Calais VA clinic taking steps to address problems with its opiate distribution

Posted Aug. 23, 2012, at 6:19 p.m.
Last modified Aug. 24, 2012, at 9:14 a.m.

CALAIS, Maine — The VA Maine Healthcare System and the administration and staff of the system’s Community Based Outpatient Clinic in Calais are undertaking steps to address and resolve the findings of a recent Department of Veterans Affairs investigation that substantiated irregularities related to prescribing and monitoring opiate-based painkillers.

The inspection included interviews with clinic staff and the person who filed the original complaint. It also involved review of the electronic medical records of 15 patients who were prescribed such drugs over the three-month period between November 2011 and February 2012.

The VA Office of the Inspector General found evidence in those records that the clinic’s providers did not appropriately assess chronic pain patients on opioid therapy and did not adequately monitor them for the misuse of the powerful and potentially addictive drugs, including hydrocodone and oxycodone products.

The records showed that six of the 15 patients had not been reassessed at least every six months, as required, with time frames instead ranging from seven to 13 months. Investigators also found that one clinic provider failed to follow up on an opioid patient’s positive urine analysis for illicit drugs. They also found that 13 of the 15 patients whose records were reviewed obtained prescriptions from multiple clinic providers.

The investigation did not explore allegations that clinic employees were profiting from diversion of opiate-based prescriptions for recreational use “due to lack of specific information.”

Jim Doherty, spokesman for the VA Maine Healthcare System, said Thursday that, after reviewing the report, system officials “concur with the recommendations to tighten up the writing of prescriptions for opioids as part of our treatment plans for our veteran patients coping with chronic pain.”

Doherty said the system is stepping up efforts to recruit a “qualified physician” to head up the provider staff at the Calais clinic, which has been without a full-time physician since January 2011.

“As always, our goal remains to provide only the best health care for our nation’s heroes, Doherty said.”

The clinic at 50 Union St. in downtown Calais provides primary care, preventative health, social work and mental health services to approximately 1,100 veterans. Among the clinic’s patients has been Harry Boone, 79, of Eastport, who for at least the past six years has been taking as many as 11 doses of two opiate-based painkillers in dealing with chronic back pain associated with a service-related injury.

Until recently those prescriptions were being filled without charge at the Calais clinic. Not anymore. Boone said Dr. Michael Jukes, a primary care physician who staffs the clinic part time, recently opted not to renew Boone’s prescriptions.

“He sent me a letter and said he was not comfortable continuing me on this powerful narcotic,” Boone said. “He said it was morally and ethically wrong, and that these drugs were developed for cancer patients not for back pain. He refused to sign my renewals.”

Attempts to contact Dr. Jukes on Thursday were unsuccessful. Doherty said federal privacy laws would preclude Jukes from discussing his interactions with Boone.

Boone complained, but to no avail. Instead he said he removed himself from the clinic’s patient rolls and sought care through a private-sector physician, who did renew his prescriptions. But unlike the painkillers he received through the VA without charge, his new prescriptions require a hefty co-pay, he said.

“When I left the Air Force in ’71 after putting in 20 years, I was promised free medical care for life,” Boone said. “Well, so far that free medical care for life has cost me about $50,000. I don’t know what’s going on up there [in Calais], but they do have a problem.”

The report by the VA Office of the Inspector General attributes many of the issues now being addressed in Calais to a chronic staff shortage. “The poor opioid management practices and lack of coordinated care occurred, in part, because of a chronic shortage in provider staffing,” the report says.

Abuse of opioids has evolved into a major public health and law enforcement problem in Washington County, as it has beyond Down East. According to the U.S. Centers for Disease Control and Prevention, the number of deaths each year in America from overdoses of prescribed opioids now exceeds the death rate from heroin and cocaine overdoses combined.

U.S. Rep. Mike Michaud, the ranking member of the House Veterans’ Affairs Subcommittee on Health, said Thursday he finds the Office of the Inspector General’s report “troubling” and sent a letter to Dr. Robert Petzel, undersecretary for health at the U.S. Department of Veterans Affairs.

“I am particularly distressed by the OIG report because I sent a letter in May regarding the lack of a full-time health care provider at the Calais CBOC,” Michaud said in the letter to Petzel. “In VA’s response, I was informed that there has been ‘significant trouble’ finding doctors who would relocate to Calais, but I was reassured that ‘this does not mean veterans are not receiving care.’ The OIG’s report makes clear that, while the veterans at Calais may have been receiving care, it has not been an adequate quality of care.”

Michaud also suggested a study to determine the extent of understaffing at VA clinics nationally.

In response to the investigation’s findings, a four-page action plan has been developed to address issues raised in the report. It has been approved by both Dr. Michael Mayo-Smith, director of New England’s VA health care network, and Susan Mackenzie, the Calais facility’s acting director. Some elements of the plan already have been implemented.

Letters were sent in June to Calais clinic veterans receiving opioid treatment, reminding them that an on-site or telemedicine pain assessment will be done at least every six months.

Such patients also have been asked to provide written consent for participation in the Maine Prescription Monitoring Program, a statewide database designed to track the dispensing and use of certain classes of prescription drugs that are commonly abused.

VA Maine says in its action plan that by November it will have developed formal guidelines to stipulate the maximum acceptable prescription dosages for treatment of chronic pain not related to cancer.

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