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Report Points to Shared Blame in Former Tomah VA Employees Overprescribing Narcotics

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Tomah VA Medical Center, Facebook
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The Tomah VA is once again in the limelight. In 2014, the federal government launched an investigation there after a veteran died of what’s called “mixed drug toxicity.” The probe found that not only were some medical providers over prescribing narcotics, but that many people had reported the problem and nothing ever came of those reports. On Tuesday, the Senate Homeland Security and Governmental Affairs Committee held its second hearing in Tomah. Fingers of blame were pointed in several directions.

From the onset of Tuesday’s hearing Wisconsin Republican Sen. Ron Johnson made clear his belief: if the Office of Inspector General had done its job, the problems in Tomah would have been caught long ago. The office is charged with fighting abuse in federal programs.

“There are just inherent problems. For example, inherent problems of accountability, inherent problems unfortunately within an office of inspector general, which is not living up to its mission. So the Office of Inspector General under Richard Griffin was loyal to the VA instead of being loyal to the finest among us,” Johnson says.

The Senate committee Johnson heads concluded that the federal agency failed to release a report that determined a former Tomah VA employee was overprescribing narcotics. Some patients had given that employee, David Houlihan, the nickname “candy man.”

The federal investigation also noted that during a 2012 interview with Houlihan and his nurse practitioner, both may have been under the influence. While the Office of Inspector General failed to release the report, Sloan Gibson says the buck stops with his department. Gibson is Deputy Secretary of Veteran Affairs.

“At the end of the day, we own this. VA leadership owns this. We had ample opportunity over a period years to fix this, that’s leaderships responsibility and we failed to get it done,” Gibson says. 

Gibson told the hearing Tuesday that new federal legislation is not necessary.

“It was a failure of leadership, should not have happened—period. And I don’t need a policy or a rule to try and enforce that. We’re back to principals,” Gibson says. 

Gibson says in the two years since lawmakers gave him the job of helping oversee Veterans Affairs, positive changes have occurred at the Tomah VA.

“Continuing efforts include developing and academic detailing team to review the medical centers most complex chronic pain patients and provide additional recommendations for their care. Creating a veteran pain school to assess and customize alternative pain management strategies for veterans,” Gibson says.

Gibson says Tomah has reduced the number of vets receiving opioids by nearly one fourth. A few people who testified Tuesday say there’s now a danger of overreacting - some veterans claim they’re having trouble getting the medication they need from the Tomah VA. Yet Doctor Gavin West says medicine is moving in new directions. West is a special assistant for VA clinical operations.

“Forever the medical system as a whole including VA and our academic centers was moving toward prescribing pills. We found out that was wrong and that that was actually killing people. Now we’re turning a big aircraft carrier around and the way that we’re doing it is exactly the way you mentioned. Through complementary and alternative medicines and there are other medicines to treat pain. There are not just opioids,” West says.

Throughout the hearing, lawmakers, the VA and the Office of Inspector General made clear that the opioid problem isn’t limited to the VA, it’s a national concern.

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