Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Prescribing Practices in the
 

Pain Management Clinic at
 

John D. Dingell VA Medical Center
 

Detroit, Michigan
 

Report No. 11-00057-195 June 15, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections evaluated 

allegations of poor prescribing practices for controlled substances in the Pain 

Management Clinic (PMC) at the John D. Dingell VA Medical Center (the facility), 

Detroit, MI. A complainant alleged that: 

	 PMC physicians prescribed controlled substances without adequate evaluation of 

patients. 

	 Supervisors coerced PMC providers to write controlled substance prescriptions for 

patients not under their care. 

	 Patient injuries and deaths occurred as a result of PMC providers prescribing 

practices. 

We substantiated that providers were prescribing controlled substances without adequate 

evaluation of patients and found that the facility did not have a policy outlining 

requirements for the ongoing assessment of patients treated with opioid (narcotic) 

medications. 

We did not substantiate the allegation that supervisors coerced providers to write 

controlled substance prescriptions for patients they had not evaluated. We also did not 

substantiate that injuries or deaths resulted from the prescribing practices of PMC 

providers. 

We recommended that the Medical Center Director ensure that managers define the 

expected frequency of provider evaluations for patients treated with opioid medications 

and ensure peer review of the PMC physician responsible for opioid prescriptions without 

adequate patient evaluation. The VISN and Medical Center Directors concurred with the 

inspection results. We will follow up on the planned actions until they are complete. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Director, Veterans In Partnership (10N11) 

SUBJECT: Healthcare Inspection – Prescribing Practices in the Pain Management 

Clinic, John D. Dingell VA Medical Center, Detroit, Michigan 

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections (OHI) 

received allegations regarding prescribing practices for controlled substances (CS)1 in the 

Pain Management Clinic (PMC) at the John D. Dingell VA Medical Center (the facility), 

Detroit, MI. The purpose of this inspection was to determine whether the allegations had 

merit. 

Background

The facility is part of Veterans Integrated Service Network (VISN) 11. Located in 

Detroit, MI, the facility has 267 beds and provides primary, secondary, and tertiary care. 

The facility has 108 acute care beds, an onsite 109-bed Community Living Center, and an 

offsite 50-bed Domiciliary Residential Rehabilitation Treatment Program. The facility 

provides acute medical, surgical, and psychiatric care. The facility also has 

two community based outpatient clinics (CBOCs) located in Yale and Pontiac, MI, which 

provide primary care and psychiatric evaluations. The facility is affiliated with the 

Wayne State University School of Medicine. 

According to Veterans Health Administration (VHA) policy,2 facilities are expected to 

accommodate the needs of veterans with acute and chronic pain using a stepped care 

delivery model, beginning with the Primary Care Provider (PCP). If pain control is 

inadequate, the PCP is to obtain PMC consultation. The PMC provider’s role is to 

establish pain control through various modalities, then return the patient for ongoing 

primary care. In February 2010, a Behavioral Pain Clinic (BPC) was established at the 

facility to provide multidisciplinary care for chronic pain patients considered to be 

1 These are drug categories considered to have a potential for abuse or addiction but that also have a legitimate
 

medical use.
 2 VHA Directive 2009-053, Pain Management, October 28, 2009.
 

VA Office of Inspector General 1 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

unsuitable for PCP management for one or more of the following reasons: 

	 the need for opioid3 titration 

	 problems with tolerance/addiction 

	 suspected diversion or medication interaction 

	 other complex issues that require additional time and expertise to manage 

The OIG Hotline Division received a complaint regarding the management of patients on 

prescribed CS in the PMC. 

A complainant made the following allegations: 

	 PMC providers prescribed CS without adequate evaluation of patients. 

	 Supervisors coerced PMC providers to write controlled substance prescriptions for 

patients not under their care and without evaluation. 

	 Patient injuries and deaths occurred because of PMC providers’ prescribing 

practices of CS. 

Scope and Methodology

OHI conducted an onsite inspection January 12–14, 2011. We reviewed the electronic 

medical records of patients provided by the complainant; facility policies and procedures 

governing pain management; and federal, state, and VHA policies. We interviewed 

senior managers, employees from the PMC, the Chief of Pharmacy Service, and other 

employees who provide care to patients prescribed medications for pain control. For an 

independent assessment of facility prescribing and monitoring practices, we identified all 

patients for whom oral opioid medications were prescribed during December 2010. After 

adjusting for the relative analgesic potency of medications,4 we reviewed patient medical 

records with the largest aggregate prescribed opioid doses. This review was limited to 

the following oral opioid medications: morphine, hydrocodone, oxycodone, methadone, 

and hydromorphone. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

3 Opioids are medications with effects similar to those of opium and opium derivatives. The term is often used as a
 

synonym of “narcotics.”

4 Brunton LL, Ed. Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 11th Ed. New York:
 

McGraw-Hill, 2006.
 

VA Office of Inspector General 2 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Inspection Results

Issue 1: Management of Patients on Controlled Substances

We substantiated that PMC providers prescribed CS without adequate evaluation of 

patients. 

The VA/Department of Defense Clinical Practice Guideline for the Management of 

Opioid Therapy for Chronic Pain5 recommends that patients be evaluated every 

1–6 months. We reviewed 20 patients electronic medical records, including those named 

by the complainant and those with the largest aggregate opioid doses identified from 

among the 4,445 patients who received these medications during December 2010. 

We found that during 2010 five patients on chronic opiod therapy had no evaluation and 

six patients had evaluations more than 7 months apart. For 10 of these patients, 

prescriptions were written by one PMC physician. 

Issue 2: Alleged Coercion of Providers by a Supervisor

We did not substantiate the allegation that PMC supervisors coerced providers to 

prescribe CS to patients not under their care. We interviewed PMC staff and providers 

and none of the interviewees recalled witnessing this behavior. Several staff members 

recalled being present at a staff meeting at which a provider was asked to cover during a 

colleague’s absence. The colleague had numerous patients who would require 

medication renewals. The provider agreed to provide coverage if each patient were 

scheduled for an evaluation. Neither the supervisor nor the colleague felt that it was 

necessary to re-evaluate each patient, and another PMC provider was assigned. 

Issue 3: Prescribing Practices and a Patient Death

We did not substantiate the allegation that PMC providers’ prescribing practices resulted 

in the death of a patient. We reviewed one patient’s medical records who died 4 days 

following the initial evaluation by a BPC provider. The provider documented a thorough 

assessment and detailed the patient’s instructions about the medication prescribed. The 

patient was to return in 4 weeks for a follow-up appointment. 

There were no other cases of injury or death related to pain management reported or 

discovered during this investigation. 

Case Summary

The patient was a service-connected, Iraqi war veteran who received primary care at the 

Pontiac CBOC. During 2006–2009, management of the patient’s chronic pain included 

5 VA/Department of Defense Practice Guideline, Management of Opioid Therapy for Chronic Pain, May 2010. 

VA Office of Inspector General 3 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

oral opiates, a nerve block, transcutaneous electrical nerve stimulation (TENS),6 and 

chiropractic manipulations. The patient had a history of taking more than the prescribed 

amount of hydrocodone/acetaminophen and intermittently presented to the CBOC or the 

facility’s emergency department (ED) complaining of incomplete pain relief. The CBOC 

provider prescribed oxycodone and morphine sulfate, but the patient reported adverse 

reactions to both. 

In mid-February, a CBOC provider noted that the patient reported inadequate pain relief 

and that he was “having trouble staying asleep.” Additionally, the patient informed the 

CBOC provider that he was receiving treatments from a chiropractor twice a week and 

that the treatments had provided “some improvement in mobility of neck and back, but 

the pain is persistent.” The CBOC provider ordered a magnetic resonance imaging 

(MRI) study of the cervical spine and changed the patient’s medication from 

hydrocodone/acetaminophen to oxycodone. 

In March, the CBOC provider contacted the patient regarding the MRI results. The 

report indicated herniated cervical discs in two areas. The provider then ordered a 

neurology consult for further assessment. During this encounter, the patient also reported 

an adverse reaction to oxycodone. The provider changed the patient’s pain medication 

back to hydrocodone/acetaminophen and requested the patient return any unused 

oxycodone. The patient returned 26 oxycodone tablets to the provider that 

same day. 

During a follow-up appointment at the CBOC later that month, the patient reported a pain 

level of 9 on a 1–10 pain scale, and that he was using 

16–20 hydrocodone/acetaminophen tablets daily to relieve pain. As a result, the provider 

changed the medication from hydrocodone/acetaminophen to morphine sulfate tablets. 

The provider advised the patient to go to the ED if he experienced any problems prior to 

his next appointment. 

Within two weeks, the patient reported that he developed a rash from the morphine 

sulfate. In response, the provider discontinued the morphine sulfate, restarted the 

hydrocodone/acetaminophen, and requested a pain management consultation, advised the 

patient to use a TENS unit along with analgesic cream, and continue chiropractic care. 

The patient returned the unused morphine sulfate to the pharmacy for disposal. 

Four days later, a Neurology Service provider evaluated the patient and recommended 

referral to the Neurosurgery Service. At that time, the patient again reported continuing 

pain unrelieved by medications. 

6 Transcutaneous electrical nerve stimulation is a technique used to control chronic pain in which electrodes applied 

to the skin deliver intermittent stimulation to surface nerves and block the transmission of pain signals. 

VA Office of Inspector General 4 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

In early May, a BPC provider evaluated the patient. During this encounter, he reported 

that he had run out of pain medication. The provider prescribed methadone, and 

documented patient education on the medication and its possible side effects. In addition, 

the provider also documented that the patient was instructed not to combine pain 

medications. The BPC scheduled a follow-up appointment for 4 weeks. On the day after 

this last BPC visit, a Neurosurgery Clinic provider evaluated the patient and advised him 

to continue with the current pain medication and treatment modalities. 

The patient did not return to the BPC as scheduled and facility staff later learned that the 

patient had died 4 days after his last clinic visit. The facility obtained a copy of the 

patient’s death certificate, which listed the cause of death as multi-drug toxicity. 

Conclusions

We substantiated the allegation that PMC physicians prescribed CSs without adequate 

evaluation of patients. 

We did not substantiate the allegation that PMC supervisors coerced providers to 

prescribe CSs to patients not under their care. 

We did not substantiate the allegation that PMC providers’ prescribing practices resulted 

in the death of a patient. 

Recommendations

Recommendation 1. We recommended that the Medical Center Director ensure that 

managers define the expected frequency of provider evaluations for patients treated with 

opioid medications. 

Recommendation 2. We recommended that the Medical Center Director ensure peer 

review of the PMC physician responsible for opioid prescriptions without adequate 

patient evaluation. 

Comments

The VISN and Medical Center Directors concurred with the inspection results (See 

Appendixes A and B, pages 6–9, for the full text of the Directors’ comments). We will 

follow up on the planned actions until they are complete. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 5 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Appendix A

VISN Director Comments
 

Department of

Veterans Affairs Memorandum

Date: May 25, 2011 

From: Director, Veterans In Partnership (10N11) 

Subject: Healthcare Inspection — Prescribing Practices in the Pain 

Management Clinic at John D. Dingell VA Medical Center, 

Detroit, Michigan 

To: Director, Chicago Office of Healthcare Inspections (54CH) 

Thru: Director, VHA Management Review Service (10A4A4) 

Attached is the response from the Detroit VAMC. If you 

have any questions, please contact Kelley Sermak, Acting 

Quality Management Officer at (734) 222-4302. 

Michael S. Finegan
 

Director, Veterans In Partnership (10N11)
 

VA Office of Inspector General 6 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Appendix B

Medical Center Director Comments
 

Department of

Veterans Affairs Memorandum

Date:	 May 25, 2011 

From:	 Medical Center Director, John D. Dingell VA Medical Center 

(553/00) 

Subject:	 Healthcare Inspection — Prescribing Practices in the Pain 

Management Clinic at John D. Dingell VA Medical Center, 

Detroit, Michigan 

To:	 Director, Veterans In Partnership (10N11) 

The information attached includes response to the recommendation 

in the Office of Inspector General’s report. 

Dr. Pamela D. Reeves
 

Director, John D. Dingell VA Medical Center (553/00)
 

VA Office of Inspector General 7 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Medical Center Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendation 

Recommendation 1. We recommended that the Medical Center Director 

ensure that managers define the expected frequency of provider evaluations 

for patients treated with opioid medications. 

Concur Target Completion Date: September 30, 2011 

Facility’s Response: 

In February 2010, the Pain Management Service initiated a process to bring 

itself into compliance with the stepped care delivery model for treatment of 

chronic pain. For Veterans chronically receiving stable doses of Schedule 

II Opioids, responsibility for prescriptions was transferred to Primary Care. 

This process continues to the present with the goal of relieving the Pain 

Management Service from providing prescriptions; except for those 

Veterans who require close supervision and those requiring relative high 

doses of opioids for which the Primary Care Providers lack adequate 

experience. These represent a relatively small number of Veterans. 

The process will be completed by September 30, 2011, with the result that 

treatment of chronic pain will be based again in Primary Care. 

This process will increase capacity and will allow the pain management 

team to conduct frequent, face to face encounters with our patients on 

Schedule II Opioids. To increase the capacity, the nurse practitioner in the 

pain clinic will have an added 8 hours of clinic time by June 1, 2011. 

The Medical Center has established a policy for Schedule II Opioid use that 

requires patient visits for evaluation of pain management at a frequency of 

not less than every 6 months. In addition, telephone contact must be made 

between visits at a frequency of not less than every 3 months. All Veteran 

contacts regarding issues of pain management require documentation as 

stated in Medical Center Numbered Memorandum 11I-71, Chronic Opioid 

Use, dated May 16, 2011: 

If the dose or frequency changes, long-term prescriptions of opioids for 

chronic pain will be re-entered and/or rewritten and adjusted accordingly, 

VA Office of Inspector General 8 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

patients who are undergoing dose modifications will be evaluated via a 

face-to-face encounter with the prescribing provider on a 30-day basis or 

more frequently. 

If the therapy continues without a change in dose or dosing frequency for at 

least 3 months, a new prescription should be submitted to the Pharmacy to 

be refilled every 28 days and the patient must have a face-to-face encounter 

with prescribing provider every 6 months or sooner. 

There should be at least one telephone encounter during the 6 month gap 

between face-to-face visits ideally at the 90 day mark. 

The patient database on Schedule II Opioids will be reviewed periodically 

by the ACOS for Integrated Clinical Services and the Chief of Pharmacy to 

identify Veterans who have not been seen within 6 months. This process 

has been implemented. The national data reporting software was modified 

to allow those alerts to be generated for patients on Schedule II Opioids not 

seen in the VA within 6 months, as opposed to the previous version that 

allowed such a monitor only after 12 months of not having a VA visit. By 

August 31, 2011, all patients will receive appointments. 

Recommendation 2. We recommended that the Medical Center Director 

ensure peer review of the PMC physician responsible for opioid 

prescriptions without adequate patient evaluation. 

Concur Target Completion Date: August 15, 2011 

Facility’s Response: 

With respect to the Pain Management Clinic physician responsible for 

10 of the 11 patients referred to in the draft report receiving opioid 

prescriptions without adequate evaluation, all 10 cases will be sent out to a 

VISN 11 VA Medical Center for a Focus Professional Practice Evaluation. 

This was the decision made with discussion between the Chief of Staff at 

the John D. Dingell VAMC and the Senior Medical Officer at the Office of 

Quality and Performance. A Focus Professional Practice Evaluation 

(FPPE) will be completed by August 15, 2011. 

VA Office of Inspector General 9 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Appendix C

OIG Contact and Staff Acknowledgments
 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Verena Briley-Hudson, NP, Chicago Regional Director 

JoDean Marquez, RN, Team Leader 

Wachita Haywood, RN 

Jerome Herbers, Jr., MD 

Judy Brown, Program Support Assistant 

VA Office of Inspector General 10 
Prescribing Practices in the Pain Management Clinic at John D. Dingell VA Medical Center, Detroit, MI 

Appendix D

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans In Partnership (10N11) 

Director, John D. Dingell VA Medical Center (553/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Carl Levin, Debbie Stabenow 

U.S. House of Representatives: Hansen Clarke, John Conyers, Jr., John D. Dingell, 

Sander Levin, Thaddeus McCotter, Candice Miller 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 11