Each step helps more adequately address patient pain levels while making it easier to spot those trying to scam the system, Berryman said. But each has its potential problems.
The pain management specialist works with providers to determine the right level of pain medication for a patient, Rappold said. The hospital tries to find the right level of long-term pain medication that provides constant treatment.
Ideally, that's morphine.
Since 2009, Beckley has tried to use morphine for all long-term narcotics-based pain treatment. But that might have led to a spike in the number of prescriptions for hydrocodone or oxycodone.
"We are converting to a long-acting morphine because it is not as easy to divert the use of that, either by giving it to friends or wives or whatever or by selling them," Berryman said.
It takes a long time to find the right dosage for each patient, he said. In the meantime, a provider might need to prescribe a "rescue medication" like hydrocodone or oxycodone. It bridges the gap between morphine use until providers can figure out the correct amount of morphine that particular patient needs, Rappold said.
Depending on how long it takes to find the correct morphine dosage, it could require several short-term prescriptions for the "rescue medications," Berryman said.
The Center for Investigative Reporting's data show since 2009, the per-patient prescription rate of morphine has gone up. The same rate for hydrocodone went down from 2011 to 2012, but it's still seven times higher than it was in 2002, according to the report.
The VA tries to promote healthy lifestyles and avoid prescription painkillers as often as possible. Therapy, localized injections or other non-opiate pain medications are considered before more powerful prescriptions, Rappold and Berryman said.
As shown by the report, many patients are deemed in need of the powerful painkillers. Many patients don't think they've been treated until they're prescribed medication, Rappold argued.
"If you go to your doctor and they don't give you a prescription for pain or whatever you happen to have, you feel like you've actually not been treated appropriately .<!p>.<!p>. You didn't get anything for your money that you paid to go see the doctor," she said.
There's no way to completely eliminate abuse, Berryman and Rappold said, but other policies help track and address problems.
By signing the contract, patients submit to spontaneous pill counts or blood tests. If pill totals or test results don't mesh with prescription schedules, it could be a sign of a problem, Berryman said.
If they believe a patient is addicted or selling the drugs, they gradually reduce the medication until the person no longer receives it. Berryman didn't specify how long it takes to "taper" a patient off the drugs.
Once the person is no longer receiving the medication, hospital policy says the person can't receive the same prescription for 6 months, Berryman said.
There is an active suboxone clinic at the VA center, Berryman said. Suboxone is a medication used to wean addicts off powerful prescription drugs. Although it can also be abused, it's proven a successful means for stopping dependency on other drugs for many people.
The VA also routinely refers patients to local treatment centers, Berryman said.
The VA's policies aren't foolproof. Patients know how to avoid positive tests, and tests are only administered after someone is suspected of misuse, Berryman said. The six-month policy is also discretionary.
Patients aren't allowed to get prescriptions for powerful painkillers from the VA and other providers at the same time, but it does happen.
Rappold guessed at least once or twice a month, prescription providers face a problem with a patient and powerful painkillers. Pharmacists, doctors and others at the hospital can typically see signs of people abusing or misusing their medications, Berryman said.
"I wish there was a magic formula that we could use to separate the people who need them from those who don't. And if we could do that without offending or without crossing legal lines, we would do that in a heartbeat," Berryman said.
"We believe people first, we wait to be disproven. When we see evidence of disproving that presumption, then we act on it, period. No matter who it is."