Data obtained by CIR shows the number of opiate prescriptions at the Tomah VA more than quintupled from 2004 to 2012. Credit: Darren Hauck for CIR

A U.S. Senate report released Monday confirmed the dangerous overuse of opioid prescriptions at a Department of Veterans Affairs hospital in Wisconsin, and it did not waste words in casting blame. The 365-page report begins:

“The tragedies of the Veterans Affairs Medical Center in Tomah, Wisconsin (Tomah VAMC) – the veteran deaths, abuse of authority, and whistleblower retaliation – were preventable.”

The Senate report alleges that after years of government ineptitude, the deadly and tragic situation in Tomah finally received proper attention due to public exposure in the media, thanks to coverage by Reveal from The Center for Investigative Reporting.

“Allegations of drug diversion, opioid over-prescription, retaliation, and mismanagement festered. As a result, veterans died.

“However, since the Center for Investigative Reporting article brought the longstanding problems to light, three subsequent investigations into the Tomah VAMC found, among other problems, inappropriate and unsafe prescription practices at the Tomah VAMC. These investigations, largely spurred on by public awareness and transparency to the problems at the facility, have finally begun to lead to some accountability for wrongdoers at the Tomah VAMC.”

The third paragraph of the report summarizes the Reveal investigation:

“In January 2015, an article published by the Center for Investigative Reporting exposed the realities of the Tomah VAMC. The article told the story of Jason Simcakoski, a 35-year-old Marine Corps veteran who passed away at the Tomah VAMC in August 2014 from a lethal cocktail of medication. It recounted allegations against the facility’s chief of staff, Dr. David Houlihan – who veterans dubbed the ‘Candy Man’ – relating to over-prescription, retaliation, and drug diversion. The article also exposed the existence of a then-secret report, written by the VA Office of Inspector General and dated March 12, 2014, concerning the Tomah VAMC.”

Monday’s report included new details about that secret inspector general’s report, including a handwritten note from VA officials who, during a 2012 inspection, believed Houlihan and nurse practitioner Deborah Frasher appeared high on drugs. The note indicates the officials reported it to then-hospital Director Mario DeSanctis. But it appears that they never followed up on their suspicion, such as requiring a drug test, or included their observations in the secret report that was first released publicly by Reveal.

“At the conclusion of the interview with Mr. DeSanctis, the recorder was turned off, and we unofficially informed him of our observation at the site visit that Dr. Houlihan had apparently constricted pupils and peripheral vasoconstriction and [Redacted] had apparent sedation with small slurring of speech and intermittent eye closings. We suggested he may want to order some drug tests of the staff.”
Days after publication of the January article, U.S. Sen. Ron Johnson, R-Wis., chairman of the Senate Committee on Homeland Security and Governmental Affairs, launched a bipartisan investigation into the allegations surrounding the Tomah VA hospital.

The results and impact have been ongoing. According to Monday’s report: “Since January 2015, Chairman Johnson’s investigation and increased public attention on the facility have led to changes. The facility’s director, Mario DeSanctis, and its chief of staff, Dr. David Houlihan, have been fired. The Deputy VA Inspector General, Richard Griffin, retired under intense scrutiny of his work. President (Barack) Obama heeded the calls of Chairman Johnson and other senators to appoint a new VA Inspector General, Michael Missal, who Chairman Johnson shepherded through his Committee to confirmation by the Senate.” Frasher also resigned.

Nathan Halverson can be reached at Follow him on Twitter: @eWords.

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Nathan Halverson (he/him) is an Emmy Award-winning producer for Reveal, covering business and finance with a current emphasis on the global food system. Before joining Reveal, Halverson worked on projects for FRONTLINE, the Investigative Reporting Program at the UC Berkeley Graduate School of Journalism and PBS NewsHour. He was the principal reporter on Reveal's story about the Chinese government’s involvement in the takeover of America’s largest pork company, Smithfield Foods Inc. He was awarded a 2014 McGraw Fellowship by the CUNY Graduate School of Journalism, and he received a bachelor's degree in economics from the University of Minnesota. He has won a New York Times Chairman’s Award and has received reporting honors from the Society of American Business Editors and Writers, California Newspaper Publishers Association, San Francisco Peninsula Press Club and Associated Press News Executives Council. Halverson is based in Reveal’s Emeryville, California, office.