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Correspondence and emailed statements re: Huntington VAMC prescribing

June 2015 - October 2016

Excerpts:

Huntington VAMC statement

Sent via email from Debbie Brammer, Public Affairs Officer, June 24, 2015

The Huntington VA Medical Center (VAMC) has been unable to substantiate the
information provided in the comparison of the Huntington VAMC with Tomah. A great
deal of hard work has gone on at the Huntington VAMC over the past several years, and
as a result, the facility continues to see positive trends in reducing the prescribing rates
of opioids and anti-psychotics.

In 2008, the Huntington VAMC began aggressive measures to ensure the

appropriate and safe prescribing of opioid medications. The VAMC is an active
participant in the VA Opioid Safety Initiative and has been successful in reducing the
percentage of patients prescribed opioids from 21.3 percent in first quarter of Fiscal Year
2012 to our current number of 17.8 percent for the second quarter of Fiscal Year 2015,
which is the most recent data available. Physician prescription data for controlled
substances is routinely monitored and feedback provided to both VAMC leadership and
providers. Patients on opioids with a urine drug screen (UDS) completed within the
previous year has increased from 28% in Q2 FY14 to 69% in Q2 FY15. Percentage of
patients checked in a state prescription monitoring program within previous 90 days
increased from 46% in July 2014 to 80% in March 2015.

Additionally, the Huntington VAMC participates in the VA Psychopharmacology

Initiative which is focused on safe and appropriate monitoring of medications, including
anti-psychotics. Huntington VAMC continues to see a downward trend in the number of
patients with a PTSD diagnosis receiving an anti-psychotic. In the second quarter of
Fiscal Year 2014, the percentage of PTSD patients prescribed anti-psychotics was 25.8
percent. The most recent data for Fiscal Year 2015 shows a reduction to 23.2 percent.
Other actions taken include providing focused education for Primary Care and Mental
Health practitioners and conducting individual case management reviews for all PTSD
patients on anti-psychotics.

Concerning the psychiatrist, Dr. Marlin Schauland was a term employee at

Huntington VAMC, starting June 24, 2007. Dr. Schauland underwent the appropriate
credentialing and privileging process used for all medical staff applicants. There is
nothing in his credentialing record indicating issues with the DEA, and in fact, when
queried in 2007, there was no report of any past issues. He was terminated upon
expiration of his term appointment on July 25, 2008.
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Huntington VAMCs current leadership team employs a stringent process reviewing

provider candidates to ensure that they have not only the required education, training
and licensure, but are also of the highest moral and ethical character. Applicants who
have had identified problems with either state licensure or DEA certification are
uniformly declined.

Respectfully,

Debbie Brammer, Public Affairs Officer

***

Inquiry to Deborah Brammer, Huntington VA Public Affairs: Thursday, October 13, 2016

Following up on my earlier queries, I want to get clarity on the scope of cooperation of the Huntington
VA -- or the other West Virgniia VA facilities -- in sharing information with the pharmacy board about
veteran patient opiate use, designated as the state PDMP (perscription drug monitoring program.). I'm
enclosing a VA internal review of a roll-out of the planned data sharing, circa 2014, and excerpts of
testimony by Dr. Clancy undersecretary of VHA, in which she admits she didn't' know that most VA
facilities weren't sharing data as she had been led to believe -- and she was hoping that reporting VA
patient opiate use would become compulsory, but it wasn't at that time. I'm aware that you told me
that 17 percent of ALL patients at the Huntington VA receive opiates, as I understand the information.

Here's previous reply about opiate prescribing levels and trends you sent me that differs from the
Center for Investigative Reporting's analysis of VA-supplied data., noted in a Post-Script.

But what I'm seeking to get at is the scope of cooperation with the state PDMP; whether your doctors
are required to provide that opiate prescribing information; very critically, do you require patient
permission of VA patients to disclose that information and if they don't grant it -- no matter their history
of opiate addiction--your rules bar you from providing that information?; and to what degree are VA
clinicians who treating pain patients, PTSD patients and addicts are required and expected to get non-
VA opiate use information from the state PDMP. Are there any yardsticks, measuring tools or
incentives to monitor cooperation, exchange and any progress being made -- and to incentivize and
monitor that your clinicians are indeed exchanging information in full regarding opiate prescribing
going to your veterans patients and so your clinicians have a full picture of medications they're
receiving inside the VA and outside the VA system. That's especially important as Dr. Clancy notes
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below as the VA moves into a Choice model with an expanded network of non-VA providers. Here's
my excerpts of query to the West Virginia Pharmacy board.

Here's excerpt from Dr. Clancy testimony in 2015, in longer postcript at end of the email:

Dr. Clancy: I will tell you that I am very worried about this [lack of sharing information with
PDMPs,] particularly since I learned extremely recently that we are not reporting to all the
State programs, because in the context of our buying more care out of network, either through
our usual non-VA care program or through the Choice program, this becomes an even bigger
risk for us and for veterans, most importantly.

(Emphasis added: the undersecretary for health of the VHA didn't know that her local/regional
programs weren't reporting data as she expected to the state PDMPs. What's happening in
West Virginia, and when did reporting and exchanges begin -- and a] is it compulsory for VA to
both report opiate prescribing and use by patients AND get that information from the state
PDMP on these sampe patients; and b] is it your local VA or national VA policy not to provide
to state PDMPs opiate use and prescriptions about individual patients if the patients don't
want you to make such disclosures? This isn't a minor point but it also shouldn't require a
months-long FOIA search. )

Sincerely,

Art Levine

fyi: Here's Huntington VA data on opiate use -- which national experts view as shockingly high-- is
over 17 percent of ALL patients on opiates, so these issues of exchanging information amid the
nation's highest rate of overdoses become especially important. Your reply to me on opiate use last
year:.

The Huntington VA Medical Center (VAMC) has been unable to substantiate the information provided
in the comparison of the Huntington VAMC with Tomah. A great deal of hard work has gone on at the
Huntington VAMC over the past several years, and as a result, the facility continues to see positive
trends in reducing the prescribing rates of opioids and anti-psychotics.

In 2008, the Huntington VAMC began aggressive measures to ensure the appropriate and
safe prescribing of opioid medications. The VAMC is an active participant in the VA Opioid Safety
Initiative and has been successful in reducing the percentage of patients prescribed opioids from 21.3
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percent in first quarter of Fiscal Year 2012 to our current number of 17.8 percent for the second
quarter of Fiscal Year 2015, which is the most recent data available. Physician prescription data for
controlled substances is routinely monitored and feedback provided to both VAMC leadership and
providers. Patients on opioids with a urine drug screen (UDS) completed within the previous year has
increased from 28% in Q2 FY14 to 69% in Q2 FY15. Percentage of patients checked in a state
prescription monitoring program within previous 90 days increased from 46% in July 2014 to 80% in
March 2015.

***************************

Inquiry to West Virginia Board of Pharmacy, October 13, 2016

-----
From: Art Levine
To:David Potters, executive director, West Virginia Board of Pharmacy

Cc: John Eadie, Brandeis University drug monitoring exchange; press offices Sen. Joe Manchin, Sen. Richard Blumenthal

Sent: Thursday, October 13, 2016

Subject: [sharing VA opiate data with state Prescription Drug Monitoring Program (PDMPM])

Dear David Potters: I'm Art Levine, going to press [soon] with some book chapters on veterans and
overmedication concerns and deaths in West Virginia and information from other states. (I've
previously published on overmedication with antipsychotics for children.)

I'm trying to clarify what sort of information regarding opiate use outside the VA system by individual
veterans getting services in local or regional VA facilities do you share , and when did the Huntington
VA, for instance, begin sharing their information with you -- and is there a requirement that their
clinicians access your state's database information. As of 2015, the health undersecretary, Dr. Clancy,
didn't know that a majority of state VA systems weren't reporting to the state PDMP programs, and
she conceded that there there was no requirement that they access non-VA, civilian data. There was
also internal disagreements among IT officials over sharing this information, despite regulations
passed by VA in 2013, in theory allowing the VA to share opiate use information, with some
restrictions

I don't need a formal extensive reply that could take weeks -- I'm just seeking some basic on the
record or background information, preferably over the phone, about current scope and guidelines for
cooperation and when it began.
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I want to know what your agency's current practices and extent of cooperation with local VAs are. You
are as aware as anyone in the country that overdoses, often fatal,are at epidemic levels in your state,
often involving opiates and heroin, as shown in this story about a wave of over 20 overdoses in one
day where the victims live -- in Huntington..

West Virginia has the highest rate of fatal drug overdoses of any state and the highest
rate of babies born dependent on opioids among the 28 states that report data. But
even compared with other communities in West Virginia, Huntington sees above-
average rates of heroin use, overdose deaths, and drug-dependent newborns. Local
officials estimate up to 10 percent of residents use opioids improperly.

Huntington VA has had a traditionally high rate of opiate prescribing, exceeding national VA opiate
prescribing and even, it seems, at scandal-scarred Tomah in Wisconsin [although Huntington VA's
data differs from this analysis based on VA data provided Center for Investigative Reporting].

Through 2012, this was the prescription rate, below: http://va-opiates.apps.cironline.org/#/system/53

When did this VA system start sharing data on opioid use with your PDMP, and how extensively are
their doctors doing so -- and are they required by the VA agency to do so -- using your database to
learn about non-VA prescribing to veterans and sharing information with your system? Are there any
benchmarks or yardsticks to monitor progress of such information sharing?

Huntington, WV Huntington VA Medical Center

[Source: Center for Investigative Reporting]
Data for all drugs from 2001 through 2012
1. Home

Region

Huntington, WV

145.4
prescriptions per 100 patients

340,167 patients

494,470 prescriptions
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165.56 % change

Thanks,

Art Levine

P.S: Here's an important exchange in hearings last year between Sen. Blumenthal and Dr. Clancy of
the VA about precisely this issue, with an overview of state program/VA cooperation:

Senator BLUMENTHAL. Even under this new system, will the prescribing providers in the VA system
be compelled to provide information to the State prescription monitoring programs, that is the State
registries?

Dr. CLANCY. Because I have been paying a great deal of attention

to Wisconsin in response to concerns from Senator Baldwin and

other members of the delegation, and we have been reporting to

the Wisconsin State program for some time, I made the blithe assumption that we were reporting to all
the State programs.

Senator BLUMENTHAL. But that is not true.

Dr. CLANCY. Correct. We are reporting to 20 of them. [Was West Virginia one of them?] We have

identified that we have an internal disagreement among some of

our IT folks around privacy and security issues, which we will be

resolving very promptly.

Senator BLUMENTHAL. In some States, 20 of them

Dr. CLANCY. Yes.

Senator BLUMENTHAL[continuing]. Out of the 49 that have prescription monitoring programs

Dr. CLANCY. Yes.

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Senator BLUMENTHAL[continuing]. You are providing this information to State systems, but in some
29 of them you are not doing

so. Connecticut happens to be one where it is not occurring. [What is the status of information sharing
and when did it begin in West Virginia?]

Dr. CLANCY. That is correct. Now, obviously, resolving the difference of opinion here could lead to
one of two outcomes. One, we

immediately report to 49. The other is that we have to come up

with an alternative solution that fits our standards for security and

privacy. Either way, this will happen.

Senator BLUMENTHAL. I understand there are privacy concerns.

Just to be very clear, if I am a VA patient right now in Connecticut, or those 29 other States, I can go
to a private provider

and that private provider has no way of knowing the doses of

opioids that I am receiving through the VA system?

Dr. CLANCY. Correct.

Senator BLUMENTHAL. It is a blind one-way source of information

where it is working now, and if I am reading your testimony correctly, where you use the wordand I
am quotingVA providers

can now access the State Prescription Drug Monitoring Program

(PDMP), it is not compulsory that they do so?

Dr. CLANCY. Is it compulsory?

[Discussion off the record with Mr. Valentino.]

Dr. CLANCY. Not yet, but it will be.

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Senator BLUMENTHAL. When?

Dr. CLANCY. We are saying in the next 3 months.

Senator BLUMENTHAL. I would like a definite timeline.

Dr. CLANCY. Alright. We will get back to you with a very specific

date. I will tell you that I am very worried about this, particularly

since I learned extremely recently that we are not reporting to all

the State programs, because in the context of our buying more care

out of network, either through our usual non-VA care program or

through the Choice program, this becomes an even bigger risk for

us and for veterans, most importantly. (Emphasis added: the undersecretary for health of the VHA
didn't know that her local/regional programs weren't reporting data as she expected to the state
PDMPs.)

******

Reply from Michael Goff administrator of state drug monitoring program, West Virginia
Oct. 14, 2016

Message body

Mr. Levine,

We have worked with the four WV VA Medical Centers, to enable them to report their VA dispensing data to the
WV PMP. They have been very cooperative with us, and have been reporting their controlled substance
dispensing information to the WV Board of Pharmacy since late last year. They didnt all start reporting at
the same time, but I believe they each began sometime in October or November 2015 [emphasis added]. I
have no way of knowing if there are other dispensings that were not reported to us as a result of the patient
privacy concerns you mention. Those would have to be separated from the VA data prior to uploading to our
database.
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With regard to how often the physicians and pharmacists working at the VAMC use the WV PMP data, I have
no easy way to tell. The practitioners obtain access to the PMP data system individually, not as the VA, so it
would be difficult to identify which practitioners were accessing the data for VA purposes.

Let me know if you have additional questions. Mike

Michael L. Goff
CSMP Administrator

West Virginia Board of Pharmacy

*************

Correspondence with DOJ/DEA official; West Virginia Osteopathic Licensing Board; Huntington
VAMC regarding Dr. Marvin Schauland and DEA registration requirements

From:Laura Harris, DOJ

06/10/15 at 2:01 PM

To:Art Levine
Message body
Hello Mr. Levine:

DEA does not require a doctor to tell anyone that their license has been revoked. The requirement is upon the
registrant, for the registrant is regulated.

If you have any further questions, they can be directed to DEAs Office of Diversion, www.deadiversion.usdoj.gov

Thank you,

Laura

SA Laura A. Harris

Washington Field Division

Public Information Officer

CS Coordinator

************

Query to Huntington VA, DOJ/DEA, West Virginia Osteopathic Licensing Board

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Re: Dr. Schauland

From: Art Levine

Sent: Tuesday, June 09, 2015

To: Shepard, Diana K; Harris, Laura A.; Diana Bowen

Subject: West Virginia didn't know that his DEA registration was revoked....did VA know that, and were they were required to be told
about it by Dr. Schauland?

Dear Diana Shephard, [West Virginia Osteopathic Licensing Board]: When did you learn he wasn't practicing
in West virginia? What was this complaint regarding? WV Board Opened Complaint 2008-19: 7/2/2008

[Questions in brackets included in this email to VA, DOJ, West Virginia officials.]

[Laura Harris, DOJ/DEA: These answers from West Virginia [below] make it important for me to understand:
Was Schauland required -- or not required -- to tell his employer he no longer had a DEA registration license? if
he did not do so, and just started writing controlled scrips under the facility's DEA registration, is that following
the law or not?]

West Virginia says it does not know and takes no action regarding controlled substances prescribing as long as a
physician has a valid license , it seems -- a different perspective than you provided. Please clarify this for me, in
light of these answers from the West Virginia licensing board.

From Diana Shephard, West Virginia Osteopathic Licensing Board.

06/09/15 at 6:33 PM

To Art Levine
Message body
Mr. Levine:

I will provide a synopsis of Marvin Schauland's licensure history with the WV Board of Osteopathic
Medicine and then direct your attention to the documents provided from his licensure file with the West
Virginia Board of Osteopathic Medicine.

1) Issued a WV Osteopathic License: 12/4/1973

2) Last renewed WV License: 5/29/2007

3) WV Board Received Disciplinary

Alert from AMA: June 2008

4) WV Board Opened Complaint 2008-19: 7/2/2008

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5) WV Board notified by FSMB of

Michigan Board Action: 7/16/2008

6) Dr. Schauland does not renew

WV License: 6/30/2009

6) Received PA Board Action: 6/6/2010

7) Surrender of MN License: 10/22/2010

8) WV License Reinstatement Denied 7/22/2011

and complaint dismissed:

Dr Schauland never notified the Board of his DEA revocation. We found that out Dr. Schauland's DEA was
not renewed in 2007, but because Dr. Schauland was not practicing in WV that was not a pertinent fact to
us. If he was practicing in the VA system, the WV Board would not have been informed of that. Any
physician can practice in the VA system in any state in the Union with only one state license. The state
housing the VA facility may (and usually doesn't) know the physician is there. That is a VA rule.

Therefore, the WV Board of Osteopathic Medicine could not and would not take any action against Dr.
Schauland's ability to prescribe because to our knowledge he was not in West Virginia. Only the VA system
knows where the doctor is practicing. As far as Dr. Schauland using the VA hospital DEA registration
number, again, only the VA system in which he is working would know that. Not the licensing board.

I hope this answers your questions of the Board. As you can see, the state licensing boards have very
little authority over any physician working in the VA system. It is a closed system.

Diana Shepard, CMBE

West Virginia Board of Osteopathic Medicine

405 Capitol Street, Suite 402

Charleston, WV 25301

****

[Query to Huntington VAMC FOIA/press official, Diana Bowen included in this query]: What did the
Huntington VA know about DEA registration revocation of Dr. Schauland's and when did it know it? How
notified/when notified/ and why allow Dr. Schauland to continue prescribing controlled substances if you knew
his personal registration was revoked?

Other questions about prescribing trends and numbers for antipsychotics and tranquilizers, etc. are still pending
with your FOIA office, Diana.
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Thanks,

Art Levine

******

Above correspondence with WV Board Board of Osteopathic Medicine in reply to this query:

From: Art Levine

Sent: Tuesday, June 09, 2015 5:08 PM

To: Shepard, Diana K
Subject: Re: WV Board of Osteopathic Medicine/ PLEASE SEND ME INFORMATON, DOCUMENTS,
HEARINGS, action, CORRESPONDECE RE: Dr. Marvin Schauland:

Dear Diana: I'm especially interested in any actions your board may have taken and if there's any record of Dr.
Marvin Schauland informing you of his status in the 2007-2008 period when his DEA registration number was
removed and he faced potential disciplinary action from the Minnesota Licensing Board, enclosed.

I'd also appreciate clarifying if -- as the DEA claims -- it's the state's decision whether he is permitted to
prescribe controlled medications under the VA hospital DEA registration number after the DEA lifted its
authorization for him personally to do so. And if the state doesn't take any action or it isn't prohibited, he could
as long as he was a licensed physician in West Virginia can, it seems, freely prescribe controlled medications
under the VA Huntington hospital's DEA registration number.

Sincerely,

Art Levine