BLAND — Nearly everything that Kevin Keller did in his final years bore the mark of constant pain, even the note he left in the end.
His right arm rendered useless by a crippling stroke, Keller used an unsteady left hand to scrawl a brief letter to his best friend.
“MARTY,” it read. “SORRY I BROKE INTO YOUR HOUSE AND TOOK YOUR GUN TO END THE PAIN! FU VA!!! CAN’T TAKE IT ANYMORE”
By the time Marty Austin found the note in his Bland home late on the night of July 25, Keller had already driven to a Veterans Affairs outpatient clinic in nearby Wytheville, where the U.S. Navy veteran was a patient. Keller parked his red pickup truck at a pharmacy next door, walked to the front of the closed medical office, pounded on the locked doors in a final act of frustration and then used Austin’s 9 mm handgun to shoot himself in the head.
VA officials declined to talk about Keller’s case, but Austin and two other friends of the 52-year-old said he had spoken to them many times about the suffering he endured after doctors and nurses at the VA clinic in Wytheville began to wean him off painkillers.
“The medications were the only thing that was helping him, and when they took that away from him, his life just went downhill,” Austin said.
Keller’s suicide comes as the U.S. Department of Veterans Affairs seeks to reduce the amount of opioid painkillers prescribed to patients at veterans hospitals and clinics across the country.
It also illustrates how difficult that process can be.
With prescription drug abuse accounting for a wave of addiction and overdoses in Southwest Virginia and across the country, health care providers have become more cautious – particularly with the use of opioids, which are especially potent painkillers that can deliver a double-edged dose of pain relief or just more pain.
In February, the VA announced an Opioid Safety Initiative, described as a multifaceted approach to find alternative ways to treat pain. At the Veterans Affairs Medical Center in Salem, which serves most of Southwest Virginia, officials say they began to address patient safety related to opioids even before the national initiative began.
By lowering patients’ dependency on opioids, VA officials say, they can improve and extend their lives.
That may well be true in some cases, said John Andres, who served with Keller in the Navy aboard the USS Independence. As someone familiar with both the VA health care system and the needs of a friend who suffered a major stroke in 2004, Andres believes the system has failed in at least one case.
“He fell through the cracks of some kind of bureaucracy,” Andres said.
Keller was not an addict on the verge of an overdose, his friends say. Nor was he the victim of a psychological breakdown, they say. The way they see it, he made a calculated choice between two abysmal options: living in severe pain or no longer living.
“They told him that being taken off the narcotics, it would extend his life,” Austin said. “And he impressed to them that he did not want a longer life if he was going to be miserable and couldn’t do anything because of the pain.”
Working through the pain
After completing his stint in the Navy in the early 1980s, Keller returned to Aquia Harbour, the small town where he grew up in Stafford County.
He found work as a press operator at Billingsley Printing & Engraving in Fredericksburg. On nights and weekends, he liked to ride motorcycles, play poker and shoot pool with a group of friends that included Austin and Andres.
Keller also developed a talent for woodworking, crafting everything from picture frames to poker tables.
A diabetic, Keller suffered a stroke in 2004 that left the right side of his body partially paralyzed. After that, he could only walk with the help of a cane, and had to teach himself how to write with his left hand, and he had to park his beloved Yamaha 650 for good.
Keller could have gone on disability, Austin said, but he was determined to keep working. Gary Billingsley, a co-worker at the print shop, recalled how Keller rigged up a system of ropes and pulleys so he could operate the press.
“He could run the press as well with one arm as anyone else could do with two. It was really amazing,” Billingsley said.
But Keller often had to take a break and sit down as sharp pains shot down his right leg and to his foot. “You could tell he was in pain,” Billingsley said. “He would tell you that it hurt, but that was about it. He wouldn’t try to make you feel sorry for him. He just made do.”
Keller fought through the pain with the help of several different drugs he received from the VA. His friends said they did not know the type of medications he was on, but said they included opioids. Commonly prescribed opioids include OxyContin, Percocet, Vicodin and Lortab.
Preparing for an end
About three years ago, the pain became too much.
Keller quit his job, began to receive disability checks and moved to Bland County, where it was cheaper to live and he could depend on help from Austin, who had moved to the area several years earlier.
Keller was divorced at the time, Austin said, and had no family members in the area. Efforts to reach Keller’s son in Florida and his sister in Colorado were unsuccessful.
Not long after he arrived in Bland County, Keller began to talk about how the doctors at the VA clinic in Wytheville were reducing his prescription painkillers, Austin said. He would try to stretch his pills out to the end of the month, but often came up short when the pain was too bad.
“He was frustrated,” Austin said. “He spent days on end on the phone with different people, trying to get help.”
Austin said his friend would sometimes smoke marijuana to ease the pain. He tried buying extra pain pills on the black market but said they were too expensive.
Those things likely did not please the doctors at the VA, and Austin said Keller fared no better when he tried to go on private insurance because his medical records followed him.
By then, Keller was spending most of his time inside his Bland apartment, watching television and fuming about his sedentary lifestyle. Although his friends did not realize it at the time, Keller’s patience with the VA bureaucracy was wearing dangerously thin.
“Basically, it was falling on deaf ears,” Andres said of Keller’s pleas to be returned to his previous regimen of painkillers. “Once they came down with a mandate from above, I think it was out of even the doctors’ hands.”
While his friends worked on a three-wheel motorcycle that Keller could use to tool around town, he was quietly making different plans.
He closed out his bank accounts, packed his belongings into cardboard boxes, and left instructions on how to care for Max, his Chihuahua. And he began the laborious work of writing farewell notes to his closest friends.
Final instructions
A few minutes after 9 p.m. on July 25, an employee of an auto parts store in Wytheville heard someone banging on the doors of the VA’s community-based outpatient clinic, just across the street on Peppers Ferry Road. Police were called to scene, according to Wytheville Police Chief Rick Arnold.
An officer was en route when a second call came in: shots fired.
Keller was found lying on the pavement in front of the clinic’s entrance, dead from a gunshot wound to the head. A second shot had been fired, but Arnold declined to say where it went.
An autopsy determined that the 9mm shot that killed Keller was self-inflicted, Arnold said.
The police chief confirmed that Keller was a patient at the clinic, but declined to say what role that might have played in the suicide. The investigation has been turned over to VA authorities, he said.
“Due to privacy regulations, we are unable to provide any information related to the care and treatment plan of this specific veteran,” VA spokeswoman Ann Benois wrote in an email.
The statement also read that the VA staff “extends our sincere condolences to the family and friends of this veteran.”
On July 25, Austin was working the night shift and didn’t get home until close to midnight. As soon as he walked inside his house, he spotted a letter that had been left on the back of his couch. In addition to writing in the note that couldn’t take the pain anymore – and directing an obscenity at the VA – Keller asked Martin to check on Max back at his house, where he would also find his cellphone.
After reading the short note, Austin noticed with a sinking heart that his 9mm handgun was missing from the end table where it normally hung from a holster.
Later, after learning that his worst fears had been confirmed, Austin went to Keller’s apartment, where he found more letters. Some were to family members and friends, private messages that Austin declined to share.
Two of the letters were to nurses at the Wytheville clinic.
“They were pretty harsh letters,” Austin said. “He wrote that ‘I don’t want the medications. I need the medications. And if you had given me the medications I needed, I would be alive today.'”
A new classification
Whether from the rigors of war, the strains of non-combat service or just the natural progression of civilian life that follows, veterans suffer from much higher levels of chronic pain than the general public.
More than half of all veterans receiving treatment from the VA health care system report having chronic pain, which is often accompanied by depression, brain injuries, post-traumatic stress disorder and other ailments, according to the Veterans Health Administration.
The use of opioids for pain relief is generally reserved for patients with moderate to severe pain who have not responded well to previous treatment with less potent medications.
Because patients can quickly become dependent on opioids, their use is being restricted both in the VA system and the private sector. Starting next month, the U.S. Drug Enforcement Administration will list hydrocodone, a class of opioids that includes Vicodin and Lortab, in a more restrictive category of drugs (including oxycodone) that are considered to have a higher potential for harm or abuse.
The new classification means, among other things, that prescriptions for hydrocodone-based drugs cannot last as long, and a doctor must see a patient before a refill is approved.
About 17 percent of all VA patients were prescribed opioids in the final quarter of 2012, according to information from the Opioid Safety Initiative. The level for the Salem VA’s service area was slightly higher – 20 percent.
Two years ago, the VA’s inspector general was asked by a U.S. Senate committee to conduct a review after the Center for Investigative Reporting published a report showing that VA prescriptions for opioids had increased 270 percent over the past 12 years.
About 13 percent of the opioid users studied in the inspector general’s report were diagnosed with active substance abuse. The report also found that 71 percent of opioid users were also prescribed benzodiazepines such as Valium and Xanax, a dangerous mix.
Cutting back opioids
Against that troubling backdrop, the VA in February announced its Opioid Safety Initiative, which it described as “a comprehensive effort to improve the quality of life for the hundreds of thousands of veterans suffering from chronic pain.”
A pilot program the year before in Minneapolis cut high-dose opioid prescriptions by more than 50 percent through improved patient education and use of alternative treatments such as behavior therapy and acupuncture, the VA reported.
“Early results give us hope that we can reduce the use of opioids for veterans suffering with chronic pain and share those best practices across our healthcare networks,” then-VA Secretary Eric Shinseki said in a statement at the time.
Advocates for those in pain have voiced concerns about a growing reluctance by doctors to prescribe opioids, in part because of tougher enforcement of drug laws by federal and state prosecutors.
“It seems like there are more and more roadblocks to access to care,” said Penney Cowan, founder and executive director of the American Chronic Pain Association.
However both Cowan and Bob Twillman, director of policy and advocacy for the American Academy of Pain Management, were reluctant to comment on Keller’s case – or to pass judgment on the VA’s broader opioid initiative, saying it often comes down to a medical assessment of each individual patient.
“I suspect there are some people for whom a reduction in their opioid painkillers would be a good thing,” Twillman said. “I suspect there are others who would benefit from a larger dose.”
For those who need to be taken off opioids or have their doses tapered down, he said, “The question is, what do you do instead of that?”
A mix of care
At the Veterans Affairs Medical Center in Salem, a new pain clinic opened in March.
“The emphasis is on an interdisciplinary team management, to make sure than non-pharmacologic treatments are endorsed,” hospital director Dr. Miguel LaPuz wrote when announcing the opening in a recent newsletter.
Other approaches currently being used at the hospital include chiropractic care, physical therapy, exercise programs, acupuncture, aqua therapy and behavioral interventions such as biofeedback and even hypnosis.
While opioids are still dispensed for cancer patients and other high-pain ailments, the VA has taken a number of steps to reduce their use, including pharmacy restrictions on OxyContin after it was identified by the FDA as a “problematic agent,” Benois, the hospital spokesperson, wrote in emailed replies to questions from The Roanoke Times.
The Salem VA is also beefing up its suicide prevention efforts. By one estimate, 22 veterans kill themselves every day in the U.S.
As for reducing opioid use, the results so far have been generally positive, Benois wrote.
“Some veterans have reported that their quality of life has changed as they were moved from strong pain medications to lesser dosage and finally to none at all,” the email read. Others reported lower levels of depression and better pain stabilization.
However, “some express dissatisfaction with the program and may not be compliant in taking their prescribed medication or may be combining it with other medications from different resources,” Benois wrote.
No longer in pain
With the details of Keller’s medical treatment not being disclosed, the only account to emerge has been from his own last words – and those of his friends.
Austin believes that Keller’s last acts were a statement that needs to be heard, especially as problems with patient care and long wait times for appointments at the VA have attracted national attention in recent months. (Wait times to see a doctor at the Salem VA were shorter than those at other hospitals.)
“You know as well as I do how much the VA has been splattered all over the news,” Austin said.
“My opinion is that he did what he did – and where he did it – to try to bring more attention to the VA. And if it was too late for him, maybe it would help somebody else.
“That’s the only thing that I can do, try to get Kevin’s word out, to try to help somebody else.”
A few weeks ago, Austin had Keller cremated. The ashes are being held in a hand-made wooden box that a friend built. In a tribute to Keller’s passion for woodworking, the box includes a piece of cedar taken from a log he was keeping for a future project.
This Thanksgiving, back in Stafford County, there will be a memorial service.
By then, it may be easier to take some comfort in the fact that Keller is no longer in pain, but the frustration he felt is likely to live on among those who knew him best.
“Who came up with the mandate that says nobody is in pain anymore?” Andres said. “You can’t tell me all of a sudden that nobody needs opioids. Because you know there was at least one person who needed them. And he’s dead.”