Four more veterans died under suspicious circumstances than previously reported at the U.S. Department of Veterans Affairs hospital in Tomah, Wisconsin, under the leadership of its chief of staff, psychiatrist Dr. David Houlihan.
The deaths, revealed in a rare congressional field hearing today in the small Wisconsin town, bring to 33 the number of unexpected deaths The Center for Investigative Reporting has found occurred during Houlihan’s decade at the helm. The medical center became known as “Candy Land” for the ease with which narcotic painkillers were prescribed.
They include Kraig Ferrington, a 45-year-old Army veteran and union plasterer who died of an overdose of seven medications prescribed by Houlihan in 2007, and three veterans that a VA pharmacist told lawmakers died in the VA parking lot in 2008 and 2009.
“We are doing everything we can to make sure these tragedies don’t happen to others,” Sen. Ron Johnson, chairman of the Senate Committee on Homeland Security and Governmental Affairs, told a packed audience of 400 veterans and family members at the Cranberry Country Lodge.
The hearing brought together many of the people who had suffered and complained for years about Houlihan’s practices to no avail. Members of Congress from both parties made the trip to the rural community, which had until recently been more famous for cranberries and cheddar cheese than notorious for narcotic painkillers.
They heard from Ryan Honl, a Gulf War veteran and West Point graduate who quit his job as a secretary at the VA last fall and filed a federal whistleblower complaint before bringing concerns about the “zombification” of patients to the media.
There was Noelle Johnson, a pharmacist who was fired in 2009 after she refused to fill prescriptions for high doses of morphine that she believed were unsafe.
She testified that Deborah Frasher, a nurse practitioner who worked closely with Houlihan, told her that “everyone needed a cocktail” of opiates, tranquilizers and an amphetamine – a drug combination the VA and other health professionals consider unsafe.
Frasher also said Houlihan told the hospital’s pain committee that he didn’t want opiate doses lowered because veterans “would bring their guns to the pharmacy, and start shooting.”
Also testifying were family members of those who died, including Heather and Marvin Simcakoski, the widow and father of Jason Simcakoski, a 35-year-old former Marine who died of an overdose in the Tomah VA psychiatric ward in August.
“He would fall asleep while we was eating, drive up on the median, there were times he would sleep all day,” Heather Simcakoski tearfully told lawmakers. “When you have that many medications in your system, you don’t know what it feels like anymore.”
Today’s hearing marked the sixth congressional hearing where overmedication and abuse of authority at the Tomah VA have been discussed since CIR revealed the problems in a story published Jan. 8.
Within a week of that story’s publication, Houlihan and Frasher were removed from their positions pending the completion of an internal investigation.
On March 10, they were placed on administrative leave after a preliminary review found that Tomah patients were 2.5 times more likely than the national average to receive high doses of opiates. On March 20, the VA told Congress that Houlihan’s boss, Tomah hospital Director Mario DeSanctis, had been “reassigned to a position at the Great Lakes Health Care System network office, a position outside of the medical center.”
At the hearing, DeSanctis told lawmakers that he had begun to change hospital protocols before the controversy erupted, even before the VA inspector general completed a report into allegations of overmedication and abuse of authority last March. He also said he was asked to conceal that report, which was not published by the inspector general until CIR revealed its existence in January.
Under questioning from Rep. Sean Duffy, R-Wis., the VA’s Interim Undersecretary for Health Carolyn Clancy said Houlihan, Frasher and DeSanctis all remain on the payroll.
“That’s what makes people angry here,” Duffy said. “People aren’t being held accountable and aren’t fired.”
Clancy said the agency was simply being thorough to ensure that any dismissal could withstand legal challenges.
“We have significant challenges to overcome here in Tomah and we own them,” she said. “The bottom line is there have been a number of failures.”
The VA Office of Inspector General, the Wisconsin Department of Safety and Professional Services and the U.S. Drug Enforcement Administration also have opened fresh investigations of Houlihan and the Tomah VA.
Throughout the three-hour hearing, lawmakers expressed exasperation that few alternatives to narcotics are being offered. Rep. Tim Walz, D-Minn., an Army veteran, said he had been pressing the VA to adopt a more nuanced approach to pain management since 2008.
“In Minneapolis, they have one chiropractor for 10,000 people and they have a yoga class at 2 p.m. on Wednesday,” he said. “Work that into your schedule.”
In previous congressional hearings, the VA has held up its Minneapolis hospital as a model for offering alternatives to opiates.
The issue of the wider community impacts of the prescriptions appeared to be of particular concern to Sen. Tammy Baldwin, D-Wis., who cited a March CIR report that began with a case five years ago, when a Marine Corps veteran stoned on opiates from the Tomah VA rear-ended an Amish buggy, killing a 6-week-old baby.
“The ripples are indeed being felt across America,” Baldwin said, describing opiate addiction as “a weed whose root is planted in our VA system.”