Doctors at the U.S. Department of Veterans Affairs medical center in Tomah, Wisconsin, hand out so many narcotic painkillers that some veterans have taken to calling the place “Candy Land.”
They call the hospital’s chief of staff, psychiatrist Dr. David Houlihan, the “Candy Man.”
Current and former hospital staff members describe patients who show up to appointments stoned on painkillers and muscle relaxants, doze off and drool during therapy sessions, and burn themselves with cigarettes. They told The Center for Investigative Reporting that Houlihan himself “doped up” or “zombified” their patients and that workers who raised questions have been punished.
Data obtained by CIR shows the number of opiate prescriptions at the Tomah VA more than quintupled from 2004, the year before Houlihan became chief of staff of the hospital, to 2012, even as the number of veterans seeking care at the hospital declined. In August, a 35-year-old Marine Corps veteran died of an overdose in the inpatient psychiatric ward.
“It’s a system that’s gone completely haywire,” said Ryan Honl, a Gulf War veteran and graduate of the U.S. Military Academy at West Point who in October resigned from his position as a secretary in the hospital’s mental health clinic after two months, filing a federal whistleblower complaint on his way out.
The problems at this rural medical center underscore the difficulty the VA is having maintaining standards of quality patient care, even after a national scandal forced VA Secretary Eric Shinseki to resign last May.
The exponential growth in the use of narcotics transformed the Tomah VA from a conservative prescriber of painkillers to one typical of runaway opiate prescription practices throughout the VA health care system.
During the same period, the number of pills handed out skyrocketed. In 2004, the Tomah VA dispensed about 50,000 oxycodone pills to roughly 25,000 veterans. By 2012, that number had grown to 712,000, the data shows.
Last March, the VA’s inspector general found that Houlihan had on average prescribed the equivalent of 25,000 milligrams of morphine to each of the 128 patients he saw in 2012, a level investigators said was “at considerable variance compared with most opioid prescribers” and “raised potentially serious concerns” that should be brought to the attention of the federal agency’s leadership.
Independent experts who reviewed CIR’s findings said it was disturbing that the top prescriber of painkillers was a psychiatrist, charged with treating mental, rather than physical, ailments.
“There are a ton of questions here. It doesn’t seem right at all,” said Dr. Stephen Xenakis, a psychiatrist and retired brigadier general who served as commanding general of the Army’s Southeast Regional Medical Command.
Following extensive news coverage of the VA’s national opiate epidemic, the agency vowed to limit prescriptions and offer alternative pain treatment. The number of veterans on VA-prescribed opiates has declined by about 6 percent over the last year.
But insiders say problems in Tomah continue, suggesting the agency does little to rein in rogue prescribers, who are able to write escalating numbers of prescriptions with impunity.
“Houlihan is a symptom of failed leadership from Washington on down,” said Honl, the former employee. “They turn the other way while veterans, who expect to be taken care of after the politicians send them to war, suffer.”
For his part, Houlihan said there is nothing unusual about his prescription practices. Many veterans had come to the Tomah VA after receiving large doses of opiates in private practice or during their military service, he said, and he worked to taper them back to safer levels. He maintains that doctors at the Tomah VA are relying increasingly on Suboxone, an opiate used to help veterans fight addiction to other narcotics – though he had no statistics to back that claim.
“The problem is there is a lot of chronic pain,” Houlihan said. “You don’t hear a lot of veterans complaining about me.”
Two days before Jason Simcakoski died of an overdose in the Tomah VA psychiatric ward, the head of the unit, Dr. Ronda Davis, discussed his care with Houlihan.
Simcakoski had checked himself in, citing an addiction to painkillers and severe anxiety that was destroying his relationship with his wife and 11-year-old daughter. The Marine Corps veteran’s medical record shows Houlihan advised Davis to add Suboxone to his existing cocktail of 14 drugs, which included antipsychotics, tranquilizers, muscle relaxants and the opioid painkiller tramadol.
“They had my boy on so many meds that it blew my mind,” said Simcakoski’s father, Marvin, a building contractor from Stevens Point, Wisconsin, who visited his son the day he died. “They like people to be zombies over there so they don’t have to care for them.”
An autopsy report prepared by the University of Wisconsin Hospital and Clinics declared the cause of death to be “mixed drug toxicity.”
“I wouldn’t say it was enough to kill a horse, but it was enough to kill this man,” said Frank Ochberg, a leading traumatologist and clinical professor of psychiatry at Michigan State University, who reviewed Simcakoski’s medical record at CIR’s request. “He wasn’t otherwise frail or compromised. He was a young man with a decent life expectancy; a tragic, unfortunate death.”
In Washington, the VA’s director of media relations, James Hutton, would say only that the agency is “looking into the situation” in Tomah. He said no senior agency officials would be willing to comment.
Doctor’s checkered career
Houlihan joined the VA in Wisconsin after a decade of private practice in Iowa, where he worked for a Dubuque medical group. In April 2003, he was disciplined by the Iowa Board of Medicine for being “inappropriately engaged in a social relationship with a patient,” hiring a current or former patient and bringing a patient’s medicine home with him.
Houlihan did not fight the medical board’s findings. In an interview, he downplayed their significance, blaming them on contentious divorce proceedings. The social relationship was simply a person he ran into on the street, he said, while the patient he employed was an electrician who worked on his house as a subcontractor during a home repair.
But Mark Bowden, executive director of the Iowa medical board, said the sanction “should be a serious concern to any potential employer” because it related to Houlihan’s ability to set professional boundaries with his patients.
“When the practice is psychiatry, it even takes on a more concerning level because you’ve had a patient who is likely mentally vulnerable,” he said.
In February 2004, Houlihan let his license to practice medicine in Iowa lapse. By then, he was working as a psychiatrist at the Tomah VA. In August 2005, he was appointed chief of staff, charged with overseeing care for veterans across western Wisconsin.
Over Thanksgiving weekend last year, the new VA secretary, Robert McDonald, responded to a slew of emails from Honl that sought a direct response to his Oct. 4 whistleblower complaint.
“Thanks for your input,” McDonald said. “We take your concerns seriously and investigate.”
Internal VA documents show Tomah VA employees have been complaining about Houlihan’s prescription practices for years.
For example, last March’s inspector general report followed a series of complaints to the agency watchdog dating back to March 2011. The investigation, obtained by CIR, has not been published or shared with the House or Senate committees that oversee the VA.
Houlihan remains on the job, while pharmacists who have raised questions about his prescription practices were fired or resigned in protest, according to the inspector general. One was let go after he refused to dispense controlled substances, citing concerns about patient safety and drug diversion.
“There were outrageous refills, patients who told us they lost their drugs for the fifth time,” said Ron Pelham, who resigned as the hospital’s chief pharmacist in May 2013.
Pelham now works at the local Wal-Mart. He said Houlihan’s most frequent narcotic prescription was for 30-milligram oxycodone pills, which are popular on the street because they can be crushed easily and snorted.
Jennifer Brooks, a psychologist and retired Navy commander who resigned from the Tomah VA in January 2014, said Houlihan’s patients tended to be those “with drug-seeking behavior, veterans who had gone to other physicians seeking narcotics and been turned down.”
It’s not only prescriptions for outpatients that have drawn staff attention. Heavy doses of opiates and benzodiazepines also have been given to addicts living in the facility’s residential drug rehabilitation center, according to hospital staff. Some have taken to calling it the “Houlihan Cocktail.”
Jacob Ward’s parents say he was among those drugged at the facility. Ward, an Iraq War veteran, sought inpatient care for post-traumatic stress disorder after going AWOL from his unit in 2005.
His father, John Ward of Coon Valley, Wisconsin, said his son was tortured by nightmares and dulled his emotional pain with marijuana and alcohol after a tour as a cavalry scout. The elder Ward was relieved when his son checked himself into the VA in Tomah, he said, but found him unrecognizable when he went to visit.
“They narcotized him until he was in la la land,” John Ward said. At the hospital, he said, his son “spoke slowly with slurred words and rarely opened his eyes. It was the worst thing that they could have done for him.”
Jacob Ward’s quality of life continued to deteriorate after his time at the Tomah VA, according to his father. He became a full-blown addict and, in 2008, he joined two roommates in an armed robbery of a sports bar in La Crosse.
In 2009, a circuit court judge sentenced Jacob Ward to 10 years of probation rather than prison – provided he seek treatment at the Tomah VA. There, “they drugged him again,” his father said.
On Sept. 4, 2013, Jacob Ward died of an overdose of heroin and cocaine in a Milwaukee apartment. He was 27.
A culture of fear
Hospital staff, who confirmed John Ward’s account of his son’s care, described a culture of fear at the hospital. They said Houlihan regularly threatened those who disagreed with him. Many said they were afraid to speak to CIR for fear of retribution.
In 2011, when Houlihan demoted the head of the hospital’s mental health residential rehabilitation program after the two clashed over narcotic prescriptions, Brooks – the psychologist – wrote to the VA health care system’s regional director, describing “a workplace atmosphere of fear and hopelessness.”
During one staff meeting in which concerns about prescribing muscle relaxants to addicts were raised, hospital staff said Houlihan yelled and threw medical journals endorsing the off-label use of benzodiazepines across the table.
“We were supposed to be doing hard work, getting these veterans to fight through their anxiety and fear, to talk about killing someone or running over a child in your convoy,” Brooks said. “But their eyes would be dilated, their sentences would be blurry. Sometimes they’d be on so many medications that they’d fall asleep.”
In a June 2013 email obtained by CIR, Houlihan upbraided a physician assistant who had told two veterans that he planned to reduce their narcotic prescription load.
“I understand you may have issues with controlled medications. That is your issue,” Houlihan wrote. “I take personal issue with you changing meds on my Veterans.”
“I expect this practice to stop immediately,” he added.
Houlihan brushed aside allegations that he has created a climate of fear or retaliated against employees who disagreed with his prescription practices.
“I’ve had a good working relationship with my people,” he said.
However, after he became aware of CIR’s investigation, the hospital’s management instructed front-line staff not to speak with the media. That order was reinforced by an all-staff email from the hospital’s communications department.
The inspector general’s report pinpointed two other health care professionals at the Tomah VA with extremely high numbers of narcotic prescriptions.
One, referred to as “Y” in the auditors’ report, was named co-chairman of the hospital’s pain committee under Houlihan.
That clinician prescribed the equivalent of 5.3 million milligrams of morphine in 2012, more than any VA employee in a region that covers parts of Illinois, Indiana, Michigan and Wisconsin. The clinician, who the auditors said worked closely with Houlihan, had a caseload of 182 patients.
The auditors also found that Houlihan and his colleagues refilled opiate prescriptions before they were used up, violating hospital policy. Refills of painkillers also were doled out to veterans who came up clean in urine drug screens, indicating they likely were selling their medication instead of taking it.
Even though the auditors expressed serious concerns, they said those concerns “did not constitute proof of wrongdoing.” They recommended no punishment for Houlihan or any other staff investigated.
Houlihan cited that fact in his interview with CIR. “I’ve been investigated again and again,” he said, “and they’ve never found anything wrong.”
This story was edited by Amy Pyle and copy edited by Sheela Kamath and Nikki Frick.