fioricet, that posed

Vet­er­ans died of drug over­doses at TWICE the rate of civil­ians.”

a risk of res­pi­ra­tory fail­ure or death when com­bined with Subox­one and sev­eral of his other drugs. He was in­gest­ing this drug cor­nu­copia de­spite the well-known dan­gers of po­ten­tially fa­tal in­ter­ac­tions between Subox­one and all three ben­zo­di­azepines he was tak­ing—val­ium, Resto­ril and Serax—and with some of his other high-risk med­i­ca­tions.

Marvin Sim­cakoski told a joint con­gres­sional field hear­ing on the Tomah scan­dal in March 2015 that he’d spent years try­ing to save his son, but he says his fears were dis­missed by VA doc­tors as ig­no­rant sec­ond-guess­ing. “I was al­ways told that I wasn’t their pa­tient, even though I was his dad, who truly cared about him a lot more than they did!” His voice quak­ing with an anger, he added, “What I would like to know is, if Ja­son was their son, would they have had him on all of th­ese meds?”

Af­ter that con­gres­sional hear­ing, the VA an­nounced it was con­duct­ing a crim­i­nal in­ves­ti­ga­tion; that probe and other in­ves­ti­ga­tions led to a few Tomah med­i­cal of­fi­cials get­ting vil­i­fied in the press, and even­tu­ally fac­ing em­ploy­ment sanc­tions. Houli­han was fired more than a year af­ter Ja­son died, but he was prac­tic­ing medicine un­til Jan­uary 2017, when he agreed to sur­ren­der his li­cense as part of a deal with state reg­u­la­tors to drop their in­ves­ti­ga­tion of him.

Ja­son’s fa­ther and widow took their cam­paign against the VA’S med­i­ca­tion prac­tices to D.C. They worked with Demo­cratic Se­na­tor Tammy Bald­win of Wis­con­sin on leg­is­la­tion to curb and mon­i­tor opi­ate over­pre­scrib­ing, and ap­peared at a news con­fer­ence in June 2015. The Ja­son Sim­cakoski Memo­rial Opi­oid Safety Act was signed into law in July 2016.

Heather hopes the bill will save lives, but she and other VA crit­ics know there are weak­nesses in the new plan to rein in over­med­i­ca­tion: weak over­sight of staff, wors­ened by the VA’S elec­tronic records and drug-in­ter­ac­tion alerts that too of­ten fail to work, and on-screen drug warn­ings that are widely ig­nored. In 2015, the VA paid over $1 mil­lion to the widow of for­mer para­trooper Ricky Green, who died af­ter get­ting his opi­ates and tran­quil­izer dosages cranked way up af­ter back surgery. The VA phar­ma­cists ad­mit­ted un­der oath that their soft­ware hadn’t flagged the higher dosages or that Green had a sleep ap­nea con­di­tion that fa­tally in­ter­acts with the drugs.

The VA’S en­tire make-shift health soft­ware sys­tem—known as Vista—is so bad Shulkin an­nounced in June that the VA was pur­chas­ing a brand-new com­mer­cial sys­tem at an es­ti­mated cost of $16 bil­lion; it’s based on one re­cently bought by the De­fense Depart­ment so that, in part, as their elec­tronic health records are rolled out, they can be shared seam­lessly, but that won’t nec­es­sar­ily fix the problems with the VA’S phar­macy soft­ware. Even more trou­bling, Chris Miller, the depart­ment’s ex­ec­u­tive in charge of mod­ern­iz­ing the Pen­tagon’s soft­ware us­ing the same con­trac­tor as the one hired by the VA was then sent over to ad­vise the VA, but he fled, ap­palled over mis­man­age­ment, within weeks of his ap­point­ment in early June. “The peo­ple problems are not re­solved and the user problems are not re­solved just be­cause you have a new tool com­ing on board,” a VA of­fi­cial says. “The peo­ple problems are at the core of the demise of the VA.”

That’s one rea­son no one knows how many vets have been killed by ac­ci­den­tal pre­scrip­tion over­doses in the past decade, although a hand­ful of rig­or­ous stud­ies sug­gest the death toll is in the thou­sands. One of the very few schol­arly re­ports

on ac­ci­den­tal over­dose deaths of vet­er­ans, done by Univer­sity of Michi­gan and VA re­searcher Amy Bohn­ert in 2011, used 2005 data to con­clude that 1,013 pa­tients re­ceiv­ing VA ser­vices died an­nu­ally through un­in­ten­tional over­doses, mostly from pre­scrip­tion med­i­ca­tions. At that time, le­gal opi­oids, present in nearly a third of the ac­ci­den­tal over­dose deaths, were the most com­mon sub­stances in­volved, while non-nar­cotic psy­chi­atric drugs and seda­tives were in­volved in 22 per­cent of the deaths she stud­ied. (Across all civil­ian and mil­i­tary pop­u­la­tions, le­git­i­mately man­u­fac­tured opi­oid med­i­ca­tions ac­count now for only 15 per­cent of opi­oid fa­tal­i­ties.) When the Austin-amer­i­can States­man looked at Texas records in 2012, nearly 20 per­cent of all deaths of vet­er­ans get­ting VA ben­e­fits they stud­ied were due to mostly ac­ci­den­tal over­doses of pre­scrip­tion drugs—not from sui­cides.

De­spite the Tomah and other tragedies, vet­er­ans con­tin­ued to die from over­doses in VA hospi­tals and res­i­den­tial treat­ment fa­cil­i­ties, some­times abet­ted by drug-ped­dling em­ploy­ees—while the agency failed to ac­cu­rately track the drug-re­lated deaths of vet­er­ans. The Low­ell Sun re­ported last year that two vet­er­ans grap­pling with addictions who lived in VA res­i­den­tial fa­cil­i­ties in Mas­sachusetts died of opi­ate over­doses within weeks of each other. Their deaths are now the fo­cus of a VA crim­i­nal in­ves­ti­ga­tion into drug deal­ing by a ring of em­ploy­ees and pa­tients at the hospi­tal. Ad­min­is­tra­tors ini­tially de­nied any­thing was amiss, and the AfricanAmer­i­can whistle­blower who helped ex­pose the al­leged drug ring re­vealed in Fe­bru­ary that he had been de­moted, and ha­rassed by col­leagues—in­clud­ing find­ing on his desk a teddy bear with a noose around its neck and the sign, “Go home or die.”

Lethal Cut­backs

fol­low­ing the tomah over­pre­scrib­ing scan­dal, the VA said it would fol­low tougher new DEA guide­lines on opi­ate pre­scrib­ing that, some ad­vo­cates say, harm pa­tients with le­git­i­mate pain is­sues. That’s in part be­cause those pa­tients are now re­quired to see their doc­tors in per­son once a month for re­fills—a near-im­pos­si­ble task be­cause of the back­log and de­lays through­out the VA sys­tem. Equally trou­bling, the crack­down on opi­ate pre­scrib­ing—a swing from one dan­ger­ous ex­treme to an­other—may be con­tribut­ing to an in­crease in heroin and il­le­gal

The one thing the VA is very good at is throw­ing PILLS at the prob­lem.”

opi­ate med­i­ca­tion use among vet­er­ans, as well as sui­cides from pain-wracked vet­er­ans in poorly mon­i­tored with­drawal. (Even with new opi­oid guide­lines, the num­ber of vet­er­ans with opi­oid-use dis­or­ders in­creased 55 per­cent from 2010 to 2015.)

Although the VA boasts that those tougher guide­lines have led to a de­cline of nearly a third in opi­ate pre­scrib­ing, it doesn’t track vet­er­ans who have turned to heroin and il­le­gal pre­scrip­tions as a re­sult of the cut­backs—or no­tice the dev­as­ta­tion this crack­down is caus­ing. It has be­come in­creas­ingly clear that too many VA doc­tors are fo­cus­ing on tak­ing pa­tients off opi­oids with­out of­fer­ing ap­pro­pri­ate ad­dic­tion coun­sel­ing or ad­dress­ing how they’re need­lessly hurt­ing all the chronic pain pa­tients they’re tak­ing off th­ese meds. “They’re not fo­cus­ing on pa­tient­cen­tered care; they’re fo­cus­ing on num­bers,” one VA staffer says. At one point, this em­ployee says, a doc­tor in a ma­jor VA med­i­cal cen­ter was spot­ted cry­ing in the hall­way be­cause he was ob­li­gated by ad­min­is­tra­tive fiat to kick a chronic pain pa­tient off opi­oids in a way that he knew would hurt his pa­tient.

Even when pa­tients re­al­ize they’re en­dan­ger­ing them­selves, the VA’S clin­i­cians too of­ten don’t of­fer much mean­ing­ful help. Take Mal­lory Dinkel, an Air Force in­fantry sol­dier who had her leg and hips

se­verely dam­aged in an at­tack on her Humvee in Kuwait in 2004, but re­turned for mul­ti­ple com­bat tours in Iraq be­fore be­ing med­i­cally dis­charged in 2013. Grap­pling with PTSD and a poorly un­der­stood form of chronic pain, com­plex re­gional pain syn­drome, she stepped up her ro­tat­ing use of pre­scrip­tion mor­phine, Per­co­cet and other drugs un­til she was forced in Jan­uary 2016 to quickly un­wind all opi­oids. “It was aw­ful: I was con­stantly vom­it­ing, sweat­ing, hav­ing mi­graines and get­ting the shakes,” she says, un­able to move from her couch for two weeks ex­cept to crawl to the bath­room. “Noth­ing was men­tioned about ad­dic­tion, and I didn’t get treat­ment.” All she got be­fore go­ing cold turkey on her own—de­spite the risks of sud­den with­drawal with­out med­i­cally su­per­vised ta­per­ing—were two one-hour classes on the dan­gers of opi­ates and how to in­ject her­self with nalox­one to pre­vent over­doses. “The VA didn’t do a thing,” she says, turn­ing to costly, un­proven ke­tamine in­fu­sion treat­ment for de­pres­sion and pain re­lief through a fam­ily friend’s cen­ter that she can no longer af­ford. “I’m bat­tling on my own now.”

Can’t Stop, Won’t Stop

the cal­lous in­dif­fer­ence of both the va and Con­gress to the over­med­i­ca­tion cri­sis has only re­cently started to change, and that’s just for opi­ates, not an­tipsy­chotics. What has got­ten worse in the last decade is the VA’S de­ter­mi­na­tion to hide the truth. The Sen­ate gov­ern­men­tal af­fairs com­mit­tee’s Re­pub­li­can ma­jor­ity, for in­stance, con­cluded in May 2016 about the Tomah VA Med­i­cal Cen­ter de­ba­cle: “The over­pre­scrip­tion, re­tal­i­a­tion, vet­er­ans’ deaths, and abuse of author­ity at the Tomah VAMC did not oc­cur in a vac­uum. Vet­er­ans, em­ploy­ees, and whistle­blow­ers tried for years to get some­one to ad­dress the problems. The Tomah VAMC is a mi­cro­cosm of both the VA’S cul­tural problems with re­spect to whistle­blower re­tal­i­a­tion and the VA Of­fice of In­spec­tor Gen­eral’s dis­re­gard for whistle­blow­ers.”

Th­ese whistle­blow­ers are no­tably skep­ti­cal about the var­i­ous re­form and ac­count­abil­ity ges­tures such as pub­lic wait­ing lists of­fered by Shulkin. Take Shea Wilkes, then a men­tal health ad­min­is­tra­tor at the Shreve­port, Louisiana, VA hospi­tal who was busted back down to so­cial worker af­ter, in 2014, he ex­posed 37 wait-time deaths among those peo­ple on a se­cret men­tal health wait­ing list of 2,700 pa­tients. While not­ing that the VA has now seem- in­gly been able to pro­vide some same-day cri­sis men­tal health ser­vices, as promised, he says that all too of­ten pa­tients can’t get prompt, reg­u­lar coun­sel­ing: “The one thing the VA is very good at is throw­ing at the prob­lem.”

In VA hospi­tals all over the coun­try, dis­si­dents such as Bran­don Cole­man are still pun­ished for try­ing to save lives or fight fraud. He is a bearded, blunt-talk­ing ad­dic­tion ther­a­pist for­merly with the Phoenix VA and a dis­abled Marine Corps vet­eran who se­verely shat­tered the bones of his left foot dur­ing a train­ing ac­ci­dent at Camp Pendle­ton that led to nine failed surg­eries, and he felt he had to file a for­mal fed­eral whistle­blower com­plaint in De­cem­ber 2014 over the mal­treat­ment of vet­er­ans at that no­to­ri­ous VA hospi­tal. With his past as a meth addict who came close to shoot­ing him­self in 2005, he was alarmed that the un­der­staffed ER was al­low­ing sui­ci­dal or homi­ci­dal pa­tients in cri­sis—of­ten brought over by ad­dic­tion coun­selors—to sim­ply wan­der off. One pa­tient killed him­self in the park­ing lot af­ter be­ing ig­nored by the staff.

“It crushes me when a vet­eran suc­cess­fully com­mits sui­cide,” he says—and since 2011, at least six of the ad­dicts he coun­seled killed them­selves be­fore he was pushed out of his job early in 2015. “There are

You don’t break the ‘code,’ or your ca­reer is over... It’s a FEAR­FUL en­vi­ron­ment.”

dozens and dozens who com­mit sui­cide in the Phoenix area each year,” Cole­man says. Af­ter go­ing pub­lic with his con­cerns in Jan­uary 2015, a spe­cial­ized year­long out­pa­tient pro­gram he ran in the evenings for ad­dicted vet­er­ans with crim­i­nal con­vic­tions was shut down by Phoenix VA ad­min­is­tra­tors, he was forced to take ad­min­is­tra­tive leave, and he was in­ves­ti­gated for pur­port­edly threat­en­ing a col­league.

In May 2016, the in­de­pen­dent OSC sided with Cole­man. It gave him a gen­er­ous fi­nan­cial set­tle­ment that al­lowed him to pay off all his debts and help his kids buy a home and cars. He was re­in­stated as an ad­dic­tion spe­cial­ist at an out­pa­tient clinic un­af­fil­i­ated with the Phoenix sys­tem, and he was able to restart his life-chang­ing pro­gram for ad­dicted vets. Dur­ing more than a year of forced leave, he be­came an in­for­mal leader of the na­tion’s count­less VA whistle­blow­ers. He sums up his tra­vails this way: “I kicked the VA in the nuts, and I won my case.” To­day, he rides around in a prized new classic car, a blue 1968 Mus­tang, with a li­cense plate that reads, “THX VA.”

Cole­man may now be in a po­si­tion to stop the abuse of whistle­blow­ers—he’s a staff mem­ber of the new VA whistle­blower pro­tec­tion of­fice. While his ap­point­ment is per­haps the most pos­i­tive in­di­ca­tor yet that the VA might try to re­form, that’s a heavy bur­den to place on him. He’s got­ten well over 50 calls and emails from des­per­ate staffers turn­ing to him for help since his ap­point­ment was an­nounced.

For ex­am­ple, one new test case Cole­man and his col­leagues are re­view­ing in­volves an Mit-trained Tomah VA en­gi­neer, Jae Pak, who was fired af­ter try­ing to halt an al­legedly shoddy, un­safe se­ries of de­layed hospi­tal re­pair projects—by a com­pany friendly with ad­min­is­tra­tors—that were way over bud­get. He faced a spu­ri­ous dis­or­derly con­duct charge (the case was dis­missed). Equally trou­bling, crit­ics say, he was forced out un­der the watch of a new Tomah hospi­tal di­rec­tor, Vic­to­ria Brahm, and a new re­gional VA chief, Re­nee Oshin­ski, who both, while at re­gional head­quar­ters al­legedly down­played for nearly a decade the pre­scrib­ing and re­tal­i­a­tion cam­paign led by Houli­han, Sen­ate in­ves­ti­ga­tors found; the of­fi­cials claimed they re­sponded ap­pro­pri­ately.

One added weapon for re­form could be a new bill mov­ing slowly through Con­gress de­signed to quickly dis­ci­pline or re­move ad­min­is­tra­tors who harass whistle­blow­ers. It is named af­ter Christo­pher Kirk­patrick, the psy­chol­o­gist who killed him­self af­ter be­ing driven out of his job at Tomah for protest­ing deadly pre­scrib­ing.

For now, pa­tients at VA sites such as the Phoenix and St. Louis hospi­tals (where the chief of psy­chi­a­try, Dr. Jose Mathews, was forced out in 2013 af­ter re­port­ing that sui­ci­dal pa­tients were ig­nored by staff) con­tinue to see hon­est, ded­i­cated clin­i­cians and other em­ploy­ees get pun­ished.

What Cole­man will do about such al­leged re­tal­i­a­tion and cover-ups re­mains to be seen. With a quick search on Google News, it seems there’s a new re­tal­i­a­tion or health scan­dal re­ported ev­ery few days, although most never get much me­dia at­ten­tion. So even be­fore Cole­man’s ap­point­ment was pub­licly an­nounced, he told Newsweek: “I still get two to four calls a week from VA whistle­blow­ers I have never met who are cry­ing, scared and los­ing their ca­reers all for merely telling the truth. It has not stopped be­cause the VA has never been made to stop.” Adapted from the new book Men­tal Health, Inc.: How Cor­rup­tion, Lax Over­sight, and Failed Re­forms En­dan­ger Our Most Vul­ner­a­ble Ci­ti­zens, by Art Levine. © by Art Levine, 2017. Pub­lished by The Over­look Press, Peter Mayer Pub­lish­ers, Inc., Over­look­press .com. All rights re­served.

BIT­TER PILLS he a ents of i cakoski show a text from their son. At right, his wife and daugh­ter. A for­mer arine, Sim­cakoski was tak­ing 16 dif­fer­ent Va re­scribed drugs be­fore he died.

MA­LIGN NE­GLECT The VA’S over­med­i­ca­tion e idemic wasn’t on the list of re­form ri­or­i­ties Shulkin, above, re­leased in ay. And the dis­as­ter is likely to worsen un­der the Trum ad­min­is­tra­tion be­cause of its as­saults on ed­i­caid and ba­macare.

BREAK­ING THE CODE n VA hos itals all over the coun­try, dis­si­dents such as arine Cor s vet­eran Cole­man, right, with his chil­dren, are still un­ished for try­ing to save lives or ght fraud.

THE CANDY STORE The VA didn’t even start re rtin a atients et­tin iates t state data­bases un­til the end

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