On a clear August morning, Amish carpenter William Miller and his family climbed into their black horse-drawn buggy and headed out to the nearest big-box store, a 16-mile journey from their central Wisconsin farm that takes them two hours.
They never made it. Less than a mile from their destination, the buggy was rear-ended by a 1997 Dodge Caravan. The van wasn’t moving fast, but as it passed by it suddenly swerved, knocking the carriage on its side. Miller and his son, John, were fine. But his wife, Elizabeth, who was cradling 6-week-old Ada Mae, was thrown from the carriage and landed on top of her daughter.
Ada Mae stopped breathing. An autopsy would list the cause of death as “crush injury to the chest.”
A year later, after the driver pleaded guilty to homicide, William Miller wrote to the sentencing judge. “Words like grief, helplessness, anxiety, fear, and lonesomeness come to mind,” he wrote. “I would have scarcely thought it possible such a small infant could possibly have left such a void. And the consequences and results have been far reaching and long lasting.”
At first glance, the 2009 accident that killed Ada Mae would seem to have nothing to do with problems at the U.S. Department of Veterans Affairs hospital in Tomah 60 miles away, which earned the nickname “Candy Land” for its skyrocketing rate of opiate prescriptions. Some veterans called its chief of staff, psychiatrist Dr. David Houlihan, the “Candy Man.” He was in charge for nearly a decade – and was one of the hospital’s top prescribers.
But the man behind the wheel of the Dodge van that day was a Marine Corps veteran, and he was stoned on painkillers and tranquilizers from the Tomah VA. Brian Witkus was a known addict who “would fall or injure himself,” court records say, to get “more pills or a higher dose of medication.” His doctor, Witkus says, was Houlihan.
Ada Mae’s death is one of dozens of tragedies that begin to hint at how the flood of narcotics from the VA scarred this region.
It begins with the veterans themselves, who have become addled and addicted and who have overdosed. The collateral damage ranges from distraught sisters to fatherless children and dead girlfriends.
The ripples do not stop there.
Patients of the Tomah VA have been arrested for dealing drugs, brandishing firearms in bars and passing out in the middle of the street. One totaled her truck and her car on her way to the VA.
Out in the community, police and prosecutors know these men and women so well that they refer to them by street names like “Turtle,” “Airman,” “Black Mark” and “Detroit.”
Inside the hospital’s brick walls, psychologists, nurses, social workers and the VA police just call them “Houlihan’s Hooligans.”
In recent years, hospital staff have discovered younger veterans stealing from elderly patients and others dealing VA-prescribed painkillers and shooting OxyContin and heroin on hospital grounds. Inside the hospital, VA police reports document the fallout: strung-out veterans tossing wheelchairs across rooms and a trash can out of a window, setting fire to magazines, wielding a meat cleaver.
A search of Tomah police records by The Center for Investigative Reporting and the La Crosse Tribune found that employees at the Tomah VA had called 911 more than 2,000 times in the past five years, seeking local law enforcement help with cases of battery and burglary, an attempted kidnapping and 24 unexpected deaths.
Dr. G. Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins Bloomberg School of Public Health, has studied the widespread damage caused by opiates, which he attributes to their addictive potential and their ability to impair judgment.
“You don’t have to be a criminologist to know that people who have dependence on these products may be driven to great lengths to self-medicate and treat their addiction,” Alexander said. “When these drugs are overprescribed, it’s a problem with both direct consequences and direct potential risks, but also for the broader ripple effects that this overuse has on friends and family members and the broader communities of which they are a part.”
In January, CIR disclosed that the number of opiate prescriptions at the Tomah VA had more than quintupled from 2004, the year before Houlihan became chief of staff, to 2012 – and that the federal government had all but ignored the problem for years.
Reached on his cellphone, Houlihan said he has been told not to talk while investigations into his prescription practices and management style are underway. This week, he was placed on administrative leave after a preliminary review by the VA found that Tomah patients were 2.5 times more likely than the national average to receive high doses of opiates.
The report’s author, VA interim Undersecretary for Health Carolyn Clancy, told journalists that “a very large percentage of those patients” also receive benzodiazepine tranquilizers, such as Valium and Xanax, a combination that she said increases the risk for what she called “patient safety events.”
The internal investigation also found that veterans’ medications were not changed even “in the face of aberrant behavior.”
Yet neither the VA’s internal investigation nor any of the five other federal and state government inquiries launched in the past two months will begin to trace the insidious way the lack of VA oversight harmed a swath of Wisconsin, reaching from Tomah to Milwaukee, nearly 200 miles away.
Opiate prescriptions’ collateral damage
Angela Colby died eight years ago after she overdosed on oxycodone. The pills were not hers; they were prescribed to her boyfriend, an Afghanistan War veteran, by Houlihan. She was 23.
Police arrived at the couple’s studio apartment in Wausau before dawn to find Colby’s boyfriend, Matthew Schuster, crying hysterically. He had called 911, he said, after finding Colby cold, without a pulse. He told the officers that the two had fallen asleep watching television and he hadn’t noticed anything out of the ordinary until he returned to bed after grabbing a middle-of-the-night snack.
But when officers looked around the apartment, they quickly spotted signs of something amiss. The trash can was full of pill bottles from the VA. There were also tubes from ballpoint pens, minus the ink, used to snort the pills.
When police took Schuster back to the station, he told them that Colby had been snorting his medication.
“Matthew saw Angela cutting up a pen and he told her not to do that,” Detective Kay Hansen wrote in her report. He admitted to sharing his oxycodone with his girlfriend, the officer said, but said he “told her not to use the medications in that manner and they should be taken orally because it was dangerous to snort.”
When police interrogated Schuster, he confessed to being an addict but said he had been to rehab and no longer abused the oxycodone Houlihan prescribed; nor, he said, did he abuse any of the other opiates, tranquilizers, antidepressants or antipsychotics officers had found at the scene.
Over the next few weeks, police in Wausau continued to investigate Colby’s death and eventually referred the case to the district attorney, who declined to prosecute.
The rub, the local police chief says today, is that the drugs were obtained legally.
“We have a major problem with prescription drug abuse, but I don’t think we have a handle on it like we do with heroin and meth,” said Wausau police Chief Jeff Hardel.
If heroin had been in the apartment, arresting Schuster would have been the logical course of action, Hardel said. But the VA had prescribed all of the drugs that officers found in his apartment. Investigating Houlihan, Hardel said, never occurred to him.
Court records and police reports contain four phone numbers for Schuster. All were disconnected.
Colby’s death is one of at least five fatal overdoses with direct links to the Tomah VA while Houlihan was in charge. Some, like Colby, overdosed primarily on prescription medications. That was true for Jason Simcakoski, a 35-year-old former Marine who died in the Tomah VA’s psychiatric ward in August after Houlihan suggested the opiate Suboxone be added to a prescribed mixture of 14 medications.
Others happened when prescription abuse accelerated into heroin addiction. This progression, seen around the country, contributes to a fatal overdose rate among VA patients that the agency’s researchers have pegged at twice the national average.
“The effects produced by oxycodone and hydrocodone are indistinguishable from the effects produced by heroin,” said psychiatrist Dr. Andrew Kolodny, chief medical officer of Phoenix House, which runs more than 100 drug treatment clinics nationwide. “If we don’t see that the many veterans who became addicted are provided with effective addiction treatment, we will continue to see veterans turn to heroin, and we will continue to see very high overdose death rates.”
Jacob Ward, 27, overdosed on heroin and cocaine in a Milwaukee apartment in September 2013. He was a patient at the Tomah VA, too, and his parents said he first was exposed to opiates in the psychiatric ward overseen by Houlihan.
On Oct. 8, 2012, 5-year-old Danielle Bobak awoke to find her father, Marine Corps veteran Michael Bobak, dead alongside his girlfriend, Tracey Small, in their home a half-mile from the hospital. A toxicology report by the University of Wisconsin School of Medicine and Public Health found that both had lethal doses of heroin in their systems, but Michael Bobak also had a long list of prescription painkillers and tranquilizers in his urine.
“He was supposed to take his daughter to preschool,” said Michael Bobak’s father, Cecil. “Instead, he was dead.”
Veteran’s drug-fueled decline
The day before he died at 26, Derik McGovern joined his three sisters and his mother for dinner at his grandmother’s house. They shucked corn and put it on the grill with brats and hamburgers. They played volleyball, jumped on a trampoline and fooled around with the family’s golf cart.
McGovern had faced his share of problems after he deployed to Iraq in 2008. He told family members that he had been shot in the stomach and a roadside bomb had wrecked his knee. VA doctors performed a series of surgeries on his knee, but his sister Hannah said the main treatment her big brother received was oxycodone.
“He was gone a lot,” Hannah, 14, said in a Facebook message. “He got addicted. They gave him however many he asked for.”
Court records chronicle McGovern’s descent while under the care of the Tomah VA.
In April 2010, he was arrested for driving under the influence after his Chevrolet Cavalier was T-boned by a Dodge Intrepid, throwing it onto a neighboring lawn. McGovern told officers that he had tapped his brakes, but witnesses said he blew through the intersection.
In the police report, Tomah police Officer Nathan Stafford noted: “Sgt. (Christopher) Weaver told McGovern to sit down on the bumper of my squad car. … I walked over to McGovern and shined my light just under his eyes. I observed his pupils to be constricted and his lids were half closed.”
A search of McGovern’s car revealed a nearly empty bottle of 28 oxycodone pills prescribed a few hours earlier. But charges would later be dropped when the blood drawn by police detected oxycodone levels within legal limits.
Three months later, McGovern was arrested for disorderly conduct, harassment and impersonating a police officer when he stalked his ex-girlfriend. Then, in September 2011, McGovern – then 23 – pleaded no contest to a host of charges and agreed to serve 25 days in jail and pay court costs. He told the court that he suffered from post-traumatic stress disorder and bipolar disorder.
Two and a half years later, in February 2014, McGovern was arrested again, this time for kidnapping and armed robbery after an altercation with another felon. After McGovern was jailed, sheriff’s deputies charged him with criminal damage to property. He had used a juice box to carve the words “Kill Me Kill Me Kill Them” into his cell wall.
On July 1, 2014, McGovern died alone in his Tomah apartment of a heroin overdose, leaving behind an infant son, Lucian. McGovern’s roommate found him. His arms, the autopsy report later said, were covered in track marks.
Dealing drugs on hospital grounds
The tendrils of narcotic abuse crept inside the Tomah VA itself. In recent years, police reports and court records show that veterans repeatedly have been caught with drugs on hospital grounds, sometimes even selling their recently filled prescriptions, while addicts have preyed on other patients and hospital staff.
Derik McGovern’s roommate, Damien Ehlert, was among those arrested for dealing prescribed narcotics. In December 2013, VA police stopped Ehlert’s maroon Ford truck after he swerved erratically on hospital grounds.
Ehlert’s eyes were dilated and he had to lean on the truck so he wouldn’t fall over, the officer wrote. Eventually, he slid down to the ground.
When police asked him why a bottle of oxycodone prescribed the day before was empty, Ehlert said he had been selling the VA-prescribed narcotics in front of the hospital’s addiction treatment center. He also mentioned that he had shared his painkillers at least a dozen times with McGovern, who promised to pay him but never did.
Betty Sumiec is one of the victims of an addicted veteran. Last February, the retired dairy farmer came to the Tomah VA to visit her husband, Edwin, an 88-year-old Army veteran who is paralyzed from the waist down.
Sumiec left her husband’s room for a few minutes. When she returned, all her money was gone. VA police tracked down the thief in the parking lot. He was a 32-year-old Iraq War veteran with multiple convictions for drug charges.
“He was a nice, fine-looking kid, but he talked funny,” Betty Sumiec said. “The police said he was a druggie. That’s why he talked the way he did.”
The perpetrator, Jacob Zimmerman, pleaded guilty to petty theft and was granted leniency on the condition that he apologize to Betty Sumiec. But she says that apology never came.
Five months after the theft, a police officer in Adams, Wisconsin, found Zimmerman passed out in the middle of the street with a .40-caliber Smith & Wesson handgun sticking out of the bottom of his shorts. Zimmerman told police that he wasn’t sure how he ended up with the gun. Perhaps someone drugged him, he said.
Timothy Benton goes by the street name “Turtle.” Out in the community, he stands charged with selling heroin during a police sting. Local police also have a recording of him offering methadone to a police informant during another undercover operation.
Hospital staff have been concerned about the Marine Corps veteran since at least July 2013, when a medical resident complained that Benton, then 33, “approached him in the elevator and asked him to ‘get high.’ ” The exchange was caught on security cameras.
Officers also tracked Benton down in the VA parking lot, where he was cutting his toenails with a knife next to his Ford Ranger pickup, with a pit bull in the cab.
When one of the officers asked to search his backpack, Benton said, “All I have is extra clothes,” according to court records. But inside, they found a hypodermic needle, pen tubes and cotton balls – all covered in an unidentified fine residue.
Something similar happened with Army veteran Kevin Underwood. In December 2013, a random check of his hospital room revealed a gray sack containing a syringe and spoon with white residue hidden inside a stack of his clothes. A toxicology test identified the white powder as crushed OxyContin.
When police questioned him, Underwood, then 35, initially said he was hiding the drugs for another patient. But eventually, he admitted he had been “shooting up OxyContin.” Two months later, he pleaded guilty to possession of drug paraphernalia and paid a $267 fine.
Ehlert, Zimmerman, Benton and Underwood could not be reached for comment.
The dangers posed by the criminal activity created considerable tension between Dr. David Houlihan and the police who patrol the hospital. VA police records show that when drug-addled veterans assaulted other patients and hospital staff, Houlihan repeatedly intervened to prevent the assailant from being arrested.
Lori Hensley, chief steward of the American Federation of Government Employees local that represents rank-and-file officers at the facility, traces the law breaking to a policy Houlihan implemented in 2010. It required his approval before any veteran could be arrested on the premises. The policy also required that any prescriptions had to be written and ready to go before a veteran could be arrested.
On Dec. 6, 2010, Hensley wrote to Houlihan to protest, labeling her email: “VA Police Officer Safety Concerns.”
The “time it takes to get this type of communication completed could put many at high risk of getting hurt,” Hensley wrote. “What happened to past practice in which our highly trained professional VA Police Officers were given authority to intervene as needed?”
Houlihan brushed those concerns aside. “The veterans are patients above all,” he emailed back a half-hour later. “That they are in a hospital is an indication that they are in a potential state of crisis. To arrest without taking this into consideration puts the veteran at risk.”
Current and former employees also tried to go above Houlihan. They wrote to their congressmen and senators, filed whistleblower complaints, even exchanged emails directly with VA Secretary Robert McDonald.
Fed up, nursing assistant Janelle Arnold said that last year, she confronted Houlihan’s boss, Mario DeSanctis, director of the Tomah VA.
She called Houlihan the Candy Man, she remembered, telling DeSanctis: “Your own chief of psychiatry hands out narcotics like they’re candy. … I know I’ve had people come to me and say that they can get narcotics from him.”
But DeSanctis, she said, “sat back in his chair and laughed.”
DeSanctis, however, does not seem to recall that exchange. In fact, he says no one used the phrase “Candy Land” or “Candy Man” in his presence before CIR revealed widespread problems at the hospital in January.
Taking the ‘Houlihan Cocktail’
In her home outside Kansas City, Missouri, Dawn Bishop tosses and turns late into the night, fearful that a phone call could come from Wisconsin informing her that her brother, 39-year-old Air Force veteran Jason Bishop, has died of an overdose.
Jason Bishop has a long history of painkiller addiction dating back to a botched surgery in the military in the 1990s. But over the years, he had slowly turned his life around. After a divorce, he assumed custody of Chloe, his 9-year-old daughter, and used a VA home loan to buy a farm outside La Crosse.
Dawn Bishop thought things were getting better. Then her brother went to the Tomah VA for health care and ended up seeing Houlihan.
“This guy came in and sat on the floor and talked to him,” she said. “Jason thought Dr. Houlihan was awesome. Nobody had ever done that before.”
Soon, Jason Bishop was receiving a witches’ brew of powerful medications, including amphetamines, benzodiazepine tranquilizers and two types of morphine. Dawn Bishop said he started to call her at all hours, rambling incoherently.
“He ballooned up to over 200 pounds, got lethargic and had terrible fatigue,” she said.
“I don’t want to be resigned to losing my brother,” she wrote in an email. “I battle against that every day. It is a LOT harder for a family to have an impact when doctors are telling him this is ‘what he needs.’ ”
Hospital staff call the combination of medications prescribed to Jason Bishop the “Houlihan Cocktail.” They said their chief of staff was dedicated to it and would threaten them when they tried to remove some of the powerful drugs he had prescribed or lower the dose.
Army Reserve Capt. Mary Forslund, a former nurse practitioner at the VA’s Wausau clinic, said Houlihan brought up the cocktail during her job interview.
“I didn’t really understand his train of thought, but I was also intimidated at the time because he was the chief and I was a brand-new nurse practitioner,” Forslund said. “He told me that many people disagreed with the way he did things, and so I just tried to stay out of the whole thing.”
The Houlihan Cocktail runs counter to the VA’s own regulations, which warn doctors to be especially cautious when prescribing addictive narcotics to patients with mental illness. Doctors also are supposed to avoid prescribing tranquilizers and opiates to the same patients, because the combination can cause them to stop breathing.
Giving veterans amphetamines for PTSD isn’t even addressed in the regulations.
“Using amphetamines off-label for PTSD sounds strange, and that would be a controversial use of amphetamine,” said Andrew Kolodny, the Phoenix House medical officer. “I would hope that a physician engaging in a dangerous and questionable practice would be able to point to real evidence supporting that practice.”
In his patients’ medical charts, Houlihan justified his use of amphetamines for PTSD patients by citing research – a paper published in 2011 in the Journal of Psychopharmacology by Dr. David Houlihan.
The paper is not based on a typical double-blind study, with one group of patients receiving an experimental treatment and a control group of patients receiving a placebo or conventional therapy. Instead, it is a narrative describing three combat veterans who Houlihan said improved after he provided them with Ritalin, a stimulant typically associated with reducing hyperactivity in children.
Forslund said she watched the cocktail destroy the health of many of her patients.
“I’ve seen perfectly healthy guys who come into my office and then I see them a year later, and they’re fat, they’re dulled, and they have no quality of life at all, and it’s because of that cocktail,” she said. “They can’t think straight, their wives are disgusted and some of these guys have no idea how to take medications. They just want pills.”
For his part, Jason Bishop said he’s been seeking acupuncture, surgery and other treatments to get to the root of his pain. His medical record shows he’s been receiving the Houlihan Cocktail, but he said he hasn’t been taking all of his pills.
Instead, he’s hidden nearly full bottles of morphine sulfate, Xanax and Ritalin in a drawer underneath his bed where his daughter won’t see them.
“Every time I went in there, I would get asked, ‘Do you need more?’ ” Jason Bishop said of Houlihan and other doctors at the Tomah VA. “I would say, ‘No, I don’t need more, I don’t want more, find something that works for me and fix the problem.’ ”
Dealing with the aftermath
The body of baby Ada Mae Miller is buried in a simple grave a half-mile from the Millers’ family farm, in a cemetery now nearly obscured by snow. The buggy was fixed long ago. More than five years after Brian Witkus took his daughter’s life, William Miller said his family has begun to recover.
“Obviously, you never forget,” he said, his voice quavering with emotion, “but we don’t live in the fear and dread that we did after the first months.”
Miller was not aware that drugs were a factor in the crash, and he declined to discuss the role VA-prescribed painkillers could have played in the accident beyond saying that “abusing narcotics is wrong. If he was doing it, that was a factor in the accident, that’s why he was convicted in court.”
Religion offers some solace. “Perspective brings compassion,” Miller said. “We believe in allowing God control of our life. Why he allowed this to happen, we won’t know until the other side. The only thing for us to do is accept and move on.”
As for Witkus, he served three years in prison and was released after completing a drug rehab program. Today, he lives in a halfway house in Wausau. His beard is gray, his face haggard and he walks with a cane.
His main complaint is that as a condition of his parole, he is no longer allowed to take tranquilizers, while the amount of painkillers he’s being prescribed has been cut in half.
He remembers Houlihan as a good doctor.
“He was pretty understanding,” Witkus said. “He didn’t really push the meds on me. I think he’s an awesome doctor.”
During a 45-minute conversation in January, Witkus never mentioned the Millers’ baby. Asked if he had anything else he wanted to say, he brought up a conversation he once had with a psychiatrist.
“I had a psychiatrist when I was in prison over in Jackson County, over in Black River Falls,” he said. “She was a student and she asked me, she says, ‘With all your bad things that happened to you, what would you change in your life?’ I said, ‘Ma’am, I would not change a thing.’ ”