For addicted veteran, regulation is enemy... Update and news to share

By Joseph P. Kahn/ 08/27/2010
posted 08/28/2010
BRAINTREE — In the space of a few hours, on bomb-clearing patrol near Balad, Iraq, US Army Corporal Eric Small and his unit were rocked by three separate roadside explosions. He sustained serious injuries to his head, back, neck, and hip. Small’s combat days were over.




It was the summer of 2008, and Small spent 10 months convalescing in military hospitals. He came home to Massachusetts with two lasting wartime souvenirs: a Purple Heart medal and a painkiller addiction.

But in a bitter irony for Small and his family, the same government that sent him to war balked for months before agreeing to pay for the treatment his doctors feel best addresses his drug addiction. Small’s frustration is shared by some medical specialists who say it’s shameful to deny him, and others like him, coverage for a condition he acquired doing his patriotic duty. The issue has been federal regulations that restrict coverage for treatment of drug addiction for military personnel.

“I never dreamed when I joined the military that I’d be put in this situation,’’ Small, 29, said at his Braintree apartment, with his wife, Shannon, and baby daughter, Isabella, nearby. “I wasn’t a drug addict. I didn’t do drugs. Suddenly I’m going through withdrawals, wanting my body to stop being the way it is.’’

Percocet, the painkiller Small had been taking, is potent and can become highly addictive. Small no longer takes the drug, having been put on buprenorphine, a cutting-edge medication used to treat opiate dependency. Addiction specialists consider it the gold standard for treating drug dependencies like his, safer and more effective in many cases than older-generation drugs like methadone. Buprenorphine is also approved by the Federal Drug Administration for treatment of chronic pain.

Paying for buprenorphine, which costs $250 a week, has left the Smalls more than $3,500 in debt and scrambling to make ends meet.

Tricare, the military’s health care provider, did recently agree to cover the cost of Small’s buprenorphine, sold under the brand name Suboxone. But that approval did not come easily; it took months of negotiation between Small’s physician and Tricare, which will not approve the drug for “maintenance therapy of opioid dependency,’’ but will for detoxification and supervised drug withdrawal. In Small’s case, Tricare is covering the drug for pain management as well.

To many addiction specialists, all that amounts to a distinction without a real difference — and a conundrum for doctors wanting to provide optimal care for patients like Small. (Small’s physician declined to be interviewed.)

“There’s no assurance that next month Corporal Small won’t be denied coverage or any assurance the next person [who asks] won’t be denied too,’’ said Dr. Robert Newman of New York’s Beth Israel Medical Center, a leading addiction specialist who has been advocating for a change in government policy. “We’re talking about physicians paid by our government who decide their patients require a certain treatment, and yet an insurer can arbitrarily overrule them. I see no justification for this. None.’’


The American Medical Association, in its published policy on physician-prescribed drugs, offers “strong support’’ to doctors who lawfully use an FDA-approved drug “for an unlabeled indication when such use is based upon sound medical opinion’’ — in other words, prescribe a drug for pain control when the primary reason for taking it is to help the patient kick a drug habit.

The AMA also urges third-party payers such as Medicare to cover prescription drugs under such circumstances, deeming them “reasonable and necessary medical care.’’

Chris Hassan, CEO of Colonial Management Group, a California-based chain of addiction-treatment centers, said the US military and federal government have been slow to pay for new medications that treat drug addiction. “Medical treatment of addiction in the VA [Veterans Administration] system is not even standard-of-care, never mind cutting-edge,’’ Hassan said. “We put people in harm’s way, then create another problem for them by putting this stigma on them. It’s like someone getting blown up by a land mine and then you deny him a wheelchair.’’

The roadblock to coverage in cases like this is a Department of Defense regulation. It stipulates that while insurance benefits may be extended for drugs that treat illness or injury, they “cannot be authorized to support or maintain an existing or potential drug abuse situation.’’ Drug-maintenance programs swapping one addictive drug for another are not covered.

In April, Representative James McGovern of Massachusetts joined seven other members of Congress in petitioning Defense Secretary Robert Gates to amend Tricare benefits to cover methadone and buprenorphine. “Military families struggling with addiction need help,’’ their letter concluded. In June, Defense Undersecretary Clifford Stanley assured the congressmen that Tricare is “pursuing changes’’ in its policy of disallowing coverage for opioid dependency.

Small is fortunate compared to many who have returned from Iraq and Afghanistan with lifelong disabilities. Beyond the brain injuries and shattered bodies are epidemic levels of post-traumatic stress disorder and suicide. In Small’s unit alone, the 509th Combat Engineer Company, two soldiers took their own lives while in Iraq, according to Small.

This spring, retired Army General Barry McCaffrey warned that serious drug use among US military personnel in Afghanistan had doubled since 2006, while the Drug Policy Alliance has estimated that nearly one-third of Afghanistan and Iraq vets show signs of post-traumatic stress disorder. That condition is “strongly associated with substance abuse and dependency,’’ according to the National Institute on Drug Abuse. Moreover, as Newman and others note, drug dependency affects tens of thousands of veterans’ dependents and survivors as well.

Small remains on active-duty status and will probably be discharged early next year, when he should become eligible for full VA benefits, including medication coverage. However, he’s concerned that his treatment for drug dependency may give the Army an excuse to deny him some benefits, his Purple Heart notwithstanding. Until his discharge, meanwhile, he draws a $3,300 monthly salary and housing allowance.

Hoping to become an emergency medical technician, he harbors no ill will toward the Army, he said, and feels he received good medical care and counseling, for the most part. Yet he acknowledges he’s not the same man who joined the military three years ago with the intent of someday becoming a police officer or firefighter.

Nine months in a Texas military hospital changed everything, said Small, who at one point was taking 20 different medications for pain, anxiety, depression, and insomnia. Shannon Small said her husband’s pill consumption didn’t seem to concern his Texas doctors.

“Maybe because so many other people there had their arms and faces blown off,’’ she said. Because his injuries were less visible, if no less painful, she added: “they were kind of shrugging him off. Like, ‘Take more Percocet — it’ll mask the pain. Then we’ll deal with you later.' "

Small’s problems weren’t confined to his physical discomfort, the couple said. Plagued by anxiety attacks, he began refusing to get in a car unless he could drive himself. “I was mentally stuck,’’ he said, reflecting on his long convalescence. He still will not ride with others driving, even his wife, and avoids crowded places.

By Small’s last hospital stay, in Missouri, his addiction to Percocet had become painfully obvious. Last September he admitted his problem to his superior officers, who had him checked into a rehab clinic. Put on methadone during his seven-day stay, he suffered painful withdrawal symptoms, however, and went back on Percocet to ease his discomfort. A few weeks later another physician treating Small recommended Suboxone, which proved to be a positive, if expensive, step.

Only after Small’s months of resubmitting insurance forms did Tricare consent to pay for his treatment, and even now he’s been told he can’t recoup what he spent on Suboxone out of pocket.

Speaking publicly about his situation “isn’t to get money,’’ Small said, while his daughter cooed in a playpen nearby. “It’s for others in my situation. The rule needs to get changed. People need to know what’s happening to the veterans who come home, that we’re not over there shooting people — and getting shot at — for nothing.’’

Article Source:
Boston Globe/boston.com

Video interview with Corporal Small

Hello to all!!
I read this article days ago & wanted to reply to what it is that I actually got out of this article. And maybe to get some of your own personal opinions as well...
First & foremost, I would certainly like to thank US Army Corporal Eric Small for his bravery & the protection that he provided for all of us here in the USA with having by being "there", away from dear wife Shannon & their precious new little baby! I don't know that he would ever get the chance to read it, but THANK YOU FROM THE BOTTOM OF MY HEART FOR YOUR SERVICE TO OUR COUNTRY!!!
Now that he has given himself to our country & upon returning home, our country has treated him with what I can call a true lack of respect by not caring to treat the issues that HAVE occurred while he was in Balad, Iraq. As I am sure that you have all read the extent of his injuries, as well as the psychological issues that this has also caused him & the government has the gall to not bother treating him properly & without a "fight" on his part to get the actual medications needed. Hasn't he fought enough already? I really thought that this quote essentially "hit the nail on the head."
Chris Hassan, CEO of Colonial Management Group, a California-based chain of addiction-treatment centers, said the US military and federal government have been slow to pay for new medications that treat drug addiction. “Medical treatment of addiction in the VA [Veterans Administration] system is not even standard-of-care, never mind cutting-edge,’’ Hassan said. “We put people in harm’s way, then create another problem for them by putting this stigma on them. It’s like someone getting blown up by a land mine and then you deny him a wheelchair.’’
Then, the article continues on with the following statement.
The roadblock to coverage in cases like this is a Department of Defense regulation. It stipulates that while insurance benefits may be extended for drugs that treat illness or injury, they “cannot be authorized to support or maintain an existing or potential drug abuse situation.’’ Drug-maintenance programs swapping one addictive drug for another are not covered.
Now I am unsure of how you all feel regarding Suboxone, but my beliefs are that Suboxone is NOT another habit forming drug. In fact, just the complete opposite. You do NOT grow a tolerance to Suboxone, your dosage will never need to be increased once you have "leveled out" at a certain working dosage, usually just "tweaked" a little bit at the beginning to see what dosage works for the specific patient & their needs, as well as the fact that the longer that you remain on Suboxone, the less you begin to need, as your brain begins to heal itself from the prior abuse of the painkillers. As well as being prescribed for the treatment of pain issues as well as the addiction factor. He is not at these doctors appointments requesting Percocet or Oxycontins, but the best pain reliever that he can obtain that is non-habit forming. Now, where lies the problem? If he had obtained the disease of diabetes while in the military, they wouldn't blink an eye about covering his insulin, as it controls the disease, yet does not cure it. Some medications ARE needed for long term maintenance of particular diseases & as the AMA has proclaimed, ADDICTION IS A DISEASE! How about epilepsy? Is that not also a disesase? And is that also a disease that requires long term maintenace meds? Yes it is & yes it does, as I am epileptic, but it is "controlled" by LONG TERM MAINTENANCE MEDICATIONS, which does also cause dependency because ANY medication that a person takes on a daily basis can become dependent upon. Even Tylenol. Geesh, even our Coca Cola and coffee that we drink every single day, then go a day without it & see how poorly you feel because of the withdrawals. Headaches, nausea, moodiness, irritibility- then drink a cup of coffee & see how quickly those same symptoms disappear.
I guess that my main point is that this brave young man went into the military for the United States of America, the best country in the world, and was injured throughout his time overseas. He was returned to the "best country in the world" & has been treated disrespectfully, like he has done something wrong, with a stigma placed on him as a "drug addict" and has NOT received the care that is needed to make him well again. I realize that he is now on the Suboxone, but only because of his determination & the FIGHT within himself to be able to be freed from the bondanges of addiction. He fought long & hard for it!! The next soldier may not be able to do so & who knows where that person will end up without the option of knowing about Suboxone & having it be paid for by the insurance provided to every soldier who enlists? I really hope that Corporol Eric Small will begin to bring a new perspective to the VA & the Dept. of Defense for the next brave young man who returns home in this type of situation. God bless every soldier & their families for the sacrifices that they make to protect "our homeland!" Thank you, thank you, thank you!!
I believe that I have said my piece & shall close this up now, yet I would really appreciate ANY feedback from our many members & your opinions on this article, as well as my own personal opinion. I am sure that each & every one of you who read this will have some type of perspective on the situation & I ask you to please share it with the rest of us, as we may all see it differently.
God Bless the USA!
Yours,
Beth

My husband work as a civilian army detective. One of his job duites is to screen the random UA's the soldiers and other employees have to take. As stated above, the military (I don't know about the other branches but I do know about the Army) does not support ORT of ANY kind, methdone or suboxone and even though the soldier may have a legit script from a doctor for suboxone (or methdone) they can still be punished and filed on just for taking it because it is against ARMY regs to participate in ORT.

Also, my husband could lose his high level security clearance AND his job because I am on MMT. He's not on MMT, but just because I am, he would be in jeopardy if they were to find out. The Army sees it as a potential dangerous situation where he could be "tempted" to break the law for my benefit.

Now what do you make of that?

My husband went to a training a while back where they talked about ORT and the guy talking was suppose to be an EXPERT in ORT.........WHAT A JOKE!
He had biased, outdated info and my husband said it was all he could do to sit there and listen to it and not say something KNOWING the guy was giving out inaccurate info and had NO FREAKIN CLUE what he was talking about! My husband knew more about the programs than their supposed EXPERT did!

But there again, if he were to have corrected the guy or showed he had more knowledge about it than the average person is suppose to, then he would have had to admit to why and how he knows so much about this subject which in turn could cost him his job.

It is a shame that the military is treating these soldiers and other employees this way.

In the article bfye is quoting from it said that it “cannot be authorized to support or maintain an existing or potential drug abuse situation.’’ What do they think they are doing when they keep prescribing the pain meds that got the person addicted in the first place??? That person no longer needs the meds for pain anymore, they need it to sustain or maintain their addiction but they have no problem refilling those pain scripts but they have a problem with a valid, PROVEN treatment for that pain pill addiction.

Makes no sense to me.

RuthAnn
Methadone; A Flicker Of Light In The Dark
www.medicalassistedtreatment.org
www.suboxoneassistedtreatment.org
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If you cannot afford to call us, send us an email and
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Hello RuthAnn-

I have many things that I would like to reply to within your post, yet do not have the time at the moment as I am heading out the door for an appt today. BUT, I had to ask you this one question before I responded anyways & it will probably sound quite ignorant to you, but what is ORT? Is that a military acronym or one regarding maintenance meds that I have never heard of before? I would certainly appreciate you explaining it to me, as they say that you learn something new everyday! Thank you for your response!

Yours in Recovery,
Beth

Beth, I am sorry, I didn't realize I didn't say what ORT was at least once in my post! LOL! Don't feel ignorant at all, it seems like they are always coming up with some new saying for everything, especially in this world of being politically correct about everything so it is hard to stay up on the latest name for everything.......my bad because I usually do spell out any acronyms I use the first time around and I just wasn't paying attention.

Dee,
That is horrible how they treated that guy. Did he ever manage to get any help even from an outside source?

RuthAnn is so right, there are many different abbreviations with different meanings. It is hard to keep up with them. I still have a hard time with some of them.

Actually RuthAnn, I am in the process of trying to see what I can do to help him. I know there has to be something that can be done. This is just not fair. He is someone who served our country and now when he needs the help, the door is being slammed in his face.
I will keep you posted as to how things go.

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Dee,
This is the first time I've read this story and it's terribly sad for anyone in this day and age to have to go thru something so horrific.
It makes me so angry for anyone to have to suffer in anyway,but,to want help from addiction and can not get it is so wrong. Not too mention how painful and hopeless that one feels.

I'm so happy this poor guy finally got the help he needed and deserved.
Thanks for sharing these stories.
Everyone needs to know there is hope. Sometime you have to fight for it but it's always worth the fight.