VA's new goal: Treat root causes of pain

The backroom of the James Ballentine VFW Post #246 in Minneapolis' Uptown neighborhood looks more appropriate for meat raffles and ladies' auxiliary meetings than for medical treatments.

But one night this spring, the post — just 7 miles from one of the country's major Veterans Affairs medical centers — became the best refuge for veterans struggling to cope with the pain of injuries from their military service. Eight acupuncture chairs, four chiropractic chairs and three treatment beds were set up, awaiting vets who would soon be arriving.

Alternative therapy — from acupuncture to yoga — is a key part of the VA's new effort to reduce vets' dependence on highly addictive pain medication. The Minneapolis Veterans Medical Center is helping lead the effort, with a first-in-the-nation chronic pain program that emphasizes education and other alternatives to drugs.

But the free services offered by the Minneapolis VFW post are not authorized by the VA. They are an outgrowth of the frustration and anguish many vets feel about being ordered into a program that can serve only a fraction of those in need. The Minneapolis VA's inpatient pain program, for example, has managed to graduate only 33 vets in the year that it has been operating.

The VA says it's adding more services. But as more vets find themselves cut off from prescription painkillers, the demands on the strapped VA system are bound to grow.

"You don't have a real comprehensive, coordinated project available to these vets," said Dr. Gary Kaplan, a clinical associate professor at Georgetown University School of Medicine who recently attended a conference about the military's pain management program. "It's a tragedy."

Shayne Johnson came to the "feed 'em & treat 'em" event at the VFW. The post, which provided free appetizers and a sit-down dinner, sponsored the event with Northwestern Health Sciences University in Bloomington, which provided free chiropractic evaluations, acupuncture and massage.

Johnson suffers chronic pain as a result of his service in Iraq as a Navy Seabee. He said the chiropractic care he gets from Northwestern and from a private provider he pays out of his pocket have turned out to be better than the alternatives offered at the Minneapolis VA.

At the VA he got one series of chiropractic treatments several years ago, but he said the appointments were difficult to schedule, often as much as three weeks out. He said the VA also kept pushing muscle relaxants, and he was concerned about getting dependent. He would return to the VA if programs were better. "I would go there all the time if I could get a chiropractic visit."

Vets say they have waited up to two months for an appointment with the Minneapolis VA's sole chiropractor.

Christopher Cassirer, president of Northwestern, said he has offered to help the Minneapolis VA expand its chiropractic treatments, to no avail.

While the VA says it is embracing alternative therapies, critics, including members of Congress, say the VA appears to want to keep the services under its own roof, where it can monitor treatment and control costs.

The Minneapolis VA hired its first chiropractor in 2014 and was overwhelmed by the response, with more than 850 visits in less than five months. Because of the demand, 23 veterans have been allowed to make appointments with chiropractors outside the VA. The Minneapolis VA said it hopes to have its second chiropractor in place this summer.

Dr. Carolyn Clancy, then the interim VA undersecretary of health, told a congressional committee in June that the VA is conducting research to identify predictors for veterans who abuse opioids and which veterans might respond best to nonnarcotic treatments. "We have some research going on in that area and we have a lot more to learn," she said.

Success stories

Few dispute that the VA had a painkiller problem. Prescriptions for narcotics such as oxycodone and methadone had tripled nationally in the 11 years before the VA realized it had created a crisis of drug dependency among veterans.

The new goal: Instead of doling out addictive drugs that mask chronic pain, identify and treat its root causes.

Late last year, the National Institutes of Health and the VA announced 13 research projects totaling about $21.7 million over five years to study nondrug approaches to pain.

Given the limited number of people able to enter the trials, it could take at least five years to get productive data, said Georgetown's Kaplan.

Air Force veteran John Szuch has no doubt about the value of these alternative approaches. "It literally changed my life," he said.

Szuch was a tail gunner on B-52s, flying combat missions during the first Gulf War.
His service left him with a herniated disc and a severe stabbing pain in his thigh. Years of pain medications did not help.

He had tried meditation and sleep therapy. He was sedentary and anxious. His VA psychologist recommended he apply to the Minneapolis VA's chronic pain rehabilitation program.

The four-week intensive residential program is the only pain program in Minnesota accredited by the Commission for the Accreditation of Rehabilitation Facilities.

Patients meet with practitioners from seven disciplines to develop a treatment plan that includes hourlong group sessions led by psychologists, occupational therapists, pharmacists and nurses.
Up and running for a little more than a year, it has graduated 33 vets, including Szuch.

"You have to be at the bottom of the barrel for the people offered this class," he said. "People who go into this class, we're in some bad places mentally. But you have to have the willingness to still want to get better."

Yoga videos and needles

Other veterans in the Minneapolis pain programs complain of one-size-fits-all treatments and persistent problems with scheduling, particularly for younger veterans with jobs or schooling and veterans who live far from a VA clinic.

Brian Lewis was sexually assaulted aboard the USS Frank Cable in 2000 and was discharged a year later with chronic pain from internal injuries that left him with a 100 percent disability rating. Lewis said pain medications were dispensed freely when he was at the Baltimore VA.

When he moved to Minnesota to attend law school and sought treatment at the Minneapolis VA, he was told doctors weren't comfortable with his level of medications because of the new drug policy.

At one point his pain pills were reduced to one Vicodin a day. The remaining pain is so intense that he says he often has to lie on the floor while he studies, and some days he has felt suicidal. The ordeal is testing his relationship with his fiancée and his best friend.

The VA has offered to sign him up for yoga classes, but Lewis is in law school in St. Paul when the class is offered at the clinic in Minneapolis.

He lost 70 pounds in four months and has been hospitalized twice at the VA for a stomach ailment and the pain.

"When there's nothing that can be done about the physical pain, the psychological pain takes over," Lewis said. "If I had one thing to say to my fiancée and my best friend it would be to say that I am sorry for what I've become."

Persian Gulf War veteran Kurt Saylor has made the three-hour trip from Grand Rapids to the Minneapolis pain management clinic every month for chronic pain that extends from the middle of his arms to his hands and from the middle of his legs to his feet. He sleeps two to three hours a night.

"They gave me a video to watch, yoga, and said, 'Do this every morning.' How is that going to make me sleep? " he said.

Robin Smith, who was in the Marines for 3 ½ years in Vietnam, has been in pain since a steel beam almost cut his right leg off during a typhoon.

He said acupuncture treatments have helped.

He initially enrolled in the Minneapolis VA pain program but said he was told the policy would allow him acupuncture only 10 times a year. He now pays for acupuncture himself through a civilian provider.

Without it, he is in pain all the time.

"People ask you what's the level of your pain? Is it a 10? What is a 10 that never goes away? It's still a 10," he said.

In response to written questions, the Minneapolis VA said it's clear the inpatient program, while optimal, might not work for veterans with work, family, school or other obligations. For those veterans, it said other care is available.

Refuge for veterans

Displeasure with the VA's pain treatment has prompted some veterans to seek relief in renegade programs such as Eagle's Healing Nest outside Sauk Centre, Minn.

Eagle's Healing Nest is a somber and restful place. There are 23 white crosses planted on the main lawn of the 125-acre campus, a reminder of the estimated number of U.S. veterans and active-duty military personnel who kill themselves every day.

Many vets who come here have been bounced around by the VA. They suffer from substance abuse problems and many have been prescribed addictive narcotics by the VA for pain, only to find them recently restricted.

The center offers drug and alcohol counseling and therapy. Every week, a chiropractor comes to the campus and the sign-up sheet is always full.

Founded in 2012, Eagle's Healing Nest often works with the local VA to help vets in crisis. But it is always at arm's length, by design of founder and director Melony Butler, who relishes her role as a rogue operator in the massive VA machinery.

"Imagine being a combat vet with many achievements and now you are being told you are an addict; and you're addicted based on the medication that those who are supposed to care for you gave you," she said.

In the day room of one Eagle's Nest cottage, Vietnam vet and long-term resident Joe Simenstad pulls up an X-ray of his spine from a computer. The image shows bones as a twisted and contorted road.

Surgery won't solve his pain, he has been told. Chiropractic treatments at the VA have made it worse. Physical therapy and hanging on an inversion board have offered only brief relief. The same for acupuncture and massage.

He admits that he has abused drugs and alcohol in the past and has even relapsed while staying at Eagle's Nest. But he said he went out seeking illegal drugs only when the VA cut off his pain meds.

In a controlled environment where staff dispense the medications to him, he said the medications offer the best relief. "The point is, there is life after addiction, and even addicts have pain," he said.

U.S. Rep. Tim Walz, D-Minn., said there is a need to balance concerns about the amount of pain meds prescribed with the damage done by faulty weaning. Alternatives are being discussed, he said, including the assignment of a pain care management specialist to each veteran. "You've got to be offering these guys more than one yoga class a week," he said.

After a hearing in April about pain prescription abuse at a Tomah, Wis., VA hospital, Walz, a member of the House Veterans Affairs Committee, sent a letter to the VA asking what he thought were straightforward questions, such as how many pain specialists it had hired, how long it takes for a vet to see a pain specialist and how many VA pain clinics actually exist.

Two months later, Clancy wrote back, apologizing for the delay. She said the VA had provided pain clinic services to 140,000 vets through the end of 2014, a 10 percent increase from 2013; that 105 VA hospitals now provide pain clinic services; and that the VA had added eight doctors to its pain clinics in 2014, bringing the total to 124.

Clancy's letter was dated June 25. Two days earlier, the Senate had confirmed Clancy's replacement.

Mark Brunswick • 612-673-4434

Read Part I of this series.