‘Repressive Atmosphere’ Surrounds Veterans Getting Hooked at VA Hospital

This story is making waves, but one worries that the policy and regulation ramifications might make targets of doctors and veterans, and create new barriers between them.

Doctor: Veterans get hooked, not healed, at VA hospital

By Bill Sizemore, The Norfolk Virginian-Pilot

Two doctors who worked at the Hampton VA Medical Center say powerful narcotics are being over prescribed to veterans there, leaving them addicted while their underlying medical conditions go untreated.

The doctors have warned that the high volume of narcotics may be feeding a pipeline of dangerous drugs that are illegally resold in the community, with potentially fatal results.

Federal authorities are looking into the allegations.

One of the doctors was fired after airing her concerns.

When Dr. Pamela Gray joined the staff at Hampton in 2008 after 23 years of private practice, it didn’t take her long to become uncomfortable with the kind of care being delivered there.

Veterans were being given morphine, OxyContin and similar narcotics with a high potential
for addiction – often two, three or more such drugs in large doses – for months, even years, on end, she says. Time after time, when she checked patients’ charts, Gray could find no up-to-date diagnosis or lab results that would justify such treatment.

When she objected to her superiors, she says, she was ignored. She says she was sometimes
ordered to write unjustified prescriptions for narcotics.

Finally, early this year, she took her concerns to U.S. Sen. Jim Webb and the inspector
general of the U.S. Department of Veterans Affairs.

Weeks later, she was fired – a reprisal, she believes, for blowing the whistle on her employers. She is challenging her dismissal.

The medical center declined to discuss the circumstances of her termination.

Gray says that when she inquired about the source of the Hampton center’s narcotics policy, her superiors said it originated with a rheumatologist who worked there in the 1990s: Dr. Stephen Plotnick.

Plotnick lost his medical license last year after being accused of contributing to the deaths of a series of patients with high doses of narcotics.

Plotnick worked at the Hampton center from 1994 to 1999. He then went to work for the Portsmouth Naval Medical Center and later entered private practice inVirginia Beach.

He has settled at least three medical malpractice lawsuits brought by survivors of patients who died of overdoses, and several more cases are pending in local courts.

He did not respond to requests for comment.

Gray is not the only doctor who has objected to the Hampton VA center’s proclivity for dispensing narcotics.

Dr. Jennifer Pagador quit in late 2008 after only three months on the job, shocked by the level of narcotic use she encountered. Gray says several other doctors have quit for the same reason.

Three contacted by The Virginian-Pilot declined to comment on the record about their reasons for leaving.

“We are told to just continue giving the patients narcotics,” Pagador, who now works in an urgent-care clinic in Virginia Beach, wrote in her exit interview. “Most of them are addicted. Some come to the clinic in active withdrawal…. I, in good conscience, cannot continue to give massive doses of narcotics to patients who are obviously addicted.”

In many cases, Pagador says, the patients had had no recent lab work or urine drug screening.

On her own volition, she began doing drug screening and found that some patients tested negative for the drugs they had been prescribed – an indication, she believes, that the drugs were being diverted for illegal resale in the community.

Gray, too, strongly suspected that narcotics were being diverted and resold, but she was never able to find any hard evidence of it.

A review of 43 VA medical centers by the VA inspector general’s office in 2008 found that 77 percent of them had suspected drug diversions during the previous year.

Last year an Army veteran was sentenced to 30 months in federal prison for obtaining prescription drugs from doctors at VA facilities in Michigan and illegally distributing them, leading to the overdose death of a 25-year-old sailor.

The National Institute on Drug Abuse has called prescription drug abuse a “serious and growing public health problem.”

According to a model policy adopted by the Virginia Board of Medicine in 2004, narcotic prescriptions should be based on a diagnosis and documentation of unrelieved pain, including a medical history, physical examination and periodic reviews of the course of treatment by the doctor. If the patient is at high risk for abuse, urine drug screenings are suggested.

Before multi-month refills can be prescribed for certain federally controlled narcotics,VA regulations require that patients sign an agreement with their doctors promising to take the drugs only as prescribed and acquiescing to random screenings. A violation of the agreement can result in the drugs being withheld.

The Hampton center adheres to that policy, spokeswoman Jennifer Askey said by e-mail. Gray says it is followed only sporadically.

In recent years, many states, including Virginia, have set up statewide prescription drug databases. Pharmacists are required by law to report all prescriptions filled for certain federally controlled narcotics. Doctors and pharmacists are encouraged to consult the database to guard against prescription fraud, “doctor shopping” and other abuses.

Federal pharmacies, however, are exempt from the reporting requirement. So none of the drugs dispensed by the Hampton VA center can be tracked by the state system.

Gray says that when she suggested the center voluntarily use the state database as a way of curbing drug abuse, she was told, “We don’t have to – we’re the federal government.”

Early in her tenure at Hampton, Gray says, she learned that it was the only VA medical center on the East Coast without a written standard operating procedure for narcotic refills.

So she instituted one. It required that before narcotic prescriptions could be refilled, patients must have been seen by their primary care doctors within the past three months. In addition, lab tests and a urine drug screening must have been done within the past six months.

The policy was widely ignored, Gray says. The center’s current pain management policy, provided by the VA to The Pilot, contains no comparable requirements.

Moreover, Gray says, on more than one occasion she was pressured by non medical administrative personnel at the center to write narcotic prescriptions for patients she had never seen.

Once, she documented such pressure by writing a note in a patient’s chart. She was later ordered to remove the note. When she refused, her supervisor deleted it over her objection.

She also says she got death threats from veterans upset that she wouldn’t prescribe narcotics for them. “I hope Dr. Gray dies a long painful death,” one patient was recorded as telling a nurse in a phone call seeking a refill.

On one occasion, Gray felt so threatened by a veteran in the examining room that she pressed the “panic button,” installed to protect doctors’ safety, summoning the police.

Nine months into the job, Gray says, “I was at my wits’ end.” In December 2008, she e-mailed her supervisor that she intended to resign, saying, “The problem with abuse of narcotics at this institution is far greater than anyone realizes.”

She decided to stay after getting reassigned to a different clinic.

The trigger for her ultimate dismissal appears to have been her advocacy on behalf of John Morgan, a Marine veteran from Chesapeake who was turned away from the Hampton VA emergency room in November 2008 despite showing classic symptoms of a stroke.

Morgan’s undiagnosed stroke, which left him permanently disabled, prompted a critical report from the VA inspector general and a malpractice lawsuit against the emergency-room doctor who discharged him.

Morgan became a patient of Gray’s after suffering another stroke last year. When she tried to refer him to a neurologist for a follow-up assessment, she encountered repeated resistance. The referral was finally approved after a flurry of combative e-mails.

“I was frustrated,” Gray says. “I was desperate to get care for my patient.”

In November her supervisor reprimanded her for using “inflammatory and derogatory” language and discussing patient care by e-mail.

In January she was informed that a professional standards board would be convened to review alleged deficiencies in her performance.

By then, Gray says, it was clear to her that she had been targeted for removal. She decided to fight back.

She laid out her concerns to representatives of Webb and the VA inspector general, who conducts oversight of VA programs and investigates wrongdoing in them.

The inspector general’s office has told Webb it is reviewing the allegations.

Gray provided detailed accounts of what she considered unjustified use of narcotics. Among the examples were these:

*A veteran with carpal tunnel syndrome got repeated refills by mail for a cocktail of narcotics – morphine, methadone, tramadol, Percocet and fentanyl – despite having had no doctor visits or lab work since 2004.

“Carpal tunnel is a soft-tissue injury that’s fixable with no pills,” Gray says. “Their treatment was, just give him opioids forever and ever.”

“Opioid” is the medical term for powerful pain relievers like morphine.

When Gray refused to go along, the veteran went to another VA doctor and got his refills.

*Another veteran was receiving large doses of morphine and oxycodone based on an 11-year-old diagnosis of lupus, a chronic autoimmune disease. When Gray could find no record of any lab results since 1997, she ordered new lab work done. The test for lupus was negative.

She refused to refill the vet’s narcotics, and he, too, found another doctor to write the prescription.

*A third veteran had been getting morphine and oxycodone refills by mail since being diagnosed with rheumatoid arthritis in 2000, but new lab tests found no active inflammation. He slept through much of Gray’s examination.

Gray tried to taper him off the narcotics, but within days his wife called back, asking for more drugs.

In February, a month after her visit to Webb’s office, Gray was summoned before the professional standards board. She was quizzed from a written list of questions including this one: “Are you aware of the specific complaint by some nursing staff that you do not speak to them when they initiate a greeting to you?”

In March, a month before the end of her two-year probationary period, she was fired. At the time, she says, she was given no reason. In a written report she received two months later, she was cited for “poor interpersonal communication skills.”

She has filed a complaint with the U.S. Office of Special Counsel under the federal Whistleblower Protection Act alleging reprisal by the VA. That office has made a preliminary determination to close the case without taking any action.

One of her attorneys, Adam Lotkin, says Gray has been persecuted for standing up for her patients and refusing to back down. “She’s taken the path of most resistance,” Lotkin says. “Unfortunately, it cost her her job.”

Lotkin also represents John Morgan, the disabled veteran who is suing over his undiagnosed stroke.

“I believe there are good doctors at the VA who are being coerced into practicing medicine that they are uncomfortable with,” Gray says. “They fear reprisal. It’s a repressive atmosphere. If you don’t knuckle under, you’re gone.”

The stakes are high, she says: Millions of veterans are coming back from Iraq and Afghanistan, many of them with medical conditions that will require treatment.

“If the VA’s answer is just to give more opioids, we are doing them a disservice,” Gray says.

“These are young people. Don’t sentence them to a lifetime of opioid use.”