FOR ADDICTED VETERAN, REGULATION IS ENEMY

Government Balks at Covering Treatment for Painkiller Dependency

BRAINTREE - In the space of a few hours, on bomb-clearing patrol near
Balad, Iraq, US Army Corporal Eric Small and his unit were rocked by
three separate roadside explosions. He sustained serious injuries to
his head, back, neck, and hip. Small's combat days were over.

It was the summer of 2008, and Small spent 10 months convalescing in
military hospitals. He came home to Massachusetts with two lasting
wartime souvenirs: a Purple Heart medal and a painkiller addiction.

But in a bitter irony for Small and his family, the same government
that sent him to war balked for months before agreeing to pay for the
treatment his doctors feel best addresses his drug addiction. Small's
frustration is shared by some medical specialists who say it's
shameful to deny him, and others like him, coverage for a condition
he acquired doing his patriotic duty. The issue has been federal
regulations that restrict coverage for treatment of drug addiction
for military personnel.

"I never dreamed when I joined the military that I'd be put in this
situation," Small, 29, said at his Braintree apartment, with his
wife, Shannon, and baby daughter, Isabella, nearby. "I wasn't a drug
addict. I didn't do drugs. Suddenly I'm going through withdrawals,
wanting my body to stop being the way it is."

Percocet, the painkiller Small had been taking, is potent and can
become highly addictive. Small no longer takes the drug, having been
put on buprenorphine, a cutting-edge medication used to treat opiate
dependency. Addiction specialists consider it the gold standard for
treating drug dependencies like his, safer and more effective in many
cases than older-generation drugs like methadone. Buprenorphine is
also approved by the Federal Drug Administration for treatment of chronic pain.

Paying for buprenorphine, which costs $250 a week, has left the
Smalls more than $3,500 in debt and scrambling to make ends meet.

Tricare, the military's health care provider, did recently agree to
cover the cost of Small's buprenorphine, sold under the brand name
Suboxone. But that approval did not come easily; it took months of
negotiation between Small's physician and Tricare, which will not
approve the drug for "maintenance therapy of opioid dependency," but
will for detoxification and supervised drug withdrawal. In Small's
case, Tricare is covering the drug for pain management as well.

To many addiction specialists, all that amounts to a distinction
without a real difference - and a conundrum for doctors wanting to
provide optimal care for patients like Small. (Small's physician
declined to be interviewed.)

"There's no assurance that next month Corporal Small won't be denied
coverage or any assurance the next person [who asks] won't be denied
too," said Dr. Robert Newman of New York's Beth Israel Medical
Center, a leading addiction specialist who has been advocating for a
change in government policy. "We're talking about physicians paid by
our government who decide their patients require a certain treatment,
and yet an insurer can arbitrarily overrule them. I see no
justification for this. None."

The American Medical Association, in its published policy on
physician-prescribed drugs, offers "strong support" to doctors who
lawfully use an FDA-approved drug "for an unlabeled indication when
such use is based upon sound medical opinion" - in other words,
prescribe a drug for pain control when the primary reason for taking
it is to help the patient kick a drug habit.

The AMA also urges third-party payers such as Medicare to cover
prescription drugs under such circumstances, deeming them "reasonable
and necessary medical care."

Chris Hassan, CEO of Colonial Management Group, a California-based
chain of addiction-treatment centers, said the US military and
federal government have been slow to pay for new medications that
treat drug addiction. "Medical treatment of addiction in the VA
[Veterans Administration] system is not even standard-of-care, never
mind cutting-edge," Hassan said. "We put people in harm's way, then
create another problem for them by putting this stigma on them. It's
like someone getting blown up by a land mine and then you deny him a
wheelchair."

The roadblock to coverage in cases like this is a Department of
Defense regulation. It stipulates that while insurance benefits may
be extended for drugs that treat illness or injury, they "cannot be
authorized to support or maintain an existing or potential drug abuse
situation." Drug-maintenance programs swapping one addictive drug for
another are not covered.

In April, Representative James McGovern of Massachusetts joined seven
other members of Congress in petitioning Defense Secretary Robert
Gates to amend Tricare benefits to cover methadone and buprenorphine.
"Military families struggling with addiction need help," their letter
concluded. In June, Defense Undersecretary Clifford Stanly assured
the congressmen that Tricare is "pursuing changes" in its policy of
disallowing coverage for opioid dependency.

Small is fortunate compared to many who have returned from Iraq and
Afghanistan with lifelong disabilities. Beyond the brain injuries and
shattered bodies are epidemic levels of post-traumatic stress
disorder and suicide. In Small's unit alone, the 509th Combat
Engineer Company, two soldiers took their own lives while in Iraq,
according to Small.

This spring, retired Army General Barry McCaffrey warned that serious
drug use among US military personnel in Afghanistan had doubled since
2006, while the Drug Policy Alliance has estimated that nearly
one-third of Afghanistan and Iraq vets show signs of post-traumatic
stress disorder. That condition is "strongly associated with
substance abuse and dependency," according to the National Institute
on Drug Abuse. Moreover, as Newman and others note, drug dependency
affects tens of thousands of veterans' dependents and survivors as well.

Small remains on active-duty status and will probably be discharged
early next year, when he should become eligible for full VA benefits,
including medication coverage. However, he's concerned that his
treatment for drug dependency may give the Army an excuse to deny him
some benefits, his Purple Heart notwithstanding. Until his discharge,
meanwhile, he draws a $3,300 monthly salary and housing allowance.

Hoping to become an emergency medical technician, he harbors no ill
will toward the Army, he said, and feels he received good medical
care and counseling, for the most part. Yet he acknowledges he's not
the same man who joined the military three years ago with the intent
of someday becoming a police officer or firefighter.

Nine months in a Texas military hospital changed everything, said
Small, who at one point was taking 20 different medications for pain,
anxiety, depression, and insomnia. Shannon Small said her husband's
pill consumption didn't seem to concern his Texas doctors.

"Maybe because so many other people there had their arms and faces
blown off," she said. Because his injuries were less visible, if no
less painful, she added: "they were kind of shrugging him off. Like,
'Take more Percocet - it'll mask the pain. Then we'll deal with you later.' "

Small's problems weren't confined to his physical discomfort, the
couple said. Plagued by anxiety attacks, he began refusing to get in
a car unless he could drive himself. "I was mentally stuck," he said,
reflecting on his long convalescence. He still will not ride with
others driving, even his wife, and avoids crowded places.

By Small's last hospital stay, in Missouri, his addiction to Percocet
had become painfully obvious. Last September he admitted his problem
to his superior officers, who had him checked into a rehab clinic.
Put on methadone during his seven-day stay, he suffered painful
withdrawal symptoms, however, and went back on Percocet to ease his
discomfort. A few weeks later another physician treating Small
recommended Suboxone, which proved to be a positive, if expensive, step.

Only after Small's months of resubmitting insurance forms did Tricare
consent to pay for his treatment, and even now he's been told he
can't recoup what he spent on Suboxone out of pocket.

Speaking publicly about his situation "isn't to get money," Small
said, while his daughter cooed in a playpen nearby. "It's for others
in my situation. The rule needs to get changed. People need to know
what's happening to the veterans who come home, that we're not over
there shooting people - and getting shot at - for nothing."